How registered nurses might develop appropriate leadership skills
Throughout this discussion I will talk about NHS leadership frameworks, give a definition of leadership, discuss styles, and theories such as transactional and transformational models. Mention the Knowledge Skills Framework, explaining how good clinical supervision and perceptership during orientation can have a positive influence on a good patient care outcome. Giving an overview of the skills and attributes that enable nurses to become leaders,
NHS Scotland (2004), proposed a Leadership Framework, the paper talked about improving the health of Scotland and reforming how healthcare is delivered.
Its aim, to develop new leaders on all levels of the NHS, as this will be crucial for the ambitious goals set out for the health service. Department of health 2004 (DOH) is hoping to create visionary leaders who can empower individuals; they are looking for effective leaders with a complex mix of attributes, behaviours and skills, who must also be able to reflect upon and evaluate themselves (Oliver 2006).
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Nurses demonstrating an effective leadership style will be in a powerful position to influence the successful development of other staff, this in turn will lead to the ultimate goal of any healthcare organisation which is influencing the quality of patient care through good nursing leadership. (Frankel 2008)
When we think of leaders we think of great people such as Churchill, Kennedy, Florence Nightingale and many more, these people are regarded as leaders because they had a vision to change things for the better, they inspired their fellow men with words of wisdom, they challenged authority and seized on opportunities.
These challenges are carried out every day in all kinds of clinical and non- clinical settings in the NHS, not many nurses will make the history books, but a good nurse leader will be respected, and become a role model for others.
However, there are some theorists who believe that leadership is in-born and that some traits of a leader's personality such as intelligence, initiative and confidence are what creates leaders. (Goffee and Jones, 2000). There are also those who disagree, Kouzes and Posner (2002) for example, argue that the skills of a leader are observable and learnable. Ellis and Abbott (2009), agree with, Faugier &Woolnough, (2002), who looked at models of leadership, and believe that people get intrinsic satisfaction when given more control over their work, they tend to be more productive and better motivated.
According to Murphy (2009), good leadership plays a very important role in the provision of good patient care. Since the publication of The NHS plan (DOH 2000) the NHS has drastically changed its managerial stance, recognising that the concept of, effective leadership, is the key to modernising today's health service. (Warriner 2009) The goal of the government is to steer the NHS away from a bureaucratic and scientific management and on towards an organisational culture of self management (Oliver 2006), this will provide a dynamic and responsive health care system with a work force that can cope with frequent organisational change. To achieve this goal the NHS need, to have clinicians who can demonstrate leadership skills and can act as role models at all levels of the service
Leadership, according to Grim (2010), is a "complex entity", there are many definitions, Benton (2005), described leadership as "the art of influencing people to accomplish the mission", another definition by Huczynski and Buchanan (1991), defines leadership as; "a social process in which one individual influences the behaviour of others without threats or violence". Cook, (2001),Â stated that; "Leadership is not merely a series of skills or tasks; rather, it is an attitude that informs behavior".
Thefore, leadership styles are often based upon behaviours that are used to influence change. There are different styles of leadership; autocratic, these types of leader set their own goals; they do so without allowing other team members to participate in the decision making, they lead from the top down. (Faugier &Woolnough, 2002). Bureaucratic, leadership has no grey areas, they stick to the rules, regulations and policies rigidly. Laissez faire leadership is a more risky kind of leadership as the staff members are left to their own devices in meeting the goals set out. According to Faugier &Woolnough, (2002), Ellis and Abbott (2009), a better and fairer leadership style may be situational leadership, this style allows the leader to switch between all the above styles depending on the situation they are dealing with and the competence of the workforce he or she is working with at that time.
Many organisations, the NHS included, have adopted transactional and transformational models of leadership. The transactional approach to leadership according to Frankel (2008), is more management orientated, it assumes that work is done only because of rewards and no other reason, it is task orientated, sets goals for employees focuses on day to day operations and gets things done.
Members of these teams can do little to improve or change their job. Transactional leaders, will do things right, whereas transformational leaders, will do the right things. (Taylor 2009) This could be the reason why transformational leadership, is used in many corporate situations, it suits many circumstances in business as their leaders are exceptionally motivated, trusted, set clear goals, encouraged and supported, their teams inspire others. Transformational leadership is a style that is focused on change, its more complexed,the way it shapes and alters the goals and values of other staff, to achieve a collective purpose which will benefit the nursing profession (Grimm2010).
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Transformational leadership if used by higher management is supposed to have a cascading effect or domino effect as others call it, these leaders see that the relationship between leader and follower as being critically important in the running of the organisation. There is an emphasis on empowerment by being honest and open, building a bond of trust that can encourage their staff to become independent in their decision making. If the transformational model of management is started at the top and works down to the shop floor with every member of staff having that shared vision, any organisation could move mountains, you would have an effective workforce which will then have a positive effect on patient outcomes. (Taylor 2009)
The models are tools to help the nurse become a good leader, they are frameworks on which to build an effective leadership style, ideas from all of the models can be used and switched about to suit the individual leader.
