Leadership And Management In Nursing Education
Topics explored in this assignment will include defining leadership styles, workplace culture, and leadership preparation in nursing education. In accordance with the Nursing and Midwifery Council (NMC) Code of Conduct (2018a), all names and locations used throughout this essay will be changed to maintain confidentiality.
The King’s Fund (2013) defines leadership as “the art of motivating a group of people to achieve a common goal”. The NMC Code of Conduct (2018a) states that a registered nurse must ‘Provide leadership to make sure people’s wellbeing is protected and to improve their experiences of the health and care system’. With this in mind, by way of promoting professionalism and trust, the NMC has an expectation that upon registration, nurses become leaders. For a registered nurse in practice, leadership is an essential competency and it is through this that a nursing team can be led towards the achievement of effective decision making, positive outcomes, and shared objectives (Almeida et al. 2014).
There are three common styles of leadership (Foret-Giddens, 2019). An autocratic leader has a need for authority, believes they have a right to manage, exerts control, dictates behaviour, and makes decisions alone. These managers have clear objectives and are highly directive (Kaiser, 2017). Democratic leaders involve the entire team for discussion and decision-making and will have a shared vision. A team lead by a democratic leader may allow the more outspoken members to become dominant, leading to ineffective decision-making. The Laissez-faire approach is characterised by a more easy-going leader who often promotes autonomy, individuality, and self-direction (Pullen, 2016; Durmus and Kirca, 2019). However, by assuming that all team members are happy or capable of being left to their own devices, members may feel unsupported and lost (De Vries and Curtis, 2019). This may result in a disconnected and unmotivated team (Gopee and Galloway, 2017). To be an effective leader, the ability to recognise personal qualities is crucial. Acknowledging strengths and limitations in areas such as self-control, self-awareness, self-confidence, resilience, and determination directly influence how we conduct ourselves and relate to others. Individuals in leadership roles of an organisation will usually display generic behavioural competencies such as compassion, supportiveness, commitment to improving care, focusing on performance, accountability, performance managing, and problem solving (Durmus and Kirca, 2019: Foret-Giddens, 2019). According to the NHS Leadership Academy (2020), research shows that leaders who lack this awareness will find it increasingly more difficult to lead effectively and will have an obvious bearing on colleagues and the overall culture with the team (Foret-Giddens, 2019).
Psychologist Julian Rotter (1966) developed the Locus of Control (LOC). Originally applied in health and psychology, it is now widely utilised in organisational behaviour. Rotter (1966) defined the Locus of Control as ‘the degree to which the individual perceives that the reward follows from, or is contingent upon, his own behaviour or attributes versus the degree to which he feels the reward is controlled by forces outside himself. The LOC was later redefined by Boshoff and Van Zyl in 2011 as ‘referring to the extent to which individuals believe that they can control events which affect them’. Rotter (1966) identified two major forms of LOC, internal and external. A transformational leader will inspire, encourage and motivate team members and adopt an internal LOC believing that influence over outcomes depends solely on their behaviour, skills, and knowledge (Foret-Giddens, 2019). Transactional leaders are not wanting to make changes which more often, will have a negative effect on other team members demonstrating an external LOC believing events, results and outcomes depend on forces beyond their control such as fate, luck, or chance (Robbins and Davidhizar, 2020). A team led by a transformational leader who believes in ‘I make things happen and ‘I control my own future is more likely to be highly motivated and enthusiastic allowing them to achieve goals and produce positive patient outcomes, whereas a team with a transactional leader who has a ‘Why bother’ and ‘There’s nothing I can do to change things’ attitude will be less motivated and uninterested in improving patient outcomes (Foret-Giddens, 2019; Pishgooiee et al. 2019).
