‘Leadership involves the use of interpersonal skills to influence others to accomplish a specific goal’.

(Sullivan and Garland, 2013)

Strong effective leadership is essential to guarantee patient safety, and for creating and maintaining high quality maternity services. Clinical leaders motivate individuals, act as agents for change, and promote positive nursing outcomes for employees and patients alike. Clinical leadership can help improve efficiency and reduce costs within the services by streamlining clinical decision making and using best practice approaches whilst maintaining high quality care standards (Ahmed et al., 2015). Leadership theories provide important “foundations for practical leadership within organisations”(Sullivan and Garland, 2013) and can help drive change in the workplace. While there are numerous leadership theories to draw on, I feel that the contemporary theories of transactional and transformational leadership are most appropriate to promote this change in my workplace. The goal of the transformational leader is to develop the followers’ commitment to the goal over oneself . The transformational leader inspires, which may encourage their followers to become leaders. In saying this, a transformational leader may be inadequate “in the absence of a transactional understanding of which tasks must be undertaken” (Curtis and Sheerin, 2019). Marquis and Huston (2017) agree with this statement, maintaining that without these traditional management skills the transformational leader will fail. The tansactional leader is focused on the day-to-day tasks and whilst working according to policy and procedure. In summary these leadership theories help to motivate and empower my colleagues to implement my proposed change whilst working within policies, procedures and best practice.

Change Theories

According to the National Medical Director of the NHS, Sir Bruce Keogh KBE;

 “There is a new generation of clinical leaders who are eager to take up leadership opportunities and act as agents for change”.

(Ahmed et al., 2015)

This is sentiment is also echoed by Marshall and Broome (2017). Change is a vital component for an efficient healthcare service. Change is the mechanism through which something becomes different. It is situational. Transition is the psychological. An effective manager must be able to manage both the situation and the people it affects. Without this skill conflict may develop which can affect the whole team, productivity, and care (Sullivan and Garland, 2013). Change may be planned or unplanned, welcome or unwelcome. Unplanned, unwelcome changes are frequently unsuccessful, Kotter and Schlesinger (1979) are quoted as saying;

‘few organizational changes tend to be complete failures, but few tend to be entirely successful either’.

Intentional application of knowledge and skills by a leader to bring about change is seen as planned change. It is well thought out and deliberate and  often arises from the recognition of the need for new ways of decision-making, practice and policies. Some team members will embrace change while others may resist (Lewin, 1951). Strong leaders should be educated in change theories and, be able and willing to, apply these theories appropriately to accomplish change (Marquis and Huston, 2017). Experts believe it’s how change is led which makes the difference in the organisations’ ability to negotiate change (Marshall and Broome, 2017). A change theory or framework is an important instrument for introducing a viable change within an organisation. There are many different change theories to draw on such as Kotter’s (1996) eight steps for organisational transformation (see Appendix 1), Carney’s (2000) change management model (see Appendix 2), Lewin’s (1951) force-field model (see Appendix 3), Lippitt’s (1958) phases of change (see Appendix 4), etc. Many health services also develop their own change frameworks to promote transformational, sustainable change as seen in Appendices 5 and 6 (HSE, 2018; NHS, 2018). For the purpose of this assignment I will draw on Kotter’s eight steps with the additional step of evaluating the process from Carney’s model.

Governance

Clinical governance;

“promotes an integrated approach to quality improvement and attempts to bring all quality activities under one umbrella, melding administrative and clinical elements and providing a framework for clinical accountability”.

(Brennan and Flynn, 2013)

A crucial component of clinical governance is to observe closely and enhance professional performance. This consists of contrasting tasks such as continuous professional development, identifying and managing under-performance, regulation, appraisal, et cetera. Overseeing and developing quality health care is an explicit statutory duty for the Irish healthcare services. Successful healthcare organizations will have put into practice all of the following principles essential to promoting quality of care (Buttell, Hendler and Daly, 2008):

Leadership

Measurement

Reliability

Practitioner skills

The marketplace

An adverse outcome, such as a near miss event (an incident which could have resulted in harm, but did not either by chance or timely intervention (HSE National Incident Management Team, 2017)), provide opportunities to prevent errors through learning. In response to adverse outcomes, such as the Leas Cross scandal (HSE, 2006), The Quality and Patient Safety Directorate and the Health Information and Quality Authority (HIQA), an independent authority, were established to ensure high quality, safe services are designed and delivered to patients and clients. The Health Service Executive (HSE) developed a manual for clinical governance development across the continuity of care, in which they developed and outlined ten principles for good clinical governance to help inform and guide actions (see Appendix 7). The National Quality Improvement Team was also established by the HSE. They have published the “Framework for Improving Quality in Our Health Service (2016)” which is being used as the foundation for their “National Strategic Plan 2019 – 2021”.

