The essay will critically analyze both leadership and management theories from the top of the organization to the bottom. These theories were used to implement this change to enhance quality care in this clinical area. The essay will also critically analyze and evaluate the nurses' self management skills In fulfilling their role as clinical managers within interdisciplinary and the changing context of the healthcare. Similarly, the essay will discuss the Implications upon quality assurance and resource allocation for service delivery within the health care sector.
These will be related to current government strategies. The effects of government strategies in involving the seer and career or significant others In decision making process within current clinical and legal frameworks (Department of Health Bibb) will also be debated. Similar debate will also be on the nurses' involvement in policy making (Antitrust 2003). Further discussion on government strategies will be discussed on the Introduction of clinical governance and essence of care. Brained (2006) states that the purpose of implementing change is to improve effectiveness and quality.
The whole process of change was based on the Introduction of the care of the dying booklet which meant hat all healthcare professional documented their notes in the same booklet. The change took place In a large hospital to Implement a new policy which was politically driven by the government to improve quality of care. Like most hospital organizations, the hospital traditionally uses a bureaucratic management approach (Marquis and Huston 2006) reinforced with authoritarian leadership to facilitate efficiency and cost effective care.
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This is done through planning, coordination, control of services, putting appropriate structures and systems in place and monitoring progress towards performance activities (Financial 2006 and Bugler and Woolworth 2002). According to Marquis and Huston (2006) bureaucracy was introduced after Max Weeper's work to legalize and make rules and regulations for personnel to Increase efficiency. The ward manager as a change agent had to design and plan the process of change.
Designing change Involved understanding the purpose of change and gathering data as supported by Glower (2002). Planning included identifying driving forces and ways to reduce restraining forces (Glower 2002). Unlike the top management who used bureaucratic management theory, the ward manager applied the human relations management theory (Marquis and Huston 2006) at ward level. This management theory is designed to motivate employees to achieve excellence. To be the shortcoming of bureaucratic theory which failed to include the human aspects (Marquis and Huston 2006).
Often referred to as motivational theory, Luzon (2002) agrees that this theory views the employee in a different way and helps to understand people better compared to the autocratic management theories of the past. It is based on theory Y of Douglas McGregor (1960) X and Y theories cited in (Luzon 2002). Theory Y assumes that people want to work, are responsible and self titivated, they want to succeed and they understand their position in the organization.
Perhaps the appropriateness of this theory can be linked to the implementation of clinical governance which emphasizes that it is the responsibility of health care professionals to ensure effectiveness, high standards and quality (Brained 2006). This puts health care professionals in a responsible position and motivates them to provide high quality care. This explains why theory Y was used as opposed to theory X which according to Luzon (2002) assumes that people are lazy, unmotivated and require discipline.
According to the human relations theory, there are some positive management actions that lead to employee motivation thus improving performance (Marquis and Huston 2000). Some of these actions used by the change agent were empowering and allowing employees to make independent decisions as they could handle, training and developing, increasing freedom, sharing big picture objectives, treating employees as if work is natural and other ways of motivating staff as supported by Marquis and Huston (2006 and Luzon 2002).
The use of human relations theory in the implementation of this policy is well justified in contrast to other management theories. For example, theory X presumes that people must be coerced, controlled, directed and threatened with punishment (Luzon 2002). This theory adds that an average person has inherent dislike of work and prefers to avoid responsibility (Marquis and Huston 2006). In other words, theory X prefers autocratic style while theory Y prefers participative style.
Managers using theory y seek to enhance the employee's capacity to exercise high levels of imagination, ingenuity and creativity solving organizational problems. With the human relations theory, members feel special and involved rather than being enthroned by threats and sanctions from the change agent (Downing and Barr 2002). The team of health care professionals was aiming to achieve the same goal. This goal was to provide high quality care to patients approaching end of life. This involved a lot of organizational psychology and motivation to facilitate effective teamwork.
Among the factors that facilitate effective teamwork, leadership is the most significant as stated by College (2000). Tiffany (2005) supports that leadership is on government's modernization agenda for the National Health Service and is an influencing factor. Therefore, the change agent needed equally effective leadership style. To facilitate this, she applied the transformational leadership style. Collaborative, consultative and consensus seeking. These are the same characteristics of the leadership style used by the change agent.
Contrary to this leadership style is the transactional leadership style which is based on power of organizational position and authority to reward and punish performance (Maiden 2002). Based on Rosier (1990)g's research, College (2000) states that gender affects leadership style and women prefer transformational style. Perhaps this explains why the change agent chose this style for this particular change. As in any form of change process, resistance, which falls under the unfreezing stage of Linen's (1951) cited in Murphy (2006) change theory is one of the common obstacles that needed to be dealt with (Curtis and White 2002).
