Introduction of an evening well baby clinic
1.Introduction, Aim and Objectives
1.1This report will provide evidence of the application of leadership knowledge to the role of the health visitor’s practice. The report will look at my leadership style and skills in relation to developing and implementing an evening well baby clinic. When implementing this clinic I will aim to address and discuss past leadership experience and how I will use this within my team to achieve the best outcomes for families within my practice area.
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Attention will be paid to relating this to improving the quality of care as highlighted in the Nursing and Midwifery Council (NMC) Standards of proficiency for specialist community public health nurses, 2004. The standards also state that I, as a Specialist Community Public Health Nurse (SCPHN) must work in partnership with all team members and clients. I will apply my existing and newly developed leadership skills when managing my evening well baby clinic (NMC, 2004 and DOH, 2009). This report will include a discussion on my best practice and the use of evaluation and reflection in learning from experiences. The report will also include issues related to the quality of care and how my leadership can maintain or improve it.
The aims and objectives of this report are to provide a clear expression of the quality issues in clinical care and to analyse my understanding of leadership and leadership styles in relation to quality of care. I will then look at change theories, management and leadership styles within my practice area and consider what the strengths and weaknesses are. Consideration will also be given to conflict management and my style of leadership within the team in order to promote effective working.
2. Knowledge and Copmetence of Leadership Practice
2.1Whilst undertaking the SCPHN course I have had many opportunities and experiences to develop my leadership, and reflect on the kind of leader I aspire to be. There are two types of leaders: transformational and transactional (Hartley and Benington, 2010). I feel that I am currently a transformational leader as I try to motivate staff members, encourage vision and ideas and inspire team members and clients to achieve the best possible outcomes. As identified by Huber (2010), vision is a key aspect of any leadership activity. I feel that my evening well baby clinic has shown my vision through the ideas and implementation of activities within the group. I shared my vision with fellow team members and this promoted motivation and inspiration. Transactional leadership is a more direct approach setting out clear goals and offering rewards to staff members in order to meet objectives (Hartley and Benington, 2010).
I adapted aspects of this approach but felt that a transformational approach was more appropriate for my team and my practice. Whilst the transformational model of leadership may be seen as dynamic and therefore appeal to change agents, in this scenario the proposed change is largely transactional. It could be argued that the evening clinic will not provide staff with new skills or knowledge and it is unlikely to be seen as a particularly innovative as it is simply expanding an already existing service within the practice area. However, it is important to recognise the need for transactional change, in this instance practical concerns of an evening well baby clinic are being addressed. The evening clinic will not only benefit service users, but I feel that it will also give the health visitors a new perspective and insight into families that they would not normally see, thus it will improve service delivery and help achieve both local and national requirements.
2.2 I feel that in order to look at management and leadership theories, it is important to understand the differences between them. Warren (2005) states that the key role of leadership is vision, from this management embraces the vision, into the day to day running of the organisation thus allowing the leader to transform how the care is delivered while management focuses on budgets, targets and health and safety etc. Kotter (1990) furthermore illustrates the importance of both management and leadership within organisations for the implementation of a seamless service. This is supported by Marquis and Huston (2009) who argue that within nursing, management and leadership should be integrated. I believe that it is vital for leaders to have the ability to be both managers and leaders at the same time in order for quality of care to take place. It is important to remember that management and leadership are very different but have overlapping functions (Ellis and Hartley, 2009, Gopee and Galloway 2009). To combine aspects of leadership and management skills are an essential part of the SCPHN role. Gopee and Galloway (2009) support Huber (2010) about the key importance of a visionary approach to leadership. It is important to reflect on the differences between leadership and management, to have the ability to utilise management in order to enhance my leadership and promote flexible, positive and appropriate team development. This is contradicted by Goodwin (2006) who postulated that leaders must have vision but do not need management skills, but management must have vision.
