This essay will analyses leadership and how it impacts on organisational culture and the effects on nursing staff, this paper will show the difference between leadership and management, consider the impact and influence of organisational culture on patients and their outcomes, this essay will explore the theories of leadership and show the elements required to have an effective sustainable culture for better patient outcomes.
Organisational culture effects the environment in which nurse’s work and patient care (Lok & Crawford 2003, p.321). Studies have reported that when employees are dissatisfied with the organisational culture there is higher staff turnover, less commitment and patient care outcomes are poorer (Meterko et al 2004, p. 492).
Many hospitals within Australia are governed by a bureaucratic organization, where there is structure, goals, and staff are managed systematically with formal leadership “things are done this way “attitude, this makes change very difficult and nurses feel they are in an oppressed group (Crookes et al 2008, p.p 97-98). To change this form of culture nurses need to become leaders (Meterko et al 2004, p. 493).
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Day et al (2008) identified five cultures within the Australian health care system 1. Culture of blame this is where staff are dissatisfied with the organization, there is poor communication, there is conflict among staff and the union is often involved (Day et al 2008, p. 72). 2. Culture of reaction this is where management is trying to resolve ongoing staff issues and trying to improve communications (Day et al 2008, p. 72).
3. Culture of consolidation this is where there is always change and staff verbalize they are tired of change (Day et al 2008, p. 72). 4. Culture of ambition this is where staff look for new better ways of doing things there is a risk of having too many projects that can cause the projects to fail or not be completed (Day et al 2008, p. 72). 5. Culture of success this is where staff think about the future and where they are heading, are proactive in problem solving, are close knit, focused and effective workers (Day et al 2008, p. 72). Organisational culture is built by its members; they exhibit common values, beliefs and perceptions of the organization (Day et al 2008, p. 73).
To be an effective leader the nurse must learn certain skills, to be more self aware and understand their weakness and strengths, this will in turn build self confidence (Dierckx de Casterle et al 2008, p. 758). They need to become an effective communicator inspiring as well as listening, have a clear vision, but being able to be flexible to change the vision with the nursing staff and the organisation (Dierckx de Casterle et al 2008, p. 761). Leadership within nursing may relate to specific activities or behaviours and may be both supported and limited by the organisation and its culture, but there is also a myriad of professional cultures as well, all of which impact upon the culture of the organisation (Mullins 2006, p.6). This relates to the ways in which “individuals and groups interact within the structure of the organisation” (Mullins 2006, p.6). McCormack and McCance (2006) argue that for nurses “to deliver person-centred outcomes, account must be taken of the prerequisites and the care environment that are necessary for providing effective care through the care processes,” (p.472).
Chiok Foong Loke (2001, p. 193) highlights five distinct practices that leaders use to affect performance in nurses and the organisation. These practices include challenging the process, inspiring a shared vision, enabling others to act, modelling the way and encouraging the heart (Chiok Foong Loke 2001, p. 193). The study conducted by Chiok Foong Loke (2001, p. 200) explored the relationship between the five leadership behaviours, their findings suggests that the five leadership behaviours should be introduced by administrators to nursing staff and constantly encouraged as leadership is an observable and learnable set of practices (Chiok Foong Loke 2001, p. 200).
Leadership can contribute to the success or failure of an organisation (Lok & Crawford 2003, p. 324). Leadership as a concept is considerably complex, and theories of leadership are multiple and often opposing or challenging each other. There are the theories of innate or trait leadership, in which people are said to be ‘born’ leaders possessing natural abilities in this field, which are countered by theories that state people can learn leadership attributes, knowledge and abilities, and so occupy leadership positions (Day 2000). However, it is important here to distinguish between leadership and management, because leaders can be transformational leaders, and tend to be followed because they inspire others by their behaviours, while managers are those that occupy formal positions of power or authority within the organisational hierarchy (Day 2000). Of course, leaders can be managers, and some argue that anyone in a leadership role should best have innate leadership traits, while others suggest that these leadership abilities can be acquired (Green 2003). Effective leadership however depends on the ability to work within the organisational culture and to mediate between the organisation and the employee (Green 2003). Often, because of the way that the health care service and the healthcare unit is structured, leadership strongly relates to the leadership of teams, in which often leadership is conferred by support and acceptance, rather than by the authority of an individual’s position (Grint 2005). This however can only occur if there is an underlying culture which allows individuals to express their leadership traits or skills (Grint 2005).