Proposed Change

Currently, in my area of practice, we are performing care that is not backed by current evidenced based literature. It is a practice that is only carried out in one ward, in my area of practice. When a woman is a patient of this particular ward, regardless of her risk, before every internal vaginal examination, carried out by a midwife, an examination pack is opened in which sterile gloves, sterile jelly, and 0.05% chlorhexidine gluconate solution are placed. The woman is then given a perineal cleansing using the chlorhexidine solution followed by the required internal vaginal examination. On further investigation, in my area of practice, no current guideline or policy exists for the procedure of carrying out a vaginal examination. We do have a protocol for “Urinary Catheterisation and Management for Maternity Patients”. It suggests that the appropriate cleansing solution is sterile water or saline, however the health professional may asses for the use of chlorhexidine solution in the event of Group B Strep (GBS) or prolonged rupture of membranes (PROM). The policy does however acknowledge that the evidence for the choice of cleansing solution is unresolved.

([Anonymised Hospital], 2018)

“An initiative for quality improvement means leadership in change and change management”

(Marshall and Broome, 2017)

Finding ways of ensuring that clinicians recognise and understand the need for continuous reflection upon the quality of the care provided and learning from practice and mistakes to continually improve the services they are providing

REFERENCE LIST

[Anonymised Hospital] (2018) Protocol for Urinary Catheterisation and Management for Maternity Patients, [Anonymised], Ireland: [Anonymised Hospital].

Ahmed, N., Ahmed, F., Anis, H., Carr, P., Gauher, S. and Rahman, F. (2015) An NHS Leadership Team for the Future, London, United Kingdom.

Brennan, N. M. and Flynn, M. A. (2013) ‘Differentiating clinical governance, clinical management and clinical practice’, Clinical Governance: An International Journal of Nursing Management, 18(2), pp. 114-131.

Burns, J. M. (2003) Transforming Leadership. New York: Grove/ Atlantic, Inc.

Buttell, P., Hendler, R. and Daly, J. (2008) ‘Quality in Healthcare: Concepts and Practice’, in Cohn, K.H. and Hough, D.E. (eds.) The Business of Healthcare United States: Praeger Publishers, pp. 61-94.

Carney, M. (2000) ‘The development of a model to manage change: reflection on a critical incident in a focus group setting. An innovative approach.’, Journal of Nursing Management, 8(5), pp. 265-272.

Curtis, E. A. and Sheerin, F. (2019) Leadership for Intellectual Disability Service: Motivating Change and Improvement. First edn. New York, United States: Routledge/ Productivity Press.

Department of Health (2016) Creating a Better Future Together: National Maternity Strategy 2016-2026, Dublin,Ireland.

HSE (2006) Leas Cross Review Health Service Executive (HSE).

HSE – Human Resources Division – Organisation Development and Design (2018) People’s Needs Defining Change – Health Services Change Guide,. Kells, Co. Meath, Ireland: Health Service Executive.

HSE National Incident Management Team (2017) Safety Incident Management Policy: Health Service Executive (HSE).

Kotter, J. P. (1996) Leading Change. Boston, United States: Harvard Business School Press.

Kotter, J. P. and Schlesinger, L. A. (1979) ‘Choosing strategies for change’, Harvard Business Review, (57), pp. 106-114.

Lewin, K. (1951) Frontiers in Group Dynamics: In Management United States: Houghton Mifflin.

Marquis, B. L. and Huston, C. J. (2017) Leadership Roles and Management Functions in Nursing : Theory and Application. Ninth edn. Philadelphia, United States: Lippincott Williams and Wilkins, p. 712.

Marshall, E. S. and Broome, M. (2017) Transformational Leadership in Nursing, Second Edition : From Expert Clinician to Influential Leader. New York, NY: Springer Publishing Company.

National Quality Improvement Team (2016) Framework for Improving Quality in Our Health Service: Health Service Executive (HSE).

National Quality Improvement Team (2019) Strategic Plan 2019 – 2021: Health Service Executive, (HSE).

NHS England Sustainable Improvement Team (2018) The Change Model Guide, England.

Quality and Patient Safety Directorate (2012) How are we doing in clinical governance development: an assurance check for health service providers: Health Service Executive (HSE).

Sullivan, E. J. and Garland, G. (2013) Practical Leadership and Management in Healthcare For Nurses and Allied Health Professionals. Second edn. Harlow, United Kingdom: Pearson Education, p. 321.

APPENDICES

Appendix 1:

Kotter’s (1996) Eight Stage Process for organizational transformation can be summarised as follows:

Establishing a sense of urgency

Creating the guiding coalition

Develop a vision and strategy

Communicating the change vision

Empowering broad-based change

Generating short-term wins

Consolidating gains and producing more change

Anchoring new approaches in the culture

Appendix 2:

Carney’s (2000) Change Management Model:

Appendix 3:

Lewin’s (1951) Force-Field Model:

Appendix 4:

Lippitt’s (1958) Phases of Change theory:

Diagnose the problem

Assess the change agent’s motivation and resources

Assess the change agent’s motivations and resources

Select progressive change objects

Choose a change agent role

Maintain the change

Terminate the helping relationships

(Sullivan and Garland, 2013)

Appendix 5:

HSE Change Framework (2018)

Appendix 6:

NHS Change Model (NHS England Sustainable Improvement Team, 2018):

Appendix 7:

Principles for Clinical Governance development: (2012)

Appendix 8: