Management Essay - Management Leadership Care

This essay is going to critically discuss how effective management and leadership would enhance and sustain quality of care in the clinical area. Firstly, the definitions of management, leadership and quality of care shall be made, secondly the assignment is going to draw upon relevant management theories and leadership styles in relation to maintaining quality of care.

The essay will also highlight evidence based practice and the learning outcomes from it. A problem solving approach will be used to write this essay using the nursing process were the quality of care has been compromised on the delivery of care for Mr Brown who is suffering from acute psychosis.

His daughter complained that he has been left incontinent of urine for the third time that she has come to visit. The assignment is going to critically analyse how such a complaint would be managed to enhance the quality of care using a problem solving approach. (An action plan will be enclosed see appendix).

Inter-professional practice is the learning process of a group working together to achieve a common goal, working together collaboratively and co-operatively, thus enhancing the quality of service provision and patients outcome (Bray and Howkins 2006). It is believed that inter-professional working will flatten the management structure, enhance collaboration practice and teamwork (Leathard, 2003).

However Hallet and Thompson, (2001) argues that without teamwork the potential of clinical governance is not achievable, co-operation across and between disciplines, between the NHS and the public it serves is fundamental to building better structures and safer high-quality care. In this case the team comprises of Mr Brown, the carers (family, friends and helpers), health care team (nurse, doctor, pharmacist).

Problem solving and decision making are vital abilities for nursing practice nevertheless, not only are these processes involved in managing and delivering care but also they are essential for engaging in planned change. Professional nursing organizations have affirmed that competency in decision making and problem solving is essential in nursing practice (Wise, 2003). Both problem solving and decision making require critical thinking which is a higher cognitive process and both can improve with practice.

Problem solving includes a decision making step is focused on trying to solve an immediate problem which can be viewed as a gap between “what is” and “what should be.” Decision making includes defining objectives, generation options, identifying advantages and disadvantages of each opinion, ranking the options, selecting the option most likely to achieve the predefined objectives, implementing the option, and evaluating the results (Wise, 2003).

There are advantages to group problem solving e.g under the right circumstances and proper leadership group can deal with more complex issues, a group tend to have and try several approaches, complex, complete, accurate and less bias information from the group. There are also disadvantages of group problem solving e.g more time and resources, conflicts and power can intimidate less confident member.

Nursing process is used by nurses to decide who should care for particular patients, the nurse must assess each patient’s needs, goals, and match the skills of the person assigned responsibilities with the tasks that need to be accomplished (assessment). After the assessment the nurse identifies the member of staff best suited for the task at hand.

Critically thinking this through before delegating helps prevent problems later hence using a problem solving approach (plan). The nurse determines which personnel have the knowledge and skill to care for the patient and assigns the task (implementation). Nurse determines whether patients care has been meet (evaluation).

(DH, 1999) Asserts nurse leadership is critical to the quality of care, treatment and outcomes, to staff morale and to the learning climate and opportunities available to students and others.

Complaints procedure?

Complaint is an oral or written expression of dissatisfaction requiring a response (DH, 2000). A complaints document needs to be completed since or when the quality of care has been compromised. National Health Service NHS (2007) warned 30 NHS Trusts over the way they deal with patients complaints. About 140,000 formal complaints are made about NHS care in England every year and the number is still rising.

There are standards that are significant to the discussion that have been posed by the government policies to safeguard and improve the quality of care for patients, the National Service Framework (NSF), Clinical Governance, National Institute of Clinical Excellence (NICE), Mental Health Act (1983) and Essence of Care just to mention a few, for the purpose of this essay the author is going to focus on Clinical Governance and NSF.

Quality care is the satisfaction of consumers or patients with services given by members of the multidisciplinary team. It can be measured by a quality assurance tool model (Clegg, 2000). Quality of care in health as a phenomenon is developing through small incremental steps. In health care, there is a correlation between the quality of patient care, staff moral and effective nursing leadership (Ibrahim, 2001).

When Mr Brown’s care plan is being reviewed a trial and error method can be used as a problem solving approach. This is a method whereby one solution after another is tried until the problem is solved or appears to be improving. However, experimentation is a type of problem solving in which a theory is tested to enhance knowledge, understanding, or prediction (Sullivan and Decker, 2005).

Patient-centred care should be the right approach to maintain quality of care for Mr Brown. According to Tappen (2001), patient-centred care brings as many services as possible to the patient rather than bringing the patient to these service for example availability of the dietician, occupational therapist, pharmacist, and other relevant health workers close.