By inspiring a shared vision within the team (McGuire and Keenly 2006) the change agent managed to increase driving forces and reduce resisting forces at the same time. College (2000) values vision as a very important ingredient of transformational leadership, adding hat it should be engaging and inspiring. Transformational leadership was first put forward by James Burns (1978) cited in Marquis and Huston (2006). According to him, a relationship of mutual stimulation and elevation converts followers into leaders, a fact shared by Murphy (2005).
If a leader can stimulate followers, he or she can engage followers into a problem solving attitude (McGuire and Keenly 2006). In addition, people engage together in a way that allows leaders and followers to raise each other to higher levels of motivation and morality (Marquis and Huston 2006). This approach emphasizes on the leader's ability to motivate, coach and empower the followers rather than control their behaviors (McGuire and Keenly 2006). Maiden (2002) states that this style is widely used in all types of organizations in dealing with change.
Frequently, it is contrasted with transactional leadership which is a traditional way in which followers' commitment is gained on the basis of exchange of reward, pay and security in return of reliable work (Mullions 2002). However McGuire and Keenly (2006) state that if transactional leadership is predominantly used, followers are likely o place limits to organizational commitment and behave in a way only aimed at contract requirements. Despite the differences in various leadership styles, most researchers conclude that there is no one leadership style that is right for all circumstances (Reynolds and Rogers 2003).
Fiddler (1967) cited in Maiden (2002) agrees that a single leadership style is rarely practiced. Therefore situational theories were introduced in order to deal with various situations. Perhaps this is why the leader used the situational approach to leadership in order to meet the demands of different situations, an idea also shared by Marquis and Huston (2000). Reynolds and Rogers (2003) suggest that the effectiveness of day to day activities depends on balancing between the task at hand and human relations to meet everyone's needs.
Different competence levels, motivation levels and commitment levels of staff on this clinical area Justify why a situational approach was (2003) support that situations like this require the leader to adapt their style. However, they warn that it is important to know when to lead from the front, when to empower and when to let go. This situational approach enabled the leader to work on followers' strength and weaknesses. Moreover, Reynolds and Rogers (2003) warn that it is not always easy to find leadership styles that suite the needs of every situation and not everything falls into place from the beginning.
Marquis and Huston (2000) criticize that situational theory concentrate too much on situation and focus less on interpersonal factors. Support was given to followers according their needs. Supportive behavior, as supported by Reynolds and Rogers (2003) helps people to feel comfortable in their situations. This was facilitated by the use of a two way communication system which involved existing, praising, asking for help and problem solving. Consequently, as performance improved, the leader's supportive behavior shifted to delegation.
Delegation was mostly directed to staff with high competences, commitments and motivation. Reynolds and Rogers (2003) support that the style of leadership alters as performance improves from directing to coaching to supporting to delegation. Basing on research studies, Reynolds and Rogers (2003) warns that using different approaches to different staff can practically difficult in terms of developing the whole group as well as maintaining fairness. This further exposes the imitations of situational approach.
Nevertheless, it is equally important to assess followers' capabilities and developmental needs so this explains the relevance of situational approach to this clinical area. The delegation was directed to some members of the team while others still wanted to be directed. In addition, this was because of the leader's trust in people, working to their strength and sharing the vision as supported by Kane- Arroba (2006). Delegation is defined as transferring responsibility of an activity to another individual and still remain accountable (Sullivan and Decker 2005).
Davidson et al (1999) caution that critical thinking and sound decision making must be applied before delegating because it increases rather than decrease nurses' responsibility. They clarify that to ensure safe outcome, delegation must be the right task, right circumstances, right person, right instructions and right supervision. Pearce (2006) shares the same thoughts and adds that you must be clear about what you delegate, inform other members, monitor performance, give feedback and evaluate the experience while remembering that you remain accountable. However,
Kane-Arroba (2006) and Taylor (2007) argue that delegation is another way of empowering the subordinates. However, like every team going through the process of change, problems arose and were solved as they came. Apart from dealing with problems like resistance and lack of resources, there was an even bigger problem of interdisciplinary working for both nurse orientated, it needed authorization by a doctor in order for a patient to be commenced on care of the dying pathway. Whether inside or outside health care, interdisciplinary working was introduced with the same concerns of improving quality (Wesson 2004).
