Nursing is a multifaceted profession that encompasses a wide range of tasks and responsibilities one of which is being a nursing leader. Until recently, nursing literature had primarily focused on executive and other formal leadership roles when discussing nursing leadership (Huber, 2017). However, in recent years, the nursing leadership discourse has changed to include bedside nurses that do not hold official management positions. Stanley (2016) writes that today, leadership cannot and should not be confined to top management levels. In actuality, the medical workforce will benefit profoundly from nurses taking charge and influencing others within their scope of leverage and responsibility (Stanley, 2016). Leadership means better rapport with patients in direct care as well as ownership and accountability when making decisions such as treatment plans, patient discharge, and others (Alvinius, 2017). Besides, nursing leaders are likely to be better at collaborating as well as communicating their agenda.
One of the subfields of nursing where the ability to be a good leader takes a high priority is mental health nursing or psychiatric nursing. The United Kingdom National Health Service (n.d.) reports that today, one in four adults and one in ten children experience mental illness at least once in their lifetime. In any given week, one out of six respondents admits to having a common mental problem such as anxiety or depression (“Mental health facts and statistics”, 2017). A recent survey by McManus, Bebbington, Jenkin,s, and Brugha (2016) further revealed the concerning picture of mental illness in the United Kingdom. The researchers show that today, six out of one-hundred people suffer from a generalized anxiety disorder, 1.3 – from obsessive-compulsive disorder and 3.3 – from depression (McManus et al., 2016). Besides, even though the mental illness rate has not increased significantly in recent years, how people cope with this burden has become more unhealthy (“Health status, illnesses, and other conditions”, 2015).
All these facts and figures suggest that mental health nurses might be experiencing quite a lot of workload as well as all the challenges associated with working at psychiatric wards. One of such challenges is making decisions regarding patients’ status as in the case offered for analysis. The case describes a situation in which a young woman is supposed to be transferred to a supported living accommodation from a medium-security unit. On the day, when it was to happen, a nurse discovers that she does not have anyone to help her escort the patient, so she puts the transfer on hold. The patient became verbally and physically aggressive as she was understandably unhappy with having to wait. Eventually, for the sake of minimising rminimizingxperienced band-six nurse escorted the patient in a secured vehicle with security. This essay describes the elements of leadership in the analyzed case and provides theoretical underpinnings of nursing leadership, especially in the field of mental health nursing.
Leadership is defined as both the action of leading a group of people or an organization and the ability to influence others. In the nursing field, leadership has been defined as influencing others with the purpose of improving the quality of care across the board. Weiss, Tappen and Grimley (2019) write that historically, the nursing field has been dominated by women. Given the gender dynamics that until recently, have primarily benefited men, female nurses have been seen not as thoughtful strategists but as functional doers (Weiss, Tappen & Grimley, 2019). Today, in the United Kingdom, documents such as the NHS Long Term Plan highlight the importance of clinical leadership (National Health Service, 2019). Nursing leadership is also part of the ambitious transformation of mental health care, as noted by the National Health Service (2019). The documents prioritize prioritize development and helping nurses become decision-makers whose actions are driven by education, evidence and experience, as well as ownership and accountability.
Today, there exist numerous theories and approaches describing leadership. Probably the most about the case analyzed are transformational and participative leadership. Participative leadership, also known as democratic leadership, is a style that enables each team member to participate in the decision-making process (Grossman & Valiga, 2016). The premise of participative leadership is that it helps followers to feel more engaged in the management process (Grossman & Valiga, 2016). They may feel more committed and conscientious about common goals as well as motivated to work with more efficiency (Grossman & Valiga, 2016). In the analyzed case, the nurse in charge of the night shift made a decision to communicate her concern about the patient to the managing board. Team doctor, team consultant and other informal leadership roles did not shun the nurse or discard her opinion altogether. Instead, they took her concerns with utmost seriousness and held an emergency MDT meeting. If the described facility did not uphold the values of transformational and participative leadership, they might have as well transferred the patient without sufficient escort. Another option would be to put the transfer on hold, which would have further destabilised the patient. Instead, the medical team acted promptly and professionally, putting equal weight on each person’s opinion, which helped to achieve the outcome that proved to be positive for each party involved.
Nursing literature also highlights the importance of participative management and democratic leadership style in general. Drennan et al. (2015) provide the results of the project commissioned by NHS Health EducationSouth London (HESL) part of Health Education England. The purpose of the project was to understand the roots of the high turnover rate in the nursing field. Through a series of semi-structured interviews, Drennan et al. (2015) were able to pinpoint the key factors for job dissatisfaction with poor management and leadership being some of them. In particular, respondents shared their negative experiences with dealing with leaders who did not pay regard to their opinion. They were unhappy about the work environment that did not allow them to communicate their ideas and disregarded their concerns.
