Essay: To what extent the psychiatric services can be improved in the special observation ward in a general hospital under Hospital Authority by nurse leader?

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  • To what extent the psychiatric services can be improved in the special observation ward in a general hospital under Hospital Authority by nurse leader?
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What is leadership about?
There are many different people defined leadership in different ways (Heacock, 2013). According to Hickman (1998), leadership aimed to induce the followers to follow and take action in order to complete the specified goals, and it can helped to show the values of the leaders and the followers and also their motivations can be showed. According to Jooste (2004), leadership is more complicated and not simply acted as a role by how to control the followers, and leaders always tried to help and teach the followers to complete the task by step by step such as planning, leading, controlling and organizing. According to Northouse (2009), leaders can have the ability to affect the followers to complete a specified goal. Rogers (2003) stated that leaders can help the followers to become more aware of the uncertainty and possible outcome about the possible changes. The above information showed that a leader must have good leadership skills in order to affect the followers about what is happening and the values to change the current conditions. It can helped the followers to have a more and better understanding of the specified goal, as a result, the followers are more willing to follow and complete the tasks smoothly.
Importance of Leadership
According to the Strategic Service Plan of the Hospital Authority (2009-2012), health care workers and the frontline staff need to increase and enhance their related skills for the raising patient’s service’s needs, the number of patients, the complexity of medical devices and more complicated medical cases. In order to solve the above problems and needs, Hospital Authority has focused on three main different aspects such as including management skills, leadership skills and clinical competence. Hospital Authority emphasis the importance of leadership and put sufficient resources such as overseas training and classroom courses in order to enhance the leadership skills to current ward mangers, nursing officer, advanced practice nurse and future leaders. According to the Hospital Authority Annual Plan (2011-2012), one of the key objectives was ‘Build People First Culture’ and the one of the priority services for 2011-2012 was to ‘Enhance professional competencies and build up effective management and leadership’.
Overview of psychiatric services in Hong Kong
According to the Hospital Authority Mental Health Service Plan for Adults (2010-2015), there was estimated 1 million to 1.7million people were having psychiatric problem in Hong Kong and about 70,000 to 200,000 people were suffering from severe psychiatric problems. And around 40,000 of them with diagnosed schizophrenia and nearly half of them were treated at out-patient setting.
According to Chui, Mui and Cheng et al. (2012), the aim for public psychiatric hospital was to minimize the psychiatric admission rates and wanted to focus on psychiatric community services such as psychiatric out-patient clinic, psychiatric community out-reach team services and the Consultation Liaison team (CLT) in public general hospital for patients who needed to have psychiatric services. Hospital Authority tried to minimize the psychiatric admission rate by implementing some services since the year 2009.
Why I chose the topic to discuss and how it is important to me and others
I chose this topic because I am working in a ward call special observation ward which strongly supported by the Consultation Liaison team (CLT) services in public general hospital for patients who needed to have psychiatric services. Some of the patients are not physically fit for transfer to psychiatric unit, some of them are patients who are transferred back from psychiatric unit for medical problem, some of them are elderly with newly diagnosed dementia with relatives cannot accept the reality even with poor social support. However, many problems such as placement problems, complaint cases, safety problem and long waiting lists for patients who needed to admit to my ward existed.
This paper will start with the introduction and my selected real case scenario in my ward (special observation ward). I will compare different leadership models such as laissez-faire leadership, transactional leadership and transformational leadership. I will discuss the leadership style of my leader in my case scenario. For the discussion part, force field analysis will be used for analysis the data and I will summarize the findings, and also, I will discuss how the situation can be more effectively with how to improve the situation. Reflective summary will be the last part of this paper with my comment.
Case scenario:
I am working in a special observation ward in one of the general hospital under Hospital Authority and this ward aimed to receive patient with unstable emotion or some psychiatric problem, but they are not physically fit for transfer to psychiatric hospital or need some close observation in general hospital. There are only 24 beds available with long waiting list that patients needed a bit long time to be admitted to my ward. There are only 3 APNs, 13 RNs and 5 ward assistants to support the ward within 3 shifts with heavy workload and stress.
My ward manger wanted to improve the quality of service and reduce the long waiting time for admission. She carried out a lot of guidelines and policies for staff to follow. Some of the policies are: 1) Discuss with relatives whom patients got dementia to find a placement to reduce the length of hospital stay, 2) Team in-charge should screen out cases who can be early discharged or transfer to psychiatric hospital. 3) Writing detailed report in each patient’s record to reduce the chance of getting challenge when patient’s service department receives complaints.
One month later, 1) some relatives complained that nurses forcing them to find old age home within a short period of time and forcing patients to discharge even they were not yet prepared well. 2) Doctors felt unpleasant and complained that nurses overriding their decisions about the discharge plan as some newly upgraded nurses does not have sufficient knowledge to screen suitable cases which causing low morale and conflicts. 3) Nurses needed to spend a lot of time in writing patient’s record causing low morale because nurses always need to spend their own time after duty turnover to finished writing detailed patient’s record (usually more than one hour). Also, many junior nurses do not have sufficient knowledge about detailed and special required documentation skills which put the nurse in-charge in a very difficult position.
