CAN802: Advanced Professional Nursing Practice – Assessment Answer

Introduction

In the last few decades, the health care system and nursing practice have undergone rapid changes to improve patient and organizational outcomes. However, the implementation of any change is challenging and various stakeholders influence the change process. Nurses are one of the important stakeholders in the implementation of best practices. Through the use of their leadership skills, they provide necessary managerial support and resources to implement best practices (ten Ham-Baloyi 2022). Cummings et al. (2021) argue that nurse leaders influence change through their unique leadership styles. They facilitate the implementation of innovative approaches by challenging the status quo, breaking down traditional barriers, engaging in effective communication processes and adopting of best ideas. Thus, having an understanding of leadership styles and approaches that could facilitate practice change is important.

The report aims to conduct interviews with two nurse leaders and address the question of leadership approaches and characteristics that influence practice change. The two leadership styles that are likely to influence practice change are transformational leadership style and transactional leadership style. The statements of the two nurse leaders will be supported by the evidence-based research literature on leadership theory and practice change. The report mainly supports the transformational leadership style as a superior leadership approach compared to another approach in motivating followers and making a big change successfully in health care. The report will provide a brief insight into the interview convention and participants. The responses from the interviews will be collated and analyzed under various themes such as leadership style and practice change, communication to lead change, emotional intelligence, self-awareness and relational transparency to lead a change. All these will be highlighted through the lens of two clinical leaders.

Discussion on Leadership Interview

Interview Convention

To get more understanding of the relationship between leadership approaches and practice change in clinical settings, the interview was conducted with two nurse leaders. The first nurse A was a clinical nurse manager with 10 years of experience in the emergency department. The second interviewee was Nurse B, a registered nurse who was recently promoted to leadership. She had six-month experience in a leadership position. He specialized in wound management and acute pain. Verbal consent was taken from each nurse and all measures were taken to keep the information confidential. To avoid privacy concerns, pseudonyms have been used in place of real names (Arifin 2018). The interview question has been attached in the appendix. The duration of the interview was around 30 to 45 minutes.

Leadership Style and Practice Change

With the huge demand for health services, nurse leaders are in constant pursuit of innovative practices and bringing in changes that elevate the quality of care. If something does not work well in clinical settings, nurse leaders try to adapt and improvise in filling the gaps in everyday clinical practice (Giuliano et al. 2022). During the interview with the two nurses also, they discussed their involvement in quality improvement or practice change initiatives. Nurse A narrated his role in improving compliance with hand hygiene in the emergency ward. He discussed the identification of gaps in care such as insufficient hand-washing practices at critical moments and an increase in the burden of hospital-associated infection. By the use of audit and interaction communication and feedback, resource constraints and lack of facilities for hand washing at important locations were identified. The use of a clinical audit is an important measure to highlight discrepancies between actual practice and the expected standard of care and it is an important quality improvement tool (Hut-Mossel et al., 2021). Thus, various wash basins were added, in case of a shortage of water, alcohol-based sanitisers were introduced and visual cues were placed for reminders. These measures optimized compliance with hand hygiene and the use of aseptic techniques while handling patients (Lawson and Vaganay-Miller 2019). The second interviewee B discussed her role in improving the team communication process and decreasing adverse event rates. Gaps in communication between senior and junior healthcare professionals were identified and she used Zoom meetings, daily hurdles and online feedback sessions to decrease the power gap and enhance interprofessional team communication. They discussed the leadership approach and the characteristics that supported them to overcome hurdles in practice change. This will be further discussed concerning different leadership styles.

