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Leadership and Management in Nursing
A Critical Approach
Benny Goodman September 2017
Leadership and Management in Nursing –
A Critical Approach
© 2017, Author: benny goodman: email@example.com
ALL RIGHTS RESERVED. This book contains material protected under International and national Copyright Laws and Treaties. Any unauthorized reprint or use of this material is prohibited. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system without express written permission from the author / publisher.
Table of Contents
- Five key areas for developing leadership. 6
- What is ‘Leadership’?.. 8
- The Transition to Professional Practice. The reality for the Newly Qualified Nurse (NQN)? 20
- Leadership in the public sector. 24
- Transformational Leadership and ‘Self Efficacy’. 33
- Trust as a core aspect of leadership. 41
- Leadership Development and Organisational Change. 47
- Developing self: Critical Reflexivity. 53
- Gender issues. 63
- Teamworking.. 69
- Continuous Quality Improvement – the PDSA model and ‘Error Wisdom’. 73
- Care, Quality and Soft Metrics. Are we doing the right things?.. 78
- Leadership as positive deviance, our ethical responsibilities in a globalised world. 85
- A Manifesto for Action Nursing.. 90
Further Reading: 105
Useful websites. 106
Leadership and Management are currently emphasized within health care as important aspects of the nurse‘s role. This document aims to address some of the issues but cannot cover all relevant material. The focus here is on understanding what we may mean by these two words within a critical, and criticised, context.
Thus this is an attempt at investigating the context in which nurse work. If the context is not understood then some of the tools used by nurse leaders, e.g. the PDSA model of quality improvement, may result in small useful changes but leave wider structural issues untouched. If one understands the problems one faces then there is a chance that the right answers may be offered. It is my contention that nursing is political and requires political and policy awareness.
This is also not a technical training manual. It does not provide a ‘how to guide’ to use in everyday clinical practice. There are technical managerial tasks that nurses are required to use and apply – budgeting, staff allocation, auditing, running meetings, staff appraisals, evaluating new IT and technology for use in practice – but many of these come with an organisation’s ‘training manual’, or a procedure book or a set of ‘how to’ policies. These reduce nursing management to a set of pre-determined technical tasks which although very necessary can easily be learned via a set of behavioural techniques and training sessions.
What follows is an attempt at some critical analysis of the exercise of leadership and the application of managerial techniques in an attempt to encourage critical reflexivity and critical analysis. The hope is that this leads to the offering of solutions (by you) to the problem of delivering high quality services in settings that sometimes makes this a challenge.
©Benny Goodman 2017
A text to support this document:
Barr J and Dowding L (2016) Leadership in Healthcare. Sage. London.
Sage’s Companion Website: https://study.sagepub.com/barr
“self discovery and self awareness are critical to developing the capacity to lead. And personal reflection and analysis of one’s own leadership behaviours are core components in that process. Equally as valuable is insight from those who know the individual leaders well, who have experience of them in a leadership role…”
(Kouzes and Posner 2011 p13).
This statement introduces the idea that leadership is as much about knowing yourself as it is about working with other people. I would add that understanding how other human beings go about their everyday lives and work is the other side of the coin. We also need to grasp the basic fallibility of human thinking and action, and then to move on from directing blame solely upon individuals for errors to designing work practices for developing success.
This paper aims to develop an understanding of the role, interactions and the goals of nurse leaders. There is no one story here. Leadership and Management have to be seen in organisational contexts in which the psychology and sociology of human thinking, gender and interprofessional practices affect how nurses perceive themselves, their patients and those they work with.
At the most basic level this requires an understanding of yourself and of others. This is a starting point. From here we also need to be able to understand the place of nursing in wider socio-political contexts, e.g. we need to know how certain management practices come about and constrain or enhance nursing care.
As you know nursing is all about people, and in the literature we talk about ‘human factors’ when trying to understand a process of service delivery. In the aviation industry, where mistakes can be fatal, there is an attempt to analyse all systems to identify how errors occur and then to plan to prevent them. This is done because there is an acceptance that ‘human factors’ play a huge role in how successful or otherwise the system is. So in addition to understanding yourself, you need to understand and plan for ‘human factors’ and errors that can cause issues to arise. This is then an attempt to develop what is being called ‘error wisdom’
Note: you will find hyperlinks in the text such as patient centred leadership which should take you to web based resources.
1. Five key areas for developing leadership.
Cunningham and Kitson (2000 a,b) evaluated the United Kingdom’s Royal College of Nursing’s (RCN) clinical leadership courses and suggest that there are 5 key areas for which leadership needs developing in individual nurses. So, to help us think about how we exercise leadership it is useful to consider these 5 as a guide to personal development:
- Managing self: Who are you? What are your strengths and weaknesses? What motivates you? Are you emotionally intelligent? What is your default ego state? What is your relationship to the organization in which you work? What are you hopes, dreams and ambitions? What are your personal and professional values? How do you think?
- Managing the team: What theories do you hold about working with people? What makes for good team working? What personal core skills are required for team working? What assumptions do you have about how people work? What power dynamics are you aware of? What are the local ‘human factors’?
- Patient centred care: What does this mean in detail? What behaviour and attitudes do you possess that hinder or foster this? Is there a difference between the theory and practice of Patient centred care? What are our safety systems?
- Networking: Who is in your network? What tools do you use to network? What skills are required for networking? What does networking mean in nursing? Why is networking valuable?
- Political awareness: What are the policy drivers affecting you and your work? Who are the key players? How can you affect decisions? At what level should you operate? What organisational structures help to hinder you and your team‘s development?
- There is a need to understand yourself. (Managing self, patient centred care).
- There are three levels of analysis – micro (patient), meso (clinical setting) and macro (Hospital-Health Service) (political awareness).
- Psycho-social issues underpin the exercise of Leadership and Management : Gender and Power and Interprofessional Practice. (Managing the team and networking).
- We need to use various tools to affect change (networking, team issues, patient centred care).
- We need to examine the current and the future situation (political awareness).
The following sections examine some theoretical explanations of what leadership is, and what some core components of it may be. There is also a need to set health care leadership in the context of public sector provision and consider how private sector management and leadership may not apply quite so well. The nature of doctor –nurse relationships will highlight how gender and patriarchy might construct how we practice. Then we will examine a model for quality improvement taking into account human factors. Finally we will examine our future direction and ask what are we leading for?
Photo by Oliver Cole on Unsplash
2. What is ‘Leadership’?
Leadership is a slippery concept. There has been a great deal written about it and it has often been paired with the term ‘management’. They are not the same thing, so of course we need to think about these two words, words which are often used interchangeably in the literature. Reference to just leadership in this document is the general default position to avoid the clumsy use of ‘leadership and management‘. Part of the learning process is to think about why we are using these words at all.
Often the word ‘leadership’ has a particular value placed upon it. It is seen as ‘a good thing’, it is a ‘romanticized’ idea that will rescue failing organisations and therefore ‘we need more of it’. For some people there is the notion of the ‘heroic leader’ who will make necessary changes. This idea is often promoted by those in leadership positions, for example Barack Obama’s ‘yes we can’ slogan during the US elections reflects his belief that he can lead the United States to a better future.
As a counter, Roy Lilley (2013) recently argued;
“I am fascinated by the NHS’s latest fad; ‘leadership’. Bosses are seldom ‘leaders’ but it doesn’t stop them becoming the boss. ‘Clinical leadership’ is a nice phrase but putting Docs in the driving seat doesn’t guarantee a smooth ride. Can you put people through a programme and wait for a leader to roll out the other end? No! You can create knowledge of leadership, an awareness of leadership, you can study the great leaders of history but you won’t ‘make’ a leader. It’s much deeper than that. Leaders need followers and understanding them gives us an insight into leadership. Why do people follow a leader? Often blindly, often into crime and sometimes into sin and stupidity. Leadership is a power for evil as well as good”.
The King’s Fund (2012) takes a more nuanced view arguing for the necessity of good management. However they do take up the theme of ‘No more heroes’, indicating that leadership by charismatic individuals who are highly skilled and knowledgeable is not necessarily the answer in a complex organisation. They argue that a new style of leadership is required – ‘shared’ or distributed’ leadership, with far less reliance on the heroic leader. In this view effective leaders work through others motivating and engaging followers. In 2012 the King’s fund published ‘Patient Centred Leadership’ to suggest 5 key findings. One of which is the need to value front line staff and focus on patients and their care.
Therefore we have to treat leadership development as a very complex issue involving the understanding and development of the total context in which the leader finds themselves!
Overview of some of the theory.
This section will very briefly give an overview of just three approaches to leadership:
- Person Theory.
- Action Centred theory.
- Behaviour Theory: The Leadership Framework
- Leadership Styles.
This is a very simple overview and is by no means exhaustive or detailed. There is a web reference at the end of the section to follow this up if you require more detailed knowledge.
- ‘Person’ theory: This emphasises ‘Traits, attributes, qualities and characteristics’. This set of theories tries to understand that leadership as part of the characteristics of the person. It is sometimes referred to as the ‘Great Man’ theory of leadership. What is required here is to understand what makes a ‘great man’, and it might assume that leaders are born rather than made.
In this way of thinking we would study great leaders such as Florence Nightingale and ask ourselves what it was about them that made them do what they do? However, this way of thinking about leadership is now a bit passé. It also rules out the possibility that leadership can be exercised by anyone, as it assumes that someone has to have special qualities. Remember, great ‘leaders’ of the past often got the position through patronage, privilege and socio economic status denied to many other people. In addition, appraisals by individuals of their own superiority, of their capacity to lead, are open to Fundamental Attribution Error and Self Attribution Bias (Heider 1958) whereby we attribute successful outcomes to our own skill but attribute failures to external factors or bad luck.
Florence Nightingale “The lady with the data”
- Action Centered Theory. John Adair’s theory moved on from great man theory to try and understand leadership as an action and puts a focus on leadership arising through the three elements: the team, the task and the individual. This is a more dynamic understanding involving follower behaviour as well as the leader themselves.
Action Centered Theory would require an analysis of these three elements to fully appreciate what leadership is. If the team is large, with many new members, little training and professional development, and then they are asked to perform quite complex tasks requiring difficult procedures that have no obvious way of performing them and then finally the individual charged with delivering the project, has a great deal of practical and professional knowledge but little in the way of emotional intelligence, then leadership would have to be exercised in a particular way to get the job done. The individual would have to consider the nature of the task, and the team they have, and come up with a way of working that suits the situation. Leadership then is not one simple phenomenon, it varies with these three elements. Leading in a palliative care team would be different to leading in critical care outreach team. If you think about the tasks, the teams and the individuals how might this then vary in these contexts?
Adair’s theory may allow some deeper understanding of the complexity of leadership but there are other ways of thinking about it. After all analysis gets you so far, but does not always give you a way of adopting a leadership style or behaviour, So, how do you know what is best in Nursing?
Adair’s Action Centered Leadership:
- Leadership Behaviours.
An example of theory that focuses on the individual leader’s characteristics and behaviours is that of Kouzes & Posner (1987) who suggest the following are common to successful leaders:
- Challenge the process – First, find a process that you believe needs to be improved the most.
- Inspire a shared vision – Next, share your vision in words that can be understood by your followers.
- Enable others to act – Give them the tools and methods to solve the problem.
- Model the way – When the process gets tough, get your hands dirty. A boss tells others what to do, a leader shows that it can be done.
- Encourage the heart – Share the glory with your followers’ hearts, while keeping the pains within your own.
The positive aspect of this is that it outlines leadership behaviour and attitudes but of course cannot deal with the socio-political context which may also have to be addressed. Take the first point of ‘challenging the process’. This might be help in identifying a care quality issue such as the poor nutritional support to acutely ill and frail elderly patients. However the long term resolution to this issue might be beyond the individual’s ability to provide the ‘tools and methods’ to do so. Nonetheless, it does provide some positive encouragement and an outline framework of what needs to be done.
Leadership Framework: another outline of what leadership is.
In the UK, the National Health Service Leadership Academy has published its ‘Healthcare Leadership Model’ developed for all staff regardless of profession or role. Thus it is not just for NHS managers, but includes potentially the whole workforce. It is a ‘behaviours’ approach to leadership outlining those areas for leadership behaviour that need developing. It is argued that the framework applies to all staff at any stage of their career.
The concept of ‘Leadership’ adopted for this framework is that leadership is most successful when there is shared responsibility for the success of an organisation or the care that is being delivered. Leadership is not therefore to be restricted to those who hold management and traditional leader roles. Another word for this is ‘shared’ or ‘distributed’ leadership, accepting that not everyone might act like a leader but everyone can contribute to leadership by using behaviours described in the framework.
The NHS LF recognises that staff will have differing opportunities to apply the behaviours, and this depends on the context in which they are working. Therefore they previously have outlined 4 stages of career and leadership development. Someone who is just joining the organisation can engage in stage 1 and as they progress and get experienced, they may progress through the stages. These stages are the contexts on which the 9 core domains of leadership behaviour may be engaged in.
The 4 stages of the NHS Leadership Framework (NHS LF) are:
- Own practice/immediate team. Your team might be multiprofessional and will require you to build relationships. Consider how the 5 core domains apply at this level.
- Whole service/across teams. The next step, this is about working with other teams and may require networking and communication with a wider body of staff beyond your immediate clinical environment. Identify what your ‘service’ is and what are the teams that make it up.
- Across services/wider organisation. Hospital healthcare services might include critical care, stroke rehabilitation, radiography and pharmacy. At this level you will need to consider working across these teams in the wider organisation
- Whole organisation/healthcare system. This takes you beyond the hospital or community services and might address national and international issues. For example pain assessment and management in acute care has been identified as an issues that requires action across the whole NHS.
You might want to reflect on what stage is appropriate for you to exercise the 9 domains of leadership behaviours, this might require you to examine your own personal goals and aspirations.
- Leadership Styles
Gopee and Galloway (2014) outline ‘leadership styles’. Kurt Lewin in the 1930’s developed a framework to include 3 styles – Authoritarian, Democratic and Laissez faire.
|Laissez faire Permissive
||Seeks views of everyone
||Limited use of policies and rules
||Unwavering from policy
||Applies fixed rules
Describe a situation in which you have seen or experienced any of these styles of leadership.
What are the strengths and weaknesses of each – are there certain situations which make a style more or less useful or likely?
See this for more detail: https://www.mindtools.com/pages/article/newLDR_84.htm
The Blake-Mouton Managerial Grid (1964), and it highlights the most appropriate style to use, based on your concern for your people and your concern for production/tasks.
With a people-oriented style, the focus on organizing, supporting, and developing the team members. This participatory style encourages good teamwork and creative collaboration.
With task-oriented leadership, the focus is on getting the job done. The manager defines the work and the roles required, puts structures in place, and plans, organizes, and monitors work.
Where in the grid would you place your clinical area and why?
