Leadership, Management, and Caring Theory in Healthcare

Introduction: Young Leaders and Leadership Criteria

James Strong, the former CEO and managing director of Qantas Airlines, twice sat on the panel convened at the Sydney office of CPA Australia to select those who would be recognized for the annual 40 Young Business Leaders list. Strong believed in the importance of nurturing young talent and threw himself wholeheartedly into leading much of the discussion among prominent leaders from all over the globe. Criteria for entrants included "the ability to land a top job, develop others and get the most from a team," and leading by example was also a must-have attribute ("CPA Australia," 2014).

To appreciate the scope and depth of the list-building endeavor, it is informative to explore the other participants on the panel and the criteria each articulated for evaluating entrants. James Strong looked for entrants who had "done well from a tough start" ("CPA Australia," 2014). CPA Australia's president, John Cahill, emphasized "a sense of integrity," while the company's CEO stressed the importance of "having passion and the courage to fail." The executive chair of Women on Boards, Ruth Medd, was on the lookout for "professionally well-rounded" entrants ("CPA Australia," 2014). Philanthropist and financier Chris Cuffe considered entrants who demonstrated early that they "have the get-up-and-go to experiment," evidencing emerging leadership traits. In concert with Cuffe's criteria, public practitioner Jason Cunningham was watchful for "young leaders who were likely to be ahead in sports, volunteering, and other activities" ("CPA Australia," 2014).

From these proven leaders and their insights on leadership, it is possible to distill the attributes and propensities essential for strong leadership and good management practices. A discussion of these dynamics follows.

The business management literature is replete with studies intended to discover and articulate the differences between leaders and managers (Cummings et al., 2010). Operating a business is like a sojourn on unmapped territory, fraught with known hazards and unknown risks, and a destination that seems continually just out of reach on an indistinct horizon. Leaders tend to set the company compass — determining what direction to travel, how fast to travel, and what to jettison when the load has grown too heavy — and create the necessary alignment to get the whole caravan moving in a new direction. Managers are more typically engrossed by activities such as what to do when a wheel comes off, or the river cannot be forded, or which shortcut to recommend when another caravan threatens to overtake the travelers.

Leadership, Management, and Teams

Setting this analogy aside, a more formal definition of leadership is getting people to work efficiently and effectively toward a common goal, such that the work is accomplished through the agency of people other than oneself. What, then, is management? In 1997, Warren Bennis published a book titled Managing People Is Like Herding Cats. The origin of the phrase "herding cats" has not been definitively established, but Bennis (1997) wrote: "Cats, of course, won't be herded. And the most successful organizations in the 21st century won't be managed!" He elaborates elsewhere in the book: "Management is getting people to do what needs to be done. Leadership is getting people to want to do what needs to be done. Managers push. Leaders pull. Managers command. Leaders communicate."

Retaining the most talented people in an organization is no easy feat. Highly intelligent and highly creative people synthesize information in ways that can produce insights that are difficult for others to grasp. Moreover, highly capable people may find it difficult to be patient while others catch up; they want to take action and are often compelled by a sense of urgency. These capable "cats" do not take well to being herded, nor do they always herd others effectively. Highly talented people may find that the constellation of skills enabling one to maintain long-term relationships or productively coach others is a mystifying conundrum. If enough disgruntled colleagues register complaints, an organization may find it easier to push out rare talent than to figure out how to keep the wheels turning smoothly.

This dynamic serves as a reminder that diversity in the workplace encompasses more than ethnicity, race, gender, age, and primary language. Diversity also includes a broad spectrum of talent, education, and areas of specialty — any one of which can function to undermine or support teamwork.

Team members typically include a senior facility manager, middle managers in areas of specialty, and back-office staff. The role of the senior manager combines oversight and troubleshooting, carried out in conjunction with middle managers. In any large organization — particularly one with multiple facilities — communication is among the primary concerns: the more layers a message must travel through, the greater the opportunity for its meaning to be misconstrued. Even when communications are written, the rationale behind a decision or the participation of deliberating parties will not always be clear to those who receive only the written message. The chaos, conflict, and confusion that can result from a reduction in force offer a perfect example of the importance of inclusive communication, in which critical information is shared across all stakeholders.

