Management and leadership within health visiting team in Edmonton locality.

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MANAGEMENT AND LEADERSHIP WITHIN HEALTH VISITING TEAM IN EDMONTON LOCALITY

INTRODUCTION

MANAGING PEOPLE

The author is a health visitor working with five other colleagues of the same grade "G " and three health visitor assistants in a clinic. The person responsible over staff management is the Locality Nurse Manager who is "I" grade. The author, is currently employed with no management role for managing others, therefore will draw on her most recent experience in a management and leadership role as a "F" grade Nurse in an acute General Medical ward and some relevant management experience from health visiting in this present job and from the previous employment as a health visitor.

I will use as a benchmark the leadership/management style in the Leadlap/Clinlap model (see Table 1) to critically discuss and analyse the National Health Service (NHS) modernisation agenda and the working together documents (Do It 1998). Factors that impact on nursing/health visiting workforce environment, the role of Legislation and some management and leadership theories will be included.

In the document "Working Together: Serving a Quality Workforce for the NHS, the following statements were made by Mr. Allan Milburn in 1998.

"The NHS has always depended on the skill and dedication of its staff. Millions of patients have benefited from their care. And it is the staffs of the NHS who are the key to delivering the Governments ambitious programme of Modernisation for the service. That means attracting and retaining high quality staff, committed to developing their skills and keeping them up to date. A "First Class" healthcare staff also required first class employers. Employers who are committed to providing a good, safe working environment, free from discrimination and harassment"

The above statement contains these elements:

* Fulfilment of the Governments ambitions programme of modernization.

* Attracting, and retention of staff with high quality and those who are committed to developing their skills and keeping them up to date to deliver a first class service

* Employers who are committed to providing a good, safe working environment free from discrimination and harassment.

* The organization needs to set up policies that nurture dedication and attract staff with the correct skills including rewarding them beyond their wages.

* Good human resources policy as an employer, which gives a good quality-working environment that permits Excellencies.

What is a First Class employee? The future of Nursing Report by Chief Nursing Officer (CNO) in The NHS Plan (2001) identified 10 key extended roles for nurses working differently and smarter. However people are now more informed through the media, Internet, mobile phones and so on, are causing high expectations from the public. (See Appendix 1 for further discussion of Mr Allan Milburn's statement).

Where do we want to be in our people management capability?

Fulfilment of Modernisation Programme

As commented by the chief executive then, the above document signals a new approach to managing human resources for leaders and managers in the National Health Services (NHS) and it is called "Agenda for Change".

Since the NHS is changing, the present Government has set out an ambitious programme to modernise the NHS and to improve the health of the UK population. The aims of the modernisation are to create new services, which are modern and fit for the 21st century, dependable and it is there, when the expectant demanding public need them (Department of Health 1997). The main policies are directed towards the boxed points below:

* Helping people to live healthier and longer.

* Making sure everyone has fast convenient and quality health service whenever they use the service and wherever they live.

Good leadership

The needs for implementation of leadership at strategic level was identified in the CNO Report the NHS Plan (2001), and in the document 'Making the Difference', the Government has recognised the need to support and strengthen the nurses, midwives, and health visiting roles in order to give them the potentials to become effective leaders (DOH, 2001). Effective leadership must therefore start from the strategic level and to be cascaded down to encounter level in order to gain total commitment of an organisation. So what is leadership? (See Appendix 2)

There is confusion between the term "leadership style" and management style. The view taken here is that leadership refers to those aspects of management concerned with direction and guidance of team and or individuals. While management is about today, is rational processes and processes management, leadership is about tomorrow and it's emotional horizon and change management (Stewart 1996, p1- 3). The recent research by Alimo and Metcalfe et al (2003) reports that leadership is perceived as engaging others as partners in developing and achieving a shared vision and enabling us to be led, creating a fertile and supportive environment for creative thinking and challenging assumptions about healthcare that should be sensitive to the needs of a range of stakeholders inside and outside health.