Patient-centred care has the advantage of reducing any red tape or bureaucratic tangle of services in the ward. However, according to Douglass (2000) patient-centred care has the disadvantage of high costs in terms of staffing and staff training. Nevertheless, in wards the managers have an obligation to implement a patient-centred care approach in order to maintain quality care without counting on the cost, each patient had his/her primary nurse.

Clinical Governance

Assessment of quality of care requires assessment tools, Clinical governance (CG) is a powerful, new and comprehensive mechanism for ensuring that high standards of clinical care are maintained throughout the NHS and the quality of service is continuously improved, it is a system for improving the standards of clinical practice, DH (2000). It was described by the government as a new system in the NHS trusts to ensure that clinical standards are met and that processes are in place to ensure continuous improvement.

According to Walshe, (1999) several activities such as clinical audits, education and training, research and development, risk management, and complaints are part of the (CG). The system will be open to public scrutiny, Health Improvements Programmes (HImPs), accountability agreements and personal development planning. However DH (1999), NSF focuses on the mental health needs, which Mr Brown clearly requires.


In the modern health service it is no longer acceptable for any clinician to abstain from continuing education after training because too much of what is learnt during studying becomes outdated quickly. It has also been the professional duty of both the clinicians and the trust to remain up to date in their continuing professional development.

However the NSF addresses mental health promotion, therefore the staff caring for Mr Brown need to be educated on his conditions since he is not only suffering from an acute psychosis but a physical condition. The Royal College of Nursing (2000) asserts that most importantly the need for consent by the client to permit any procedure. Mr Brown needs to be educated hence consent can only be given when he is in full knowledge of the facts.

Hence the Mental Capacity Act (2007) (see appendix )

The nurse has a duty of care, Nursing and Midwifery Council NMC (2008) emphasizes the need to provide leaflets for a complaints procedure, to (patients) Mr Brown and his (family) daughter and a copy for the health professionals

Clinical Audits

Improvement in the quality of health care is dependent on the contribution of nurses, and with the expansion of the nurse’s role in recent years, it is essential that effective management, objective assessment of nursing practice takes place. Clinical audit provides a means for such assessment. The DH (2003) defines the clinical audit as a review of clinical performance against set standards to improve the quality of patient care.

The ultimate goal of audit is to improve patient care, which should be an aim for all nurses. A cyclical process of improving the quality of clinical care, clinical audits has been part of good clinical practice for generations. Audits have been facilitated by trained staff and committees in the NHS trusts, and through Medical Audit Advisory Groups (MAAGs). Although clinical auditing is very important it is very difficulty to implement due to the high cost of training staff and time involved. However, its implementation would cost in the short term but it would prove beneficial in the long run.

Patients like Mr. Brown are likely to spend less time in hospital. Documentation for all patients to establish a pattern of reference for research is vital (Malik, 2004). Health Authorities have sought to use clinical audits as a tool for coordinating and promoting action on clinical effectiveness. Since Mr Brown has been incontinent of urine, DH (2000) asserts that the good practice in incontinence services guidelines suggest targets for all areas of the health service and the use of performance indicators and audits to monitor progress.

Clinical effectiveness

Clinical effectiveness is a measure of the extent to which a particular intervention works. The measure on its own is useful, but enhanced by considering whether the intervention as well as the intention is appropriate and whether it represents value for money. Aspects of efficiency and safety from the perspective of individual patient and carers in the wider community are vital.

Clinical effectiveness has been promoted through the development of guidelines and protocols for particular diseases. Theses are based on evidence of effectiveness as assessed following randomized controlled trials, meta-analyse and systematic reviews, and made more understandable by the use of terminology such as numbers needed to treat (NNT’s), the development of NSF’s, formation of NICE and the Commission for Health Improvement (CHI) (DH, 2000) .

Risk management

There are risks to the patients, risk to the practitioners and risk to the provider organization. All these risks need to be minimized as part of any quality assurance programme. Patient risk can be minimized by ensuring that systems are regularly reviewed and questioned-for example, by critical event audit and learning from complaints (Complaints Procedure).

Statutory regulations can help to minimize risk to patients for example Data Protection Act, Control of Substance Hazardous to Health (COSHH) regulations, Medical Control Agency approval, and indemnity insurance. The trust has to ensure that clinicians are immunized against infectious diseases, work in a safe environment (COSHH) and involve a specialist nurse for Mr Brown for cross-infection education. A good high quality employment practice is essential for risk to the organization, well designed policies on public involvement.

Research and Development

Good professional practice has always sought change in the light of evidence from research. Techniques such as critical appraisal of the literature, project management and the development of guidelines, protocols and implementation strategies are all tools for promoting implementation of research evidence.

