A critical evaluation
This essay will discuss, analyse and critically evaluate the application of leadership and management and organisational culture, as well as relevant leadership and management theories evident to an acute medical ward. This essay will also discuss how this may affect the care management of patients. As well as explore the effect organisation culture may have upon multidisciplinary team collaboration and develop potential strategies that could be applied to the leadership and management structure.
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Ward X is 34 bedded acute medical ward at a UK NHS trust, managed and led by one senior Ward Manager and several Band 6 Registered Nurses’, referred to as ‘Ward Sisters’. Each shift, one assigned ward sister would oversee the ward for the duration of the workday, the ward manager would also be in charge of the ward. The Ward Manager took responsibility and charge of the ward, supervising and mentoring the many staff, while also working alongside them when staff shortages called for it. The ward sisters worked as a team with the registered nurses’ (RN) and other health care professions, such as care-coordinators, and nursing assistants (NA). The other ward sister and RNs led 1-2 bays of patients. For the purpose of this essay all names of the trust and wards have been changed to protect confidentiality in line with the Data Protection Act (1998) and Nursing Midwifery Code (2018).
According to Tappen (2001, p. 6) management is a formal, specifically designated position within an organisation, whereas leadership, is an unofficial, achieved position that may be assumed by more than one person at a time. It can be argued the differences of leadership and management are non-binary, and both definitions change regarding its context. However, despite their differences, there is widespread acknowledgement that the two are intertwined. Tappen (2001, p. 6). Sullivan (2017, p. 44) mirrors a similar view, stating that management and leadership are terms that are often used interchangeably; however, they are not the same, only that in its context a good manager should also be a good leader. This could be mirrored in practice as there are many types of leadership roles, which have similarities to manager roles yet have less power and influence. On ward X the ward manager had more influence and control than the many ward sisters, which although were influential leaders, lacked the responsibilities to manage roles. However, Sullivan (2017, p. 45) argues one may be a good manager of resources and not a good leader of people, likewise a person who is a good leader may not manage well. This has been reflected in practice, as the ward sisters with good management skills often lack the leadership skills to motivate and encourage others. Overall, Jackson (2008) states although sometimes leadership and management can be used interchangeably, they are undoubtably two different concepts. The focus of management is on systems, control and order, whereas leadership involves holding and enacting an idea, and guiding progress through motivation and inspiring others (Jackson, 2008, p. 28, cited in Dignam, et al, 2012, p. 65).
The relationship between leadership and the person centredness of care has been known to have little evaluation in nursing research. However, Backman, et al (2016) highlights recent theoretical frameworks, such as the person-centred nursing framework (McCormack, et al. 2010, cited in Backman, p. 767) and the person-centred framework for long-term care (McGilton, et al. 2012, cited in Backman, et al. 2016, p. 767) imply the importance of leadership for person-centred care. These frameworks are derived from the person-centred theory and suggest, clinical leadership is crucial for person-centred care. (Backman, et al. 2016, p. 767).
An organisation’s success or failure is dependent upon its leaders, and all care professionals can be considered to be in positions of taking the lead in some aspects of care. Gopee and Galloway (2017, p. 76). Culture according to Robinson and Brown (2013 p. 783) is made up of the shared beliefs and values of people in a group or organisation which, together with their practical skills, knowledge and understanding, drive their behaviour. Organisational culture according to Kaufman and McCaughan is a complex mixture of different elements that influence the way things are done, understood, judged and valued, culture is associated with concrete elements such as the symbols, rituals and language encompassed in an organisation (Kaufman and McCaughan, 2013, p.51). Sullivan (2017, p. 29) suggests that as organisations grow and evolve in responding to and meeting the needs of those it was created for and a working environment and work culture develop. The relationship between workplace environment and employees establish a perception of workplace culture, in the same ways that staff’s personalities enable staff’s individuality (Schein, 2004, cited in Eskola, 2016, p. 726). In health care, workplace culture qualifies peoples work and care for their patients by reflecting a microsystem level of culture, which most care is delivered and experienced (Manley, 2008, Manley, et al. 2011, cited in Eskola, 2016). Several healthcare scandals in the UK, such as the failures at Mid Staffordshire NHS Foundation Trust (Francis, 2013). The Francis Inquiry (2013) stated that organisational culture was a pervading cause of the failures within the trust. The report identified many warning signs which should have been addressed, and identified a culture focused on doing the system’s business, not that of the patients, a tolerance of poor standards and risks to patients’ and a failure to tackle challenges to the building up of a positive culture, to name a few. Gopee and Galloway (2017, p. 126).
