Management and leadership within health visiting team in Edmonton locality.
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).
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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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 enrichment, staff development and training, secondment, job sharing (Whiteley et al 1996). This is a good example of a role model which I can reflect that with my former Team leader who would occasionally allowed her staff to take turn to lead at strategic meetings on her behalf to gain leadership experience Whiteley et al (1996) urges managers to increasingly create a climate and conditions in which staff are motivated constructively, replacing the " I have to" with" I want to and choose to".
Motivation
Mazlow and Aldefer Theory: Mazlow explained motivation in terms of needs which individuals seek to satisfy. He argues that these are in the form of an heirachy-physiogical, safety, social, "ego" and what he termed "self actualisation" or what a man can be he must be". His contribution to the understanding of behaviour was that of multiple motives. Alderfer developed Mazlow's ideas of a need driven approach relating to existence needs, relatedness needs, and growth needs. This is known as the ERG theory. It gives less emphasis to Mazlow is strict hierarchy because different need satisfying behaviours may operate at the same time. This theory will suit our present team as there seems to be no growth in Health visitors (HV) teams career and there is no motivation for personal development from the strategic management although Personal Development is one of the strategic agendas for the way forward for nurses/health visitors, nothing practical is happening within our practice at present as there are no mentors, no clinical supervisors and no personal supporter apart from child protection supervision. This does not reflect well on the Trust's recruitment and retention strategy for Improving Working Lives (IWL) standard, for as an employer, it should have been accredited by April 2003 and practice plus by April (2005 EPCT doc HR 2003-2008). High workload, in a deprived locality is contributing to a low morale among staff as most of HVs feel that their capabilities are not being fully utilised by the management since there are no involvement in leading Public Health Agenda. More over there is no "Team Working" (See Fig 2 for Mazlow in hardy 19930) for self-actualisation).
Hackman and Oldman (OUBS 1998) link motivation to job characteristics. They argue that people's attitude such as motivation, job satisfaction and the quality of work, are influenced by various critical psychological states. These are the degrees at which people experience work as meaningful. Feel responsible and have an individual need for further growth (See Table 2 for Hackman and Oldman)
Within our organisation lack of motivation could also be due to many of the workforce being within in the retiring age within next five years.
Considering the above issues, our team of health visitors require a Transformational leadership for the effective management and transformation of the existing culture. This type of leadership is characterised by four components. Idealized influence, Inspirational motivation, intellectual stimulation and, individualised consideration (Bass and Avolio 1993). For example when tying to influence others, as an effective leader I would go with a clear idea. To seek to obtain the trust of the team members, cover essential items clearly. I will also have evidence-based facts with me, have self-control of my personal emotions and never loose site of my idea. Listed below are characteristics of a Transformational leader: qualities
* Vision which is intellectually rich, stimulating and true.
* Honesty and Empathy
* Well developed character without ego power
* Concern for the whole shares of power
* Capacity to enthuse (Alimo-Metcalfe and Alban-Metcalfe 2003)
I will use 4Ds (See Table 4) adapted from (Lewis 1995) in Leadlap/Clinlap Model (see Table 4) to support my plan for transforming the staff members' interests in order to deliver Quality Services. Ziggy Ziggler in Scott (1992) states that clinical leaders must focus on the main thing at all times.
Table 4: Nursing/Care/Service Priorities determined via the 4D
Critical to short-term Nursing/Care Survival
DO IT
Critical for Long-term Nursing/Care Survival
DELIGATE IT
Less Critical to Short-Term Nursing/Care needs
DELAY IT
Currently, not seen as critical for Long-Term needs
DROP IT
Effective Clinical/Services - Resource Management (After Lewis, 1995).
Effective time management involves prioritising. In practice I will assess what are important. Thus my Priority will be according to the followings:
* A) Jobs of uttermost importance for example, in health visiting these are critical life threatening cases such as when a child's life is in danger and needs Protection (DOH 1989); domestic violence where life is threatened, while in nursing these are cases like cardiac arrests and anaphylactic shocks. These are important and crucial therefore "Do it".
b) Jobs that are important such as auditing of outcome of work, my New Birth visits, attending important meetings and case conferences; "Delegate them".
c) Jobs that are useful like health visiting Forum, study days, attending less crucial meetings "Delay it".
d) Jobs of less importance; "Drop it".
There are also time constraints: Urgent jobs to be done as soon as possible, fairly urgent jobs to be done by a near dateline and, not so urgent jobs can wait for a while. Possible outcome of Priorities also need to be considered. For example placing problems ahead of opportunities, taking the easy way, settling for low achievement and playing it safe at all time are prioritizing badly Dorling Kindersley (DK 2000). All managers need to understand the nature of the job they do in order to be effective. Henry Fayol argued for the teaching of management at school together with conventional subjects. The main task of the organizational head is to forecast and to plan. "Thinking and ensuring success is one of the keenest satisfaction for an intelligent man to experience". Fayol recommended the boxed points below.
e) Planning to set goals,
f) Organising, for specific roles
g) Directing (commanding) for clear process
h) Controlling and co-coordinating for open relationships.
Grundy (1993) recommend the followings for time management.
Usual time spent Time needed to Spend
2% for Diagnosing 20%
10% for Planning 20%
80% Implementation 40%
6% Control 10%
2% Learning 10%
A.S.T.R.E.A.M., S.M.A.R.T
The goals for our HVs are to deliver a first class care to improve the quality of patients/client care in the Edmonton Locality. Our goals are achieved using A.S.T.R.E.A.M. Before using this tool, we need to know our Primary Care NHS Trust's goals at Strategic Level, as our goals are to match strategic goals.
I will use the Ashridge Model to analyse the Organisational objectives (See figure 1).
Figure 1: An Ashridge Mission
The analysis provided by the Ashridge model highlights some key objectives, which can be achieved in the next two years and how I can plan to meet these objectives. Further more potential obstacles to the objectives are identified in the section Strategic Clinical Questions (SCQ 3) where I discussed current rigid and obsolete assumptions and ideas in connection with our Team uncertainties related to delivering a first class service to improve life.
