Clinical Leadership Within the Context of Improving Safe and Person-Centred Care
Summary
As the demand for clinical care continues to increase, healthcare organization throughout the world are struggling with financial and other forms of limitation. Hence, different models of care have been adopted to ensure that, despite the underlying limitation, quality, effective and safe care is provided to those in need. Such models include the person centred care model. The need for further changes has even become more apparent. Hence, the need for leadership styles that can drive change amidst of existing complexities.
The role of Advanced Nurse Practitioners has emerged over the years for a number of reasons. One major issues are that traditional managerial roles do not meet the needs of nurses as care givers and patients as care providers. Adoption of visionary and heroic leadership models have not proved effectiveness in the healthcare sector. Advanced Nurse Practitioner includes both clinical care leadership and organizational management leadership. The adoption of Advance Nurse Practitioners leadership is yet to be fully realized.
ANPs face a number of barriers and challenges in their provision for both care and leadership. This include the lack of authority with the current structuring of the healthcare sector. ANPs also explicitly lack the skills and resource to provide organizational leadership. Such barriers result from policy implications. With the acknowledgement of the role of ANPs, a number of policies have been adopted to enhance their leadership roles. They include provision of doctoral program, adoption of the scope of practice and function and the urge to meet their skill needs through active engagement in policy formulation.
Clinical Leadership within the Context of Improving Safe Effective and Person-Centred Care
Introduction
Throughout the world, contemporary hospital care has continued to struggle with numerous challenges amidst of rising demand, changing consumer expectation and then need to ensure patient-centred care. Clinical leadership has become apparent in the provision of quality and safe care. Healthcare systems have continued to change. While some progress and change have been achieved so far, many experts expound on the need for further changes in the healthcare system in order for more people and more individuals to access quality and affordable care into the future. While the need for change into the near future has become apparent in the healthcare system, many point out to certain aspect that should be fulfilled to experience an effective change in the healthcare system. One of the things that is highly required in the healthcare transformation is leadership (Daly et al. 2014 p.75). Many stakeholders in the healthcare sector agree that leadership must be experienced from the doctors and other clinicians, in their informal or informal capacities. While the definition of leadership in the clinical setting, as well as its function, may be disputed, its relevance cannot be downplayed. Hence leadership in the clinical setting has been studied and practised alongside other aspects like patient-centred care, provision of safe and quality care and the role of different forms of clinicians towards clinical leadership.
The Case for Clinical Leadership
The urge for leadership in the clinical context has not always been existent. However, nurses and other clinician have continued to offer leadership and managerial service. The need for more engagement into leadership has, however, been fuelled by a number of developments in a few decades ago. In the last few decades, healthcare systems globally have been subject of regulation and accountability that are aimed at driving change and exercising control over clinical activities. Despite the increase in regulation and control, there has been explicit imbalances between clinical power and financial power. Anderson (2018 p.14) writes that, clinical power entails the authority and mandate that is held by clinicians in decision making. On the other hand, the financial power entails the power of the government has the sole provider of public health, hence mandated with the provision of resources that are required in the clinical setting.
The influence of the financial power over the clinical power has seen to be ineffective. Top-down approaches to management have since been ignored, for a number of reasons. Doctors and other caregivers occupy a special position in relation to the care receivers and the general public. Hence, they always tend to have an important position to play in the implementation of policies and other changes that have rather been developed by non-experts in the clinical setting. However, over the years, the role of doctors and clinicians in policy implementation has been incremental. In that, nurse and other experts are now seen as important in the coordination of care that is system-wide and focused on the needs and expectations of the care receivers.
Due to the economic burden of care, there has been an absolute need to engage caregivers. Indeed, the provision of healthcare has become expensive, and the need to improve the quality of care is challenged with the provision of limited resources. Caregivers have shown the capability to provide work with limited resource through patient advocacy. Hence, patients have shown the desire to engage clinicians in the rationalisation and allocation of resources. As opposed to the traditional approaches of managers, doctors, and other caregivers today have been provided with an incentive to directly engage in leadership. Hence, clinical leadership has become an important and integral part of the nursing practice.
