The focus of this essay is the safe discharge of patients from a hospital environment. It will explore the wider health and social care context that influences leadership and management, and which of these drive contemporary service development. The essay will critically appraise the theories that underpin leadership and management within healthcare, outline the qualities and skills required to lead and manage individuals and how this affects the working of inter-professional teams. Furthermore it will demonstrate an understanding of professional and organisational cultures and whether this has an impact on professional practice and service delivery. An incident from a practice placement will be used as a comparative throughout the essay; this will enable personal reflection and understanding. In accordance with the Nursing and Midwifery Council (NMC, 2008) a pseudonym will be used, maintaining confidentiality at all times.
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During a final year placement within an Elderly Rehabilitation ward at a local hospital, a failed discharge occurred. Mrs Harris, (pseudonym) an 86 year old female patient was discharged home with a rise in the level of her package of care. Mrs Harris was re-admitted to the ward three days after her discharge due to an ineffective package of care that had been arranged. A failed discharge has vast implications for all individuals involved and for the NHS Trust in which it occurred. Safe discharge planning is an initiative that was introduced into the hospital environment to protect patients and members of staff from such incidences occurring. The rationale for focusing on this initiative is to aide future development for a registered nurse, learning to incorporate leadership and management skills into the natural working style of a nurse. By ensuring that failed discharges are as rare an occasion as possible a nurse must understand what is expected and how to properly organise all aspects of discharge planning effectively. In order to maintain patient safety, the multi-disciplinary team must work towards the same joint goals and ensure that a patient is safe in all aspects of their health and social care needs.
Leadership and management is an important aspect within healthcare professions, including the role of the newly qualified nurse (Mahoney, 2001). By definition, leaders and managers have large differences, although the characteristics of each can be interchangeable (Field, 2002). Leadership always involves leading people and is fundamentally about relationships with those people, whereas management predominantly focuses on the task involved (???).
Clinical leadership has been defined as facilitating evidence-based practice and improving patient outcomes through local care. Lansdale (2002) defines effective leaders as enabling people to move in the same direction towards the same destination at the same time, because they want to not because they have been told to do so. Originally, Lewin et al (1939) identified three main leadership styles: laissez-faire, autocratic and democratic, yet it is perceived that the most effective leadership style is that exhibited by democratic leaders. Democratic leaders can be characterised as being participative and encouraging collaborative teamwork (Gopee and Galloway, 2009 pg17).
However, there are several ways to define the role of a leader in more depth, depending on individual viewpoint, which are leadership models, philosophies or styles. A leadership model, such as the action-centred leadership model, pioneered by John Adair in 1973, states that a leader must complete the task at hand, whilst simultaneously creating and maintaining a team environment and ensuring that each individual on the team is able to meet their own individual needs (see appendix A). On the other hand, Greenleafs (1977) servant leadership is a philosophy by which the leader willingly serves the followers. A servant leader wants to make a positive impact for the benefit of a cause and not for reasons of wealth, popularity or power. Lastly, trait theorists believe that there are makeable differences in the traits possessed by leaders, and those who are not. Trait theorist stem for the branch of thinking that leaders are born and not made (???). Two main styles of leadership where defined by trait theorist, which are transformational or transactional leaders. Transformational leaders have the ability to deal with complex issues, motivate others to perform and are effective communicators (Clegg, 2000). Transactional leaders focus on the completion of the task at hand (Day et al, 2000). However, both Senge (1990) and Gardner (1990) both agree that leadership qualities and skills can be learnt and are not only inherited.
Becoming a leader is not a formally designated role, unlike management. Management traditionally forms part of a hierarchy within a structured organisational setting, with prescribed roles. It is directed towards the achievement of aims and objectives through influencing the efforts of others (??). Planning, organisation, co-ordinating and controlling staff is seen as the appropriate tasks of an effective manager. McCally and Van Velson (2004) state, that the manager’s duty is to support colleagues in their autonomous roles through training and guidance, as it is the responsibility of the qualified nurse to keep their training up to date (NMC, 2008). There is literature available for numerous management theories, such as Taylors (1915) Scientific Management School, which was particularly focused on performance drivers such as efficiency and productivity. However, he ignored the human aspect of employment, focusing on the division of labour, which caused increased fragmentation in the workforce. The NHS Modernising Agenda (2012) insists that the NHS should consist of a flexible workforce, empowering and engaging frontline staff to continuously improve quality outcomes, therefore Taylor’s theory would not be appropriate if applied to the NHS.
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A systems theory is another management theory that took more of an holistic approach in the view of organisations, with a focus on the inter-relationships between structures and human behaviours. These theories help us understand the relations between individuals, groups, organizations, communities, larger social systems, & their environments and help us enhance our understanding of how human behaviour operates in a context. Pugh et al (1963) took on a new approach to the systems theory, known as the contingency theory. This theory argues that there is no “right” way to structure an organisation, due to variables within each “part” of the organisation; an adaptation will be required in order to be successful. According to this theory, three contingencies are principally significant; these are the organisations size, operating environment and its technology. An example of this in the Modern NHS is safe discharge planning for patients, which almost always requires a multi-disciplinary team to work together, including social services and local authority.
According to Yoder-Wise (1999) not all managers are leaders, but it is suggested that in order to be an effective manager, there is a need for strong leadership skills, including effective communication. It would be useful for a newly registered nurse to define their own leadership and management style. This can be done by adopting Ansoff’s (1987) simple SWOT analysis (Strengths, Weaknesses, Opportunities and Threats). Tappen et al (2004) indicates that using this tool on an individual level can guide you through your own integral strengths and weaknesses, highlighting external opportunities and threats which may be helpful in becoming more self-aware, a characteristic that is admirable in a nurse.
From the available literature, being a leader appears to be about building relations within a team and enabling individuals to take ownership of a task, instilling confidence and maintaining a solid workforce. In order to efficiently lead and manage fellow colleagues, a newly registered nurse requires strong interpersonal and emotional skills, with the ability to define and allocate tasks whilst maintaining standards and encouraging team spirit. A nurse is also required to inform individuals of their progression and performance whilst enabling self-assessment. As a registered nurse it is essential to nurture these skills early on and incorporate fair leadership and management ability into your everyday routine. With this in mind, a newly qualified nurse is able to learn how to become a great leader. Within the healthcare environment, several overlaps between the styles may be necessary depending on the task at hand, therefore a newly qualified nurse would benefit from incorporating elements of the leadership and management theories discussed (???).
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