CAN802 -  Advanced Professional Nursing Practice

Assignment Task

Introduction

Nurses are identified as the largest group of professionals within the healthcare system (Asamani, Naab & Ofei 2016) and therefore their role in health improvement should be recognised (Aitkenhead et al. 2018). Weintraub and McKee (2019) urge for continuous transformation to meet the disease burden and achieve improved health while Yadav et al. (2020) suggest that difficulties faced in healthcare, particularly in quality and safety are a direct result of diminished leadership performance.

Leadership has been postulated by Stanley (2011) as the ability to produce change through ingenuity and inventiveness occurring optimally when leaders are empowered, however, it must be remembered that both concept and application are comprehensive within differing environments (Porter-O’Grady & Malloch 2016). The term clinical leadership is somewhat fresh to the profession and may not be clearly defined. Nevertheless, Stanley and Stanley (2018) advise it is essential when applying practice change as implementation can be greatly impacted by leaders, both positively and negatively.

Due to its complexity, multiple leadership theories have emerged and evolved which have been widely studied. Both quantitative and qualitative research has focused on the attributes and characteristics associated with leadership theories as well as the personal values and beliefs that these leaders hold and utilize to classify their leadership style. Traditionally leadership is more frequently viewed form a hierarchical perspective rather than leadership theory which considers values, beliefs and behavioural alignment with the organisation or leader (Cardiff, McCormack & McCance 2018). Gopee and Galloway (2017) inform that healthcare has adapted to include various types of leadership including trait, functional, behavioural/style and contemporary. The latter is described by Lussier (2015) as a leadership theory that strives to establish how leaders connect with, stimulate and assist followers.

Two leadership styles within contemporary theory will be considered in the ensuing discussion, that is transformational and transactional and in addition, how both of these leadership styles can be used simultaneously to meet the needs of the context and the individuals to provide effective leadership. Relevant examples obtained from two clinical leaders will be provided to emphasize the characteristics and attributes involved that influence practice change effectively.

Interview Conventions

Information was collected from two nurse leaders following attainment of verbal consent to each participate in an interview. Questions were provided to each participant via email in advance and a suitable time agreed upon to conduct the interview in a private room. Potential for interruptions during each interview was minimized by placing a sign that stated ‘interview in progress, do not disturb’ on the door with good effect.

Participants

The first interviewee, known as Nurse S throughout this discussion, had 11 years nursing experience which included chemotherapy and Emergency Department nursing and was currently in her second management position as a rehabilitation Nurse Unit Manager (NUM). The second interviewee, known as Nurse C, had 25 years nursing experience which included ward nurse, Acute Pain Clinical Nurse, Clinical Nurse Educator and currently held a NUM position for eight years.

Responses from both participants were collated and analysed and are included in the following discussion.

Practice change and leaders

Practice change is defined as making adjustments that improve service provision which involves participants engaging in implementation while leaders are expected to initiate that change (Gopee 2018). Leaders can be identified through their emphasis on high quality care provision (Stanley & Stanley 2017) which can only be achieved through implementation of evidence-based practice through practice change. Therefore, leaders are an important aspect of healthcare innovation (Weintraub & McKee 2019) worth consideration. Furthermore, Iacono and Altman (2016) recognise that all nurses can be identified as change leaders and due to frequent patient contact are in prime location to both highlight areas in need of change and potentially have maximum impact through participation in practice change, particularly when considering bottom-up strategies for quality improvement. 

A literature review conducted by Stanley and Stanley (2017) provided the top attributes associated with leaders, which included, being competent, an effective communicator, supportive, value/belief focused, quality focused, a role model, motivator, mentor, visible, team focused, approachable, having comprehensive clinical knowledge, empowering and participating in staff development/education. These will be further discussed in relation to the leadership styles identified.

Transactional Leadership Style

Contingent reward, active and passive are all factors to consider regarding transactional leadership style, however, passive is considered to have negative impacts on environments within transactional leadership style (Manning 2016).