According to Douglass (2000) leadership is the use of ones skills to influence others to perform to the best of their ability towards goal achievement. Leadership may be viewed as the process of guiding, teaching, motivating, and directing the activities of others towards attaining goals (Ellis and Hartley, 2004). Management, on the other hand, involves the coordination and integration of resources through planning, organizing, directing, and controlling in order to accomplish specific goals and objectives within an organization (Broome, 1998).

Douglass (2000) states that management is a process of getting work done through others and nursing management is the process of working through nursing staff members to provide care, cure and comfort to patients. Management and leadership have similar ends but different mean (Girvin, 1998). Management is usually viewed as getting things done through other people whereas emphasis on leadership is on interpersonal skills in a broader context (Mullins, 2005).

According to Huber (2000) it can be concluded that leadership can occur in any group as opposed to management, management is focused on an organisation or institution usually an employer of nurses.

Planning for patients can be tackled from different angles using different leadership styles. Arguably, leaders are perfectly capable of changing their behaviour from situation to situation and that different environments call for different leadership styles (Reynolds and Rogers, (2003). A leader can either be transactional or transformational depending with the situation.

According to Ellis and Hartley (2000) a transformational leader is defined as a leader who motivates followers to perform at their full potential by influencing changes in perceptions and by providing a sense of direction to the group. Angie (2000) goes further to define a transactional leader as one who relies on the power of organisational position and formal authority to reward and punish performance.

Transactional leadership approaches followers with the intent of exchanging one thing for another such as using financial and status incentives. It is premised on motivating followers by some form of instrumental exchange, either a monetary or symbolic reward system (Burns, 1978). The focus is on the needs of the task and the organization and how followers can use to achieve those aims.

Clegg, (2000) further suggest that a transformational leader has the ability to motivate others to pursue high standards and long-term goals. This humanistic approach is defined by an open, empowering culture where communication, strong values are paramount. Bass et al (1987) argued that transformational leadership is universally applicable and that regardless of culture, transformational leaders inspire followers to transcend their own self-interests for the good of the group or organization. Transformational leadership is seen as being preoccupied with the development of followers rather than the achievement of targets (transactional leadership) and has been equated in some books as equivalent to “leadership” as opposed to transactional leadership which is equated to “management”.

Communication is one of the most important processes that takes place in a healthcare organization. It has major effects on the performance and success of individuals, teams and the whole organization. Communication is an essential part of good practice, the patient can make an informed only if the patient is given clear information at every stage of the care process. Listening is a vital part of communication and building a trusting relationship will improve care (UKCC, 1996).

Planning requires good and effective teamwork and communication, NMC (2004), believe all professionals are expected to work cooperatively within teams and also to respect the skills, expertise and contributions of their colleagues. Inter-professional practice has a close relationship with multi-professional work. Multi-professional refers to the cooperative work of different professional groups for the achievement of the same goal (DH 2000).

Payne (2000) Ovret (2001) A team is a group of people each of whom possesses particular expertise; each of whom is responsible for making individual decisions; who hold together a common purpose; who meet together a common purpose; who meet together to communicate, collaborate and consolidate knowledge , from which plans are made, actions determined and future decisions influenced.

The (DH) states that an effective team can lead to effective inter-professional working, effective working within a team tends to lend towards an ability to work effectively with other professionals within groups and teams. Miller (1999) suggests that teamwork helps individuals to understand professional discourse; how individuals talk with and about other professional and how they justify their practice, he says effective communication, shared values, and respect for other professional constitutes to good team-working. Teams can improve inter-professional working by communicating well, co-ordinated services and prompt referrals (DH, 1999).

In the United Kingdom hospitals have began to question and analyse activity in a structured way, looking at quality issues, standards of care and cost effectiveness.

Leadership style and organisational culture are associated with an increase in productivity and staff satisfaction (Ellis and Hartley, 2000). In health care, there is a correlation between the quality of patient care, staff moral and effective nursing leadership. The purpose of this essay is to critically analyse the application of leadership theory to nursing practice. Discussions in this assignment emanates from personal experience on the author's role as a student nurse working in a team of nurses and support staff in a mental health ward.

The most important part of problem solving is defining the problem, how they are perceived determines the solution and identify needed changes (Sullivan and Decker, 2005). The potential causes of Mr Brown’s problem could vary, it could possibly be the medication (antipsychotics) that hes on or the times he takes his daily food and drink intake, that the nurses could be attending to something else for example handover. Hence a care plan needs to be formulated using the nursing process. The nurses need to form a therapeutic relationship with Mr Brown and an assessment needs to be done for him which is the orientation phase of the relationship (Arnold and Boggs, 2003).