Management is very important in the NHS hence the introduction of general management in the late 1980s. An effective manager makes it possible for the visions of leaders in his/her organization to be implemented by providing discipline to the leader's vision by using procedures, standards and guidelines of a particular practice. While management is a set of techniques and approaches that can be learnt, and managers have staffs, leaders have followers, vision and are motivators (Stewart 1998). Thus a manager must also have the qualities of leadership in order to be effective. Whiteley et al (1996 p 63) states that people expect leaders to transform and change the direction of the organisation and take the staff along with them while managers are those who merely transact business, keeping things steady as such. The effective manager is one who gets the job done. Leadership implies some attempt to move things, to change things, to provide vision and direction to the organisation.

Jumaa and Alleyne (1998a) emphasise that, the effective clinical Team Leadership has Specific Goals, Explicit Roles, Clear Process and Open Relationships. While Rojan (2000) points out that the leader must have knowledge or information about data, and explicit knowledge so that it can be incorporated into processes, products and services. It is about converting individual learning into organisational learning. This is known as "Tacit Knowledge" which are observed, talked about and written and published to effect change in practice. Thus, this knowledge gives criteria for effectiveness in uses of Resources, Expert Power in practice and Personal Power such as "Nurse Consultant". For example an effective manager/leader would use her/his position to acquire new knowledge through sponsorship of her/his team members to relevant courses to fill the knowledge gaps in their practice. The Manager/leader must also have skills required for strategic thinking. Open University South Bank (1998) recommends the followings in the box below.

* Relevance and realism of thinking

* Rigor of thinking

* Varied approach to information-processing

* Use of theory to explain practice, and practice to build and test theory.

* A critical, challenging approach

* Awareness of pluralism in thinking about strategy

Our organization has used Ashridge Model to express their vision and strategies for their key objectives for transforming our practices as an Agenda for change strategies. (See Fig 1 for Ashridge Model) However, Whiteley et al 1996) warns that the danger with transforming leader is that many are left behind in the dark if the vision is not communicated well.

Major Theories of Leadership

* The Trait Theory

* Behavioural Contingency Theory

* Attribute Theory

* Transformation Theory

Trait theory: Attempts made to identify common characteristics of effective leaders but most studies singled out intelligence, which means solving complex problems and discovering patterns.

Initiation. It includes the use of initiatives related to stamina and energy.

Self assurance- Perception of a place in society and self-confidence. John Hunt of the London Business School claims that leaders trait tend to be found in the first born of families, are high achievers, have high energy levels, think and plan over long time spans, are goal directed, they are politically active, loners and psychologically able to differentiate things of important from those that are not. This theory fell out into disrepute after concluding that effective leaders are either above average height or below. (Open University Centre Business School 1998)`

Style theory came at the time of reaction to scientific management. It advocates "participation" culture, linked to the notions of satisfaction. It represented a more democratic humanistic approach of the use of manpower in organisations.

Hardy (1999, p117) proposed the "best fit approach" with effective performance that dependent on the environment. It includes power or positions of the leader shown in the box below.

Hardy (1999) could be describing the quality of a Transformational Leader shown below.

* Position status

* An expert knowledge, skills and the right attitude (ASK).

* Personality, good relationship with subordinates and good organisational norms (structure)

* Variety of tasks

* Varieties of subordinates.

While Bass and Alivo (19930 describe transformational leadership with 4 components

* Idealized influence by people who recognize in leadership

* Inspirational motive recognized in the leader

* Intellectual stimulation

* Individualised consideration

The Clinical Leadership Theory by Jumaa and Allyene (1998) proposes a Leadership Model (CLINLAP), which is a clinical leadership learning and action process.

The Leadlap/clinlap model is identified as "strategic management and leadership process that positions processes learning as a force that drives the health and social care organizations on a day to day basis in the management of goals, roles process and relationships (Jumaa 2001). Strategic learning requires among other things two major points in the box below.

* Visual acuity to see clearly really seeing what is going on.

