8Bit File

Clinical champions

A clinical champion is someone within the primary care team who is enthusiastic and driven to get a project or change implemented. It may have been their idea or something they are passionate to support and they are often willing to go the extra mile to ensure the project’s success.

This person could be a GP or nurse who is passionate about a particular project and is able to be the key driver for the project on a day to day basis.

To function well as a clinical champion they will; however, need the active support of the project sponsor described above.

Having an effective clinical champion ensures the project is integrated into everyday work for everybody. Without engaged leaders throughout the primary care team, it can be very difficult to change daily practice and achieve success.

Common goals

A key to ensuring engaged leaders is taking the time to determine a common goal or vision. When determining a vision or goal it is also important to consider how you would measure success. The following questions may be helpful:

• “For our team to know this project has been successful, we will be doing.
• “Our patients will be…..”

Clinical training and background are not synonymous with leadership. So where does a potential clinical leader turn to for advice? This small handy volume is specifically written for this purpose with information about the softer skills of leadership. It is not linked to any particular healthcare system or clinical discipline. Focus on leadership as a means to influence healthcare culture is attracting attention internationally currently. There is a lack of published material aimed at clinical leadership and the time is ripe to channel and develop formal pathways to support this unmet need. There is an appetite for understanding what leadership involves and the book is aimed at that. It provides useful information presented in a highly readable style.

Readers will find the style a refreshing change from the usual academic material. Accounts of hands-on experience with non-pedantic pragmatic advice are reflected strongly in the book. It draws heavily on the concept that perceptions may not be shared. This may be the basis for fruitful communication and mutual understanding, if not necessarily agreement. Clinical leadership is an evolving discipline and seldom do currently practicing individuals have an accredited qualification. They rather build up ‘on -the -job’ experience. This compendium of real life experiences and educational facts attempts to bridge the gap and prepare healthcare professionals to hit the ground running in their leadership roles.

The book’s narrative pace will make it a good holiday or long journey read. The subject matter is neither dry, trivial nor trite.

Contents:

• Leaders, Managers and Administrators
• So What is Leadership?
• Leadership Qualities
• The Leadership Role
• Perception
• Team Working
• Team Building
• Team Leader
• Complaints and Feedback
• Difficult Situations or Difficult People? Is It Me?
• Clinical Engagement
• Influencing and Negotiation
• Service Transformation
• Negotiation and WIIFM
• Communication
• Committees
• Followership
• Helping Others to Help You
• And Finally …
• Clinical Leaders: Heroes or Heretics?

Globally, health care systems in the developed world continue to struggle with escalating demands for services and escalating costs. Service design inefficiencies, including outmoded models of care contribute to unsustainable funding demands.¹ An example is the continuing practice in many settings to look to hospital emergency departments to provide what are essentially, primary health care services. While some progress and reforms have been achieved, numerous experts point to the need for further system change if services are to be affordable and appropriate in the future. They note that,

Effective clinical leadership has been linked to a wide range of functions. It is a requirement of hospital care, including system performance, achievement of health reform objectives, timely care delivery, system integrity and efficiency, and is an integral component of the health care system.^2–4 Though most people are provided with health care within the community setting, hospital care continues to garner the bulk of funding and attract considerable attention in relation to care quality and related concerns. Indeed, hospitals are very costly and diverse environments that vary in size and complexity, determined in part by their overall role and function within the larger health care system. The services provided by individual hospitals are determined and driven by a number of mechanisms, including government policy, population demographics, and the politics and power of service providers.

Clinical leadership in contemporary health care

The importance of effective clinical leadership in ensuring a high quality health care system that consistently provides safe and efficient care has been reiterated in the scholarly literature and various government reports.^6–8 Recent inquiries, commissions, and reports have promoted clinician engagement and clinical leadership as critical to improving quality and safety.⁹ As one Australian example, a key priority nursing recommendation of the Garling Report was that Nurse Unit Manager (NUM) positions be reviewed and significantly redesigned “to enable the NUM to undertake clinical leadership in the supervision of patients […] to ensure that for at least 70% of the NUM’s time is applied to clinical duties.” The remaining time could be spent on administrative and management tasks. In the more recent Francis report⁷ from the UK, a recommendation was made for similarly positioned ward nurse managers to be more involved in clinical leadership in their ward areas. In the United States, clinical leadership has also been identified as a key driver of health service performance, with the Committee on Quality of Healthcare suggesting considerable improvements in quality can only be achieved by actively engaging clinicians and patients in the reform process.

