- emotional intelligence:
the emotional and social characteristics, skills and enablers that determine how we perceive and express ourselves, understand and relate to others, and cope with daily living
- leadership:
undertaken or carried out by people who try to unify people around values and then construct the social world for others around those values
- management:
the process of leading and directing all or part of an organisation through the deployment and manipulation of resources
- evidence-informed practice (EIP):
ensuring health practice is guided by the best research and information available
Contexts of practice
What do we actually mean when we talk about a practice context? In this chapter, we are referring to your area of healthcare or practice setting. As you know, this can mean almost anywhere there are healthcare professionals and consumers of care. Healthcare contexts are complex environments, and they have multiple components that impact on their structure, functions and the ability of those within them to provide care. The local community, the local environment, and the political and economic circumstances all affect practice contexts, which in turn influence the leadership, management, capacity and capability of healthcare employees. This chapter focuses on some of the components that impact on contexts of practice.
Understanding healthcare organisational structures
All of us belong to several different organisations. We might be a member of a sporting organisation, a professional organisation and/or a social organisation. We tend not to think consciously about their description as an organisation because we see them as specific components of our lives that allow us to reach our goals by following rules and processes set with a group of like-minded people. These organisations are simply a part of our day-to-day lives. Each organisation with which we interact – whether it is large or small – influences varying aspects of our lives.
- organisation:
a collection of individuals brought together in a particular environment to achieve a set of pre-determined objectives
Organisations impact on the ways in which communities and groups within communities operate. They influence the way policies and standards are defined, monitored and enacted, the authority and communication pathways used, and how goods and services such as healthcare are provided by governments and other agencies. Mancini (2015a) notes that external factors such as economics, social structures and demographics are major interactive components that influence the actual structure, mission statement and philosophy of the organisation. These internal and external elements also influence the level of satisfaction of employees who work within the organisation, the people who may reside within an organisation such as a residential care facility, and those in the surrounding communities who access the resources provided by the organisation, such as healthcare.
We understand the impact of these elements when we hear, see and read about changes in healthcare delivery systems that are the result of the prevailing politico-economic and social climate in the country. Flowing on from these are changes to nursing roles and how care is provided – elements that will continue to change as organisations respond to both internal and external influences. While Hein’s (1998) description of an organisation as a ‘living organism with interactive parts’ was written some years ago, it remains a good analogy today.
All organisations have a formal structure, which determines the roles of the individuals within the organisation, how the power and decision-making are delegated, how resources are allocated and the communication pathways within the organisation. The major organisational structures identified in the literature include the tall or bureaucratic organisation, the functional structure, the flat or decentralised organisation and the matrix structure (Ellis & Hartley, 2009; Mancini, 2015b). Mancini (2015b) writes that bureaucracies historically have been described in a negative fashion as a tall structure with the decision-making flowing from the top down to the workers, with clear lines of labour and control. The traditional bureaucratic structure keeps control at the top, giving little or no autonomy to the workers at the lower levels. The modern versions may possess some of these characteristics, but they often delegate autonomy and authority to some workers so the organisation can deliver its services and meet its goals, mission and philosophy more effectively. If you look at large healthcare organisations, you will see elements of a bureaucracy with aspects of a functional structure evident. Functional structures are very common in healthcare organisations. According to Mancini (2015b), the functional structure enables specialities to be housed within departments that offer similar services, with the department manager or supervisor reporting to a head of a major over-arching area. Both of these types of structure have clearly defined rules of reporting and lines of authority. Alternatively, the flat or decentralised organisation has less rigidity and more flexibility, as the management structure has been ‘flattened’ with the removal of a layer of management (Grohar-Murray & Langan, 2011). Matrix structures, on the other hand, are an integrated matrix of teams within a functional, bureaucratic structure that enables effective communication and consultation between healthcare teams in order to handle the diverse range of problems and specialities that can be found in a healthcare system (Grohar-Murray & Langan, 2011).
- healthcare team:
a group of people with common health goals and objectives, who work together to meet them
What do these structure look like? Figure 8.1 gives a visual representation of how an organisation chart might look, showing the formal relationships and lines of communication and reporting within that particular organisation.
Create an organisational chart for an organisation with which you are familiar. It might be the sports club to which you belong or an organisation where you have been employed. Fill in the lines of control and communication, and include specialist areas where appropriate. If it is a large, complex organisation, you might concentrate on a department or section and draw how it would fit into the bigger picture. When you have completed the chart, write out your responses to the following questions, explaining (with references to relevant literature) whether this structure enables the organisation to deliver its goals effectively:
Figure 8.1 Illustration of an organisational chart
Informal organisational structures
Now you have an understanding of formal organisational structures and the concepts of the chain of command, power and control, and lines of communication, it is time to look at the informal structures that exist within organisations. These do not show up on the formal organisational chart, yet they have a considerable impact on the practice context of employees, as this is where the majority of the organisation’s communication takes place (Ellis & Hartley, 2009). Ellis and Hartley (2009) note that the informal structure is as essential to the functioning of the organisation as the formal structure. It provides the social and communication infrastructure that assists employees to feel happy at work, and to achieve their goals through cooperation and communication. Hein’s (1998) seminal work on informal organisational structures takes a different viewpoint, discussing the idea that the informal structures will often give a more accurate indication of the state of the formal structure – particularly if there is general dissatisfaction with the work environment. As healthcare workers continue to deal with rapidly changing practice contexts, role challenges and increasing work-related stressors, there is a growing awareness of the need to look more closely at the impact – both positive and negative – of informal organisational structures.
Organisational culture
Organisational culture is not always an easy concept to understand. According to Mancini (2015a), the culture of an organisation is interlinked with the values and beliefs, or norms and traditions, of the organisation, and includes both the formal and informal structure and functions. For example, the formal organisational culture can be seen in the written documents such as the organisation’s mission, vision and philosophy statements, policies and procedures, and organisational position descriptions, while the informal culture is found in the daily experiences of employees. Do employees feel comfortable that what is written really reflects how staff and patients are treated, or is there dissonance between the two (Mancini, 2015a)? Jones and Bennett (2012) cite French and Bell’s (1990) iceberg model of organisational climate, noting that the formal or tangible components are visible while the intangibile components – such as values, attitudes, perceptions, routines and stories around the everyday activities of the organisation – are hidden. These authors also note that the culture of an organisation will be influenced by the structure, and by the levels of power and control within and between employee groups.
- organisational culture:
reflects the norms or traditions of the organisation and is exemplified by behaviours that illustrate values and beliefs
Teams in healthcare
Nurses working each day within the healthcare sector need to have a good understanding of the organisational culture with which their work is conducted. Knowing how to manage different staff perceptions, routines and the culture within healthcare work is important, as it is these intangible concepts that shape the culture and perceptions of individuals and ultimately affect how work is conducted and the way communication occurs in teams (Mac-Kian & Simons, 2013). Within healthcare, team approaches to care delivery are common, so the ability to work with and understand the people within health teams is important. While a team will always be constructed of multiple different personalities, gender differences, cultural and social differences, what matters is how each of these differences is negotiated, accepted and tolerated, and establishing a consensus within the team to ensure the common aim of quality care delivery is achieved.
Power and team influence
Many variables have an impact on the success of teams. One critical key to success is effective communication within and between individual team members. In a clinical setting, there are individuals who make things happen through indirect power and influence. Such individuals are present in all workplaces: they are people who make those things that impact on the level and quality of care at the bedside happen. They have the power to affect other people’s thinking and often change the way work is done (Stanley, 2011). These individuals can be categorised as those who are willing to share knowledge, are liked by colleagues for their professional capability, have the capacity to maintain a cohesive team, and are able to communicate well with everyone at both a clinical ward level or a management level.