There are many types of theories on organisational culture and management, which consequently makes the notion of organisational culture a complex one. One such theory is Handy’s types of culture, which consist of The Club Culture (Zeus), The Role Culture (Apollo), The Task Culture (Athena), and The Existential Culture (Dionysus) Handy (2009, p. 10). The task culture is descriptive of the type of culture that was rarely presented but very much attempted on ward X. Management is seen as being basically concerned with the continuous successful solution of problems, first define the problem, then allocating to its solution the appropriate resources, and then wait for the solution. Handy (2009, p. 16). The ward manager had attempted this in their approach to management but failed as they were too focused on completing their tasks, to define specific problems and allocate resources to resolve them. However, the strong sense of the staff knowing their roles and responsibility and their role in achieving a goal, was similar to task culture, as Handy (2009, p. 16) states it’s a good culture to work in if you know your job, since the group has a common purpose, there is a sense of joint commitment, that only resulted in conflict as time restraints were present. An organisation can vary in and out of each of the types of culture described by Handy (2009, p. 10), no culture is bad or wrong, only inappropriate to its circumstances. Wilkinson (2011) suggest that organisation culture and working conditions can contribute to bullying in the working environment (Wilkinson, 2011, p. 506). Workplace bullying in nursing environments has be noted as a reoccurring theme, in particular, the issue of workplace bullying has been reported to be more serious among nurses who work in hospital environment characterised by strict hierarchies and workload, than other occupations (Kang and Lee, 2016 and Waschgler, et al, 2013, cited in Choi and Park, 2019). According to Sullivan (2017, p. 324), ignoring someone, treating them in a condescending or patronizing manner and failing to assist can be categorised as bullying behaviour. Robinson and Brown (2013, p,. 783) suggest a fundamental change is required to develop an open and caring culture, where everyone understands and takes responsibility for their role in delivering compassionate and safe care. The negative impact of workplace bullying is broader than the effects on hospital staff, team performance and subsequent patient care, bullying results in physical, psychological and emotional harm to those being bullied (Wilson, 2016, cited in Logan and Malone, 2018, p. 417) Understandably, such individuals experiencing workplace bulling cannot perform optimally and, by extension, underperforming teams result in poor patient care (Logan and Malone, 2018, p. 417). Therefore, it is essential that there is a culture where staff can openly talk about any experiences of bullying that may be happening.
An example of organisation culture that could possibly negatively impact patient care is when NA would falsify respiration rate reading while completing observations on patients. This was something that was known throughout ward X and was seemingly not addressed, for a long period of time. It was considered something everyone did, which mirrors a description of organisational culture as ‘the way things are done around here’ (Hemmelgarn, et al, 2006, cited in Eskola, et al. 2016, p. 726). Respiratory rate is an extremely valuable indicator as it is an integral part of early warning systems and a diagnostic measurement for systemic inflammatory response syndrome (Mukkamala, Gennings and Wenzel, 2008, cited in Wong, 2018). Only nursing assistance were observed in falsifying respiratory rate records. When staff were observed doing this and consequently approached by the ward sister, conflict arose in the team. Sullivan (2017, p. 199) describes conflict as the consequence of real or perceived differences in mutually exclusive goals, values, ideas, attitudes, beliefs and actions, within either an individual or more or within one group or more. A strategy to manage conflict could be by negotiating the issue and give and take on elements, such as asking why this was happening, and discussing options on how to resolve this. Some reasons stated by the NA included time restraints and cutting corners to achieve their roles task was almost expected of them, which was a result of the transactional leadership style at the time. The RN could suggest shadowing with the NA to help develop and motivate them in a more positive culture. Shadowing has several positive features such as team learning. Learning together facilitates the creation of relationships which enable the wider team to work together more efficiently. Bach and Ellis (2011, p. 130). However, Sullivan (2017, p. 277) highlights that shadowing often fails as there is no assurance that accurate and complete information is presented and will carry on one shadowing is completed.
