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1.1 This report looks at my existing leadership skills and how they have developed when implementing a postnatal group within my practice. Through developing this group, I will look at how the team responds to my leadership and how I approach situations. As part of my continuing professional development, I will identify changes needed in my approach to future practice in order to provide a quality working environment and improved development of service provision. This community health care project was chosen because Hall et al (2009) states that governments are increasingly interested in community healthcare programmes because, in partnership with other agencies, they can reduce social exclusion and the inequalities within and between local communities.
Support groups can relieve feelings of isolation and loneliness – in a study of women with post-natal depression, the support from others meant that mothers gained in self-esteem and felt empowered (Eastwood et al, 1995).
1.2 The Specialist Community Public Health Nurse (SCPHN) must follow performance standards in association with health enhancing activities (Nursing and Midwifery Council, 2004, p12). Part of these standards state that I am responsible for applying leadership skills and managing projects to improve health and well being. Promoting partnership working and leading public health interventions through innovative and visionary approaches is key to my role as a SCPHN. Historically much of health service provision has been service led rather than needs led, designed and developed at the convenience of the providers rather than the patients (Wilkinson & Murray 1998). Healthy lives, brighter futures (DOH, 2009a) and Saving Lives: Our Healthier Nation (DoH, 1999) highlight the importance of there being partnership between services, children and parents which must be driven by strong leadership by SCPHN’s. These improvements need to be achieved through an agreement between health practitioners and services and parents, children and young people.
2 . Aims
2.1 The aims of this report are to identify different leadership approaches and my own approach and evaluate positives and negatives of these approaches to improve my leadership skills. To explore the SCPHN role as a leader and the opportunities and obstacles that may impinge on effective leadership requirements in public health nursing through leading the development of a postnatal group. All SCPHN’s interventions should operate on a partnership and empowerment model of delivery, which ensures acceptability of the service by both professionals and clients. Further aims will be to understand the principles of change management and conflict management, to enable effective resolution and promote a cohesive team environment.
3. Leadership in Practice
3.1 Through my experience as a SCPHN I believe that I hold transformational leadership traits, which include communication, motivation, decision making and conflict resolution. I believe my current skills lie in communication and motivation but areas where development is required are conflict within teams and on an individual basis. Two types of leaders have been identified – transactional leaders set goals, give directions and use rewards to reinforce employee behaviours associated with meeting or exceeding established goals. Transformational leaders have the ability to motivate performance beyond expectations through their ability to influence attitudes (Mcguire & Kennerly 2006, p.180). I endeavoured to follow Johnson’s (2005) research, which suggested that highly effective leaders need both vision as well as a specific plan in order to carry out their plan if goals are to be achieved. I have demonstrated vision by creating this idea for a postnatal group. As a transformational leader I will try to share my vision with my followers, enthusing them with a high level of commitment (ChangingMinds, 2002-2006). In previous professional roles I was a follower and therefore I need to develop leadership skills. It is important as a practitioner to be aware and incorporate the qualities of both leadership styles in practice.
3.2 In my role as a leader I need to use interpersonal skills to influence others to accomplish a specific goal – exerting influence by using a flexible approach of personal behaviours which is important in forging links, creating connections amongst organisations in order to promote high levels of performance and quality care (Sullivan & Decker, 2009). I have approached a fellow SCPHN within the team and by recognising her individual expertise and praising her knowledge have encouraged her to contribute to the group by leading a session on women’s health. As a leader I recognise Rafferty’s (1993) work by caring for the people I lead and I can see that by encouraging and praising my team I am able to promote high levels of performance, which therefore results in the delivery of high quality care.
