Student cohort: September 2018

Module code and name: NS 622 Leadership and Collaborative Inter-professional

Practice

Word count: 2,805

Submission Date: Tuesday 26th January 2021

Seminar leader: Michael Farquharson

Module leader: Michael Farquharson

The importance of leadership in a healthcare setting is generally understood to be a
vital component in providing effective care, and nursing leadership in particular is a
crucial element as nurses currently constitute the single largest healthcare discipline
(Swearingen, 2009). However, the importance of effective collaborative working has
also been recognised, as laid out by the findings of both the Victoria Climbié
(Laming, 2003) and Bristol and Alder Hey (DoH, 2001) cases. In both cases failure of
members of different teams to collaborate effectively had disastrous and tragic
outcomes for the service users affected. This essay will consider the importance and
value of effective leadership and interprofessional working, different leadership
styles, considering the positive and negative aspects of each, and how they relate to
the case study concerned. It will also consider the role of self while engaging with
other members of the multidisciplinary team, as well as service users, families and
other stakeholders in the provision of care. This essay will also incorporate elements
from a case study from hospital practice to demonstrate the aspects of leadership
and collaborative working covered within. Any personal identifiable information will
be removed in keeping with the principles of confidentiality.

The case study encountered in practice was of a Parkinson’s patient transferred

between wards in a completely unresponsive state. The Sister in charge of the bay
was observed to take control of the situation, directing tasks towards other members
of the team present, accepting relevant suggestions to assess the patient's condition,
as well as escalate the issue to other members of the multidisciplinary team,
including pharmacy, RESUS team and on-call doctor in order to determine the cause
of the patient’s current clinical state and to resolve the cause of the issue.

The terms “leadership” and “management” are often conflated with each other.
Management is typically seen as more focused on tasks and delivery of results
(Ryan, 2016), whereas leadership is considered to be more based on providing
guidance and being based in “vision, ideas, direction, and inspiration (Ayeleke et al,
2017). While the two roles are somewhat different and have separate theories
regarding their practice and influences, increasingly, particularly in a healthcare
setting, there is significant overlap between the two. This is particularly demonstrated
by the tendency in recent years for senior clinicians to move into management roles
within care organisations (Ayekele et al, 2017). This is particularly important in the
healthcare setting as the quality of care provided, the core function of healthcare
professionals, is deeply influenced by how staff are treated and how they regard their
working environment (Kline, 2019).

Leadership is often defined in a literal way, as the “position, capacity or ability to

lead, guide or direct” (Cummings, 2014). However, Swearingen (2009) suggests that
current educational programmes for nurses do not adequately prepare new nurses to
take on a leadership role. This is a role that nurse are required to step into,
practically from the first day as they are required to take on responsibility for the care
of multiple patients and other duties on a ward as called upon to do so (Cummings,
2014). As such the development of leadership skills is essential to providing
effective patient-centred care and delivering the best outcomes for the patient (King’s
Fund, 2015). Unfortunately, according to Kline for the British Medical Journal (2019)
some 24% of NHS staff have reported “bullying, harassment or abuse by fellow
workers and managers”, which undoubtedly has a detrimental effect on staff morale,
retention and, ultimately, has a negative impact on patient care, to say nothing of
costing the NHS budget some £2.28 billion annually (Kline, 2019)

Collaborative leadership provides a means to address some of those issues that

arise from poor leadership. Collaborative leadership envisions a form of leadership
that is less focused on an individual issuing direction from above, to a more
distributed “democratic and participatory” (Lawrence, 2017) system that includes
different skill-sets and attitudes in order to achieve the desired outcome. Lister,
writing for the World Health Organisation (hereafter, WHO) recognises that
leadership, particularly in healthcare, is based more in building relationships, rather
than being based on the efforts of an individual (Lister, 2007). In the case study
cited, this approach can be seen, as while the Sister in charge took control of the
initial situation as it arose, she handed the decision making regarding further
examinations that would be required to clarify the patient’s condition over to the
medics who attended. The value of this is particularly demonstrated by the
involvement of pharmacy staff in the process, as this allowed the patient’s
medication to switched to a transdermal patch, in order for them to be able to receive
the dosage they required to manage their Parkinson’s symptoms. One of the issues
with collaborative leadership however, is that taking the time to take on different
opinions and perspectives, can result in decision making being slowed (Brearly,
2017), which is obviously not and ideal outcome in an emergency situation, when
time is of the essence. Another potential issue is that there exists the possibility that
as all participants have an equal voice, then the risk is that the role of leader can
become eroded and effective decision-making diminished (Brearly, 2017).

