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Leadership Styles

Question:

Discuss about the Change Management using Transformational Leadership and Lewin's Change Theory.

Change in any organization is inevitable for efficient service delivery and profitability to be achieved. With every change comes resistance and overcoming the resistance is one step to successful implementation of a proposed change. Involving all stakeholders in every phase of a change process is another critical step to a successful change implementation(Gilbert, 2009).

In this paper, the implementation of a Bar Code medication system is proposed as the ideal solution to minimizing medical errors and improving patient service delivery. The paper discuses two different leadership styles: transactional and transformational- and concludes that the transformational coaching leadership style will be most effective in realizing the proposed change. The role of nurses as change agents is also discussed with practicality of the coaching leadership style acting as a link between effecting change among the nurses and between the nurses and patients.

The proposed change management theory to be used is the Kurt Lewin theory.  The implementation of the Bar Code system will require that nurses are weaned off the current methodology of medication delivery and administration (unfreezing), educated on the new Bar Code system (freezing), and evaluated on their use of the same in the final stage of refreezing.

Formal leaders in an organization that command the faith of their employees tend to have the subordinates look up to them for several things. During times of necessary and drastic changes, employees will often expect sensible and effective planning decision-making, that is effective, confident, and complete as well as regular communication that is made in a timely manner. In addition, during these times when there is change being effected, employees will view the leadership as being committed, concerned, and supportive of their welfare, while simultaneously recognising that there is need for tough decisions to be made. In summary, a climate of trust should exist between the employees and the leaders which in turn brings hope for the future and which make coping with the  change easier (Kellerman, 2007).

In organizations that have poor leadership, there are no positive expectations by the employees. Where there is distrust, employees perceive that leaders' actions will be  indecipherable and in ways that have no-one's interest at heart. Poor leadership results in a lack of hope, which in the long haul results in a non-functioning organization. The organization ought to handle the unpleasant change practical impact and more so, must do it under the weight of employees that have no hope in the leaders' ability or the entire system altogether. The key to a successful change is the involvement of leadership prior to, during, and after the implementation of the change. The leadership therefore needs to have laid a foundation of trust prior to embarking on any changes (Llopis, 2013)

The manner in which a leader provides direction, plan implementation, and people motivation, is referred to as leadership style. Leadership styles need to be adopted with regard to a specific situation , the specific needs of the people, and the particular challenges that the origination is facing (Martindale, 2011, p. 32). This paper will look at two leadership styles,: transformational leadership and transactional leadership and then determine the most suitable leadership style for the proposed change.

Proposed Change: Bar Code Medication System

A transformational leader does not work under the confines of his/her employees' perceptions. The main goal that such a leader has is to transform or change the needs of the employees and re-direct the way that they think. A transformational leader inspires and challenges the employees with a sense of excitement and purpose(Schultz & Schultz, 2010, p. 201). Transformational leaders have a vision which points at what they are aspiring to become and communicates this vision to the employees. There are three characteristics of a transformational leader and these include: charismatic leadership posses a wide knowledge field, has an energy level that is high, a personality that is self promoting, and is a risk taker who uses irregular strategies that aim at stimulating the followers to be independent thinkers; intellectual stimulation; and individualized consideration  (Schultz et al., 2010,p.201)

A transactional leader focuses on motivating employees through a punishment and rewards system. The two foundational basis for this type of leadership include: management-by- exception and contingent reward. The leader maintains a status quo by using management-by-exception and intervenes when there is failure of employees to meet set goals and proceeds to initiate corrective action that aims at improving performance. This helps in reducing the manager's workload as they only step in to deal with a deviant employee. Contingent reward on the other hand, offers psychological and materialistic rewards for employee effort and also recognizes their good performance (Liu, Liu, & Zeng, 2011, p. 282).

A transactional leader will identify the needs of the employees and offer rewards in response to meeting those needs in exchange for a specific performance level. A transactional leader will focus on enhancing efficiency of already  established procedures and  routines. Such a  leader is more concerned with abiding by existing organizational rules as opposed to making  changes within the organization. The transactional leader will standardize and establish practices that aim at driving the organization to achieve maturity, operations efficiency, productivity increase, and operations efficiency (Liu et al., 2011, p. 282).

Based on the proposed change, transformational leadership will be the most appropriate . The current leadership at my place of work is both transactional and transformational. There are leaders that are transformational and those that are transactional. However, in this particular proposed change, transformational leadership will be most effective.

Evidence-based research  shows that in healthcare, transformational leadership increases nurse satisfaction, reduces turnover of staff, and promotes an environment for positive work environment (Lin, McLennan, & Hunt et al., 2015). Transformational leadership forms a critical element in the implementation of change or toward the achievement of work environments that increase the safety of patients. There are four sub styles that are encased within transformational leadership: coaching, affiliative, democratic, and authoritative (Benincasa, 2012).