During the recent Covid-19 pandemic crisis, several clinical ward areas in a local hospital were transformed from their usual use to Intensive Care or isolation units. This meant that many nursing staff had to be re-deployed to work in other areas, some of which were unfamiliar to the staff. During handover, a staff nurse was told by the Nurse-in-Charge of the shift, that she had to move to a contingency area to work. The nurse displayed signs of anxiousness at the prospect of being moved. When she voiced her concerns and tried to explain that she did not feel comfortable working in the suggested area, the Nurse-in-Charge became quite defensive and replied with such phrases as “It’s not my fault”, “I don’t make the decisions”, and “We all have to do it at some point” (Schein, 1992). The staff nurse did move to the contingency area but was visibly distressed and upset by both the decision for her to go and the reaction of the Nurse-in-Charge (West et al. 2014). She had demonstrated autocratic leader traits which were not appropriate in this incidence. Using this style of leadership did not exhibit positive personal attributes or good, effective communication skills to the team (Manning, 2016). The outcome may have been improved by turning the situation into a positive experience for development and learning, listening to the nurse’s concerns, and supporting her through them. This may have occurred had a more Laissez-faire approach been adopted (Kaiser, 2017). It would have been beneficial for the nurse to have received reassurance that this was an acknowledgement of her competence to carry out the task, and shown empathy that although it is daunting to have to work in an unknown area, she has the full support of her colleagues should she needed assistance. While at the time, the situation did not provoke a reaction amongst the other staff members, it may have caused an impact on the workplace culture, such as: When you are told you have to move work area, you have no say, cannot voice your concerns if you have any and that this particular Nurse-in-Charge lacked essential skills required by a leader to promote a positive climate, recognise staff contributions, give helpful feedback, support staff, promote fairness and transparency and develop trusting relationships (Dermus and Kirca, 2019).
In 2009, research suggested that nurse education courses did not prepare students to take on future leadership roles leading to inadequate, ineffective nurse leaders (Swearingen, 2009; Pullen, 2016). Feather (2009) called for the recognition of the importance of nurse leaders and the part they play in patient care and the workplace culture (Manning, 2016). The NHS Leadership Academy (2020) implemented their Healthcare Leadership Model with the aim of encouraging healthcare professionals to expand their knowledge of the quality of the NHS service and to develop their own leadership skills. The model comprises nine dimensions, supported by tools and resources appropriate for development (NMC, 2018b).
Over recent years, studies have been undertaken to investigate management and leadership failings within the care community relating to communication and culture change. Robert Francis QC (2013), released his report which examined the causes of the failings in care, between 2005 and 2009, at Mid Staffordshire NHS Foundation Trust which saw hundreds of patients come to harm or die. The report highlighted major shortcomings in the leadership and organisational culture and a total of 290 recommendations were made. The Francis Report (2013) stresses the fundamental role of nurses in leadership as it was found that the worst failures of care in Mid Staffordshire, occurred on the wards that were lacking strong and caring leadership. Francis (2013) defines a positive culture as ‘A shared positive safety culture’ and emphasises the importance of creating and maintaining the appropriate culture, in which quality care responsive to individual patients’ needs, can be delivered (NMC, 2018a).
In response to the Francis Inquiry, the Prime Minister ordered a review into poor patient care. The Keogh Review (2013) into patient safety was carried out by Professor Sir Bruce Keogh. The review investigated fourteen NHS Trusts which were persistent outliers in measures of hospital mortality, leadership, and governance. One of the common concerns which arose from the review was that there was evidence of a substantial separation between the key issues and risks as told by the clinical leadership and the actual reality of what was happening inwards and departments within the hospitals (Keogh, 2013). The Berwick report (2013) states that ‘Cultural change and continual improvement come from what leaders do’ and defines leadership throughout the NHS at all levels. The report also highlights the importance of consistent and continuous monitoring and learning to ensure that no avoidable harm comes to any patient (Berwick, 2013; Keogh, 2013).
All three of these reports into patient safety, draw attention to the failings and the need to learn lessons from them by highlighting the key factors leading to healthcare professionals losing sight of quality (Francis, 2013; Berwick, 2013; Keogh, 2013). NHS England’s response to the reports was to take the NHS back to its core values, making organisational declarations that they can and will do better, and with an emphasis on compassion (NHS England, 2014).
The Francis Inquiry (2013), The Keogh Review (2013), and The Berwick Report (2013) all have similar recommendations. They all identify a necessity for greater support in educating and developing managers and leaders and the need to eliminate the blame culture in the healthcare setting (Foret-Giddens, 2019). Studies evidence that within healthcare, a culture of good leadership is related to increased job satisfaction, better staff retention figures, and improved patient outcomes (MacPhee, 2012; Pullen, 2016) and that via the key role of senior staff, the culture is filtered through all levels of the healthcare system (The King’s Fund, 2013).