Autocratic, or authoritarian leadership is another style of leadership that can be

applied across a broad range of industries and situations. It is characterised by the
concentration of power and centralisation of decision making in a single, central
figure, from whom authority and directives proceed (De Hoog et al, 2015). It is
primarily associated with military or political figures, such as Stalin or Julius Caesar,
but its uncompromising nature and immediacy of action has use. These qualities are
of most use in settings where extremely rapid decision making is essential to resolve
literal life-or-death situations, in hospitals and emergency care in particular (St.
Thomas University, 2018). The value of this can be seen in the case study provided;
the Sister in charge gave immediate instructions, fully expecting the tasks that were
issued to be carried out immediately and without question. Given the severity of the
emergency that arose, this is the type of response necessary to affect a positive
outcome for the patient. Autocratic leadership is known to have its issues, and has in
many ways fallen from favour. Aside from the association with poorly regarded
historical figures, Khan et al (2015), suggest that creativity and independent thought
can be stifled by such an approach. As such team members may feel their opinions
and input undervalued or feel mistreated (De Hoog et al, 2015). The same study (De
Hoog et al, 2015) suggests that autocratic leaderships in groups also elevate the risk
of struggles arising for power and influence within the group, depending on the
relative position and roles of the group members.
It is arguable that for situations, such as medical emergencies, a more effective
leadership style would be a democratic form, particularly given the need for working
alongside members from different teams and disciplines. Democratic leadership
relies on collective decision making, active participation by group members and
honest sharing of feedback, both positive and negative (Gastil, 1994). This has its
basis in the formation of relations based on mutual trust and respect, which confers
the advantage of making members of the team feel more valued in their work,
making for a workforce that feels more valued and empowered (St Thomas
University, 2018). In the case study, this is demonstrated by the Sister incorporating
feedback and suggestions from the team, such as the suggestion to test the patients
capillary blood glucose in order to rule out hypoglycaemia or similar conditions that
could have accounted for his unresponsive state. This was also demonstrated by the
deferring to other members of the multidisciplinary team as their specialisation
dictated, rather than attempting to direct them according to the actions that the Sister
felt were the correct response. The most significant issue that arises from adoption
of a democratic style of leadership is that decisions can take longer to reach and
implement (Xu, 2017). Particularly in an emergency, this is not ideal, as time is of the
essence in maintaining the life of the patient.

Communication plays a vital role in successful leadership, arguably the most

important a good leader must have (Luthra & Dahiya, 2015). These skills are vital to
persuading others to follow their directions to reach the desired outcome (Khan, et
al, 2015). Nurses, whether in an official leadership role or not, are required by the
NMC Code (2018) to “use a range of verbal and non-verbal communication methods,
and consider cultural sensitivities, to better understand and respond to people’s
personal and health needs.” De Hoog et al (2015) also suggest that considerate
behaviours, such as expressing concern and support for colleagues can improve
team morale as well as establish and maintain positive interpersonal relations
between members. This ties in to the requirements of the NMC Code (2018) to both
“respect the skills, expertise and contributions of your colleagues, referring matters
to them when appropriate” and “maintain effective communication with colleagues.”
Issues with communication, can unfortunately, arise all too easily between individual
practitioners, one of the main points at which this can arise is identified as patient
transfers (McKnight et al, 2002). This is particularly highlighted in the case study, as
the patient was handed over with incomplete if not outright inaccurate information
about the patient’s current condition. In particular that the patients Parkinson’s
medications had not been delivered routinely as the condition requires to prevent
their symptoms becoming difficult to manage (Cotton, no date). McKnight et al
(2002) also identify issues with communication between different parts of the
multidisciplinary team being hindered due to clashes in personality, citing incidences
of highly opinionated practitioners disagreeing causing a hindrance to patient care.

