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- Kunle Emmanuel
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For many years there has been an emphasis on developing nurses as leaders, culminating in the launch of the Leadership Framework and the NHS Leadership Academy in 2012.
The NHS Institute for Innovation and Improvement (NHSI) acknowledges that an unprecedented level of responsibility is being devolved to frontline staff, and identifies the Leadership Framework as a significant resource to ensure that the whole workforce has the leadership knowledge, skills and behaviours needed to improve health and care (Sheikh, 2012). At the launch of the Leadership Framework in 2011, the health secretary said: “Effective and successful leadership from all staff is crucial to the delivery of high-quality healthcare to counter the challenges we face” (NHSI, 2011).
Leadership has been identified as the panacea for ills facing the NHS, but what is the role of management? Day-to-day management of services, resources and staff is the bread and butter of healthcare workers, but this is rarely acknowledged, even by staff. Management skills are valued less than leadership and clinical skills, yet the NHS would come to a halt without them.
The King’s Fund report The Future of Leadership and Management in the NHS (2011) supports this view, suggesting that excellence is needed in both management and leadership, and that “politicians in particular need to recognise that leadership in the NHS can only be as effective as the environment in which it is allowed to operate”.
The report’s authors stress that the NHS will only be able to meet the significant challenges ahead if the contribution of managers is recognised and valued; they say this includes all clinically qualified staff, at every level, who are involved in management. The report warns that viewing such managers as bureaucrats, concerned only with administrative form-filling, is insulting and can lower staff morale and inhibit the engagement of clinicians with management roles. Good management is as vital to care as the hands that deliver it, and the King’s Fund (2011) is clear that high-quality health services do not happen without skilled management.
Management and leadership links
While there is undoubtedly a distinction between management and leadership, Covey (2004) suggests they are closely linked, explaining that effective management and leadership both require putting first things first. Leadership decides what the “first things” are, but it is management that puts them first, day by day, moment by moment. Management is the discipline that carries things out (Covey, 2004).
The King’s Fund report (2011) concurs, defining leadership as the art of motivating people toward a common goal or vision, and management as getting the job done. It identifies a correlation between high-quality management and leadership and outcomes such as higher-quality care, better productivity, higher clinical governance scores and fewer patient complaints.
Although the two are closely linked, they are not the same. If we have only leaders, we will have no followers; if there is a vision, we need people to organise and plan how to reach it. Leaders rise out of the need to improve a situation or attain a goal but, once this has been done, managers take over the day-to-day functions required to sustain improvements. In an ideal world, leaders would be good managers, and managers would be effective leaders, but this is not an ideal world.
Who leads and who manages?
Simply giving someone the title of leader or manager does not make them proficient in that role, and the titles themselves may be misleading. A nursing team leader is effectively a manager, with little of the power or authority that goes with a leadership role, whereas a ward manager is expected to be a leader, motivating and being a role model to their staff through organisational change. Given the importance of good management in creating a healthy work environment, it is crucial that the differences and challenges of these roles are acknowledged to create more realistic expectations of those who hold them (Baker et al, 2012).
Giving titles may also be unhelpful as may divert responsibility for management and leadership functions away from the rest of the team. The Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust (Francis, 2010) repeatedly identifies a lack of leadership as significantly contributing to the poor care rife in some of the wards, but primarily aims criticism at those leading from the top. Turnbull James (2011), however, recommends a move towards a less formal and more collaborative model, where leadership is exercised across shifts 24 hours a day. This model could be extended to management practices, as Baker et al (2012) point out that every member of a healthcare team has some management and reporting functions as part of their job.
Turnbull James (2011) highlights the danger in ignoring this individual responsibility, suggesting good practice can be destroyed by one person who does not see they can exercise leadership, or who leaves something undone or unsaid because someone else is supposed to be in charge.
The Mid Staffordshire inquiry (Francis, 2010) seems to support this view; it is critical of a hospital culture in which staff separated themselves from management, and identifies a high degree of confusion among staff at all levels as to who was responsible for nursing care. It appeared that no one took charge and neither did individuals take responsibility for managing their own practice. This led to a general acceptance of poor care and behaviour, with systems designed to improve performance, such as audit, appraisal and professional development, given a low priority.
Preparing nurses for management
Although performance management falls within the remit of managers, Baker et al (2012) found a lack of training in this. They also said that new nurse managers, promoted from direct care roles, are often not given formal training for their new role but expected to hit the ground running. The same could be said of newly registered nurses and newly appointed nursing staff. Clinical aspects are usually addressed but management needs are rarely identified or seen as a priority (Baker et al, 2012).
It is assumed people will gain these skills on the job - but they need good role models. It could be argued that, if learning on the job was effective, we would have a more competent and confident workforce.
A framework for developing managers
So, where is the framework for developing effective managers? There is an argument for considering this for all staff, as all roles require organisational skills such as communication, planning, prioritisation and documentation. For designated nurse managers, staff allocation and human resource issues seem to occupy a large portion of their time (Baker et al, 2012). This includes administration such as organising the off-duty rota and skill mix, as well as staff recruitment and induction. Performance management linked to appraisal and dealing with poor performance is a key responsibility, alongside clinical supervision and staff development. However, these often take a back seat to clinical demands, as they are generally seen as lower priority when a service is short staffed.
Clinical governance is often seen as management responsibilities, but this is to misunderstand the term. All staff are required to ensure patients receive high-quality care. They do this through professional and contractual obligations to:
Adhere to organisational policies and best practice;
Attend statutory, mandatory and professional training;
Participate in risk assessment and risk management, ensuring compliance with regulatory standards;
Identify and report where these are not happening.
This list confirms the complexity and variety of management responsibilities and skills needed in different roles.
A management framework that mirrors the Leadership Framework (NHS Leadership Academy, 2013) could be invaluable in enabling all staff to attain the management behaviour required to deliver good care. Some of it could be adapted from the Leadership Framework, specifically the section on managing services. However, work is needed to draw up a management framework equivalent to the one for leaders.
Management skills should be considered a priority if we are to avoid a repeat of the standards of care and behaviour that led to the Mid Staffordshire inquiry. Unfortunately, this is unlikely unless management skills are seen as valuable and needed by everyone, rather than add-ons for those who desert clinical care for an easy life behind a desk. A good start would be for the government and NHS to start promoting them with enthusiasm, giving them the same priority and profile as their leadership cousin.
Source: http://www.nursingtimes.net/home/clinic ... 80.article
Baker S et al (2012) What do you do? Perceptions of nurse manager responsibilities. Nursing Management; 43:12, 24-29.
Covey S (2004) 7 Habits of Highly Effective People. Free Press: New York.
Francis R (2010) Independent Inquiry Into Care Provided by Mid Staffordshire NHS Foundation Trust, January 2005 - March 2009.
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