The framework for overcoming rigid and obsolete assumptions is proposed in the section on implementing a quality service. By using A.S.T.R.E.A.M for setting goals I have arrived at the following objectives in the box below, some of which are derived from Enfield Primary Care Trust (EPCT) (2003- 8) Human Resource Strategy:
* Broad organisational changes
* Policy directives that allows improving working lives, retention of staffs, job satisfaction. Rewards for capable employees and career development with an innovative approach to workforce design.
* Concerns about accountability when delivering services
* Quality initiative for improving standards of cares as recommended by UKCC (1996) and the new NHS Modern; Dependable (DOH, 1997). Partnership with clients is becoming integrated into nursing/health visiting philosophy
* Educational drives towards reflective practice the restorative part of clinical supervision.
* Concern about practitioner health and the prevention of burnt-out.
* Increased value will be placed on therapeutic intervention and concomitant requirements for self-awareness.
* More specialist staffs, such as nurse and therapy consultants with extended scopes and roles.
* Health Visitors and School Nurses to have wider public roles.
* Policy that model workforce projection and expansion.
* Working Together and encouraging Team Work
The word A.S.T.R.E.A.M gives ownership to the team because the team has accepted all the goals.
Agreeable - Improving the quality of lives and practice are modernisation agendas. Therefore the Trust has adopted this as one of its internal and external strategy for improving the standards and quality of services that its staffs deliver to the patients/and clients.
Specific - Edmonton area has already been identified as an area requiring change. It is specific and tangible with clearly focused objectives as previously discussed. For example, the commitment of the management and the experiences and competencies of the nursing team will be desirable to achieve the change.
Time - Our goals for improving the quality of lives will be implemented within the next six months and evaluated six months later post implementation.
Realistic and Relevant - Health Improvement is one of the cornerstones in the clinical governance. It is also relevant because it embodies useful Public Heath functions for health visiting staffs as indicated below.
a) Health improvement. Patients and their carers are encouraged to improve the qualities of their lives to reduce incidences of coronary heart diseases, diabetes, strokes and cancer caused by smoking and unhealthy eating
b) UK has the largest percentage of teenage pregnancies before the age of 16. These leads to demand on extra NHS resources. Sex education, contraception and family planning are vital.
c) Socio economic factors affect the way people live. These include poor housing, poor education, poor environment and unemployment, which must all be tackled.
Measurable - This project will be evaluated within six months of implementation and then followed by on-going yearly evaluations and improvements.
Where are we now?
Factors to manage in order to achieve change
Explicit Roles
The question our organisation should ask is, where are we now in improving our nurses/health visiting staff capabilities in order to deliver a first class service to our patients/clients?
I will use PESTO framework to establish the emotional impact on our HVs in relations to our objectives.
PESTO framework: The major drive for recruiting, developing and retaining quality staff comes from external factors, which will influence the Trust's strategy for a need for change in their practice. PESTO stands for Political, Economical, Sociological, Technological and other factors such as Environmental policy procedures, guidelines and standards all of which have an impact on the Trust as an organisation.
External Factors of PESTO
There has been a major influence in the strategy and structure of the local Trust. Since 1997, the Government has stated in its document "Modern Dependable" (1997) the need for modernisation by health improvements throughout the NHS and the needs for fair access to services for all the people and in all hospitals. Furthermore, the highest possible standard of quality and efficiency is expected from all the national services (DOH 1997).
Economically, it is expensive to attract and also difficult to recruit and retain high quality staffs especially in nursing/health visiting because it is now mandatory to train manager for excellence (NHS Management Code of Conduct, 2002) and develop them as patients/clients expectations are now too high. It is also expensive to train skilful workforce that can deliver effective services. But the long-term benefit of such investment will be a high standard and quality of services to clients/patients in the whole Trust. People's health will improve. High standard of delivering care will also reduce litigations. We now live in an environment where clients/patients are well informed and armed with knowledge through mass media, Internet and e-mails. This however seems to be a lip service because the whole organisation need to change. Clinlap Model could be used to tackle lack of resources such as time, lack of human workforce, equipment, information, material and money (T.H.E.I.M.M.) implication and the goals must be agreed.
Technological advances for nurses/health visitors will facilitate delivery of high standard services that will make a big difference in a deprived area like my locality. The ability of nurses/health visitors who are highly motivated and appropriately rewarded for their quality skills to override many influences on the individual's cathartic behaviours is tremendous. Cathartic behaviours are those behaviours such as seeking to facilitate the discharge of disabling distress, distorting the staff.
Our Trust and Locality members have also adopted this purpose in their strategic plan. Quality and standard is being monitor through Clinical Governance. Clinical Governance is defined as "a framework through which the NHS organisation are accountable for continuously improving of their services and safeguarding high standards of care by creating an environment to which excellence in clinical care (DOH 1998). Within our EPCT, we have just had our Performance checked by CHI for the effective delivery of health care. The question is, why is this necessary? This is of course the first time the Government is looking at health issues in details. It could however, be to cut down the costs in delivering services.
Internal factors
Having analysed the external environmental factors, I will now consider the internal environment within my locality. These are the nearest or immediate stakeholders or components that can be controlled to a large extent at least by the organisation's managers. I will use 7s Framework to make sense of the internal environment as the 7ss stands for strategy, structure systems, staff, skills, styles and shared values of the people that make the organization.
The Trust has embraced the implementation of Human Resources Strategy 2000-2008 and has acknowledged the NHS Plan 2000, which states that "The strength of the NHS lies in its staff, whose skills, expertise and dedication underpins all it does". Heavy and demanding workloads and lack of qualified HVs due recruitment problem nation wide, is causing staff shortage and low morale. Minzberg (1973) suggests that a manager should consider it essential to be prepared to play a number of roles in their work some of which are boxed below:
* Leader of the team-a negotiator, a key person
* Administrator-resource allocator
* Conflict-handler- a negotiator
* Innovator-entrepreneur.
However the most important thing Whitely et al (1996 p 13) recommend is that managers needs to be more versatile in their approach and should be prepared to assume more than one role, because different situations require different styles and approach. Thus, a new strategy brings fresh challenges and new opportunities. According to DK (2001), the effective manger's role is to motivate everyone by ensuring that they are appreciated that means giving them a part to play in achieving a success, then to encourage the team to train and be rewarded. These includes:
* Abilities to recognise that s/he cannot do everything therefore to delegate work to others. This will provide job enrichment and challenge to colleagues and subordinates.
* The needs for care for staff.