2.3 In my leadership experience I believe that having an effective working relationship with your team can influence the outcomes of a project – this is supported by Hartley and Benington (2010) as a key leadership quality. Kotter (1990) suggests that leadership sets directions and motivates people, inspiring them to have the ability to adopt a visionary position, to set direction, and to anticipate as well as coping with change. I have adapted this approach by undertaking regular team meetings where ideas and goals were set. Then time was given for the team to feedback their own personal vision which promoted self esteem and ownership of the project to enhance team motivation towards a common goal. Through this feedback time, team members were able to identify their own strengths and interests to bring to the project, any areas of weakness that were identified were discussed and any relevant training was given. Cooperation and collaboration from other agencies was resourced to provide the best quality service for staff and service users alike. This enabled learning from each other where any potential conflict would be avoided by staff working within their capability within their role, and recognising that each member of staff is accountable for their own practice.
2.4 I believe that leadership from health visitors within the practice setting is key to quality care being given, along with a range of services being available and accessible within the community. In order to achieve this I considered my leadership approach to improving services for the community in which I work, based on guidance and policy highlighted in the Department of Health’s NHS plan (2000). The white paper; The New NHS: Modern Dependable (DH, 1997) advocated improvements to the quality, range and accessibility of services available within the community. In order to improve the quality of my service I decided to implement a change in time and working structure for staff. Acheson, (1998) highlighted that within primary care it is important that services are not only effective but readily accessible. Acheson concluded that the NHS should be aiming to provide equitable access to effective health care for all. The project that I have implemented is aimed to improve the quality of existing services by making the time more convenient to clients. Anecdotal evidence from parents who have or are due to return to work has highlighted a current deficit in service provision. Service users have indicated general dissatisfaction at there being no clinic available at a time accessible to working parents. When discussing inequalities it is easy to focus on disadvantaged families living in deprived areas. It is important to acknowledge that working parents have difficulty accessing services during the working day and are therefore also experiencing inequality. In response to this as a leader I have identified a gap in service provision and an opportunity to reduce inequalities in health by providing this service. As the leader of this project it was my responsibility to communicate and promote collaborative working with multi disciplinary organisations and to be a positive role model to the staff within my team. The document Our health, Our care, Our say (DH, 2006) identifies aims and objectives for professionals to guide them in their role of improving services in the community. It also states that more co-ordination between services is needed and greater consistency across the health service in order to reduce inequalities. It advocated a more flexible service in order to increase accessibility and it recommends involving service users and the local population in decision making.
3. Leadership Styles and the Complexity of Care Delivery.
3.1 In the last year as a student health visitor I have been able to observe many different leadership styles which has enabled me to be adaptable and to manage the changing environment. On reflection I believe that I have chosen aspects of these styles to develop my own style. Hartley and Bennington (2010) suggest that ‘better leadership’ within health care is central to improving the quality of healthcare.
Through research I have found that there are many different leadership styles, Hersey et al (2007) identified these styles as authoritarian, laissez-faire and democratic. Within my career I have encountered many of the leadership styles, this has enabled me to choose aspects of these styles within my own practice.
I found the laissez-faire approach of no interference and lack of decision making and a lack of structure to be confusing and unclear. The advantages of this approach with groups are that they are fully independent and promote professionals working together (Huber, 2010). The authoritarian approach from previous leaders has been very directive and not team focused. I found this approach did not encourage togetherness and therefore I would not want to promote this within my team. In conflict situations I can see how it would be an efficient approach. I aim to be a democratic leader who works with their team, sharing responsibility and decision making – although this may be a long drawn out process I believe it will facilitate an improved project.
