The implementation of the care of the dying policy at the writer’s area of practice involved the process of change. This involved the use of both leadership and management theories which are essential to increased effectiveness as supported by Moiden (2002). The change was a political one due to the government initiatives to improve end of life care (Department of Health 2008). Antrobus (2003) states that political leaders aim to deliver improved health care outcomes for patients. The essay will critically analyze both leadership and management theories from the top of the organization to the bottom. These theories were used to implement this change to enhance quality care in this clinical area. The essay will also critically analyze and evaluate the nurses’ self management skills in fulfilling their role as clinical managers within interdisciplinary and the changing context of the healthcare.
Similarly, the essay will discuss the implications upon quality assurance and resource allocation for service delivery within the health care sector. These will be related to current government strategies. The effects of government strategies in involving the user and carer or significant others in decision making process within current clinical and legal frameworks (Department of Health 2000b) will also be debated. Similar debate will also be on the nurses’ involvement in policy making (Antrobus 2003). Further discussion on government strategies will be discussed on the introduction of clinical governance and essence of care. Braine (2006) states that the purpose of implementing change is to improve effectiveness and quality. The whole process of change was based on the introduction of the care of the dying booklet which meant that all healthcare professional documented their notes in the same booklet.
The change took place in a large hospital to implement a new policy which was politically driven by the government to improve quality of care. Like most hospital organizations, the hospital traditionally uses a bureaucratic management approach (Marquis and Huston 2006) reinforced with authoritarian leadership to facilitate efficiency and cost effective care. This is done through planning, coordination, control of services, putting appropriate structures and systems in place and monitoring progress towards performance activities (Finkelman 2006 and Faugier and Woolnough 2002). According to Marquis and Huston (2006) bureaucracy was introduced after Max Weber’s work to legalize and make rules and regulations for personnel to increase efficiency.
The ward manager as a change agent had to design and plan the process of change. Designing change involved understanding the purpose of change and gathering data as supported by Glower (2002). Planning included identifying driving forces and ways to reduce restraining forces (Glower 2002). Unlike the top management who used bureaucratic management theory, the ward manager applied the human relations management theory (Marquis and Huston 2006) at ward level. This management theory is designed to motivate employees to achieve excellence.
The human relations theory was introduced in attempt to correct what was believed to be the shortcoming of bureaucratic theory which failed to include the human aspects (Marquis and Huston 2006). Often referred to as motivational theory, Lezon (2002) agrees that this theory views the employee in a different way and helps to understand people better compared to the autocratic management theories of the past. It is based on theory Y of Douglas McGregor’s (1960) X and Y theories cited in (Lezon 2002). Theory Y assumes that people want to work, are responsible and self motivated, they want to succeed and they understand their position in the organization. Perhaps the appropriateness of this theory can be linked to the implementation of clinical governance which emphasizes that it is the responsibility of health care professionals to ensure effectiveness, high standards and quality (Braine 2006).
This puts health care professionals in a responsible position and motivates them to provide high quality care. This explains why theory Y was used as opposed to theory X which according to Lezon (2002) assumes that people are lazy, unmotivated and require discipline. According to the human relations theory, there are some positive management actions that lead to employee motivation thus improving performance (Marquis and Huston 2000). Some of these actions used by the change agent were empowering and allowing employees to make independent decisions as they could handle, training and developing, increasing freedom, sharing big picture objectives, treating employees as if work is natural and other ways of motivating staff as supported by Marquis and Huston (2006 and Lezon 2002).
The use of human relations theory in the implementation of this policy is well justified in contrast to other management theories. For example, theory X presumes that people must be coerced, controlled, directed and threatened with punishment (Lezon 2002). This theory adds that an average person has inherent dislike of work and prefers to avoid responsibility (Marquis and Huston 2006). In other words, theory X prefers autocratic style while theory Y prefers participative style. Managers using theory y seek to enhance the employee’s capacity to exercise high levels of imagination, ingenuity and creativity solving organizational problems. With the human relations theory, members feel special and involved rather than being controlled by threats and sanctions from the change agent (Dowding and Barr 2002).
The team of health care professionals was aiming to achieve the same goal. This goal was to provide high quality care to patients approaching end of life. This involved a lot of organizational psychology and motivation to facilitate effective teamwork. Among the factors that facilitate effective teamwork, leadership is the most significant as stated by Clegg (2000). Toofany (2005) supports that leadership is on government’s modernization agenda for the National Health Service and is an influencing factor. Therefore, the change agent needed equally effective leadership style. To facilitate this, she applied the transformational leadership style.
Markhan (1998) cited in Clegg (2000) defines transformational leadership style as a collaborative, consultative and consensus seeking. These are the same characteristics of the leadership style used by the change agent. Contrary to this leadership style is the transactional leadership style which is based on power of organizational position and authority to reward and punish performance (Moiden 2002). Based on Rosner (1990)’s research, Clegg (2000) states that gender affects leadership style and women prefer transformational style. Perhaps this explains why the change agent chose this style for this particular change.
As in any form of change process, resistance, which falls under the unfreezing stage of Lewin’s (1951) cited in Murphy (2006) change theory is one of the common obstacles that needed to be dealt with (Curtis and White 2002). By inspiring a shared vision within the team (McGuire and Kennerly 2006) the change agent managed to increase driving forces and reduce resisting forces at the same time. Clegg (2000) values vision as a very important ingredient of transformational leadership, adding that it should be engaging and inspiring.
Transformational leadership was first put forward by James Burns (1978) cited in Marquis and Huston (2006). According to him, a relationship of mutual stimulation and elevation converts followers into leaders, a fact shared by Murphy (2005). If a leader can stimulate followers, he or she can engage followers into a problem solving attitude (McGuire and Kennerly 2006). In addition, people engage together in a way that allows leaders and followers to raise each other to higher levels of motivation and morality (Marquis and Huston 2006). This approach emphasizes on the leader’s ability to motivate, coach and empower the followers rather than control their behaviors (McGuire and Kennerly 2006). Moiden (2002) states that this style is widely used in all types of organizations in dealing with change.