Since staff shortage is nation wide problem, I will look into how to recruit, retain and attract quality staff that I can retain under our management.
Recruitment and selection for Effective Skill Mix
A vacancy sometimes occurs due to resignation, retirement or a gap has been identified.
The NHS Trusts are often large employers they need a wide range of skills and rely on people with skills to provide the care for which it is known (DOH 1998 p 20). However, the bulk of costs in health and social care are in staff salaries and wages and associated costs like National Insurance, and pension contributions (Whiteley et al 1996 p 191). Therefore the people employed need to be utilised to maximise the gain from their skills (Strike 1995 p 8). Strike insists that while the service relies on its people, it is not cost effective to pay staff to hold the skills that are not needed or the responsibility they do not exercise, or to employ more staff than is necessary. See box below
* Identify the set of tasks and process to be undertaken.
* Analyse the skills or competencies required to undertake those tasks
* Design jobs or roles that contain the skills required, before employing the staff required.
However, staff shortages are well known in NHS. Getting the right skill-mix enables the varied needs of patients to be met most economically by bringing together only the skills that are needed at a particular point in time. For example Cochrane et al (1996, 1999 and 2000) when suggesting the design of workforce for tomorrow's service suggested two new breeds of health workers. A health care practitioner that combines the roles of the nurse, doctors, therapist, and a health care practitioner assistant that is currently being tried in a Medical Admission Unit at Kingston Hospital (Allen 2003).
Real/Perceived dissatisfactions: With the new roles emerging and old ones changing the need to guarantee public safety is a priority (UKCC 1984). A nurse who is an employee of a Workforce Development organization reported dissatisfactions with new nursing roles. She revealed that when primary care trusts came into being last year, innovative nursing posts were axed because of shortage of funds (Hartley 2003). Hartley suggested that the on going problems with resources are also preventing PCTs from proposing the creation of innovative nursing posts in the three-year delivery plans. PCTs are reported to be requesting for increase in numbers of nurses in traditional roles other than the Government's drive for the extended nursing roles. Other dissatisfaction has been published by a right-wing think-tank Dr Maurce Slevin. A consultant at St Bart's and the London NHS Trust urging, "Managers must go". He argues that the NHS now has more managers and support staff up to 269,080 in total compared to the 266,170 nurses. His figures are based on DOH's Annual NHS Hospitals Community Health Services, a Non-Medical Workforce Census. Dr Sleven also blamed inadequate salaries for poor nursing recruitment, and low staffing levels because skeleton staffs consisting of health care nurses are now running wards (News: Nursing Times February 2003).
As soon as a notice of resignation is given the line manager should consider whether there is a need for a replacement. If there is a need, the total replacement time scale should be about 73 days. It is possible that the post is no longer required at all. A vacancy therefore presents a manager with choices about the post. It is necessary to discuss the vacancy with Department of Human Resources (HR). The next step is to scrutinise the job description and personnel specification for the vacant post. This is important because it will describe and set up information about the complexity of the job. It can also be useful for managing the prospective candidate. It also includes the required person's specification and aimed to attract applicants (see Appendix 3 for Ethical and Legal considerations during recruitment and selection).
During the selection interview, one should look for the following effectiveness in a candidate:
* Competence
* Positive attitude
* Cooperative and can work in a team
* Complementary skills that fits in our team
Finally the job is offered to the candidate after receiving satisfactory references and he/she signs a job contract and a formal induction into the job begins.
Induction is the process of receiving and welcoming employee in a new organization. It is a gentle introduction of work practices aimed at the followings:
* To smoothen the preliminary stages when everything is likely to be strange and unfamiliar
* To establish quickly a favourable attitude to the organization in the mind of the new employee so that she/he is more likely to stay
* To obtain effective output from the new employee in the shortest possible time (Amstrong 1996).
Follow-up: It is essential to follow up a newly engaged employee to ensure the followings:
* She/he has settled
* Check how well she/he is doing.
* Identify any problem earlier.
* Find out misfits and correct.
Training Needs
Training needs are analysed using four methods shown in the box below
* Analysis of business and human resource plan determined by the organisation
* Job analysis for content, required standard of performance, required knowledge and skills and required competence
* Analysis of performance reviews for learning and development needs for continuous development
* Training surveys to develop a training strategy and its implementation and to assess its effectiveness and quality
The above analyses will identify gaps in our practice that will help us plan our training and personal development and life-long learning.
Continuous Personal Development (CPD) and life long learning
As the pace of change in the delivery of health care continue to increase and the public's expectations of service from registered practitioners keep on growing, the principles and values of personal development and life-long learning become increasingly important. This involves new expanding roles for health professionals to meet increasing technological advances in treatment and care (UKCC 2001). This requires practitioners to demonstrate their responsibilities by developing a portfolio of learning and practice and by being able to recognize when further learning may be require. Life-long does not simply mean keeping up to date, but also requires a different approach to practice starting from pre-registration. CPD can be used as an opportunity to develop successful career. Managers have access to data showing the performance of individuals, and have a key role in encouraging use of such data and in helping to interpret it in a constructive manner. This can also be used as part of an appraisal process (Rughani 2000).
Developing Teams for Continuous Quality Performance
The contribution that team working can make to the effective delivery of quality health care was emphasized in the NHS Plan (2000), and recently in the "Shifting the Balance of Power within the NHS: Securing Delivery" (DOH 2001). The NHS Plan (2000) sets out a blueprint for action, emphasizing the need to strengthen the role of the NHS in health improvement, prevention and development of services that are accessible, convenient and delivered to a consistently high standard. As key public health and primary care practitioners, health visitors have important parts to play in achieving these goals. In the document "Securing Delivery", the emphasis is on the Trusts to develop greater responsibility for clinical teams and to promote the growth of clinical networks across NHS organization. The organisation should encourage life-long learning among the team for them to provide efficient and effective services in the long-term. Martin and Henderson (2001 p25) define the word "managerial" as effectiveness. It is a measure of the extents to which one achieves a pre-set goal. The quality of objectives is as important as the set objectives themselves. Efficiency means doing the best with minimal resources available. However in the NHS, poor performance has been due to inefficiencies in working practice. Poor performances have also been due to lack of important resources such as knowledge, skills, and the right attitudes.
