Describe the basic concepts underpinning leadership and management and discuss the leadership skills: Leadership & Management Essay, UCD, Ireland

“Leadership and Management skills are complementary; both can be learned and developed through experience, and improving skill in one area will enhance abilities in the other” (Cherry and Jacob, 2017. p 297)

Describe the basic concepts underpinning leadership and management and discuss the leadership skills that are required to advance excellence in nursing practice and patient care. Also, critically discuss two leadership skills which you will utilise as nurse manager to achieve the goals of your organisation.
Contents

Introduction

More than ever before, today’s rapidly changing and demanding healthcare environment requires highly developed management and leadership skills. Within their area of practice, leading and managing skills  are essential for all nurses (Sullivan 2012). Yoder-Wise (2014) states that “the nursing profession constitutes the backbone of the healthcare system both in numbers and in its span of influence across the system” (p.4).

Therefore, higher demands for staff to continuously improve directly challenges nurse managers and leaders in organising and directing quality change. Findings from Ghiasipour et al. (2017) outline the relationship between poor leadership, reduced patient satisfaction and the cost implications for the health services. It is therefore imperative that nurses and midwives are equipped with the knowledge to participate in local and national policy development and improvements within healthcare (Bishop 2009).

Leadership

Leadership is difficult to define as there is no single definition which incorporates all aspects of the leadership process. However, it is important to note that leaders need to have a vision; they are willing to take risks, initiate change, quality improvements and empower others to choose to follow towards achievement of shared goals (Marquis and Huston 2017). Mar (2013) defines leadership as “the art of motivating a group of people to act towards achieving a common goal. …. the person that possesses the combination of personality and leadership skills that makes others want to follow their direction” (p.1).

Leadership Theories

Dating to the 1800s the Trait Theorists assumed leaders’ are born, the Behavioural Theorists, 1930s, believed personal traits could be built on with education and later the Contingency Theorists classified the Authoritarian, Democratic and Laissez-faire (let do) styles. Contemporary leadership theories include Transactional, based on social exchange, and Transformational, much cited in nursing literature, focuses on inspiring and motivating employees to a common cause (Sullivan 2018). Scully (2015) discusses the emergence of Connective Leadership, where roles can be shared amongst a team, encouraging one towards one’s own goal and one’s group goal.

Management

Management in nursing is defined as “an engaged process of guiding others through a set of derived practices and procedures that are evidence-based and known to satisfy preestablished outcomes based on repeated clinical situations” (Yoder-Wise 2014; p.5). Furthermore, Marquis & Huston (2017) define management as “the process of leading and directing all or part of an organisation through the deployment and manipulation of resources” (p. 40).
Management theories

In the early 1900s Classical Theorists were interested in efficiency, “time and motion studies”, authority and bureaucracy. From the 1920s Humanistic Theorists focused on the employee, Maslow developed his Hierarchy of Needs model to understand human motivation and McGregor forwarded his X and Y theory suggesting motivating employees with responsibility (La Monica 1994). From the 1970s Modern Theorists such as Senge focused on group problem-solving within organizations.

It is the author’s opinion that managers differ from leaders in that a manager is assigned the role by their organisation whereas leadership is a role that can be assumed by one who has the motivation and skills. So a manager may not be a good leader but still fulfil their role and a leader might not be good in a management position but effective as a team player motivating colleagues towards the organisational goals.

Leaders are visionary, inspiring, motivating, empowering and have the courage to challenge the status quo and act with integrity. Mannix et al. (2013) as cited by Scully (2015) suggest in the present healthcare environment of “economic, technological and academic challenges” (p.440) that the nursing profession needs good leaders and role models. The author suggests the speed of change in the diversity, both multicultural and multigenerational, of interdisciplinary healthcare staff lends still new challenges to nursing managers.

Considering the number of professionals on healthcare multidisciplinary teams that nursing managers need to relate with, leadership skills such as problem-solving, critical thinking, creativity, decision making and negotiation are vital. The organizational goal of the author’s workplace is “to provide the highest quality healthcare”. Whilst this is a broad goal, it encompasses everything the nursing profession strives for as patient advocates. The two leadership skills the author will address in this assignment to achieve this goal are problem-solving and critical thinking.

Problem-solving

In the literature reviewed the Problem-solving Process is recommended rather than Trial-and-error or Experimentation Methods. According to Sullivan (2018) the Trial-and-error Method implements solution after solution until an improvement occurs or the problem is solved and the Experimentation Method relies on pilot projects and trials to test a prediction or a hypothesis. The Problem-solving Process is based on defining the problem, gathering information, analysing it, developing solutions, selecting, implementing and evaluating the solution (La Monica 1994, Sullivan 2018, Yoder-Wise 1999).

