Cooperation, collaboration, influence and authority in leadership and the nurse as health service manager in rural Western Australia

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1 Cooperation, collaboration, influence and authority in leadership and the nurse as health service manager in rural Western Australia Dr Jan Lewis Curtin University Perth 1

2 Background In Western Australia, health services in rural areas were traditionally managed by a general administrator and the Director of Nursing (DON) During one of the restructures of rural health services in the 1990s a new role was created General administrators were removed and the Director of Nursing was required to assume the general and administrative responsibilities as well as the management of clinical services This role was imaginatively labelled the DON/HSM 2

3 Responsibilities of the DON/HSM Direct clinical services Manage the delivery and integration of health programs in their localities Be responsible for meeting local health care gains as contracted Established and maintained links with stakeholders as required 3

4 Manage all resources for the health service Liaise with other health service providers and non-government organisations Participate and assist in all needs analyses Undertake a clinical caseload as required Lead operational and strategic planning for the health service (Central Health Authority 1994) 4

5 The DON/HSM as clinician manager In combining general administrative and clinical functions, the DON assumed a clinician manager role. This was a new role that had emerged in the early 1990s principally in the UK in the NHS in an attempt to place resource allocation decisions with the people who consumed the most resources Most of the literature focused on medical doctors in this role but there was also interest in nurses and allied health professionals. 5

6 The clinician manager role Combines clinical responsibilities with a management function Management function is more than is generally associated with clinical practice Has an organisation wide focus Requires specialist management skills Planning, strategic and operational Financial management Human resource management for a diverse group of clinical and general staff 6

7 Represented a shift in focus from patient centred clinical practice to that of resource allocation for the organisation as a whole It was presumed that this role be an integration Hence DON/HSM rather than DON and HSM How to achieve that balance between the requirements of the manager with the welfare of the organisation as highest priority and the requirements of the clinician to place the patient as highest priority was not explained and is still poorly understood. 7

8 The research The aim was to investigate clinician manager s perceptions of their experiences in their adaptation to and their enactment of the new role Sense making, a process by which individuals ascribe meaning to the events in their environment provided a theoretical context that directed the inquiry Grounded theory was the methodological approach The research sample were DON/HSMs in rural and remote health services in Western Australia Data was gathered from in-depth interviews 8

9 The research sample 31 DON/HSMs of rural health services who had been in the position more than six months were interviewed The rural health services generally comprised of A hospital with a small inpatient occupancy but with a high outpatient attendance. Most did not have an operating theatre or a delivery suite. Community health services that often employed allied health professionals and aboriginal health workers as well as other nurses Home and community care (HACC) services Aged care hostel 9

10 Medical services were provided by general practitioners who had a private practices in the town and had admission rights to the hospital under contractual arrangements. The number of GPs in the town varied from none to 6 Allied health professionals such as physiotherapists, speech therapists and occupational therapists generally visited on a rotational basis from a regional base 10

11 11

12 Stakeholders The role of the DON/HSM cannot be explained without considering the relationship between the role and the stakeholders of the health service Stakeholders are those individuals and groups who rely on the organisation for the achievement of their goals but who in turn the organisation relies on for their support or cooperation 12

13 Stakeholders Health Service Staff Community DON/HSM Government Department General Practitioner 13

14 The health service staff The DON/HSM role requires responsibility for clinical staff, nursing and allied health, as well as general staff Human resource management was reported to be one of the biggest challenges of the job Industrial relations Establishing new relations Conflict resolution 14

15 Staffing shortage and in rural areas often meant A high turnover of staff Often a small core of long serving local staff A largely part-time workforce Use of agency nurses working on a shift by shift basis Positions unfilled for varying lengths of time Holiday relief and unpopular shifts problematic The commitment of the staff to their job variable A considerable amount of time was spent pursuing staff and negotiating working hours 15

16 The GP A complex relationship The GP controlled who was admitted to the hospital and the treatment they received Impacted on the budget and the clinical practice for which the DON/HSM is legally accountable The DON/HSM could also influence the practice of the GP and therefore impact on the GPs personal income The boundaries between nursing practice and medical practice constantly being renegotiated Influenced by personal relationships 16

17 The community The health service is important for a town as a symbol of the towns standing provider of health services provider of employment There is the sense of ownership of the health service and high expectations both personally and professionally of the DON/HSM The GP is considered more important Patients frequently have personal connections with the health service which adds and emotional element of the role 17

