A learner has variety of modes available to understand a concept. However, nothing can beat the richness of learning encompassed in the learner observing its application oneself. With this objective, this course offered us a field visit to Jinnah Post Graduate Medical Center (JPMC) in order to analyse organization structure and culture of a health care organization. The purpose of this paper is to analyse application of different leadership and management concepts in that organization along with recommendations to improve the same, with special emphasis on various dimensions of their organizational culture.
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“Organizational culture is defined as the values, beliefs, and norms of an organization that shape its behaviour” (Davies, Nutley, & Mannion, 2000). The organization we visited was JPMC which is located in at Rafique Shaheed Road in Karachi, Pakistan. JPMC is the biggest public sector hospital in the country, established in 1959. It is a federal government hospital running under the rules of Governmental policies funded by government and NGOs. JPMC is the tertiary care hospital which is accessible for public free of cost and charging only 5 Rs. / for OPD patients. At present, it comprises of 1185 beds with the diversity of inpatient and outpatient care services, school of nursing, college of nursing, school of physiotherapy, medical college etc.
In 1949 the first School of Nursing in Pakistan was established in JPMC. It started with the 3 years of diploma programme with 7 nurses. However, at that time the idea was not primarily to impart nursing education but to develop staff who can take care of wounded refuges and sick population. From the very initial stage, nursing profession faced challenges. It was difficult to cater the young girls and encourage them to join nursing. This was due to a variety of reasons. Sending females of the family to earn livelihood was not that common in our culture back in those days. Convincing parents for female employment and that too with duties in morning, evening and night shift must have been a daunting task for nursing leaders of that time. Such reluctance was mainly due to our cultures norms prevailing at that time. Several strategies were used to inspire people for this profession such as through political campaigns and by the attraction of influential people like Mrs Rana Liaqat Ali. She played a pioneering role for nursing profession. Nevertheless, the nursing profession is still struggling to make its respectable place in that particular organization.
Being a nurse leader, I identified a number leadership and management issues during visit that require senior management deliberation and thought process. There was no formal Human Recourse Department in the organization, nursing staff motivation was not visible, there were no proper policies for conflict management, and quality assurance etc. Though there are a host of human resource related issues that may be discussed but I have chosen to reflect upon that should not only be a starting point to solve all these issues but also holds pivotal importance in development of nursing profession and leading the healthcare setup in that organization. I feel that having a transformational and empowered leadership in place may enable the organization to deal rest of those issues in more pragmatic manner.
Empowerment among Nursing Leaders
In this paper I will ponder on need for a transformation and empowerment of nursing leadership at JPMC. However, before exploring the application of these concepts, it is important to understand its theoretical background. Empowerment refers to entrusting someone else with the authority to execute given powers. Empowerment enables nurse leaders to act creatively and effectively. According to Sullivan and Decker (2004) “An organization in which nursing leaders are innovative, creative, and energetic will tend to operate in a fast moving, goal oriented fashion.” Empowerment also enables nurse leaders to think and act strategically. Nurses are the biggest health force in JPMC and having a principal role as health care providers. Nursing leadership in JPMC has their well-organized organogram yet unfortunately many of the positions are vacant because very few nursing personnel meeting the eligibility criteria for those positions. Complexity in health care system is increasing day by day which imposes many challenges on nursing profession in JPMC. Therefore, it demands nurses to be highly competent, innovative, have leadership potential, and demonstrate flexibility in adapting to changes, throughout their functional and professional relationship (Porter O’grady, 2003). According to Sullivan and Decker 2004, there are in general three levels of management in nursing: first level which includes nurses’ managers, middle level which consists of directors and upper level entails the executives. JPMC is a great example of following this criterion as they have well defined organogram. However, upper level management has the responsibility for establishing and sustaining a safe, caring environment for nursing practice and patient care. I felt that nursing leadership in JPMC is struggling hard so far for the empowerment. At many occasions, nursing leadership at JPMC does not seem to be empowered and has subsequently not empowered their own subordinates. This has created an organization culture where everyone feels very little autonomy and looks at others to make important decisions. This hinders delivery of effective healthcare.
One of the examples which show lack of empowerment among nursing leadership includes the selection criteria for staff and nursing leader positions. For JPMC, staff nurses are hired by the Ministry of Health after giving the public service commission exam. According to Sullivan and Decker (2004) in order to prevent negligent hiring organizations is liable for the character and actions of the employees they hire, for this they must make sure about applicants’ backgrounds in regard to licensure, credentials, and references. However, examination is not enough in hiring the best suitable nurses for an organisation. Moreover, whenever there is a vacant position, chief nursing executive write to the director and then they hire nurses based on quota system. As mentioned by the chief executive nurse, many times leaders are hired on top positions based on references and association with various people at top level, instead of merit. This is one of the reasons that educated, well deserved, experienced and empowered leaders are not hired which result in hindrance of recognition of nursing profession. Hemani (2003) highlighted “India where independence was gained at the same time, and the level of nursing education in India has had far more recognition internationally than Pakistan” (p. 122). This lack of meritocracy eventually impacts overall organizational culture generating feelings like demotivation, favouritism etc. This is just one example where lack of empowerment to nursing leadership subsequently affects entire healthcare cycle which eventually makes nursing as less preferred profession and JPMC as less preferred employer among young girls who may become nurses.