Interdisciplinary working has been emphasized by a number of government initiatives (Martin Bibb), more recently the INS Plan (Department of Health AAA). To ensure the demand for interdisciplinary working is met, there has been a lot of emphasis on professional education and training. Effective interdisciplinary working is meant to facilitate delivery of quality services and is fundamental to success of clinical governance (Brained 2006). However, Wesson (2004) argues that there is little evidence to support the effectiveness of interdisciplinary working.
There is also insufficient evidence to purport that collaboration improves quality of care given to patients (Wesson 2004). Nevertheless, if interdisciplinary working is to be achieved it is important to appreciate the potential barriers to this type of working. In this particular organization there were some barriers that impeded interdisciplinary working. These barriers needed problem solving skills from both the change agent and the nurses. In many cases there were some disagreements between nurses and doctors as to when to commence the care of the dying pathway for a patient.
Although the policy as self explanatory in terms of when to commence it, doctors were often reluctant to authorize it. Wesson (2004) states that occupational status, occupational knowledge, fear and distrust of other occupational groups are some of the barriers to effective interdisciplinary working. Additionally, different backgrounds, training, remuneration, culture and language can contribute to professional barriers, mistrust, misunderstanding and disagreements (Wesson 2004). To solve this problem the change agent and senior members of the medical team held regular meetings to discuss problems like this.
This way of problem solving is well recommended by Wesson (2004) who explains that if interdisciplinary working is to be successful, structures and procedures should be in place to support it. This is a way in which organization reflects emphasis on teams rather than individual professional groups. Wesson (2004) adds that if this is reinforced with communication between managers and other professional groups, it is likely to be successful. Perhaps in future interdisciplinary learning may be necessary to overcome some of the barriers to interdisciplinary working.
Despite lack of evidence or its effectiveness, interdisciplinary learning has been identified as a government priority (Wesson 2004). Therefore study programmer for health care professionals are important to facilitate this approach to learning. However, after the implementation of the new policy it was equally important to measure the effectiveness of this change to improve quality. According to Overexert evaluation and is concerned with effectiveness of a treatment, intervention, service or policy. Among the methods of evaluation used were structured interviews, observations and content analysis of the document.
Allegiant (2002) recommends these methods give enough information in terms of whether an intervention is successful or not. Allegiant (2002) adds that this qualitative evaluation provides evidence of appropriateness and affects decision making among policy makers. So upon successful implementation of this policy it was the ward nurses' responsibility to audit the effectiveness of this policy. Wesson (2004) and Brained (2006) recommend clinical audit as a way to demonstrate the effectiveness of health care interventions and a way of developing quality.
But for a number of reasons ruses were unhappy with the auditing process. While some members of staff believed that results would be used to penalize them, some were understandably not happy with the amount of work being piled on them in addition to staff shortages. College (2001) highlights that staff shortages contribute to emotional exhaustion and fatigue due to pressurized attempts to deliver quality. Such problems are highlighted by Wesson (2004) among the problems faced with nurses in auditing.
Since this was a multidisciplinary document, some nurses argued that nursing auditing is normally perceived less credible than medical audit. Again, such a problem is shared by Wesson (2004) as an obstacle to multidisciplinary auditing. If doctors are not involved in clinical audit the value of the overall quality management is questionable. Yet clinical governance emphasizes on the importance of multidisciplinary evaluation (Brained 2006). In addition, some questionnaires were sent to relatives and careers of patients who were on care of the dying.
However, this way of evaluation was inaccurate since relatives would voice their personal feelings more than the patient's feelings. This way of evaluation was made even more difficult by the fact that most patients on this are of the dying policy died and were unable to give evaluation. Higgins (1999) agrees that there are problems in measuring quality of life in patients with progressive illness. In addition, it is inadequately measured and there is very limited evidence for hospital and palliative care teams (Higgins 1999).
In a positive way, Higgins (1999) suggests that these difficulties should not prevent the application of palliative care where it is cost effective and patient and family satisfaction is proven. The emergence of clinical governance and essence of care serves to emphasize user and career involvement. This is in relation to benchmarking which involves measuring quality and evaluating changes (Department of Health 2001). Specifically, the publication of Patient and Public Involvement in the New INS (Department of Health 1999) is evidence of the government's support of user involvement.
The INS Plan (Department of Health AAA) is further proof of the government's efforts to place user involvement at the centre of service development and evaluation. Significantly, the INS Cancer Plan (Department of Health Bibb) also emphasizes on the need for the same reason of achieving user involvement, there has been a lot of funding from Cancer Services Collaboration, Supportive Care Networks and Cancer Partnership Project (Titter et al 2004). A positive example of user involvement is the involvement of cancer patients in making decisions regarding their treatment options so they can make their choices.
