The King Edgar Hospital’s National Health Service Trust

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Table of Contents

The Environment
The Change
Leadership
References

The King Edgar Hospital’s National Health Service (NHS) Trust has failed to meet the set national targets. Among the approaches identified as key strategies which may be reducing inefficiencies is the implementation of the nurse lead (NLD) discharge scheme. This scheme’s aim is to reduce the time taken to vacate beds in use by already discharged patients hence making them available for new patients in the emergency or on waiting lists. In the process of implementing this scheme several factors will be put into consideration. The environment and its influences will be considered, the change process will also be analysed involving both the plan and its implementation and finally leadership will be considered.

The Environment

In any environment where change is needed, there is always likelihood that there are initiating factors. A sociologist once noted that changes are only manifested and implemented where the forces of change are stronger than the restraining forces (Lewin, 1951). Thus, the failure to meet set targets or objectives is a significant factor in change.

PESTLE Analysis

Looking at the current position of the trust using a PEST analysis will increase the understanding of the position of the trust and give context to the changes.

Political Influences

King Edgar Hospital Trust is a part of the National Health Service which is a universal healthcare system. The NHS is subject to a high level of political influence which begins with the way in which the NHS was set up. It was first formed by Beaven in 1948 in a cross party imitative. In undertaking this, there was a link between politics and health care established in a very direct manner. This link has continued ever since, because trusts such as King Edgar have undertaken many more commercial practices including the development of a contract culture, which arguably should reduce the political pressure felt. However, it may be argued that this constant changing and need for cutting costs has lead to the existence of King Edgar Hospital trust. it was as a result of political pressure for health care services to be improved that the three hospitals merged in order to form the King Edgar Hospitals Trust.

Funding by the trust is directly linked to performance of the healthcare. Where a healthcare trust attains its goals they have a degree of latitude in the way the budget is spent with a low level of political interference. King Edgar Healthcare Trust has attained a moderate fail, achieving only one star out of three, resulting in intense pressure in various targets.

Economic Influences

Each and every health authority is faced with economic influences. As a public body there are high levels of accountability regarding the use of public funds (Nellis and Parker, 2006). There is always public pressure to reduce the expenditure on public services which is almost impossible. They require that the health care provides all types of quality service but at the lowest possible cost in order to reduce on taxation bills. Cost and patient care will often appear to be in conflict due to the limited resources especially where cost-cutting measures are taking place. King Edgar Hospital Trust needs to undertake performance improvements, but since they are cash-strapped there are insufficient resources for any investment to take place. This results in the need to utilize existing resources in a more effective manner. It is notable that the introduction of NLD is taking place at the same time with other cost-cutting measures. The aim of the change coincides with the environmental need to reduce costs by increasing efficiency, creating a better utilization of beds, reducing the waiting list and reducing the economic cost of keeping patients ready for discharge. On assessment, at any particular time 17% of the bed occupants were patients ready for discharge hence the processes delayed the discharge reducing efficiency and the overall cost.

Social Influences

Other than economical influences, social influences are also of great importance in this scheme. In the past the role of nurses undertaking the NLD has been that of subservient to the medical or clinical staff. However, the roles have reversed in the recent years thus requiring the nurses to undertake a higher level of professional development because of increased professional responsibility such as prescription of treatments. It was the UKCC Code of Professional Conduct in 1992 along with the Allied Scope of Professional Practice in 1992 which first introduced the idea of nurses being decision makers who could delegate. The level of responsibilities for nurses increased with the Statutory Instrument 1997 No. 1830 and The Prescription Only Medicines (Human Use) Order 1997 which authorised on who could prescribe treatment (Montgomery, 2007). This change extended the role of the nurses making them able to be responsible for the care given by others as a consequence of a nursing decision.

The plan of Burns supported by Andrews and workshops operated by Green with support from Edwards and Thornton was to increase further the professionalism and skills so as to increase internal efficiencies in a way that is likely to be acceptable to patients. This may be argued as a way of building on the existing framework rather than an innovative a new approach. Increase of the nursing professionalism was also supported by the reintroduction of matrons such as Edwards and Thornton in the wards as a practical measure to increase cleanliness and performance.

Technological Influences

In every organization there is always the need to adapt and change in order to face challenges. In the case of the King Edgar Hospitals Trust there is a requirement of improving by utilizing the existing resources only. Among them is the underlying Information Technology infrastructure that could be utilized amid the required measures. For example the consideration of readmissions where nurses were undertaking this judgement in order to monitor the efficiency and determine whether or not some critics were correct in assuming that there would be higher costs from most discharges as a result of readmissions. Therefore, the information technology within the organization may be leveraged so as to support the changes taking place and provide some baseline information.

