Management & Leadership in Advanced Practice
The National Health Service (NHS) has undergone several changes over recent years in an attempt to manage the increasing demands on the healthcare system due to an ageing population, increased rates of chronic disease and rising NHS costs (Anderson 2018).
Many of these changes impose a rising demand on healthcare professionals to deliver high quality care and improved patients’ outcomes in very difficult circumstances when minimal staffing levels and budgets are ever decreasing.
The key challenge facing all NHS organisations is to nurture cultures that ensure the delivery of continuously improving high quality, safe and compassionate care.
Management and Leadership are deemed to be imperative for the NHS to sustain success.
Following the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis 2013), numerous failings in care were described, a lack of leadership across the healthcare professions was deemed to be a contributory factor to this.
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Vaill (1996) described the healthcare as frenetic and unpredictable environment as ‘permanent white water’ and argued that while good management skills are still essential for day-to-day operations, navigating ‘permanent white water’ successfully must begin with effective leadership.
The economic and other challenges in healthcare now and over the coming years will make it imperative that front line clinicians and practitioners have the leadership capability to drive radical service redesign and improvement strategies such as Simply Prudent Healthcare (Welsh Government, 2016).
This essay will critically analyze the concept of management and leadership theories specifically in relation to advanced practice and healthcare.
Management and Leadership
The terms ‘management’ and ‘leadership’ are often used interchangeably, however there are significant differences between them. Kotter (1996) suggested that management is concerned mainly with order and consistency, while leadership is centered on change and movement. Management focuses on controlling complex processes, whereas leadership is about challenging existing ways of doing things and setting new directions in organisations.
Effective leaders do not necessarily have a nominated or formal designated authority, and their leadership is achieved through empowering others with an emphasis on an interpersonal relationship within the team. Managers, however, are often described as being more outcome driven and involved more in planning, organizing and controlling resources such as staffing and budgets (Anderson, 2018).
Rigolosi (2013) describes the key difference being that a manager’s authority stems from an appointed or elected position in an organization and they carry the responsibility of accomplishing the organizations goal through specific professional services while leadership is a much broader concept because all health care professionals can be leaders. Any person who has followers who count on this person’s expertise to carry out objectives is a ‘leader’. Furthermore, anyone who is responsible for giving assistance to others is also considered to be a leader.
Leadership is a key skill for nurses at all levels, while this may be seen as stating the obvious for those whose position puts them in documented managerial roles, even the most recently qualified practitioners/nurses can offer leadership to students and other colleagues such as healthcare assistants. In summary management is about tasks, whereas leadership is about perception, judgement, skill and philosophy.
Management and Leadership within Advanced Practice
With healthcare services constantly adapting to trends and policies, healthcare professionals especially nurses, are having to lead, organise and deliver care in an increasingly challenging and changing environment (Govier, 2009).
The role of the advanced nurse practitioner was developed in 2004 following the reduction in the number of hours junior doctors could work under the European Working Time Directive (British Medical Association, 2016). This resulted in a need for other clinicians, including nurses to undertake advanced practice roles (McBride, 2004).
The Framework for Advanced Practice in Wales (NLIAH) (2010) sets out four pillars of advanced practice – Education, Advanced Clinical Practice, Research and Management and Leadership. These pillars articulate the core principles that advanced practice is a level of practice rather than just a role or title.
These four pillars work in combination with many other management and leadership frameworks such as NHS Wales Leadership Qualities Framework (LQF) (NHS Wales, 2005) and the Healthcare Leadership Model (NHS leadership academy, 2013).
Advanced nurse practitioners have a responsibility to understand the increasing complex demands on the NHS, including the ageing population and innovations in clinical treatments (Hardy et el, 2013). Rose (2015) highlights that advanced nurse practitioners are required to have an understanding of the necessity of responding to and influencing changes in healthcare policy and practice. As such, strategic and clinical leadership are integral to the advanced nurse practitioner’s role. Cook (2001) believes that leadership is as much about having the correct attitude and behavior as it is about skills and knowledge.
The bureaucratic management theory, a concept devised by Weber (1947) works on the assumption that power educes obedience through force or the threat of force which induces individuals to adhere to regulations. Characteristics of this theory included clear division of labor, formal hierarchal structure – involving superiors being separated from subordinates, formal and impersonal relations, management by rules and selection based on technical competence.