Other Leadership Theories
|This focuses on particular environmental variables that determine the best leadership style according to the situation. Authoritarian style where the leader is most experienced. Democratic style may prove most effective in groups consisting of skilled experts
|This proposes that leaders choose the best course of action depending on the situation and type of decision required. An authoritarian style may be appropriate where the leader is the most knowledgeable and experienced. Democratic style may prove most effective in groups consisting of skilled experts
|Participative leadership theories focus on the input and contribution of others. In doing so this assumes individuals are able to feel better values and committed to the decision-making process although the leader retains the right to allow member input
|Also termed ‘Transactional’ this focuses on the role of supervision, organisation and group performance. This style also focuses on a system of reward and punishment
|Also termed ‘Transformational’ focuses on the connections formed between leaders and their followers. This has shown to motivate and inspire group by allowing them to recognise the importance of the task. Focus on members fulfilling their potential as well as group performance. This type of leader is thought to poses high ethical and moral standards
Read: Leadership in healthcare by Barr and Dowding (2016) Ch. 4: Theories of leadership.
Barr, J & Dowding, L. (2016) Leadership in Health Care. 3rd Ed. London: Sage
Glazer, G. Fitzpatrick, J (2013) Nursing leadership from the outside in. NY: Springer Publishing
Gopee, N and Galloway, J. (2014) Leadership and Management in Healthcare London: Sage.
Marquis, B. & Huston, C. (2012) Leadership Roles & Management Function in Nursing. Theory & Application. 4th edn. Philadelphia: Lippincott, Williams & Wilkins.
Phillips, A. (2013) Developing leadership skills for health and social care professionals Radcliffe Publishing
Scouller, J. (2011) The Three Levels of Leadership. Management Books
· What knowledge do you have already of what leadership means?
· What are the differences between leadership and management if any?
· What words have you heard or used to discuss leadership/management?
|FAQs on leadership:
- What is the shape of the “perfect” leader and does he or she exist?
- Does a leader need to be motivated? How can leaders maintain themselves to stay motivated?
- Does every manager need to be a leader?
- ‘Anyone can become a leader’. Is it really possible? Aren’t there people who traits make them unfit to be a leader?
- In which way will new technologies affect leadership and leaders?
- What is the relationship between leaders and followers?
- Does a leader need power? How can a leader avoid being corrupted by the power?
- Is there any trend that could be called “the new leader”? Or have things really not changed that much over the last 2000 years?
- Leaders must divide their time in three parts: one for handling finances, another for quality, and a third for relationships. How is this applicable?
- What’s the worst fault a leader can have?
- As far as communication is a key point, how can a shy person be a leader?
- If so much material is written about leadership, why are there so few real leaders in organisations?
- The role of principles of leadership is so extensive that it puts one to think – isn’t a good leader a kind of superman or superwomen? How can that be?
- Is a military model of leadership adequate to an organisation, as far as it based most on authority and discipline?
- Is there an ideal percentage of leaders in a company? Can an “excess” of leaders turn into a problem?
- What is better for an organisation that does not have huge sums to invest in training: try to build a team of leaders, with all the failure possibilities, or concentrate on building a good team of efficient managers?
- Can someone be a good leader, but not a good manager? Which is better?
- Is there any index of success for turning common managers into leaders, i.e., a tax of effectiveness of training?
- How do you keep people’s loyalty in an organisation that is downsizing? Isn’t it asking too much of a leader?
- One of the main trends in the new economy is people working at home, connected to work by net. How can one be a leader with much less eye-to-eye contact?
See the discussion here on the ‘Performance Juxtaposition Site’
The next section will introduce us to understanding leadership as being affected by the social and occupational context in which it works. So, the characteristics and the abilities of individuals have to operate and will be affected by your working environment.
This is especially salient for newly qualified nurses.
Photo by Piron Guillaume on Unsplash
3. The Transition to Professional Practice. The reality for the Newly Qualified Nurse (NQN)?
The current context is complex.
In the UK, we have the Health and Social Care Act 2012, Deficit Reduction targets (‘Austerity’), Brexit, the NHS funding gap and Trust deficits, lack of integration of health and social care, ‘safe’ staffing levels, skill mix, post Francis fall out, and for the NQN: preceptorship and managerial support, competence worries and occupational socialization. The NQN also has to consider ‘patient opinion’, the 6Cs, revalidation and the new nursing framework. These latter three may be passing fads, but it is too early to say.
Linking these together is the NQNs ability to exercise personal agency within these social structures.
- Exercising ‘personal agency’ is the degree to which one is free to do way one wills out of free will. It is one’s personal action.
- Social structures are complex sets of social relationships that enable or constrain personal action.
An illustration of the complexity of ‘agency/structure’ is patient discharge from hospital.
Nurses exercise personal agency when they act to discharge a patient. They do so within the social structures laid down by others (e.g. managers, doctors) who provide guidelines, policies, procedures as well as the informal ‘custom and practice’ rules we all intuitively pick up on.
The UK’s Parliamentary Ombudsman reported (May 2016):
“Vulnerable patients and their families suffering harrowing ordeals due to poor hospital discharge”.
Some context is of course required to understand the scale of the problem. This report states that 221 complaints were investigated, 50% of which were upheld. The office is the final tier that deals with complaints that cannot be resolved locally and reports 6,286 complaints to the NHS dealing with ‘admissions, discharge and transfer’. This has to be put alongside the number of discharges. An indication of the scale of complaints can be gleaned from the delayed transfers of care data. There were 169,900 total delays in March 2016. This one month figure puts the 6,286 annual complaints to the NHS, and the 221 investigations by the ombudsman, into context.
Does this mean that this is a minor issue that while unacceptable is not to be taken as indicative of deeper structural issues in which the personal agency of the NQN has to operate? Discharge planning is of course a multidisciplinary and multiagency activity and therefore problems with discharge cannot be laid at the door of any one profession.
It does give pause for critical reflection upon the nurses’ role in this process, and if vulnerable patients receive sub optimal care, we have to ask what power does the nurse have to prevent inappropriate discharge? Do nurses, especially newly qualified nurses, feel they can exercise personal agency in this regard or are they part of structured actions characterised by hierarchy and patriarchy within managerialist structures?
Discharge of vulnerable older adults is a canary in the mine and is just one of the many issues NQNs have to face. We can only try to prepare nurses’ with a level of critical reflection and critical reflexivity that might equip them to address structural and managerial issues that directly affects patient care. This requires that we expose them to critical discussion of the context of care and opportunities to develop resilience and resistance strategies.
The following is an indicator of the structures in which newly qualified nurses in the UK have reported.
A small part of the literature on the experiences of NQNs:
Horsburgh and Ross (2013) have stated that we know that inadequate staffing levels, eclectic support and concerns over competence provide the challenging context for NQNs. In their study the NQNs stated:
“…flung in at the deep end”
“…sink or swim”
Colleagues were perceived as “ingrained in the woodwork” and resistant to change, even of a minor nature. That there was:
Whitehead et al (2013) undertook a systematic review of support for newly qualified nurses in the UK. This was done in 2011. Three themes were identified:
- Managerial Support Framework.
- Recruitment and Retention.
- Reflection and critical thinking in action.
They conclude that there is strong evidence that NQNs benefit from supported and structured preceptorship which then improves retention. This could have been hypothesized beforehand. The three themes indicate contextual issues.
‘Managerial support frameworks’ are the responsibility of employing organizations, but we can discuss in class what this means. The related R and R issues again are not our remit. However the third: ‘reflection and critical thinking in action’ is something we can try to facilitate in the very short time students are in education settings.
|Kelly (2014) commenting on Horsburgh and Ross argues:
“However, the need for individual nurses instinctively to take personal responsibility for quality healthcare delivery, to break through cynicism and malaise and to effect change requires individual leadership attributes described by Friedman et al. (2003) as resilience which includes self-mastery, bounce-back-ability or ability to handle stress together with resourcefulness, self-belief and motivation. These are all traits which can and should be nurtured through supportive clinical environments but to a large degree should be innate in the next generation of nurses and cannot always be reliant on others to direct and instruct on these matters”.
To what degree can we nurture these ‘leadership attributes’ ? Is the emphasis on ‘personal responsibility’ placing undue burdens on new nursing staff who have to exercise responsibility without full control? Does the discharge issue illustrate that in some cases nurses do not, or cannot, exercise control over sub optimal care? When nurses do exercise control, what are the enabling factors that allow them to do so?
Gardiner and Sheen (2016) reviewed literature on the graduate nurse experience of support.
“The first year of practice as a nurse is recognized as stressful. Graduate nurses (GNs) report gaps in their education, reality shock, burnout and other negative experiences that influence their intentions to remain in nursing. The review thirty-six articles that focused on GNs and their transition to nursing, as part of a graduate nurse program (GNP), from 2005 to present.
Result: The review identified three main themes that influence the transition from student to registered nurse. These themes included,
1) feeling stressed and overwhelmed by nursing responsibilities,
2) the amount of support from senior nurses and
3) the importance of feedback on their performance as nurses.
The literature supports the idea that clinical practice not only must deliver high quality patient experiences but also high quality staff experiences – this leads one to think about leadership styles and behaviours when exercising personal agency but also critically examining the social structures in which nurses work, for example the quality of mentoring of new staff as manifested in staff training and professional development.
4. Leadership in the public sector.
This section critically examines the socio-political context in which nursing operates and argues that nursing leadership has a political dimension requiring civic and political action by nurses.
Private sector skills
There are various technical skills, involved in exercising leadership and management, they include:
- Financial accounting
- Project management
However nurses working in health care organisations are rarely involved in these activities. It will not be until they move from the clinical role (the NHS LF stage 1) to health care management (the NHS LF stage 2-4) that they would undertake these skills. This is not to rule out the exercising of these skills entirely, but they would be based around limited, small projects and budgets. Marketing of course is an entirely different activity rarely, if at all, addressed by nurses.
Nurses are primarily called to assess, plan, implement and evaluate patient health care needs as their primary role. They will do so using their own experience, expert opinion, research evidence, case studies, family and patient input. This places them firmly in stage 1 of the NHS LF of ‘own practice/immediate team’. To keep in this stage might restrict the practice of nursing far too narrowly, and some nurses might consider the need to develop a much wider perspective.
Application of Leadership Theory and the Public Sector
A point to bear in mind is that the leadership literature only really emerged since the 1950’s and then predominantly in the United States of America, and applies mostly to the corporate private sector (Parkin 2010, Goodman 2011). Therefore we have to be very careful in applying the theories and concepts to clinical nursing and public sector organisations. Therefore we need to understand how the public sector service is being reformed and funded and therefore what leadership might be required.
A key difference between the private and public sector is of course the latter is ‘not for profit‘, and in healthcare we ought to want a shrinking market for critical illness not a growing one!
Strategic vision is arguably thus not about research and development for new products to open up new markets based on cost and quality. Strategic vision includes efficiency, effectiveness and high quality patient experience. Public sector health issues have focused on the need to provide care, compassion, dignity and cleanliness. These are not commodities as such and cannot be developed and tested in the manner of many other commercial products.
The measures of success do not focus only on the finances, there are multiple non-financial measures. These non financial measures of success also need to be highlighted by clinical staff.
However, the continuing financial crisis and the pressure on public funding for health care systems is a very real context that all health systems have to respond to. Therefore no matter how public hospitals are governed, health managers and senior clinical staff will have to address these political pressures. Judgment about a hospital’s worth will be based not only on its financial results but also (contested) indicators such as mortality rates and the patient experience.
However, this is not straight forward and raises some serious issues about such issues as risk assessment and managerial techniques put in place to provide high quality care.
Risk, Rationality and Managerialism
The emphasis on efficiency, effectiveness and profitability in health care, results in part from what has been called ‘managerialism’. Manageralism has been understood as both a process and an ideology, a defining characteristic being the application of scientific and rational means to the achievement of certain organisational goals.
Hood (1991) referred to ‘New Public Management’ which since the 1980’s was aimed at reforming the public sector through the application of market mechanisms and a focus on outcomes and efficiency. Both in Spain and the UK the health services are facing funding issues and pressures on clinical staff to be risk averse and as economic and productive as possible. These aims are not bad in themselves, but they might start bringing too much pressure on front line staff resulting in poor care. Why might this be so beyond lack of staff?
Fitzsimons (1999) wrote that manageralism is a form of ‘instrumental reasoning’ in which efficiency is a defining goal, regardless of the value of the activity itself.
In the current context of health services, a focus on patient safety, efficiency and effectiveness by management might be characteristic of this frame of mind.
It might be an efficient use of beds to discharge older people late at night but what value does it bring to the person being transferred/discharged?
The suggestion is that modern society and sits health systems is increasingly characterised by a rational approach to issues including the management of risk and it is this instrumental rationality that has unintended consequences for the care experience.
The sociologist Max Weber’s theory of ‘rationalisation’ suggests that modern societies become increasingly rational and bureaucratic whereby social life becomes more and more prone to scientific analysis, measurement, bureaucratic control and the application of ‘instrumental rationality’ to social problems and issues. Instrumental rationality is a mode of thought and action that identifies problems and works directly towards their solution, often focusing on the most efficient and cost effective methods of achieving certain ends.
It may not stop to ask what those ends should be, or what effect the efficiency has on human relationships.
| Think about your clinical area.
Can you think of examples of where efficiency and rationality might not be in the patient’s best interests as they experience it? Think: Nutrition in Hospitals?
Photo by Hanny Naibaho on Unsplash
Instrumental rationality in a neoliberal and austerity era of economic policies results in the domination of the market in all spheres of human life and the prioritization of the bottom line and financial efficiencies.
The health service over the past few decades has increasingly sought to eradicate uncertainties in care, and to control its costs, by the application of practices of regulation and surveillance – protocols, monitoring, targets, audits, evidence based practice and performance measures. This sets up a dichotomy for care staff in that they deal with ‘the human’ in direct contact, but at the same time are expected to complete myriad managerial tasks many of which are about controlling risk. These tools, on their own, do not automatically result in poor care. However they are part of a wider organisational and social mindset that can reduce patients into being diagnostic categories, numbers and a ‘data set’.
Thus there is a challenge for clinical nurse leadership in a public sector organization in which private sector skills and outcomes are being applied. However, the judgment of worth (‘value for money’) may contradict more human goals that are the basis of nursing care.
We have to ask what patients want from a healthcare system as well as what society is willing to pay for. A concept to apply is that of ‘Public Value’- what is the public getting for its money?
Public Sector ‘value’.
Shareholder dividend is one measure of private value, shares prices another, but what may be public value? Mulgan (2006) and Chapman (2009) suggest that public sector leadership is best expressed when it is fully involved in the lived experience of the community in which it serves.
We need to ask ourselves and our patients exactly what that ‘lived experience’ actually is.
Recent high profile failures in care services in the UK are expressions of a ‘lived experience’ that is far from acceptable.
Chapman (2009) identifies the following characteristics that indicate public value is being added by an organisation:
- The level of service provision is improved.
- The quality of service is increased, particularly in treating all recipients with respect.
- The equity or fairness with which the service is delivered is increased.
- The service provision is sustainable and takes into consideration the needs of future generations.
- The provision of the service is done in a way consistent with the expectations of a liberal civic society.
- The service provision enhances the level of trust between government and citizens.
However, these are lofty ideals and for clinical nurses this needs to be translated into practical action. A case can be put forward that all 6 are under severe pressure in the current context of austerity politics and public sector cuts in funding.
If nurses cannot provide shareholder value, if they cannot increase the hospitals profits or if they do not reduce costs, if they cannot therefore increase private value, how can nurses work to towards increasing public value, if at all?