I will compare different leadership styles and analyze the leadership style in this scenario. According to Hickman (1998), transactional leaders will only correct the problems or mistakes once it happened in which will threatens the leader’s management plan and no changes will be made if nothing happened. Hickman (1998) also stated that transactional leaders also avoid development and improvement as they do not have motivation to have any changes. According to Bass (1990), transactional leadership will use rewards or punishments to the followers in order to achieve the goals.
For the transformational leadership, Hickman (1998) stated that transformational leadership will try to motivate the followers to achieve the goals and needs to changes, and the morality of the followers could be higher. Transformational leader need not to use the authority or power to control the followers. According to Bass (1990), transformational leaders will acted himself/herself as role model to the followers in order to obtain trustfulness and loyalty of his followers. Besides, through mentoring and empowering, Transformational leaders also use the mentoring and empowering skills to let the followers to enhance and develop the potential power in order to complete the specified goals.
According to Gill (2011), there are no guidelines and protocols for the followers to follow for the laissez-faire leadership style. The morale of the followers may be high or low as the followers can do whatever they wanted. However, the followers will have their own style of work and therefore more easily to reach the specified goal.
However, both transactional leadership and transformational leadership will set a clear objectives and goals for their followers with clear guideline. As a result, the followers can have a better understanding of what they should do in order to achieve the goals.
The leadership style of my case scenario:
Firstly, in this scenario, the leadership style of my ward manager was autocratic leader style and she was as a transactional leader. She has the greatest powers and the highest position in order to influence all the staff including nurses, doctors and patients with their relatives. According to Bass (1990), transactional leader got the power to make the plan and ask the followers to perform that in order to achieve the specified goals with the authority power.
In this scenario, she used her power to set some guidelines and policies for the staff to follow in order to improve the quality of service and reduce the long waiting time for admission. The advantages were 1) Admission rates to special observation ward were increased from average 10 patients per days after one month time as evidenced by the admission book. 2) Patient’s Services Department sent an e-mail to department head to appreciate the detailed documentation written in patient’s record in order to minimize the investigation time to answer the complaint cases. 3) Discharge rates were increased as many elderly with placement or caring problem were directly discharged to aged home other than home. And also, the cases which were medically fit for transfer to psychiatric unit were screened out earlier. That evidences were showed in the discharge record. Although her goals were achieved, there were disadvantages such as 1) Low morale of the nurses as they have to spend a lot of time in writing documentation by using their own time. 2) Heavy workload for staff for writing detailed documentations together with the routine work. Junior staff may have difficulties in proper and special documentations and senior staff also felt fatigues by doing their own work together with teaching and supervising the junior staff. 3) Poor relationship between nurses and doctors together with the relatives. As they always said that nurses forcing early discharge of patients which leading to increase in complaints.
Changes and Force Field Analysis
According to Carney (2000), the basic and essential skills for all nurse leaders are manage, implement and support the changing process in order to ensure the followers to adopt about the changes. If the leaders lack of the quality of leadership skills, the changing process may be not successful. Force Field Analysis (Lewin, 1951) stated that it can help to how and what were the difficulties about the followers encountered. In the year 1951, Force Field Analysis was done in order to assess the followers for how to the implement the Family-Centered Care Program from the original situation. There were some advises given to improve the leadership skills according to the analysis result of the Force Field Analysis.
Force field analysis is a model designed by Lewin on the year 1951. It is useful to determine the effectiveness of the variables included and also helped to develop some strategies to change or by intervene some of the variables. Lewin assumed that both driving and restraining forces will be occurred when there were any changes existed. Driving forces are equal to the forces in which it keeps the changes are going on continuously. And the restraining forces are equal to the forces that occurred to resist the driving forces. According to Baulcomb (2003), equilibrium can be occurred once the leader can be able to decrease the restraining forces and allow reaching to the desired status by increasing the driving forces.
From the analysis, restraining forces were 1) Poor documentation skills of new staff, 2) Poor communication skills between staff and relatives, 3) Heavy workload due to extra jobs such as teaching new staff and extra time for detailed documentations, 4) High stress from staff to choose potential early discharge patient would due to conflicts with doctors and relatives and 5) Increase in the number of complaint cases. And the pushing forces were 1) Reducing waiting time for admission, 2) increase discharge rate, 3) improve documentation skills of staff and 4) increase the quality of services.
What has been successfully done listed in the Force Field Analysis in this scenario?
1) Reduce the waiting time for admission to special observation ward.
2) Increase the discharge rates in special observation ward.
3) Increase documentation skills for some of the nurses in special observation ward. (but not all).
What has been addressed but failed to success at the beginning without changes?
1) Increase documentation skills for some of the nurses in special observation ward.
2) Reduce the rate of complaints (as increasing rate of conflicts about placement issues)
3) Improve the quality of care as the morale of nurses is low and they feel stressful with heavy workload.