Sullivan (2018) suggests that problem-solving can come into play when a gap is found between an actual situation and a preferred situation. La Monica (1994) refers to this as identifying the priority need area which sits
between the ‘actual’ and the ‘optimal’ (p.108). Yoder-Wise (1999) and Sullivan (2018) discuss taking ownership of, or responsibility for, a problem by questioning oneself about it’s importance, one’s desire to delve into it, one’s qualification and authority, resources available, benefits of it being solved.
The National Healthcare Service Leadership Academy, NHS LA, asks if one has self-confidence to question the way things are done and if one would encourage colleagues to solve identified problems. According to Yoder-Wise (1999) doing nothing about the problem is “purposeful inaction” (p.93). On the same question, Sullivan (2018) suggests some problems may be “self-solving” if allowed “to run a natural course” using an example of interpersonal issues between staff members but advises against using a Laissez-faire style of management for every issue or problem (p.136).

The Process

In defining the problem, interpretation of the facts should be regarded objectively to decide if a long term or short term solution is required (Sullivan 2018). In gathering data Yoder-Wise (1999) advises all involved should have access to pertinent, valid and accurate information.

In analyzing the data Yoder-Wise (1999) suggests identification of possible solutions may result. La Monica (1994) advises deciding on why the problem exists and on who can participate in solving it. In developing solutions Yoder-Wise (1999) discusses being open minded and creative whilst Sullivan (2018) suggests combining the best parts of several solutions. La Monica (1994) discusses brainstorming to foster creativity.

In selecting a solution the options should be weighed for their advantages and disadvantages, taking into consideration not only feasibility, time and budget but also the organizational goal. In implementing a decision Yoder-Wise (1999) advises a “plan B” in case of negative consequences (p.96). Sullivan (2018) warns against abandoning a feasible solution because it is unpopular. La Monica (1994) advises one to expect some negative consequences to a solution and warns against rushing the process. In evaluating the solution Yoder-Wise (1999) advises organising, in advance, the ‘when, who and how’ of evaluation (p.96).

Discussion

A problem identified by the author, a nurse in an ambulatory service in a private facility, is a lack of registered nurses, RNs, to undertake intravenous cannulation, IVC. The issue is important as IVC is required prior to certain procedures. The author has the knowledge, interest, and authority to begin to address the problem.

The benefits will be an improvement to the service in line with the organizational goal. A long-term solution is required as a short-term “stop-gap” solution exists already, i.e. the RNs who do IVC have to interrupt their work to cannulate other patients. The data is that IVC is part of the expansion of the scope of practice of RNs in Ireland (Nurse and Midwifery Board of Ireland, 2015).

The facility has a policy that if an RN is certified in another institution in the last three years they must undertake three supervised IVCs to seek approval for the facility. If an RN is unable to provide certification they must complete an IVC study day, SD. The author found that neither the hospital Clinical Facilitator nor the CNM of the unit have data on the RN’s IVC certification but anecdotally the CNM is aware which RNs can do IVC.

Critically thinking, the author decided to gather data by asking the RNs about their IVC certification status. She found; 34% of the nurses are approved and cannulating; the required IVC SD takes place in an outside unit and is oversubscribed; when RNs complete the IVC SD they still need 3 supervised IVCs to be approved (as per policy);

the approved assessors are not always available; on induction of the overseas RNs, ORNs, (who have the previous certification) were misinformed that they could not do IVC in the hospital until they do the IVC SD and this was confirmed to them by the CNM; ORNs report that the hospital has not invited them to produce documentation of previous IVC certification;

one RN (Irish) reported being IVC certified at the SD but could not achieve 3 supervised IVCs to be approved, within the mandatory 3 months, due to unavailable assessors. On analysis, the policy has been misinterpreted by those inducting new staff and by the CNM of the unit. Misinformation has filtered down to new staff. RNs have not been invited to show their previous IVC certification.

There is not enough assessors to supervise 3 IVCs when staff completes the IVC SD. The solutions are to study and understand the policy in detail (imperative), AND either a number of existing IVC RNs on the unit become assessors and assess each RN with prior IVC certification OR run an IVC SD in the facility OR do nothing. Selecting the solution will be the CNM’s decision. Thinking strategically the author would choose to commence education of RNs who do IVC to assess as they would be available to assess all the RNs who have certification from their previous job increasing numbers of RNs who IVC in a short timespan.

The second option would need to be overseen by the Director of Nursing. Implementing the author’s choice would be less expensive than the second and less onerous to implement. Either a Train the Trainer SD or a Preceptorship SD should suffice to become an assessor. On evaluation, if the feedback is positive it could be extended to every unit. It would improve the service for patients needing IVC in line with the organizational goal.

Critical thinking

Critical thinking according to Papp (2014) is “the ability to apply higher-order cognitive skills (conceptualization, analysis, evaluation) and the disposition to be deliberate about thinking” (p.715). Sullivan (2018) suggests we think critically when we examine and question assumptions, analyze and evaluate the evidence, and then reflect to come to a justifiable conclusion. De Bono (1993) suggests that in addition to critical thinking, one needs to be constructive, creative, and generative in their thinking.