Beyond the requirements of team working, nurses are often required to communicate
with family members of patients as well as the patients themselves. Peplau (1988)
states that the primary goal of nurses in communication with patient is to develop “a
clear and adequate conception of the experience with illness.” It has been estimated
that the cost to the NHS of poor communication, whether through litigation,
inadequate adherence to treatment regimens or repeat hospital visits totals over £1
billion per year (Ali, 2017). Listening is also an important part of the communication
process, incorporating full attention being paid to effectively pick up any verbal and
non-verbal cues issued by the patient. This can help the patient to trust the nurse
and improve their self-esteem and a feeling of acceptance (Kourkouta &
Papathanasiou, 2014). The NMC (2018) also specifies that practitioners “be able to
communicate clearly and effectively in English,” as this is arguably the majority
spoken and written language used within the UK. Kojima (2020), however, makes
the point that approximately one in ten people in the UK, rising to one in five in
London, do not speak English as their first language. This has the potential to create
barriers to effective communication, and as a result potentially cause harm to
patients.

Self-awareness is another important element in the toolkit available to nurses to

provide the best care to their patients. Reflection on past experiences and practice is
a requirement of maintaining professional standing, intended to demonstrate the
ability to practice in a safe and effective manner on a three yearly-basis (NMC,
2019). This is considered such a vital part of the nursing role that it has been
incorporated directly into the NMC Code, stating that nurses must “gather and reflect
on feedback from a variety of sources, using it to improve your practice and
performance (NMC, 2018). In the broader sense, self-awareness is defined as
“ongoing, deliberate, intrapersonal, relational, extra-personal and contextual process
of self-discovery” (Younas et al, 2019). Peplau (1988), regards self-awareness as a
tool to enable the development of processes that are productive and purposeful, and
therefore are those that will assist the patient in their treatment and recovery. This
ties into Younas et al (2019) identifying the usefulness of self-awareness in
preventing nursing staff from projecting their own stresses and emotional state onto
their patients, as it is acknowledged that some behaviours have the potential to
trigger such responses in practitioners if they are unprepared for them. The case
study attached demonstrates this, as the Sister handling the situation that arose was,
while clearly dissatisfied with the handover she was given as it was not accurate,
completely calm and professional while interacting with colleagues and attempting to
obtain a response from the patient. While self-awareness is undoubtedly an
important skill for nurses to have, it does have its limitations. It is, unfortunately, not a
skill intrinsic to all people and, as Younas et al (2019) point out, there has been
limited research into self-awareness and what research there is has focussed on
teaching methods to enhance the skill within individual nurses. While this is valuable,
it does not provide a definitive, quantifiable means to assess or demonstrate the
skills in individual practitioners. Parveen (2015) points to the concept of the Johari
Window, which describes the different aspects of self-awareness. Included in this
framework is the concept of “Unknown” information about self, that is information
about individuals that is unknown to others or even themselves. Given the possibility
that this will include personal deficiencies that could impact our practice, this
presents an issue in that it is all but impossible for people to improve an aspect of
themselves if they remain unaware of it.

