Change management in the health care setting is complex; it involves continuous improvement of standards of practice and culturally sensitive care while implementing new technologies to address public health issues such as mental health, Indigenous peoples’ health, addiction, and an aging population (Romanow, 2002; Truth and Reconciliation Commission of Canada, 2015). Grossman and Valiga (2012) describe the climate of healthcare as an “environment of constant and unprecedented change.” A leader in such a dynamic environment must use clear communication to bring a team together and help them achieve a goal in a coordinated effort (Callaghan, 2007). Healthcare staff consider their work climate to be positive when management is coherent, integrated, and supportive (West et al., 2011). This perceived supportive work climate has been consistently associated with lower levels of patient mortality across all sectors of healthcare; including primary care, acute care, ambulance, and mental health (West et al., 2011).
Interestingly, hospitals with a “clan culture” are rated more highly by patients in terms or respect and dignity; however, organizations with this type of culture tend to perform poorly on regulatory agency ratings (West et al., 2015; Meterko et al., 2004). A study of 8454 employees across 125 US hospitals found a positive association between clan culture and inpatient satisfaction (Meterko et al., 2004). Clan culture emphasizes loyalty, participation, cohesiveness, tradition, and morale (Meterko et al., 2004). On the contrary, hospitals that demonstrated a hierarchical culture (focusing on bureaucracy, regulation, and hierarchy) were negatively associated with inpatient satisfaction ratings (Meterko et al., 2004). Furthermore, a hierarchical culture that stresses the importance of rules, policies, and control, can inhibit a positive climate for safety due to fear of backlash for reporting safety issues (Hartmann et al., 2009). An advantage of transformational leadership is it creates a climate that has openness about errors and values staff well-being (Munir et al., 2012; Apekey et al., 2011). Therefore, one way to ensure patient care excellence is to improve the workplace environment for staff, which can be measured by a climate score (West et al., 2011). In England, climate scores for 150,000 hospital employees were associated with significant benefits for staff, patients, and the organization (West et al., 2011).
Benefits of Positive Climate Scores in Healthcare (West et al., 2011) :
1) Decreased patient mortality 2) Increased patient satisfaction 3) Decreased staff absenteeism 4) Increased staff satisfaction 5) Decreased staff turnover 6) Increased financial performance 7) Increased quality of patient care
An international comparison of nearly 1000,000 nurses across 1496 hospitals in 9 countries examined the relationship between work environment variables and patient care (Aiken et al., 2011). Environments that had high scores in terms of nurse participation in decision making, manager ability, and nurse-physician relationship had a strong positive association with perceived quality of care (Aiken et al., 2011). In the UK, the culture type of 189 hospitals was examined (Davies et al., 2007). Again, the results were favourable for those that had a clan culture (as seen in 54% of hospitals) with fewer patient complaints and higher staff morale (Davies et al., 2007). Video 1 provides interesting food for thought.
Video 1. Broken Cultures in Health Care (Sinek, 2019).
Improving services and setting direction are domains that are greatly impacted by public policy, resources, funding, and organizational leadership as a whole. Political forces and external agendas greatly impact professional planning (Antrobus & Kitson, 1999). Antrobus and Kitson (1999) state “The ideology and language used by nurses differs from that used in policy and by policy-makers.” They describe how this creates a policy-practice divide and forces nurse leaders to interpret and communicate these ideological and policy concerns (Antrobus & Kitson, 1999).
In the healthcare industry, transformational leadership is the most prominent style utilized (Scully, 2015); however, an increasingly popular style known as connective leadership is seen as more appropriate in certain situations due to the nature of the interdisciplinary teams (Sahoo & Das, 2012). Any healthcare worker can demonstrate leadership skills; a position of authority is not necessary to be a leader and they are not confined by their perceived rank within the larger system (Grossman & Valiga, 2012).
The connective leadership style asserts that leadership should be shared or distributed amongst team members (Sahoo & Das, 2012):
"Connective leaders can perceive common ground and possibilities where some more traditional leaders see division and difference.”
