Leadership

Critical Discussion Of Management And Leadership Within The Quality Care For Mrs Patel This paper will be discussing the nurse’s role in the delivery and monitoring of quality care for Mrs Patel using a problem solving approach. It will contain a critical discussion of leadership and management theories and the significance of relevant government policies and documents. Inter-professional working will also be discussed as well as communication and evidence based practice. For the purpose of this assignment, the main theories that will be focused on are Lewin’s 3-stage model of change, Laissez faire, and transformational leadership. According to the case study given, Mr Patel had complained that his mother had been losing weight since she had been admitted into the ward. According to Hallstrom et al (2000), 50 percent of hospital patients have pre-existing malnutrition that is worsened by hospitalisation. Hallstrom et al also state that malnutrition is a substantial factor, which contributes to delayed discharge. It can be seen that nutrition is an issue within nursing care as the department of Health (DOH 2001) have published 10 benchmarks within ‘The Essence of Care’ concerning nutrition in order for best practice and quality of care to take place. These include screening and assessment to identify patient’s nutritional needs, monitoring, and eating to promote health. Bailey (2006) also suggests that patients who have just been admitted should be nutritionally assessed and weighed so that any weight changes can be noted and any nutritional problems rectified. This screening process should have taken place when Mrs Patel was admitted onto the ward. Bailey (2005) insists that the nutritional requirements of a patient are met through the nurse and the nurse should implement screening and ensure that nutrition is maintained for the patient, although Bailey (2005) also suggests that poor staffing levels is the reason for nutritional screening not taking place. Mr Patel made a complaint about his mother loosing weight. Complaints demand that nurses are able to adopt a problem solving approach and within nursing it is certain that problems will come up that need solutions (Huber 2000). Ralston (2005) adds that it is essential for leaders in nursing care to understand problem solving within the management of patients. Although, it depends on the knowledge of the nurse leader and the complexity of the problem whether a solution is made (Firth 2002). Ellis and Hartley (2005) agree that problem solving is one of the essential skills for managers and state one way that problem solving can be approached is through confrontation. As stated in the case study, the problem is Mrs Patel losing weight. Confrontation could be in the form of directly asking the care team if they have noticed any changes in Mrs Patel’s eating habits, if she has expressed that she doesn’t like the food being served or if she needs any assistance to eat. The problem could be simple to solve if the care team communicate. In order that the situation regarding Mrs Patel’s nutritional status is addressed and resolved appropriately or for the problem to have been prevented, Inter-professional working needs to take place. A large number of people may be involved in Mrs Patel’s care therefore communication is required to be of an excellent standard. As an example of the multi-disciplinary team that will be solving Mrs Patel’s nutrition problem, the people that may be involved are doctors, dieticians, nurses, health care assistants, and speech and language therapists (Copeman 1999). According to Leathard (2003), there are over 50 terms to describe the idea of people from different professional groups working together. These terms include inter-sectoral, multi-disciplinary, inter-professional, and interagency. Although Priest and Roberts (2006) state “In multiprofessional working, staff combine their unique skills in a team effort to benefit patient care. Interprofessionally, staff are sharing their expertise to care for patients in better ways.” Pp62. Bloxham (1997) defines interagency working as shared planning and/or delivery of work across various differing organisations and professions involving different professional skills. Leathard (2003) stated that inter-professional working compliments and heightens collaborative practice and teamwork by levelling out the management system. As identified by Rushmer (2005), Successful health services are dependant on collaborative working as patients are constantly moving from one professional group to another to receive services that the designed to meet the patient’s needs. It is clear that in Mrs Patel’s case inter-professional communication had broken down, as it seems that none of the staff on the ward noticed her weight loss, which resulted in her son making a complaint. This problem is apparent throughout the NHS. So serious is poor team working felt to be that ‘The NHS Plan’ lists it as one of the reasons that the NHS has failed to deliver on healthcare priorities in the past (DOH 2000). It has been said that poor communication between the professional clinical groups caring for a patient causes ineffective inter-professional working (McClure 1984) therefore, communication is of utmost importance in all aspects of care. Also in management, leadership and problem solving (Rushmer 2005). Poor communication has been to blame in a number of disastrous failures in care. As identified by Priest and Roberts (2006), the Victoria Climbié case is one of these disasters. Lack of communication can be fatal. Priest and Roberts also point out that poor communication is regularly pinpointed as a cause of patient complaints. As a response to these complaints, the Department of Health developed ‘The NHS Knowledge and Skills Framework’. It states that by the time professionals register, they should all be skilful