Legal and Environmental Influences

The healthcare environment has been subject to a number of the influences; among them are potential legal consequences. Such may result from diagnosis and treatment where professionals will be accused depending on backing from the employer (in this case the trust). The hospital has to operate within a legal framework, including legislation laid down regarding targets and performance. The level of action taken against medical staff as a result of negligence and malpractice is increasing within the United Kingdom thus creating increased concern in medical staff (Fenn, 2007). In the end there is conflict within the medical staff resulting to a shift in responsibility especially where there is a perceived shift of responsibility down the hierarchy.

Doctors have traditionally taken the responsibility of discharge decisions because they are well-placed to undertake such decisions due to their medical training. However, changes in the legislative environment increase the possibility of nurses to undertake NLD. Nevertheless, a concern arose in the later stages of the change process which was the potential of a legal liability on the part of nurses. Within an environment where there is always awareness of legal issues it may be argued as inevitable hence requiring consideration.

Internal Factors

Generally, the King Edgar Hospital Trust is under a number of pressures and the move to NLD may satisfy a number of them including some internal factors that may need to be considered. The NHS staffs already have pressure in their jobs, and the introduction of changes may be an automatic assumption of increase in their workload. This is especially true in the context of former changes where a negative internal cost benefit analysis occurred. Nurses and the other medical staff have undertaken their career choices based on vocational drives rather than simply undertaking a job resulting in high levels of commitment. This reduces the likelihood of resistance from them in cases of any changes.

The three hospitals impacted by the change are all facing different pressures, Clover and Friar Hospitals have been under significant pressure to reduce waiting times in accident and emergency, and the issue of bed occupancy linked to the admission of patients from accident and emergency. However, in one Bronte the same urgency is not available. Therefore, the three hospitals are in slightly different positions, although they all need to respond to the external or macro environmental issues, the internal influences, resistance to change and perception of change.

The Change

Different change models exist which can be utilized to consider the way in which change took place. Looking at the process the ultimate aim of introducing NLD was to increase efficiency in bed occupancy. Having been carefully implemented there were significant advantages as it allowed winning of employees for their support of the change (Kotter 1995). A more comprehensive eight step change model was put forward where there were only three stages of winning the support of the employees as well as undertaking and entrenching that change. This breaks the process down further and identifies key elements which need to be in place for change to be successful.

Kotter’s Change Model

According to Kotter the first stage is to create a sense of urgency so as to create motivation for the change to be implemented. Approaches such as an open and honest dialogue can be very useful. It was noted that if a nurse was against the change and uses it as a move to increase their workload, the employees developed a sense of urgency following demonstration to management of the problems. They would take them around different areas and show them delays in areas, such as accident and emergency units where patients were waiting a long time, as well as in the bed bank making them see for themselves the problem and develop a sense of urgency. The creation of a sense of urgency was rewarded, the individual that was taken around shadowing the manager for a day not only became converted to the change, but became an advocate of them proactively calling the base banking order to call patients in following the release of a bed from a discharge patient.

However, the results realized from Bronte Hospital indicate that this facility, the smallest of all three, has a different level of urgency created. While the start of the hospital appreciated the need for increased efficiency, especially at Clover Hospital, they did not see the need for their own organization to go through the same process. It may be argued that urgency here is lacking as a result of lack of senior management presence. A major proponent of the change that was heavily supported involved Matron Helen Edwards. Therefore, creating a sense of urgency for change could not only be seen as the need for improved patient performance, but also as a result of the management presence. This indicated a potential lack at Bronte hospital.

The second stage is to form a powerful guiding coalition, where people are going to be impacted by the change. It is necessary that leadership is seen to support the decision, with leaders at different potential areas within the hierarchy get involved. It should also be noted that there are a number of individuals that could influence the way the changes are perceived. Burns creates a number of strategic alliances with key members of staff, including gaining support from the medical staff. A case at hand was when one doctor wrote to the chief executive, sending copies to Edwards, stating that he believed the change was unnecessary and a waste of time. Andrews replied indicating his support for the change, and stating that ‘resistance was futile’, a move which was necessary in order to support the change.

Although the change would eventually free doctors from certain duties, power structures within organizations are often reluctant to accept these changes (Huczyniski and Buchanan, 2007). By gaining a practical and emotional commitment from individuals who can be seen as centres of social influence as well as organizational leaders, there is the potential to create positive forces for change which will win individuals over. Within the approach taken for the nursing staff, the way that the communication took place at Green’s workshops organised and run by Green, undertaking the involvement could also be seen as a way of winning over the support of leaders that would be involved. The recruitment of those involved also took into account the need for their support, as seen with Edwards and Thornton then supported by Burns and Green.