Huber (2010) stated that the challenges of a democratic style are getting people with different professional backgrounds to work together and decide on a plan of action. To overcome this I ensured that the team shared common goals. I consider that the change in work practices that I brought to the team motivated the staff to examine their own working practice. This was shown to me through the interest and suggestions that the team offered in the form of their ideas to meet this challenge. By tapping into the moral dimension of a proposed change – in this instance promoting the need for staff to contribute in order to protect child safety – and also to reduce the health inequalities that the children and families who would not otherwise be in a position to attend a “well baby clinic” during the day could face. I recognised early on in the process that there was resistance to working unsocial hours. The clinic required two members of staff, one needing to be qualified health visitor, to ensure staff safety and adhere to the local lone working policy. Within the practice area as a whole there are approximately twenty health visitors, eight nursery nurses and two staff nurses employed by the Trust. This highlighted that staff may only be expected to cover one clinic every ten months. Some staff volunteered to work the clinic more often and this provided relief for those staff who were not so keen to work into the evening. Working into the evening provided a benefit to thee staff as this allowed them to commence work later in the day, therefore demonstrating that as a democratic leader I inspired staff to change by motivating followers to surpass their own self-interest for the sake of the team and organisation (Bass 1990).
3.2 Situational leadership was formulated by Hersey and Blanchard (2007) and postulates that leaders adapt their style according to the situation. Supportive behaviours encourage the team to facilitate the problem solving (Northouse, 2010). Situational leaders have two main types of intervention: those which are supportive and those which are directive. The effective situational leader is one that adjusts the directive and supportive dimensions of their leadership according to the needs of their workforce (Northouse, 2010). Most team members were found to be highly motivated in the project, identified by their suggestions and ideas, eliminating the need for a directive role. The supportive behaviours I employed encouraged a participative approach characterised by the use of finely tuned interpersonal skills such as active listening, giving feedback and praising.
3.3 I can see that my democratic style of leadership encouraged staff participation and commitment. This was achieved by assessing staff competence and commitment to completing the task. One member of staff appeared to take little interest and did not offer ideas, this displayed a lower level of commitment compared to other staff members and hence I directed her more. This was overcome using the coaching behaviours supported by Hersey and Blanchard (2007). This form of coaching allowed encouragement through two way discussions about the proposed changes and resulted in increased levels of commitment and motivation from this individual member of staff, integrating her into the change process.
On reflection this can also be identified as reducing resisting factors to a change within a force field as by adapting to the needs of that team member, I encouraged her to take part and share her ideas. Rather than hindering progress and potentially opposing the change, she felt included and valued. I aim to develop my leadership style further by gaining feedback from my team members and by reflecting on what have been positive and negative experiences, whilst maintaining a link with best evidence based practice.
3.4 When implementing my evening well baby clinic and introducing my new leadership style, it was important to remember that change would be needed. When proposing change I recognised the need for a structured process. Keyser and Wright (1998) support this by stipulating that if structure is not used then the change process could easily fail. It is important therefore, to acknowledge the diverse nature of the process. Lewin (1951) identified three stages in the process of change – ‘unfreeze, move and refreeze’. Within my project, the ‘unfreeze’ process was achieved when communication and planning was undertaken with both staff and trust management to gain their support for the proposed evening clinic. The ‘move’ process involved trialling the evening clinic for a period of six months to produce evidence of it’s effectiveness. The evidence would be gained from numbers of attendees and also through evaluation forms given to all attendees of both day and evening clinics. If the evaluation of the service proved it to be successful it would ultimately result in the clinic becoming an established clinic this would conclude the ‘refreeze’ process. Through informal face to face discussions while implementing the clinic, I gained people’s thoughts and opinions.
In Kassean & Jagoo’s study (2005), they identified the unfreezing stage as that of enabling people to express their thoughts on the current situation. Sheldon and Parker’s (1997) research went on to explore the concept that people can only be empowered by a vision that they understand and that it is important that the strategies used foster inclusion and participation so that all team members are fully aware of the need for change.
