Deeper Understanding of Leadership and Management, and Their Influence on Nursing Practice in Psychiatric Inpatient Unit

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This essay will explore the concept of leadership, management and professional practice and how these influence nursing practice in a later life psychiatric inpatient unit. The author will consider leadership and management styles in the above clinical area. Moreover, the essay will explore the concept of organisational culture, its effect on healthcare delivery and some of the factors that can be used to improve its influence in an organisation. In conclusion, the author will develop some potential strategies or changes that could be applied to the leadership and management structure to enhance patient care.

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Modern hospital care is confronted by many challenges such as workforce, changing consumer expectations and demands, financial constraints, increasing requirements for access to care, mandates to improve patient care, and issues regarding the levels of quality and safety of healthcare. Therefore, Sfantou et al. , (2017) highlight the need for effective leadership in healthcare professionals to strengthen the quality and integration of care. Likewise, Xu (2017) point out how effective clinical leadership ensures high-quality health care is provided and maintained in the healthcare setting. Similarly, Rokstad et al. , (2013) explain that good leadership plays a crucial role in developing nurses’ understanding of patients’ needs, values and the acceptance of innovations to obtain successful change which leads to a positive care culture. Sullivan and Garland (2013) define a leader as anyone who uses interpersonal skills to influence others to accomplish a specific goal. Further, leadership has been described as a process whereby an individual influences a group of individuals to achieve a common goal. In the care setting, nurses influence the way care provided as they have a responsibility to identify priorities, manage time, staff and resources. In the clinical area above, shift handover is done only by a qualified nurse. Nurses lead the handover session where income staff must receive a report on patient’s status before commencing care.

According to Scovell, (2010) handover is a crucial part of providing quality nursing care as any errors or omissions made during the handover process may have dangerous consequences. During handover, the incoming nurse delegate duties to other members of the team such as support workers, assistance practitioners for patient care continuity. The Code states that nurses must work with others to protect and promote the health and well-being of those in their care. Part of that work involves the communication of patients’ details and treatment information to ensure the smooth transition of care. During handover in the ward, the nurse would delegate duties to other members of the team while considering their skills to manage patient care effectively. Sullivan defines a manager as an individual employed by an organisation who is responsible and accountable for efficiently accomplishing the goals of the organisation. The author further states managers focus on coordinating and integrating resources. Likewise, Sullivan and Garland point out that a manager’s job is to create stability and predictability to maintain a set of principle that will provide results. Registered nurses are responsible for managing nursing care and are accountable for the appropriate delegation and supervision of care provided by others in the team. In the above-identified clinical setting, a nurse was responsible for coordinating the shift whereby nurse decided when how breaks should be taken considering ward environment. A nurse who was leading the shift was responsible for making sure they had enough number of staff to provide care to the patient and could ask for more if needed. Hence, all nurses are in management roles, not in a formal organisational sense but practice as seen in the above example.

Sullivan and Garland (2013) state that management is about coping with complexity, providing order and consistency to the quality of care and work roles. Northouse (2016) suggests that management was created as a way to reduce chaos in organisations to make them run more effectively and efficiently. According to Sullivan and Garland (2018), identifies the primary functions of management like planning, organising, directing and controlling. Northouse (2016) argues that this functions of management provide order and consistency leading to stability. Nurse plan, organise, direct and control what goes on in their unit, but they consider patient safety and care. The nurse has to consider staffing level, skills of the staff available and the safety of everyone. In conclusion, management help to maintain the quality and appropriateness of nursing care provided in the ward environment. Likewise, nurse managers are supposed to be critical thinkers in problem-solving, decision making and be creative. As suggested above, leadership is a process that is similar to management in many ways.

According to Northouse (2016), both leadership and management involve influence and effective goal accomplishment. Likewise, Sullivan and Garland (2013) imply that management roles always have an element of leadership in them. However, Northouse (2016) states that leadership is also different from management. The author argues that management produces order and consistency, while leadership produces change and movement. For example, management establishes agendas while leadership creates a vision. Management provides a structure for organising and staffing while leadership aligns with the people and communicate goals. Hence both management and leadership are needed to improve patient care. There is also strong evidence to suggest that effective nursing leadership benefits from an independent working culture, which empowers leaders to identify and challenge poor practices especially where they are given the authority to act and discharge their duties. Similarly, Kings funds, (2015) reports that NHS is emphasising the need to empower front-line staff regarding their decision-making competencies and the need for an effective leadership style. Likewise, leadership and management influence the nature of patient care in various ways. More importantly, Xu (2017) highlights that leadership is the process of controlling others to understand and agree about what needs to be done and how to do it, and the method of facilitating individual and collective efforts to accomplish shared objectives. These show that leadership and management help to maximise efficiency and achieve organisational goals. In clinical settings, effective clinical leadership has consistently been identified as an essential component to ensure quality care. Their strong evidence that suggests the type of leadership in a clinical setting can influence patient care. This essay aims to use different leadership theories to interpret a common scenario in the above-identified clinical setting to improve leadership effectiveness. Simultaneously, the essay will explore various leadership styles and explains how they relate to nursing practice. Psychiatric observations are a routine part of clinical practice, the purpose of which is to ensure the safety of patients during their stay within an inpatient ward as well as promoting therapeutic engagement with patients. There are the four levels of psychiatric observations described in the NICE guidelines; the service user was on level four. According to nice guidelines, level four is a One to One Observation or within arm’s length and is the highest observation level. The service user in this scenario was on this level. A support worker was assigned to care for this service user. During a ward round, the nurse found the support worker on her phone. When asked why she was on her phone, she said that the service user was asleep and appeared safe.