Since 2008 Spain, along with many other European countries, has been experiencing external and internal ‘economic restructuring’ and unemployment. This includes budgets cuts, rising unemployment and public sector pay cuts. Mills (2014) argued Spanish nurses are Europe’s most stressed, with 20,000 losing their jobs and many going overseas to work. This is not a new external stressor as countries experience periods of recession and economic retraction over the economic cycles. However, this period (2008-2014) is particularly difficult for Spain resulting in very high youth unemployment, the ‘indignados’, and nurses seeking work overseas.
The Politics of Nursing in the public sector: Care is expensive: get used to it.
This summary of a recent article is worth reading as it sets up what some are experiencing as they struggle to reconcile care and the cultures that surround it:
“Nursing faculty are facing challenges in facilitating student learning of complex concepts such as compassionate practice. There is currently an international concern that student nurses are not being adequately prepared for compassion to flourish and for compassionate practice to be sustained upon professional qualification. An exploratory…study was undertaken using in depth interviews with five nurse teachers in the North of England. Findings…indicate that nurse teachers recognise the importance of the professional ideal of compassionate practice alongside specific challenges this expectation presents. They have concerns about how the economically constrained and target driven (my emphasis) practice reality faced by RNs promotes compassionate practice, and that students are left feeling vulnerable to dissonance between learned professional ideals and the RNs’ practice reality they witness. Teachers also express discomfort due to a perceived promotion of an ‘unachievable utopia’ within practice, identifying how the constraints within practice could be better managed to support professional ideals. The nurse teachers within this exploratory study identify the need for strong nurse leadership in practice to challenge constraints and realign the reality of practice with professional ideals, and the need to foster student resilience for maintaining the professional ideals of compassionate practice”. (Curtis 2013).
Although this is a qualitative research study involving 5 study participants, the themes may well resonate with many nurses.
A key point made in the article is that of the requirement for ‘strong nurse leadership’ in clinical practice to deal with those factors that make care and compassion difficult to practice fully. That being said, no amount of good leadership will address the basic problem of the cost of caring: ‘who pays?’ Poor quality care is the fault of the person giving it, personal accountability for neglect and abuse cannot be sidestepped. However, we need to bring our critical thinking about the context of care. This includes poorly funded care provision for low status ‘Cinderella’ services. Too much of the discussion of the failings in care do not take into account the political economy of care in societies and the historical antecedents that have brought us to where we are. Instead, we get discussions around changing ‘cultures’.
The political economy of care
Reconciling professional ideals to actual practice is very difficult given the organisational cultures many nurses work in, and the almost grudging support given to nurses by the political system set up by what the health sociologist Graham Scambler calls the ‘Corporate Class Executive’ (CCE) acting with the ‘Political Power Elite’ (PPE). The bottom line, and that is a phrase the CCE recognise, is that care costs money. The political context in the UK over the last three decades has been one of the application of ‘neoliberalism’ : this is the idea that markets always know best; the state should withdraw as far as possible from providing services; the cutting back of state regulation or keeping to what has been termed ‘light touch regulation’ such as that applied to the Financial services industry; and the emphasis put on individual freedom to choose how such things as health and education should be purchased. This has been a slow process starting with the selling of nationalised assets such as in the utility companies, council housing and railways alongside the introduction of markets within health and education. This project continues despite arguments that is it a failed economic model resulting in increasing inequalities, worker’s wages dropping in value and a growth in ‘precarious’ jobs (low wage, part time, zero hours). Culturally, neoliberalism focuses attention always on the ‘bottom line’ – how much does a service cost? The corollary is that if services are not profitable or that they require huge state subsidy then they should probably not be offered.
One of the critiques of the Mid Staffordshire NHS trust in the UK was that corporate self-interest was put ahead of patients’ safety. This illustrates the focus on the ‘bottom line’ rather than on public services. There have been many reports regarding the health and social care of elderly people and it seems to be that their needs are outstripping both private and public provision for them.
As governments embrace austerity policies, this tendency for capitalism to funnel resources, research and development into goods and services that make a return while ignoring public provision for those things that do not have immediate impacts on improving shareholder value or the price of stocks, increases. Care is seen as a cost and not a benefit to those who decide where the investments should be made. Private care companies will provide care only with an eye to the balance sheet. This may result in hiring under educated and poorly trained staff who too often lack supervision and development in high patient to staff ratios.
Does this mean that lack of compassion is directly related to economic policies? To accept that is to think in an overly simplistic cause effect relationship. Societies are more complex than that. Of course poor quality care pre dates capitalism and the NHS, however capitalism and its often hidden twin patriarchy sets the agenda and the organisational forms and institutional arrangements in which care takes place. This now means as budgets get cut and savings asked for, nurses as workers will be asked to provide more for less.
This has been always the case; nursing work as womens’ work has largely been invisible emotional labour which has been poorly paid and supported, instead their rewards have been patronising labels such as ‘Angels’. Nurses know what they need to provide care and they can do it if given supportive organisational cultures and the power to actually direct, organise and manage care properly. Roy Lilley argued that the Francis report 2013 into care failings in an English hospital,
“…talks about ‘culture change’. Effectively making the people we have make the services we’ve got, work better. On that basis Francis fails. What we’ve got doesn’t work. Never will. Think about it; nearly all the quality problems the NHS faces are around the care of the frail elderly. Why? Because the NHS was never set up to deal with the numbers of porcelain-boned, tissue paper skinned elderly it is trying to cope with. The NHS’ customer-base has changed but the organisations serving them have stood still…..Fund the front-line fully, protect it fiercely, make it fun to work there, that way you’ll make Francis history.”
And there you have it. Do the austerity addicts think it is the proper role of the state to fund the front line? No, they hanker after a US style private provision with the family, the big society volunteers and women to take up the slack. That will not wash in a hospital ward or a care home full with frail elderly patients.
Nurses do not work in a socio-political vacuum. However, one would think that they do if the content of curricula and the learning experiences planned are anything to go by. Indeed any discussion around political economy, patriarchy and capitalism is liable to be met with surprise, apathy, disdain apart from those engaged in teaching the social sciences in nursing. I would argue that nursing cannot shy away from addressing these questions. Nurses as women, who experience the requirements to care in both their domestic and public lives, bear the brunt of the demands of a society which needs that care to be done but is unwilling to fully fund it. It might be fair to suggest that since about the 1980’s both feminism and social democratic politics took their eyes off the ball or felt that because progress had been made the struggle was nearly over. It is not. We need to argue for the social value of care and against privatised individualised provision falling unfairly on the shoulders of those who often do not have the resources to provide it.
Caring is not sexy – it is not fancy infrastructure projects, it does not make millions at the click of a mouse; hedge funds and private equity firms don’t crack champagne bottles over the needs of the frail elderly. Care is unglamorous emotional labour, involves often dirty body work, offering little in the way of recognition and prizes – there are no Golden Globes, Oscars or Baftas. There is no end point, no project that is completed and shown off, no bonuses to be earned. Nurses are in a political struggle whether they realise it or not.
This section has outlined the context in which clinical nurses work and suggests that outside pressures impact on clinical care. It further suggests that clinical nurses need this political awareness to meet calls for value for money as health care systems come under funding pressures and the need to demonstrate quality services. Nursing leadership is therefore highly political and requires analysis and alternative critiques to be forcefully put forward.
The next section deals with a style of leadership and its relationship to working practices. A psychological and personal resource is discussed to consider how well we might be able to fulfil our role.
5. Transformational Leadership and ‘Self Efficacy’.
Transformational Leadership (TL).
In this section we are going to look at the concept of transformational leadership and the psychological concept of ‘self-efficacy’. Transformational leadership can be seen as a ‘relational theory’ of leadership due to its focus on interpersonal relationships.
“Leadership is ‘causative’, meaning that leadership can invent and create institutions that can empower employees to satisfy their needs. Leadership is morally purposeful and elevating, which means, if nothing else, that leaders can, through deploying their talents, choose purposes and visions that are based on key values of the workforce and create the social architecture that supports them.” (Bennis and Nannus 1997 p 202).
· Identify the regulatory and legislative frameworks within which this form of leadership has to operate. What laws and regulations govern clinical nursing practice?
· Can nurse leaders genuinely create the social architecture that supports them?
· What does social architecture actually mean?
Transformational Leadership (TL)
James MacGregor Burns first described these two distinct styles of leadership in his 1978 book, ‘Leadership’.
See Burns’ Transforming and Transactional leadership styles (http://www.businessballs.com/)
|Where the leader taps into his followers’ higher needs and values, inspires them with new possibilities that have strong appeal and raises their level of confidence, conviction and desire to achieve a common, moral purpose.
||Where the leader causes a follower to act in a certain way in return for something the follower wants to have (or avoid). For example, by offering higher pay in return for increased productivity; or tax cuts in exchange for votes.
There is a good deal of literature on these two styles and so it would be useful to access such works as:
Alimo-Metcalfe, B. & Alban-Metcalfe, J. (2001). ‘The development of a new Transformational Leadership Questionnaire’. The Journal of Occupational & Organizational Psychology, 74, 1-27
Bass, B. M. (1990). From transactional to transformational leadership: Learning to share the vision. Organizational Dynamics, (Winter): 19-31.
Bass, B.M. & Avolio, B.J. (Eds.). (1994). Improving organizational effectiveness through transformational leadership. Thousand Oaks, CA: Sage Publications.
Bass, B. M., & Riggio, R. E. (2006). Transformational Leadership (Second ed.). Mahwah, NJ: Lawrence Erlbaum Associates.
|What is Transformational Leadership? This is available on:
Transformational leaders are those who transform their followers into becoming leaders themselves. From Wikipedia: “Transformational leadership is a leadership approach that is defined as leadership that creates valuable and positive change in the followers. A transformational leader focuses on “transforming” others to help each other, to look out for each other, to be encouraging and harmonious, and to look out for the organization as a whole. In this leadership, the leader enhances the motivation, morale and performance of his follower group.”
From Bass and Riggio (2006, page 3), “Transformational leaders are those who stimulate and inspire followers to both achieve extraordinary outcomes and, in the process, develop their own leadership capacity. Transformational leaders help followers grow and develop into leaders by responding to individual followers’ needs by empowering them and by aligning the objectives and goals of the individual followers, the leader, the group, and the larger organization. Evidence has accumulated to demonstrate that transformational leadership can move followers to exceed expected performance, as well as lead to high levels of follower satisfaction and commitment to the group and organization.”
There are four components of Transformational Leadership (Bass, B. M. 1998 Transformational Leadership. New York: Lawrence Erlbaum Assoc, Inc.):
Idealized Influence (also known as Charismatic Leadership) – Transformational leaders act in ways that make them role models. They are respected, admired and trusted. Followers identify with them and describe them in terms that imply extraordinary capabilities, persistence and determination. These leaders are willing to take risks. They can consistently be relied upon to do the right thing, displaying high moral and ethical standards.
Inspirational Motivation – These leaders embody the term “team spirit”. They show enthusiasm and optimism, providing both meaning and challenge to the work at hand. They create an atmosphere of commitment to goals and a shared vision.
Intellectual Stimulation – a Transformational Leader encourages creativity and fosters an atmosphere in which followers feel compelled to think about old problems in a new way. Public criticism is avoided.
Individualized Consideration – Transformational leaders act as mentors and coaches. Individual desires and needs are respected. Differences are accepted and two-way communication is common. These leaders are considered to be good listeners, and along with this comes personalized interaction. Followers of these leaders move continually toward development of higher levels of potential.
· Think about the points above…are you able to identify someone you know who fits that description? If so, write down which ones apply and give examples.
The theory is that TL encourages ‘Self Efficacy’ and ‘work engagement’ leading to ‘Extra Role Performance’ (ERP).
“Positive personal and environmental factors increase work engagement which in turn increase specific positive behaviours such as ERP” (Salanova et al 2011 p2263):
- Does Transformational leadership encourage extra role performance?
- How does transformational leadership build on or develop a persons’ sense of ‘self efficacy’?
- What are the ‘positive personal and environmental’ behaviours? Describe them.
Extra Role Performance (ERP)
|Definition: ERP is behaviour which is not required as part of the formal job role, however it facilitates the smooth running of the organisation as a social system.
· What behaviour at work would you consider to be extra to your work role? Describe some of them.
Extra-role performance are certain behaviours of employees, which are not part of their formal job requirements as they cannot be prescribed or required in advance for a given job but they help in the smooth functioning of the organization as a social system.
Some of the extra role performance behaviours are: helping co-workers with a job related problem; accepting orders without fuss; tolerating temporary impositions without complaint; maintaining cleanliness and physical hygiene of the work place; promoting a work climate that is tolerable and minimizes the distractions created by interpersonal conflict; and protecting and conserving organizational resources etc. (Bateman & Organ, 1983).
Salanova et al (2011) suggests that there are two psychological mechanisms at work here, i.e. that TL does enhance ERP by establishing a sense of self efficacy and work engagement.
Bandura’s Social Cognitive Theory (SCT) suggests self-efficacy is one’s belief in one’s ability to succeed in specific situations. Therefore your sense of self-efficacy can play a very large part in how you approach the achievement of goals, tasks, and challenges. Social cognitive theory suggests that an individual’s actions and reactions in almost every situation are influenced by the actions that individual has observed in others. This includes our social behaviours and cognitive (thought) processes.
So, people with high self-efficacy, that is, those who believe they can perform well, are more likely to view difficult tasks as something to be mastered rather than something to be avoided.
They don’t fear failure but relish taking on new tasks.
Thus employee behaviour is a result of:
- a) personal resources (e.g. self-efficacy)
- b) contextual resources (e.g. Transformational Leadership)
- c) their personal motivation (e.g. work engagement)
Your role as clinical leader might be to work in such a way that you do not destroy your colleagues’ sense of self efficacy, that you work in a collaborative manner providing TL and that you understand your own motivation and that of others. Leadership then is a social process not a trait one has.
|Definition: Self Efficacy:
‘belief in one’s capacities to organise and execute the course of action required to produce given attainments’. (Bandura 1997 p3)
Those with SE:
· See troubles as challenges
· Have a high commitment to activities
· Invest their time and energy
· Reflect on your own levels of SE, how would you (or your supervisors) know if you have a high level of SE, what indicators are there?
How does TL do this? Salanova et al (2011) suggests:
- By fostering close relationships that have less distance despite power differences.
- By considering the individual needs and capabilities of staff.
- By creating mutual trust and openness
- Through the richness of verbal communication
- By using bi-directional feedback
- Through acting as role models so that others learn through the leader’s experiences (role modelling or vicarious experiences) and verbal persuasion (inspirational motivation and individualised consideration).
As you may note some of these may arise through personal characteristics and some can be learned or mentored by other transformational leaders.
|After examining the above aspects of TL, identify and discuss role modelling and verbal persuasion. Consider the generalisability of this study to your own experiences.
For Transformational leadership and staff retention see:
Read this for a critique of TL:
Hutchinson, M., and Jackson D. (2012) Transformational leadership in nursing: towards a more critical interpretation. Nursing Inquiry. 4th October
Transformational leadership has become a dominant leadership theory for nursing, but it has to be seen in its context. It fails to address the issues of power, politics, dominance and resistance in organisational cultures (Hutchinson and Jackson 2012). We have already discussed the public sector as a context, and later we will be addressing issues of gender and power relationships to illustrate how leadership may actually operate.