However, leadership in health care is often very complex, and some authors claim it faces unique contextual challenges. For example, Schyve⁵ claims aspects of governance are sui generis in health care, noting. Indeed, across the health care sector, evidence exists of the need for clinical leadership to optimize care delivery. In addition to challenges associated with resources and demand, episodes of poor patient outcomes, cultures of poor care, and a range of workplace difficulties have been associated with poor clinical leadership,^8,9,14 and these concerns have provided the impetus to examine clinical leadership more closely.

Definitional issues in clinical leadership

Within the health care system, it has been acknowledged that clinical leadership is not the exclusive domain of any particular professional group.¹⁵ Rather, all members of the health care team are identified as potential leaders.¹⁶ Like “leadership,” the concept of clinical leadership can be defined in a range of ways; and while a standard definition of clinical leadership providing absolute agreement on meaning is not crucial to progress and is likely to prove difficult,¹⁷ it is useful to consider the various ways clinical leadership is conceptualized and presented in the literature. While effective clinical leadership has been offered up as a way of ensuring optimal care and overcoming the problems of the clinical workplace, a standard definition of what defines effective clinical leadership remains elusive.^15,18 Indeed, in some ways it is easier to consider what constitutes poor or ineffective clinical leadership.

A secondary analysis of studies exploring organizational wrongdoing in hospitals highlighted the nature of ineffectual leadership in the clinical environment. The focus of the analysis was on clinical nurse leader responses to nurses raising concerns. Three forms of avoidant leadership were identified:

placating avoidance, where leaders affirmed concerns but abstained from action; equivocal avoidance, where leaders were ambivalent in their response; and hostile avoidance, where the failure of leaders to address concerns escalated hostility towards the complainant.¹⁴

These forms of leadership failure were all associated with negative organizational outcomes. Similarly, McKee et al employed interviews, surveys, and ethnographic case studies to assess the state of quality practice in the National Health Service (NHS); they report that one of the most important insurances against failures such as those seen in the Mid-Staffordshire NHS Trust Foundation is active and engaged leaders at all levels in the system.^14,19

Despite the definitional uncertainty, a number of writers have sought to describe the characteristics, qualities, or attributes required to be an effective clinical leader. Synthesis of the literature suggests clinical leadership may be framed variously – as situational, as skill driven, as value driven, as vision driven, as collective, co-produced, involving exchange relationships, and as boundary spanning (see Table 1). Effective clinical leaders have been characterized as having advocacy skills and the ability to affect change.^20,21 As well, effective clinical leaders have been linked to facilitating and maintaining healthier workplaces,^22,23 by driving cultural change among all health professionals in the workplace.²⁴ To achieve these positive outcomes, clinical leaders need to be seen as credible – that is, be recognized by colleagues as having clinical competence^18,25–27 and have the skills and capacity to effectively support and communicate with members of multidisciplinary clinical teams.^18,25 Taking an individual perspective, effective clinical leaders require personal qualities that reflect positive attitudes toward their own profession, have the courage and capacity to challenge the status quo, effectively address care quality issues, and engage in reflective practice.^18,14 Pepin et al found that clinical competence, the capacity to lead a team, and being prepared to challenge the status quo were necessary skills for clinical leaders in one Canadian study.²⁸ In an Australian study, findings indicated that student nurses want clinical leadership attributes from their clinical preceptors to include being supportive, approachable, and motivating, while being effective communicators.²⁹ Table