The second part of problem solving is gathering information and all relevant facts that provide clues to the scope and solution of the problem (Sullivan and Decker, 2005). The nurse needs to collect data (Data collection) which includes a description of the health problem or need from the clients perspective (Mr Brown), the clients expectation for treatment, strengths and resources available to the client, and a working diagnosis that will serve as the basis for planning and different therapeutic interventions (DH, 2006).

One of the fundamental principles underpinning the current government’s agenda for the ’new National Health Service’ is a shift towards quality care. According to Walshe, (1999) quality care has become the driving force for decision-making at every level of the service. All NHS trusts will be required to put framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish (Rayner,2003).

Management theories

Various managent stlye can be employed dependent on the culture of the business, the nature of the task, the nature of the workforce and the personality and skills of the leaders. For the purpose of this assignment particular emphasis will be on quality of care in a health care setting.

This idea was further developed by Tripathi and Reddy (2006) who argue that the style of leadership is dependent upon the prevailing circumstance; therefore leaders should exercise a range of leadership styles and should deploy them as appropriate, in this case Mr Brown’s complaint.

An Autocratic or authoritarian manager makes all the decisions, keeping the information and decision making among the senior management. Objectives and tasks are set and the workforce is expected to do exactly as required. The communication involved with this method is mainly downward, from the leader to the subordinate, critics such as Elton Mayo ( ) have argued that this method can lead to a decrease in motivation from the employee's point of view hence complaints like the Browns since there is no communication.

The main advantage of this style is that the direction of the business will remain constant, and the decisions will all be similar, this in turn can project an image of a confident, well managed business. On the other hand, subordinates may become highly dependent upon the leaders and supervision may be needed.

In a Democratic style, the manager allows the employees to take part in decision-making: therefore everything is agreed by the majority. The communication is extensive in both directions (from subordinates to leaders and vice-versa). This style can be particularly useful when complex decisions need to be made that require a range of specialist skills: for example, what sort of nursing needs would be appropriate for Mr Brown , and the upper management of the business is computer-illiterate. From the overall business's point of view, job satisfaction and quality of work will improve. However, the decision-making process is severely slowed down, and the need of a consensus may avoid taking the 'best' decision for the business.

As suggested by Dinah (2001) the ultimate responsibility for the quality of clinical care rests not with individual clinicians nor with clinical teams, but with the healthcare organisation and particularly those who lead it. In my ward there was lack of motivation among staff and effective systems for assuring and improving the quality of the health service they provided..

According Tappen, (2001) the most effective leader or manager is one who creates an environment in which people are highly motivated and, therefore ,highly productive. Huber (2000) further suggests that motivated nurses have a sense of energy enthusiasm, and goal-directedness. There are several theories of motivation for the purpose of this essay we will consider Maslow’s theory of motivation and human needs, and McGregor’s Theory X and Theory Y.

Maslows (1970) developed a theory of motivation based on the idea that some human needs are more basic or prepotent than others. However Mcgregor (1960) compared two different sets of human beliefs about human nature, describing how they led to two different approaches to leadership and management. According to Ellis and Hartley(2000) theory X is based on the common view of human nature that an ordinary person is lazy, unmotivated, less intelligent, irresponsible and prefers to be directed rather than act independently.

Based on this view of people, managers must direct and control people to ensure that the work is done properly. Theory Y on the other hand, believed employees enjoyed their work, were self-motivated and were willing to work hard to achieve personal and organisational goals. According to Tappen (2001) theory Y leaders and managers remove obstacles, provide guidance, and encourage growth.

However, we can sum up an effective leader as one who promotes open communication, set goals, intervenes in conflicts and involves team members in decision making. Individual characteristics constitute an important variable that determines the type of manager a nurse can be. Arguably, hospital policies can also influence the management and leadership styles in the wards.

The leaders implements the decision after selecting the best course of action, change is a carefully worked out, preconceived plan. Nurses are considered as change agents, a change agent is someone who identifies major problems areas, identifies the opportunities for change, builds a readiness and commitment (Broome, 1998). Nurse leaders must initiate the changes they believe are necessary to strengthen nursing practice, enhance QOC and create a better system, critical analyses of change models see appendix.

In conclusion any decision style can be used appropriately or inappropriate, the situation and circumstances should dictate which style of management/leadership should be used and most appropriate. One way to evaluate the quality of outcomes is to compare ones agencies performance against that of similar organizations (Benchmarking).


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