6. Trust as a core aspect of leadership.
Mullarkey et al (2011) argue from a review of the literature that trust between managers and staff needs fostering as it leads to empowerment and positive organisational outcomes. The argument is that nursing is a complex microenvironment entailing changes and pressures from various internal and external sources. Support is required to guide staff through this. But what does ‘support’ mean? What do Clinical Nurse Managers (CNMs) have to do to ‘support’ ?
- Staff need to see leadership skills in practice (role modelling/vicarious experience – a key part of TL?)
- CNM‘s need to provide support for personal issues: thus approachability, availability and flexibility using their ‘Emotional Intelligence’.
Fundamental to this relationship is Trust. There is a dearth of literature exploring this from the point of view of CNMs and staff.
Roots of meaning can be found as ‘faithfulness and loyalty‘.
Cherishing alliances, building good relationships, uplifting lightness, motivating others and staying positive, pressing on resolutely with potential adversity seeking to attain your vision.
Trust is a process, involving a relationship where there is vulnerability, expectation on others and giving of self.
Definition: “a willingness to engage oneself in a relationship that has reliance upon either a person(s) or thing(s), with an expectation that vulnerability may arise from either the trustee’s or the truster’s performance. The primary aim, however, is to provide empowerment to both parties” (Hams 1997).
Take a few moments to reflect on that definition. Can you think of examples in clinical practice that illustrate all of the dimensions:
What fosters trust in the workplace?
Arguably ‘Trust’ arises from confidence in and perception of competence, technical skills, social skills, plus a belief that the trustee is working in the truster‘s best interest.
We might suggest that a nurse exhibits traits of trustworthiness through a:
- display of listening skills
- by showing respect
- though caring
- by honesty
- ensuring confidentiality.
In addition we might think that fostering trust by CNMs requires 5 specific characteristics:
- emotional stability
- outgoing personality (extraversion)
These last three relate to the big 5 personality traits: OCEAN. If this is the case knowing who you are may indicate the degree to the level of trustworthiness you have.
See http://www.outofservice.com/bigfive/ or
https://www.bbc.co.uk/labuk/experiments/personality/ for your own online test.
- Openness indicates how willing we are to explore new ideas and ways of doing things.
- Conscientiousness indicates how well we plan and exhibit self-control.
- Extroversion indicates our desire for stimulation.
- Agreeableness indicates how easily we get along with others.
- Neuroticism indicates how we deal with negative emotions such as stress and anxiety.
(image source: BBC)
Reflect on your personality type are you able to identify, accurately, where you fit on the BIG 5 scale? What may this say about you own trustworthiness? Would the people who know you recognize your own description of yourself?
Trust relies on fostering relationships, having good role models, engagement with staff energies and creativities. These 3 are components of TL, therefore TL has trust as core component.
This section ends on the issue of work stress and health. It might be clear by now that good working social environments and personal relationship are aspects of TL. This suggests that a focus on getting the work done (transactional) may fail to pick up on the health and stress impacts of working environments. In an organisation that is directed to achieving work targets rather than worker satisfaction this might not matter in the short term. However a transformational leader will have this in mind.
Work and Health.
The Whitehall studies (Marmot 1967) suggested that an important factor for a person‘s long term health was that of control over one’s work.
The less control one has the more likely one is to suffer serious illness in later life.
The study showed that men in the lowest employment grades were much more likely to die prematurely than men in the highest grades, having less autonomy over their role. Furthermore, these socio-economic inequalities in health did not appear to be fully accounted for by differences in well-known risk factors, such as smoking.
A Finnish study was conducted in a cohort study similar to Whitehall, but with greater analysis of the worker’s stress. The study determined that decision autonomy was not a significant contributing factor to coronary heart disease, but that lack of predictability in the workplace was a significant factor. In the Finnish study, “predictability” was defined as high stability of work and lack of unexpected changes, and was found to correlate closely to employment grade (Vaanane et al 2008). Others argue that because there is a strong correlation between low employment grade and domestic stress, stress from a lack of control at work cannot be the whole story (Yarnell 2008). In this line of reasoning, the size of one‘s paycheck alone could significantly contribute to overall stress. Those with fewer resources have a harder time making ends meet, a situation that can be a tremendous source of chronic anxiety.
Comparative psycho-social stress and social inequalities have been strongly implicated in a range of unequal health outcomes between socio-economic groups in many countries (Marmot 2010, Wilkinson and Pickett 2009).
Whatever the exact mechanism, evidence is mounting that work conditions and associated socio-economic position has health and disease affects. So ‘stress’ from lack of control, lack of predictability or low pay is a work related issue.
That is to say that important work factors can impact on your health and wellbeing.
For further evidence and work on this see: ‘Five Ways to Wellbeing’ published by the New economics foundation: http://www.neweconomics.org/projects/five-ways-well-being
Clinical leadership that does not address these issues miss very important aspects of working life, but to what degree can nurses address these wider determinants of health?
So far we have discussed leadership from the perspective of the individuals themselves.
However there is a need to consider the organisation itself and ask whether organisational cultures support or hinder the exercise of good leadership. Do organisations need to change? Is it reasonable or fair to expect individuals to become leaders in poorly run organisations.
7. Leadership Development and Organisational Change.
“Too much emphasis on leadership without an equal concern for transforming the organisations nurses…work in, may result in leadership being added to the list of transient management ‘fads’ which have characterised health care in recent years” (Hewison and Griffiths 2004).
In the UK and the US there has been a drive for developing and improving leadership within healthcare organisations especially focusing on the development of skills for nurses. The goal of course is to improve the quality of patient care. Has this worked?
Large et al (2005) conducted an evaluation of a large Clinical Leadership Programme (the Clinical Leadership Programme started in 1994). They gathered data from 16 healthcare organisations. A clinical leader at each of the 16 locations was selected for the study. In addition, 36 service users from the clinical areas of these leaders were selected, along with 14 directors of nursing and 15 local facilitators, to help assess the effectiveness and impact of clinical leadership development. In total, 143 key stakeholder interviews were undertaken at case study sites.
“The most significant finding of this study is the positive change that took place in the leadership capabilities of clinical leaders. Overall, clinical leaders were more confident in their leadership approach and showed a greater sense of value and optimism about their clinical roles. All described an increased commitment to improving care for service users and developing team effectiveness. This was illustrated in the team goal setting and action planning described by clinical leaders, colleagues and directors of nursing. The study’s findings clearly demonstrate that clinical leaders can be empowered to influence the provision of care. Their new leadership strategies promoted better alignment of the team, which in turn helped increase team effectiveness. This was reflected in the improvements in service user care and clinical practice that emerged”.
As a practice-based development programme, the CLP provided a toolkit of interventions to support experiential learning for the programme participants.
- 360-degree review • Personal development planning • Mentorship
- One-to-ones with local facilitators • Action learning • Needs led and intervention workshops
- Patient stories and observations of care • Shadowing • Teambuilding • Networking
Therefore any generalisations from leadership programmes from this study must take into account the actual interventions and multiple measurements involved.
However, it was previously suggested by Edmonstone and Western (2002) that there was confusion among the CLP participants as to the appropriateness of programmes for some staff with insufficient discussion around what Leadership Development (LD) is in the NHS. Further, Hewison and Griffith (2004) suggests that the evidence for the success of LD in health is at best ambiguous and has to be seen as only one element in the changes that need to occur in healthcare.
Hewison argued (2011)
“The focus on leadership as a solution to the organisational ills of the NHS remains. However much of this is rooted in assumptions that producing effective leaders will result in improvements in management and organisation. I think this is too simplistic and does not take account of the evidence. Although it is part of the solution, the NHS is so organisationally and relationally complex that other substantial issues need to be addressed”
The evidence suggests:
- The need to establish baseline measures of leadership effectiveness.
- The need identify specific organisational benefits (if possible) of CLPs.
- The need to report specific impacts of CLPs on the delivery of care.
- The need to clarify the link between changed behaviours (e.g. delegation, using articulated expectations and planning ahead) and patient outcomes, organisational goals.
Is it possible to identify clear links between inputs (CLPs) and outputs (various)? Do we have to change assumptions about identifying what works? If we do, how will this sit with managers charged with delivering measurable targets?
It is also to the nature of organisations in which nurses work that requires attention. Leadership is just one aspect of a much wider context.
|What does an organisation feel like to work in? Consider your own experiences: How would you best describe your relationship to senior management:
1. How are strategic decisions made?
2. To what degree do you feel that establishing of order and control over work patterns and decision making is important for managers?
3. How does change come about, does it come from planned projects from managers or does it emerge from the floor?
4. To what degree do you have a shared vision for the organisation? Is it explicit, is it communicated to you by management?
5. How important is it that you conform to organisational practices, how is challenge to current organisational practices dealt with?
6. To what degree is learning new methods of care organisation and delivery and cultures encouraged?
7. How quickly does you organisation react to change and handle differences?
8. What levels of proactivity by staff are encouraged?
9. What metaphor would you use to describe how your organisation works? (For example, an oil tanker, slow to turn around when directional change is needed and on which the captain is in charge).
Leadership as already argued operates in a context. This context includes organisational cultures and practices. So we need to think about what types of organisation we work and how we can affect changes in culture and practices.
Photo by rawpixel.com on Unsplash
Faugier and Woolnough (2003) describe three ‘types’ of organisation:
- Leadership within my organisation is generally driven by senior management to establish order and control. Strategic decisions are made through a formal planning process. Change is planned and programmatic. Employees…feel like a cog in a wheel.
- My organisation has a shared direction about the future. Leaders and employees all ‘sing from the same hymn sheet‘. The organisation encourages conformity but discourages challenging and learning.
The living organisation.
- My organisation acknowledges unpredictability and difference and constantly adapts to the environment in which staff are encouraged to challenge and progress.
Faugier and Woolnough in their study found respondents (38% response rate from 12,000) stated their workplace was:
A Machine: 45% of respondents
A Choir: 9.1%
A Living Organisation: 30.3%
“If these results are considered with responses concerning senior managers, we may have some serious work to do to ensure clinical staff feel engaged and empowered. So many clinical staff feel like cogs in a wheel and the levels of disengagement and disillusion are so high that the implications for patient care are obvious”
Leadership thus has to operate as one element only in a complex healthcare system.
- In a public sector organisation clinical leaders cannot easily affect, or redefine public policy or legislation set by politicians.
- Nursing culture may inhibit leadership development: has nursing got the respect of the public, politicians, policy makers and other professional groups?
- The focus on developing the person, competencies and traits (often based on male assumptions about what leadership looks like) may be in conflict with the exercise of leadership that focuses on relationships (shared leadership) within complex organisations.
- The ratio of professional nursing staff to nonprofessional staff requiring training, supervision and regulation by clinical leaders.
- Health care organisations may be risk averse and heavily regulated which counters leadership development that encourages risk and creativity (e.g. transformational leadership)
- Healthcare organisations must create the conditions which support and enhance new models of leadership. A key message is that we need to demonstrate that leadership training is directly linked to identified patient outcomes, can we say with certainty that the patient experience is improved when we train nurse leaders? Is this too simplistic a question?
The last point however is hampered by the difference between clinical leadership and managerial leadership with the context of ‘disconnected hierarchy’ in professional organisations (Edmonstone 2009).
There is a view that there are competing ideas about what clinical leadership is, what professional values and assumptions it is based on and how this contrast with notions of managerial leadership. Managerial leadership may have very different assumptions and values about how healthcare is delivered. (Edmonstone 2009)
|Read and discuss “clinical leadership: the elephant in the room” Edmonstone 2009 http://www.ncbi.nlm.nih.gov/pubmed/18770874
1. What is meant by clinical leadership as opposed to managerial leadership?
2. Discuss the notion of the disconnected hierarchy.
3. What are the problems of general management?
4. Outline and discuss the differences between unitary and pluralist views of organisations – how do these descriptions fit the ideas of machine, choir and living organisation?
5. To what degree is the argument presented applicable to your context?
This section has addressed the context in which people have to work and considered leadership operating in certain types of organisation. We need to consider whether leadership training is linked to better patient outcomes, we need to think about the organisations leaders have to work in and we have to consider if clinicians and mangers have different goals, values and assumptions?
Next we examine the relationship between professional groups in clinical settings to think about how professional cultures and assumptions affect interprofessional working
8. Developing self: Critical Reflexivity.
A concept to get you thinking about your thinking: critical reflexivity which then relates to action or inaction based on a reevaluation of values, norms, beliefs and attitudes. First, a short discussion on reflection and reflexivity, because these terms are sometimes interchanged.
An Invitation to Social Construction (2009) by Kenneth Gergen introduces reflectivity with the following explanation:
“Critical reflectivity is the attempt to place one’s premises into question, to suspend the ‘obvious’, to listen to alternative framings of reality and to grapple with the comparative outcomes of multiple standpoints…this means an unrelenting concern with the blinding potential of the ‘taken for granted’…we must be prepared to doubt everything we have accepted as real, true, right, necessary or essential”.
All good stuff. This is central to the task of many social sciences and should apply especially in nursing theory, education and practice. Just because it has been taken for granted that we transfer old people at two in the morning does not mean we have to accept that reality, or accept the standpoint of the decision makers for such transfers. We might want to listen to the alternative framing of that event as disruptive and fearful, and question if it is right, necessary or essential.
Critical Reflexivity takes this to the next step; to examine how one’s own status, role, gender, class, profession, occupation, ethnicity, and socialisation affects the development of norms, values, beliefs and attitudes, how all of that feeds back into how one acts in society and culture, to reconstruct society and culture in a dialectic relationship between culture and self. To be reflexive is to attend to one’s own standpoints to critique them, to be aware of how they were constructed, to enable change and the potential reshaping of self. It understands how one’s thinking can be socially structured but not determined, how it operates and how it may lead to courses of action. It is linking culture with self, seeing that culture flows through self and that self both constitutes and is constituted by culture.
If a realization dawns that one and one’s colleagues have transferred old people after midnight as a matter of course, as routine, as accepted practice, this may lead to consideration of that practice and perhaps the seeking of alternative courses of action along with cost/benefits of alternative action, including upsetting colleagues or transgressing managerial targets.
Importantly however Reflexivity leads to an examination as to why one acted in the way one did. It may be that one has been so socialized into that practice that it never comes up for critical examination.
Another example: A reflexive student nurse may realise that she has a common response in group work: to leave the leading of that group to others. Critical reflexivity may reveal what the roots of that attitude and behaviour are. For example, she might consider that her gender socialisation that valued and rewarded subservience, that labelled ‘assertiveness’ as unfeminine, was so strong that she internalised this view and has been acting out that patterned behaviour for a number of years. Here immediately is a challenge to critical reflexivity: is this level of self critique too difficult? If it is not, might it raise a terrible realization that change may be too difficult, costly or impossible?