Professional communication
Professional communication between healthcare professionals and the patients/clients within the health service is critical. What is said and what is not said often shape the perceptions of the care provided. This includes the trust and rapport of the healthcare providers and the individuals’ approach and attitude towards their professional communication. For example, the communication might be from nurse to nurse (intra-professional) or between different members of the healthcare team, such as doctors, pharmacists, physiotherapists and nurses (inter-professional) (see Chapter 2). The leader of a healthcare team allocates care according to the clinical demands of the day. For example, the registered nurse will use their decision-making ability in line with clinical needs, staff relations and organisational capacity.
- professional communication:
a process by which information, perception and understanding are transmitted from person to person
Practice statements relating to leadership and communication are well documented in the nursing literature and the professional nursing codes of ethics and standards of professional practice in Australia; these are integral to the role of the registered nurse (Acree, 2006; Avolio & Bass, 1999; Dignam et al., 2012; NMBA, 2006). The National Competency Standards for the Registered Nurse (NMBA, 2006) identify the characteristics of leadership as being inherent within the practice of a registered nurse. For this reason, all registered nurses play a role in leadership in the clinical environment, irrespective of their level of expertise. This is inclusive of care planning, delivery, evaluation, referral and consultation with members of the multidisciplinary team. The ways in which this is communicated and conveyed effectively within the team are essential to patient care, standards of practice, and personal and professional development (Anderson & Helms, 2000; MacKian & Simons, 2013; Stanley, 2006a; Thompson, 2012).
Vertical and horizontal communication
To communicate successfully in teams, nurses must be able to communicate both horizontally and vertically within the team.
Horizontal communication
Horizontal communication refers to communication with other members of the team, each of whom forms a direct part of the team. For example, a typical team on a morning shift within a busy 36-bed medical ward could include one clinical nurse, three registered nurses, two enrolled nurses and two personal care workers. The handover is provided to the staff and a work allocation of patients is distributed among the group. This team nursing approach to care is common, and both verbal and written communication is essential to the coordination of care and operational management (Anderson & Helms, 2000; Bokhour, 2006). Nurses are required to work cooperatively with each individual, interacting effectively, providing feedback, accepting and being involved in critical discussions and exhibiting the capacity to self-reflect (Bokhour, 2006; Ortega et al., 2013).
Throughout the shift on the medical ward, many tasks are conducted that are based on patient needs, activities of daily living, diagnosis and treatment plans, medical and healthcare team ‘rounds’ and resultant care-planning decisions in a nursing and medical and healthcare team context. This horizontal primary communication is directly related to care provided, and is aimed at quality patient outcomes. Communication tools like ISOBAR or ISBAR provide health professionals with structured communication pathways to communicate care decisions (ACSQHC, 2011) (see Chapter 2).
Vertical communication
Vertical communication within the healthcare team is an example of two-way communication. It is through vertical communication that healthcare management provides information to employees and receives information from staff about corporate progress or concerns within an organisation. This type of communication includes both upward and downward communication, and the conveying of information occurs through established channels or communication portals (MacKian & Simons, 2013).
Effective team communication and the capability to lead within a team are complex and multifaceted qualities. There is no ‘normal’ routine; however, the way we send and receive messages and what is done with the content are critical. This process affects the leadership styles, the power of individuals and the trust and respect that develop in teams, where communication and feedback play a pivotal role.
Emotional intelligence in nursing
The concept of emotional intelligence (EI) is essential in a clinical team, as it ensures effective team interaction and productivity, and is imperative for effective coordination of the team. Emotional intelligence can be identified in the power or drive shown by informal leaders in motivating the team towards collective action, facilitating or mentoring supportive relationships and inspiring a transformational influence within the team (MacKian & Simons, 2013; McCloskey et al., 1996). Individuals with emotional intelligence have the skills necessary to both manage and lead a team proactively; they possess both the skill and ability to inspire others to achieve common goals (MacKian & Simons, 2013; McQueen, 2004).
To assist nurses to determine how to use concepts of emotional intelligence within their practice, Goleman’s (1998) model of emotional intelligence is further elaborated upon below. The model has five elements:
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