18 The Department of Health (DoH) The DoH had ultimate control over the role of the DON/HSM Restructuring and change of policy over which the DON/HSM has little control is a constant source of frustration. The DoH has high expectations of the DON/HSM as leaders of the rural health service Recent training sessions have been directed at the DON/HSM as a transformational leader. 18

19 Views of leadership Transformational leadership studies argue that charismatic leaders can inspire followers to greater commitment by satisfying their needs and validating their identities. The personality of the leader is seen as a significant substantive and causal influence on the thoughts and actions of followers. 19

20 Leaders are endowed with an unquestionable moral and functional superiority and it is assumed that leaders exist independent of context and time Considering leadership to be the function of an individual in a position of authority with specific traits and abilities to harness organisational resources to achieve organisational goals does not appear to be useful understanding of the DON/HSM role. 20

21 Legitimate authority What constitutes authority can be understood in different ways. Weber (1997) describes three approaches Legal authority derived from a position and established by rules. A defining attribute of management, grounded in an employment contract defining an employee s duty is responsibilities and accountabilities 21

22 Traditional authority conferred by a belief in tradition established by custom in which obedience and loyalty are due to the person who occupies a position Charismatic authority the individual s enable the exercise of authority and the expectation of obedience based on personal appeal. 22

23 Leaders and followers In all views, leadership is a relationship between leaders and followers that is understood in terms of the legitimate authority of the leader Even newer models of leadership related to shared governance and collaborative leadership assumes that there is a leader that can share their authority with a group of followers 23

24 Identification of followers relates to Hierarchical position in the organisation Traditional beliefs The followers readiness to identify themselves as followers. Status as a leader depends on the qualities colleagues ascribe on the basis of their Perceptions of the person Understanding of organisational roles Understanding of traditional professional roles 24

25 To legitimise a leadership role there needs to be Followers who recognise themselves as such An acknowledgement of a legitimate authority of the leader 25

26 Stakeholders perceptions Do they consider themselves to be followers of the DON/HSM? Do they believe in the DON/HSM has legitimate authority? 26

27 Stakeholder Followers? Legitimate authority? The health service staff General staff Nursing staff Other profession staff Yes Yes No Yes *? Yes * The GP No? The Community No Yes The Department of Health No Yes 27

28 Conclusion The relationship between the legitimate authority conferred by appointment to the position and the autonomy of practice traditionally claimed by health-care professionals is a constant source of friction The DON/HSM as a clinician manager embodies the tension between the managerial and professional structures and cultures There is no common understanding amongst the stakeholders of who should be enacting the leadership and the followership role 28

29 Sources of legitimate authority are in conflict. With respect to clinical practice the DON/HSM and the GP both have legal authority underpinned by legislations and reflected in the Codes of Practice of their respective professional organisations. The interface of the two roles is not always clearly articulated. The DON/HSM has a legitimate authority with respect to their appointed position as the manager of the health service. Credibility as a DON does not mean credibility as a DON/HSM Increased credibility with others as a HSM may mean decreased credibility with nursing staff 29

30 The GP has a traditional authority associated with medical practice, which may be considered the most credible by some stakeholders. Charismatic authority in rural health services often resides in unexpected places for example the cook. In rural health services these tensions may relate to relationships between individuals with no group support Conflicts and inconsistencies that large organisations are roomy enough to accommodate can be catastrophic in small rural health services 30

31 Conclusion To expect a rural DON/HSM to be the charismatic heroic leader central to models of transformational leadership offers little to the integration of the clinical and managerial aspects of the position nor does it acknowledge the reality of managing health services in rural and remote areas 31

32 Staff development for clinician managers would be much more productively directed towards Developing tools for understanding the complexity of their environment Developing skills in negotiation, facilitation, collaboration and cooperation Enhancing abilities in using influence to integrate the diverse demands of the stakeholders for the betterment of the health service. 32

33 There needs to be a recognition by trainers, senior management and job incumbents that there is no easy match between the realities of the job of the clinician manager and generally accepted models of leadership and management A greater effort must be made to understand the factors that impact on the practice of clinician managers in rural health services To ignore the context of practice can only be considered perilous to the health service and to the nurse in this difficult role. 33

34 References Weber, M Legitimate authority and bureaucracy. In Pugh DS (ed) 1997 Organisational Theory 4 th edition. London: Penguin. 34

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