Introduction
In recent years, health services in the Republic of Ireland (ROI) have been undergoing substantial reform. This reorganization of services has come in the wake of the Brennan report (2003), which found that while health care services in the ROI were managed by the Irish Health boards (IHBs), there was insufficient focus on creating a unified national system and that the IHBs had no incentive to control the cost of their services effectively.
The report also found that there had been insufficient evaluation and analysis of health care programme, and related expenditure, and that investment in developing information management systems had been inadequate. As a result of the reports findings, the IHBs were transformed into the Health Service Executive (HSE) (2005), with a remit to improve the efficiency and effectiveness of health and personal social services by undertaking activities formerly the responsibility of the IHBs.
As in the world-wide context in recent years Irish health-care has undergone much change, which has led purchasers and consumers alike to call for a more efficient and effective service. In a national context for more than a decade there is evidence that the health system has been badly managed, grossly under-staffed and loosely funded (MacAnthony, 2001). However, of all the public services within Ireland, health care has seen the most substantial increase in financial allocation in recent years and yet there is not much to show for it by way of improved facilities. Further, millions of pounds have been pumped into the public health service, which appears like a celestial black hole. Thus the forces of change can be identified as including competitive pressures, advancement in medical breakthroughs, alternative health-care delivery mechanisms, changing cost structures, monitoring by public and private groups, increased information availability and markedly better informed customers. For some it is now the case that reform is a matter of life and death (MacAnthony, 2001).
Review of Relevant Concepts
Transformational Leadership
Transformational leadership is recognized as the most appropriate leadership method for health care (Demings 1987, Kouzes and Postner 1995, Sofarelli and Brown 1998). Its principles include: Vision, Trust, Participation, Learning, Diversity, Creativity, Integrity, and Community (Sofarelli and Brown 1998).
Burns (1978) suggests that the transformational leadership style seeks to “satisfy needs’ by involving the ‘whole person and followers’, resulting in reciprocal relationships between leader and followers.
Transformational leadership theory suggests that leaders use their ‘charisma’ to provide vision and direction for their followers and, ultimately, to achieve transformation of organizations.
Encouragement and praise for achievement are essential to the success of this leadership style, and can help to gain trust and respect from team members and consequently improve their motivation and morale.
The transformational programme states that respect for colleagues and praise for success are fundamental parts of the future management of the HSE, which suggests that it is informed by the transformational leadership ethos.
Leadership development
No one really manages an organisation by shuffling numbers or rearranging organisational charts. What is really managed in an organisation is people and leadership is the ability to inspire people to work together as a team to achieve common objectives (Spinks and Wells, 1995). The health-care field needs leaders who can rebuild trust, restore efficient processes and ensure quality through organisational transitions (Dye, 2000). Being a health-care leader today means being faced with daunting challenges, including complex organisational structures, unfamiliar operational and strategic issues, and rapid change. Overcoming these obstacles requires new leadership competencies and a renewed attention to traditional competencies. These competencies are rooted in leadership values that give focus in turbulent times and help individuals deal with stress and align others during organisational change (Dye, 2000).
Leaders who keep learning may be the ultimate source of sustainable competitive advantage. Although the best-practice firms differ in their emphasis on making leadership development strategic, the development programme of each includes elements of the five critical steps:
building awareness of external challenges, emerging strategies, organisational needs and what leading firms do to meet the needs;
employing anticipatory learning tools to recognise potential external events, envisage the future and focus on action the organisation can take to create its own future;
taking action by tying leadership-development programmes to solving important, challenging business issues;
aligning leadership development with performance assessment, feedback, coaching and succession planning; and
assessing the impact of the leadership-development process on individual behavioural changes and organisational success.
A study undertaken by Fulmer et al. (2000) shows that, despite the diversity of approaches to leadership development in best-practice companies, all share common goals: anticipating, supporting and aligning the organisation’s strategic initiatives with development, as well as gaining and sustaining competitive advantage. And increasingly, those companies choose an action-oriented, ongoing learning process closely linked to the strategic needs of the business.
The most effective leaders possess and live by deep, unwavering values that guide their personal and professional behaviour and thought (Dye, 2000). Heskett and Schlesinger (1997) identify predictable issues shared by leaders of a range of service organisations:
the importance of values alongside a good strategy;
the strategic importance of human resource management and organisational capability;
the need to communicate mission and values constantly;
the need to provide daily examples of what they believe; and
the need to set outrageously high goals and then do everything possible to provide the capability needed by those in their organisations to meet them.