The policy of that ward does not allow staff to use a phone while on duty. On this case, the support worker did not recognise her mistake and did not know using a mobile phone while on assignment for personal reason was against hospital policy, patient safety was jeopardised and quality care could not be provided, not to mention diminished patient satisfaction and adverse outcomes. Hence, the nurse in charge of the shift had to take action. The biggest challenge for the nurse was getting the support worker to acknowledge the mistake and subsequently change her behaviour. The ultimate goal in this scenario, however, is to prevent it occurring again, to convince her to take her job more seriously, and to encourage a positive attitude toward her work to promote patient care. The first theory that can be utilized in this scenario is the transformational leadership theory that was evident in this clinical area. Northouse (2016) defines transformational leadership as a relationship between the leader and the follower in which they motivate each other to higher levels, resulting in value system congruence between the leader and the follower. Equally, Sfantou et al. , (2017) show transformational leaders typically can inspire confidence, staff respect and they communicate loyalty through a shared vision, resulting in increased productivity, strengthen employee morale, and job satisfaction. Therefore, a leader acts as a manager of change, making exchanges with employees that lead to an improvement in production. Sullivan (2018), explains that transactional leadership is derived on the principles of social exchange theory. The author states the primary premise of the social exchange theory is that an individual engages in social interactions expecting to give and receive benefits or favours. Similarly, Fischer (2017) agrees that transactional leadership involves the use of contingent reward in which the contract between an employee and employer depends on the performance of certain tasks in exchange for a reward, such as wages.

As explained by Sfantou et al. , (2017), according to transformational leadership theory, first, the charge nurse in the scenario should schedule an appropriate time and designate a private room for a one-on-one talk with the worker to reassure her of the leader’s respect and trust. At this stage, it is crucial to mention that this is just talking, similar to the process of story-telling rather than a process of criticism. Second, when communicating with the support worker, the nurse should listen carefully to her thoughts, as it is imperative to recognise her needs and concerns. Third, the nurse should analyse the severity of this problem. The nurse should explain what is expected of the support worker and try to motivate her towards further career development, for example being more familiar with the trust’s policy. By utilising transformational leadership, the nurse’s behaviour can influence others. Hence, the nurse will improve the organisational commitment and is more likely to create a positive culture enabling the organisations to achieve its goals. In contrast, transactional leadership is based on a culture of performance where behavioural norms strictly followed. Often these leaders only engage with their colleagues following an error, thereby fostering a culture of fear rather than one of security among staff. Transactional leadership influences followers to do what the leaders want. If an organisation is run like a business, leaders will have a culture of doing the system business. Likewise, Francis report highlighted that one of the reasons for the failure of Mid Staffordshire NHS Foundation Trust was having a culture focused on doing the system’s business and not that of the patients. NHS as an organisation has its own structure, Sullivan and Garland (2013) describe organisation stature as the division of labour and the relationship between and among the workgroup. According to classical theorist, organisations use departments as a means of allocating responsibility, reinforcing authority and to provide a formal system for communication. Organisational structures generate the lines of power and influence in an organisation. Hence they can dictate which staffs possess decision-making powers. Therefore, an organisation that utilises transformational leadership, nurse leaders becomes innovative, creative and energetic, hence improving patient care. Francis report highlighted how the Mid Staffordshire trust culture was one of self-promotion rather than critical analysis and openness. These led to poor leadership which affected patient care. Sullivan (2018) states organisational culture comprises of the underlying assumptions and values held by members. Likewise, Sullivan and Garland (2013) define organisational culture as the norms and tradition maintained or, in the way things are done here. To improve patient care, Nightingale (2018) advocates that organisations should seek to implement a culture where conditions are suitable for growth, which, in healthcare terms, would include promoting clinical excellence, staff engagement and morale, and protecting the culture while it is developing. Similarly, transformational leaders are enthusiastic, emotionally mature, visionary and courageous lifelong learner who inspires and motivates by empowering and developing followers. The Code states that nurses should practise effectively by working cooperatively with their colleagues (NMC, 2015). Further, Nightingale (2018) indicates that Nurse should be aware of the role of organisational culture in influencing healthcare delivery and how they can provide adequate patient care. Organisational culture enables nurses to understand an organisation’s underpinning values, which should encompass person-centred care and work in partnership with patients (Nightingale, 2018). To improve the health and wellbeing of staff and patients, NHS culture is embedded in its constitution. NHS values indicate what’s the organisation norms and tradition. Mullins and Christy (2013) outlined how traditions and values are essential facets of organisational culture. For example, in the above-identified clinical area, only nurses could conduct a handover. Organisation culture reflects what the team practices, provides meaning and direction for work.