3.3 In my leadership experience I have recognised the need to focus on the relationship between the people and the organisation – this is described as Action Centred Leadership by Adair (1979) (Appendix 1). Adair highlighted the importance of a leader having the ability to meet three functions these where; to achieve the required task; to maintain the team and to meet the needs of individual team members. I have recognised the complexity of achieving successful leadership which requires the overlapping of these three functions in variable proportions to achieve the desired outcome. I have identified that both my team members and I have individual strengths and weaknesses and therefore task completion requires a multidisciplinary team approach, considering the organisational skill mix and resources available. Team members need to have an understanding of what is expected of them, and an understanding of how their individual contributions relate to the whole project. When developing the idea for the postnatal group we had a team meeting to share ideas and to ensure that everyone was aware of the aims of the project. Consideration of the needs of the team involved my considering training needs, communication systems and team development in order for my multi-professional team to function. Prior to commencement of the postnatal group a multidisciplinary team introduction meeting was held to ensure that every team member was familiar with their colleagues expertise and skills.
As a leader it is important to recognise team members have individual skills, needs and problems, and to give praise and status to everyone. Again training and development is essential in order to maintain quality of care delivery as outlined in the benchmarks within the Essence of Care (DoH, 2006). When delegating work to others as a registered practitioner I have a legal responsibility to determine the knowledge and skill level required to perform delegated tasks. Like other public bodies, health service providers are accountable to both the criminal and civil courts to ensure that their activities conform to legal requirements. As a registered practitioner I am also accountable to regulatory and professional bodies in terms of standards of practice and patient care (RCN, 2006).
If a focussed and effective group is to develop huge importance should be given to valuing all the skills and contributions of team members. As the team leader on this project I made myself available for one to one support for staff and held regular update sessions to see how their role was developing within the project and give them opportunity to raise concerns or highlight areas of improvement.
3.4 As a leader in Health Care it is my role to promote and develop partnerships between clients and other agencies, to empower and motivate individuals in order to develop services and service provision in communities. In 2006, the Essence of Care (DoH, 2006) outlined the importance of partnership working – health promotion is undertaken in partnership with others using a variety of expertise and experiences. In many areas of the health service funding is limited but if individuals within my community can be motivated to take the lead on this project, they may be able to apply for extra funding (such as lottery grants) in order to be able to achieve future aims and targets.
3.5 An important aspect of leadership is having a good understanding of your team and an awareness of team relationships which includes how you view yourself as a leader and how your team view you. Having the ability to reflect on your own leadership style is essential in order to promote flexibility and the ability to change methods to suit different teams and individuals. I look to my manager to provide active displays of recognition, commitment and vision to ensure that my skills and those of other health professionals are utilised to improve the health and well being of communities, families and individuals (McMurray & Cheater, 2004). I realise that vision is a key characteristic of effective leadership; it reflects the ability to create and articulate a realistic, credible, attractive picture of the future for individuals and organisations that grows out of and improves upon the present (Robbins, 2000). I agree with Barr & Dowding (2010) who stated that you do not need to be a manager to be a leader but you do need to be a good leader to be an effective manager.
4. Leadership styles applied to the complexity of delivery of care.
4.1I have encountered many different leadership styles in my work in the Health Care sector. Many theorists have discussed leadership styles; Lewin et al (1939) identified three main leadership styles. Laissez-faire – can present as disorganised, team members not aware of what is required from them with feelings of panic and lack of time. I have worked with a Laissez-faire leader which led to stressful situations where the leader would shout and not warn team members of future roles and responsibilities. This led to a very disjointed team and high levels of absence with stress related conditions. Directive/Autocratic – this mode of working generally focuses on task specific allocation which great emphasis on precision delivered in a military style. I see my own leadership style as being non confrontational and therefore an autocratic leadership technique is not my preferred choice.
I aim to develop my leadership style to become a participatory leader – with a quiet contributory presence, encourage a happy team spirit where each member of the group supports and values each other, and there is a sense of belonging. I aim to deliver quality patient care with effective monitoring of standards, by allocating task driven duties, which give my team feelings of achievement. To progress and develop the skills required to achieve this form of leadership style I need to be aware that different teams require flexible approaches and this style may not suit all. I will need to seek continuing professional development and take advantage of available training throughout my career to develop my leadership skills. I can continue to grow as a leader by maintaining evidenced based practice and keeping abreast of key research into healthcare leadership. I recognise that there are disadvantages to this participative style of leadership – it can be time consuming when decisions need to be made quickly which can prove costly in terms of resources.