Critical thinking isn’t always connected to problem-solving. It can be a part of a process of decision-making in the selection of options (Yoder-Wise 1999). In the author’s opinion, in nursing practice, experience is often gained from seniors. It is important to empower junior RNs to question long held practices of all RNs, in other words, to think critically. Empowerment is described by Kuokkanen et al (2007) as encouraging and allowing individuals to take responsibility to improve their practise and contribute to the organisational goals. Evidence based practice has become the ‘gold standard’ in nursing with the change in education taking place at university level. We as a nursing profession must critically think and question the validity of all of our practices.

NHS LA (2013) advises researching and thinking about different ways of doing one’s job more efficiently. So for example the frequently termed present day problem in nursing of staff retention could be flipped to a positive outlook by a critical thinker seeing replacement staff as bringing new ideas to an organisation.

Critical thinkers might see multigenerational and multicultural staff as an opportunity for new learning that can be evaluated and put into practice. The HSE (2005) in their Management Competency User Pack encourages managers to proactively identify ways to improve services and to empower staff.

Managers need to address the challenge of encouraging RNs from diverse cultures to think critically and verbalise that thinking. Deference to one’s seniors can be embedded in diverse societies where questioning management is not the norm.

Policy makers at national level might take note to instigate programmes for ORNs to help them integrate into the Irish healthcare system empowering them to use their voice to advocate not only for their patients but also for their own skills whilst working in Ireland. A culture of group critical thinking on a ward could afford a safe place for new suggestions and ideas to be explored.

Discussion

Berkow (2011) cites decreased length of stay, increased patient acuity and an increase in clinical protocols as “a perfect storm” where nurses have more responsibilities in less time, allowing little time for critical thinking, yet it is an RN competency (p.168). The author’s workplace is an ambulatory service encompassing day surgery beds, minor theatre, infusion room and endoscopy. It is in this ‘perfect storm’ that critical thinking has been perhaps lacking in the past in the already mentioned issue of RN’s IVC approval.

The author used critical thinking to disseminate the data through conceptualization, analysis, and evaluation (Papp 2014) and asked a number of questions to delve into the issue. The author was aware of varying factors such as many Irish RNs on the unit have never cannulated whilst all ORNs have cannulated in their previous employment but are not approved for this facility.

The findings were 66% of the RNs on the roster are not approved to do IVC in the facility but it should be noted the roster is made up of full and part time staff which will have a further negative impact on availability of cannulating RNs.

The scope of this assignment cannot address all of the issues that have been found in the data gathered but the author would like to note the issues that need to be further explored; all 17 of the ORNs have previous experience in IVC but only 8 are approved in the facility and all work full time; of 26 Irish RNs,

only 7 are IVC approved in the facility but only 4 of those work full time. Lack of critical thinking is leading deskilling, impacting negatively on the facility finances and organisational goal. Our national and local policy makers should be aware that in 2007, O’Brien advised the need for changes in both national and local policies in the NHS to avoid the deskilling of ORNs and the loss of skills to the NHS and ultimately to the patient. Whilst O’Brien was focusing on ORNs this could be a multidiscipline wide issue.

Change

Briefly, just some of the 8 key steps of change Kotter (1996) discusses are “establish a sense of urgency” (patients waiting for an IVC prior to procedures), “create a vision” (all RNs on the unit can do IVC) and then “communicate the vision” (inform all those who induct new RNs) and “institutionalize new approaches” (RNs hospital wide can do IVC). Meredith (2008) discusses Bennis et al’s (1993) Normativere-educative Strategy of implementing change from the bottom-up based on the belief that we are social beings and want to be involved in the change process.

The author senses a change implemented by the Normative-re-educative Strategy would be embraced by colleagues who have required IVC skills. The Power-coercive Theory of change (authority expect individuals to do as instructed) would not be suitable in this scenario as the author is aware some RNs do not feel IVC is within their scope of practice. All RNs have their scope of practice to guide them and that cannot be compromised.

Conclusion

Management and leadership in nursing have been addressed in this assignment. Two leadership skills, problem-solving and critical thinking, have been described and discussed in relation to a scenario in the author’s workplace showing the importance of both skills in nurse leadership. Using the Problem-solving Process found in the literature and following the step-by-step process, the author has developed her critical thinking nursing competence to find solutions to the problem.

The author has tied together critical thinking and problem solving with regard to a shortage of nurses cannulating in a unit where it is required and has touched on the change theory that might be used to implement the new practice. She is ready to share her vision with the management and staff of the unit and implement change and thereby strive to achieve the organizational goal.

She suggests a change to local policy that restricts nurses from using their skills and proposes national policymakers design a program for overseas multidisciplinary healthcare workers to aid their better integration into the Irish healthcare system for the benefit of patients, staff, and themselves.