In the mental health domain, the ‘obvious’ and ‘taken for granted’ may be the background assumptions, values and epistemologies of biomedical psychiatry, or of cognitive behavioural therapy. The mental health nurse who uncritically accepts the tenets of either may not be sufficiently critical of the outcomes of much of ‘standard’ mental health practice. Alec Grant, Reader in Narrative Mental Health, argues for example:
“Mental health nurses and other state psychiatric workers are systematically stripped of their capacities to be kind through, among other things, being neoliberalised, classed, gendered, Psydisciplined, and socialised to institutional psychiatric custom and practice” (Grant 2015).
It matters not whether one agrees with Alec, critical reflexivity requires examination of base assumptions, and how one’s own experiences and culture shapes one’s assumptions. Again, realizing one’s embeddedness in certain practice cultures and epistemologies may have both negative and positive cathartic effects?
Margaret Archer’s ‘Modes of reflexivity’.
Graham Scambler (2013), in wishing to establish a theory of agency in sociology argues:
“Humans…are simultaneously the products of biological, psychological and social mechanisms while retaining their agency…socially structured without being structurally determined” (p147).
Who, and what, we are arises socially, as well as from our physical biological selves, as well as from our psychological thinking and motivations. Society structures who we are without determining who we are. Family life structures us – giving language, culture, hopes and aspirations but does not determine these aspects of ourselves. There is room for agency. A clinical setting structures us – giving us a language, a discourse, acceptable modes of professional behaviours and explicit values, for example the 6Cs.
Margaret Archer argues:
“reflexivity mediates between the objective structural and cultural contexts confronting agents, who activate their properties as constraints and enablements as they pursue reflexively defined ‘projects’ based on their concerns” (Archer 2010).
The way a student or a NQN thinks about a course of action in any given clinical context will be manifest in what they do, what aims they set themselves and based in how they see their abilities, options and constraints.
Obese and overweight people choose ‘freely’ to eat more than they need, but they do so within the structure of the obesogenic environment. Nurses choose ‘freely’ to discharge vulnerable older adults, but they do so within the structure of certain management and interprofessional environments.
So we need to see that agency works within a context, e.g. a religious family, in which the social outcome is structured by that family but not determined by it. This happens in the following way:
- The family provides the external, objective situation and context which the free agent is then confronted with. The agent does not have a choice about this. The family provides situations of constraint and opportunities for the ‘agent’. This objective situation operates in relation to…
- …the agent who has their own internal, subjective concerns in relation to physical nature, social realities and cultural practices.
- The action undertaken by structured free agents, in this case children, are produced by ‘reflexive deliberations’, i.e. internal conversations, about the situation and their own concerns.
- The clinical practice setting provides the external, objective, situation and context which the nurse as ‘free agent’ is then confronted with. The agent does not have a choice about this. The clinical setting provides situations of constraint and opportunities for the ‘agent’. This objective situation operates in relation to…
- …the nurse who has their own internal, subjective, concerns in relation to their personal nursing theory and values (Biomedical? Humanistic? Recovery? Family Centred?), social realities (the doctor-nurse-management relationship) and cultural practices (e.g. managerial control practices).
- The action undertaken by structured free agents, in this case nurses, are produced by ‘reflexive deliberations’, i.e. internal conversations, about the situation and their own concerns. Nurses determine their choices of practical action in relation to their objective circumstances.
Margaret Archer (2003, 2010, Scambler 2013) argues that the interplay between our internal concerns and our social and environmental contexts is shaped what she calls a ‘mode of reflexivity’. A ‘mode of reflexivity’ is the manner in which we think about our thinking, our ‘inner conversations’ that then shape our actions. Archer then outlines 4 ‘ideal types’ of modes of reflexivity:
- Meta reflexivity: our inner conversation is subjected to our own criticism. We may then critique whether effective action is possible before we act. This is about self-monitoring, our thinking about how we think, and when dominant results in self questioning such as ‘why did I say that?’, ‘why am I so reticent to say what I think?’ This mode of reflexivity may be what I am calling critical reflexivity.
- Autonomous reflexivity: our inner conversation requires no confirmation with others, they are self sustained and lead directly to action. Here we have a ‘lone inner dialogue’ which leads to action.
- Communicative reflexivity: our inner conversations require confirmation and communication with others before we act. A nurse who is predominantly uses communicative reflexivity will consider what their peers are thinking and will want to act in such a way as to fit in.
- Fractured reflexivity: our internal conversations intensify the disorientation and distress we already feel and this leads to inaction.
Critical reflexivity. In Margaret Archer’s typology this is ‘meta reflexivity’ (MR), understanding who I am and why I think and then behave as I do and to question the basis of that thinking. One considers such things as gendered patterns of thinking, or class based patterns of thinking, or the possibility of heuristic thinking and our propensity to use emotion when reasoning. It means understanding perhaps ‘ego states’ and how we can be called into subservient ‘subject positions’ by powerful others. The MR, when considering what to do and before doing it, tends towards the perpetuation of ‘rumination’ considering alternative answers or different ways of looking at the question.
For an MR nurse, one may think about such things as professional and organisational patterns of thinking and how this shapes one’s own thoughts and actions. Taken to extreme this may lead to self-doubt and inaction.
Meta reflexives are values driven over and above considering outcomes or consensus. Meta reflexives think about whether there is a correct course of action, what drives thinking before action, and whether their own thinking is free from bias, cognitive errors, or delusion. Meta reflexives will consider paradigms and epistemologies that underpin professional practice. They will seek out an understanding of power structures and ethical positions.
In many clinical areas the pressure of work, managerial demands, time constraints, procedures and power structures militate against meta reflexivity. Socratic questioning would be an unaffordable luxury. The meta reflexive NQN in this context could be seen as a nuisance, idealistic, time wasting, inefficient and unrealistic. Meta reflexivity may also come at a personal cost. Greater understanding may lead to a realisation that one’s personal agency is limited. Yet, without it we may end up doing “what we’ve always done”.
In educational settings that focus on competency and skill acquisition, rooted in instrumental rationality and biomedicine, MR runs counter to the need for learning procedures, processes and facts. It also runs counter to the epistemology of much of evidence based practice rooted as it is in often taken for granted empiricism. In clinical practice where the focus is on getting the work done, a student operating within MR may run the risk of ‘not fitting in’.
When a NQN does not challenge the discharge of a vulnerable patient, when the care pathway is clearly poorly thought out or is nonexistent , whose interests feature in their thinking? Is a NQN able to critically reflect upon the whole process to understand why they have just colluded in a system that is systemically abusive by default if not by design?
An ‘autonomous reflexive‘ does not stop to consider how their decisions will be thought of by others, they act because they think it is the correct course of action for themselves. They may well delude themselves it is for the good of others. They act decisively, trusting themselves sufficiently to commit to the conclusions they have come to. They are outcomes driven, over and above issues of value and consensus. These outcomes must align however with their own interests. If an AR has a ‘bank’ of critical theory and meta reflexivity to draw upon they may fearlessly challenge power structures and ways of doing things unafraid of personal consequences. However they may in all likelihood not engage in meta reflexivity and thus don’t have this benchmark of critical self analysis. They do not consider it useful to think about what other people think of them or their action. If the AR does not have this political-philosophical ‘bank’ they operate within their own interests and ethical standpoints that support them.
The AR can be a leader for change, they can be disruptive of social orders, they don’t consider the emotional needs of others necessarily as relevant. They can be focused on particular goals whether they be good or ill. They do not require the validation of others before they act. Their thinking is self-referential, that is they refer to themselves for judgment as to the worth of acting. They may reinterpret professional codes, and ethical practices, to fit in with what they have decided is right. They may use manipulative measures to steer other people into action that meets the AR’s interests. Coaching and counselling skills would be very useful to the AR in meeting their own ends in this regard. Student nurses who display AR may have experienced criticism, and chastening during their education, as they don’t play by the rules just because they are rules.
The NQN who is an AR may have developed a thick skin, and my act according to whatever rules they see as right. If the discharge of a vulnerable patient is viewed as being in their own interests (if the following fits their goals: the work gets done, the team is appeased, management targets are achieved, it makes them feel good) then they will just get on with it. If the AR’s interests are in line with patient’s interests, include acting with an ethical code that puts the vulnerable patient first, over and above the needs, wishes and requirements of the team, the management and the process, their action will gladly disregard what others think.
Communicative reflexives consider the needs, wishes and thoughts of others. They will require validation by other people before acting. They rely on trusted others to complete and confirm their tentative decisions. They consider how any action will affect other people, and the opinions of other people become very important. They are consensus seekers and value this over and above outcomes or values. They refer and may defer to others’ thinking and action and will not readily rock the boat. They are team players and value the smooth running of the team even if that team has lost sight of the purpose of action. Leading change will be through consensus building rather than personal affirmative action. At worse they may collude with what Arendt called the banality of evil (‘not thinking’).
The context of many clinical placements for the student nurse will affirm consensus and validate the thoughtful consideration of other’s needs. Mentors may look favourably upon a CR if the boat is not being rocked. They are particularly open to professional socialisation and developing the consensus of professional identity. A NQN working in a toxic clinical environment may well feel unease, but if their CR is dominant they may be very reticent to challenge and fall back on post hoc rationalisation for action that may be sub optimal.
There is one last mode: the fragmented reflexive. One’s thinking is so disoriented and unclear that thought and action are difficult or impossible. Thinking about action or the matter at hand brings them no nearer to an answer, this then intensifies the feeling of distress. Values, consensus or outcome thinking is secondary to personal survival in an uncertain world. FR may be rooted in mental health problems, psychological disturbances or disadvantaged social status. The FR requires someone to lead them, to look after them, to tell them what is right. If they are ‘high functioning’, self caring and independent living, they may require a good deal of supervision and control to prevent harm to themselves and to others. Occasionally a student nurse gets recruited with a degree of FR. A NQN, if they got that far would be a danger to themselves and to patients.
So, we have internal conversations. Our inner speech is rapid and often contracted into single words or phrases that contain a rich complexity of meaning. Words and phrases have, in Archer’s phrase, ‘semantic embedding in our biographies’. The word below: ‘lifeworld’, has a rich meaning to sociologists but means relatively little to others. The word ‘compassion’ has recently undergone a change in its richness of meaning as it newly embeds into the biographies of nurses. For student CR’s: if we need to confirm our deliberations with other people, we need those to whom we express our thoughts to ‘get it’, they need to share our ‘lifeworld’, to ‘know where we are coming from’. If they don’t, then we have a personal trouble. If they do ‘get it’, dialogue is smoother.
Biographies however are not individual, we live them out with others in a context. This context becomes a ‘contextual resource’. Biographies become ‘intertwined’ (student/mentor) in which the idiosyncracy of shared meanings also become intertwined. This eases the sharing of inner conversations because we all share that idiosyncratic meaning. Hence we talk in short cuts, in jargon, half sentences. Archer calls this shared biographical context ‘similars and familiars’: “they speak the same way, share the same meanings, draw upon a commonwealth of references and a common fund of relevant experiences”. This might be what Tuckman referred to as the norming and performing stage of team dynamics. Archer calls it ‘contextual continuity’.
For a young nurse confronted with new decisions, such as her role and function in a new clinical placement, this contextual continuity is a resource. Engaging in CR, the students’ internal conversation searches for many variations on important questions: ‘what matters here? ‘what should I be doing ? How should I speak to patients or seniors?’ If this inner conversation is shared with ‘similars and familiars’, there may be confirmation and completion of the inner voice’s questions. If there is regular acceptance of the students’ expression this makes for a context in which communicative reflexivity can flourish; a student whose reflexivity starts with an inner conversation but is finished only when initial conclusions have been confirmed through external dialogue.
However, if the context is ‘discontinuous’ from the students’ own biography, there are no ‘similars and familiars’ who share the same lifeworld, there may be serious consequences. For those who learn that their inner conversations make sense only to themselves, attempts at expressing inner conversations may then be rebuffed by incomprehension or misunderstanding. Efforts at making oneself clear may involve self exposure, continued failure to communicate may well be hurtful and result in defensiveness. One may resort to withdrawal.
The neophyte CR and AR nurse will have to navigate these difficult waters differently. It might well be that the AR will resist the misunderstanding and the rebuffs and continue to answer her inner conversations in her own way albeit within the very real constraints of power, not the least of the mentor. Again we may hypothesis that a CR will try to fit in and learn what the ‘similars and familiars’ actually are, thus appeasing and pleasing mentors far more readily.
What is your inner voice saying?
A note: these are ideal types of reflexivity and may be open to change within certain role sets and status. The status of Clinical Manager may be more fertile ground for an AR to flourish, if it allies with a role set that is based on command and control directives. The status of student nurse may be fertile ground for the CR to flourish especially if its role set includes the giving of ‘compassionate care’ and meeting the emotional and physical needs of others.
The professional context in which whistleblowing is a very dangerous activity, in which parallel hierarchies prevail, where stress, burn out and high turn over is prevalent, where high patient acuity and demand is common, in which care pathways are absent, poorly designed, supported and resourced, in which clinical leadership runs in parallel with managerial leadership, in which risk management and rational action based on managerial demands take priority, in which resources are scarce, in which skill mix and professional cultures are damaged, where clinical leadership is either absent or denigrated, all of this will affect one’s reflexivity and thus one’s actions.
Any NQN who cannot even begin to think about this (the non meta reflexives) will probably be socialised into certain practices and take their lead from those they work with. An hypothesis is that many students come into nursing already as communicative reflexives and thus are vulnerable to social, professional and political pressures. Positive comments of the student’s practice by mentors are not necessarily, and always, oriented to evaluations of the students’ leadership capacities. Many mentors themselves may lack leadership qualities and critical reflexivity and thus do not have the tools of analysis to engage in this.
These modes are ideal types and a critique is that they need empirical verification and require embedding into the complexity of human experience. For example, already mentioned is a consideration of status, role set and organisational context. In addition we may need to consider psychopathy or other mental health issues for why we act. We need also to consider that we are social and relation beings with personal narratives and that this impacts on how reflexivity is manifest. When exercising clinical leadership, it may assist a nurse’s personal and professional development to consider what their inner conversations actually are, to lead them rather than be led. If there is a tendency always to get thoughts verified by others before acting, and to worry about what others may think of ones actions this may need addressing. Similarly, if there is a tendency to act without the consideration about the impact of that action on others and self, then personal development may be required. A problem may be that this will also require what Peter Senge calls a ‘learning organisation’ to allow this to flourish.
Exercise: DISCUSS and devise a series of questions that may assist in personal reflection upon our own modes of reflexivity, are we able to identify whether this applies to us, in what context and in what role? Are we able to identify educational practices and practices in the clinical environment that foster certain modes? Are student nurses able to develop self analysis of this nature and then work on this understanding to communicate better in the clinical and personal environment?
This may be tested in class first by outlining what ‘modes of reflexivity mean’ and then facilitating discussion on what this may look like in practice followed by personal reflection on their own dominant mode. This work could feed directly into a PDP and SWOT analysis.
To what degree do you agree with the following statements?