During the interview with Nurse S it was apparent that she was more inclined to transactional leadership. When questioned as to the motivation behind taking a leadership role, Nurse S replied that there was a ‘sense of fulfilment in getting tasks done’ and she was ‘focused on the solution’. This is described as a common feature of a transactional leader by Ellis (2019) and Lussier and Achua (2016). An informative study by Asamani et al. (2016) showed that achievement-orientated leadership was most relevant to staff productivity and therefore should be considered when implementing practice change.

Furthermore, Nurse S alliterated that she was ‘organised’ and provided an example of how she has made the ward environment more ‘structured’ through implementation of a quality improvement project on patient safety and communication by introducing a team safety brief each shift which was used to highlighting three points for communication and one focus of improvement staff needed to consider when ensuring safe practice and improving care standards. Order and structure are identified as key features of transactional leaders by Gopee and Galloway (2017).

Lussier (2015) informs that transactional leadership is fundamentally based on the concept of reward and punishment. Throughout the interview Nurse S provided responses that included ‘staff get rewarded and punished’, ‘the chain of command is very definite and clear’, ‘there are rules and boundaries’ and ‘if they cross the line there are consequences’. Interestingly, both Nurses provided the same example of managing resistance. Each nurse sent an email requesting staff to allocate annual leave within a stated time frame or annual leave would be allocated for them. Both nurses followed through with their intent. Followers that met the goal were given their choice of annual leave and thereby benefited from the transaction while simultaneously benefitting the organisation by assisting in forward planning. This is known as a substyle of transactional leadership labelled as contingent reward (Lussier & Achua 2016). A quantitative study by Abdelhafiz, Alloubani, and Almatari (2016) showed that contingent reward was used ‘sometimes to fairly often’ confirming information provided by Ellis (2019) that transactional leaders identify tasks, set goals and recognise task completion through reward which gains respect from followers. However, this can be a negative attribute for some followers due to the uncertain nature of COVID19 and may result in discontentment within current environments. Further examples provided by Nurse C included, a ‘chocolate in return for staff to complete staff rounding sheets’ and ‘swapping to work a shift this week in return for a day off next week’. Both Nurses alliterated that they organise afternoon teas occasionally as a reward for hard work and achieving goals which increase positivity within work settings.

Nurse S also stated that she used ‘specific, measure, attainable, realistic and timed - SMART goals’ when putting forward requests to followers. Transactional leaders often have short to medium-term focus according to Gopee and Galloway (2017) which is reflected in the task driven nature of these leaders. This can be seen as a negative aspect of transactional leadership, and indicated by Lussier and Achua (2016) may actually lead to a disintegrated relationship between both leader and follower once the goal is attained. Considering the overall positive and negative impact on followers and the environment may be useful when continued practice changes are necessary to increase quality and safety standards.

Nurse C shows her focus for meeting organisational targets/commitments and why followers should be ‘on board’ at safety huddle each shift by providing information on the need to improve Key performance Indicators (KPIs) and stated that ‘staff need to know what is expected of them’. An example offered was blood documentation improvements in which she implemented a three-point strategy in regards to the transfusion policy. She elaborated that she had said, ‘I would like you to improve on three items when completing the transfusion form’, gave clear instruction stating that by breaking down the process into smaller, non-time consuming changes it was very achievable and would improve KPIs for ‘our’ ward’. Nurse S provided examples of the importance of meeting KPIs around falls, infection control and auditing which was discussed in safety briefs. According to Lussier and Achua (2016) transactional leaders often try to keep both organisation and followers content although Gopee and Galloway (2017) warn that this has led to short rather than long-term focus in standards. Often followers can see the benefit, but claim that time constraints are preventative in accomplishing goals. Ignoring concerns of those that are carrying out the work necessary to achieve the goal may prove detrimental to a leaders’ successful implementation of practice change. 

