5 Providing Nursing Leadership within the Health Care System

Something unforeseen and magnificent is happening. Health care, having in our time entered its dark night of the soul, shows signs of emerging, transformed.

—Barbara Dossey and Larry Dossey (cited in Porter-O’Grady & Malloch, 2011, p. 433)

Introduction

As the health care system responds to changes in the environment, nurse leaders refine and adapt leadership tools and care processes. Leadership tools such as organizational mission, vision, and value statements, which guide both administration and patient care providers through their daily work, are routinely reviewed and modified. “Delegation of care” or transfer of responsibility from one classification of care provider to another is an example of an important health care process adaptation that has occurred in response to rapid system-wide changes. Nurse leaders play an important role within this complex adaptive system as they retain a focus on maintaining a strong care provider culture that supports quality care and improved patient outcomes, regardless of unending change.

 

Learning Objectives

  1. Apply systems theory to health care.
  2. Identify the relationships between organizational culture, leadership, cultural intelligence, and change.
  3. Identify the importance of the vision, mission, and value statements of an organization.
  4. Conclude that relational leadership and empowerment play an important role in organizational cultural change.
  5. Examine the standards for delegation of care established by the Saskatchewan Registered Nurses’ Association (SRNA) from RN to unregulated care providers and from physician to RN.

5.1 Systems Theory and Health Care

In Chapter 1, we discussed complexity science and complex adaptive systems in nursing. It is important to realize that causality in a complex adaptive system is not linear, meaning that it is difficult to predict the end result of a specific employee- or patient-focused intervention. As nurses we know that the success of our patient-centred care interventions is dependent upon many factors. All too often, despite extensive planning and hard work, a patient care intervention fails to lead to the intended results. Factors beyond our control, and often beyond our knowledge, change the intended outcomes. This is typical of events in a complex adaptive system.

So how can we be successful leaders if we cannot predict what will happen when we attempt to guide others? Perhaps a review of the first two principles of the complex adaptive system, discussed in Chapter 1, will provide an answer to this question. The first principle, which is focused on using the lens of complexity, and the second principle, which describes good enough vision, provide us with clues on how to lead others within the complex adaptive health care system. Organizations and nurse leaders acknowledge that they cannot control change, and thus they do not try to control every aspect of organizational change. Successful health care leaders attempt to give a general sense of direction to employees, rather than focus on specific details. Next, leaders also encourage employees to develop innovative responses that best meet their individual strengths and needs and meet the health care system’s ultimate goal of quality patient care. Leaders cannot predict all the factors that will influence the final results of change activities, but by following these principles, they know that the final response will be what is best suited to the environment, or health care system, and the needs of the individual.

 

Essential Learning Activity 5.1.1

What are we talking about when we speak about systems theory in a health care organization? For a deeper understanding, watch this video titled “System Theory of Management” (7:37) by Nguyen Thanh Thi, then answer the following questions:

  1. What are the three basic system types? Describe each type.
  2. What type of system is a hospital?
  3. What is synergy? What is entropy?

There are three fundamental concepts that, when applied to our individual organizations, can transform the way we provide health care. For additional information, watch this video titled “Systems Thinking and Complexity in Health: A Short Introduction” (5:02), then complete the following exercises:

  1. List the three fundamental concepts that can transform the way we provide health care.
  2. Define these three concepts and give an example of how they can make a difference to health care provision.

Finally, watch the video “Interview with Judith Shamian on International Nurses Day 2016” (4:44) as she speaks about inviting citizens to work with nurses in creating a positive health care system. Judith Shamian is President of the International Council of Nurses.

5.2 Organizational Vision, Mission, and Values

Organizational leaders provide a sense of direction and overall guidance to their employees through the use of organizational vision, mission, and values statements. An organization’s vision statement defines why the organization exists, describes how the organization is unique and different from similar organizations, and specifies where the leaders hope the organization is going (Sanders, 2013). The mission describes how the organization will fulfill its vision and establishes a common course of action for future endeavours. Finally, values are developed to assist with the achievement of the vision and mission and provide strategic guidelines for decision making, both internally and externally, by members of the organization (Hibberd, Doody, & Hennessey, 2006). The vision, mission, and value statements are expressed in a concise and clear manner that is easily understood by all the members of the organization. The vision, mission, and values provide guidelines for every person participating in all activities occurring within the organization, encouraging them to walk the talk.”