Defining Clinical Leadership
The definition and description of clinical leadership is vital in determining who can be a leader and what is expected of a leader. The study area of clinical leadership is rather young. However, substantial work has been compiled in the exploration of clinical leadership and yet numerous definitional issues on clinical leadership. McGuirre et al. (2016 p.367) highlights that, within the clinical context, it is widely accepted that anyone can become a leader and that clinical leadership is not a domain that can only be assigned to a particular group of persons. Hence, the definition of leadership or its description is not tied to particular clinical specialities, but rather anyone that can offer service in the healthcare system can also provide leadership.
Just like leadership, the concept of clinical leadership can be described in varying ways. Hence, there is no standard definition of leadership. Literature review on clinical leadership tend to focus on what may be the difference between effective clinical leadership and ineffective clinical leadership, relative to offering optimal care and overcoming care barriers in the clinical environment. Lamb, et al. (2018) explored some of the forms of ineffective leadership through secondary research. Three forms of ineffective leadership were identified. They include the placating avoidance, in which a leader shows concerns but fails to act; equivocal avoidance, in which leader are docile in response and hostile avoidance; where the leaders tend to become hostile towards the subject. Ineffective leadership and leadership failures have long been recorded and documented in the National Health Services. Important lessons have been drawn from these experiences, and the means of achieving effective leadership have been further advanced.
The Role of Leadership in Contemporary Healthcare
Contemporary healthcare is built around hospitals. In Scotland, hospital and other care facilities have continued to experience increased strain and scrutiny. Anderson (2017 .31) notes that increased demand and fiscal requirement have continued to press hospital. As opposed to the near past when the hospital was viewed as lifesavers, today, hospitals are viewed as potential sources of harm. Hence, hospitals have been required to increase their accountability, scrutiny and visibility relative to care. The increased scrutiny has led to an enhanced emphasis on the role of the health professional, which include nurses in developing, monitoring and evaluating better strategies in providing care like the use of evidence-based practice and the advancement of person-centred care as the primary model of providing care in the hospital setting.
In the contemporary healthcare sector, the roles and responsibilities that are place on leaders have become more and more complex; hence the need for different forms of leadership has become an apparent urgency. To ensure that cost efficiency is achieved, and to improve productivity, immense changes in the reorganisation of leadership style has been experiencing. Joseph & Huber (2015 p.56) notes that, coupled with financial related goals is a growing attention towards improving safety and quality. Hence some of the common assumption of leadership have been ignored as they are not well suited in delivering the changes expected in point of care. Accordingly, there have been calls for a transition into a new approach of hospital leadership hence a major transformational shift in the conceptualisation of leadership. This shift has been in part in response to the growing recognition that having designated leaders that assume a position of leaders is limiting in capacity in meeting the fundamental feature of clinical practice and ensuring that demand-driven change in enacted.
Some of the issues that have led to shifts in leadership approaches include overwhelming evidence that nurses and other clinicians may experience dissatisfaction within their working environments (Shariff, 2014 p.10). Hence, issues like emotional exhaustion and burnout have continuously emerged, with the conceptualisation of work experience affecting the quality of care that clinicians may offer to their clients. Hospitals, just like any other workplace are filled with complex socio-political issues that may undermine the process of engagement and leadership among clinicians with power dynamics, disciplinary issues and competing discourses within and organisation coming into play. The strained relationship between the administration and clinical practices are well evidenced in the NHS. Hence, over the last few decades, different forms and layers of leadership have been developed to overcome such disparities, with consensus towards the need to enact leadership that will meet the needs and expectations of clinicians rather than meeting the traditional managerial function. These include the advancement of leadership within the area of Advanced Nurse Practitioners.