* Recognition of the value of the data, including use data contributing to a strategic vision, continual monitoring of result. (Tap into the deep things)

* Articulate a bold vision and communicate repeatedly

* Invite others to participate and accountable for the system

* Comfortable with adept at managing resistance Refrain from holding individuals

I have chosen to use this Model because it recognises stakeholders' needs and gives tools to do the job. It had provided a pragmatic approach for the development of Management and Leadership activities in Group clinical supervisions with District Nurses therefore it has been tested for its effectiveness. It provides power to the leader and her followers. The assumptions are that it believes in strategic workplace learning for continuous quality improvement, which is now, needed so much in the New NHS. Whilst the Leadlap/Clinlap model may gives satisfaction to many stakeholders, Alimo-Metcalfe and Alban-Metcalfe (2003) remind us of the cost of poor leadership. In the NHS it is estimated that 27% of staff have psychiatric problem developed at workplaces suggesting poor leadership. The study by CBI of the cost of absenteeism to UK organisation estimates it at around 3 billion pounds per year, and it is suspected that 60% of absenteeism was due to stress at work. 60-75% of employees in any organizations reported that the worst and most stressful aspect of their job is dealing with their bosses. This shows that Leadership is clearly a moral imperative, but it is also an organisational imperative. The Leadlap/Clinlap Model that I am using in this essay has five phases as shown in (Table: 1)

Table 1: Models, Techniques, Frameworks and Concepts in this Report

STRATEGIC CLINICAL QUESTIONS (SCQ)

HIERARCHY OF TEAM ISSUES (Phases of CLINLAP)

CLINLAP STAGES

ACTIONS REQUIRED

) Where do we want to be in our People Management Capability? (SCQ1)

Specific Goals

)

2)

Stakeholder Analysis

Role of motivation and leadership 4Ds and A.S.T.R.E.A.M

2) Where are we now?

(SCQ2)

Explicit Roles

3)

4)

Roles and Goals

PESTO

Recruitment and selection

Training

Continuous quality performance

3) How can we, through CAPABLE staff, get to our clinical service goal? (SCQ3)

Clear Process

5)

Re-assessment of organizational needs

Identification of gaps

Rewards

Time management

Job design

Staff appraisal

4) Which route must we take to get CAPABLE staff to our service goal?

(SCQ4)

Clear Process

6)

SWOT analysis

Project Management Effectiveness defined

Create "fit" between action and team/org.

5) How should we plan the 'exploration', as well as check our progress, to ensue we arrive at our desired proposal goal, through our CAPABLE STAFF? (SCQ5)

Open Relationships

7)

Implement high quality health care service

Create "anchor person"

Check resources needed

Specify actions

Pilot project "Team Working"

Attend to legal, ethical and ethnic problems using counseling, culture paradigm, 7Ss and 7Es

Why do we need effective managers/leaders?

* Quite a number of workforces are of retiring age in nursing. For example, within Enfield Primary Care Trust EPCT (EPCT info/hr strategy 02-08), there is poor skill mix due to ageing workforce. 36% of General Practitioners (GPs) retire in 10 years, of practice 26% practice nurses (PN) and 46% of community nurses in 5yaers of practice (EPCT 2003-8)

* It is difficult to recruit Nurses and train them to become specialists as health visitors

* There is a need for reconfiguration to give an attractive role of nursing (See Appendix 2)

* There is a need to review pay

* Nurses/health visitors need to be rewarded for their skills.

Team Manager/Leader's Objectives

The objectives of the Manager/Team leader are shown below.

. To attract, recruit and retain high quality staff, committed to developing their skills and keeping them up to date, in order to work as a team that deliver a first class service.

2. Offer Training and personal development and Life Long Learning and to monitor their Performance.

3. To provide a good, safe working environment free from discrimination and harassment.

The question our organisation should be asking is where do we want to go with our People Management Capability?