Leadership styles refers to the behaviour patterns of a leader or an individual who attempts to influence others (Avoka Asmni, et al., 2016, p. 24). According to Wong, et al (2013) leadership requires certain amounts of influence to accomplish a goal, and it therefore may require a specific leadership style or combination of style (Wong, et al, 2013, p. 717). Abdelhafiz, et al (2016 p. 384) suggests that effective leadership styles are positively related with nurse satisfaction, as well as with patient and organisational outcomes. Gopee and Galloway (2017, p. 73) state there are many ways of categorising leadership styles, the tradition classification being authoritarian, democratic, permissive and bureaucratic. Sullivan (2017, p. 45) also highlight that there are many different styles of nursing leadership theories noted in nursing literature. Frequently used leadership theories including transformational leadership, transactional leadership, emotionally intelligent leadership, and authentic leadership have guided nursing research and interventions, likely based on the importance on relationships for effecting positive change and outcomes (Gardner et al, 2005 and Hibberd et al, 2006, cited in Cummings, 2018, p. 20). The manager on ward X presented a transactional leadership style in practice, as they were very task orientated and was aware of goals that needed to be met. This mirrors Wong, et al (2013, p. 710) description of a transactional leader’s role, which recognise their followers needs and monitoring their role fulfilment. While the ward manager exhibited transactional leadership style, it could be argued that staff’s needs, and competencies were not being met. For example, RNs on this ward had issues with getting competencies such as cannulation skills signed off, however NA were given this training. In the example of the ward manager on ward X, it was more likely that they interacted with staff they considered to be more friendly with. This therefore could indicate favouritism and staff whom may not be considered close with the ward manager may have missed opportunities. It was well known that the ward manager was close to many of the NA and this may be the reason they had more opportunities than the RNs that were perceived as less close. As for patient care, nurses could be argued to be more appropriate to have this skilled signed of as they undertake more theory-based practice.
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Although the ward manager presented a transactional leadership style, the ward sisters leadership approach was similar to transformational leadership. The ward sisters presented a more approachable leadership style and appeared to show more trust and confidence in the RNs and NA than the ward manager, focusing on tasks that needed to be completed but also having a strong awareness on other staff. The ward sisters were more involved in communicating with the RNs and involving them in decision making, which therefore empowered the RNs and increased their team productivity. This is backed up by Liukka, Hupli and Turunen (2013, p. 639) that suggest that staff in teams whose managers use transformational leadership methods, appear to have better job satisfaction and better conflict management, than those in teams where managers adopt transactional leadership styles (Cummings, et al., 2010; Kim and Yoon, 2015, cited in Liukka, Hupli and Turunen, 2017, p. 639). A systematic literature review by Cummings, et al, (2018) reported that culture and climate were better in association with authentic, supportive, transformational, structural, and change oriented leadership (Cummings, et al., 2018, p. 50).
A transformational leader is someone who inspires followers to adopt the goals of the organisation and to sacrifice their own personal interests for the organisations sake, it involves a leaders ability to interact, empathize, and support followers more than the organisations expectations (Bass, 1999, cited in Enwereuzor, Ugwu and Eze, 2016, p. 349). Transformational theories of leadership are based on the idea that leaders are people who motivate others to preform by encouraging them to see a vision and change their perceptions on reality. Barr and Dowding (2019, p. 74). Gopee and Galloway (2017, p. 235) suggest that it is important for the ward manager to recognise the importance of motivation and its relevance to their role, as motivating staff are a significant aspect of transformational leadership. Sullivan (2017, p. 397) describes transformational leadership as a style focusing mainly on effecting revolutionary change in an organisation through commitment to its vision. In nursing, transformational leadership has been associated with improved job satisfaction, organisation commitment, improved nurse self-efficacy and engaged and empowered employees (Failla and Stichler, 2008; Nelson et al. 2009 and Weberg, 2010, cited in Andrews, 2012, p. 1103).
