Leadership and management in healthcare

Introduction

The purpose of good leadership and management is to deliver services to the community in an efficient, equitable, sustainable and appropriate manner. Notably, This can only be accomplished if the main resources for service delivery such as finances, human resources and the aspect process of care provision are combined together and carefully synchronized. Good leadership and management of healthcare effectively are important for the establishment of a system with high performing healthcare delivery. A lot of research has shown that the connection between the performance of health systems and the management capacity, and the management capacity deficit has been for a long time cited as the major constraints in the realization of the health targets in different nations. According to Johnson (2015) Health management can be defined as the process of accomplishing healthcare targets through financial, technical and human resources and these consist of operational and strategic management activities. For instance, human resource management, chain management, governance, management of finance, improvement and management of performance, without which resources cannot be distributed effectively to aid in maximization of health outcomes. Good leadership and management of health and social care are specifically critical in the public sphere of low and moderate incomes nations due to the fact that resources are scarce and their distribution is important to accomplish the global and national goals for health outcomes. Trained health professionals and nurses are a guarantee of quality services. It also increases the patient’s confidence in the capability of the doctors to manage their conditions (Johnson 2015). It should be noted that efforts are being made to transform healthcare and enhance the ability of hospitals to manage chronic health conditions.

On the flipside, poor healthcare is a precursor to deterioration of the patient’s medical conditions. This leads to increased public concerns against the hospital and a decline in community health standards. The community with poor hospitals often experiences the population grappling with chronic health problems. The management of hospitals, however, plays a crucial role in enhancing healthcare (Taplin et al., 2013). This paper focuses on a case study and explores the role of leadership and management in healthcare.

Case study

There were a lot of complaints from the patients regarding the state of ward 10E at the Royal London hospital. Several negative comments and feedback had been given. Most comments were specifically concerned about the quality of services being rendered. As grave and important as the matter is, an investigation had to be conducted. The manager was tasked to personally inquire about the rising issues. After which they were instructed to actively engage in the practical running of the hospital. One patient complained that the nurse assigned to support him used to visit once in a day and even after reporting the issue still he was not provided with any support from external staff. He was asked whether he had reported the issue to the coordinator. He said on several occasions the coordinator told him that the deteriorating situation was due to the fact that there was a significant deficit in the number of nurses as compared to a large number of patients they were assigned to attend to. Other patients mentioned that the wards were not clean as well as the meals to the patient were not provided on time. Sometimes the meals were served earlier than the desired time and sometimes they were served late than expected.

After receiving some similar feedback regarding lack of cleanliness, inappropriate delivery of support and care by nurses and inadequacy in the delivery of meals the manager hosted a visit to the wards to inspect the situation closely. While he was at the hospital inspecting the situation, he noticed that the nurse to patient ratio was very low and this significantly contributed to poor service delivery. After careful observation of the issue, he realized that on certain days of the week, there was a significant decrease in rates in terms of service delivery. So many issues arose concerning the laziness and slow service performance by the staff; these days were identified to be Friday, Saturday and Sunday. During these days, he noted that there would be no one to supervise the staff whilst carrying out their duties and sometimes staff on duty would not even be present. Moreover, students on health practice would sometimes be allowed to perform various tasks, which in normal circumstances, they would not be assigned to do. These students would attend to the patients without being supervised. The same students would also be in charge of referrals or appointments, there in making any judgments that in their capacities, cannot make. The professional and much more experienced staff would be unavailable in most of these instances.

It was noted that recent funding issues with the hospital coerced them to reduce the number of some senior experienced staff and recruit low waged untrained fresh staff that were not skilled enough to perform the duties as per the hospital standards. It was also observed that the ward coordinators were not able to manage their teams properly due to the low nurse-patient ratio and therefore patients were not attended to by making excuses for suspended services. Many patients that were brought by families and friends late in the night would not be attended to at all till morning. Most patients were forced to look elsewhere for better and faster services due to the urgency of their situations.

Critical analysis using a reflective model

Reflective model enhance efficiency and provides a commitment to long-term learning and competency-based education within a variety of reflective portfolios. Changes in health care culture have promoted a move towards openness and reflection on difficult clinical encounters. Reflection could be understood as a metacognitive method that happens before, throughout and after situations, with the aim of developing a larger understanding of self and the state of affairs. Reflection within the context of skilled occupation is termed as reflective practice. In distinction to drugs, different health care professions, as well as nursing and clinical medical care specialties, have used reflective practice for many years, mostly in order that it's currently thought-about routine.