- I often act before really thinking about how my actions will be interpreted. AR
- I may be slow to decide what to do because I’m thinking about my colleagues needs or feelings. CR
- I often think about how my gender should act in a situation. MR
- When I know how my colleagues interpret my actions, I still go ahead. AR
- I really value what my colleagues, peers and family think of me and this can restrain my action. CR
- I often wonder why colleagues say and do the things they do. MR
- There is often a right and a wrong way of doing things, and I’m pretty sure I know what they are. AR
- It is very important that the team gets along and works together. CR
- It is very important to know where one’s values and assumptions about practice in everyday clinical settings come from. MR
- Getting the work done, making the patient’s journey complete is far more important than ensuring a decent team spirit. AR
- Team values, cohesion and lack of conflict are very important. CR
- Getting the clinical philosophy clear and setting out value positions must take a high priority. MR
- I rarely act without discussing things first with colleagues. CR
- Other’s feelings, interpretations of my action are of secondary importance to achieving the goal of patient care. (AR)
- There is little point in considering what epistemologies underpin practice guidelines, I’m not even sure what epistemology means in any case. AR
These questions are for discussion only. It is of course the case that answers to this may reflect espoused reflexivity rather than reflexivity in action in a clinical or personal capacity.
9. Gender issues.
A ‘typology’ of gender characteristics in health care.
|Directive leadership styles
|Focus on mistakes
There is an argument that there are gendered dimensions to knowledge and understanding and clinical practice (Sundin Huard 2001). There are differing epistemologies, that there is a feminine psychology (e.g. Gilligan 1982). These differences are experienced as definitions of management and leadership, how leadership is exercised, who gets the authoritative positions and what methods are adopted in working with others. These differences also affect what the goals of care are. The gendered ways of knowing are not specifically and only related to one‘s actual gender. Men can adopt female thinking and vice versa. An argument is that two main health care professions are gendered in their epistemologies and this is mirrored in the management – nursing relationship.
Kanter (1977) theorized that groups with differing proportions of men and women behaved very differently, thus gender ratios in organisations are important aspects of understanding group dynamics and processes, however care has to be taken to include differences in national cultures as we have a great deal to learn about gender differences across cultures. (van Emmerik et al 2010).
There is a suggestion that men and women approach leadership from very different values and behaviour patterns Two basic constructs to describe leadership behaviour based on the Ohio State approach are:
- Consideration: friendly and interpersonally supportive supervisory behaviour. Creating a supportive environment of warmth, friendliness and helpfulness, by being approachable, looking out for the welfare of the group, doing little things for subordinates and giving advance notice of change.
- Initiating structure: emphasis on assigning tasks, specifying procedures to be followed, clarifying expectations of subordinates, scheduling work to be done.
It is suggested that leaders can be placed on a continuum between consideration and initiating behaviour (Stogdill 1963 in van Emmerik et al 2010). There is belief that women adopt consideration behaviour and men adopt initiating behaviour. Women may adopt more interpersonal styles but only in female industries, in male industries they may adapt their behaviours or because they are selected by men in those industries.
van Emmerik et al (2010) studied the leadership behaviours of 12,546 managers (73% men – 27% women), in 437 organisations in 32 countries. They found that where there are relatively higher numbers of female managers this is associated positively with consideration behaviours, male managers in organisations with more female managers tend to engage less in initiating structure, but this does not hold for women.
Consideration is used more globally than initiating, indicating a feminization of management, but both leadership styles are adopted by women. They conclude that individual differences (gender) are more important than organisational societal differences when explaining leadership behaviours. However care has to be taken not to extrapolate to all cultures and more work has to be done to explore other variables (modernity, economic wealth, political systems).
Photo by Jad Limcaco on Unsplash
In what ways do men and women think differently, if at all?
The argument here tends to focus on those positions where authority in established leadership positions are formally acknowledged (a form of managerial leadership). Clinical leadership exercised at peer to peer levels may not manifest as quite so gendered.
Killeen et al (2006) focuses on aspirations and how men and women see themselves as leaders. The study uses the auto industry as an exemplar of a male industry and clothing as a female industry. In a comparison of responses within the US and Spain they argue that:
“more important than…sex, was the responsiveness to an organisation’s male or female context (cars or clothes), role, hierarchy and the national contexts…young women have more difficulty than young men in projecting themselves into the future as an organisational manager”
However, this picture gets complicated when the industry and managerial level is taken into account. In line with ‘Role Congruity theory’, females regarded managerial careers more positive in the clothing industry and males the reverse. This does not extend to the CEO level where either gender would regard this as positive (although unlikely).
The barriers that flow from women‘s doubts that leadership roles are possible for them may be more general, not just an inability to see themselves in high-level positions. The idea that the unequal domestic division of labour (and the cost of child care) dampens women‘s hopes that they can gain managerial roles is supported.
In Spain, where they suggest that the status of women as employees is not as high as in the US, men evaluated the managerial roles more positively than women, whereas in the US there was no difference. Is there a greater perception in Spain than in the US that managerial roles are male roles?
They conclude that women in both countries have a weaker sense of possibility, rooted in a belief that leadership roles may cause problems for close relationships (which they value more highly). Role congruity theory would suggest that there is a self-selection process, as women perceive more positive roles for themselves in ‘female‘ industries. In both cases women took into account the future changing world as giving women more opportunities and access to leadership roles in an era of increasing gender equality. There, however, remains a sense for women that there is a trade-off between powerful occupational roles and achieving good close relationships.
Santamaría et al (2008) demonstrates that there are very few women in top positions at both Barcelona (Hospital Clinic) and Hospital de la Santa Creu i Sant Pau (HSCSP). And that this probably represents other Spanish hospitals. In a medical context women are underrepresented:
- As first authors of original research
- On research ethics committees
- On editorial boards of major medical journals
In 2007 a law was passed for gender equality to enable opportunities for both genders. This paper suggests that there is a long way to go still.
· To what extent is hospital management ‘male‘ and thus less attractive as an option for women?
· To what extent do nursing values either help or hinder the development of a female leadership role?
Patriarchy comes from two Greek words – patēr (πατήρ, father) and archē (αρχή, rule). It describes the structuring of a society the basis of the family. Traditional families pass on lineage through fathers. On this basis it is considered have primary responsibility for the welfare of the family. The concept of patriarchy is now often used to refer to the expectation that men take primary responsibility for the structuring of society, acting as representatives through public office. There is a hierarchy in the family and thus in society.
Patriarchy is seen as an ideological system which has come to be defined as a form of male dominance. Or, more specifically, an ideological structuring of society whereby certain members of society (men) believe themselves in positions of dominance over others.
(see Simone de Beauvoir (1949) The Second Sex and Germaine Greer (1970) The Female Eunuch).
Sweet and Norman (1995) undertook a selective literature review of the nurse-doctor relationship in the context of the history of patriarchal relationships. They concluded that, while much has been written generating anecdote and opinion, there had been little empirical work to establish an evidence base around the impact of patriarchy on this relationship. They cite some empirical work, Heenan (1991) and Mackay (1993), which suggested dissatisfaction and poor working relationships amongst nurses resulting in negative consequences for patients, but much is of this is over 10 years old since publication. They argue that the relationship is characterised by each profession having ideal expectations of each other which are not always met. The hospital setting and clinical speciality may also impact on how doctors and nurses work together. They also suggest further research would benefit both parties in the attempt to highlight strategies which reduce the potential conflict inherent in the relationship.
Tyke (2004) a practice nurse stated:
“I have often wondered why men choose to specialise in gynaecology. A rather outspoken friend theorises that they have to be either perverts or women haters. Misogyny has always run rife in medicine, says she, because of a patriarchal society that suppressed women. Physicians were traditionally men with power and status (not much change there, then). Women, when not keeping house and churning out offspring, did the grotty jobs like cleaning, laying out the dead, and of course, nursing.
Today I saw nine women in morning surgery, all harping on about fairly nebulous symptoms. There was nothing to get your teeth into and actually treat, like good old conjunctivitis or an ingrowing toenail. At a bit of a loss, it was all too convenient to cop out: “It’s your hormones, luv, we’re all slaves to them.” And this excuse was stoically accepted. My busy, practical side wanted to deal with these patients sharpish and get on, but my feminist side was ashamed at trivialising their complaints. For, as my friend points out, demanding women are easily dismissed as hormonal.
Medical statistics show that women make up the vast majority of patients attending general practice. So are women a bunch of hypochondriacs with too much time on our hands?
The Ancient Greeks blamed everything on the uncontrollable, wandering womb and then that crackpot Freud came along and diagnosed all women as hysterical. Women probably do come to surgery more than men, but not necessarily because they are ill. They frequently consult for health-related matters, like contraception or smears. Often they are the only adult who is available to accompany a child, so indeed we do see many female customers in this job.
If unwell, women often request female doctors. Perhaps they expect them to naturally be more empathetic, especially with matters “down below”. Not necessarily so. A female GP I know totally rejects the possibility of PMS, considers post-natal depression to be the punishment of wimps and generally hates seeing women patients. Mind you, she rather fancies herself as a bit of a babe and flirts with anything sporting a Y chromosome. The male patients, of course, lap it up‟.
In this piece there are a few comments that need further analysis: if women make up the majority of patients in GP practice what are the real reasons? Do certain conditions fall into ‘legitimate‘ and non legitimate‘ medical concerns, and of who decides this? And are these decisions purely based on medical science? Does culture play a part?
Gender is therefore a variable to be taken into account in both defining what leadership might look like and in terms of opportunities for women leaders. Do we therefore have to retrain, re educate, men and women about male assumptions and values in health care management?
The above discussion is of course based on the fact that men and women come together in small or large groups to provide a service in health. They thus form ‘teams’. There is a large literature on the nature of team and team working and so it is to this topic we now turn.
As just stated this topic appears a good deal in the literature, the focus is on ensuring good team work to improve patient outcomes. There are descriptions about what makes a team, what holds teams back from working effectively, how we develop a team and what the proper role for team members may be. However we also need to think critically about our teams in actual practice. Is teamworking myth or reality in clinical practice? The previous sessions may indicate that culture, organisational development and notions of what leadership and management may be will affect how a team performs, whether it actually is a team or merely a group as MacGregor (2008) argued:
“most teams are not teams at all, but merely collections of individual relationships with the boss. Each individual vying with the others for power, prestige and position”.
This comment followed Miller’s (1999) contention that:
“some health care teams exist in name only, demonstrating little evidence of collaborative working underpinned by shared goals”.
Chase (1995) had previously examined teamworking in critical care environments and observed two parallel hierarchies consisting of medics and nurses. The suggestion here is that clinical teams may divide along professional lines and are not teams at all but are merely groups.
As indicated above nurse may be in relatively powerless positions to affect policy (Bishop 2009) as cultural influences affect working practices.
“nurses…tend not to own any power in policy making terms…gender stereotyping, medical dominance and inadequate professional leadership…conspire to keep us in places where others want us”.
Discuss the difference between what makes an effective team and how this differs from being ‘a group’.
The Characteristics of a ‘team’ (Clark 2008):
- Shared goal or task
- Mutual accountability
- Personal growth
Teams may share the following management functions:
- – Planning
- – Organising
- – Setting performance standards
- – Assessing teams’ performance
- – Change management
- – Resource management
Katzenbach and Smith (1993) differentiate between what constitutes a true team and what is a working group:
- True teams share leadership roles as they see fit;
Working groups have a strong & clearly focused leader.
- True teams take mutual, collective, accountability;
Working groups take individual accountability.
- True teams create specific team objectives that they deliver themselves;
Working groups’ objectives are imposed, mandated, granted, and/or the same as the broader organizational mission.
- True teams deliver collective products/outcomes;
Working groups deliver individual products/outcomes.
- True teams encourage open-ended discussion and active problem solving meetings;
Working Groups runs efficient meetings.
- True teams measure performance directly by assessing collective products/outcomes;
Working Groups measure effectiveness indirectly by their influence on others.
If we consider the above points we can judge whether we are working in teams or groups, consider also the notion of parallel teams/groups and what this might mean for interprofessional collaboration. Does it matter that we are a group rather than a team? Is the clinical team of the various professionals really a team or are we working in our various groups as ‘groups’? In what way does this link with patient outcomes…? The theory about team working is that we get better outcomes, creativity and productivity…does this apply in nursing?
Within nursing teams and their relationship with other professions there are various barriers to team development. Tuckman (1965) outlined a typology for group dynamics and argued that teams went through various stages of development. The implication here is that if a team gets stuck at one stage they will not get to optimum performance.
“Tuckman’s Stages” was based on research he conducted on team dynamics. He believed (as is a common belief today) that these stages are inevitable in order for a team to grow to the point where they are functioning effectively together and delivering high quality results. In 1977, Tuckman, jointly with Mary Ann Jensen, added a fifth stage to the 4 stages: ―Adjourning. The adjourning stage is when the team is completing the current project. They will be joining other teams and moving on to other work in the near future. For a high performing team, the end of a project brings on feelings of sadness as the team members have effectively become as one and now are going their separate ways.
The five stages:
- Stage 1: Forming
- Stage 2: Storming
- Stage 3: Norming
- Stage 4: Performing
- Stage 5: Adjourning
If a workplace experiences high turnover or always has new members arriving and leaving after short periods of time, how do teams then get to ‘performing’ ? How are new members integrated into the team – by being proactive or passive? Social dynamics implies that it is the everyday experience of working with people that individuals get to know what is required and what their place is. Do we need to add a power analysis based on professional status, gender or class?
Team Role Theory (Meredith Belbin)
As part of the development process, which it is suggested a leader has to facilitate, is the recognition that each team member may have a specific team role, a set of attitudes and aptitudes that they bring. Belbin suggested various team roles which if brought together will support effective team working. Consider the various roles outlined by Belbin (2003) and reflect if teams did not have, for example a ‘completer finisher‘
See : http://www.belbin.com/rte.asp?id=8
Effective Team building might be affected by more than the individual characteristics that each person brings to the team: For example, Interprofessional barriers to both stages of development and the roles that team players enact might be:
- Sex role stereotyping
- Separate professional education
- Separate lines of management
- Business culture v care culture v cure culture
- Poor Communication
- Differential Status.
- Lack of informal interactions
- Differing Value systems
Consider then how we overcome barriers and move from being a group to becoming a team. What individual and group, organisational actions need taking?
So far we have examined how cultures shape working practices, how individual professionals work together and how gender may shape leadership. Team working is seen as an important aspect of care delivery. We now turn to a goal of care delivery, enhancing or improving the quality of patient care.
10. Continuous Quality Improvement – the PDSA model and ‘Error Wisdom’.
Clinical leadership might be focused on improving service delivery and the quality of patient care. In order to do this leaders need some tools to help them. This section outlines one such tool – a process for systematically implementing change – PDSA, and another focused on ‘thinking’ about errors around patient safety – Error Wisdom.
Brocklehurst (1999) has suggested a number of approaches to quality improvement.
- Standards based approaches: These involve first defining or setting standards
- of practice and then measuring actual performance against these standards,
- g. Accreditation; clinical guidelines, RCN Dynamic Quality Improvement; and more recently Benchmarking
- Data Based approaches: Data collected and used to construct quantitative
- indicators of performance. League tables being the commonest.
- Problem-focused approaches: Define what is meant by poor quality care and
- try to stop their recurrence e.g. Complaints procedures; confidential enquiries,
- critical incident analysis. Tend to be negative and can be de-motivating
- System or Process Focused Approaches. Quality is also a function of
- organisational rather than individual performance. The concept of Total
- Quality Management (TQM) stresses the importance of leadership and
- organisational culture to quality improvement, and focuses on the use of a
- range of tools to examine and change processes of care.