Capability is the capacity for a team with a given resources to perform some task or activity. In this case it will be to meet the Government's Modernisation agenda for health visitors to lead teams that include nurses, nursery nurses and other community workers to improve the quality of lives by delivering a first class service given by highly skilful health visitors (DH 2002).

Following the description of Leadership, my first task is to identify all the stakeholders (Tables 2 and 3) that are going to be affected by my leadership capability. This is important for the following reasons:

. Identifying stakeholders helps to emphasize the different stakeholders interest and groups so that a manager/leader have a balance of views taking everybody into account when making decisions. That will therefore give opportunities to influence the management environment through the ways in which relationships with stakeholders are managed. In this way, those who have power to influence or block change can be identified and managed

2. It also helps the manager/leader to appreciate the relationship between an organisation and its external environment and this in turn will help the manager/leader to response to their impact and different pressures as they change over time. (See Tables 2 and 3) for stakeholders Matrix analysis)

Stakeholders Matrix analysis, Powers of internal interests associated with effective Leadership/Management before and after my influences

Table 2: Stakeholders' Power/Interest Matrix Before my Influences

Low Interest

High Interest

Low Power

Minimal effort (A)

Keep them informed (B)

(Examples: Parents, GPs, Other Clinicians (-ve), Health visitors (-ve), and Health visitor Assistants (+ve), Social Workers)

High Power

Keep them satisfied (C)

(Examples: Clients, Chief Executive, NICE/CHI, Line Manager, Finance Directors, Union, Nurse Advisor, Strategic Director)

Key players (D)

Examples: Nurses, Midwives, Practice Nurses, School Nurses,

H health visitors, health visitors assistants Educationists, Students)

Table 3: Stakeholders' Power/Interest Matrix After my influence

Low Interest

High Interest

Low Power

Minimal effort (A)

Keep them informed (B)

(Examples: GPs)

High Power

Keep them satisfied (C)

(Examples: Clients/Parents)

Key players (D)

(Examples: Health visitors (+ve), Educationists/Students (+ve), Chief Executive (+ve), Director of Nursing (+ve), Finance Director (+ve), NICE/CHI (+ve), Nurses Advisor (+ve), Strategic Director (+ve) Other Clinicians (+ve))

Stakeholder

The current situation is that there is a shift to consumer-orientated society. Therefore, when considering issues within an organisation, stakeholders interests needs to be addressed because they are the people who can influence the running of the organisation. Stakeholders are people who have a "Stake" in the organisation, in a sense these people have keen interests in what the organisation does and how it runs (Martin and Henderson, 2001). In a voluntary sector, stakeholders include individuals funding the organisation, individuals who are donating to the organisation and volunteers who work for the organisation. In the public sector such as the NHS, these would include citizens, taxpayers who fund the services, beneficiaries from these services such as patients, clients and their carers and other service users. All organisations have internal and external stakeholders. Internal stakeholders for Enfield Primary Care Trust (EPCT) would include employees such as health visitors, nurses, doctors, managers and directors. These are linked to external organisation, which affects the running of EPCT services. These would be patient carers, service users, suppliers and other relevant customers. My internal stakeholders for an effective management/leadership capability would be the health visitors, General Practitioners (GPs), line managers, health visitors' assistants, community midwives, health visitors' clerks, human resources director, director of services, Director of Nursing, Assistant Director of Nursing, Director of Finance, administrators and district nurses. The external stakeholders will include EPCT clients, their families and carers, social services, universities, students, Commissioner for Health Improvement CHI, Community Health Visitor Practitioner (CHVP), and Nurse Midwife Council (NMC).
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In order to gain staff members commitment to change within my organisation, as an effective leader I would need to motivate them. Goleman (1999) states that "Great Work Starts With Great Feelings" This is a key function of management and leadership because managers need to care for their staff and one form of that care is the time they give to motivate them. Whiteley et al (1996) points out that motivation is about listening to staff, their needs, their hopes, providing them with encouragement and support, providing a gentle push where necessary and negotiating with them plans for ...

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