In order to motivate the team members, I will use team approach instead of individual learning. I will raise consciousness about the staffs' resistances to/and avoidances of what should be faced or dealt with using one or more of the methods listed in the box below (Heron, 1989).
* Confronting interpretation
* Objective confrontation
* Subjective confrontation
* Skill feedback confrontation
* Inviting a confronting interpretation
Clear Processes
People's management objectives
. Promote, maintain and improve the health of the local population
2. Use the team's resources efficiently and effectively.
3. Enable team members' personal and professional development.
4. Enable personal and community responsibility for individual's health
My organization requires Team Working, which has to be developed from scratch.
Development of a Team Based Organisational Need
Developing a Team Based Organisation
Audit organizational structures and culture
Audit of external environment
Identification of types and location of teams
Implementation of team management and leadership systems
Implementation of team based working
Evaluation and maintenance systems
Job design for team members in the organisation
According to Whiteley et al. (1996) job descriptions should be subject to regular review. They are important in many ways as listed below.
* They provide a clear indication of what is expected of a member of staff
* They form the basis of recruitment and selection, i.e. in drawing up an advertisement
* They provide the basis for assessing training need
* They provide a baseline for appraisal.
(See Appendix 3 for check-list and example for a role of Health Visitor Assistant Grade D)
Persons Specification
This helps a manager to select a new post, replacing someone in the existing post, or when considering a clarification or setting a role for existing staff member which might have come due to an appraisal interview. These formats may be useful. Physical consideration is important if any aspect of the job may require special qualifications or if someone needs to adapt within an area or work, e.g. a disable person.
Gaps Identified leading to Training of Staff
I will use appraisal system to assist in identify training needs amongst the staff. Training needs analysis is suggested by Whiteley (et al 1996) and can be carried on by external facilitator using a variety of methodologies listed in the box below:
* Observation, work analysis, comparison of job description, questionnaires, interviews.
* General supervision, information from patients feedback/surveys/complaints and suggestions
* Evidence from the audits, (external bodies like CHI which has just visited our Trust) or internal audit where gaps are identified.
* General observation, impressions from other managers, supervisors
* Individual's review /self assessments of one's own training needs
* Peer group assessments, e.g. our team members have just suggested training for some of the HVAs
* Comparison made from 'benchmarking" our organisation with others. Comments assessments from the courses that the staff have been on
In The NHS Plan and Making a Difference 2, the Government's strategy for nursing and midwifery, highlighted the need to introduce new roles and new ways of working for nurses and midwives to help improve services and raise the quality of patient treatment and care. The successful future of the NHS depends on a workforce able to work in various ways. Managers can make the best use of nurses and midwives' skills by reviewing their current roles and looking at innovative ways to develop key roles. These key roles support new health straggles and government policies to enable nurses to realise their full potentials.
However, sometimes training may be required to develop skills and knowledge for effective performance, personal growth and career development. Specific job training in necessary skills and knowledge to prepare changes introduced through a policy, legislation, re-organisation and Government proposals (see Appendix 3 for legal framework and Ethical considerations).
I will require feedback which I will obtain using the methods below. The timing of confronting someone is very important. The content is what we say. The context is what is in it and the process is what is done.
* Interpersonal skill
* Prescriptive intervention
* Confronting intervention
SWOT
I will use SWOT Analysis to review our team goals. SWOT stands for:
Strengths-of the team and organization compared with competitors
Weakness-of the team/organization compared with competitors.
Opportunities-for the team members in its environment such as rewarding system within the team
Threats-to the team organisation in its environment (Morton-Cooper and Bamford1997).
4Ds
I will use the 4Ds to analyse individual's attitudes and satisfaction as shown below.
The CLINLAP MARTIX :PROVIDING THE route to Continuous Quality Service
High
2 Differentiated
Service
(st Way)
Dedicated High 1
Quality Service
(3rd Way)
4
Degenerated (Maicious)
Service (No Way)
Desirable Forced
Service 2nd Way
Low Level of stakeholder Satisfaction High
To illustrate Project management, I will use Team Working as my Project. Currently we are not working as a team, therefore I will use a theoretical Team Working Project as described below in the next section.
How should we plan the "exploration" as well as check our progress to ensure we arrive at our desired proposal goal, through our CAPABLE STAFF?
Open relationships
What is a Team?
A team is a group of individuals who work together to produce products or deliver services for which they are mutually accountable. The team members share goals and are held mutually accountable for meeting those goals them, they are interdependent in their accomplishment, and they affect the results through their interactions with one another. Because the team is held collectively accountable, the work of integrating these with one another is included among the responsibilities of each member (Adair 1986). However (Jumaa and Alleyne i898a) lack of resources namely time, personal human, information, equipment, material and money (T.H.I.E.M.M.) make team working very difficult. In the NHS Plan (2001), the need to break down barriers between staff was emphasized so that there have been repeated initiatives aimed at teamwork because professionals were not sharing information. Unnecessary boundaries exist between the profession which hold back staff from achieving their true potentials. A team approach places a high value on working together as a group and not as individuals. However when there is a promotion, we are not promoted as a team, although each one would have contributed to the goal of the organisation. Handy ( 1999) suggested that in the area of work we always assume that we are a team but are a group. In effective teamwork the emphasis is placed on goals achievement i.e. aligning strategic goals with organizational goals.
Team Development Project
It is crucial for achieving effective team working that each member of the team is clear about the contribution s/he makes in order to achieve he team's objective, and that each member understands the contribution that other team member makes. I will use A. S. T. R.E A. M. to give clear goals
Through role negotiation, the needs of individual roles are met, and the activities of the team members become integrated more to meet the objectives of the team as a whole. Team members also develop a better understanding of each others' contributions to the team (See Box1 below). This project will be managed by a team leader, who will be the anchor person of the project.
The leader has to be flexible, has the skills and capable to lead the team.
People's management objectives
To set target that are understood by all team
Enable team members' personal and professional development.
Set Team performance management
Implement Team Performance Review
Role Negotiation
Step 1
Each team member lists his /her objectives and principle activities on a piece of flipchart paper.
Step 2
Each piece of flipchart paper is hung on the wall around the room and team member examine each role, only asking questions that clarify objective and roles.
Step 3
Each team member writes for other members of the team
a) what they would like each person to do less. (b) do more, (c) maintain at the present level of activity.