- Personal & Professional development: Continuing Professional Development
- Individual Performance Review, Clinical Supervision.
These have much in common, may overlap or be used concurrently. They all fit into the
cycle of what is known as Continuous Quality Improvement (CQI)
It may be helpful to start with identifying what dimensions of quality we may focus on:
- client quality – what clients and carers want from the service (individuals
- and populations so called ‘patient satisfaction’)
- professional quality – meets needs as defined by professionals and carries
- out procedures deemed to be necessary in a professional manner.
- management quality – the most efficient and productive use of resources
- (budget, staff, equipment)
Once we have identified the dimension of quality we can address CQI which is a management philosophy which contends that most things can be improved. CQI has
been found to work effectively in manufacturing industries and now also in healthcare.
The core concepts of CQI are:
- quality is defined as meeting or exceeding expectations of others
- success achieved by meeting needs of those we serve (so we need to talk to them)
- most problems are found with processes and systems not p[people. CQI aims improve processes (minimising bureaucracy)
- unintended variation in processes can lead to unwanted variation in outcomes. CQI
- aims to eliminate unwanted outcomes
- possible to achieve continual improvement through small incremental changes
- continuous improvement is most effective when it becomes embedded in our
So, how might we put this into practice? Langley et al (1996) develop a model for improvement which is use in health care services (not least by the NHS Modernisation Agency) as a framework for developing testing and implementing changes that lead to improvement. This includes 3 key questions and then a process for testing change using Plan Do Study Act (PDSA) cycles
Answering the questions helps bring the problem or issue into FOCUS
Find a process that needs improvement
Organise a team that knows the process
Clarify the current knowledge of the process
Understand the variation in the process
Select a process for improvement
The model starts with 3 basic questions:
- what are we trying to accomplish?
- how will we know that a change is an improvement?
- what changes can we make that may result in an improvement?
Then, the PDSA cycle:
Plan – set the objective, make predictions, plan to answer the questions (who, where, when) collect data to answer the questions.
Do – carry out the plan, collect the data, begin analysis of the data.
Act – want changes are to be made to the next cycle. Can the change be implemented?
Go to the web address below for a fuller description of the improvement model:
CQI that uses the PDSA model aims to improve the quality of the service. However we will also have to address errors in systems and processes in an attempt to eliminate them This accepts the ‘human factors’ involved in decision making and practice and then designing systems to reduce human error. The aviation industry provides a model for health care, based on the fact that errors can very quickly result catastrophe. Critical care environments may share similar experiences in that errors could lead quickly to even more severe illness or death.
Error Wisdom and Human Factors
We all know of or have read of errors in clinical practice. ‘To err is human’ is an old English phrase. So how do we go about eliminating errors that could lead to serious harm and death? There are at least two approaches that leaders can take:
- Person – this is when we look at unsafe acts themselves, including errors and procedural mistakes made by healthcare staff. Take a drug error for example. We could try to find out why the person failed and then discipline or retrain the person. This has often been the approach adopted by managers. It is easy to focus on the failing of the person rather than an analysis of the system which allowed that error to occur.
- System – here we know that errors will occur, and that they are consequences rather than causes of harm. This accepts the fallibility of humans in their work and so we need to change the working systems in which people work rather than a focus on trying to change people. We try to design a system that defends against errors and focus on the person, the team, the task, the workplace and the organisation itself.
Errors happen often because either the barriers to prevent them do not exist or that the various steps all line up to allow the error to take place. For example in the aviation industry a pilot cannot land an aircraft with its wheels up because there are barriers preventing that. However if all the barriers fail: no warning light, no audible sound, the ‘wheels down’ automatic switch does not work, the co-pilot fails to notice…then the system is not robust enough to ensure the aircraft cannot be landed. In many accidents and failures there are technical failures in the system that can be found, often however it is the human factors that count!
Consider the human factors and procedural events involved in the total system of administering medications. What defence mechanisms are in place to prevent errors?
¨An 18 yr old male patient largely recovered from leukaemia mistakenly received an intrathecal injection of the cytotoxic drug ‘vincristine’. Given by a junior doctor supervised by a senior doctor”. The patient dies 3 weeks later.
· Hazards of injecting vincristine intrathecally were well known
· This particular adverse event had occurred several times previously
· The administration of vincristine is an error trap
· Error prone situation rather than error prone individuals
The message here is that we need to do a systems analysis rather than focus on blaming a failing individual. We need to look for the root causes of why patients are harmed and design as far as possible ‘fail safe’ mechanisms. A challenge in health care is that much of nursing is people based and so there are not quite so many technical fixes available to us. Nurses do not come with ‘fail safe’ switches or internal automatic back up systems. We may also need to partner technological designers as clinicians have first hand experience of the technologies they use and might therefore help in the design.
Error wisdom may include mental preparedness (Reason 2004):
- accept that errors can and will occur.
- assess the local ‘bad stuff’ before embarking upon a task
- have contingencies (back ups) ready to deal with anticipated problems
- be prepared to seek more qualified assistance
- do not let professional courtesy get in the way of checking your colleagues knowledge and expertise, especially when they are strangers
- appreciate that the path to adverse events is paved with false assumptions
The next section considers how we know we are doing the right things?
11. Care, Quality and Soft Metrics. Are we doing the right things?
Peter Drucker said that management is about ‘doing things right’ and that leadership is about ‘doing the right things’. In this section, clinical leaders are challenged to consider how they know what quality care looks like and if we are indeed doing the right things by collecting the right data?
The failings over 10 years at Alexandra Hospital in Worcester (BBC 2012) indicate the pervasive nature of not only poor quality care but actual abuse. Worcester’s experience lead us to consider quality and audit processes in clinical practice as one assumes student nurses at Alexandra hospital witnessed “patients lying in their own excrement” (BBC 2012). Although failings in basic day-to-day care in Worcester were highlighted by a CQC report, this should not lead us to complacency about the robustness of quality and audit reporting mechanisms.
The incidents of poor quality of care at Mid Staffordshire NHS Trust raised many questions. One of the most pertinent is that, given the extent of the poor care, how did staff and systems charged with evaluating the quality of clinical placements miss what was going on? This was addressed at a seminar at the NET2012 conference held in Cambridge in September 2012. The university charged with placing students at Mid Staffordshire NHS Trust had to address the serious issues that arose in clinical practice and presented some of their insights.
Are Mid Staffs and Worcester outliers or are other Trusts currently harbouring their own dark secrets? Abuse at the levels described might, or should be, easy to spot. If we cannot see it we might ask ourselves is that because it does not exist or is it because our tools lack precision and validity? A more challenging issue is care that is not abusive but is just ‘not right’ in some often intangible way. This leads us to ask whether there is a suboptimal level of care occurring in Trusts that is happening ‘under the radar’. We may then ask how do organisations, who are remote from the clinical area, define what is quality care beyond the obvious which, incidentally, seem to have escaped many members of staff in their formal evaluative processes and every day working practice?
There are numerous quality assessment and management frameworks in the published literature in addition to the regulatory frameworks and organisations in existence, whose raison d’etre is protection of the public. Educational audit processes at Mid Staffordshire NHS Trust and Stafford University were commended by the NMC and by SHA reviews before 2012. However, it is clear that they were not robust enough to predict and prevent individual abuse and managerial failures. One may ask what indicators were being looked at? What metrics are being used to make judgements about quality? For example, student comments about wards included “very busy area”. Is this a proxy term for “poor care?” Was another indicator that the Trust had cancelled joint meetings between themselves and the University, on several occasions? These two indicators might not have found their way into the hard metrics accessed by the Trust, the University, the NMC or the SHA.
A University might review its educational and placement audits and reporting mechanisms in the light of evidence of poor quality care. Universities and Trusts may have regular meetings to discuss concerns and then develop action plans to address them. This may be reactive to serious incidents and events, and may not rely on the ability of picking up on ‘soft intelligence’ which results from soft metrics. Audits and joint meetings are important pillars in upholding the quality of care provision and the student experience, but what other pillars are there, and which ones can Universities address?
Thus we need to consider what can be done to prevent the poor standards on the first place. Quality frameworks such as Donabedian’s (1966) ‘Structure, Process, Outcome’ already exist to do just this and illustrate the long history of this topic. The NMC’s code is expressly written to protect the public from poor quality care. There is no shortage of frameworks and mechanisms in existence and yet all of the weight of published literature on quality did not prevent Mid Staffs and Worcester.
Antecedents to poor care
Have we investigated in enough depth both the antecedents to poor care and the social process of collecting evidence of it? A paper on sub optimal care of the deteriorating patient (Quirke et al 2011) may indicate areas for investigation by HEI’s and Trusts and serves as an illustration of the multi factorial nature of the issues.
‘Suboptimal care’ (SOC) in acute settings refers to errors in assessment, delays in diagnosis and treatment and poor management of the acutely ill and deteriorating patient. Thus ‘suboptimal care’ is a different concept to ‘poor care’ generally. That being said, the antecedents to suboptimal care might teach us something about poor care. They may provide pointers, or places to look and research.
Quirke et al (2011) identify 4 categories of the antecedents for SOC:
- Patient complexity
- ‘Outliers’ e.g. medical patients in surgical wards.
- Multiple co morbidities.
- Ageing populations.
- Medical and Surgical Technologies.
- Day case and throughput.
- Healthcare workforce,
- Workload and nurse/patient ratios.
- Skill mix.
- Working practices. Junior doctors hours, rotations.
- Teamworking, communication and documentation of plans.
- Shiftwork, staff shortages, casual and locum agency staff
- Assessment skills and deficits in knowledge.
- Deficits in management.
- Lack of recognition of deterioration
- Vital signs interpretation.
- Availability of equipment
- Supervision of junior doctors
- Medical review by PRHO rather than registrars
- Use of Health Care Assistants
- Supervision of HCA’s by RNs
- Time of admission: midnight-9am.
- Availability, reliability and consistency in equipment use
- Variety of equipment
- Task orientated vital signs by machines and risk.
To apply these categories to an analysis of poor quality care in non-acute settings is a short step. To take just the first category, ‘patient complexity’. Elderly patients with long term conditions have complex nursing as well as medical needs and often will be prescribed a long list of medications. Their social, cognitive, emotional and physical needs require regular assessment and evaluation by suitable experienced and qualified health professionals. This should alert us already to the need to ensure that whosoever is responsible and accountable for that care requires education, support, supervision and on-going development.
The second category of ‘health care workforce’ indicates that this complexity may then, as in the acute ward, be delegated in many cases to healthcare assistants in settings with low Registered Nurse to health care assistant ratios which result in role drift and the mentoring of student nurses (Hasson, McKenna and Keeney 2012) . Any objective analysis of this would alert us to understanding that combining complex care needs with poor skill mixes will make suboptimal care more likely.
In the third category: ‘Education’ we might reflect that educational and training needs of staff may be lacking and could be compounded by funding strategies for continuing professional development.
As for ‘organisational issues’, medical supervision by the appropriate level of doctor and again health care assistant use may also impact on care delivery. To this category I would add the leadership and management skills of nurses in clinical areas which if not properly developed and supported, compounds the above categories.
The HEI’s role
If we then address the question of a university’s ability to influence and prevent the antecedents, then obviously patient complexity is a given. An HEI can’t directly influence Trust decisions on health care workforce, except through rigorous partnership working. Education is of course university core business. The Organisational issues are Trust business and can again only be addressed through partnership.
Many of the antecedents for poor care might be picked up by appropriate hard metrics, e.g. skill mix ratios, the qualifications and experience of health care professionals, assessment and care plans indicating complex needs, and no doubt a focus on this may well indicate potential weaknesses in the systems. It remains the case though that hard data still might not provide valid measures of good quality care.
‘Soft metrics’ or ‘Soft Intelligence.
The business world has identified soft metrics (Cottrill and Gary 2006) as a way of assessing the risk of companies. These include things such as reputational value, role creativity, trustworthiness, and flexibility. Hard metrics include data such as share price, sales and number of customer service complaints.
Soft metrics are intangible, difficult to quantify, qualitative criteria or data which may be used to evaluate risk or the quality of a product, individual, company or service. Soft metrics might include such things as the ‘buzz’ or talk about a company or service which rarely appear in formal evaluation or risk assessment processes. It may be related to an intuitive ‘feel’ about how an organisation is being run. They may construct the tacit knowledge individuals have about their workplace. In hospitals, there may be some indicators that can be identified, such as waiting times for answers to telephone calls, no one at the nurse’s station or irritable visitors. They may include the physical appearance and environment of a clinical area. These indicators might collectively be construed as the metrics that provide ‘soft intelligence’.
An example from one of our own students who wrote to me in an email about wanting to discontinue:
“My reasons for wanting to step off the course are that I am riddled with self doubt about my capabilities and the responsibility of the job quite frankly scares the shit out of me! Although I am passing theory and practice I dont feel like the practice experience is particularly thorough (my emphasis). Please forgive me if that sounds arrogant as I obviously dont know what the nurses perspective is. In my albeit limited placement experience I very much feel like you can flatter your way through. This has led to me feeling like I can get away with not reading or doing much more than turn up and be nice to people, say nice things make them feel good (my emphasis). This is not the kind of nurse that I envisioned myself being but I feel it is where I will end up”.
This can be easily dismissed as the view of one student only, and the fault for her feeling about practice in this way lies within herself. To do this may be a mistake. I read that comment in the context of the dismissal of the need for graduate nurses, the difficulties in addressing evidence base practice and a general culture of anti-intellectualism within healthcare settings. This latter concern is shared by many academic nurses (e.g. Shields et al 2011, Goodman 2012, Morrall and Goodman 2012). This is an example of soft metrics that would not appear in quality processes and yet might be telling us something vital.
Two processes – hard and soft
Therefore two processes are in operation. There are formal educational and placement audits on the one hand, and a host of evaluative comments, feelings and intangibles, on the other. If the results of the formal process do not match the results being generated by soft metrics then the possibility remains that a false picture emerges about the quality of a service, placement or organisation. This is not new, ‘Street wise’ customers will avoid certain restaurants despite formal measurements of quality. Students already discuss among themselves which wards are to be avoided or tolerated. Quality is often an elusive concept and yet patients know when they are receiving poor quality care.
Formal evaluative processes and quality frameworks are human created ‘technologies’ designed to fulfil certain functions and are open to questions of validity. As with all technologies great care has to be exercised to avoid thinking that the results of measurements are valid and not mere constructs of the technology themselves. There are risk implications from relying on technologies to provide data. We already know for example that relying on task oriented vital signs assessments recorded by machines actually require patient assessment using sensory skills as well (Wheatley 2006). Bureaucratic technological processes have a habit of fooling us that ‘something is being done’ when in fact all it is doing is fulfilling the needs of the bureaucratic process itself. That is to say it is data collection for data collection’s sake.
The challenge then is for HEI’s to incorporate soft metrics in their processes while acknowledging that by its nature the soft intelligence it creates might be unreliable and non-quantifiable. Universities may rely on their own hard metrics and reports provided by the NMC and the Strategic Health Authority, which arguably could let them down in failing to identify the poor care issues in its placement areas. Listening to soft intelligence or identifying soft metrics could provide an adjunct to better predict failing areas. However, soft intelligence will be harder to accept for those of a more empirically minded orientation and may not provide the hard justification for action that might follow.