Governing and accrediting bodies stress on the importance of reflection. Reflection is vital in embedding a culture of openness and practice feeling, aiding compassionate care, and has been counselled as a key tool in recent health care policy. It is conjointly vital for learning, as delineated by Kolb (1984) and has been postulated to develop the therapeutic relationship and expertness by difficult underlying beliefs and assumptions, and absolutely impacts upon resilience.

Price (2004) explains that there are quite a number of reasons that justifies why many health professionals would engage themselves in reflective practice. These reasons include to perceive one's perceptions, motives, values, feelings, and attitude related to the care of the consumer; to offer a modern outlook to pursue things and to counter existing feelings, thoughts and actions; and to dwell on the alternative reflective scenario that could also be approached otherwise. In the nursing sector, there is a rising issue that actions might run the danger of routine practice, therefore degrading patients and their requirements. In victimization reflective practice, nurses are able to set up their actions and consciously monitor the action to make sure it's helpful to their patient.

The act of reflection is seen as the way of promoting the establishment of autonomous, qualified and self-reliant professionals, likewise as a way of developing simpler tending groups. Undertaking reflective practice is related to improved quality of care, stimulating personal and skilled growth and shutting the gap between theory and practice. Medical practitioners can combine reflective practice with checklists (when appropriate) to reduce diagnostic error. This study focuses on Gibbs reflective model as a way of guiding reflection in healthcare.

Gibbs reflective model

Gibbs' Reflective Cycle was set up in order to assist in the provision of structures to learning from previous experiences. This cycle covers half the stages: Description of the expertise, thoughts and feelings regarding the expertise, analysis to create a sense of the case, a summary regarding lessons learned and alternative solutions and action plan for managing similar things within the future, or general changes that would be possibly applicable.

Description

The manager of the Royal London hospital received numerous complaints from the patients and the general public regarding the quality of services offered by the nurses with regard to the untimely attendance by the nurse, laziness and attendance by unprofessional staff. One of the patients categorically noted that the nurse assigned to support him used to visit once in a day and even after reporting the issue still he was provided with any external staff support. Additional complaints were concerning the cleanliness of the wards and the untimely attending to the patients.

The manager initiated an investigation and made some critical discoveries about the state of the hospital and the services offered. On his inspection, the manager discovered that the nurse to patient ration was very low occasioning in nurses experiencing burnouts and inability to attend to all the patients in a timely manner. The poor service delivery was particularly rampant on Fridays, Saturdays and Sundays. This was attributed to the fact that most staff did not show up to work on these days, and that the supervisors were not on duty on those days prompting students on attachment to attend to patients. Additionally, lack of supervision on some days of the week coerced inexperienced students to perform diagnosis which should only be performed by professionals.

It was also discovered that the recent lack of funding made the hospital to cut down the number of support staff in order to reduce the management costs. This further caused deterioration in service delivery since it significantly reduced the number of professionally trained and qualified staff in the facility. The wad co-coordinator found it difficult to balance the staff and resorted to turning down some patients who needed medical attention. In fact, it was noted that patients who were brought in the hospital in the late night had to wait until morning before they could be attended to.

Feelings

Psychosocial care is essential not only to the patients but also to the workers that helps in the provision of that care. According to Sussman and Baldwin (2010),) patients often have important informational and emotional desires that usually remain unmet throughout their medication period. Therefore, emotions and feelings are critical elements of healthcare. Different elements of feelings emerge from the case study. As a manager at Royal London Hospital, I encountered different feelings regarding the nature of the situation.

As a manager, I felt overwhelmed by the situation on discovery of patients receiving low-quality services from incompetent workers due to an inadequate number of professional nurses and staff in the facility. Additionally, patients were not attended to in a timely manner with the ward coordinators resorting to making excuses for denying patients from seeking services in the hospital. Therefore, the combination of low staff, low-quality service delivery and financial constraints place a huge burned on the manager to resolve the situation.

As a manager, I felt distressed by the conditions of the hospital. Having received the information about the untidiness of the hospital, I found it frustrating that the patients were hosted in unclean wards which potentially increased their chances of contracting other infections. Additionally, failure to attend to patients admitted at the hospital past 12 midnight is a critical issue since due to the fact that the condition of the patients may worsen.