The second relevant framework, transformational leadership describes a framework in which followers have trust for leaders and are compelled to do more than what is asked of them (Hawkins, 2017). The transformational leadership style comprises four core dimensions: idealised influence, inspirational motivation, intellectual stimulation and individualised consideration (Hawkins, 2017). Applying the framework to the analyzed case, it becomes apparent that given how much trust the bedside psychiatric nurse had in the MDT, it was providing enough idealised influence and inspirational motivation. The intellectual stimulation aspect is reflected in the way the MDT was soliciting the employee’s perspective and considering all options available for resolving the issue. Lastly, individualised consideration meant that the MDT knew how to manage nursing talent in the most optimal way, which helped them to choose an experienced band-six nurse to escort the patient.
The positive impact of transformational leadership is grounded in hard evidence. Boamah, Laschinger, Wong and Clarke (2018) hypothesise that transformational leadership leads to structural empowerment, a concept that encompasses access to information, support, resources and opportunities. For this reason, medical facilities that adhere to transformational leadership may experience better patient outcomes as well as enjoy improved job satisfaction in its employees. The results of the study by Boamah et al. (2018) proved to be consistent with the hypothesis. Boamah et al. (2018) discovered that transformational leadership had indeed been associated with workplace empowerment, which led to improved job satisfaction and a decrease in the adverse patient outcome rate. Moreover, nurses who were more satisfied with their job situation were more precise and efficient in the workplace, proving that job satisfaction and patient outcomes are interrelated.
Patient-Centered Care in Mental Health Nursing
The question arises as to what kind of approach toward mental health care prioritises the patient in a way that has been shown in the analyzed case. Vanderboom, Thackeray and Rhudy (2015) opine that the presence of complex health conditions, which is true in the case of the described patient, was a key characteristic of patients requiring care coordination. Nurses who participated in the study by Vanderboom et al. (2015) highlighted the importance of applying holistic, patient-centered and relationship-based care, in which caregivers see patients beyond their disease. In the interviews, respondents said that the most simple interaction that acknowledged the humanness and uniqueness of a patient would always make quite a big difference (Vanderboom et al., 2015). They described building relationships on the basis of trust and mutual respect, the ones where the patient becomes the center of the treatment and decision-making processes, as the most beneficial.
With regard to the patient in the case, the decision about her transfer was clearly made based on patient-centered care values as well as scientific evidence. It is a common misconception that patients with mental health disorders are achieving better results in clinical settings. In actuality, as Slade et al. (2015) demonstrate in their study, such patients have better chances to recover in community settings where they have more autonomy and self-agency. Those treated in strictly clinical settings show resistance to recovery as well as higher readmission rates (Slade et al., 2015). The analyzed case only confirms these results: since the patient was informed about the possibility of being transferred to supported living accommodation, her behaviour has significantly improved.
Moreover, it is safe to say that the approach that the medical staff has undertaken as per the case description fits not only patient-centered care but also patient-perspective care. Carey (2016) defines patient-perspective care as care where the quality and the appropriateness of help are largely defined by the helpee, not only the helper. According to Carey (2016), a patient-perspective framework requires genuine curiosity as well as humility from the caregiver. This framework suggests that medical workers accept that they might never completely understand what mental patients are going through. For this reason, it would be wrong to always take a paternalistic stance and impose their opinion (Carey, 2016). The medical team in the analyzed case was apparently aware of the importance of providing the patient with an opportunity to start a different life, which is why they did not put her transfer on hold and found alternative ways to transfer her. In other words, doctors and nurses were able to take the patient’s perspective and do what was in her best interests.
Admittedly, the medical staff empowered the patient by giving her a voice in the decision-making process and respecting her values and preferences. Patient empowerment is a relatively new term in nursing research that is rather difficult to conceptualise. Bravo et al. (2015) attempted at the conceptualization of the term mapping themes underpinning published definitions of patient empowerment with the focus on the views of key UK stakeholders. Bravo et al. (2015) described what patient empowerment may mean at the levels of patients, healthcare providers and healthcare systems. Only two levels can be identified in the present case as it does not address the healthcare system on the whole. Using the framework by Bravo et al. (2015), it becomes apparent that the patient was empowered: the woman executed her rights and took her opportunities relating to autonomy, self-determination and power in the context of the healthcare relationship. Patient empowerment was supported by the healthcare providers in question through respecting patient autonomy and adhering to a partnership style in the healthcare relationship.