The concepts are not set in stone, to be an effective leader, the manager needs to change from transactional leadership to a transformational one. Hurley and Linsley (2007) suggest a amalgamation of the two is needed to free nurse leadership from self imposed boundaries these two models together could support and underpin clinical leadership with humanistic principles.
As a newly qualified registered nurse, leadership will be a daunting thought, being the newest member of staff, the leadership mantle will not rest on easy shoulders, through good preceptors during orientation, the new staff nurse will become a team player, as team work is essential to ensure that patients receive the optimum care and the best service available. A new nurse will become part of a multidisciplinary team, which will include a complex mix of people with individual personalities, cultural beliefs and behaviours who will work together with an overall aim of achieving a common goal, good effective patient care.
Good leadership is essential as the dynamics of the team will be subjected to constant change depending on every day problems such as, staff shortages, absenteeism, and change of responsibilities. The role of the leader is to ensure that the problems would not have any effect on patient care. Leadership is rarely thrust upon the unsuspecting nurse; it is a set of knowledge, skill and attributes that are developed over time (Morgan 2000).
Therefore, knowledge and skills must be kept up to date throughout the practitioners working life to develop these skills the practitioner must go through the Knowledge and Skills Framework (KSF). (DOH 2004),
KSF, is an effective ongoing tool used to show the broad skills and knowledge, that a nurse or practitioner needs to be effective in their particular post or position. The framework was introduced alongside the Agenda for Change (AfC) pay system to ensure every NHS nurse receives an annual review to assess the knowledge and skills required to do his or her job.
The aims of the KSF were to show clear and consistent development objectives so that practitioners were aware of what skills would be needed for their chosen role, to help and encourage the development of staff in such a way that they can apply the newly gained knowledge and skills to their post and to help identify any knowledge and skills that may support career progression and encourage the need for life long learning. (Hinchcliff 2008 & Cook 2001 )
The KSF will ensure that practitioners are fit to practice and continue to provide a framework for good quality care, recognised that investment must be made to improve nursing practice and educate nurses to be effective leaders.
Leadership skills are implemented at the start of the nurse training programs, communication, critical thinking, listening, self awareness, empathy, motivation, reflection, and problem solving. These skills will be required from every registered nurse from the onset of their career to show that, an individual can achieve leadership and decision-making skills, and will go on to enhance services in our complex and diverse healthcare environment.
Communication, one of the main skills that a newly qualified nurse can excel in immediately after training, a good handover, passing on messages such as doctors orders, blood results, listening to what patients are saying and also what they are not saying, body language, telephone calls, information appertaining to the patient in her care, this skill may be intrinsic but it can also be a learned skill.
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There are many theories and models on communication, much has been written about this subject models such as, The Circular Transactional Model of Communication, (Bateson 1979), and a Skill Model of Interpersonal Communication Hargie & Dickson 2004) to name only two of them. (Timmons & McCabe 2009) The theories and models may not have a direct influence on how the nurse communicates with her patient, but by reading them it allows discussion and in a nursing context this could illustrate a difference between a task centred approach or a patient centred approach when dealing with her patients.
A research study carried out by Burns (2009) found that participants felt that leaders need to have, effective communication and interpersonal skills, to be able to tell staff were they are going wrong or encourage them if they are on the right track, they need to be good listeners and keep the staff informed, sharing the vision, negotiate care, or successfully manage care.
To have leadership skills nurses must be more assertive, it is well documented (Timmons & McCabe 2009) that in the past most nurses tended to take a submissive role in communication behaviour, today's nurse with good mentorship and support can be frank, flexible and open-minded and with the right encouragement can motivate and encourage others, without being confrontational or challenging, this can work in the patients best interest, to have a confident practitioner who is responsible and accountable for her actions.
Sengs (2006) view on this was that these individuals have emotional maturity they seek understanding of their roles, similarly Goleman (1998), found that key skills should be found in effective leaders, such as, self awareness and assertiveness, these are the leadership skills that nurses have to develop.
A good leader needs to understand themselves, be aware of their own feelings, actions, values, attitudes, beliefs and how they influence relationships and interactions with others, thus, a nurse cannot understand other's until they themselves are self aware.
Self-awareness is a lifelong process and requires the individual to look inside themselves and reflect take on board feedback from others. (Senge 2006) Assertiveness, another valuable skill in the element of communication, Balzer-Riley (2000) suggests that, assertiveness is a gift that expresses thoughts feelings and ideas without the anxiety of having a negative effect on others. Self- regulation; this is the component of emotional intelligence that enables the individual to be reasonable in the workplace, with appropriate control over feelings and impulses, these leaders are open to change and have the capacity to create environments of trust and fairness.