Authoritative leaders will steer people toward a vision and are the most effective leaders (Benincasa, 2012). The leader communicates the vision in a vivid manner to employees and motivates them by demonstrating the individual employee's work role in the bigger vision. Latitude is offered to the employees on achievement of the vision. The authoritative leader is most effective in nursing practice when a clear turnaround and direction is needed (Benincasa, 2012).

Nurses as Change Agents

Democratic leaders will always encourage the employees to give their input  and hence, build a consensus when all persons are involved. It is also referred to as participative leadership as all persons, excluding the leader, have a final say on the final decision. In nursing practice, this kind of leadership style is useful when the leader is uncertain about the right steps to take and therefore, seeks ideas from others. It  allows nurses to feel that they have a voice when it comes to decision-making; builds nurses' morale; and reduces disruptive behaviour and workplace bullying (Benincasa, 2012).

Affiliative leaders create emotional bonds with employees through creation of a sense of belonging and offering feedback that is positive. This style is ideal for the building of team harmony, repairing broken trust, or increasing morale. In nursing practice, this leadership style allows for improvement of communication. For affiliative communication to be more effective, it is combined with authoritative leadership (Benincasa, 2012). 

Coaching leaders aim at developing future leaders. These leaders identify the employees' weaknesses and strengths, set goals for development, and assist employees in achieving them. A coaching leader is interested in the employees' career and personal aspirations as well as in achievement of personal growth. According to King (n.d.), nursing practice should revolve around setting  of goals by nurses together with the patients rather than planning care without involving the patient

The proposed change will use Kurt Lewin’s theory of change management and apply it to the introduction of  Bar Codes technology of medication delivery and administration at the hospital facility. By using Lewin's theory, a better understanding will be gained in the change effect on the organization, identification of successful implementation barriers, as well as identification of actions of human behaviour opposing forces. 

A SWOT analysis is used in providing prompts to nurse tutors, clinical leaders managers, staff, and nurse mentors involved in analyzing what clinical procedures are effective and which ones are not,  in preparation of  a particular plan (such as quality checks, assessments, CQC) (Morrison, 2011).A SWOT analysis is used in planning or analyzing activities that have a potential impact on the management, planning, and financial decision. It enables the clinical staff and management to do a comprehensive analysis.

  • Strengths– these are the factors that potentially have a positive effect or can enable the achievement of the hospital's objectives
  • Weaknesses– these are the factors that potentially have a negative effect or can be a barrier to the achievement of the hospital's objectives
  • Opportunities–these are the external factors that can potentially have a positive effect on the achievement or surpassing of the goals or objectives of the hospital which had not been considered previously.
  • Threats– these are the external factors that can potentially have a negative impact on the achievement of the hospital's  goals or objectives, or making them unachievable or redundant.

Strengths

Outstanding nursing staff

Highly committed to hospital mission

Excellent facilities

Healthcare quality is outstanding

High level of efficiency at the hospital and ward

Utilization of state-of-the-art technology

Hospital has invested in healthcare informatics

Focused improvement of community healthcare

Personnel are highly committed

Employees have a clear understanding of the hospital's goals

Hospital is focused on improvement of quality.

Weaknesses

Inadequate resources

Clinical staff shortage

Clinical processes lack continuity leading to effort duplication

Poor communication resulting in disrupted patient care

Utilization of health informatics is poor Insufficient training of management

management training

Patient data lacks relevance and is untimely

Opportunities

Growing urban community

Increased business in managed care

Growing numbers of programs in community healthcare

Introduction of protocols to improve efficiency and quality at the hospital

Threats

Government reimbursement has reduced

Speciality physicians as a competition

Provider networks in the healthcare industry offering increased competition

Increasing deficits in the federal and state budgets

Uninsured population is growing

Kotter’s 8 Step Change Model

The 8 step model transforms a change to a campaign where the employer pitches the change to the employees who are expected to eventually buy into the need for it. The 8 steps involved include: Increasing the change urgency; building a dedicated team that spearheads the change; creating a vision for the change; communicating the need for the change to take place; empowering the employees with the ability to embrace the change; creating short term goals; staying persistent; solidifying the change (Kotter International, 2017).

The process is a  simple step by step that focuses on preparation for accepting the change. Transition to a change is simplified in this model. However, the proposed change for the hospital in question will not use this model because the process takes a relatively long time and no one step can be skipped.