A study by Andews (2012) highlights the most effective leadership style in practice, was transformational leadership. The findings of the study backed up previous studies focusing on effective leadership styles. The study indicated that the majority of nurses were satisfied with attributes consistent with a transformational approach. (Andrews, 2012, p. 1103). This leadership style is mostly associated with effective patient outcomes and quality management. A systematic review by Wong, Cummings and Ducharme (2013, p. 720) found that transformational leadership style was linked with lower patient mortality and reduced medication errors, restraint use, patient falls, and hospital-acquired infections (Wong, Cummings and Ducharme, 2013, p. 720). It has been argued that these may improve patient outcomes as transformational leaders treat errors as opportunities to improve practice and encourage the reporting of near misses and accidents in clinical practice (Merrill, 2015, cited in Liukka, Hupli and Turunen, 2017, p. 640). Although research suggests that transformational leadership yields the best results for staff satisfaction and positive patient outcomes, it appears one leadership style does not necessarily meet all nursing leader’s needs (Lawrence and Richardson, 2012, p. 76). Bass and Dowding (2019, p. 75) suggest a criticism of transformational leaders may be the tendencies to focus on the bigger issues of life and because of their high visibility are unwilling to spend time facilitating the implementation, thus to followers, it may be perceived that the leaders are autocratic and success is about the detail of getting things done.
Management theories, according to Gopee and Galloway (2017, p. 36) can be categorised in different ways, such as the four approaches promoted by Mullins (2016, cited in Gopee and Galloway, 2017, p. 36) as universal management theories for all organisations, these include ‘the classic approach, human relations approach, systems approach and contingency approach’. In relation to the ward management style presented on ward X, the approach that best reflects practice is the classical approach. The ward manager had clear ideals on the roles and responsibilities that the sister nurses, RNs and NA should achieve and believed to enhance staff’s efficiency through thoughtfully designed tasks. According to Sullivan (2017, p. 15) the ward manager shows similarities to the classical approach. The classical approach or reductive theory focuses on the nature of work to be accomplished, the creating of structures to achieve work and dissecting the work into component parts. Sullivan (2017, p. 15). Although this is one of the earliest management theories, there are noted weakness to this approach that negatively influences the staff and patients’ outcomes. For example, Gopee and Galloway (2017, p. 37) state over-emphasis on rules and regulations can stifle growth and initiative and lead to frustration and conflict, as well as neglect of the staff’s aspirations. Regarding the classical approaches, the outcome of patient care was mainly considered top priority, as RNs and other NA created workarounds when necessary to achieve patient care objectives, however Gopee and Galloway (2017, p. 37) state how staff’s concerns and care may be missed when using this style of approach.
A theory that better emphasises staff and patient care is the behavioural approach. This approach according to Northouse (2019, p, 80) works by not telling leaders how to behave, but by describing the major components of their behaviour. The behavioural approach reminds leaders that their actions towards others occur on a task level and relationship level. Northouse (2019, p. 80). The ward manager can achieve this by considering the individual members of staff’s personal prospects in relation to their post, such as their personal and professional development needs, rather than focusing on their role and the work they need to complete. Goppe and Galloway (2017, p. 38) state that the behavioural approach encourages groups of staff to work as teams, rather than separate individuals. The issue of this approach is that the ward manager would most likely struggle to create personal relationships with all the staff. Gopee and Galloway (2017, p. 39) state that the feasibility of implementing this approach into practice is questioned as it depends on the levels of employees’ motivation and their knowledge and competence, it could also be said that it is difficult to please all staff. No approach can be officially titled the most effective management approach, in some situations to achieve good patient outcomes some leaders need to be more task oriented whereas in others they need to be more relationship orientated. Northouse (2019, p. 80).
Overall, there are many different leadership and management theories and styles that can influence staff and patient outcomes. Not all theories and styles are clear cut, and it is possible for them to merge into a different style of leadership and management. Organisational culture can have a negative impact of leadership and management and can impact how leaders and managers can achieve efficient leadership and management skills to get the best outcomes for staff and patients alike. The right leadership and management skills are necessary in battling negative organisational culture, as evident in the Francis report.
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