The role of leadership and management is crucial to ensuring good stewardship of scarce resources. Absent informed and timely leadership, the following scenarios pose a danger in the healthcare setting:

The continued growth of healthcare expenditures will reach such high levels that they become unsustainable; care that should be provided and is justified from every consideration will not be provided; and care that is not of certain value will nevertheless be funded.

Nursing Care Models and Caring Theory

One of the primary roles of healthcare leadership has been to facilitate the contemporary shift away from providers and toward patients and their families (Graetz et al., 2011). The important changes that managers have had to address deal primarily with alterations in the Australian system of healthcare financing, so that it no longer subsidizes health inputs (Graetz et al., 2011). This shift has helped to focus system resources on outputs — that is, on measuring and monitoring patient outcomes as reflections of quality healthcare (Graetz et al., 2011).

Some roles within the organization could be improved by using action research as a format for addressing the practice changes required of an agile organization (Graetz et al., 2011). The organization is structuring its team-building effort around the theory of caring. The transformation of the healthcare sector from a provider focus to patient-centered care is mirrored in the initiative to demonstrate that, through their clinical activities and professional transactions, nurses care about patients as well as care for them — and that both dimensions are important to patient well-being (Tonges & Ray, 2011). The plan is to use action research to study how caring theory can be manifested by integrating routine interventions that connect healthcare processes, care expectations, and nursing actions (Tonges & Ray, 2011).

The team-building initiative and the action research component are modeled after the Carolina Care Model developed at the University of North Carolina Hospitals (Tonges & Ray, 2011). The Carolina Care Model includes a performance framework for ways to actualize caring theory and to support nursing practices that promote patient satisfaction (Tonges & Ray, 2011). Embedded in this initiative — and essential to the Carolina Care Model — are efforts to transform cultural norms in order to sustain model implementation (Tonges & Ray, 2011).

The Carolina Care Model has enabled Swanson's Caring Theory to be operationalized and has fostered practice changes that enhance the hospital experiences of patients and their families (Tonges & Ray, 2011). The model also demonstrates the linkages between caring theories and the development and implementation of evidence-based methodologies (Tonges & Ray, 2011).

The tasks and protocols comprising nursing rounds practice are designed to analyze patient needs, anticipate those needs as much as possible, and ensure regular, personalized contact between patients and nursing staff (Tonges & Ray, 2011). In the process of anticipating and meeting those needs, patients increase their trust in nurses and in the hospital procedures and policies that influence the quality of care they receive (Tonges & Ray, 2011). These actions, taken together, foster patient trust, which is closely linked to patient satisfaction — assuming that patient needs are adequately or superbly met (Tonges & Ray, 2011). Beyond patient satisfaction, there are also benefits to nursing staff: conducting practice in a manner that reflects caring theory yields professional satisfaction, as providing safe, high-quality care results in satisfied patients (Tonges & Ray, 2011).

The rationale for selecting a particular model of care is to organize nursing work, to provide a common language and formal structure for that work, and to describe processes for delivering optimal services and patient care (Hedges et al., 2012). The basic structure of a care model articulates the responsibilities, communication pathways, work streams, and decision-making authority of those working in the healthcare context (Hedges et al., 2012). The care model selected promotes a relationship-based approach to nursing that can serve as a driver toward higher-quality patient care (Hedges et al., 2012). Importantly, the model can also serve as a mechanism for transitioning a facility unit to a new cultural norm (Hedges et al., 2012). Integrating a new care model into practice requires that all aspects of nursing care be addressed in the change model, including criteria for success, core nursing principles, leadership and administrative manager roles and responsibilities, nurse roles and responsibilities, policies and processes, and tools (Hedges et al., 2012).

Conclusion

The theory of caring and care models are the threads that run through this discussion. An examination and fitting of a model of care to a healthcare context serves as the basis for an action research project carried out with the aim of building a stronger, more effective team. The healthcare system is never static: change is a constant in healthcare as it is in most sectors. A healthcare system must develop ways of working that enable an agile organization with the potential to optimize healthcare services. To accomplish this, effective leadership and management must be resident throughout the healthcare system.