Lok & Crawford (2003, p. 324) states that leadership styles have been extensively studied. There are many types of leadership but the most effective for change is transformational leadership, nurses who had exhibited leadership behaviours were higher in organisational commitment and increased job satisfaction (Wong 2007). These nurses were also more likely to stay in their job longer (Wong 2007). They are agents of change to promote and sustain the quality of patient care including patient’s mortality rate (Wong 2007). Studies have shown that leadership behaviours in nurses correlate to positive effects on job performance, job productivity, and job satisfaction, which may lead to patient satisfaction and quality care (Wong 2007). Leadership has been accepted as the key factor of a worker’s job satisfaction and organisational effectiveness. Research suggests that nurses who demonstrated behaviours of contemporary theory model often benefit patients, their employers, and themselves (Wong 2007). This in turn impacts on other nursing professionals in a positive way, leadership behaviours are important to encourage productive nurses, giving them the confidence to act and make their own decisions, helping nurses to see the shared vision of the organisation and empowering them to change practice for better patient outcomes (Chiok Foong Loke 2001, pp.199-200) Leadership within nursing has emerged over time to impact upon the way that care is delivered and managed, and this can provide us with one example of how leadership can impact upon organisational culture. Over the last twenty years, the role and scope of nurses has expanded to include a significant movement into advanced practice, and nurses within advanced practice roles are expressing significant leadership power and position. Advanced practice nurses act as assessors of health care, individual and group needs, and provide management and clinical leadership (Walsgrove and Fulbrook, 2005).
The difference between leadership and management is leadership means lead and management means manage (Grimm 2010, p. 74). Leadership is a complex entity and is often describe as an art, effective leaders must have certain traits, they must have confidence and confidence is built over time and experience (Grimm 2010, p. 75), purpose leaders must have a purpose know which direction they wish to take the organisation and discuss this with staff with openness and honesty (Grimm 2010, p. 75). They need to have moral courage which requires the leader to have integrity and know their beliefs and values and stand by them (Grimm 2010, p. 75). They require ethical fitness, knowing what is right and wrong and have the courage to take a stand reflecting on their morals and values to ensure they have made the right decision (Grimm 2010, p. 75). Setting priorities is an important trait, trying to only have 3 to 5 issues to deal with at a time (Grimm 2010, p. 75). Leaders motivate people, empower staff and encourage practice development (Manley 2000, p. 34). The most effective form of leadership is transformational leadership, these leaders transform people and organisations encouraging and effecting necessary change (Crookes et al 2008, p. 101).
Managers control, have an assigned position, carry out functions, duties, responsibilities, manipulate people, money, time and aspire to organisational goals and have willing and unwilling subordinates (Covey & Drucker 2009, p. 31). Managers have contributed to the poor image of management and have come to be perceived as organizers, planner and controllers (McKenna et al 2010, p. 130). Therefore as stated before those in leadership positions lead and those in management positions manage.
Organisational culture plays a big part in patient care, when organisational culture is dysfunctional patients and nursing staff are the ones that suffer (Meterko et al 2004). Functional organisational cultures that have transformational leaders and teamwork have better outcomes, patient care and low nurse turnover (Meterko et al 2004, p. 492). Wong & Cummings (2007, p. 517) suggests that new organisational models have changed the process in nursing; due to the change leadership in nursing is having better patient outcomes. Patient outcomes were changed through work context and nurse behaviours that enhanced patient care (Wong & Cummings 2007, p. 517).