A culture that distributes responsibility and shares leadership is situationally dependent on who has the expertise at each moment (West et al., 2015). West et al. (2015) refer to an "ebb and flow of power" that is based on collective achievement as opposed to individual leadership from a dedicated position in a formal hierarchy. High staff engagement in the decision-making process and widely distributed leadership predicts team effectiveness across all healthcare sectors (West et al., 2015). The concept of sharing leadership is especially relevant as co-morbidity becomes more common and healthcare workers with various professional backgrounds are needed to achieve optimal patient care (West, 2012). This collaborative approach is used in modern practice throughout the healthcare system (Scully, 2015). Therefore, connective leadership is a welcomed paradigm shift in an interdependent setting (Scully, 2015).
References: Aiken, L.H., Sloane, D.M., Clarke, S., Poghosyan, L., Cho, E., You, L., Finlayson, M., Kanai-Park, M. & Aungsuroch, Y. (2011). Importance of work environments on hospital outcomes in nine countries. International Journal for Quality in Health Care, 1-8.
Antrobus, S. & Kitson, A. (1999). Nursing leadership: Influencing and shaping health policy and nursing practice. Journal of Advanced Nursing, 29(3), 746-753. Apekey, T.A., McSorley, G., Tilling, M. & Siriwardena, A.N. (2011). Room for improvement? Leadership, innovation culture and uptake of quality improvement methods in general practice. Journal of Evaluation in Clinical Practice, 17(2), 311-318. Callaghan, L. (2007). Advanced nursing practice: An idea whose time has come. Journal of Clinical Nursing, 17(2), 205-213.
Davies, H.T.O., Mannion, R., Jacobs, R., Powell, A.E. & Marshall, M.N. (2007) Exploring the relationship between senior management team culture and hospital performance. Medical Care Research and Review, 64(1):46-65. Grossman, S. & Valiga, T. (2012). The new leadership challenge: Creating the future of nursing (4th ed.). FA Davis Company. Hartmann, C.W., Meterko, M., Rosen, A.K., Zhao, S., Shokeen, P., Singer, S. & Gaba, D.M. (2009). Relationship of hospital organizational culture to patient safety climate in the Veterans Health Administration. Medical Care Research and Review, 66(3), 320-338. Meterko, M., Mohr, D. & Young, G. (2004). Teamwork culture and patient satisfaction in hospitals. Medical Care, 42(5), 492-498. Munir, F., Nielsen, K., Garde, H., Albertsen, K. & Carneiro, G. (2012). Mediating the effects of work- life conflict between transformational leadership and health-care workers’ job satisfaction and psychological wellbeing. Journal of Nursing Management, 20(4), 512. Romanow, R.J. (2002, November). Building on values: The future of health care in Canada. The Romanow Report. Ottawa, ON. Retrieved September 13, 2021 from https://publications.gc.ca/collections/Collection/CP32-85-2002E.pdf Sahoo, C. & Das, S. (2012). Women entrepreneurship and connective leadership: Achieving success. European Journal of Business Management, 4(3), 115-122. Scully, N.J. (2015). Leadership in nursing: The importance of recognising inherent values and attributes to secure a positive future for the profession. Collegian, 22: 439-444. Sinek, S. [Simon Sinek]. (2019, March 4). Broken cultures in health care [Video]. YouTube. https://www.youtube.com/watch?v=d0PuJ-_19Rw Truth and Reconciliation Commission of Canada (2015). Truth and reconciliation commission of Canada: Calls to action. Retrieved September 13, 2021 from http://www.trc.ca/websites/trcinstitution/File/2015/Findings/Calls_to_Action_English2.pdf West, M.A., Armit, K., Loewenthal, L., Eckert, R., West, T. and Lee, A. (2015). Leadership and leadership development in healthcare: The evidence base. London, Faculty of Medical Leadership and Management.
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