communicators (DOH 2003). Most of the literature refers to communication between the care team although as identified by Hoban (2005), communication between patient and nurse it vital. The nurse needs to build a trusting relationship with Mrs Patel so that she is able to communicate her anxieties and perhaps problems with eating to the nurse. Mrs Patel’s normal routine concerning eating needs to be talked about as well as any other problems that may be hindering her from eating properly (Hoban 2005). In order to look at management and leadership theories, it is necessary for them to be differentiated between. Zaleznik (1977) states that it takes two very different types of people to become leaders and managers and that they have different attitudes towards their goals and careers and in the way that they interact with people. Christian and Norman (1998) build on this by arguing that management and leadership are so different that they sometimes can be conflicting. Kotter (1990) states that leadership is about setting directions, motivating people, inspiring people, having the ability to adopt a visionary position, setting a direction, and anticipating as well as coping with change. Although he states that management is about putting structures and systems in place, controlling and organising people, and planning. Zaleznik (1977) creates a negative image of managers by suggesting that their goals arise from necessity rather than desire. This negative view of managers is supported by Malcolm et al (2003) who argue that leaders within the clinical area should stay focused on quality of care and professional issues and not cross over to the other side, which is management. Zaleznik (1977) describes leaders as having goals, which are made from passion and personal desire to inspire meaning. Mulally (2001) insists that leadership for nurses is essential for the success of the Department of Health’s NHS plan (2000). More recently, Warren (2005) differentiated between management and leadership by stating that the main difference is vision. Leadership is concerned with vision, communication and values whereas management is primarily concerned with analysis, planning and problem solving. Kotter (1990) suggests that both leadership and management are needed within complex organizations in order for them to run smoothly. This is supported by Marquis and Huston (2006) who state that the roles of the manager and the leader can and should be integrated and that it is essential for both approaches to be present within nursing. Moreover, Ellis and Hartley (2005) state that it is vital for managers to have the ability to both be managers and leaders at the same time in order for quality of care to take place. When caring for Mrs Patel evidence based practice should be considered as it shows current evidence of how best to care for a patient (Sackett et al 1996). Gibbs (2003) expands on this and states that an evidence based practitioner puts the patient and their benefits first while adopting life long learning through searching for the best current evidence for use in clinical practice and taking action guided by evidence. Evidence based practice has been identified as an integral part of nursing care and is recognised by The National Institute for Clinical Excellence as they published guidance on various clinical conditions on the foundation of evidence (Dougherty and Lister 2004). There is a wealth of literature describing and analysing many theories and styles of management and leadership. However for the purpose of this essay, three will be discussed, Transformational leadership, Laissez-faire and Lewin’s three step change theory. Burns developed the transformational leadership theory in 1978. He was the first scholar to suggest that levels of motivation and morality can be raised by the interaction of leader and follower (Marquis and Huston 2006). Burns (1978) described transformational leaders as those able to inspire others with a vision and those who are thoroughly committed. Wolf et al (1994) cited in Marquis and Huston (2006) describe transformational leadership as a relationship between the follower and the leader, which is interactive and based on trust. This relationship creates unity and the leader inspires the follower to have the same vision and purpose, which enables them to become focused and work well. The successful and high-performing transformational leader will be truly committed to the profession they are working within as well as the organization and will be willing to tackle obstacles in the way of their vision. Tomey (2000), adds to this by stating that transformational leadership is concerned with inspiration through optimism, employee development and stimulation plus attention given to the followers in light of their motives and needs. Tomey argues that this kind of leadership creates a role model for nurses that is considerate of their individual needs and provides strong direction for the care team. As the name suggests, transformational leadership is concerned with ongoing change, therefore a transformational leader needs to be able to commit to change as a process and have the ability to “reconceptualize” (pp50) systems within clinical practice (Marrelli 2004). Outhwaite (2003) adds that transformational leadership can encourage problem solving using creative solutions that the care team collectively believe are the right thing to do. The theory of transformational leadership would be appropriate for the leader to be using during the care of Mrs Patel as it promotes meeting standards that are agreed as acceptable for all of the care team such as the Essence of Care nutritional standards (DOH 2001). If these standards are adhered to, nutritional assessments would be taking place and specific care would be planned for Mrs Patel taking into consideration her needs and food preferences. Holland et al (2004) also state that repeated assessment is the key to quality care and in Mrs Patel’s case, repeated nutritional assessment is needed. Moreover nursing is always subject to change as is the condition of patients that the nursing profession is caring for, therefore the transformational leadership theory, which is primarily concerned with change, is extremely compatible and useful within the management of nursing care. However, it is noted by many management theorists such as Dunham and Klafehn (1990) and Bass at al (1987) that transformational leadership will not be successful without some transactional management. Transformational leadership must be coupled with transactional qualities of a manager who is concerned with day-to-day operations, organization, and getting things done. Another type of leadership is laissez-faire leadership, which is French for ‘Let it be’. According to Ellis and Hartley (2005), this approach is also called permissive leadership. It provides little or no guidance to the followers therefore they will develop their own goals and are responsible for their own management, This approach provides support and freedom for the care team and decisions are made amongst themselves. Marquis and Huston (2006) identify that the laissez-faire leadership style can sometime be a successful approach if members of the care team are highly motivated and focused. This way, there can be much productivity and creativity and new ideas are not suppressed. However in the case of Mrs Patel, laissez-faire is an extremely inappropriate approach to use because Mr Patel has identified a problem that needs to be solved so the care team needs to be gathered as a group by the ward manager or nurse in charge and changes need to take place. Tomey (2000) identifies that laissez-faire often fosters chaos as all members are working towards their own goals not a collective one so it is impossible for continuity of care and inter-professional working to take place. If the team are left to their own devices they will be unstructured and care will be unorganised. There are many change models within nursing management literature, however one widely used model is Lewin’s three-step change theory (Marquis and Huston 2006). Many other theorists have used this theory as the basis for their own and it is one of the most widely accepted theories (Mullins 2005). Lewin’s theory developed in 1951 comprises of three areas which address the stages that an organisation, company or indeed individual would go through when attempting to make a change (Mullins 2005). These three phases are essential for the change agent (in Mrs Patel’s case this would be the ward manager) to proceed through before a change can become part of Mrs Patel’s care. The three phases are unfreezing, movement, and refreezing (Marquis and Huston 2006). In the unfreezing stage, the change agent (in Mrs Patel’s case the ward manager) unfreezes the situation and the forces that maintain the current status quo. This makes people aware that change needs to happen. The unfreezing stage is also a time to recognise that people are unhappy (Marquis and Huston 2006). Mr Patel made the team aware that he was unhappy about his mother losing weight while she had been on the ward and this should have made the team realise that there is a need for change. Welford (2006) states that the unfreezing stage refers to addressing and challenging the current behaviour, which means challenging the care that Mrs Patel had been receiving. Everyone involved in the care of Mrs Patel must be alerted of the problem of Mrs Patel’s weight loss so that the whole team can appreciate the need for change in this situation. The second stage is movement, which is where the change is implemented. This must include the development of strategies and a problem solving approach (Marrelli 2004). The change agent should identify, plan, and implement strategies ensuring that the change is happening for the good of the patient (Marquis and Huston 2006). This stage could include changes in the care plan for Mrs Patel, or maybe protected mealtimes, which provide meal times for patients where they can eat undisturbed by nurses, doctors or anyone within the care team (NHS Estates 2001). Or perhaps a dietician referral would be appropriate. The final phase of Lewin’s theory is the refreezing stage. Bridges (2003) describes this part of the change as the acceptance and adaptive change. This is when the change agent integrates and stabilises the system into the daily routine (Marquis and Huston 2006). Welford (2006) add that this stage makes the new changes and initiatives common practice into the status quo. The manager needs to ensure that old behaviour is not resumed so their role is to be supportive to the care team and whole-heartedly back the change (Marquis and Huston 2006). The role of the ward manager in this stage is to ensure that all new policies are being adhered to. As mentioned above, protected meal times may be the change. The manager needs to ensure that there are no exceptions to the new change in order for it to work effectively and be ‘refrozen’ into place. Welford (2006) acknowledges that Lewin’s theory is by large an acceptable framework to be used as a basis for change although argues that the theory can seem contradictory as change implies moving on but the word freezing which is used throughout the framework implies “stasis” pp23. In conclusion, the author has critically discussed various management and leadership styles, highlighting important implications for the care of Mrs Patel. Nutrition has been discussed as well as the importance of communication and inter-professional working and evidence based practice. This paper highlights that it is the manager’s responsibility to lead and motivate the care team as well as give guidance and implement and encourage the use of various government policies.