Additionally, becoming aware of the need for learning and practising a sensitive, practical, and appropriate value system is the first step towards becoming a world-class leader. The health-care field was established with a simple, altruistic purpose: to serve the public. Therefore, its leaders must subscribe to the same edict by becoming “servant” to the needs of their organisations and constituents. Servant leadership can be demonstrated by sharing information, delegating authority, supporting continuing education, ensuring successes for staff, developing succession planning, maintaining a helpful spirit and attitude, leading by vision, and providing performance feedback (Dye, 2000).
Organisational effectiveness in Irish health care
As in other European countries, health care in Ireland is undergoing transformational change. The publication of the strategy document, Health Strategy, “Shaping a Healthier Future”, from the Department of Health (1994) firmly placed equity, quality of service and accountability at the heart of health care. Indeed this was the first mention of quality within the Irish health-care system since its inception 50 years ago. However, a new strategy is imminent which promises radical reform and to instill some order into the chaotic hospital system (Collins, 2001). In common with other health systems an element of rationing by waiting is to be found in the system because of limited capacity and the demand that is not constrained by price. While our modern health services show radical change in many areas (Robins, 1997), managers of health services are currently reporting a large increase in the number of patients needing beds with ever increasing waiting-lists. Further criticism has been leveled at the system with regard to opening hours of clinics and out-patient facilities for facilitating doctors and consultants, without consideration for patients (Collins, 2001). Accident and emergency departments are under particular strain, while the difficulties of dealing with the growing needs of the increasing elderly population are beginning to show. Hence, while our health service today is free for all those requiring medical treatment through a publicly funded system, the current situation is hauntingly similar to that of the Victorian era of health care in Ireland. However, as far back as 1989 a comprehensive report on the Commission on Health funding highlighted that:
The solution to the problem facing the Irish Health Services does not lie primarily in the system of funding but rather in the way that services are planned, organised and delivered.
Furthermore, according to a recent OECD (1997) report:
Although the Irish health system has delivered a continuous improvement in health standards with a growth of expenditure that until recently has been well controlled, there is still scope for further improvement in efficiency that could be achieved through better allocation of resources.
Health Care Workers’ Perceptions of Leadership in an Intensive Care Unit
Compared with other domains in health care, the intensive care units (ICUs) are units with poor leadership and poor collaborative communication between nurses and physicians as they have as much as an 1.8-fold increase in risk-adjusted mortality and significant increases in length of stay (Knaus et al., 1993). Higher collaborative interaction is also associated with higher job satisfaction of nurses and higher retention of nurses (Shortell et al., 1994). In light of these findings, what is the health care workers` perception of leadership in intensive care units? In this research paper, I present a survey-based research study of health care workers’ perceptions of leadership in the domain of an intensive care unit and of how the level of collaborative interaction of this unit can be assessed.
Survey research is useful methods of organizational assessments of critical care units. (Mitchell et al., 1995). The survey research study reported here was prompted by the concerns of the leaders of an ICU in an Irish suburban hospital about the level of collaborative interaction on their unit. Because of their awareness of the growing body of research that supports the beneficial results of nurse– physician collaboration in critical care on patients’ and organizations’ outcomes, they decided to assess the level of collaboration on their unit, establishing a basis for interventions if needed.
I will use Mitchell and colleagues (1999), Charnes Organizational Diagnosis Survey and the Moos Work Environment Scale to measure collaboration. In their survey research study of an ICU selected for such desired organizational attributes as high nurse-physician collaboration, Mitchell et al. found positive outcomes for patients and the organization, including high staff satisfaction, low turnover, high satisfaction among patients, and lower than expected unit mortality rates. In an examination of 25 ICUs, Mitchell et al. found an association between (1) ideal-type organizational structure and processes, which included nurse-physician collaboration, and (2) positive organizational outcomes, such as retention of nurses.
The instrument selected for use in the survey research study to find out the health care workers’ perceptions of leadership in the domain of an intensive care unit will be the ICU Nurse-Physician Questionnaire, which was developed by Shortell et al. (1991) for the National ICU Study. Shortell and colleagues, who published results of content validity, factor analysis, and beginning construct validity for this instrument, encouraged its use in continuous quality improvement efforts in ICUs. Shortell et al. (p.511) described collaboration as “a composite concept which . . . includes subdimensions involving unit culture, leadership, communication, coordination, and problem solving/conflict management.” Because of the fit of the elements assessed and its quality improvement nature, the framework created by Shortell et al. was selected for this survey research study.
Research Questions
Health Care Workers’ Perceptions of Leadership in an Intensive Care Unit
Two questions will guide this survey research study:
1. What are the health care workers` perceptions of the leadership in the unit’s staff including physician leadership; communication openness, timeliness, and satisfaction; problem solving; physician expertise; meeting effectiveness; and technical quality of care?
2. What is the perception of the unit’s staff to the level of collaborative interaction in the
Intensive care unit?