As a manager, I felt angry with the state of the quality of services delivered by the nurses. The discovery that nurses absconded duties on Fridays, Saturdays and Sundays further complicated the already serious condition. With the insufficient staff, the manager expected that the remaining nurses would commit themselves to work extra hard and attend to as many patients as possible. The reluctance of nurses to attend to patients who coerced unskilled workers to attend to the patients and make decisions they otherwise wouldn’t be allowed to make compromised health of the patients.

However, as a manager, I scrutinized the situation and sympathized with both the patients and the nurses. The patients were subjected to poor living conditions with poor service delivery and they were not properly cared for. This moved the manager to feel the pain of the patients and empathize with them. On the side of the nurses, the manager understood the fact that they were understaffed and therefore overworked. This often resulted in the laxity and laziness experienced by the nurses. Additionally, the manager empathized with the fact that due to the strained workforce, the nurses were experiencing burnout occasioning from being overworked.

Evaluation

The initial interaction of patients and relatives with the Outpatient Department, Accident and Emergency (Casualty) or even Enquiry Office of the hospital may result in the development of an impression by the patient and family on the level of services offered at the institution. The initial interaction of the patients and their caregivers with the hospital and its staff determines whether the patient will be comfortable at the facility or not. This provides crucial evaluation insights for the manager. Gillespie and Reader (2016) observe that one of the reliable and crucial sources of information in the hospital is the feedback from the patient and their family. This feedback can come before the crisis allowing the management to understand and mitigate against the situation prior to the occurrence of the crisis.

The public complaints enabled the manager to ascertain the state of the hospital and identify key concerns from the patient’s complains and address them. For instance, the information gathered enabled the manager to understand the cleanliness level of the hospital. The poor level of cleanliness poses a high health risk for the emergence of sanitation-related complications that could be harmful to the patients as well as the nurses.

Poor service delivery was another main concern and encapsulated a number of actions from the nurses and students on attachment. As a manager I was empowered to evaluate the situation in relation to the services provided to the patients. For instance, poor service delivery stemmed from lack of sufficient staff, leading to those who were available to be strained by overworking to meet the needs of as many patients as they could. The low nurse to patient ratio was also responsible for the situation.

The issue of absenteeism among the staff on Fridays, Saturdays and Sundays exposed the hospital to further strains leading to poor service delivery since the hospital operations were practically left in the hands of the students on attachment to manage and make diagnostic decisions. The evaluation also revealed that lack of supervision during such days gave total freedom to the staff on duty on such days to make whatever decisions they desired. This is a precursor to errors in decision making and could have implications on the patient’s healthcare should a wrong diagnosis occur.

Analysis

Healthcare is an evolving sector and new complications keep in the emerging day in day out. Hospitals ought to be empowered to manage such complications as they present themselves (Jie-HuiXu, 2017). Such needs include strained workforce, low service delivery, and financial constraints all which require effective leadership and management to manage.

Furthermore, statistics have identified that the influx of patients in health facilities is particularly prevalent during the weekends. These are the days when the hospital ought to have much staff reporting on duty. This crucial information empowered me as the manager to clearly understand the underlying reasons for the situation at the hospital and shed some light on the possible ways of managing the condition.

As a manager I was empowered to critically evaluate the allocation to work schedule of the hospital staff and understand why the level of cleanliness was quite low in the hospital an patient’s wards and why crucial services like lunch were sometimes delayed or served earlier than the recommended time, among another host of issues.

Critical analysis of the absenteeism of the professionally trained nurses on weekends was responsible for delayed attendance to patients admitted in the wards as well as a reluctance to admit patients by ward coordinator.

Conclusion

Allen (2015) explains that exceptional leadership is crucial in changing the ways of working and boosts the performance of the staff and the hospital. As a manager, therefore, I ought to have relied on this premise to bring about change in the hospital.

As a manager I should have exercised transformational leadership adopted in a democratic and non-judgmental manner. In this case, I would have conducted crisis meetings with the staff to understand the situation and develop a strategy to increase staff performance and the quality of service delivery in the hospital.

This would have entailed addressing the main concerns of the staff such as overworking without breaks leading to burnout. The students on attachment would have been encouraged to offer their services within the limitations of their professional requirements and refrain from making decisions that would only be made by professionally trained staff. As a manager aI would embark on streamlining the health services offered in the hospital by clearly defining responsibilities for each staff, and structuring decision making mandates to the relevant coordinators. All these actions would, however, call for quality leadership and effective management.