Advanced Nurse Practitioners
The role of the Advanced Nurse Practitioner has been in existence, as early as the 1960s in the United States. In the United Kingdom, the need to create a clear career progression led to the development of the ANP. To this day, the function and role of the ANP, hence its definition varies from one country to another. In Scotland, the 2015 report of Pulling Together; Transforming Urgent Care for the People of Scotland highlighted the need to adopt a consistent definition of ANPs relative to the description of their roles, competencies, education needs and compensation (Scottish School of Primary Care, 2019). Hence ANPs were defined as highly experienced, educated registered nurses who are engaged in the management of complete clinical care of patients and not focusing on any sole factor. ANPs are additionally defined by the advanced –level-capability in four major domains; clinical practice facilitating learning leadership and evidence, research and development. On qualification, ANDs are expected to have attained education ins Master Degree Level or a minimum of Postgraduate Diploma; aligned to the level seven of the NHS career framework and agenda for change band; be non-medical prescribers and demonstrate competence in their level of practice following assessment.
Advance Nurse Practitioners and Clinical Leadership
Leadership Styles in the Scotland NHS
Before the advent of advanced nurse practitioner, a number of leadership styles have shown to the prevalent in the NHS. Joseph & Huber (2015 p.59) notes that these forms of leadership are rigid and not meet the dynamic needs of the healthcare today. One such kind of leadership is the heroic leadership. Transactional leadership is the most heroic form of leadership. It is a leadership style in which the leader leads without forming any form of leadership and expected others to follow. Transactional leadership has been criticised for a number of issues, especially when applied in the clinical setting. One is that it fails to take into consideration the role of culture. Secondly, this form of leadership is more poised towards attaining results hence more of managerial rather than leadership.
Visionary leadership styles have also been adopted in the NHS for so long. Transformational leadership is one style of leadership that is based on vision. Transformational leadership is described as a partnership between the leader and the subjects towards attaining an intended change. Transformational leadership is based on evidence-based practice theory that is used as a strategy and deployed as a style for realising change within the complexity of care and the use of interdisciplinary teams. The relational nature of transformational leadership style has been deemed a vital management practice for clinical leadership education and development.
The healthcare context is always complex, and thus, certain leadership styles may not serve the intended purpose of patient-centred care. Hence a number of other strategies have been used to complement leadership approaches in the provision of safe and effective care. One such approach is the multi-disciplinary or inter-professional working (RCN, 2012). This entails persons from different backgrounds like nurses, physicians and doctors working together in a manner that brings about collaboration. This style has, however, been challenged, since different professional tend to manifest values that are within their profession as opposed to working in a collaborative manner. On the other hand, inter-professional approaches have been deemed vital in environments that require the input of various discipline. Multi-professional teamwork has been deemed as a means towards rendering teams more effective and meeting the care need of individual and communities within a single framework. When applied within the concept of community care, multi-disciplinary approaches have shown exemplary success.
Frontline leadership is another form of leadership that has been adopted in the Scotland NHS to resolve a number of issues (RCN, 2012). There are a number of issues that promoted the adoption of the frontline leadership style. One was to ensure that competencies and skills of frontline nurse and midwives are supported to assume a central role in the promotion of healthcare. Another important aspect was to identify the potential and benefits for nurses and midwives. A report filed by the Frontline Care Commission Report outlined that the public was not aware of the role of the ANP, especially those that had not received any care before. The public perception of the nurse as just caregivers had been shown to undermine their role as leaders, a major barrier facing ANP nurses.
Policy Issues Relating to Barriers and Facilitators of Leadership
Barriers
The role of the ANP has always remained controversial, in most times leaving them exposed to the criticism of their actual roles. Existing policies have contributed towards the role and function of the ANP has a leader. The ANP is viewed to offer sets of function; patient-centred leadership and organisational leader. As to the earlier, ANP role has been developed around the role of a clinical practitioner. The ANPs attachment to their nursing identity has indeed become a major barrier. For instance, when working in a multi-disciplinary team, their leadership competencies are often overlooked (Cardiff, et al., 2018 p.20). Due to the nature of their professional focusing on clinical care, ANPs are often assumed to lack competence in managerial aspects that are integral to leadership like finance and healthcare policy.