Another essential concept found in the case is the concept of inclusivity. In the case analyzed, the medical staff went as far as to include the woman in the emergency meeting so that she did not feel excluded and could contribute to the discussion. Tobiano, Marshall, Bucknall and Chaboyer (2015) define inclusivity as a way for patients to be equal participants in nursing care. Tobiano et al. (2015) point to a possible link between patient inclusivity and patient safety, which makes the promotion of the former especially important. Tobiano et al. (2015) point out two important activities that help to make patient inclusivity possible, and both of them are found in the case. Firstly, healthcare workers need to share relevant information in the process of active communication with patients in practice. The second activity is involving patients in assessment and care planning, which enhances their autonomy and gets across the goal of treatment.
Interprofessional Collaborative Practice
The administration of patient-centered care that is built upon patient empowerment and inclusivity often requires teamwork, which was extensively demonstrated in the analyzed case. The emergency meeting required the gathering of a multidisciplinary team with varying levels of experience and expertise. Together, the team was able to arrive at the right conclusion and make a reasonable decision. Morgan, Pullon and McKinlay (2015) write that today, it has been established that interprofessional collaboration improves patient care, especially when it comes to patients with complex or chronic conditions. Morgan et al. (2015) point out “top-down” organizational and “bottom-up” intrinsic factors that drive interprofessional collaboration. On the one hand, the facility itself needs to have practice policies and organisationally endorsed formal processes. There should be collaborative management in place that enables opportunities for informal communication (Morgan et al., 2015). On the other hand, employees themselves contribute to building interprofessional collaboration through shared knowledge creation and shared clinical decision making.
Modern nursing literature has an ample body of evidence regarding the effectiveness of an interdisciplinary approach. Kadivar, English and Marx (2016) write that such an approach is especially important for providing patients with optimal discharge disposition and follow-up services. According to Kadivar et al. (2016), together these measures could prevent hospital readmissions. Kadivar et al. (2016) see the absence of certain specialists on interdisciplinary teams as problematic. In their trial study, the researchers were able to pinpoint a positive relationship between the application of the interdisciplinary approach and a reduction in hospital readmission rates.
The quality of relationships in the workplace affects employees’ job satisfaction and performance and in turn, the quality of care. Wilson (2016) reports that in the United Kingdom, as many as 20-25% of nursing staff experience bullying behaviour. Typically, the bullies are senior nurses and colleagues who are in a more established position. Wilson (2016) writes that bullying causes distress and depression, with every fourth bullied nurse quitting her job.
The question arises as to what negative consequences poor workplace relationships may lead to and what their cost is in the context of the healthcare system. Kline and Lewis (2018) estimate the financial costs of bullying and harassment in the healthcare sector to the NHS in England. Kline and Lewis (2018) report that bullying and harassment result in high turnover rates, diminished productivity, sickness absence, and industrial relations costs. A conservative estimation of the losses caused by bullying and harassment is £2.281 billion per annum (Kline & Lewis, 2018). All in all, positive patient outcomes and the quality of the nursing workforce are contingent on the work environment: how healthy it is and how well the nurses are treated in the workplace.
The described case and theoretical underpinnings highlight the importance of nursing leadership. Unfortunately, from personal experience and literature research, I can safely point out that nursing leadership often faces significant personal and organizational hurdles. Cabral, Oram, and Allum (2018) discovered that while the nursing leadership community ischaracterizedd by considerable talent and expertise, there are still significant gaps in competence and capability as well as a desire to take and retain leadership positions.
In particular, the study by Cabral et al. (2018) showed that nearly a third of National Health Service director posts were filled by interim appointments or were vacant. Moreover, it was the nursing director posts that remained vacant for the longesperiodsme as compared to the rest (Cabral et al., 2018). In a series of semi-structured interviews, Cabral et al. (2018) learned that nursing leadership roles were not perceived positively. The respondents saw them as risky, demanding, isolating, and not financially rewarding. The results of the study suggest that there is a gap between identifying nursing leadership talent and making good use of it in a way that would be beneficial to all parties involved.
To sum up, promoting leadership in mental health nursing requires an effort on two levels: personal and organizational. On a personal level, nurses should operate on a set of values that priorprioritizeence, communication and ,initiative. However, personal attempts to impact decision-making within a facility may fall flat if they are not supported by relevant structures and practices. A mental health facility needs to have a well-functioning managing board that adheres to the principles of transformative and participative leadership to amplify the voices of nurses. Besides, leadership should not have a negative flair that associates it with risk and exhaustion: instead, it should be promoted and rewarded.
Surely, nursing leadership promotion is a multifaceted process, and many aspects have yet to be clarified. For example, McInnes, Peters, Bonney, and Halcomb (2015) write that there is limited knowledge regarding the hierarchical constraints of nursing leadership and their influence on the possibility of collaboration. The case analyzed may not be reflective of the situation on the whole, but it is still a positive example of collaboration between leaders and followers. On the one hand, the nurse who requested an emergency meeting adhered to the rules. On the other hand, she bolstered the courage to question the situation and take the initiative.