Transformational Leadership Style

Both nurses further discussed the leadership style or approach that they used to make the practice change successful. Based on an interview with Nurse A, it was evident that he had an interest in the transformational leadership style. She explained that she had to adapt to the situation and focus on motivating the health workers to accept the need for change first. She narrated ‘Initially, the situation was chaotic. Nobody understood the importance of hand hygiene at all moments and they regarded it as additional work that would disrupt their daily work Some team activities that supported her to develop an appropriate team climate were knowledge sharing and reflection on the need for changes. It helped change the team’s perception and get their support during the change process (Anselmannand Mulder 2020). According to transformational leadership theory, transformational leaders focus on generating awareness and acceptance of the purpose and mission of a group. They encourage employees to beyond their self-interest (Nawaz and Khan 2016). Nurse A used her communication skills to share the vision behind compliance with HH and the benefits of the change. Such a form of communication based on mutual trust and sharing of perception of safety enables the development a positive safety culture (Seljemo, Viksveen and Ree 2020). Thus, it is seen that the transformational leadership style supports engaging inteamwork.

Both nurses A and B discussed barriers in the implementation of practice change. The common barrier was staff resistance and this was mainly seen due to lack of commitment or motivation towards the change. Her leadership approach in this situation was to engage in raising team spirit, motivating team members and training staff to understand that they are capable to adapt the new practice (Anwar 2017)). Her narrative was ‘My team members complained that hand hygiene is an extra responsibility for them and they may not be able to complete it in case of heavy workload’. My job as a leader was to convince them that it is no extra responsibility. Instead by adhering to hand hygiene in their routine, they will be able to minimize their workload in the future. Training and simulations were arranged to increase their capacity to adapt to the change. The above action resonates with the transformational leadership components of inspiration motivation, intellectual stimulation and individualized consideration (Al-Husseini and Elbeltagi 2018). Transformational leaders aim to transform organizational culture by encouraging others to achieve their goals. They motivate followers to imagine goal achievement and the positive outcomes that they will achieve in the future (Moon, Van Dam and Kitsos, 2019, November).

The Nurse A intellectually stimulated the staff members by arranging training and educational sessions. Lin et al. (2020) argue that training is one opportunity to improve the abilities of the staff. Transformational leaders encourage subordinates to give more meaning to their work by learning new skills, improving their abilities and stimulating creative thinking. Similar to transformational leadership, various other leadership style supports followed to strive at work. Some relevant leadership styles explored in research literature are authentic leadership, servant leadership and empowered leadership. Similar to the transformational leadership style, authentic leaders express empathy to affect the vitality of the team. They advocate for learning and skill development to drive innovation and promote extensive information sharing (Kiersch and Peters, 2017). Nurse B was found to use an authentic leadership approach. In addition, servant leadership theory focuses on creating harmony within the organization and leaders using this approach to better equip followers with the resource needed to change. They guide their followers throughout the change process. Servant leaders lead from behind whereas transformational leader provides a common vision and develops their followers to meet those goals. The positive aspect of transformational leaders is that they are uniquely qualified to move an organization towards innovation during high external pressures. They emphasize on intellectual stimulation and creativity (Andersen 2018). Similar actions were taken by Nurse A to make the HH initiative a success. 

Transactional Leadership Style

Compared to Nurse A whose focus was on motivating the team members to follow and fully adapt to the new HH initiative, the response of NuNurse reflected her inclination towards a transactional leadership style. When questioned about the strategies she used to overcome barriers and help the team members perform, her narrative was ‘Just powerful words cannot enhance commitment towards change, I announced incentives for those who will follow the new guidelines properly and accomplish all tasks as expected. In addition, I announced penalties as well so that they make mistakes but try to learn from them and not repeat those mistakes’. Thus, she relied on rewards and punishment to achieve optimal performance or outcomes from their subordinates. Saravo, Netzel and Kiesewetter (2017) give evidence that transactional leaders believe in exchanging benefits for outstanding performance. It can exist in the form of active and passive leadership. Passive leaders are those who do not take charge of their leadership roles. In contrast, active leaders focus on corrective actions (Guhr, Lebek and Breitner 2019). Nurse B narrated during the interview that some of the staff were low in confidence and they lacked the confidence to interact with all team members. Their communication skill was very poor and she had to arrange additional training sessions for them. It is an example of active control in urgent situations.