The assessment of collaboration will be individualized to the unit being studied. The specific concerns of the unit’s leaders guided both the selection of research questions and a modification of the ICU Nurse– Physician Questionnaire. These concerns will include the effects of recent organizational changes and the association of the medical director with these changes. Accordingly, the assessment will not just focused on physician leadership but also on the nursing leadership. Additional concerns, including the effects of redesign initiatives, such as multidisciplinary team meetings, and other issues currently surfacing in the unit, will guide the selection of unit groups compared in the assessment.
Methodology
Setting and Subjects
The setting for this study will be the 22-bed combined medical-surgical critical care unit in a 383-bed suburban community hospital in Ireland. During the 3-month period before the study, the number of patients admitted will be taken and the patients` age range will be computed to get the mean age in years. All nurses and physicians who will practice in the unit will be sent questionnaires.
Instrument
A modification of the short form of the ICU Nurse-Physician Questionnaire will be used to collect data. The instrument will have separate forms for nurses and for physicians, to allow greater clarity of the referents for many questions. The 5-option Likert-type responses of each scale ranged from “strongly agree” to “strongly disagree,” with the exception of the problem-solving scales, which ranged from “not at all likely” to “almost certain.” Scale scores will be computed, after the negatively worded items will be reverse scored, by adding the values of the responses and dividing that sum by the number of nonmissing items in the scale.
The specific concerns of the unit’s leaders will guide both the selection of research questions and the modification of the ICU Nurse-Physician Questionnaire. On the basis of the concerns, the scales from the instrument to be used and added items and open-ended questions to some scales will be selected. For instance, concerns about the effect of recent organizational changes would led to the selection of the physician leadership and meeting effectiveness scales. But there are issues currently surfacing in the unit about generalist and specialist physicians which tend to lead to the creation of a new scale to measure the perception of physicians’ expertise.
The number of items in each scale in the original instrument and in the modified instrument will be listed in table form. The coefficient estimates of reliability calculated from (1) the original scales reported by Shortell et at 1991) and (2) the original scale items with the study sample, and (3) the modified scale items with the study sample will be included in the table. Principal components factor analysis with Varimax rotation procedures will be used to determine if the new items fit with the old items for each individual scale and are available upon request.
The physician leadership scale involves the extent to which staff perceive that the physician leader of the unit emphasizes standards of excellence, communicates clear goals and expectations, responds to changing needs and situations, and is “in touch” with the perceptions and concerns of members of the unit.
The scale for communication openness between groups examines the extent to which nurses and physicians perceive they can say what they mean when speaking with one another without repercussion or misunderstanding, and the scale for communication openness within groups examines the same issues within the respective group of nurses or physicians.
Communication timeliness involves the perceived degree to which information about patients’ care is related promptly to the persons who need to be informed. Satisfaction with communication involves the degree of satisfaction with nurses’ or physicians’ communication with patients and patients’ families and with one another.
The scale for problem solving between groups examines the extent to which physicians and nurses work actively to make sure that all available expertise is brought to bear on a problem, with the goal of arriving at the best possible solution. The scale for problem solving within groups examines the same issues within the groups of nurses or physicians. An open-ended item will be added to this scale: “If you have experienced conflict that has not been resolved, please indicate reasons) resolution was not reached.” The remaining 3 scales examine the perceived expertise of physicians, effectiveness of unit meetings in addressing important issues, and the technical quality of care provided.
Demographic information that will be collected from nurses included the shift they work and the number of years they have been in practice. Physicians will be asked what is their area of practice (ie, family practice, internal medicine, or surgery), specialty, and the number of years they have been in practice.
Data Collection Procedure
Because the purpose of the study will be to find out the health care workers` perceptions of leadership in an Intensive Care Unit and to assess the level of collaborative interaction in the unit, attempts will be made to include all nurses and physicians who are practicing in the unit. The questionnaire will be put in the mailbox of all nurses, including “as-needed” staff. Questionnaires will be mailed to the offices of all physicians who have admitted more than 1 patient to the ICU during the year. Physicians’ questionnaires will be coded so that a reminder letter could be sent to the physicians who did not respond within 2 weeks. Because nurses are considered as a more vulnerable group, their questionnaires will not be coded. Informal reminders will be directed to the nursing staff as a whole.
Data Analysis
Data will be analyzed using the SPSS for Windows. Descriptive statistics, including means and SDs, will be used to examine the first and second questions guiding this survey research study: 1. What are the health care workers` perceptions of the leadership in the unit’s staff including physician leadership; communication openness, timeliness, and satisfaction; problem solving; physician expertise; meeting effectiveness; and technical quality of care and 2. What is the perception of the unit’s staff to the level of collaborative interaction in the unit?
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