The third stage is the need to create a vision for change (Kotter, 1995). This involves outlining the solution, the goals and the outcome to create a vision that is easy to cross (Kotter, 1995). The fourth stage is the communication of the vision; this was done effectively through the upper hierarchy. However, when looking at the way it took place it appeared as if it trickled down the hierarchy with reliance on a gradual stage process. The initial meetings to communicate the vision were also an important stage, but as noted by Burns, they needed to communicate the urgency and importance of the change so that it begun taking place. This is also seen in the way the nurses were told to continue to nag doctors for estimated discharge time. The continual presence and promotion of the change, chasing up results and pushing forward further measures to implement the change were all positive moves. But once again, this may indicate a potential weakness at Bronte, where there was no continual presence.

The fifth stage is the removal of obstacles. The first potential obstacle is resistance to change. During the case study many of the nursing staff did not display any resistance to change, but it may be noted that resistance to change is not always visible, and can be hidden. This is what occurred regarding potential concerns of legal liabilities when NLD rates manifested a lower rate than expected. Another obstacle noted was the unwillingness or slowness of doctors to train the nurses in order for them to undertake discharge process. This reduced the number of potential nurses who could undertake the task. Nevertheless, was overcome by new system where the nurses were trained on how to undertake these discharges thus removing the obstacle in an effective manner, as well as supporting other aspects of motivation by empowering the nurses. The first discharge made by a nurse was stressful hence providing a barrier, but as time progressed more discharges were made and there was increased confidence in the nurse. It is also likely that the level of stress involved with the discharge would also decrease in the future NDL’s as a result of more support from other trained nurses. Where there is stress as a potential barrier, overcoming with a higher level of support in the wards have been beneficial.

The sixth stage is to create short term wins. This was achieved by initially approaching individuals that supported the change, as well as undertaking pilot studies in areas with high winning potential. By being able to see the successful implementation it was likely that the longer-term implementation be supported therefore staff would see the benefits over and above the costs.

The seventh stage is to build on the change. This was an issue that the management should have been very aware of as well as the need to constantly monitor progress and ensure that there is not a reversion to the old practices. According to Lewin’s approach of change, he argues that once change is implemented and seems to be successful, it is advisable for the culture and practices to acquire these as its norms so that there is not a regression to the previous practices (Lewin, 1951). This is paralleled with Kotter, who argues that quick wins do not necessarily become long-term changes. There is always a need to constantly review what is taking place, assessing the goals and considering the way it may be enhanced. This leads to the last stage which is anchoring of the changes in the corporate culture, so that the new practice is accepted as a day-to-day normality on continuous basis.

Assessment of the Plan

When assessing the plan which was implemented it was found to have a large number of positive benefits with only a small number of potential disadvantages. It was communicated that this would provide a way for the nurses to work smarter rather than harder hence achieving more without increasing the overall workload. When the plan was communicated some resistance was noted especially on the workload. It was noted in case of a discharge and an admission this would increase the workload due to paperwork associated with admissions being onerous.

The plan itself utilized an effective approach by gaining support from the senior management as well as inputs from senior staff before the changes rolled out utilizing a workshop approach. Workshop approaches have a greater potential not only in a practical sense, but in the way it facilitates increased synergy between individuals as well as developing a high level of input that can add value to the change process. Some elements of planning were far below perfection. The change was being implemented at the time as other changes were also taking place, which resulted in some crossovers between the changes thus individuals sometimes faced an increased burden due to concurrent implementation of the changes. It may also be argued that the plan appears to fail due to some obstacles , such as the barriers created as a result of nurses being concerned with the support that they would get from the trust in case of a legal action. A greater level of attention paid to the potential barriers such as this may help reduce the emergence to a later date.

Assessment of Implementation

The initial area of improvement would have been instigating a greater level of urgency at Bronte, as the management and nurses did not buy the idea of changing after this was highly constrained. This was further aggravated by the absence of the senior management on the premises. Another potential improvement on the change model would have been removing the obstacles involved in the practical undertaking of the task by providing a higher level of support at ward level. Although training was taking place, communication of the need for change was effective in the nurses being trained. The actual support at that level was relatively constrained and as such it slowed down the rate at which the change occurred.