In 2012, NHS England’s Chief nursing officer, Jane Cumming penned The 6C’s – Care, Compassion, Courage, Communication, Commitment, and Competence. Driven by the belief that culture is shaped by the language we use, each C plays a key role in the strategy and vision for leadership in healthcare (Department of Health, 2012). The initiative was introduced across healthcare settings and professionals in 2014 and although the values of the 6Cs are not new, by encompassing them as a group of behaviours, they outlined a vision for reinforcing the beliefs and values of quality healthcare and strengthen leadership (DoH, 2012; Stephenson, 2014). There are six key areas of the NHS Knowledge and Skills Framework (KSF): Communication; Health, Safety, and Security; Personal and People Development; Service Development; Quality; Equality, Diversity, and Rights. By connecting these elements to the 6Cs of nursing values, health care leaders are given the opportunity to utilise many ways to influence workplace culture (NHS Staff Council, 2010; DoH, 2012; Stephenson, 2014).
In 1995, John Kotter introduced his 8-step change management tool in his book ‘Leading Change’. It is easy to follow and provides a structured and effective framework to initiate changes in practice in a health care setting. Step one is to create a sense of urgency by recognising problems as opportunities for positive change in the culture, highlighting the need for change, and motivating the team. Forming a guiding coalition is step two. This involves leaders effectively communicating them to the team and persuading them to adopt new practices. Step three, create a vision for change that encapsulates the overall aim and is easy to understand. The vision should be inspirational to create an outcome with maximum effect. Communicate the vision, is Step four. Regular staff meetings and share and learn sessions with team members to communicate the expectations to all individuals involved in executing the changes. Step 5 is to empower others to act on the vision. It is important for the team members to work together to build the strength of the change initiative but also to identify possible obstacles and risks likely to reduce the chances of success. Create quick wins is Step 6. Often changes are difficult to sustain so it is important to demonstrate the benefits of the new vision by creating short-term wins. These wins will direct and motivate the team, encouraging them to continue supporting the change. Step 7 is to build on the change and reduce the risk of failure by avoiding complacency. Institutionalise the change in Step 8. A cultural change in the workplace is required so that the changes and new vision become and remain the new norm (Kotter, 1995; Brock et al. 2019).
In 1992, Schein defined culture as “a set of shared, taken-for-granted implicit assumptions that members of an organisation hold and that determines how they perceive, think about and react to things”. Simply translated to “it’s the way things are done around here”. The beliefs and values of an organisation are reflected in its culture. Staff who are new to the organisation learn the importance of patient safety, quality care, power, humanity, honesty, compassion, and so on. If these new staff witness more senior staff displaying aggression or poor practice, they may mirror this behaviour. The way in which staff talks to each other and about or to patients can shape an organisation, as does each interaction (West et al. 2014).
Both current and future leadership is key to the growth and development of workplace cultures. Staff observes and learn what values a leader has. The leader may have the power to reward, make choices about structure, control information, and resources and also develop and mould the work lives of other members of the team (Pullen, 2016). By learning a leader’s values, receptive team members adopt the same in order to win the approval of the leader. The teams of positive and supportive leaders are known to work more co-operatively and behave more empathetically (Schneider & Barbera, 2014; West et al. 2014; Manning, 2016).
The King’s Fund (2011) and The Centre for Creative Leadership (2011) conducted a review to evidence the importance of leadership in healthcare and stated that ‘There is clear evidence of the link between leadership and a range of important outcomes within health services, including patient satisfaction, patient mortality, organisational financial performance, staff well-being, engagement, turnover and absenteeism, and overall quality of care.’ (McCauley, 2011; The King’s Fund; West et al. 2015)
Members of a team will follow the member identified as the leader because they put their beliefs and values into practice (De Vries and Curtis, 2019). Influencing a team using positive values can result in a harmonious and effective team however if people are treated in negative ways, these behaviours might be copied. Witnessing staff being bullied, mistreated, ignored, or undervalued could be seen as organisational or workplace culture reinforced if the leader displaying this negative behaviour, is promoted or rewarded (Asamani, 2016). In clinical and healthcare settings, the environment is enriched and the critical information regarding the support and value of staff is delivered by the clinically-focused leaders (Rafferty et al. 2015; West et al. 2015).
In conclusion, it is clear that leadership should be demonstrated at all levels of healthcare and that leadership skills should start as soon as a student nurse begins their training and continue throughout their career. There is strong evidence to suggest that the delivery of high-quality healthcare is a product of effective leaders and managers. Individuals who adopt a successful leadership style and positive personal attributes can influence a change from a command and control approach to a motivated team who work together to achieve goals, empower and inspire each other and improve patient outcomes.