Canadian health care is an open system that is undergoing constant change while responding to the surrounding environment. Complexity science requires leaders and staff to handle this rapid change in a thoughtful manner. As health care continues to evolve and new models of care are introduced, managers need to consider innovative approaches that meet the needs of change while complying with their individual organization’s vision, mission, and values. According to PorterO’Grady and Malloch, “the language of leadership must reflect the requisites of embracing the mission, identifying how individual work effort contributes to it, and ensuring that work outcomes advance the organization’s mission and purpose” (2011, p. 233). Leaders look through the lenses of the vision, mission, and values statements for guidance when determining appropriate responses to critical events and unforeseen challenges, common in a complex system. Successful organizations require each employee to be committed to following these strategic guidelines during the course of their work activities. Employees who understand the relationship between their own work and the mission and purpose of the organization will contribute to a stronger health care system that excels in providing first-class patient care. The vision, mission, and values provide a common organization-wide frame of reference for decision making for both leaders and staff (Kotalik et al., 2014).

An organization’s mission, vision, and values do not remain static and unchanging over the years, thus the strategic organizational guidelines are regularly reviewed and adapted. This revision process ensures that the services offered by an organization meet the needs of its consumers or patients. Evidence of this process of revision is discussed by Conger, Knuth, and McDonald (2014), who describe a health care response to the design and implementation of an electronic health records system. The implementation of this system eventually led to the refreshment of the health care agency’s vision, a redefinition of its goals, and, finally, the reinvention of its performance measurement and reporting system. Transformations, sparked by changes in the external technological environment, met the health care agency’s mission and vision to engage, enroll, and empower care providers, and led to the development of a “culture of transparency and clinical excellence” (Conger et al., p. 55).

 

Essential Learning Activity 5.2.1

Watch this videoHow to Write a Mission Statement” (4:00), presented by M3 Planning, then answer the following questions:

  1. What is a mission statement?
  2. What are five characteristics of a mission statement?
  3. Who needs to be involved in writing a mission statement?
  4. What information do you need to write a mission statement?
  5. What should the process of writing a mission statement involve?

5.3 Organizational Culture and Nursing Leadership

Organizational culture can be described as “the implicit knowledge or values and beliefs within the organization that reflect the norms and traditions of the organization” (Mancini & Wong, 2015, p. 152). Schein (cited in Ko, Murphy, & Birdman, 2015) further describes organizational culture as “the pattern of shared basic assumptions . . . as the correct way to perceive, think and feel” (p. S676). Organizational vision, mission, and values, established by leadership, provide the foundation for the establishment’s culture. Since individual organizations have their own vision, mission, and value statements, each organization has a different culture. Not surprisingly, when there are conflicts between the mission and vision of various institutions, collaboration in providing services to the patient or consumer can also lead to disagreements (Ko et al. 2015). With the increasing emphasis upon collaboration between health care organizations, it is essential to understand how to overcome the challenges of cultural differences that may impede group efforts.

An example of the important role that organizational culture plays may be found in the recent United Kingdom (UK) health crisis. Shock waves spread across the UK’s National Health Service foundation health trusts in response to the 2013 Francis investigation into the unnecessary deaths of up to 1,200 people between January 2005 and March 2009. The first Francis report (2010) spotlighted flaws of the system, which was focused on cost savings rather than the provision of safe and effective patient care. The second report (Francis, 2013) advocated for patient-centred culture where patients take priority over all system and employee concerns. The Francis report stressed the important effect of leadership upon organizational culture and ultimately, upon the quality of patient care: “Truly, organizational culture is informed by the nature of its leadership. The Department of Health has an important leadership role to play in promoting the change of culture required throughout the health care system” (Francis, 2013, p. 64).

 

Research Note

Hung, D., Chung, S., Martinez, M., & Tai-Seale, M. (2016). Effect of organizational culture on patient access, care continuity and experience of primary care. Journal of Ambulatory Care Management, 39(3), 242–252.

Purpose

To examine the relationships between organizational culture and patient-centred outcomes in a large medical practice.

Discussion

This American study was conducted in a large physician group practice setting of 357 physicians, 41 primary care departments, and nearly a million patients. Organizational culture was found to be significantly associated with “patient access to care, continuity of care, and reported experiences with care delivery” (Hung et al., 2016, pp. 245–246).

Application to practice

When introducing change to an organization, it is essential to recognize the underlying organizational culture. Acknowledging and leveraging this aspect of collective behaviour while targeting specific patient-centred care goals will lead to improved care.