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While this bureaucratic approach was ideal to harness and routinize the workforce in the industrial revolution, Weber’s work was written in a time when workers motivation was taken for granted (Marquis and Huston, 2017). Rigid procedures and rules are demotivating for workers which could be counterproductive, however some aspects of this management theory still exist such as organizational hierarchy.
McGregor’s (1960) X and Y management theory contrasts two sets of assumptions and attitudes in managers in respect of human nature; Theory X and Theory Y. Theory X assumes that the average worker dislikes and tries to avoid work, has little ambition and needs to be coerced, controlled or even threatened to get things done. While Theory Y assumes on the other hand that the worker will exercise self-direction, enjoys work and seeks responsibility.
While an advantage of this theory could be only two main types of individuals for managers to consider how to motivate, a disadvantage could be two extremes of managerial behavior.
There are several leadership styles identified in nursing literature. Cummings (2012) stated that most styles can characterized as relational leadership or task- focused leadership. Relational leadership relate to relationships and people while task- focused leadership focuses on job completion, deadlines and directives.
Authentic leadership (a relational leadership style) is an emerging theory which suggests that in order to lead, leaders must be true to themselves and their values and act accordingly (Marquis and Huston, 2017). Authenticity can however, like many usually positive leadership characteristics have an adverse consequence when it occurs accidentally, it may positively destroy or at least severely damage a leader’s credibility and reputation (Gill, 2011)
Another relational leadership styles which is gaining prominence in the 21st century is Emotional intelligence (EI) (Marquis and Huston, 2017). EI refers to the ability to perceive, understand and control own emotions as well as those of others. Goleman (1998) identified five components of EI: self-awareness, self-regulations, motivation, empathy and social skills. Mansel (2017) suggests that it is important to recognize how your own emotions effect your performance. Many of the five components of EI are advocated within the leadership and advanced practice frameworks therefore are advantageous and often promoted within advanced practice and healthcare in general. Emotionally intelligent leaders reflect on their emotions and make rational decisions.
The most documented leadership style in healthcare is Transformational leadership. Transformational leadership is considered to be the gold standard of leadership (Cope and Murray, 2017).
The work of Burns (1978) which was further developed by Bass and Avolio (1994) demonstrated that transformational leadership is central in nursing, this has been validated by its proven influence on staff satisfaction, patient outcomes and safety culture (Cummings et el, 2012). Transformational leaders are believed to put nurses and nursing first; are positive under pressure and form connections with their followers. They also act as a role model and effective mentor while adhering to a core set of values (Anonson et el, 2014). These attributes enable the transformational leader to motivate, empower and inspire others to achieve a long-term vision with organizational goals as well as career goals. Bawafaa et el (2015) also suggests that outcomes associated with transformational leadership include reduced stress, increased collaboration and teamwork and increased intention to remain in the nursing profession. However, Mannix et el (2013) and Marquis and Huston (2017) suggest that transformational leaders may require ‘Transactional’ leadership skills for the day-to-day management of the organization and the people in it. Transactional leadership is a task-focused style, it is suggested that in crisis situations when clear direction is required, this approach is an effective style (Giltinane, 2013)
Laissez-faire leadership is a task-focused style of leadership. It involves reactive leadership such as setting tasks in times of crisis. This style of leadership is considered a ‘hands off’ approach, leaving decisions to others. Often a style seen used by inexperienced leaders or leaders who are due to leave their position. Laissez-faire leadership and/or lack of leadership can be known to have a significant negative effect on employee effectiveness and satisfaction, thus in turn may ultimately affect quality of patient care (Skogstad et el, 2014).
It is undeniable that Advanced nurse practitioners are ideally positioned and educated to act as clinical and professional leaders both within and beyond the healthcare organization (Elliot, 2017).
While preferred leaderships styles can often depend on personal attributes and characteristics, most core principles of the leadership and advanced practice framework would steer the practitioner toward the relational leadership styles such as transformational or emotional intelligence.
However, in order for advanced nurse practitioners to be able to fully enact their leadership role, a long-term strategic approach and commitment from the organization is required to focus on organization-level management to develop support structures and mechanisms that facilitate this process.
While management and leadership sit within the 4 pillars of advanced practice framework,
according to Higgins et el (2014), even with leadership being embedded into advanced nursing practice education, without the support from multi-disciplinary team, including nurse managers there is a risk of the advanced nurse practitioner’s leadership potential being unfulfilled.
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