Action plan

From the case study, it is evident that the manager requires effective leadership to manage the situation and streamline healthcare at the Royal London hospital.

First, it comes out clearly that the manager resorted to building the motivation of the staff in the hospital by addressing the issues of overworking the staff. The structuration of work schedule to allow for regular breaks of nurses while on duty was aimed at reducing the burnouts and the absconding of duties on the weekends by the staff.

The manager also opted to integrate technology to ease the workload of the nurses. The digitization of health services would reduce the workload on the hospital staff boosting their performance and the quality of services offered in the facility.

Third, the manager sought a commitment by the staff at supervisory level to exercise effective management during service delivery and focus on problem-solving other than developing excuses for poor performance. Effective management would provide a paradigm shift in service delivery to patient-centered service delivery model.

Discussion and conclusion

According to Drath et al., (2008) alignment of the objectives and direction are the main tasks of effective leadership, In this case, leaders motivate the staff to work in pursuance of the organization’s vision by staying committed to the mission and aligning the services of the principles and values established by the organization. This creates a common goal for the prosperity of the institution. Commitment by staff is a true reflection of effective leadership. Hospitals with effective leadership and governance clearly demonstrate that the staff is committed to their work and collaboratively work towards the prosperity of the hospital. This can be witnessed through a motivated and dedicated staff providing patient-centered care to all patients. The case study above portrays lack of good leadership among the supervisors. For instance, the absence of supervisors on Fridays, Saturdays and Sundays meant that the staff on those days lacked a focused direction and alignment of duties to the needs of the patients. Absence of leadership gives the staff freedom to make their individual decision, thus, some staff would report to duty and fail to attend to the patients.

Gilmartin and D’Aunno (2007) conducted a systematic study on the focus of transformational leadership in healthcare and they concluded that transformational leadership is crucial in healthcare and can be manifested in a number of ways including a committed hardworking staff, quality health care that is patient-centered and satisfaction among the staff over their work. Comparatively, junior staff reported more peculiar manifestation of these features than senior staff. Transformational leadership therefore, is associated with benefits in healthcare including staff satisfaction, well-balanced balanced workloads to the staff and general applause of the healthcare from the patients and the guardians (Munir et al. 2012). The supervisors of Royal London hospital didn’t exercise transformational leadership evidenced by the presence of all those complaints discussed above. Had transformational leadership been effectively applied, me as the manager would have identified the situation beforehand and managed the situation before it escalated to such an alarming level.

Leadership cooperation is important in healthcare and should not be limited in a specific health facility or department. Professional policy makers and government agencies concur that leadership should be elaborate and multi-departmental in order to allow exchange of knowledge in leadership and effective governance. (Ferlie et al. 2006; Lemieux-Charles et al. 2005; NHS England, 2014). In this regard, therefore, the supervisors in charge at the Royal London hospital would have sought information on managing healthcare concerns from other managers in the neighboring hospitals as well as other staff on the different supervisory level. This collective approach would have resulted in detailed situational analysis and development of effective action plans for addressing the public and patient concerns.

The changing requirements in healthcare favouring increased cooperation among all the key stakeholders have augmented the ambiguity of the traditional presentation of leadership as a summation of three entities; leaders, followers and shared goals (Bennis, 2007). This development increasingly led to the adoption of new leadership orientation that is based on commitment, direction and alignment, the three key elements of effective leadership (Drath et al, 2008). Observing leadership in such positions means that leadership development would not only involve leaders, followers and their shared goals but would also include the production of direction, alignment, and commitment.

In pursuance of leadership development, NHS England (2014) developed a framework to empower doctors, nurses and front-line staff on competent decision-making and collective leadership that upholds the values of equity and appreciation of individual efforts in collectively leading to effective hospital operations. The NHS Leadership Framework reflects the basic assumption that leadership skills and acts of good leadership can sprout from anyone regardless of their position in the hospital. This, therefore, places emphasis on the fact that junior staff could exhibit effective leadership when discharging their duties (Dickinson et al, 2013). The situations of the Royal London hospital opine that effective leadership and management is mandatory for uplifting the hospital from its current state to an empowered institution offering quality healthcare to meet the needs of the patients as well as all the problems and challenges that keep evolving in healthcare. To achieve this, leadership and management are prudent. While there is no single approach that is conclusive, blending transformative and collective leadership is a sure way of enhancing quality service delivery.

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