Today, quite a lot of UK residents are suffering from mental conditions, which puts a burden on the healthcare system and the nursing workforce in particular. In order to improve the quality of mental health care, nursing leadership and collaboration should be promoted. The analyzed case is an example of two popular leadership frameworks – transformational and participative – in practice. Moreover, the case contains the elements of patient-centered care, patient-perspective care, patient empowerment and inclusivity. The medical staff arrived at the right decision by uniting the forces of the multidisciplinary team, of which the patient was also a part. The theoretical underpinnings suggest that transformational and participative leadership are associated with better patient outcomes and improved job satisfaction. Collaborative practices were also found to be highly beneficial to both the staff and patients.
- Alvinius, A (ed.) 2017, Contemporary leadership challenges, BoD–Books on Demand, Norderstedt.
- Boamah, SA, Laschinger, HKS, Wong, C & Clarke, S 2018, Effect of transformational leadership on job satisfaction and patient safety outcomes. Nursing Outlook, vol. 66, no. 2, pp. 180-189.
- Bravo, P, Edwards, A, Barr, PJ, Scholl, I, Elwyn, G & McAllister, M 2015, Conceptualising patient empowerment: a mixed methods study, BMC Health Services Research, vol. 15, no. 1, p. 252.
- Cabral, A, Oram, C & Allum, S 2019, Developing nursing leadership talent—views from the NHS nursing leadership for south‐east England, Journal of Nursing Management, vol. 27, no. 1, pp. 75-83.
- Carey, TA 2016, Beyond patient-centered care: enhancing the patient experience in mental health services through patient-perspective care, Patient Experience Journal, vol. 3, no. 2, pp. 46-49.
- Craigie, J 2015, A fine balance: reconsidering patient autonomy in light of the UN convention on the rights of persons with disabilities, Bioethics, vol. 29, no. 6, pp. 398-405.
- Drennan, VM et al. 2015, Adult nurse turnover and retention: South London project report. Web.
- Grossman, S & Valiga, TM 2016, The new leadership challenge: creating the future of nursing, FA Davis, Philadelphia.
- Hawkins, P 2017, Leadership team coaching: developing collective transformational leadership, Kogan Page Publishers, London.
- Huber, D 2017, Leadership and nursing care management-ebook, Elsevier Health Sciences, Amsterdam.
- Kadivar, Z, English, A & Marx, BD 2016, Understanding the relationship between physical therapist participation in interdisciplinary rounds and hospital readmission rates: preliminary study, Physical therapy, vol. 96, no. 11, pp.1705-1713.
- Kline, R & Lewis, D 2019, The price of fear: estimating the financial cost of bullying and harassment to the NHS in England, Public Money & Management, vol. 39, no. 3, pp. 166-174.
- McInnes, S, Peters, K, Bonney, A & Halcomb, E (2015) An integrative review of facilitators and barriers influencing collaboration and teamwork between general practitioners and nurses working in general practice, Journal of Advanced Nursing, vol. 71, no. 9, pp. 1973-1985.
- McManus S, Bebbington P, Jenkins R, Brugha T 2016, Mental health and wellbeing in England: adult psychiatric morbidity survey 2014.
- Morgan, S, Pullon, S & McKinlay, E 2015, Observation of interprofessional collaborative practice in primary care teams: an integrative literature review, International Journal of Nursing Studies, vol. 52, no. 7, pp. 1217-1230.
- National Health Service 2019, Clinical leadership — a framework for action. Web.
- National Health Service n.d., Mental health. Web.
- National Health Service 2019, NHS mental health implementation plan 2019/20 –2023/24 Web.
- Slade, M et al. 2015, Supporting recovery in patients with psychosis through care by community-based adult mental health teams (REFOCUS): a multisite, cluster, randomised, controlled trial, The Lancet Psychiatry, vol. 2, no. 6, pp. 503-514.
- Stanley, D 2016, Clinical leadership in nursing and healthcare: values into action, John Wiley & Sons.
- Tobiano, G, Marshall, A, Bucknall, T & Chaboyer, W 2015, Patient participation in nursing care on medical wards: an integrative review, International Journal of Nursing Studies, vol. 52, no. 6, pp. 1107-1120.
- Vanderboom, CE, Thackeray, NL & Rhudy, LM 2015, Key factors in patient-centered care coordination in ambulatory care: nurse care coordinators’ perspectives, Applied Nursing Research, vol. 28, no. 1, pp. 18-24.
- Weiss, SA, Tappen, RM & Grimley, K 2019, Essentials of nursing leadership & management, FA Davis, Norderstedt.
- Wilson, JL 2016, An exploration of bullying behaviours in nursing: a review of the literature, British Journal of Nursing, vol. 25, no. 6, pp. 303-306.