4.2 As a SCPHN I must be an effective leader, which means possessing the ability to communicate with others in such a way that they are influenced and motivated to perform actions that achieve desired outcomes (Daft, 2005). As a leader we must focus on our own strengths and use a reflective approach to access the willingness of each individual to take on board change (Barr & Dowding, 2010). It is my aim to stimulate awareness of health needs and lead on such initiatives by delegating aspects of practice to other agencies and facilitating the work of relevant team members (NMC, 2004). This collaboration presents significant challenges to the success of the proposed intervention and requires me to make important professional considerations about the proper implementation of a change strategy. Effective leadership is required to ensure that various practitioners communicate with one another and provide a holistic, coordinated service tailored to local needs (DoH, 2009c). Communicating an understanding and awareness of workload, resource and time pressures for staff is important as a leader in order to delegate work appropriately to team members and to avoid further stress and aid motivational leadership.
4.3 More flexibility in service delivery has been highlighted in the NHS Plan (DoH, 2000) confirming the drive to blur professional boundaries. The resulting flexibility of approach in relation to who does what, at what time and in what setting, has changed the skill mix of teams. As a result of new flexible service delivery plans, every individual needs good leadership to be fully aware of their roles and responsibilities to avoid confusion or potential conflict. To implement the postnatal group I need to introduce a careful change management program to ensure complete engagement of the whole team. I can use the structure of a framework to shape the change process. Lewin (1951) model of planned change breaks the change process down into three stages. These stages are: Unfreezing – the existing organisational equilibrium, Moving – to a new position, Refreezing – a new equilibrium position. The unfreezing stage is commonly greeted with guilt and anxiety and it is important that as a leader I provide psychological safety that helps these anxious individuals to convert their anxiety into motivation to change. This did cause friction and resistance with some team members who were unwilling to adapt to their new roles therefore a detailed rationale for changes was clearly explained through discussion groups. Demonstrating my leadership skills through effective communication was of paramount importance in order to try to avoid hostility towards any perceived threat (although not actual). The moving stage needs a new role model (within the partner organisations) to champion the proposed change and help others to follow and establish the new service. This may involve convincing senior management for the need for change and responding to any suggestions for modifications. Time may need to be negotiated in order to share information and update staff on the necessity for communication between professionals perhaps through workshops or focus groups. The refreezing stage involves integrating the new initiative into the organisation and consolidating significant relationships. The successful implementation of this change process is crucial to the success of the initiative; this can be aided by audit of results. Evaluation of my role is vital to validate the implementation and also to help diminish the risks against conflict as professionals can feel they own a project and have the ability to make changes and modifications.
4.5 By implementing a skill mix I have ensured staff ownership from the outset, utilising a bottom up approach. Barr & Dowding (2010) state that the bottom up approach is encouraged within the humanistic technique, whereby the subordinates (followers) are encouraged to share ideas with their leaders and will be involved with the decision making process. As the leader I used a full and clearly defined evidence of staff members and their relevant skill mix in order to utilise them effectively. It is vital to utilise research and evidence of best practice in relation to postnatal groups in other areas of the UK. The current economic climate challenges our leadership skills and means that all practitioners need to scrutinize their practice to organise their work and be as innovative and productive as possible within the constraints of health service budgets (DoH, CPHVA, Unite, NHS, 2009b).
5. Leadership benefits to the quality of client care.
5.1 My role as a leader is to promote and implement concepts such as joint working and partnership with the community, addressing equity and inequality issues, collective action and an empowering agenda with a new way of thinking and methods to use in order to work dynamically (Cowley, 2008). These key concepts highlight the importance of this postnatal group being effectively led and supported by multi-agency organisations and community partnerships. As a registered practitioner and leader it is my responsibility to ensure that there is a supervision system in place within an organisation to protect the patient/client and maintain the highest possible standards of care. On-going supervision is used to assess team member’s abilities to perform delegated tasks and capability to take on additional roles and responsibilities. Supervision will be offered indirectly or directly at set points in time and team members will be given weekly opportunities to discuss any issues, concerns or worries they may have.