Step 4
Working in pairs, team members discuss and negotiate each others requests on (a), (b) and (c). This is a highly participative exercise and teams may need help, particularly if pairs find it difficult to reach agreement,( Michael A. West (1994).
Members of a team that work well together have relatively low stress. This way of working provides openness, support and trust, co-operation and also contributes towards participation and effectiveness. The leader in this is using a two-way communication, responding to the group's needs by requesting opinions, beliefs, and desires (Hersey and Blanchard, 1988). The leader is known as a Situational Leader. For further discussion of Team Questioneer, Decision Making and Communication, Focus on Quality, Support for Innovation within the team and Conditions for Effective Team Work, please see Appendix 4.
Implementing Support Systems
Our Team need to be supported using Performance Management. Considerable benefits may result from providing individuals with clear, constructive feedback, and team can gain the same benefits criteria. An important source of support that the Trust can provide for team is to help with setting clear performance criteria against which they can measure progress, achievements, and quality of services. The way targets are set, if conducted appropriately, can be a major motivating factor. Target setting works best if all team members are involved in the process. This will involve the following steps:
* Understanding by all our team members of their service user's needs
* Describing the overall goal or purpose of our team's activities (Tasks)
* Defining outcomes that will enable the achievement of our goals
* Identifying performance indicators
* Establishing measurement processes.
Review of Team Performance
Our team should have the opportunity to review their performance against present targets, whether set by the team or others in the organisation. This process enables learning to take place that they will help to enhance our team performance in future. This also promotes a review of how our team is working together that will enable our team to grow and develop.
It is important that our team members receive feedback on our performance from three main sources:
* Other members in the team, including the team leader (Locality Manager).
* Our organisation, that is from the senior management (director of nursing)- this should be received directly and reinforced by appropriate formal and informal reward structures
* The teams service users (stakeholders)
Team based performance reward systems
Performance management and payment systems can be used in a team for their collective performance. For example, rewarding the extent to which the team members' collective work promotes innovation, service quality, and continual improvement. How the reward processes are managed demonstrates the organisation's commitment to these types of performance. Reward system, such as team bonuses, high pay, an equitable payment system, real opportunities for promotion, considerate and participative management, a reasonable degree of social interaction at work interesting and varied tasks and a higher degree of control over work and work methods by team (Armstrong 1998). These must be open and clearly understood by all those involved. Our NHS Trust has reward policy in its strategies but at present it is not operating at encounter level. This is one of the gaps that need to be implemented.
Markiewicz and West (1996 and 2001) recommend that the implementation of team based reward systems should be a careful, slow and incremental process. Keys to successful team based reward systems implies that: At this stage our team must be asking, Which route must we take to get Capable Staff to our Service goal?
* Our teams must have clear achievable, but challenging objectives
* All our team members should understand and agree team goals, and it is best if we have been involved in setting these goals.
* There should be clear and fair means of measuring team outcomes.
* Our team members must work interdependently to achieve our goals.
* Our team should have access to the necessary materials, skills and knowledge to achieve the task.
* The reward should be valuable enough.
The New NHS is about efficiency and effectiveness. Effectiveness is not easy to pin down because it has to be considered in relation to the ever-changing needs and expectations of service users (Martin and Henderson 2001). Thus customer/patient satisfaction (CS) versus Resources Utilisation (RU) is no longer acceptable. Now what is acceptable is customer/patient satisfaction (CS and resources utilization (RU) i.e. CS + RU. Achieving "fit" between actions and organizational needs is achieving clarity about what you are trying to do and what you really want to do.
Effective communication system is essential to ensure clarity of purpose throughout the trust. We must constantly reinforce this purpose; check for common understanding and to ensure that our teams understand how our tasks and activities contribute to the purpose. This requires the followings:
Our team needs to identify the important information so that we can communicate and perform effectively.
To identify the most reliable source of information and negotiate access to these sources egg. e-mails addresses, telephone numbers, addresses.
We also need to establish a system to ensure regular access to required information using the most appropriate medium egg. Team brief, team meetings, formal presentation, minutes from meetings newsletters, e-mails memos and reports. To ensure stakeholders satisfaction, I will use CLINLAP MATRIX (Jumaa 2002c) to provide the route to continuous quality service (See table 3)
The question our team should be asking is how should we plan the "exploration" as well as check our progress, to ensure we arrive at our desired proposed goal, through our CAPABLE STAFF?
Implementing high quality, healthcare service within our team.
Our team objectives are:
Our aims are to improve working relationships between the Trust and health visitors and to improve the delivery of primary health care services to the population we serve.
Objectives
* The health of the local population will be promoted, maintained and improved.
* Individual, community will be able to take responsibility for their own health.
* Resources will be used efficiently and effectively.
* Team member will be personally and professionally developed.
Creating an anchor person
In order to implement a high quality service, we need a person who can manage and lead our team. A Team leader's tasks involves focusing on helping team members and to clarify the roles in the team, develop a team structure, co-ordinate their work and set goals. Good combination is essential to define clear, shared team objectives and to provide effective feedback on performance. The team leader or leaders also need to be skilled in co-ordination, planning and monitoring; our team objectives will only be achieved if tasks are allocated accurately and carried out effectively.
Resources
By using T.H.I.E.E.M., the following points can be arrived at for resources required.
* Commitments required at all levels of the organization but especially from senior management by providing strategic direction and releasing resources such money and time for training and team meetings.
* Ensuring the strategy for teamwork is put into action and clarifying what kind of monitoring and evaluation is needed.
Providing resources packs leaflets, newsletters, mentoring clinical supervisor, coaching appraisal and performance reviews are some of the roles a team leader need to provide. Having identified the resources required and our organization capabilities in team working, I will now consider how our implementation of our team working is managed. Since team working has not been practiced within our group, the objective is overcome the forces in the organisation that were resistant to change by pushing the level of effectiveness and collaboration upward. Teamwork had been tried before within this trust but the project seems to have not been taken up seriously.
Coaching individuals (Task)
Our team leader or leaders need highly developed couching skills if the team is to evolve into an empower team that take increasing responsibility for its own performance and management. This involves the provision of guidance and support to team members to help them achieve the task and work together effectively. The team leader needs to create a team environment in which team members can discover ways of improving performance.