Kurt Lewin Change Management Theory

The McKinsey 7-S model  is one that offers and approach that is holistic with regard to organizational change. The collective change agents in this model: skills, staff, style, systems, structure, strategy, and shared values. The model offers an effective diagnostic method  that illuminated the organization; offers guidance in change; combines emotional and rational components; and requires all parts to be addressed in unison. However, the main downside of this model is that it is complex, differences are overlooked, all parts are interrelated hence one change cause change in all others (Mindtools, 2016). This makes the Mckinsey 7S model unsuitable in implementing change in the hospital.

Many organizations have used the Lewin's change theory in understanding human behaviour in relation to change and resistance to it (Houson, 2015, p.55; Hoogendoorn, 2007, p.147). The theory is also known as the Force Field analysis(Lewin, 1947) and encompasses three phases namely: unfreezing, freezing and refreezing. The model's intention is the identification of factors that can hinder the occurrence of the change; opposing forces referred to as static or restraining forces, and forces which drive or promote change known as the driving forces. When a healthcare organization has a complete understanding of what behaviours oppose or drive change, they are better able to strengthen the forces that drive the change for the successful implementation of the expected change.

In the first stage of unfreezing, there needs to be an understanding of the challenges in relation to the problem that has been identified and subsequent strategies developed for enhancing the driving forces while simultaneously weakening or reducing the restraining forces. Unfreezing involves the identification of the major players that will be most impacted by the change and then summoning them in one common ground and communicating the ideas to them.      The static and driving forces are listed down during the common ground meeting. The second stage -Moving- is when the change is put into practice after the opposing forces have been equalized which in turn allows the support for the change by the driving forces. In the moving stage, the project implementation results in the desired change therefore, it is critical that communication lines are kept open between the management and the nursing staff. Finally, once the expected change is achieved, the refreezing takes place where the change stability is evaluated as well as its overall effectiveness in the healthcare practice.

Unfreezing Stage

Identification of the focus of change is the first step of the Kurt Lewin analysis and more specifically implementation of the scanning system that uses Bar Codes, for the delivery of medication in the healthcare facility. The main component in this stage is communicating the proposed change with all the stakeholders including administration, managers, and frontline nurses. It is critical that all lines of communication between stakeholders remain honest and more importantly open, as this will create a sense of trust and security among all that are involved in the change process (Gilley, Gilley, & McMillan, 2009, p. 75). By including front line nurses in the key decision making and planning groups, a feeling of being empowered will be promoted . This empowerment helps in overcoming change resistance and enables the frontline nurses to understand the project's importance and its potential benefits with regard to client care.

Suitability of Leadership Style

During this stage of unfreezing, identification of restraining and driving forces can be listed down during  discussions held in informal, open, roundtable meeting, which will enable identification of barriers that may need to be worked out. In the healthcare facility in question, some perceived restraining forces include: staff resisting utilization of computer based devices; inexperience with computers, distrust within the organization, and  user aversion to new systems. The driving forces will be those that help in propelling the project toward completion such as upper management level support, adequate financial resources, potential improved  time management, and ease of use. The key point is that the exercise will engage all stakeholders in an active way to work toward enhancing the positive drivers while minimizing the restraining forces so that the Bar Code system is adopted successfully while eliminating the dangerous workarounds, and enhancing full investment of the nurses in the long haul.

This is the stage when the actual change is taking place and includes planning and implementing project stages. Implementation of the Bar Code system in the healthcare system requires sustained team effort  which will include: clinical information services, pharmacy, information technology (IT), clinical nursing educators, program managers, nursing, and administrators. This project is sizeable and will affect all the aforementioned departments in diverse ways hence, a roll out that is effective needs to be planned with the inclusion and assistance of all stakeholders being critical. Actively involving frontline nurses creates a sense of ownership which contributes to the success of the project. At the healthcare in question, some of the areas that need consideration include timeline on implementation, equipment reliability, educational training requirements, impact on workflow, and organizational leadership and culture (Spetz, Burgess & Phibbs, 2012, p.157). It will also be critical for a project leader to be appointed who will monitor and oversee all the phases of the project. The main challenge that may be experienced in this stage may be the discovery of the utilization of workarounds which can be resolved with additional training..

This last step requires the refreezing or freezing the desired change and leads to evaluation and stability of the practice. Frontline nurses are accorded ongoing support and the stakeholders are accorded technological support  in a continuous flow, to a point when the change is completed and all users are able to use the technology comfortably. Once the technology is completed and is live, a summary and evaluation of the challenges encountered, the successes encountered, and the different problems faced through the entire duration of the project, should be done as a source of reference in the future.

