FRAMEWORK

Perhaps the last chapter is the one that unites the major underlying theme of interdisciplinary teamwork and effective leadership. Leadership relates to all areas of practice and is the means to influence change. The authors discuss current and future health care systems and their impact on leadership. The lack of research into leadership in aged care organisations is a factor that influences the future direction of service delivery. Person-centered care is a concept that acute hospitals are finding difficult to implement. Aged care services, however, have been changing toward this care approach for some time. There is merit in opening dialogue between service providers to create the preventative and primary care system that is required for the future. The vignette in this chapter gives much food for thought and opens a possible vision to consider. [RN, SG]

Introduction

Our health care system, consumers and providers, are ageing. People over the age of 65 use the most bed days, consume the most community care and represent the majority of residents in long-term care. Health professionals are increasingly over the age of 45. To ensure resources are used appropriately and consumers receive quality care requires visionary leadership. This is not a time for doom and gloom, but it is necessary that government, health professionals, industry providers, researchers and educators do things differently. More money for more of the same is not the answer. Too often management prevails and leadership is forgotten as individuals in leadership positions, but without leadership qualities and skills, bounce from managing one crisis to the next. This book is about improving care for older people; for the ideas and innovations to flourish, leadership is essential. So what do we know about leadership in health care?

What do we know about leadership in the health care context?

Despite widespread acknowledgment of the importance of effective and responsive leadership in the health care context (Daly et al 2004; Jackson 2008a; Schwartz & Tumblin 2002), the scholarly discourses around leadership in health care are still relatively scant. Recently, Dowton (2004) considered:

articles indexed over more than 30 years in five Australian journals (The Medical Journal of Australia, Australian & New Zealand Journal of Surgery, Australian & New Zealand Journal of Psychiatry, Australian Family Physician, and the Journal of Internal Medicine and its predecessor), and could barely find 50 articles dealing with leadership … Furthermore, very few of these 50 articles, editorials, or letters provided substantial information or commentary on the makings of leadership. One regionally relevant and accessible electronic archive of medical interest, the eMJA, does not index ‘leadership’, and in over 3800 entries has but three items with ‘leadership’, ‘lead’ or ‘leader’ in the title.

(Dowton 2004: 2)

Vance and Larson (2002) undertook a review of leadership research in health care and business for the period 1970 to 1999. From a review of 6628 articles, they concluded that to date, the literature on leadership in the discourses around health and business:

has been primarily descriptive. Although work in the social sciences indicates that leadership styles can have a major influence on performance and outcomes, minimal transfer of this work to the health system is evident. Limited research on leadership and health care outcomes exists, such as changes in patient care or improvements in organisational outputs. In this era of evidence-based practice, such research, though difficult to conduct, is urgently needed.

(Vance & Larson 2002: 165)

On the other hand, Hamlin (2002) notes that:

much research has been done over the past thirty years or so concerning the study of managerial and leadership behaviour. However, the majority of studies have almost exclusively been focused on the ‘absolute’ or relative ‘frequency’ of observed behaviours, or on the amount of time devoted to particular activities, and not on the ‘quality’ or ‘mastery’ of specific behaviours associated with either effective or ineffective management and leadership.

(Hamlin 2002: 248)

Nursing — as opposed to health care generally — has a more established literature on leadership that has likely been brought about by the pressures faced by the discipline over the past two decades. In the Australian context, these pressures have been caused (at least in part) by the transfer of education from hospitals to the education sector. This transfer resulted in a loss of a layer of senior nurse leaders from the health sector, as many educators and tutor sisters moved from health into education (Mannix et al 2006). Furthermore, the transfer created a need to ensure that leadership models to support the entry of new graduates were in place. Internationally, nursing has been grappling with acute and chronic shortages of nurses, particularly in specialty areas. These pressures have resulted in exploration of various leadership models that might assist in retaining staff and developing a sustainable workforce (see, for example, Thyer 2003; Jackson 2008a). The nursing literature identifies various models and styles of leadership, ranging from the very bureaucratic and autocratic styles of leadership, through to the charismatic and relationship-based approaches. The latter approaches have found particularly fertile ground in nursing (Jackson 2008b) and we have seen the emergence of models that embrace concepts such as mentoring, and that focus on creating and enhancing collegial relationships and personal growth (Grossman 2007).