Leading the team
Effective leaders see long-term goals clearly and are able to interpret their vision in a way that motivates the team. Intuition, judgement and the ability to assess and manage risk, whilst giving the team confidence and enthusing team members, are the main requirements in this role. Having considered different roles, to enhance our teamwork, I will now consider the resources needed. I will use T.H.I.E.E.M framework developed by Jumaa and All (1998) to analyse resources. T.H.I.E.E.M framework stands for input activities via Time, Human, Information, Equipment, Information, Material and Money.
Motivation
One of the tasks for the team leader is motivating the team. Hackman and Oldman link motivation to job characteristics. They argue that people's attitudes to jobs, such as motivation, job satisfaction and the quality of work, are influenced by various critical psychological states. These are the degree to which people experience work as meaningful, feel responsible and have an individual need for further growth. Thus for teamwork project to be successful team members need to be motivation for further growth. (See diagram below)
Hackman and Oldham-Job Design
How do we know we have arrived at our teamwork project goal?
The need to work with the team while holding managerial authority creates a potential problem regarding employee-employer relationship. This problem is about personal relations, communication, staff grievances, discipline, welfare and dealing with representatives of trade unions or professional association such as NMC (Strike 1995). Managers and organisation have rules and expectations, so must make them explicit in their own work situation. These are theft, assault, fraud, confidentiality, negligence and insubordination. If a member of staff is disgruntled about some aspect of his/her employment such as failing to deliver effective duty. Strike (1995) states that the initial step is to give time; listen; accept the person's feelings and avoid defensive behaviour. Depending on the problem, reassure, explain, provide a fuller perspective, provide facts, correct any misunderstanding and provide a proposed resolution. Disciplinary action will be needed if the staff does not respond to all the above.
Managers have duty to their staff in connection with Health and safety at work. The Health and Safety at Work ACT 1974 state that managers must provide a safe working environment.
It is helpful to offer counselling to our staff that feels suppressed, alienated, degrade, suppression (Heron 1990). In this case, it is important that the manger take the role as a listening ear seriously. Occasionally, some encouragement to seek further expert advice is appropriate. Developing inter-team working is crucial for effective delivery of care. Networking and collaboration encourage good team relationship and also encourage development of new ideas and talent of working (Delivering the Talents, NHS Plan, 2002).
Heron (1990) states that negative managerial emotional competence means that the Manager does not allow his/her own anxiety and distress, accumulated from past traumatic experience, to drive and distort his her attempts to manage effectively. The management in my locality had persuaded the staff to allow primary care team to be implemented in the late 1989. However the members do not even hold meetings or share vision. The activities in the culture Webb by Johnson (1988) imply that staff had not been competent in the past and that they could not be trusted in making the changes for effective teamwork project. These activities of fear and mistrust will cause lack of cooperation, hostility and resistance to the project.
Rituals and routines: health visitors who are resistant to changes and would like to practice in a routine do not embrace guidance in good practice. Teamwork is seen as a check up exercise since it requires team commitment and auditing of members effectiveness (Markiewicz and West 1996). Stories and Myths: Team work is being talked about among the local health visitors and across the trust in the light that "we have been there before" nothing changes in this Trust, "no time was given to us for team meetings by mangers due to lack of staff" "it is a burden because of high workload" (See Johnson's Culture Webb Below).
Johnson's (1988) Culture-Web Approach
Rituals & Routines Stories & Myths
Symbols The Cultural Paradigm Power Structures
Control Systems Organisational Structures
After observing the effects of cultural paradigm, I will now consider the LOOP factors frame work which will help to identify some factors that inhibits an effective implementation of Team Working and therefore helps in making decisions of what needs to be done next. The LOOP factor is described by Jumaa and Alleyne 1998a, 1998b and Jumaa 2000a and stands for Legislation, Organisational, Occupational and Personal factors (See Appendix 5 for further discussion about LOOP factors).
Having looked into the LOOP factors, I will now consider the framework 7s for feedback and evaluation. 7S are seven aspects of an organisation that needed to harmonise with each other in order to support the others or be "organised" (Waterman and Phillips 1980). These parts are:
Strategy: Our organisation is to provide an audit tool that can be used to assess the extent to which the organisational structures and culture currently support team working.
Structure: includes questions that will help us to identify the location and types of teams in the trust, and to consider the support currently available for the teams.
Systems: provides information on how to provide support for team working through performance management, reward and communication systems, and guidance on how to develop effective inter-team working.
Staff: Provides an audit tool on leadership, and information on how to lead and manage teams.
Style: Provides information on how the key managers (structure) behave in order to provide support that will promote team working.
Shared Values; details additional sources of information on how to develop a team-based organisation.
Skills: distinctive capabilities of team leader and the organisation as a whole.
The strength and weakness of our organisation can be identified using the audit tools linking the organisation. I will now use 7Es for feedback and evaluation.
The 7E s can be described as the following (Jumaa 1999b) (see Appendix 6 for further details).
* Economic
* Efficiently
* Effectiveness
* Equity
* Environment
* Empowerment
Conclusions
I set out with a specific goal of promoting leadership and motivation in my locality within the Health visitors. The specific roles and gaps were identified as lacks of team working. I corrected this by creating a theoretical team working and rewarded the members with theoretical bonuses, higher pay and real opportunities for promotion. The clear processes in my theoretical management of people were, time management, job design and staff appraisal. My open relationships included creation of the "Anchor Person" and a shared goal for the new team.
APPENDIX 1
The question is what does the Government mean by high quality staff since the NHS has always depended on the skills of dedicated staff, and why do the employers now need a new service wide approach to managing human resources in the NHS?
Quality in Service
The word "quality" has many definitions and different meanings to different people. In the New NHS, Total Quality Management (TQM) is required, this must be quality in its broadest sense: egg, doing the right things at the right time, for the right people and doing them correctly first time. It must cover the quality of patient's experience as well as the clinical results. Quality measured in terms of prompt access, good relationships and efficient administration (DOH 1998) or " A First Class Service". Thus, Crosby (1986) reminds the NHS employers and employees alike to "conform to requirement" of the public expectation, and to offer a "predictable degree off service uniformity that the public can depend on at low cost and suitable for the market" (Deming (1986).