Motivation, driven by not only external incentives such leaders are uniquely internally motivated and will display both innate optimism and organisational commitment. Empathy, also an essential skill for a good leader, it enables one to understand both the needs of the user of the service and also those of the providers. Social skills, enables the leader to find common ground and manage relationships they should be recognised by co workers as someone they would want to follow. (Timmins & McCabe 2009)
Lett (2002), gave a definition of leadership as, the skilled nurse who leads patients to better health care, Cook (2001) agrees, what sets a leader apart is the ability to develop and influence others.
Perceptorship and mentorship are not much different to leadership, Adaire (2002) defines them as, the art of influencing people to follow a certain course of action, controlling them,directing them and getting the best out of them.
A nurse who has good preceptership and mentorship style will be in the position to influence the sucssesful development of newly qualified staff and students, having a good sense of humour, patience and aproachability, ensuring that their professional standards are maintained thus enabling the growth of competent practitioners.
Elmeres (2010) suggests, that strong leadership is vital to the success of the preceptor process; the ability to guide, facilitate and evaluate nurses is an undeveloped skill .Clinical leaders must take factors such as personality clinical competence, communication abilities into account. If the preceptor cannot communicate with the new staff nurse because they are lacking in knowledge themselves or have little self esteem then they will be a poor preceptor. The role of the preceptor as an educator and facilitator of learning is the cornerstone of nursing orientation. Elmeres (2010) The preceptore needs to be able to give both positive and constructive criticism e.g., `That was a good dressing you put on` or `that's not how I would do it, but let me show you how, and then you can have another go`. These comments will build confidence and motivate the orienteer.
Orientation to a clinical area can take anything up to 18months as every one learns at different speed. It would not be conducive to the nurse if her orientation was over too soon as she may feel overwhelmed and incompetent, this would then demoralise her with no job satisfaction this could be detrimental to the patient care outcome as she could go off work sick leaving the clinical area short staffed, or need mentored again because of lack of confidence.
Clinical supervision in the workplace was introduced as a way of using reflective practice and shared experiences as a part of continuing professional development
Butterworth (1992), gave a definition of Clinical Supervision, an exchange between practicing professionals to enable the development of professional skills. Clinical supervision provides a structured approach to deeper reflection on clinical practice, which can lead to improvements in practice and client care, it has the support of the NMC, and fits well in the clinical governance framework, whilst improving nursing practice.
Reflection, just like clinical skills, reflection needs to be learned, it is an activity that is central to a nurses professional practice. Johns (2000) stated; Reflection is a window that the nurse can view and concentrate on herself within the context of her lived experience, this will help her to confront and understand the problem and work towards resolving it within her practice of what she has done and what she would like to do better. There are several models of reflection (e.g. Gibbs 1988, Johns 2000, Taylor 2006,) these models help the practitioner by asking structured questions about their experiences in clinical practice which prompt the practitioner to remember certain aspects of the event e.g. who, what, where and when.
As the new practitioner's confidence in her experiences, abilities and competence, grows, mentoring will be the next stage of her development. The NMC (2006) states that, nurses who take the role of mentors must be registered with the NMC and be on the same part of the register as the students they assess. The mentor must be on the register for at least 12 months and have completed an NMC approved mentor preparation course, which is a ten day program, (PA, Panther 2008).
Mentoring whether it's formal or informal is one of the important roles that every nurse has to take part in. The NMC (2004 4.3) states that the practitioner must communicate effectively to others and share knowledge, skill and expertise with other members of the team as required for the benefit of patients. This can be seen more frequently in the delegation of colleagues on the ward.
Delegation according to Hansten and Jackson (2004), is the transfer of selected tasks and responsibility for completion of tasks to another and retaining supervision and accountability for that activity. NMC (2004), states that, individual responsibility is the duty for which one is responsible, while accountability relates to the fact that one can be called to account for ones actions with regard to a duty. A nurse leader in charge of the ward or clinical area has to delegate to others, otherwise she would have no time to carry out her duties in view of this is she accountable for all her staff. Although the practitioner who has been delegated the task is accountable for her own actions, if the practitioner delegates to another a health care assistant (HCA) or student, then the practitioner is accountable for this person, as the law will state that due to professional accountability, only responsibility can be delegated to others, accountability and liability cannot be delegated. (Cornock 2008) This means that even though the individual took the task on, they may state, that they lacked the authority, knowledge and experience to carry out the task.
The nurse who delegated must from a legal perspective remain nearby to monitor the task, and to offer advice if needed. In America, The National Council of State Boards of Nursing (1995), brought about the `five rights of delegation` these are the right task, the right circumstances, from the right person, with the right communication, with the right supervision. NMC (2007b) also reflect on this advice with regards to delegation. (Hinchcliff 2009) .
The purpose of this assignment was to examine how registered nurses develop appropriate leadership skills, and how this can be implemented in improving a patients care requirements. Nurses who are competent in the skills of leadership will be able to plan and design the way care is delivered in the future, they will produce better patient outcomes by promoting greater nursing expertise through increased staff ability and a new level of competence this will achieve the goals of the health service providers and improve patient care outcomes.
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