5.3 As the leader of this project it is important to be aware of the five areas of clinical governance identified by Crinson, 1999 – clinical audit, clinical effectiveness, clinical risk management, quality assurance and staff development. It is important that within the leadership role I improve services based on complaints, evaluation and feedback by both professionals and clients, while accepting criticisms of my leadership skills. Any service must involve professional groups in multi professional audit. Proactively identifying clinical risks to patients/staff should make for a sound provision and aid myself as a health professional to be an effective leader. I aim to monitor my ability to measure the capacity and capability to deliver services by ensuring that there is effective clinical leadership as stated by the National Audit Office, 2007.
5.4 As a leader I believe setting high standards of quality care for clients is a key responsibility. This can be done by identifying key benchmark’s set by the NMC (2004) where it is stated that the public have the right to expect that health care professionals will practice at a high standard. The use of benchmarks can assist in identifying the need for change. Within the Norfolk PCT I believe the value of the Nursery Nurse is recognised by SCPHN’s with particular relevance to their skills being utilised. Using this as a benchmark it may therefore be suggested that integrating a Nursery Nurse into the postnatal group would compliment my role as a SCPHN in addressing the needs of the client in the most effective manner. Effective delivery of information at the postnatal group is dependent on the capacity of the workforce to implement it and having the appropriate resources to support the work force. This capacity relates to having sufficient staff in place, who have the requisite knowledge, skills and confidence to undertake assessments (DoH, DFEE & Home Office, 2000c). The team that I am responsible and accountable for leading is multi-skilled and able to share relevant information in order to offer help and support to each other.
5.5 To be an effective leader I believe it is an essential requirement to undertake evaluation and analysis of any intervention on a regular basis to give the opportunity to implement change, which is supported by Summerbell et al (2005). They highlight that stakeholders (families, school environments, and others) be included in the decision making and I believe this allows for a broad range of ideas to be shared to provide quality care and services that are effective and appropriate for the target client group. Evaluation is key to quality assurance and an essential part of the leadership role is to ensure that followers are actively involved in the quality control process (Marquis & Huston, 2009).
5.6 As a leader by utilising this service I am able to effectively share other agency resources and the skills of professionals with similar aims and objectives. The Department of Health (2000) promotes the collaboration of services and the ability to pool budgets and resources in order for services to be maintained and obtain sustainability. I believe that shared ownership of a strategy encourages partner agencies to incorporate targets into their individual plans and to work together to provide appropriate support for children and families – this is supported by Hanson, 2010. The key to successful collaborative working and partnerships is to reach a common understanding of the priorities of the community and how to best tackle them (Mitcheson, 2008). Concepts such as joint working and partnership with the community, addressing equity and inequality issues, collective action and an empowering agenda all provide me as a SCPHN with new ways of thinking and methods to use in order to work dynamically (Cowley, 2008). Once the group is more established, their own personal development aims will enable some of the clients to take a more prominent role in the leadership and development of the group as peer supporters.
5.7 Within the team I believe that the consequences of poor leadership to client care could be that staff members becoming unsettled and unhappy in their position and they may transfer these feeling towards the clients resulting in a lack of motivation on both sides. I feel that if staff are not behind their leader then this will reflect into the group through misinterpretation of the service – Coe et al (2007) and Smith and Roberts (2009) found that barriers to attending groups include misinformation about the organisation. This evidence highlights the importance of my supportive leadership of health professionals to be clear, consistent and supportive in the information they are giving.