Frequently, it is contrasted with transactional leadership which is a traditional way in which followers’ commitment is gained on the basis of exchange of reward, pay and security in return of reliable work (Mullins 2002). However McGuire and Kennerly (2006) state that if transactional leadership is predominantly used, followers are likely to place limits to organizational commitment and behave in a way only aimed at contract requirements. Despite the differences in various leadership styles, most researchers conclude that there is no one leadership style that is right for all circumstances (Reynolds and Rogers 2003). Fidler (1967) cited in Moiden (2002) agrees that a single leadership style is rarely practiced. Therefore situational theories were introduced in order to deal with various situations.
Perhaps this is why the leader used the situational approach to leadership in order to meet the demands of different situations, an idea also shared by Marquis and Huston (2000). Reynolds and Rogers (2003) suggest that the effectiveness of day to day activities depends on balancing between the task at hand and human relations to meet everyone’s needs. Different competence levels, motivation levels and commitment levels of staff on this clinical area justify why a situational approach was used in conjunction with transformational leadership style. Reynolds and Rogers (2003) support that situations like this require the leader to adapt their style. However, they warn that it is important to know when to lead from the front, when to empower and when to let go. This situational approach enabled the leader to work on followers’ strength and weaknesses.
Moreover, Reynolds and Rogers (2003) warn that it is not always easy to find leadership styles that suite the needs of every situation and not everything falls into place from the beginning. Marquis and Huston (2000) criticize that situational theory concentrate too much on situation and focus less on interpersonal factors. Support was given to followers according their needs. Supportive behavior, as supported by Reynolds and Rogers (2003) helps people to feel comfortable in their situations. This was facilitated by the use of a two way communication system which involved listening, praising, asking for help and problem solving.
Consequently, as performance improved, the leader’s supportive behavior shifted to delegation. Delegation was mostly directed to staff with high competences, commitments and motivation. Reynolds and Rogers (2003) support that the style of leadership alters as performance improves from directing to coaching to supporting to delegation. Basing on research studies, Reynolds and Rogers (2003) warns that using different approaches to different staff can practically difficult in terms of developing the whole group as well as maintaining fairness. This further exposes the limitations of situational approach.
Nevertheless, it is equally important to assess followers’ capabilities and developmental needs so this explains the relevance of situational approach to this clinical area. The delegation was directed to some members of the team while others still wanted to be directed. In addition, this was because of the leader’s trust in people, working to their strength and sharing the vision as supported by Kane-Urrabazo (2006). Delegation is defined as transferring responsibility of an activity to another individual and still remain accountable (Sullivan and Decker 2005).
Davidson et al (1999) caution that critical thinking and sound decision making must be applied before delegating because it increases rather than decrease nurses’ responsibility. They clarify that to ensure safe outcome, delegation must be the right task, right circumstances, right person, right instructions and right supervision. Pearce (2006) shares the same thoughts and adds that you must be clear about what you delegate, inform other members, monitor performance, give feedback and evaluate the experience while remembering that you remain accountable. However, Kane-Urrabazo (2006) and Taylor (2007) argue that delegation is another way of empowering the subordinates.
However, like every team going through the process of change, problems arose and were solved as they came. Apart from dealing with problems like resistance and lack of resources, there was an even bigger problem of interdisciplinary working for both the change agent and the subordinates. Although this policy was predominantly nurse orientated, it needed authorization by a doctor in order for a patient to be commenced on care of the dying pathway.
Whether inside or outside health care, interdisciplinary working was introduced with the same concerns of improving quality (Hewison 2004). Interdisciplinary working has been emphasized by a number of government initiatives (Martin 2006b), more recently the NHS Plan (Department of Health 2000a). To ensure the demand for interdisciplinary working is met, there has been a lot of emphasis on professional education and training. Effective interdisciplinary working is meant to facilitate delivery of quality services and is fundamental to success of clinical governance (Braine 2006). However, Hewison (2004) argues that there is little evidence to support the effectiveness of interdisciplinary working. There is also insufficient evidence to support that collaboration improves quality of care given to patients (Hewison 2004).
Nevertheless, if interdisciplinary working is to be achieved it is important to appreciate the potential barriers to this type of working. In this particular organization there were some barriers that impeded interdisciplinary working. These barriers needed problem solving skills from both the change agent and the nurses. In many cases there were some disagreements between nurses and doctors as to when to commence the care of the dying pathway for a patient. Although the policy was self explanatory in terms of when to commence it, doctors were often reluctant to authorize it.
Hewison (2004) states that occupational status, occupational knowledge, fear and distrust of other occupational groups are some of the barriers to effective interdisciplinary working. Additionally, different backgrounds, training, remuneration, culture and language can contribute to professional barriers, mistrust, misunderstanding and disagreements (Hewison 2004). To solve this problem the change agent and senior members of the medical team held regular meetings to discuss problems like this. This way of problem solving is well recommended by Hewison (2004) who explains that if interdisciplinary working is to be successful, structures and procedures should be in place to support it.
This is a way in which organization reflects emphasis on teams rather than individual professional groups. Hewison (2004) adds that if this is reinforced with communication between managers and other professional groups, it is likely to be successful. Perhaps in future interdisciplinary learning may be necessary to overcome some of the barriers to interdisciplinary working. Despite lack of evidence for its effectiveness, interdisciplinary learning has been identified as a government priority (Hewison 2004). Therefore study programmes for health care professionals are important to facilitate this approach to learning.
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