According to Huber (2006) “leader use their power to bring teams together, spark innovation, create positive communication and drive forward toward group goals” (p.4). Empowerment also fosters a sense of responsibility and motivation among leadership. In the light of the preceding quote, nursing leadership in JPMC is not well recognized. The leaders do not have autonomy to take decisions or impact policy making. Nurses’ participation in hospital concerns is one of the trademarks of a magnet hospital environment (McClure & Hinshaw, 2002). During conversation with one of the nursing leader in JPMC, she mentioned that in student’s hostel they had very old furniture and they wanted to get it changed. They wrote a request to director multiple times but nursing division and its requests were not given importance for long. But somehow they managed to get money by negotiations with director. For such a small work they had to struggle so hard; this small scenario is depicting that nursing division in JPMC has a long run to prove their right position in an organization.
One of the key aspects to leader’s empowerment includes strengthening nursing education system. This is well appreciated that JPMC has the deputation system; in which nurses are sent for higher education and they also get their salaries during that term. However, the pitfall of this system is that only those nurses who have significant years of experience can avail this. Whereas, it is the requirement of today’s nursing world to educate nurses across all levels in order to provide higher standards of care and meet patient’s expectations. Moreover, another aspect to empower nurses is through continuing education, this is not practiced in JPMC. At maximum they are sent on basic technical courses like infection control, cannulation, etc. According to Ladhani (2002) “issues in nursing are very complex and are like web of causes interlinked and interconnected. It is therefore very crucial to link up policies, trainings and commitment of all concerned parties together (p.9)”. Therefore, inclusion of courses in nursing education like ethics, empowerment, politics, and gender will help nurses to empower themselves (Gulzar, 2011). Nevertheless, one aspect that is worth appreciation is that JPMC is educating and hiring male nursing students and staff nurses respectively. Hence, this proves to be a positive impact on the empowerment of nursing profession as a gender mix and promoting gender diversity in this profession.
Another aspect that deserves empowerment and transformation from nursing leadership is the quality of nursing education that is subsequently affecting health care delivery quality. JPMC has very limited faculties (around eight in number) who teach all the subjects. Even they are not sufficiently equipped with the requisite knowledge and skills due to the lack of opportunities they get there for higher education. Other reasons for compromised health quality in JPMC are shortage of staff due to absenteeism and lack of resources. I am confident that if nursing leaders at JPMC are given enough empowerment and resources, with time, they will be able to expand their faculty base, develop them so as to make it a vibrant nursing education institute. Having well educated nurses and empowerment in staff selection should subsequently affect healthcare quality. When the staff would know that their leadership is empowered and has mission and vision that it is pursuing, the organizational culture would be the one that fosters the sense of motivation and meritocracy. It also helps in controlling absenteeism and promoting performance based reward culture.
Upon exploration, it was also found that nursing leaders need to be empowered in certain other ways as well to ensure quality care and effective organizational culture. We found that nursing leaders face lot of political pressure, boycotts and strikes in which the hospital services are shut down and in such circumstances the purpose of the institution is not served. Nevertheless, JPMC has ethics committee which sort out the solutions of such matters. Nurse leaders are also the part of that committee which shows involvement and empowerment of nurse leaders. Likewise, nurse leaders are also responsible for the safe environment for patients. However, they denied any kind of medication errors and sentinel events which is near to impossible or may be underreported. This is because there is no control over mal practices and due to below average education level. According to Joint Commission Accreditation Hospital (2007) in response to sentinel event “Appropriate response includes conducting a timely, thorough, and credible root cause analysis; developing an action plan designed to implement improvements to reduce risk; implementing the improvements; and monitoring the effectiveness of those improvements”. Nurse leaders and nursing staff should encourage to be empowered in identifying, reporting and managing such events in order to improve productivity.
Taking everything into account, it is responsibility of nurse leaders to establish organizational goals and do proper strategic planning in achieving the vision of their institute. Empowerment will help nurse leaders to move from being a passive observer to an active player. Besides, nursing leaders are accountable in buffering the effects of the peripheral surroundings on nurses within the organization.
Need for transformational leadership
Nurses should seek out opportunities for change to be empowered. They should not stop at the bedside, they need to raise their voices to show the difference they make in the health care. Moreover, they ought to move beyond to the larger community and professional organizations. Transformational leadership will help nurses to gain empowerment; this demand empowering others to act towards a common purpose. The organisation should allow staff to develop professional autonomy, involve nursing staff in all decision; establishing collaborative procedures between staff and management and making available work environment structure and leaders should put great emphasis on mission, vision and health policies of an organization and to implement it for the benefits of patients and staff.
As JPMC is the largest public sector hospital in Pakistan; but it is far behind to meet the forthcoming health care burdens of the society. Empowerment in nursing leadership in that organization will influence the society at large and will help in bringing positive change. Therefore, I would recommend that to become empowered; leaders should be self-motivated, visionary, educated and dedicated so that they could guard community health rights through fruitful contribution in national health policy. Furthermore, nursing leaders should maintain and sustain the co-operative, innovative and evidence based work environment that enables nurses to feel valued and respected in their profession. Finally, nursing leaders should ensure the quality of nursing education and safe clinical practices. Through overcoming educational, cultural and political hindrances we can achieve the nursing development in over country.
To conclude, I learnt that organization culture depicts the traditions and norms of an organization. According to Tharp, (n.d) An Evaluation of organization culture is important for a health care agency, to reduce uncertainty by creating common way for all employees, clarifies the expectation of an organization, gives sense of continuity, provides common identity, unity of commitment, and provides vision of the future around which the organization can rely. To bring about an effective change in an organization and adapt them in order to develop and meet the demands of the organization, which has been working on the same principles for a long time is difficult. It requires sheer efforts, multi-dimensional approach, good communication skills and leadership qualities.
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