3.5 When improving care, two potential obstacles have been highlighted by Tait (2004), these were highlighted as limited resources and the pace of change. With these in mind, a force field analysis (Lewin, 1951) has been completed to try and identify potential barriers. The issues I have identified are that it must be established early in the process the arrangements for the remuneration of staff time. Possible options being overtime payments or time owing. Staff displayed individual preferences depending on their individual perception of the benefit of each option and some staff raised the option of simply changing their hours of work. As the decision on how time will be paid, and how hours should be worked will lie with the management team it is important to establish their response promptly as this issue is likely to be raised by the health visitors very early in the change process. Another issue identified was health and safety. As the building is already used for a family planning clinic, any health and safety issues are already likely to have been addressed. I however considered it to be good practice to revisit and review the risk assessment. I identified a training issue around securing the health centre at the end of the evening – these locking up and safety procedures could be addressed with a short in-house training session. After identifying the above issues it was my responsibility as a leader to consider resources and budgets available in order to achieve all my aims and objectives.
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4.Leadership and the Quality of Client Care.
4.1 The Government outlines the need for nurses to develop leadership skills at all levels (DH 1998; DH 1999). Following Lord Darzi’s review( 2008), the Leadership Council (2010) was set up, to effect changes in health care delivery, which included supporting the national and local service. The NHS Confederation (2009) stresses that standards must be maintained through vision to avoid the regression of services through the recession. The leadership role expected of health visitors is evident in ‘Shifting the Balance of Power’ (DH 2001a) and ‘Liberating the Talents’ (DH 2002) with the expectation that health visitors will lead teams which will deliver family-centred public health within the communities they work (DH 2001b). I strongly believe that by collaborating with other agencies when setting up my evening well baby clinic I have improved the quality of care for clients within my practice area.
4.2 When implementing my project I took into consideration the feelings and expressed needs of service users (Bradshaw, 1972), and in line with both local Primary Care Trust (PCT) and government policy (Sec 2.3) regarding accessibility to services, an evening clinic was proposed for a trial period of six months. I made this decision as a leader of my team to ensure quality care and provision was implemented. To enable ongoing quality and evaluation, change will be audited and evaluated in order to inform future practice and service delivery. In health visiting I believe that the emphasis should be placed on quality of care, providing and promoting access to health information and helping people make sense of the information so that they are able to make informed lifestyle decisions (DH, 2000).
4.3 Research by Keatinge, (2005) suggests that parents preferred source of child health information comes from child health clinics. Health visitors were identified within the research to be a reliable source of information – parents felt comfortable talking to them and their advice was perceived to be reliable. Attendance at child health clinic was viewed as an opportunity to obtain regular information and advice. Another study by Bowns, Crofts, Williams, Rigby, Hall, Haining (2000) looked at parental satisfaction within the health visiting service, this found that approximately two thirds of health visitor contacts took place in the clinic and routine weighing and general advice accounted for a high percentage of recent contacts in one year old infants. Feedback from parents within my area of practice contradicts this research – attendance at clinic within my practice area is poor and parent’s comments would suggest that the implementation of an evening clinic would increase attendances.
The National Service Framework (NSF) for Children, Young People and Maternity services (DH, 2004), Standards 1-3 are particularly relevant when considering a well baby clinic, as the focus is on promoting health and identifying needs, supporting parents and providing services that are family centred. Each of these standards can be addressed in the planning and implementation of a well baby clinic. The NSF is intended to promote a culture which provides services that are designed around the needs of the family, not the needs of the organisation or staff, thus maintaining and improving the quality of care for all (DH, 2004).
4.4 Organisations must develop structures to improve quality of care (Tait, 2004). This is maintained through clinical governance, risk assessment and audit (DOH 2000B, Bishop, 2009. Christmas, 2009). Health visitor’s work within corporate caseloads but much work is undertaken independently. It is therefore important that communication and team support is encouraged. Part of my leadership role was to facilitate this communication through regular health visitor meetings and also through less formal discussion with staff, which encouraged communication and helped stimulate a wider team spirit.
Support for this is shown by Ferlie and Shortell (2001) who argue that emphasis needs to placed on shared and distributed leadership across all team members and organisations for quality care to take place and to promote organisational change.