Gray (2001) reported that the UK NHS is faced with globalisation of healthcare problems just as many other health services around the world. The major problems in the delivery of healthcare are:
* The increasing cost of healthcare
* The lack of capacity in any country to pay for the totality of healthcare services demanded by healthcare and the general public
* Marked variation in the rates of delivery of health services within a country and among countries.
* Delayed implementation of research findings into practice, in addition, inflation in healthcare cost in most countries is greater than the growth of the economy.
* The supply-led nature of healthcare in which the professional tells the patient what is available, thereby creating demand or develops and advocates the use of new service
* The provisions of inappropriate care. Although health service provision appears to be different from one country to another, the common factors that affect health service organization irrespective of their geographical latitude are:
. Population ageing. People are living longer thus the demand for nursing care to help people with chronic and degenerative illness is increasing (Do It 1998).
2. Rising patient expectations, which are being stimulated and driven by the explosion of information on the World Wide Web (www).
3. New technology such as Internet, mobile phones, computers database leading to information explosion contributing to increasing well informed public. Advances in medical sciences and biotechnology have led many people to think of high- technology hospital- base medicine as a panacea, the majority of healthcare takes place outside hospital in the community. Nurses, midwives and health visitors have important roles to focus the public expectations and also improve access to the services to make the public benefit from the available services and the new knowledge.
4. In some countries such as Africa the fourth challenge is the prevalence of AIDS.
In the 21st century public expectation is rising, people are no longer ready to tolerate waiting for services. People want accessible healthcare delivered promptly with uniformity and high standards (Do H 1999). In comparison to the pre-modern medicine Gray (2O01) mentioned that the enthusiasm and conviction of the individual clinician and of the profession as a whole was sufficient to bring about change. This is no longer the case. That was in the second era of the modernisation of medicine (modern medicine), which was based on science and was the beginning of technological development after the Second World War. This was challenged by the epidemiological doubts about its efficiency in the minds of once confident clinicians. The third era (post-modern medicine) is the 21st Century. While retaining the modern medicine needs, there is requirement to adapt to public concerns and trends such as adapting the process of care that is important to the desired out come. The process of care influences the outcomes such as patients/customers satisfactions and effectiveness of care. For example, involvement of patients as partners in clinical decision-making, although different process require different degrees of patient involvement. The public are also getting more concerned about the risk of modern medicine, which means contemporary medicine could be used as well. Therefore a change in the way of responding to the above demand needs to be addressed, as the workforce may no longer be meeting the public demands. Moreover, the NHS in UK from its inception was a promise to the tax -paying public that it is part of a welfare state providing free healthcare from cradle to grave. Salter (1998) comments that the NHS symbolizes the essence of the welfare equation regarding universal rights of citizens and it is the absolute duty of the state. Salter (1998) maintains that, the problem is some established ideas among the British citizens that determine the balance of power in the NHS and, are the ones driving the politics of change. Thus, in so far that the people of Britain perceive the NHS statutory duties as to deliver quality healthcare and they think that such care is not being delivered, they will legitimately demand that their elected representatives should press for change. Therefore, The secretary of Health is urging for professionals to work together in order that a first class workforce is recruited, retained and motivated because in this competitive environment in which there is lack of highly skilful nursing/health visiting workforce with management and leadership capabilities, it is only those employers whoa can attract workers with excellent knowledge-based skills and capabilities of effective leadership and management that are achieving improvement in their organisations.
APPENDIX 2
The NHS Plan (2001) CNO'S 10 key roles for nurses
* To order diagnostic investigations such as pathology tests and x-rays
* To make and receive referrals direct, say, to a therapist or pain consultant
* To admit and discharge patients for specified conditions and within agreed protocols
* To manage patient caseloads, say for diabetes or rheumatology
* To run clinics, say, for ophthalmology or dermatology
* To prescribe medicines and treatments
* To carry out a wide range of resuscitation procedures including defibrillation
* To perform minor surgery and outpatient procedures
* To triage patients using the latest IT to the most appropriate health professional to take a lead in the way local health services are organized and in the way that they are run.
APPENDIX 3
Check list for making up a job description
* Job details: This should include job title, current grade the name of the unit, and location of the post.
* Main purpose of the job: This should provide a statement as to why the job should exist
* Department
* Grade
* Responsibility for staff
* Scope of the job: This would cover information concerning the scope of the job in as factual as possible, e.g. responsible to Mrs B for reporting Child Protection issues.
* Authority/ Reports to: Who the line manager to whom the person should report?
* Scope of accountability
* Knowledge, skills and experience required. This should summarise the main knowledge, skills attitudes and experience required to perform the job to a competent level. If the post requires particular professional/technical qualifications then these should be indicated.
* Duties or objectives: It should provide the outcome representing the key output of the job.
* Communication and working relationships: This describes the various people within the organization with whom the job is associated with.
Strike. Anthony, J (1995) and Whiteley (1996).
Example of Role of a Health visitor assistant D grade staff nurse:
Department: Health visiting
Accountable to Locality Manager
To assistant health visitors with day-to-day management of caseload.
Clerical duties include organizing records, ordering of stationeries.
Good interpersonal skills
Has interest in personal development, mentorship and IT skills.
To assist in Health promotion and assist in Child Heath Clinic
Ability to work in a multidisciplinary team
Encourage/facilitate and empower participation in a group activities.
APPENDIX 3
The Legal Framework
This is provided by The Employment Protection (Consolidation) Act 1978 as amended by the Employment Act (1982) and the Trade Union Reform and Employment Rights Act (1993) provide for written particulars of the main terms and conditions of employment to be given to all employees working from eight hours a week within two months of starting work (Armstrong 1998 p480). He maintains that The Sex Discrimination Acts 1975 and 1986 makes it unlawful to discriminate on the grounds of sex or marital status in relation to who is offered employment and terms of employment. Thus care should be taken in briefing all interviewers on the need to avoid discrimination and to record the reason, which must be non-discriminatory, for making decisions about candidates. Similarly, The Race Relations Act 1976 prohibits discrimination on racial grounds and between racial groups against candidates in the arrangements for deciding who should be employed e.g. racial bias advertisements, and offering employment or refusing or deliberately omitting to offer employment. For example some of the real-life experiences reported by some team members state "you enter into the interviewing room and the look you are given, plus the interviewers eyes communication to each others shows you that you have
Lost the job, or you are not wanted here".