6. Dynamic and flexible approaches to leadership issues.
6.1 I have found through experience that awareness of conflict management is a key area of responsibility for an effective leader. To date I have found that in health there are a huge variety of professionals all with different knowledge and backgrounds and interacting with each other giving considerable potential for conflict. Conflict can arise through the competition of different groups vying scarce resources. An individual’s personal objectives may also be a cause for potential conflict. As a leader it is vital that I do not ignore any potential conflict situations and if conflicts do arise, I will plan solutions before patient care is compromised. I intend as a leader to promote a positive working environment through my leadership skills, the Royal College of Nursing (RCN, 2005) state that many professionals experience both positive and negative working environments and recommend a useful tool to explore relationships on an individual and team basis. I aim for my team members to view me as a leader who is able to collaborate and involve relevant parties to solve a situation rather than one who avoids conflict. Conflict can result in poor productivity (Barr & Dowding, 2010) – by being a dynamic and flexible leader who is able to resolve conflict effectively I can ensure a continuing high quality of patient care.
6.2 If I had conflict within a team I am leading, I would use a tool created by Tuckman (1965) on stages of group development. The four stages of group development – Forming, Storming, Norming and Performing – can be used to break down a difficult situation into manageable elements. During the forming stage of team development and development of the group it was my aim to ensure that I explained all tasks and objectives in a clear manner and to emphasise and reassure team members that I was happy to listen to ideas but decisions would be made so that everyone had a good understanding of what they were required to do. To team then moved into the storming stage of development where the group were happy to discuss ideas but showed respect if there was disagreement and communication skills to come to amicable decisions. The next stage is the Norming stage were the group began to support each other in their roles. This stage can sometimes develop slowly – currently the team has not reached the consistent performing stage as partners and team members continue to develop and learn how to work effectively together. By maintaining and developing the group further I hope to achieve consistently high standards of performance within the group. This will require effective communication, shared labour, greater cooperation, lower absenteeism and increased resistance to frustrations. If I continue to perform as a leader to a high standard I believe I can achieve the delivery of high quality care and a motivated team.
6.3 In order to maintain professional development and practice based on evidenced-based research I believe health professionals need to access relevant training, and share knowledge and skills within the team environment. Reflection is essential in order to look back at achievements. Consideration of what has been successful and what would be done differently in future practice to make a service as beneficial and effective as possible for children and families is essential. I aim to promote partnership working as I feel it is key to the implementation of this intervention in order to sustain it and continue future development within the area.
6.4 At the end of the project I aim to collect data in order to evaluate and analyse the cost-effectiveness of the intervention and identify opportunities for cost savings, which is part of my professional responsibility identified by NICE, 2007. I aim to involve service users and engage them in a simple customer feedback questionnaire to establish how well the initiative meets their needs.
7.1 I feel that further and continuing research is required on what clients require within a service. It is my responsibility as a SCPHN and a leader of a team to maintain evidenced based practice and respond to the needs of professionals and clients. I aim to continue developing the key skills of reflecting upon experiences and improving practice at the beginning, during and after action, to ensure improvement of services. From the experiences and reflection I have undertaken I have identified my leadership style and conclude that I will try to respond to individuals within the context of their understanding and community. Consideration of ideas generated by members of the team and client group are key to effective leadership.
7.2 I endeavour to share and input values such as honesty, respect, integrity and emotional strength as I believe they are essential for working with team members and clients. Promotion of my values and constructive criticism need to be demonstrated within any team. Adaptability and flexibility of leadership styles must also be developed and used. I aim to continue and develop my participatory leadership approach with both colleagues and clients. This will enable me to evaluate, question and confirm all of my actions within my role as a SCPHN.
8.1 As a SCPHN I should lead change and encourage change in a flexible and appropriate manner to aid the development of healthcare services.
8.2 I acknowledge that I need to develop my skills in applying quality care frameworks in practice to improve my quality assurance.
8.3 I recognise that my conflict management skills should be developed through experience and used effectively to promote good leadership.
Appendix 1 – Adair, 1997 – interaction of needs within the group
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Barr, J & Dowding, L (2010) Leadership in Health Care. London: Sage.
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http://www.changingminds.org/disciplines/leadershipstyles.htm (Accessed 24th June, 2010).