 

You may ask what the UK National Health Service leaders did to promote cultural change that supported patient safety and quality care. One of the many steps they took to generate discussion and foster learning across professional disciplines was to encourage organizations from all over the UK to establish “Schwartz rounds.” These rounds supported all disciplines from across the organization to reflect on the emotional aspects of their work, enhance their communication with each other, and improve their relations with patients (Muls et al., 2015). Quality relationships among staff were recognized as being essential for the provision of quality care to clients.

Leaders know that employees frequently resist change and innovation in their workplace using the argument that “it has always been this way.” Leaders play a pivotal role in inspiring change. When introducing innovation or transformation, it is important to recognize that cultural change cannot be commanded, but can only be inspired. Effective leaders understand both implicit and explicitly stated cultural norms and traditions when they introduce change into the organization. As emphasized in the UK health literature, leaders set an example for the staff through sharing values of a “culture of zero tolerance for substandard care” (Muls et al., 2015).

Research with magnet hospitals in the United States reinforced the need for a health care environment that is focused on the provision of quality patient care. This necessity has also been identified in the UK. When caregivers are provided with adequate resources, support, and respect, there is evidence of increased job satisfaction and reduced patient morbidity and mortality (Aiken, Clarke, Sloane, Lake, & Cheney, 2008).

Holistic leadership approaches, which include a focus on relational leadership and staff empowerment, foster a strong and robust care provider culture within the organization. When supportive care provider cultures are present, improved health is likely to be evident for both care providers and patients (Wagner, Cummings, Smith, Olson, & Warren, 2013). Research indicates that successful and effective nurse leaders have a positive impact upon the well-being of nurses, which converts into improved patient–client outcomes (Cummings, 2004).

 

Essential Learning Activity 5.3.1

Watch this podcastSpirit at Work Can Make a Difference!(20:00) by Dr. Joan Wagner on research regarding resonant leadership, empowerment and SAW, then answer the following questions:

  1. What is spirit at work?
  2. What are the four dimensions that make up spirit at work? Describe them. 
  3. Does resonant leadership have an effect on structural empowerment? On psychological empowerment? On spirit at work?
  4. How can spirit at work research contribute to the development of healthy workplaces?

5.4 Delegation of Care

Significant changes in health care over the past century have included implementation of a universal health care system, a rapidly aging population, technological advances, and scientific discoveries, and have culminated in increased stress upon the system and rapidly escalating costs. Health care leaders searched for ways to meet the increasing demands placed on the system. One solution that has been successfully implemented over the past 20 to 30 years, in response to these pressures on health care, is delegation of care. Delegation of care refers to “the transfer of responsibility for a task when it is not part of the scope of practice or scope of employment of the care provider” (SRNA, 2015, p. 8). Delegation of care most often occurs between an RN and an unregulated care provider or between a physician and an RN. Guidelines have been established to ensure the quality of patient care throughout the delegation process.

Delegation and Assignment of Nursing Care

Assignment

The RN is responsible for the coordination of patient care, which may include assessment, assignment, care planning, supervision, ongoing monitoring, decision making, and evaluation of care (SRNA, 2015). The RN assigns provision of the client’s care to the most appropriate care provider based on the previously completed RN assessment.

Assignment occurs when the required care falls within the scope of practice (i.e., LPN [licensed practical nurse], RN, RPN [registered psychiatric nurse]) or the job description (i.e., UCP [unregulated care provider]) of the care provider who accepts the assignment from the RN. . . . The RN at the point of care retains the overall accountability for the appropriate assignment and oversight of client care. This responsibility cannot be delegated. (SRNA, 2015, p. 8)

Delegation

Delegation of nursing care is different than assignment since it refers to “the transfer of responsibility for a task when it is not part of the scope of practice or scope of employment of the care provider” (SRNA, 2015, p. 8). It is important to remember that only the task can be delegated; the RN retains the responsibility for coordination of patient care. Nurse leaders must ensure the following delegation principles (SRNA, 2015, p. 9) are present in their organization before delegation takes place:

  1. Formal processes and policies must be in place to support the delegator (the one who does the delegating) and delegatee (the one who receives the delegation);
  2. At no time should the safety of the client be compromised by substituting less qualified workers to provide care and/or perform an intervention when the competencies and scope of the RN’s knowledge, skill and judgment are required;
  3. A delegated task cannot be sub-delegated; and
  4. The delegating RN is accountable for appropriate delegation of tasks and for the overall assessment, care planning, intervention and care evaluation. (SRNA, 2015, p. 9)

This accountability requires the RN to monitor the performance and completion of the delegated tasks by the unregulated care provider. Regular communication with the unregulated care provider is required during the initial delegation of the task, throughout the performance of the task, and when the delegated task is completed.