The inclusion of frontline nurses in all phases of the project is necessary as the nurses' major function is being change agents. Nurses have close contact with patients and are able to see the effects of the healthcare system and medicine on the patient (Keyes, 2014). In this project, the coaching leadership style will come into play  where the real objective will be to help the already competent nurses to become even more successful. The nurses will be expected to be mentors to those that will find challenges in understanding and utilizing the Bar Code system. By coaching them, the final result will be that all nurses being capable of using the system effectively, reduced turnaround time, reduction of medication errors, and precise patient care.  The nurses will also be responsible for patients' uptake of the new system; they will be open to the patients with regard to the change and encourage them to embrace it. The coaching leadership will improve the bottom line.

Evidence-Based Research

Medication safety is an issue of concern and  a priority in long term care and hospital facilities as medication errors  pose a serious threat to the safety of patients. Several studies have shown that fatality rates linked to medication errors in the US exceeded 7000 deaths per annum and affects 3-5% of hospital in-patients ( Dennison, 2007, p. 176; DeYoung, Vanderkooi, & Barletta, 2009, p. 1110). Medication errors' ramification affect all healthcare units, result in mistrust by consumers, increased costs of healthcare, and patient death or injury(Andel, Davidow, &Hollander et al., 2012, p.2) . Occurrence of medication errors can be at any administration and dispensing process stage however, only approximately 5% are recorded in nursing documentation, which is suggestive that there are many errors that have not been catastrophic and which have gone unreported (Wilkins & Shields, 2008).


Medication errors can be defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labelling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use”(NCCMERP, 2016). These are common in healthcare facilities across the world with serious consequences resulting in patient harm or death, prolonged stay of patients in the hospital, trust erosion between healthcare organization and the consumer, and elevated economic expenditure (Dennison, 2007, p. 176). The estimated economic impact that is as a result of medication errors is approximately 5,000 dollars for every error, and when litigation is involved, this amount can escalate to millions of dollars (Dennison, 2007, p.176).

Besides the harm done to the patient, nurses too face harm in their morale after involvement in a medication error which can lead to potential work time lost (Dennison, 2007, p.176).  Although medication errors can happen at any point of the patient care process, the nurse is most times the final defence line for capturing errors as he/she administers medication at the patients' bedside. This can be translated as the nurse having responsibility of ensuring that the right medication is administered to the patient and when drug errors occur, the nurse should be held liable (Wilkins & Shields, 2008).

There have been several strategies introduced in an effort to reduce occurrence of errors in the process of administration and dispensing of medication and these include electronic medication records and patient identification, among others. One such tool is the proposed Bar Coded medication system that can potentially reduce errors in a significant way, when correctly used (Dennison, 2007, p. 176). One of the top priorities of healthcare facilities is patient safety and delivery of safe medication, which are a critical aspect of complete patient care.

The current system  of administration and delivery of medication at the healthcare facility in question involves dilapidated medication carts and is reliant on manual checks to ensure correct drug administration at the right dosage, site, route, and time by the nurse. The healthcare facility in question should embark on a complete pharmacy system overhaul and incorporate automated dispensing machines, together with medications bar coding, and electronic medication records, to improve and modernize patient safety and care. The frontline nurses will feel the greatest impact despite the possibility of some feeling sceptical or lacking confidence in the change and their ability to embrace the new technology, hence, careful implementation will be critical.

Conclusion

Conclusion

Change is inevitable yet any change often meets resistance. Careful planning and inclusion of key stakeholders throughout the entire change process is critical for the successful implementation of any change. In this paper, the introduction of a Bar Code medication system has been discussed as  a necessary change that can potentially reduce medication errors. The inclusion of frontline nurses as the agents of change is necessary as they act as the point of contact between the patient  and the healthcare facility as a whole. By empowering nurses through transformational coaching leadership, nurses can effect change in the medication delivery and administration in the healthcare facility by first assisting each other in gaining an understanding in the workings of the system; and secondly, through education of patients on the new changes which will in turn increase acceptability of the system among the patients.

It is clear that transformational leadership is key in implementing change and the Lewin's theory of change management is the ideal way of ensuring the change is successful. By keeping communication lines between all stakeholders open and honest, and from the freezing stage to the final unfreezing change, resistance is minimized and adaptation potential is enhanced manifold times.

References

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Benincasa, R. (2012). 6 Leadership styles and when you should use them. (Retrieved on 16th April, 2017) from Fast Company. https://www.fastcompany.com/1838481/6-leadership-styles-and-when-you-should-use-them

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Martindale, N (2011). Leadership Styles: How to handle the different personas. Strategic Communication Management. 15 (8): 32–35.

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Schultz & Schultz, Duane (2010). Psychology and work today. New York: Prentice Hall. pp. 201–202. ISBN 0-205-68358-4.

Spetz, J., Burgess, J. F., & Phibbs, C. S. (2012). What determines successful implementation of inpatient information technology systems? The American Journal of Managed Care, 18(3), 157-162.

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