Coe, C. Gibson, A. Spencer, N. Struttaford, M (2007) Sure Start: voices of the ‘hard-to-reach’. Child, care, health and development. 34, 4, 447-453.
Cowley, S (2008) Community Public Health in Policy and Practice. 2nd Edition. London: Balliere Tindall.
Crinson, I (1999) Clinical governance: the new NHS, new responsibilities. British Journal of Nursing. 8 (7): 449-453.
Daft, R (2005) The Leadership experience. 3rd Edition. Canada: Thomson South-Western.
Department for Education and Employment, department of Health & Home Office (2000c) Framework for the Assessment of Children in Need and their Families. London: HMSO.
Department of Health (2000) The NHS Plan. London: HMSO.
Department of Health, CPHVA, Unite & NHS (2009b) Getting it right for children and families. Maximising the contribution of the health visiting team. ‘Ambition, Action, Achievement’. London: The Stationery Office.
Department of Health (2009c) Healthy Child Programme – Pregnancy and the first five years of life. London: The Stationery Office.
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http://www.dh.gov.uk/publications (Accessed 5th June, 2010).
Department of Health (2006) Our Health, Our Care, Our Say. London: HMSO.
Department of Health (1999) Saving Lives: Our Healthier Nation. London: HM Stationery Office.
Eastwood, P. Horrocks, E & Jones, K (1995) Promoting peer group support with post-natally depressed women. Health Visitor, 68 (4): 148-150.
Hall, D, Williams, J, Elliman, D (2009) The Child Surveillance Handbook. 3rd Edition. Oxford: Radcliffe Publishing.
Hanson, S (2010) Empowering change. Community Practitioner. 83, 36-37.
Johnson, S (2005) Characteristics of effective health care managers. Health Care manager 24(2), 124-128).
Lewin K (1951) Field Theory in Social Science. New York: Harper and Row.
Lewin, K, Lippitt, R & White R (1939) Patterns of aggressive behaviour in experimentally created social climates. Journal of Social Psychology 10: 271-299.
Marquis, B & Huston, C (2009) Leadership Roles and Management Functions in Nursing – Theory and Application. 6th Edition. London: Lippincott, Williams & Wilkins.
McGuire, E & Kennerly, A (2006) Nurse managers as transformational and transactional leaders. Nursing Economics 24(4), 179-186.
Mitcheson, J (2008) Expanding Nursing Health Care Practice – Public Health Approaches to Practice. Cheltenham: Nelson Thornes.
National Audit Office (2007) Improving Quality and Safety – Progress in Implementing Clinical Governance: Lessons for the Primary Care Trusts. London: NAO.
National Institute for Clinical Excellence (NICE) (2007) Behaviour Change. London: Department of Health.
Nursing and Midwifery Council (2004) Standards of proficiency for Specialist Community Public Health Nurses. Norwich: The Stationery Office.
Rafferty, A (1993) Leading questions: a discussion paper on the issues of nurse leadership. King’s Fund Centre.
Robbins, s (2000) Organisational Behaviour. 9th Edition. New York: Prentice Hall.
Royal College of Nursing (RCN) (2005) Working with Care: Improving Working Relationships in Healthcare. London: RCN.
Royal College of Nursing (RCN) (2006) Supervision, accountability and delegation of activities to support workers – A guide for registered practitioners and support workers. London: RCN.
Smith, D & Roberts, R (2009) Young parents’ perception of barriers to antenatal and postnatal care. British Journal of Midwifery, 17, 10.
Sullivan, E & Decker, P (2009) Effective Leadership and Management in Nursing. 7th Edition. London: Pearson Education.
Summerbell, C, Waters, E, Edmunds, L (2005) Interventions for preventing obesity in children. The Cochrane Database of Systematic Reviews.
Tuckman, B (1965) Development sequence in small groups. Psychological Bulletin 63: 384-99.
Wilkinson, J and Murray, S (1998) Assessment in Primary Care: Practical Issues and Possible Approaches. British Medical Journal 316, 1524-8.<
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