How a team works together is a vital part of implementing successful

multidisciplinary treatment of patients, especially in a time-critical situation. Any
interaction between groups of individuals, particularly where issues of status and
seniority can lead to clashes of personality (McKnight, 2002), are fraught with
potential pitfalls. Lencioni (2008) identified five potential sources of dysfunction in
teams. The first identified, and arguably the most important as the others flow from it,
is trust, or rather the absence thereof. Trust is arguably the building block of effective
relationships between individuals, teams and organisations (Jones & George, 1998),
which they identify as the expression of confidence in the parties involved in the
conduct of some sort of transaction. The foundation of this trust, particularly in
healthcare is identified as being based in the understanding of individual member’s
roles and allowing them to operate independently within the scope of their personal
capabilities (Roth & Markova, 2012). This was demonstrated in the case study by the
fact that the Sister in charge of the response deferred freely to the experts in their
fields, as they were trusted to operate effectively in order to deliver the optimal
outcome for the patient. Erdem (2003), on the other hand takes the view that there is
such a notion as too much trust, specifically unquestioning and uncritical trust. The
findings of the Francis Report (2013) arguably demonstrate this; that the culture at
Mid Staffordshire Trust was one that trusted in the systems in place to catch errors
or wrong-doing, and as such allowed those incidences to go unchallenged, resulting
in tragic consequences for the victims of those failings.

In conclusion, the research gathered suggests that teamworking is a complex issue

with many different and closely interacting elements to it. Leadership is a critical
component of effective teamworking and is a tool that should be embraced and
developed by nurses from their very first days working on the wards. There are many
different approaches and styles of leadership that can be adopted, ranging from
authoritarian to democratic, each of which has their own benefits and drawbacks,
both for maintaining relationships within teams and providing the best outcome for
the patient. Communication is also a vital component, the value of conveying
information to colleagues, patients and families in a clear and effective way also
provides and invaluable contribution to the wellbeing of service users. Self-
awareness has been identified as an essential implement in the development of
effective nursing practice, the identification of strengths and weaknesses within
practitioners serving to enhance the provision of patient-centred care and is
something that all nurses should strive to develop within themselves. Arguably the
cornerstone of effective teamworking is trust, which is essential to allow members of
the team to operate with a degree of autonomy in the pursuit of the common goals
and objectives of the team. Although it should be noted that trust should also be
tempered by self-awareness, so that the personal foibles of individuals do not
undermine the overall effectiveness of the broader group or organisation. Each of
these components has to be in place and functioning correctly in order to allow
nurses to operate at their peak individually and to integrate with and act as part of
the multidisciplinary team in order to fulfil the ultimate goal of providing the best
patient-centred care to all service users that enter our area of responsibility

Appendix – Case Study

Towards the end of a long day shift on an orthopaedic ward, at approximately 1800,
a patient was transferred from a general surgery ward. The patient was a known
Parkinson’s Disease patient and on handover the impression was given that the
patient had been fully alert and independently mobile earlier in the day. However,
when transferred onto the ward the patient was physically immobile and in a state of
extreme drowsiness and inability to communicate. The Sister in charge of the bay
took the lead in assessing the condition of the patient, attempting to elicit a response
to vocal commands, assessing his eye-opening response and response to pain, the
result of which was that the patient was determined to be completely unresponsive.
Upon reaching this conclusion the Sister directed myself and the healthcare
assistant in the bay to conduct measurements of the patient’s vital signs. The Sister
also took on board input from the personnel present, including my suggestion to test
bis blood glucose levels to rule out hypoglycaemia as a possible cause.

While this was being done, the Sister requested the on-call doctor perform an
assessment on the patient, as well as putting out a MET call and requesting the
presence of the resus team in order to evaluate the patient further. While these
investigations were taking place, the Sister took it upon herself to review the patient’s
medical notes, including his medication history. It was in consulting his medication
chart that it was discovered that on several occasions the patient’s Parkinson’s
medications had been noted as being unavailable or that the patient refused those
medications. The Sister raised this with the resus team and the on-call doctor,
identifying this as the probable cause of the patient’s current unresponsive state.
This was also identified this as being most likely to be a failure on the part of the staff
of his previous ward to obtain or administer the medications in a timely fashion as
necessitated by the patient’s illness. As a result of these investigations, the decision
was reached to alter his medication from oral tablets to transdermal patches, in order
to ensure that the patient received the appropriate dosage of his medications even if
he remained unresponsive.
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