There are several theories of organisational culture, according to Mullins and Christy (2013) there are four main types of organisational culture as described by Harrison and Handy. Power culture depends on the central power source with rays of influence from the central figure throughout the organisation. These do not reflect the current NHS leadership model, where there is a drive towards team decision-making. Dr Kirkup report on Morecambe Bay investigation found out that in the midwifery care unit became strongly influenced by a small number of dominant individuals whose over-zealous pursuit of the natural childbirth approach led at times to inappropriate and unsafe care. Hence the need for transformational leaders is required as transformational leadership aims to improve an organisation by engaging and empowering its staff, and is based on the theory that leaders cannot achieve their goals without the assistance of their colleagues. Task culture is concerned with developing teams in which individual members have a common interest in overcoming challenges and achieving targets. Moreover, task culture forms when teams in an organisation are formed to address specific problems or progress projects. Further, the task is the critical thing, so power within the team will often shift depending on the mix of the team members and the status of the problem or project. However, Nightingale (2018) point out consideration should be given to the human element of effective teamwork, for example, active listening skills, empathy and compassion. Hence, whether the task culture proves effective will largely be determined by the team dynamic. With the right mix of skills, personalities and leadership, working in teams can be incredibly productive and creative.

Organisations with a role culture are based on rules where job description is often more important than the individual. Also, Nightingale (2018) highlights role culture involves roles and responsibilities being delegated to staff that have the appropriate education, qualifications and areas of interest. For example, during handover, the charge nurse would delegate duties to staff with appropriate skills. Nightingale (2018) asserts role culture is aligned with the principles of the modern NHS. Consequently, the decision-making in role cultures can often be painfully-slow and the organisation is less likely to take risks. Leading to a bureaucracy that can cause lack of inspirational element that could unlock the potential of healthcare staff. Thus, in power culture, power is held by a few individuals who decide what happens, enable swift decision and reduces bureaucracy. However, a quick decision made by a few individuals can turn toxic and impact on team collaboration and communication. For example, Kennedy (2001) cited the Bristol Royal Infirmary inquiry into the treatment of infants with congenital heart disease, which detailed how the organisational culture contributed to inadequate care. Kennedy (2001) described a club culture to which some senior managers belonged while others were excluded; where the challenging of policies was seen as disloyal; and where healthcare staff’s career progression depended on whether they were part of a clique rather than their performance. Likewise, the organisational culture was also a common theme to emerge from Francis, which detailed the appalling suffering of many patients. The report stated that organisational culture was an essential determinant in developing a safe healthcare system, and requires a culture of openness and learning, where healthcare staff can voice concerns.

One of the recommendations of the report was to foster a common culture shared by all in the service of putting the patient first. The report concluded that a shared organisational culture provides healthcare staff with a sense of unity and fosters understanding between them, which in turn provides a framework for the implementation of optimal patient care. The key challenge facing all NHS organisations is to nurture cultures that ensure the delivery of continuously improving high quality, safe and compassionate care. Furthermore, leadership is the most influential factor in shaping organisational culture so ensuring the necessary leadership behaviours, strategies and qualities are developed are fundamental. There is clear evidence of the link between leadership and a range of essential outcomes within health services, including patient satisfaction, patient mortality, organisational financial performance, staff well-being, engagement, turnover and absenteeism, and overall quality of care. Hence, the challenges that face healthcare organisations are too significant and too many for the leadership to be left to chance or piecemeal approaches.

To improve patient care and teamwork, Lewin’s model of change can be used as a basis as it widely recognised and straightforward in its conception. It involves: ‘unfreezing’ from the existing level of behaviour; changing the behaviour or moving it to a new level; and then ‘refreezing’ it at the new level. The three phases include the clarification or diagnosis of the problem; the examination of alternatives and establishing a plan of action; and the transformation of intentions into actions to bring about change. However, Barr and Dowding, point out that any changes must regard the inclusion of relationship-building and gaining of acceptance, as these integrate the importance of relationships and people which is an essential aspect of transformational leadership. Evidence suggests that clinical supervision produces positives positive effects working, managing and organising care across organisational and cultural boundaries. CQC defines clinical supervision as “an accountable process which supports, assures and develops the knowledge skills and values of an individual group or team”. Further CQC states the purpose of clinical supervision is to provide a safe and confidential environment for staff to reflect on and discuss their work and their personal and professional responses to their work. Likewise, Fowler, (2012) clinical supervision is characterised by reflection on the previous action, its implications for future action and offering constructive feedback. Hence, clinical supervision leads to working in a supportive environment and develops a culture where genuine respect for colleagues and patients is the norm.

The essay has explored leadership, management and team working in later life psychiatric inpatient unit. Further, the author has identified the effective way of conflict resolution, de-escalation and managing complaints to maximise team functioning. Likewise, some aspects of organisational culture have also been examined and their influences. Some recommendations have been made, based on previous studies relating to the subject areas.

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