Nurse S stated that she had a ‘good hold on clinical governance’ as it was an important aspect of her practice while Nurse C has been actively involved in writing policies, procedures and guidelines (PPGs) for the organisation in the past and ‘highlights particular relevant PPGs at times during safety huddle’. Knowledge of current PPGs is an important feature of transactional leadership according to Gopee and Galloway (2017) as it shows organisational interest which can be used positively impact follower interest and thereby promote end goal achievement.

Transformational Leadership Style

Transformational leadership is acknowledged and accepted within the nursing profession (Walls 2019) and predominant currently within healthcare (Gopee & Galloway 2017) which is the type of leader Nurse C defined herself as by stating she is ‘highly motivated and largely strives to be transformational’, ‘wanted to do herself out of a job’ and that she ‘wanted to provide lots of opportunities for the staff and so that they could become empowered’. A study by Manning (2016) using a descriptive correlation research design highlighted five substyles of transformational leadership which include, behaviours, attributes, inspirational motivation, individual consideration and intellectual stimulation and discussed their importance in leadership.

Moon, van Dam and Kitos (2019) urge leaders to encourage participation in organisational programs and career progression opportunities as these are known as intellectual stimulation while Alloubani et al. (2019) implore transformational leaders to consider the satisfaction and inventiveness of followers. Promotion of continuous learning is an important characteristic of transformational leaders and both Nurse C and Nurse S highlighted this within interviews. Nurse S explained that she has ‘an older workforce who do not want to do university courses’ which she respects but she does ‘facilitate all mandatory organisational education’, ‘supports continuous professional development with in Performance Development Reviews (PDRs)’ and ‘tries to get the team onboard with research, development and quality improvement’. As Nurse C was a Clinical Nurse Educator she is very supportive of all educational endeavours relevant to the clinical setting that staff request to attend, often providing education days to facilitate learning and sending emails with new educational opportunities available. An example she included was that during a PDR she had congratulated the follower for extensive external self-education, gave advice regarding career progression and encouraged them to trial acting NUM for leave relief. Healthcare quality levels can be improved at micro, meso and macro levels and PDRs are an opportunity for leaders to identify, encourage and initiate practice change on a one-to-one basis (Ellis 2019). Another examples of opportunity provision provided by Nurse C was that she recently supported a staff member in obtaining a promotion to Clinical Nurse Specialist (CNS) within the work setting which she felt would positively assist in the support of all staff within the service, she ‘tries to create opportunities’ and ‘be supportive’. Both Nurses recognise the long term outcome for the organisation, especially when considering workforce and career progression of staff, which is a characteristic of transformational leadership according to Lussier and Achua (2016).

Individualised consideration incorporates mentoring and coaching (Moon, van Dam & Kitsos 2019; Fischer 2016) which Nurse C incorporates this into every new staff member orientation. ‘Each person is assigned a ‘buddy’ so that they feel supported’ in a new environment. She also introduces them to the education team, CNSs and ensures that they ‘feel safe when working’. Nurse S did not comment specifically on this feature but did elaborate by saying that she had learned recently that ‘90% of leading is listening and 10% is talking and I try to respond to the appropriate information’. This could be an appropriate opportunity for Nurse S to mentor and coach followers by promotion of goals and practice change. 

Success can be experienced through inspiration, motivation and enthusiasm from a passionate leader who strives to attain the target and obtains support of followers (Ellis 2019) known as inspirational motivation. During the interview Nurse C said that she would try and motivate staff together by saying ‘we can do this’, ‘this is part of our organisational values’. Nurse S provided examples like, ‘nursing is fast moving so we need to implement change’ and ’I try to keep the staff motivated’ while Nurse C stated that she ‘always tried to communicate the why’. Inspirational leaders should contemplate ethical responsibilities in regards to their professional and organisation (Abdelhafiz, Alloubani & Almatari 2016). This was identified in the interview as Nurse S stated the importance of ‘following the code of practice’ and ‘promoting organisational values’, while Nurse C stated that she would remind staff of their responsibilities, particularly in safety huddles as situations arise.