The Processes of changes in the plan were identified as necessary. For instance, areas of resistance emerged but appeared to be dealt with effectively by Taking on a human centric approach to win over the emotional support of the employees. Once again, Bronte Hospital appears to suffer due to the lack of presence of a senior manager. One major change in addition to identifying potential resistance and overcoming this as part of the implementation plan would be the appointment of a change manager at the Bronte Hospital. He/ She would undertake support and pursuance of the change in the same way that Burns and Edwards were able to pursue in the other two hospitals. This would not need a dedicated member of staff whose only duty is to oversee the change but this individual needs to be committed and believe in the change.

Leadership

A look at Burns, Green, Edwards, Thornton and Andrews, the latter of who was replaced by Smith in the way leadership took place in order to support the change can be considered. There are a number of theories concerning the way in which good leadership takes place. The study of leadership started with the study of behaviour patterns of great men with the belief that those emulated may lead to great management. This stage of leadership study goes back to the nineteenth century with the work of Galton and extended into the twentieth century (Borgotta et al, 1954). However, although the study was popular at that time, many great leaders were observed to have very different personality types so the theory was constrained. Therefore, we should not consider change leadership in this context, although some display traits that were able to gain support for example the way in which political supporters gained from strategic alliance.

The trait theory was built on the great man approach, but looked at the traits in general rather than individual leaders. The aim was to identify traits that could be adopted to enhance leadership skills. This approach was highly constrained as research indicated that there was no single trait or even a single group of characteristics that would be associated with good leadership (House, 1974). It may be argued that there are some specific traits in the change leadership, including Burns, but once again this is relatively constrained in real value. Following these theoretical approaches ideas moved onto behavioural theories. While leaders may not easily be able to change their traits, they may be able to adapt their behavioural patterns.

In addition to this there was also the ability to find strong empirical support (Fleishman and Harris, 1962). Different approaches were seen, some research looked only at the behaviour of effective leaders, and others took a more comparative approach comparing good and bad leaders in terms of their behaviour patterns (Yukl, 1989). The Ohio State and the Michigan Studies were able to identify two behavioural traits that were important; the initiating structure and consideration. The Initiating structure is where a leader will accentuate task accomplishment while consideration is the way the leader will show concern for the individuals who work for them, or for the team structure and cohesiveness (Griffin et al, 1987). In the case of Burns and the rest of the leadership there appeared to be a good balance. This is because where there was a specific task required; there was consideration for the individuals who would undertake it correctly in terms of team structure and cohesiveness. Measures were taken in order to try and increase the support for nurses at the team level, although this was undertaken through the hierarchy, and tools such as Greens’ workshops and the time taken to undertake communications or supported the consideration approach.

As leadership theories have developed the concept of a leader being able to adapt and change, the leadership position according to the situation has also emerged. A more modern approach is that of Goleman which incorporates a range of different behaviour styles into six different categories. It also notes that no manager is likely to utilize only a single approach in leadership. The approach creates a number of styles which may be described in terms of the way that the leader relates to their subordinates and expect their subordinates to react. There may be a dominant form of leadership adopted by any individual leader, but in line with modern theories it is acceptable that leadership needs to be able to adapt and change in line with the needs of the employees. Employees will need a very different type leadership in different scenarios.

There are six different leadership styles namely, coercive, authoritative, afflictive, and democratic; pacesetting and lastly the coaching style (Goleman, 2000). The coercive style of leadership may be seen akin to military leadership, where there is a requirement for employees to comply with instructions immediately and without question. This coercive style is also referred to as a command style. An initial reaction may be that this is a poor leadership style. In a modern commercial environment, the desire to demand immediate and questioning obedience is dated and unlikely to gain much support from employees. However, there are some circumstances where a command style can be beneficial, especially in situations of emergency and effective but fast leadership is required (Huczynski and Buchanan, 2007). This was not the style used in King Edgar Hospital Trust when one doctor went to the Andrews, the chief executive in order to object the changes. It may be argued that there was a command approach adopted when he was told that he had to comply. The approach is task-based rather than people based, which indicates that the attention of the leader in this situation, as such, there is less consideration as seen on the Ohio State model (Huczynski and Buchanan, 2007).

The next type is that of an authoritative leader where the individual leader will be able to gain some degree of authority as a result of their position, achievements, skills or knowledge. The leader utilizing this approach is likely to have some sort of vision for the organization and employees or a more general vision that can be communicated. Those who successfully utilize this approach are likely to have strong personal communication skills, as well as have the potential to be charismatic leaders thus able to win people over to their own point of view (Goleman, 2006; 2000). In general terms this can be a very positive leadership style, and has been utilized successfully by Burns.