Transactional leadership style has been identified as a subset of transformational leadership style and both affect organizational performance. Transactional leaders focus on clarifying roles and tasks (Purwanto et al. 2020). Nurse B’s response revealed her role in the same. She said that the most challenging part of leading a change was that most of them were not prepared. They did not have an idea of what they needed to make the change successful. I played a role in clarifying roles and discussing with them how they can adapt new skills for interprofessional team communication. In addition, she evoked the interest of the team by announcing awards and punishment. The four important components of transactional leadership styles are contingent reward, management by exception-active, management by exception-passive and Laissez-Faire leadership (Sethibe and Steyn 2017). Contingent reward is known to positively influence followers’ motivation, whereas Laissez-faire leadership and management by exception have a negative effect on employee motivation (Kalsoom, Khan and Zubair 2018).

Research studies have revealed the positive effect of both transformational and transactional leadership styles on job satisfaction levels and employee performance. A meta-analysis compared the effects of transformational and transactional leadership styles on project success. The study found a stronger effect of transformational leadership on project success compared to the transactional leadership style. The result was influenced by project-level factors as well as country-level factors (Abbas & Ali, 2021). The argument by Farahnak et al. (2020) regarding the superiority of transformational leadership over transaction leadership was that the transactional leadership style may support adherence to practice standards but it may not motivate interest in innovation. This is because transactional leaders focus on extrinsic motivation to help employees perform any task. Thus, such change may be temporary and go away when rewards are taken away. In contrast, transformational leaders influence attitudes by developing the enthusiasm of followers towards work (Burton, 2021). A similar outcome is evidenced by the response of Nurse A when she was asked what change she brought to the organization. She revealed that the staff were not introduced to the concept of innovation before that. Her role of motivating health workers and providing mutual support during the change initiative resulted in a permanent impact on their attitude. They started welcoming change and understanding the benefit of innovation for healthcare delivery. Intellectual stimulation and individualized consideration supported them to develop confidence in the new tasks and develop a positive attitude towards the organizational change (Giddens 2018). For this reason, transformational leadership styles have been identified as the best approach to lead a change.

Leader’s Communication Skills and Practice Change

The interview response reflected the individual characteristics leading to practice change. Communication was identified as a vital skill to make any practice change and quality improvement initiative successful. Both nurses displayed excellent communication skills to lead the team towards innovation and practice change. Nurse A reported using a clear communication process to share the vision and make staff understand the reason for revised guidance on hand hygiene. In addition, she added that active listening was a skill that supported her to understand the cause behind resistance and appropriately guide the team. Active listening helped in understanding individual concerns and offering the required support. It allowed her to be considerate of the health worker’s situation. The attribute is aligned with the characteristics of transformational leadership such as charismatic, individually considerate and intellectually stimulating. Through their excellent communication skills, they can drive the conviction to change and pass on the values to their followers (Becker et al., 2022).

 Despite the leadership style, communication is a key element that drives leadership. Leaders play a role in shaping the work conditions to deliver quality care. They use communication practices such as open and honest conversation to identify issues within the team and the broader context, build relationships with followers and understand the strength and weaknesses of their staff. They can negotiate, manage resistance, overcome conflict and create constructive work relationships through their communication style (Bergstedt & Wei, 2020). Nurse B narrated the use of communication to foster interest in practice change. Her method of announcing rewards was innovative. She used to personally acknowledge employees who did well and encouraged others to aim for similar rewards. Both nurses were successful in using their individual communication styles to build rapport with their team and promote staff engagement in the change process.