The ethical framework
* Ethical framework for recruitment and selection should covered the following:
* Candidates should be treated fairly and not discriminated against on ground of sex, race or religion.
* Candidate should be treated courteously
* Candidates should be treated honestly i.e. all information about the job and company
* Good professional practice should be followed in selecting and using test.
DOH (2002) Document 29495/ Code of Conduct for NHS Mangers sets out the core standards of conduct expected of NHS managers. One of the purposes is to guide managers and employing health bodies in the work they do and the decisions and choices. These include recruitment of the staff.
APPENDIX 4
Team Working Questionnaire -Interpreting Score
Clarity and commitment to objectives, the extent to which they perceive objectives to be worthwhile, and whether team members share these objectives
Low scale score (below 2.1) High scale score (above 3-4)
The team lacks vision/set of objectives that is valued by all The team has a clear, shared,
team members of the team attainable vision/set of objectives Is valued by all team members
Decision making and communication
The decision making and communication questions assess the extent to which members of the team feel they have influence over decisions made in the team, the degree to which team members interact with each other on a regular basis, and the adequacy of information sharing amongst members of the team.
Low scale score (Below 3.0) High scale score (above 4.4) The team meets regularly and all members
The team meets only infrequently and/or participate in decision making; individuals
Team members participate only partially in feel safe to make proposals to the team.
Decision making. There is a lack of trust Team members trust one another and
To make team proposals to the team. Participate fully to achieve the team's aims
Individuals may not be contributing fully and objectives.
toward team membership
A score of 3.0 or below suggests that our team might benefit from development activities that will improve communication, and collective and decision in the team.
Conditions for effective team working
There is a wide range of factors that influence team effectiveness, in addition to the skills, knowledge and experience of the individual team members, other key elements are:
* Individuals HVs should feel that they are important for the success of the team. Team members are committed and creative if the tasks they perform are interesting and challenging.
* The HV team as a whole must also have interesting tasks to perform.
* Individual contribution should be identifiable and subject to evaluation. HVs team have to feel not only that their work is indispensable, but also that other team members can see and acknowledge the contribution they make.
* Above all there should be clear, shared team goals with built-in performance feedback.
Research evidence shows consistently that where people are set clear targets to achieve, their performances generally improved (Kirkart 1995).
For the same reason it is important for our HV team as a whole to have clear goals with performance feedback. Additional factors influencing team effectiveness are:
* Organisational context that support working.
* Effective team leadership.
The team working guide (adapted from Markiewicz and West (1996 and 2001) provides tools that our team can adopt to assess how well it is working together and practical advice and guidance for team members which can help our team work together more effectively.
It would suggest that the team should use the guide as follows:
* Each team member, including the team manager/leaders should individually complete the team-working questionnaire, and add the scores to calculate the team's score.
* The team identifies which aspects they consider as priority team development areas.
* Using the information in section 2, the team chooses appropriate team development activities.
* The team develop action plan that specifies how and when the development activates will be carried out.
* After carrying out the development activities, team members again complete the team working questionnaire to assess progress (See Appendix 1 for Team Working Questionnaire)
Adapted from Markiewicz, L and D West M A (1996 and 2001). West (1994)
Focus on quality
Focus on the quality is the extend to which team members engage in debates and review processes to achieve excellent decisions and actions that they take to provide services. It is a measure of the degree to which team members feel that discussions and debates within the team are constructive, and that our team members felt that they are able to engage in the process of debate without being concerned that their contributions might be ridiculed or ignored.
Low score (below 1.9) High scale score (bove3.8)
Our team is not fully committed to achieving Our team is fully committed to achieving the
the highest performance possible. Highest performance possible, Our team
Our team members may not critically appraise their members critically appraise their work.
Work. Help in developing new ideas may not Help in developing new ideas is readily
Be readily unavailable. available.
A score 1.9 or below suggests that our team might benefit from development activities that will improve the team's ability to constructively debate and review.
Support for Innovation
Support for innovation is the degree to which there is verbal and practical support for the development of new ideas. Questions on this are verbal and practical support for the development of new ideas. Questions on this measure refer to sharing resources, giving time, and co-operation in implementing new and improved ways of doing things
Measure Low scale score High scale score
Support for (below 3.2) (above 4.4)
Little articulated or enacted support Sufficient articulate and enacted
For innovation is given. Stability is For innovation is given.
Favored above change. Our team Innovation is favoured above stability
commits few resources to innovation Our team commits adequate resources
to the development of innovation
APPENDIX 5
LOOP Factor
Legislation factors: include professional regulatory body such as the Nurse Midwifery Council (NMC), health visitor may feel incompetence to conduct some of the project given to her for the team due to lack of experience and knowledge or fear of exposure of dangerous practices that could lead to litigation. For such practitioners, Team working is usually not readily embraced.
Organisational factors: would include implicit commitments from senior management to support and embrace Team working project. Thus, if time for teamwork meetings is unprotected for example teamwork is not integrated as part of professional practice with clinical guidelines, and other concurrent change within the organization would lead to failure to deliver effective service to the clients and failure to improve Woking relationship.
Occupational factors: include high workloads lack of qualified staff causing stress and demands on staff.
Personal factors: include lack of experience, knowledge, ill health and lack of interest.
APPENDIX 6
The 7Es
Economic The contribution that team working can make the effective delivery of quality There is growing body of research evidence that team working can make a substantial contribution to improvements in quality of patient care, the efficient use of resources and staff satisfaction and well being. This will require additional resources, which will be clearly identified such as time, money, experience health visitors as supervisors, facilitator educational equipment, rooms the lead coordinator however, these should demonstrate that there is added value as a result of additional financial support. The added value should also be inform of quality outcome of service, recruitment and retention of emotionally contented staff.
Efficiency This will reflect at what changes take place in the delivery of care as a result of change in Team working. The quality of care and benefits are to clients can be monitored in terms of patients/clients users satisfaction of service against health visitors performances The contribution that team working can make to the delivery of quality health care was emphasised in the NHS Plan The NHS Plan (2000).
Empowerment This exercise will give team members autonomy to determine their own working practices, procedures results, and reflect on their work. There is cost saving. It will also highlight the gap in the service for the health visitors. However, a change in attitude, culture and behaviour of the health visiting staff towards team working needs to be monitored.
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