This is strongly supported by Titter et al (2004) who add that user involvement is also important for service development. Moreover, the aim of user and career involvement varies depending on what is being achieved (Titter et al 2004). However, health care professionals may feel threatened by user involvement for a number of reasons. Among those reasons is that health care professionals feel it is necessary to limit users' input on the basis that users have insufficient knowledge about health care services (Trite et al 2004).
Moreover, there are fears that users may make wrong decisions due to pressure of decision making (Titter et al 2004). Consequently, one would argue that limited understanding among health care professionals about users' perspectives can hinder service development and affect quality of care. Health care professionals are increasingly urged to measure the effectiveness of their practice. Titter et al (2004) ran that users' voice is not always heard in 'evidence based health care'. However, this is now changing as the principle of user and public contribution is being applied to the evaluation of health care.
With all the talk about user involvement, it is interesting to note how much nurses are involved in policy making. Many authors like Tiffany (2005) raise concerns to lack of nurse involvement in policy making. Tiffany (2005) adds that among many reasons is the suggestion that there is insufficient government interest in concerns of the nursing workforce. However, Antitrust (2003) argues that Political Leadership aerogramme have emerged in the past few years in a bid to increase the capacity and ability of nursing profession to influence policy.
In addition to that, there is suggestion that nurses distinct between policy and practice (Tiffany 2005). Tiffany (2005) simplifies that nurses believe that policy relates to managers while practice relates to nurses while Antitrust states that nurses are traditionally regarded as implementers of policy rather than policy influences. According to Tiffany (2005) this affects the effectiveness of leadership which plays a big role in influencing health care policy and nursing practice. With all the farce about quality assurance it is also important to understand its meaning and measurement.
The emphasis on quality is necessary because it is a central topic of government approaches to health care management particularly in the INS plan (Department of Health AAA). Wesson (2004) explains that the perceptions of quality vary and are dependent upon expectations, past experiences and service provided. Words like effectiveness, accessibility, efficiency, acceptability quality are two of the three dimensions of health service quality (Overexert 1992 cited n Wesson 2004) that are relevant to the quality mentioned in this essay.
Current approach of clinical governance systems is evidence that quality is an issue that needs managing. Clinical governance is the reflection of a number of quality principles supported by management theories (Barrier 2006 2004). Management approach to quality led to the development of systems like Total Quality management (Wesson 2004). This quality management system is aimed at improving competitiveness, effectiveness and flexibility in organizations (Wesson 2004). However the application of this quality monitoring system is not without limitations ND is not straight forward.
Wesson (2004) shares the same thoughts, adding that there has been little research done to Justify the effectiveness and value of Total Quality Management. In reality it is more helpful to approach the quality delivery on the basis that different systems work for different types of quality and purposes. In the nineties the system of Total Quality Management had some difficulties due to inadequate resources and lack of information systems to monitor quality (Wesson 2004) The main barrier to effective introduction of this was its origin from the commercial sector (Wesson 2004).
INS organizations had insufficient funds needed to facilitate this system. Nevertheless, with the new approach of clinical governance there is much pressure to improve quality management. Clinical governance involves the delivery of high standards and clinical excellence (Brained 2006 Indonesian 2004). Wesson (2004) adds that the National Institute of Clinical Excellence coordinates studies on the effectiveness of current and new treatments. This facilitates evidence based practice through National Service Framework which set out patients' expectations from the INS.
Managing systems of clinical audit, risks management and continuing professional development are directed to achieve high standards. The Commission for Health Improvement then monitors the effectiveness of these systems through inspection and performance levels in their clinical governance reviews (Titter et al 2004). However, according to Wesson (2004) clinical governance is another of the crowded agendas that health care managers and professionals have to deal with. Challenges like reducing waiting times are some of those short term targets that can affect long term targets like quality (Wesson 2004).
In conclusion, the whole process of change was not easy. The use of bureaucratic management theory from the top of the organization and the human relations management theory (Marquis and Huston 2006) applied on the ward level proved to be successful. Similarly the use of transformational leadership style in conjunction with a situational approach played a very important role in this change in terms of solving problems. The leader focused on a motivational, empowering, stimulating, manipulative and authoritative approach. The government's influence on quality through drivers like clinical governance and essence of care is fundamental.
The emphasis on interdisciplinary working is also a major factor which revealed the common problems faced in practice. The problems of measuring quality in patients who are dying are also highlighted and prove that more research is crucial in terms of improving quality (Higgins 1999). In addition, barriers to clinical auditing are an indication of the practical problems faced by health care professionals in evaluating. As the emphasis on user and career involvement continues it remains a challenge to health care professionals to make it successful.
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