After identify the restraining and pushing forces, some changes or solutions can be established in order to eliminate and minimize the negative factors to make improvement. For the stress issues, as many junior nurses needed a lot of time to handle the routine work because lack of experiences, so they needed to stay after duty off to finish the all the tasks including the detailed documentations. Senior nurses also have the responsibilities to supervise the junior nurses in which they also have to leave lately after off duty. Documentation class training can be implemented by some experienced staff to junior staff and some samples of special documentations can be shared for reference. For the discharge issues, there are communication problems and many doctors and relatives would not listen to nurse’s advice and leading to conflicts and complaints. This can helped by holding a meeting with doctors with agreement made before starting the program. And nurses can invite medical social worker and pre-discharge team if difficult to handle to placement problem in order to avoid conflicts and complaints from relatives. As a result, stress and workload can be reduced with the specified goals can also be achieved.
According to Cain and Mittman (2002), there should be promoting and supporting in changes within the health care setting, but should not greatly influence the existing situations. Conner and Patterson (1982) stated that the reason for the failed to changes were due to the lack of commitment for the followers to changes and it was important for the followers to accept and support the changes in order to success any changes.
In this scenario, although changes were necessary for improving the quality of services, but the leader did not provide adequate support, time and training before implemented the policies and protocol. As a result, the followers showed lack of energy and even felt stressful to support the changes.
Different leadership style such as laissez-faire leadership, transactional leadership and transformational leadership were introduced with a case scenario was shared. Force Field Analysis was used to point out the pushing and restraining forces which can help to improve the situation. There is also a discussion part to discuss the case scenario for improvement. A good leader should show the advantages to changes and to minimize the weaknesses. Regular review and support are essential and a good leader should be ready to accept feedback and suggestions.
Reflective Summary
I am a Registered Nurse who is working in Medical Department for nearly nine years and rotated to the special observation ward under medical department for about seven years. I am the second highest appointment Registered Nurse working in this ward and always needed to perform the job as ward in-charge and mentors for new comers and student nurses. As my ward manager decided to implement the guidelines and protocols as stated in Part 1, the workload was increased and I felt very stress as I needed to choose some potential early discharge cases and presented to my ward manager and doctor-in-charge. Also, I needed to spend a lot of time to explain the importance of placement issues to the relative with caring problem during visiting hour with half of my colleagues went out for dinner time and some of them will scolded nurses for forcing patients to aged home. For the potential complaint cases, nurses involved needed to write detailed documentations in patient’s record in which sometimes involves three pages of papers to write. All of the nurses feel fatigue and stress about the new guidelines.
If I am my ward manager, I will choose to be a transformational leader. It is because transactional leadership only focuses on the goals achievement with punishment and rewards were made for the followers. Although Outhwaite (2003) stated that the transactional leaders must have their own abilities to achieve a common goal and the routine job should be done sufficiently. The followers have sufficient instructions from the transactional leader to ensure the work having done successfully and effectively. However, the moralities of the staff under transactional leadership were low as they will always tried to avoid punishment by following the standard guidelines to achieve the specified goals.
I think that transformational leadership is more suitable in nursing field because the followers can have more opportunities and freedom to involve in the decision making process. The transformational leader can allow the followers to implement some tasks with their specified abilities. It provides opportunities for the followers to learn the leadership skills and knowledge. The relationship between the leader and the followers will be better for transformational leadership.
Transformational leader always try to emphasis changes and encourage having commitments. Moreover, I believed that transformational leaders will spend more time to teach and provide coaching to the followers, as a result, the followers should be more satisfied and happier. Transformational leader will also provide the followers some training and for further development of the specified areas and helps to develop the strengths of the followers.
As all of the public hospitals are facing the problem of manpower insufficient already and the turnover rates are high due to heavy workload and poor working environment. It is not practical to implement some new guidelines without sufficient support to increase the workload of staff. If I am the leader, I will have sufficient information and suggestions before implement a new guideline or policy and I will provide adequate professional training and support to the staff in order to allow them to develop their strengths. I will also listen and allow staff to provide suggestions or advises for improvement and changes because the morality will be higher if the staff having the chance for involvement.
To improve my leadership skill, I will use a reflective diary to written down some special events which are happened in my ward together with the advantages and the disadvantages of the leadership style of my ward manager in order to have further improvement or what is good for learning. It can help me to summarize all the events and make an evaluation to be a role model before I can promote to Advanced Practice Nurse. Also, I can seek the approval of my ward manager to set some projects such as the topic ‘Documentation’ by using transformational leadership style to test the effect of performing projects and it can helped to observe the response of the followers for me for further development.
I will set a three to twelve months leadership developmental plan in special observation ward -by SMART. The SMART Objectives of the project as set below:
1) To implement a documentation training course for all of the nurses working in the special observation ward to enhance the documentation skills and special documentation style especially for the patients in special observation ward. For 100% of nurses working in special observation ward have the chance to join the training course within six months time.
2) To implement a communication skills training course for all of the nurses working in the special observation ward to enhance the communication skills especially for the patients and their relatives in special observation ward. For 100% of nurses working in special observation ward have the chance to join the training course within twelve months time.
3) To increase the morale of the colleagues in my ward by receiving feedback of the new guideline to allow their involvement to improve the services within three months time.

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