Many articles assert that clinical leadership is leadership provided by clinicians often recognized as clinical leaders. Indeed, an important driver of the move toward models of clinical leadership is the notion that clinical leaders “are the custodians of the processes and micro-systems of health care.”Stanley has contributed a summary of seven clinical leadership characteristics which includes factors such as expertise, direct involvement in patient care, high level interpersonal and motivational skills, commitment to high quality practice, and empowerment of others.In contrast to managerial leadership, which operates through hierarchical superior–subordinate organizational relationships, clinical leadership has a collegiate orientation and a focus upon the patient or service interface. While some clinical leaders may hold positions of positional authority, primarily the influence of clinical leaders stems from characteristics such as clinical credibility and the capacity for collaboration. While transformational leadership positions the leader as a charismatic shaper of followers, clinical leadership is more patient centered and emphasizes collective and collaborative behaviors.

Role of hospitals in contemporary health care

In the hospital sector, the demands placed upon leaders have become more complex, and the need for different forms of leadership is increasingly evident. To derive cost efficiency and improve productivity, there has been intense reorganization. Coupled with these reforms has been increasing attention upon improving safety and quality, with programs instituted to move attention beyond singular patient–clinician interpretations of safety toward addressing organizational systems and issues of culture. Arising from these reforms has been growing recognition that many assumptions of common leadership models are not well suited to delivering change at the point-of-care delivery or to assuring increased clinician and patient engagement in decision making. Accordingly, there have been calls for a transition to a new phase of hospital leadership, one that places the clinical frontline and clinicians as crucial to leadership within organizations.This transformational shift in the conceptualization of leadership has seen debate move from managerial, senior leader, or singular leader interpretations of leadership to a focus upon clinical leaders and clinical leadership. In part, this shift has been in response to growing recognition that while designated leaders in positions of formal authority within hospitals play a key role in administration and espousing values and mission, such leaders are limited in their capacity to reshape fundamental features of clinical practice or ensure change at the frontline.

There is considerable evidence to suggest nurses may experience dissatisfaction with the working environment in hospitals, with poor work environments impacting negatively on the delivery of clinical care and patient outcomes. In seeking to understand this dissatisfaction, work engagement among nurses and other health professionals has been explored from the perspective of burnout and emotional exhaustion with work engagement conceptualized as a positive emotional state in which employees are emotionally connected to the work roles.While such studies have examined engagement with work from an emotional perspective, engagement can also be understood as a broader concept that includes an employee’s relationship with their professional role and the broader organization.This broader view on employee engagement ties in with the concept of organizational citizenship behavior, which captures discretionary behaviors that are not formally rewarded within the organization that help others, or are displays of organizational loyalty or civic virtue.

The thrust of much recent attention upon attaining reform in hospitals through clinical leadership has positioned clinical leadership as a vehicle for improving clinician engagement in not only their own work, but also the care delivery microsystems in which they operate. This type of work engagement requires forms of citizenship behaviors that are focused upon improving clinical systems and practices. For individual clinicians, broader engagement within the organization with systems and processes requires the capacity for citizenship behaviors that are clinically focused and motivated, both at the level of one’s own work and also the broader network of relationships and systems. These forms of “clinical citizenship behaviors” require a fair and just work culture in which individuals can openly identify issues and work together toward solutions.

Edmonstone  cautions that without structural and cultural change within institutions, the move toward clinical leadership can result in devolution of responsibility to clinicians who are unprepared and under resourced for these roles. Evidence emerging from the NHS suggests particular value in leadership coalitions between managers and clinicians. Further, strong clinician representation at Board level has been reported to make a difference to clinical engagement.

Preparation for clinical leadership roles

There is also a concern that many health professionals may not be well prepared to understand the nature of leadership, or take on leadership roles because of the lack of content on leadership in undergraduate course curricula. These deficiencies have been recognized by professional organizations and health service providers, especially in light of wide-ranging inquiries into the quality of health services in a number of countries. As a result, there have been efforts made to overcome these deficiencies in the preparation of health professionals. As Gagliano et al comment, there is some evidence that health service provider groups are attempting to address issues pertaining to leadership issues through design and implementation of leadership development programs.