 

Essential Learning Activity 5.4.1

The five rights of delegation provide an excellent mental checklist for RN delegation of patient care. They include right task, right circumstances, right person, right direction/communication, and right supervision/evaluation. Read more about the five rights of delegation on pages 21–23 of the “SRNA Interpretation of the RN Scope of Practice.”

Delegation by Physician to RN

In September 2014, The Medical Profession Act, 1981, was amended to give the College of Physicians and Surgeons of Saskatchewan (CPSS) “the authority to adopt bylaws that can allow physicians to delegate activities described in the College bylaw to other health care professionals” (CPSS, 2015, p. 7). Consequently, the CPSS bylaws were changed to allow physicians to delegate certain activities to RNs. The transfer of medical function (TMF) allows RNs “to perform complex, highly-skilled activities which are outside the scope of registered nursing and within the scope of the practice of medicine” (SRNA, 2016, p. 1).

CPSS principles for delegation include the following:

  1. Delegation will be from a particular physician to a particular registered nurse. Delegation will not be by “category”;
  2. The activities which may be delegated are specified in the [CPSS] bylaw;
  3. When there is a specific program which is identified (such as the Neonatal Intensive Transport Team, the RN Pediatric Transport Team or Air Ambulance), it is not necessary to identify the specific procedures that may be provided by an RN as part of the program;
  4. It will be the responsibility of the physician who delegates the activity to assess the RN’s skill and knowledge to determine if, in the physician’s opinion, the RN has the appropriate skill and knowledge to perform the delegated activity;
  5. Delegation must be done in writing, except in the case of an emergency;
  6. The physician who delegates the authority to the RN must have a process in place to provide appropriate supervision. (CPSS, 2015, pp. 7–8)

 

Essential Learning Activity 5.4.2

RN Evolving Scope of Practice

Read pages 9–13 of the “SRNA Interpretation of the RN Scope of Practice,” then answer the following questions:

  1. Why is RN scope of practice evolving?
  2. Describe RN speciality practices. What standards is RN speciality practice built upon?
  3. What is the scope of practice for the RN with “additional authorized practice”? What is required for a nurse to assume the role of an RN with “additional authorized practice”?

Collaboration between RNs, RPNs, and LPNs in Saskatchewan

Read “Collaborative Decision-Making Framework: Quality Nursing Practice” (approved by the Saskatchewan Association of Licensed Practical Nurses, SRNA, and the Registered Psychiatric Nurses Association of Saskatchewan on September 9, 2017), then answer the following questions:

  1. What factors should patient care assignments be based on?
  2. What are the four main factors that influence scope of practice? Outline what nurses are educated and authorized to do.
  3. The Continuum of Care model on page 11 requires an analysis of which three factors when making decisions about the most effective utilization of LPNs, RNs, and RPNs?

Summary

This chapter addresses the relationship between nursing leadership and the larger health care system. Understanding this relationship requires that we look at our health care system as a complex adaptive system with multiple relationships between different aspects of it that impact both the system and the health of the individuals within it. Health care organizations define their role and describe how they will fulfill this role within the greater system through their vision, mission, and value statements. Members of the organization look through the lens of these guiding statements and principles when making decisions. These guided decisions promote the development of an organizational culture, or common system of beliefs and behaviours for all employees. However, in complex adaptive systems, organizational culture may be influenced by factors other than the vision, mission, and values, leading to undesirable outcomes, as demonstrated in the UK. But even in complex adaptive systems, leaders can inspire change through a focus on relational leadership and empowerment.

Delegation of care is one recent solution to the issues of our rapidly changing complex adaptive health care system. Delegation may refer to RNs delegating care provision tasks to unregulated care providers; in this case, the delegating RN retains the role of coordinator of patient care with all the associated responsibilities throughout the delegation process. Delegation may also refer to physicians delegating specific medical tasks to RNs. In this case, the delegating physician retains the responsibilities of assessment and supervision of the RN throughout the performance of the delegated medical activity.

After completing this chapter, you should now be able to:

  1. Apply systems theory to health care.
  2. Identify the relationships between organizational culture, leadership, cultural intelligence, and change.
  3. Identify the importance of the vision, mission, and value statements of an organization.
  4. Describe the important role that inspiring relational leadership and empowerment play in organizational cultural change.
  5. Explain the standards for delegation of care established by the Saskatchewan Registered Nurses’ Association from RN to unregulated care providers and from physician to RN.