5.Dynamic and Flexible Leadership.
5.1Within the project there is a mixture of cultures that have proved beneficial when planning the expansion of the well baby clinic. Managerial support was established early in the process, so that the change would be less opposed. However in addition to this staff were encouraged to contribute their ideas and concerns so that the change process could progress more smoothly. The implementation of this strategy reduced the risks of potential conflict. Barr and Dowding (2010) state that by being a dynamic and flexible leader who is able to resolve conflict effectively, high quality patient care can be achieved. Across all organisations change can sometimes be viewed as a negative thing. The majority of the team who will be affected by this change are established health visitors. There can at times has been some resistance to change and a tendency to continue with certain practices because historically it has ‘always been done that way’ or because the team has seen other new ideas tried and fail before.
5.2 If conflict was to arise within my team I would use a conflict resolution strategy as identified by Barton (1991). This approach can be adapted by leaders to help improve team morale and productivity (Huber 2010). I believe the important factors for the leader to implement are effective communication, assertiveness and empathy. If this technique is delivered effectively I believe conflicts can be resolved quickly and with minimal upset. If conflict arises and a leader avoids confronting an issue or withdraws from the situation this can be beneficial as it allows for a cooling off period between team members, but I believe that this is not a solution as it will not resolve the conflict. Marquis and Huston (2009) support Huber’s research by saying that a leader should address conflict but also needs to recognise and accept an individual’s differences and opinions. Therefore a flexible leadership style should be adopted whenever possible.
6 Conclusion and Summary
6.1 In summary my leadership incorporates a transformational leadership model which places great importance on the needs, values and morals of others (Northouse, 2004). The goal of transformational leadership is to create a vision, to empower others and to adopt a style of encouragement, listening and facilitating. This lends itself to the nursing profession as it stimulates suggestions and discussion about change in practice – this is strengthened by Marriner-Tomey (2004) who illustrate that transformational leaders are accustomed to sharing power, using influence, developing potential and moving groups towards common goals in a non coercive way and are seen as the only leader likely to bring about lasting change within health care.
6.2 Before completing this change within practice and from previous experiences within my career, I believed that a large proportion of change within practice was dictated to staff by managers, and that as an individual within a large workforce I had relatively little influence over work practices. I also felt that I had few opportunities to lead other staff. The benefit of compiling this report has been gaining valuable insight into the dynamics of leadership and understanding that different types of change and leadership are equally important. I have also benefited from completing and seeing through the process and analysing the actual and potential problems that may occur when trying to introduce a change in practice. I feel that the knowledge gained has influenced and inspired me to strive to become a motivational and democratic leader, and more importantly to understand that to be an effective leader you do not need to be born with the skills required but leaders simply need the motivation and the will to acquire the expertise. This is confirmed by theorists who believe that leadership is a learnable set of skills and practices available to everyone regardless of stature or position within an organisation (Yoder-wise, 2002 , Kouzes 2007).
6.3 I have found this experience has given me the opportunity to understand the process of planning and implementing a change within practice. I now feel that I have a better understanding of the need to become a flexible leader so that I am able to alter my approach to different situations and people, thus preventing staff conflict.
I have discovered that there is a potential difficulty to gather the necessary evidence-base and I must pursue this further. In the future I hope my new confidence in my ability to lead and empower will make me a valuable contributor to the health visiting service. I will continue to study working practices that I would like to change, and ensure there is a good evidence-base for any new proposals and follow a structured process in order to maximise the potential success of future ventures.
7.1 In the current climate within the National Health Service it is clear that leadership practice is now the focus of staff at all levels. As health visitors are seen by Government to be leaders within their field, I recognise the need to focus on improving my leadership skills.
Within my preceptorship, I intend to observe and reflect on how other experienced health visitors approach leadership within their teams. This will enable me to further develop my own leadership style within my future role.
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