‘Any Willing Providers’ (AWPs), NHS Trusts and Universities should consider strongly supporting or creating Joint Strategic Panels charged with identifying concerns in clinical practice and the development of action plans to address them. Universities and Trusts should consider independent review of their internal audit processes to engage in critical appraisal of the validity of measurement metrics. The independent review could be undertaken by another Faculty within the University or by collaborative partnerships established between Universities. Trusts and AWPs should consider independent review of their own clinical placement audits.
Clinical leaders should understand and be open to the soft intelligence they encounter every day. Good leaders already do, but we might be seeing the ‘Dunning Kruger’ effect (Dunning Kruger) in many failing clinical areas whereby the incompetent leaders over estimate their competence and subsequently cannot spot their failings. Clinical leaders require a ‘mental space’ to critically evaluate themselves, their clinical area and the nature of the information available to them at hand.
12. Leadership as positive deviance, our ethical responsibilities in a globalised world.
“Considerable evidence suggests that neocolonialism, in the form of economic globalization as it has evolved since the 1980s, contributes significantly to the poverty and immense global burden of disease experienced by peoples of the developing world, as well as to escalating environmental degradation of alarming proportions. Nursing’s fundamental responsibilities to promote health, prevent disease, and alleviate suffering call for the expression of caring for humanity and environment through political activism at local, national, and international levels to bring about reforms of the current global economic order”. (Falk-Rafael 2006).
The theories and issues so far covered in this module are focused on the individual (micro) and organisational (meso) level of analysis. Nurses are asked to examine their personal resources and the culture of the clinical setting and the hospital environment in which they work. The immediate focus is on patient outcomes: their safety, their recovery, their dignity and their comfort. Many of the policy drivers for critical care rightly ask us all to consider the patient‘s journey, to see the issues from their perspectives as well as from our own.
You have been invited to consider whether transformational leadership is a style fit for clinical practice, you have been invited to consider how interpersonal and interprofessional relationships affect your work, you have been invited to consider how we add value in a public sector organisation, you have been invited to consider applying CQI as a process in your work.
But you have not been invited to take the next step: The macro analysis.
A macro analysis asks you to see beyond the individual, the clinical unit and the hospital. It asks you to consider wider socio-political issues that impinge on public health and well-being. Critical care rightly focuses on the seriously ill individual and the skills and competencies developed for nurses reflect that. However, Nursing is an ethical endeavour, your exercise of leadership reflects your ethical positions. The decisions you don‘t take may be as important as the decisions you do. The world view you ascribe to helps to create the world you live in. You have an opportunity for just a moment to raise your eyes above the bedside and think about your vision for the future.
A good deal of discussion in leadership theory is about vision, that leadership is a role, it is a process and can be exercised by anyone. Being a ‘leader‘ is a post holder (chosen, elected , appointed), but a formal post may or may not exercise leadership. So I wish to ask, what are you leading for, for you are all potential leaders regardless of the formal title or post you hold. What is your vision? What are your ethics? What do you care about?
Sarah Parkin (2010) argues that much of leadership education does not clearly see the impending crises of unsustainable economic, business and political practice, has failed to see the wider picture and has failed to ask what is leadership for?
We know we live in a messy world (Peccie 1982, Morrall 2009). The financial crisis that started in 2008 continues prompting the indignados movement. Spain has a 46.2% under 25 unemployment rate where young educated people argue:
“juventud sin futero, sin casa, sin curro, sin pension, sin meido”
(The Economist 2011).
We know that economic inequality has direct health effects (Marmot 2010, Wilkinson and Pickett 2009). We know what the under 5 mortality rate in many countries is still far above the stated target of the Millennium Development Goals (MDG 4). The WHO (2008) supports the ‘social determinants of health‘ approach which links social, political and environment issues with human health. Climate change is the biggest threat to public health and security in this century (Costello et al 2009, BMA 2008, 2011, Goodman and Richardson 2009, Goodman 2011).
These issues, Parkin argues, require leadership as ―positive deviancy. A positive deviant is:
“a person who does the right thing for sustainability, despite being surrounded by the wrong institutional structures, the wrong processes and stubbornly uncooperative people” (2010 p1).
There is an urgent need for healthcare professionals to address the sustainability of current politics, economics and social practices (Goodman 2011). The exact nature of that response is down to individuals. However, without some macro analysis we are in danger of leading ourselves into the dark. This then leads us to ask about out ethical responsibilities on a globalised world.
Nurses’ ethical responsibility in a globalised world?
Globalization results in large capital flows, labour movement and displacement and the increasing dominance of Transnational Corporations (TNCs) on economic, social and political life. The demise of state power for the public good and its alignment with finance capital (Harvey 2010, Crouch 2011) – results in its increasing withdrawal from public services in many European countries. The TNCs and ‘the markets‘ are two voices guiding politics. The current Eurozone crisis illustrates how politicians have to create polices that the international financial institutions feel are acceptable to them. Collier (2008) suggests that we have a bottom billion stuck in poverty, and the WHO acknowledges wide health inequalities. Even for the Rich, threats to survival are not domestic but global. Perspectives are changing from local to global, the ethics of healthcare thus need to be discussed in this context. The WHO‘s Millennium Development Goals also set a global policy framework. There is thus a need for another voice to defend global public goods such as health.
Ethical practice (Austin 2008):
Paul Ricoeur (1992) suggested that ethics are about ―aiming at the good life, and so if this is the case we ought to consider the good for all. If everyone has a right to the opportunity for a good life, what should the Nursing response be?
Acting ethically as a nurse in a global community requires a need for transformative thinking and leadership as positive deviance.
My frame of reference is that healthy lives depend on a healthy socio-economic and physical environment as outlined in the Social Determinants of Health approach (WHO 2008) which has as its outer layer in the model ‘general socioeconomic, cultural and environmental factors’, i.e. social and environmental structures. Thus, I largely agree with Peter Morrall (2009) who argues that patterns of illness and disease are largely determined by issues of social structure and increasingly physical environments. Social structures protect some while damning others to misery and poverty as evidenced in the inequalities in health literature. The affluent even in poor countries and difficult environmental conditions live in ‘safe’ enclaves where they can ensure clean water and a ready supply of food, even in famine stricken countries, money buys food. However, even the affluent will be affected by global changes in certain key environmental limits.
The key power relationships operating at present is the hegemonic stranglehold of advanced consumer capitalism in which the richest 2% own 50% of the world’s wealth (Davies et al 2006). Many do not understand or recognise the notions of limits, while others put undue faith on the resourcefulness of humanity to solve the problems but to do so within the frame of reference of ‘business as usual’ unaware that their selves are interconnected and interdependent within a much wider framework of meaning.
Thus there is a need to transform thinking. Currently leadership is the problem not the solution because we are not asking what we are leading for.
To encourage and transform leadership there is a need to engage in provocative pedagogy whereby we engage in intellectual critique through being challenged with provocative positions. We need a sociological imagination to connect personal troubles with public
issues, to fully understand their personal biographies as related to wider social forces at this point in history.
Medical and nursing disciplines cannot be immune from this process. It is not enough to learn how the body works and what to do when it goes wrong. This is navel gazing of the worse kind. Many doctors and nurses have for a long time been pioneers for social action, acting on behalf of the poor, weak and vulnerable. That is their ethic. That has been their historic mission, the problems of this messy little world may not mean a hill of beans to many but without a reawakening of consciousness and a reconnection of self to others, which includes the biosphere, the future looks grim. Peter Morrall (2009) has argued that we as health professionals and/or academics have an ethical responsibility to take individual, collegiate, and organisational action with regard to the social ills which affect human health and happiness.
However, taking a stand is hard. Ethics is hard. Ethics requires thinking. We may be the only sentient being on the planet who can think and reflect on our existence and the search for ‘truth’ It may be that we have a special responsibility to think about our decisions and why we make them. Damon Horowitz has recently argued (2011):
“Not only can we think, we must. Hannah Arendt said, “The sad truth is that most evil done in this world is not done by people who choose to be evil. It arises from not thinking.” That’s what she called the “banality of evil.” And the response to that is that we demand the exercise of thinking from every sane person”
But this may lead to Moral distress and Moral responsibility by understanding the disparities in health. If we have responsibility what does that mean? We may provoke moral distress, but then what?
An issue within critical care: Moral distress:
See: ‘Defining and addressing moral distress: tools for critical care nursing leader’
and “Healthcare provider moral distress as a leadership challenge”.
Nurse clinicians may experience moral distress when they are unable to translate their moral choices into moral action. The costs of unrelieved moral distress are high; ultimately, as with all unresolved professional conflicts, the quality of patient care suffers. As a systematic process for change, this article offers the AACN’s Model to Rise Above Moral Distress, describing four A’s: ask, affirm, assess, and act. To help critical care nurses working to address moral distress, the article identifies 11 action steps they can take to develop an ethical practice environment.
Healthcare leaders are responsible for using strategies to promote an organizational ethical climate. However, these strategies are limited in that they do not directly healthcare provider moral distress. Since healthcare provider moral distress and the establishment of a positive ethical climate are both linked to an organization’s ability to retain healthcare professionals and increase their level of job satisfaction, leaders have a corollary responsibility to address moral distress. We recommend that leaders should provide access to ethics education and resources, offer interventions such as ethics debriefings, establish ethics committees, and/or hire a bioethicist to develop ethics capacity and to assist with addressing healthcare provider moral distress
13. A Manifesto for Action Nursing
This manifesto calls for a social movement for political activism by nurses and other health professionals, to address inequalities in health and the social inequalities that highly structure, but do not determine, health outcomes. This action can operate at individual, clinical, organisational, national and international level.
Our aim is to respond to threats to health and socialised health service delivery from corporate, financial and political interests.
Our vision is for decreasing social and health inequalities in which the social gradient is greatly diminished.
Our goal is to create a networked social movement involving political and civic activism to bring critical understanding and action into the public sphere.
Intrinsic to the nursing project is a concern for the health of individuals, communities and populations but in any point in history nurses will find themselves confronting ideologies; these are erroneous worldviews or theories that justify, sanction or provide cover for financial, business or political interests. Nursing’s ethics of care should include opposing forces that suppress truths about the societies we inhabit.
As millions of people in the UK, and billions across the globe, experience a daily struggle to both give and receive support for health, illness and social care needs, nurses must ally themselves with the progressive forces which seek to redress the balance of power of what Graham Scambler calls the ‘Greedy Bastards’. To paraphrase, it is the largely unintended consequences of the actions of the ‘Greedy Bastards’ which results in gross social inequalities and inequalities in health. Action Nursing, alongside an ‘Action Sociology’, wishes to remove the ‘flowers from the chains’ so that we more clearly see what holds us back from understanding care as vital, as central, to our shared humanity and is not mere adjunct, to be ignored within the private (female) domain.
As many governments embrace austerity policies within a neoliberal political economy, capital accumulation takes on various anti-democratic forms unaccountable to the people engaged in what Marcuse (1964) called ‘the pacification of the struggle for existence’. The provision of nursing may be seen as a cost and not a benefit to those who decide where the investments should be made. Capital accumulation practices in health care delivery, especially in the care of older people and those with social and relational problems, often results in absent or stretched services, or hiring under educated and poorly trained staff who too often lack supervision and development and who work in high patient to staff ratios. It also seeks private insurance based schemes and prefers services which can return profits. Care givers also work in the private domain, the informal sector, providing vital support to the wider business of capital accumulation but with very little or no recognition or return for such efforts. This ideology is maintained by appeals to the moral character of such work, often locating it firmly within kin networks as a ‘reciprocal gift’ that would be sullied by any suggestions of a wage.
Nurse educators, clinicians and students do not work in a socio-political vacuum. However, one would think that they do if the content of curricula and the learning experiences planned are anything to go by. Indeed any discussion around political economy, patriarchy and capitalism is liable to be met with surprise, apathy, or disdain apart from those engaged in teaching the social sciences in nursing. Nursing cannot shy away from addressing these questions. Nurses who experience the requirements to provide support for health, illness and social needs in both their domestic and public lives, bear the brunt of the demands of a society which needs that work to be done but is unwilling to fully fund it. We need to argue for the social value of such work and against privatised individualised provision which falls unfairly on the shoulders of those who often do not have the resources to provide it.
Nursing care in an often uncaring society should necessarily be oriented to justice and solidarity. It should be active not passive and should exist as a form of intervention against ‘distorted communication’ that calls nurses into subservient and relatively powerless positions. This has never been developed fully in Nursing theory because the discipline has been focused on other laudable aims and lacks a critical reflexivity and critical concepts. The result is a large number of workers in health services have no analytical tools or critical thought in which to contextualise and critique their experiences with vulnerable people. Critical theoretical concepts, such as ‘governmentality’ or ‘praxis’ or ‘frontiers of control’ ‘or ‘critical reflexivity’, would be sadly be alien to most nurses.
Action Nursing therefore contests the often biomedical ‘taming’ of nursing especially in the post-1970s neo-liberal era, including the shying away from arguing about contentious or ‘risky’ issues. Witness the uncritical passivity with which nurses in the UK have accepted ‘values based recruitment’, the ‘6Cs’ and ‘revalidation’ as panaceas to the issues of the quality of care; witness as well the lack of action regarding the structural conditions of the NHS following the Health and Social Care Act.
An Action Nursing cannot stand on the sidelines as a passive recipient of the decisions made by other powerful actors. It has to dwell on exploitation and oppression that result in inequalities in health for the population and stress, burnout and compassion fatigue for nursing staff and other care givers in their homes. Action Nursing should engage in the Marcusian ‘Great Refusal; it stands against the actions of the wealthy and powerful and actions whose consequences include the social gradient seen in the mass of data on health inequalities and evidenced in people’s lives in such works as ‘The Life Project’.
This manifesto also allies itself with the manifesto ‘from Public to Planetary Health’. This is the voice of health professionals who together with empowered communities could confront entrenched interests and forces that endanger our future. This could be a powerful ‘social movement from below’ based on collective action at all levels to create better health outcomes, protect our futures and support sustainable human development.
(Acknowledgement: Many thanks to Graham Scambler for his work on action sociology which inspired this manifesto).
Leadership theory has a long history and the word can mean very different things. It has been rooted in a private sector, managerial context with not a little male bias in its understandings. There is some empirical research to demonstrate what works in certain situations but because at a fundamental level this is about the quality of human relationships there is no scientific formula that be applied to ensure specific outcomes.
Leadership then arises from within specific situations that cannot always be predicted, it is a process that be understood, developed and practiced by individuals on informal positions of leadership. To begin you will have to understand yourself before you can lead others. You will have to know the power games and ethical positions of various actors and organisations. You will have to understand the multi-factorial nature of the exercise of leadership, acknowledging that context issues which may be difficult to control or even identify that will impact upon how you work and live. However, leaders do make a difference, sometimes despite the organisational cultures they find themselves in.
Care settings bring their own cultures, pressures and issues. They are as open to influences from outside as any other setting. However, a unifying focus for all who work in care is patient safety and comfort. Identifying your personal and organisational vision to address this overall goal may be a good start.
Benny Goodman 2017
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