Self-awareness to Lead a Change

One of the leadership or managerial characteristic is self-awareness. It allows understanding of the status quo, ways to meet organizational goals and set realistic goals. It is a process that allows individuals to reflect on their values, identity, emotions, goals and capabilities. Such self-expression allows them to think, feel and act authentically. Apart from personal self-awareness, they should have collective self-awareness too. It implies understanding the values and perceptions of the team. They can respect their staff and communicate loyalty through their shared vision (Steffens et al. 2016). Nurse B narrated that she did not have much experience in leadership, but she wanted to be very loyal and transparent during the change process. Hence, she communicated all goals, visions and expectations to the team. The daily huddle and team meetings helped to strengthen her relationship with her team and get their cooperation during the change process. According to Brinkmann, Cash, and Price (2021), leadership self-awareness is an important characteristic that allows leaders to navigate the complexities of the healthcare system and lead a successful team. The ability to be self-aware can allow leaders to evaluate their skills regularly and make realistic self-improvement goals. This in turn can have an impact on professional and organizational performance. They understand how they can affect their followers and can understand and influence their followers.

Emotional Intelligence and relational transparency to lead a Change:

Emotional intelligence is also an important skill to manage resistance during practice change and support staff to overcome challenges during the change process. It allows them to connect emotionally with employees and lead with emotional intelligence. Nurse A displayed these characteristics when she identified that staff were irritated by the need to follow the new hand hygiene guidelines. They expressed being dissatisfied and regarding it as a burden. She tried to empathize yet clarify how it is not any additional responsibility but part of daily work. Thus, the attribute of emotional intelligence is aligned with the resonant leadership style. It allows people to connect with their followers and create a productive work environment.

While initiating and managing any organizational change, leaders need to take decisions based on logic and emotion (Hess & Bacigalupo, 2013). This depends on emotional intelligence. Nurse A was an expert in the use of emotional intelligence, but Nurse B confided that she faced difficulty in reacting to different emotions and taking the right decisions. Her narrative was ‘I could not sense the emotion of others and I found a gap in communication in the initial period’. But based on communication with her senior members, she realized that emotionally connecting with others is important to inspire and challenge them. Nurse B further adds ‘I tried to openly inform about the problem, why the current state of work needs to be changed and why their contribution is important’. It reflects the importance of relational transparency in leadership. It is the ability to be honest and openly share information with students. Nurse A maintained this by discussing how he focused on the professional development of the team. He stressed the importance of empowering nurses through in-formal training and workshops. Throughout the change process, he expressed taking feedback from workers and asking them to point out areas of difficulty. Regular training sessions were arranged accordingly. Brenner et al. (2022) affirm that transparency surrounding adverse events in clinical settings affects staff perception and such communication restored interest and commitment to work and quality improvement.

Conclusion

To conclude, it can be said that different leadership styles and approaches can be used to lead an organization towards practice change. While addressing the interview questions about leadership approaches and characteristics that support practice change, nurse A discussed the use of transformational leadership style whereas Nurse B discussed the use of transactional leadership style. The transformational leadership characteristics of inspirational motivation, individual consideration and intellectual stimulation are effective in motivating staff to accept the need for change and adopt new standards of practices. Based on a comparison with different leadership styles, the transformational leadership style was found to be the bests approach in inspiring and motivating followers towards optimal job performance. This is because they used knowledge sharing, communication of vision and motivational strategies to commit employees towards optimal performance. In contrast, transaction leadership relies on rewards and punishment which does not have much impact on attitude. In addition, communication, self-awareness, relational transparency and emotional intelligence were identified as some important characteristics that enables the two nurses to successfully implement the change and manage staff resistance during the change process.

References

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Appendix

Interview questions used for two nurses:

1. Please tell me about things you have done in the leadership role
2. Give an example of any practice change initiative that you have led? What did you do differently to make the change successful?
3. Did you face any resistance to change and how you have managed those situations?
4. What steps you took to support the professional development of the team during the change?
5. What is the most significant change that you brought to your organization?
6. Do you feel you have been successful in implementing practice change? explain

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