The next style that of the afflictive leader. This is an interesting approach as may be associated with a pacifist approach. The main concern of the leader is to avoid conflict at all costs, with the aim of creating a consensus between the different employees so as to create harmony and agreement (Goleman, 2006; 2000). It may be argued that this type of leadership may be beneficial where there is a requirement of negotiation to take place, but can be problematic as human nature does not allow for consensus reached in all matters. This style of leadership is in use in Greens’ workshops, where different groups were utilized to discuss different processes of implementation and potential applications before the implementation took place. There was a desire to gain consensus, and as such there was some degree of this leadership approach though it reverted to the authoritative.

The democratic leadership style maybe said to be self descriptive. The process of democracy means taking into account the views of others with the decision of the majority being that which is carried. This is the political point of view, in the organisational behaviour it means otherwise. In this case Burns is listening and adapting in order to meet the challenges that are being performed, such as concerns regarding liability. The pacesetter style is where the leader may lead by example, undertaking the tasks and embodying the values that they expect their employees to follow (Cowan, 2005). This was not suitable for Burns, but lower down the hierarchy where leadership is demonstrating the way that the change was to be implemented this may have been suitable at some point.

The last style to be considered is the coaching style. This is a very nurturing approach where the leader has a high level of concern for the employee. It may be argued that this is a style of leadership that may have resulted in high benefits and especially the ward level of support which was needed. The coaching style considers the needs of the organization as well as the individual, with the leadership providing a comfortable environment. Burns does provide support, but cannot be expected to provide for individuals at that level. Therefore, the coaching style may be argued as more suitable for the leaders that were at a more local level. The implementation of the style may have resulted in less obstacles and a greater level of confidence, which would have facilitated the change taking place at a rapid rate.

Leadership of the change project was relatively well accomplished, despite meeting some objections, challenges and difficulties during the study. It may not have been as effective as desired, especially at Bronte; where leadership was the weakest, but it had a style that was adaptive in order encounter the circumstances, provide direct vision and support. The real issue in terms of leadership may be the way it is developed throughout the hierarchy, in order to provide support as well as confidence in individuals who are likely to rise through the ranks in the future. Supporting leadership skills that can support change as well as ongoing operations is also of benefit. By taking into account the potential different environmental issues and employee, the organization would be well-placed to manage the ongoing change in an effective manner, as well as assist in the implementation of other changes as they emerge.

References

Brogotta DE G; Rouch A S; Bales R F, (1954), Some Findings Relevant to the Great Man Theory of Leadership, American Sociological Review, Vol. 19, p755-9

Cowan, David A. (2005), Learning to diversify yourself, World Futures 61.5, p347.

Fenn Paul. (2002), counting the cost of medical negligence: NHS litigation authority will be able to report on costs and high risk procedures, British Medical Journal, v325 i7358 p233 (2)

Fleishman E A; Harris E F, (1962), Patterns of Leadership Behaviour Related to Employee Grievances and Turnover, Personnel Psychology, Vol. 15, p43056

Griffin R W; Skivington K D; Moorhead G, (1987), Symbolic and International Perspectives, on Leadership: An Integrative Framework, Human Relations, Vol. 40, p199-218

Goleman, Daniel, (2006), The socially intelligent leader, Educational Leadership 64.1, p76.

Goleman Daniel, Boyatzis Richard, Mckee Annie, (2002), Primal Leadership: Realizing the Power of Emotional Intelligence, Harvard Business School Press

House, R.J; Mitchell, T.R. (1974). Path-goal theory of leadership. Contemporary Business, 3, Fall, 81-98

Huczyniski A, Buchanan D, (2007) Organisational Behaviour, London, Prentice Hall

Kotter J P, (1995), Leading Change, Harvard Business Press

Kotter JP (1990), “What leaders really do”? In Mintzberg H, Kotter J P, Zaleznik A (eds) Harvard Business Review; On leadership. Boston MA, Harvard Business School Press.

Lewin K, (1951) Field Theory in Social Sciences, Harper and Row.

Montgomery J, (2007), Health Care Law (second ed), Oxford, Oxford University Press.

Nellis J G, Parker D, (2006), The Essence of the Business Economics, London, Prentice Hall.

Pearson A. W., Davies G. B. (1981), Leadership styles and planning and monitoring techniques in R & D, R&D Management 11 (3), 111–116.

UKCC, (1992), Code of Professional Conduct, London, UKCC.

UKCC, (1992), Scope of Professional Practice, London, UKCC.

UKCC, (1992), Standards for the Administration of Medicines, London, UKCC.

Yukl G A, (1989), Leadership in Organizations, Englewood Cliffs, Prentice Hall.

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