Behaviours and attributes are other aspects of transformational leadership identified by Manning (2016) which Hill (2017) states can potentially have positive and negative impacts on settings. Moon, van Dam and Kitsos (2019) highlight the need to incorporate trust, integrity and create a positive work setting. Nurse S was very open in saying that she ‘endeavours to be a good role model’ to her followers, ‘sees no value in being awkward’, ‘I am always mindful to be fair and by the book’. She went onto say that ‘if you portray a bad behaviour, you permit it’ and that she felt that by ‘being present, visible, having an open door policy and being approachable’ she has gained the respect of followers. Hill (2017) views visibility and availability and key aspects of role modelling, particularly when referring to leadership. Nurse C also spoke of an ‘open door policy’, being ‘approachable’ and the importance of making time for followers when they asked to speak to her. Qualities of care and compassion are vital in gaining trust, faith and an enveloping sense of leader concern for followers, all of which are necessary when achieving increased standards of care (Ellis 2019). Nurse C went on to say that she ‘gives negative feedback as soon as possible in private’, is ‘passionate, open and trustworthy’ and that ‘these qualities are necessary in order for staff to engage’. Being mindful of behaviours and attributes and their effect, both negative and positive on practice change are necessary for success.

The ability to communicate the vision and goal to be obtained is essential (Ellis 2019; Hill 2017). A study by Manning (2016) used a descriptive correlation research design and highlighted the importance of communication between leader and followers and provision of feedback which can then lead to positive work outcomes. Both Nurses stated that they ‘give feedback regularly’, ‘have in-depth discussions’ when attending PDRs and ‘communicates with staff frequently via email’. Having multiple opportunities for both leader and follower to communicate is necessary when influencing practice change. It must be remembered that nursing is a 24 hour continuous profession and therefore leaders need to have open communication channels to recognise issues as they arise and provide the necessary feedback to ensure positive follower engagement. 

Nurse C and Nurse S discussed work and personal life on a continuum which is common in transformational leaders (Gopee & Galloway 2017). Both Nurses disclosed that they ‘would often bring work home’, ‘complete the rostering at the weekend’, ‘everyone has my number’, and ‘I am contactable when needed’. However, Nurse S recognised that ‘it is hard to switch off from work’ and could be seen as a negative aspect of this leadership style causing burnout.

Transformational leadership is currently being encouraged within healthcare due to its potential association to staff allegiance, alignment of individual and organisational intents, creativity, communication and inspiration to achieve objectives (Gopee & Galloway 2017). These leaders are enthusiastic, motivational and empower through education (Fischer 2016) and have the ability to conquer opposition to change (Lussier 2016).

Transactional and Transformational in Combination

Gopee and Galloway (2017) recognise that transactional and transformational styles differ in the need for exchange between parties and inclusive development respectively. Nurses are increasingly expected to raise the standard of quality provided and Fischer (2016) suggests that transformational leadership is indeed correlated with enhanced performance and quality improvement, however it must be utilized in combination with other skills for enhanced implementation outcomes. This is reaffirmed by Richards (2020) who states that while transactional leadership is valuable in attainment of short term goals there is potential for increased effectiveness when used in conjunction with other styles.

Historically, Bass (2008) argued that both transactional and transformational leadership can indeed occur simultaneously which was reinforced more recently in a quantitative, descriptive and comparative study by Abdelhafiz, Alloubani, and Almatari (2016) and again in a cross-sectional study by Pishgooie et al. (2018). Additionally, Hu and Gifford (2018) indicated that it is possible for the same leader to use different behaviours, even when their role remains constant due to consideration of situation, staff and also importantly as they develop as within their profession.

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