Existing policies surrounding the hierarchy of power between ANP nurse and doctors have resulted in collaborative issues, hence undermining their function as leaders. A follower can only be supportive of the course of the leader if he or she is subordinate. In those cases, rather than serving as subordinates to ANPs, doctors are more likely to look down on the ANPs as mere clinician. Such hierarchical issues remain unresolved even as the NHS seeks to mainstream the leadership function of ANPs. Studies have shown that doctors will tend to achieve full authority while ANPs are struggling to remain relevant to the hybrid roles.
Facilitators
The Scottish government, just like other government, have sought to resolve some of the issues that are surrounding the role of ANP as leaders. Hence, some policy changes have been realised. These include the adoption of the ANP definition that recognises leadership as their function and an area that they ought to achieve competence prior to placement. The defined scope is also in line with the level of education and skills that nurse leaders are accorded (Scottish School of Primary Care, 2019). Nurse leader have been prepared to take charge in multi-disciplinary and multi-professional team function. Equally, they have been actively involved in developing strategies and policies for health care. The current educational provisions of ANPs have been developed to reflect the complex leadership needs (Shariff, 2014 p.14). The development of the doctoral program for nurse leaders is one of the attempts to ensure that they are well equipped and prepared in the leadership and mange of organisation as a business within the practice of healthcare.
Most importantly, the current policies have sought to challenge the gender association attached with the nursing practice and thus the ANP program. The female gender is largely perceived to occupy junior roles while the male gender assumes leadership roles. NHS Scotland has created frameworks that outline leadership requirements that nurse leaders should fulfil. Additionally, fulfilment of leadership resource needs relative to the patient-centred care approach has been deemed vital in promoting the function of ANPs in their leadership and clinical role.
Conclusion
Due to the ongoing changes in the clinical setting, the need for clinical leadership has become an integral part to provision of care. The literature review shows the ongoing changes, issues, challenges and opportunities facing ANP nurse leaders. ANP nurse leadership has been aimed at bridging leadership gaps that have been existing healthcare. Despite the advancement of the specialised role of ANPs, their leadership function is still not well fitted. ANPs ought to function as both clinical nurse and leaders. The increases scope of work also dawns with complexities. In the Scotland NHS, the role of nurse leaders is unclearly defined. Hence, they may be overlooked by other professionals like doctors. This undermines approaches like multi-disciplinary practices that should promote patient-centeredness. Largely this and several other barriers have been identified and policies changes have been enacted to promote the function of leadership. They include the development of a clear educational need-based curriculum for ANPs. ANP is also able to pursue further studies, including a doctoral program, which can prepare them for organisational leadership functions.
Anderson, C., 2017. Leadership experiences of London-based Advanced Nurse Practitioners: A Case Study, s.l.: University College London.
Anderson, C., 2018. Exploring the role of advanced nurse practitioners in leadership. Nursing Standards, 33(2), pp. 29-33.
Cardiff, McCormack & McCance, 2018. Person-centred leadership: A relational approach to leadership derived through action research. Journal of Clinical Nursing, 1(2), pp. 15-26.
Daly et al., 2014. The importance of clinical leadership in the hospital setting. Journal of Healthcare and Leadership, 1(3), pp. 75-83.
Joseph, L. & Huber, D. L., 2015. Clinical leadership development and education for nurses: prospects and opportunities. Journal of Healthcare Leadership, p. 55–64.
Lamb, A., Martin‐Misener, R., Bryant‐Lukosius, D. & Latimer, M., 2018. Describing the leadership capabilities of advanced practice nurses using a qualitative descriptive study. NursingOpen, 1(4), pp. 1-9.
McGuire, Russel & Matthews, 2016. Facilitators and barriers to the increased supervisory role of senior charge nurses: a qualitative study. Journal of Nursing Management, 2(4), p. 366–375.
RCN, 2012. Frontline First; Congress 2012 Update, s.l.: Royal College of Nursing.
Scottish School of Primary Care, 2019. Advanced Nurse Practitioner Case Study, s.l.: Scottish School of Primary Care.
Shariff, N., 2014. Factors that act as facilitators and barriers to nurse leaders’ participation in health policy development. BMC Nursing, 1(2), pp. 1-20.