How does the current and future health care context impact leadership?

Leaders in health are challenged to lead constituents within the context of an ever-changing, highly politicised and volatile environment. The health system in Australia has undergone enormous change in the last 2 decades. It is clear that this change will continue as governments strive to meet current and projected challenges, while working to create new systems of care that are cost-effective, based on evidence, and that are equitable, accessible, responsive and of good quality. Health disparities exist in Australia, and Indigenous and other marginalised people in particular have needs that must be addressed so that their health outcomes match those of the mainstream population. The needs of the population for health care are predicted to increase due to a number of factors; for example, population growth, the growing incidence and burden of chronic disease, and ageing. Growth in the prevalence of chronic disease is likely to be influenced by alcohol and drug abuse, poverty, socioeconomic disadvantage, unhealthy lifestyle and diet, and possibly climate change (Australian Government 2008).

Leaders in health are challenged to lead constituents within the context of an ever-changing, highly politicised, and volatile environment.

In 2006, people over 65 years constituted 13% of the population, and this is predicted to increase to 24% by 2036 (Australian Government 2008). The burgeoning costs of acute care and management of chronic diseases (many of which are a consequence of lifestyle) are currently under scrutiny. Without changes in health involving the community, these costs may become unaffordable. A re-conceptualisation of health and health care may see more expenditure on disease prevention and health promotion, which has been held at low levels in the past. It is clear from the recent Australia 2020 Summit that health care reform is on the agenda (Australian Government 2008).

Change in the Australian health system, in the last 2 decades, has presented significant challenges for health professional groups and required them to adapt to: new health service policy environments; professional role changes; new models of care; diminishing resources for health with concomitant increases in demand for health services; workforce supply and demand issues; the rise of consumerism; rising levels of litigation in health care; and greater levels of uncertainty. This is a global phenomenon across developed countries. Leatt and Porter note that:

In the last decade, health care throughout the world has experienced broad strategic management strategies, such as re-structuring, regionalisation, downsizing of personnel, reduced bed capacity, and decreased funding. At the same time consumers are expecting higher-quality services, more information about treatment options, as well as more accountability for performance. At the service delivery level, health professionals are burnt out, feel undervalued and under-rewarded, have lost trust in their employers and governments, and appear dissatisfied. Health service workers appear more resistant to change and less open to creativity and to innovation.

(Leatt & Porter 2003: 22)

Conflict has also been a feature of the health care landscape in Australia in the last decade, often between senior clinician leaders in health care and health bureaucrats, because of differing perceptions regarding the most appropriate distribution of resources for health care, health service priorities and sometimes resentment at what may be seen as unnecessary interference by government in roles and accountabilities of health professionals. Philosophical incongruence (rhetoric versus reality) can also impact on harmonious development and delivery of health care. Many health care professionals are, for example, educated in a patient-centered approach, a principle embedded in the rhetoric of many health care systems, which then demand tight economic efficiency in resourcing to a level where it becomes impossible to operationalise the aspiration of ‘patient-centeredness’ in actual practice (Jackson & Raftos 1997; Lumby & Duffield 1994). The driver can become a systems focus on leanness and getting tasks completed quickly. The notion of multidisciplinary teams is also a part of the rhetoric, yet team dysfunction often undermines efforts to assure quality care. Indeed the notion of ‘team’ in health care remains contested, and not all health professionals subscribe to the notion of multidisciplinary health care as appropriate to all contexts (Saltman et al 2007). This is problematic, and adverse events in health care can be attributed to a number of factors, including poor collaboration and communication in health care teams (Manojlovich et al 2008).

Conflict has also been a feature of the health care landscape in Australia in the last decade.