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Wong & Cummings (2007, pp.517-518) study showed four areas of leadership and patient outcomes. 1. Patient satisfaction showed a significant increase with positive leadership behaviours and a decrease in transactional leadership style (Wong & Cummings 2007, p. 517). 2. Patient mortality reduced mortality rates were contributed to experienced staff, effective leadership and staff being retained in the role (Wong & Cummings 2007, p. 517). 3. Patient safely outcomes: adverse events, a strong relationship between leadership and patient outcomes was evident here, there was a decrease in patient falls, medication errors, increase in patient safety to due positive leadership practices (Wong & Cummings 2007, p. 518). 4. Patient safety outcomes: complications, a reduction of pneumonia and urinary tract infections were attributed to positive leadership practices (Wong & Cummings 2007, p. 518). The study concluded that the culture of transformational nursing leadership increased patient satisfaction, reduced patient adverse events and complications (Wong & Cummings 2007, p. 520).
Leadership theories go back to the 1900s where man were leaders and born to be leaders this was called the great man theory, similar to the great man theory was the trait theory it was assumed that people inherit certain traits this made them better leaders (Cherry 2010, p.1) The 1940 to the 1980s bought behavioural, contingency and situational theories these theories were about the authoritarian, democracy and laissez-faire according to these theories no situations are the same and different leadership styles were called for (Cherry 2010, p. 1). The 1980s to present bought about contemporary theories, transactional leaders who are usually managers and transformational leaders are nurse leaders (Cherry 2010, p. 1). According to Wong & Cummings (2007, p. 520) transformational leadership increased positive patient outcomes, increased patient satisfaction and reduced compilations.
Nurses are leaving the profession in large numbers due to job dissatisfaction (Joyce & Crookes 2007, p. 18). This is happening all over the world, health authorities need to make a change to keep nursing staff and increase better patient outcomes (Joyce & Crookes 2007, p. 18).
Magnet hospitals were established in the United States in the early 1980s there is evidence that magnet hospitals retain staff, produce better outcomes for patients and produce quality patient care (Joyce & Crookes 2007, p. 18) The health care system has the need to address these problems in Australian hospitals to retain staff, produce better patient care and outcomes (Joyce & Crookes 2007, p.23).
Lewins Theory of change is one way an organization could make changes that are staff and patient focused (Crookes et al 2008, p. 104). Lewins Theory was to unfreeze, move and refreeze (Crookes et al 2008, p. 104). By unfreezing the current environment and exploring the need for change, what needs to be changed, where and why (Crookes et al 2008, p. 105). The organisation can move into the second phase moving, this is where change is identified and everybody is consulted from management to staff to share their values and beliefs and affect the change (Crookes et al 2008, p. 105). The third stage is refreezing, the new change takes place promoting sustainable culture and positive patient outcomes as seen in the magnet hospital system and those hospital that have transformational leadership (Crookes et al 2008).
Conclusion
Organisational Culture effects the environment in which nurse’s work and patient care. There are many types of culture in the health care system and the most effective culture would be a culture of success were staff and the organisations have a shared vision, common values and beliefs, think about the future, have patient centred care goals and effective leaders. The multiple disciplines, specialities and professions involved within healthcare delivery require effective management and organisation, but furthermore, the complexities of patient needs require appropriate individualised responsiveness from the organisation.
Leadership has a great effect on organisational culture it can mean success and failure of the organisation, effective leadership is known as transformational leadership and has the best outcomes for patient care and job satisfaction. It is evident that culture plays a part in patient care and transformational leaders have an influence on positive patient outcomes. When there is a dysfunctional organisational culture there is a need for change, by using Lewins Theory of Leadership, unfreezing, moving and refreezing, change can take effect, having a sustainable culture improves nursing practice productivity, improves patient outcomes and quality of care.
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