 

Exercises

  1. Does the health care system in your local community function as an open, closed, or subsystem? Please explain why you have chosen this type of system to describe your local community.
  2. Chose one aspect of health care in your local community that you would like to change. Apply one or more of the fundamental concepts of systems theory, interrelationships, perspectives, and boundaries to this aspect of health care provision that could ultimately lead to improved patient care.
  3. You are a home care nurse. An elderly diabetic client has been admitted to your caseload. You conduct an assessment on this client and determine that, due to neuropathy of the hands, this client requires assistance with eye drops for glaucoma. You decide to delegate the process to an unregulated care provider. Develop a care plan for delegation of the care of this client using the five rights of delegation.
  4. As a nurse manager you will be assigning care providers to care for clients with different levels of acuity and care needs. Develop two separate client care scenarios, paying special attention to the specific skills required to care for each client. How are Scenario A and Scenario B clients different? (a) Scenario A has a client who can be cared for by an LPN, RN, or RPN. (b) The client in Scenario B requires either an RN or an RPN to provide care.

 

References

Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake E. T., & Cheney, T. (2008). Effects of hospital care environment on patient mortality and nurse outcomes. Journal of Nursing Administration, 38(5), 223–229.

College of Physicians and Surgeons of Saskatchewan. (2015). Delegation from physicians to registered nurses. DocTalk, 1(3), 7–9. Retrieved from http://www.cps.sk.ca/imis/Documents/Newsletters/DOCTALK-1504.pdf

Conger, M., Knuth, M., & McDonald, J. (2014). Creating a culture for value measurement. Healthcare Financial Management, 68(8), 55–61.

Cummings, G. G. (2004). Investing relational energy: The hallmark of resonant leadership. Canadian Journal of Nursing Leadership, 17(4), 76–87.

Francis, R. (2013). Report of the Mid Staffordshire NHS Foundation Trust public inquiry executive summary. Retrieved from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/279124/0947.pdf

Hibberd, J. M., Doody, L. M., & Hennessey, M. (2006). Business planning and budget preparation. Nursing Leadership and Management in Canada. Toronto: Elsevier.

Hung, D., Chung, S., Martinez, M., & Tai-Seale, M. (2016). Effect of organizational culture on patient access, care continuity and experience of primary care. Journal of Ambulatory Care Management, 39(3), 242–252.

Ko, M., Murphy, J., & Birdman, A. B. (2015). Integrating health care for the most vulnerable: Bridging the differences in organizational cultures between US hospitals and community health centers. American Journal of Public Health, 105(S5), S676–S677.

Kotalik, J., Covino, C., Doucette, N., Henderson, S., Langlois, M., McDaid, K., & Pedri, L. M. (2014). Framework for ethical decision-making based on mission, vision and values of the institution. HEC Forum, 26, 125–133.

Mancini, M. E. (2015). Understanding and designing organizational structures. [Adapted for the Canadian edition by C. A. Wong]. In P. S. Yoder-Wise, L. G. Grant, & S. Regan (Eds.), Leading and Managing in Canadian Nursing (pp. 149–169). Toronto: Elsevier.

Muls, A., Dougherty, L., Doyle, N., Shaw, C., Soanes, L., & Stevens, A. M. (2015). Influencing organizational culture: A leadership challenge. British Journal of Nursing, 24(12), 633–638.

Porter-O’Grady, T. & Malloch. K. (2011). Quantum leadership. Advancing innovation transforming health care (3rd ed.). Mississauga, ON: Jones & Bartlett Learning.

Sanders, E. D. (2013). TNA examines mission, vision and values. Texas Nurses Magazine, 87(3), 10–11.

SRNA, 2015. Interpretation of the RN scope of practice. Retrieved from https://www.srna.org/wp-content/uploads/2017/09/Interpretation_of_the_RN_Scope_2015_04_24.pdf

SRNA, 2016. Guidelines for Physician to RN Delegation. Retrieved from https://www.srna.org/wp-content/uploads/2017/09/PhysToRNDelegationWeb2016_04_08.pdf

Wagner, J., Cummings, G., Smith, D. L., Olson, J., & Warren, S. (2013). Resonant Leadership, workplace empowerment, and “spirit at work”: Impact on RN job satisfaction and organizational commitment. Canadian Journal of Nursing Research, 45(4), 108–128.

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Leadership and Influencing Change in Nursing by Joan Wagner is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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