Leadership is about setting the direction of a team, influencing others and managing change, whereas management involves organising resources and maintaining stability (van Diggele et al, 2020). Leadership produces change and movement whereas management produces order and consistency (van Diggele et al, 2020). Several leadership styles have been demonstrated to be effective in health and social care, including autocratic, laissez-faire, democratic, transformational, servant, situational and transactional (Thompson and Glasø, 2018; Specchia et al, 2021). McGregor's X-Y management theory, originally published in 1960, is widely used in health and social care (McGregor, 1985; Yildirim and Albez, 2022). Theory X uses coercion and control to achieve organisational goals whereas theory Y uses motivation. McGregor concluded that theory Y is the most appropriate method for managers to get the best out of their teams (McGregor, 1985; Yildirim and Albez, 2022).
A multidisciplinary team (MDT) is a group of health professionals from different professions working together to make decisions regarding the treatment of patients/service users (Jennings and Evans, 2020). It is a collaboration involving different health professionals such as doctors, nurses, pharmacists, occupational therapists and psychologists working together with patients, families and carers to deliver the highest quality of care: a comprehensive, holistic and a person-centred care that improves patient's health status (Guerra et al, 2022).
When an MDT forms, it would pass through all Tuckman's five stages (forming, storming, norming, performing and adjourning) (Kiweewa et al, 2018). It will have different roles (resource investigator, team worker and co-ordinator (the social roles); plant, monitor-evaluator and specialist (the thinking roles); and shaper, implementer and completer-finisher (the action or task roles)) based on Belbin's theory (Aranzabal et al, 2022).
MDT working is effective because it improves communication and professional working between health professionals, saves time and expedites treatment, makes efficient use of resources, reduces duplication of efforts, reduces medical and nursing errors, promotes safer patient/client care, enhances satisfaction for patients/clients, and achieves and improves desired patient outcomes and experiences (He et al, 2022). Some disadvantages of the MDT may include lengthy decision-making processes, incomplete decisions from incomplete information, the possibility of conflict, differences in member backgrounds and educational experiences, stereotypical attitudes and resistance of some health professionals to change (Guerra et al, 2022).
A recruitment strategy for MDT members would include hiring for potential as well for experience, creating a seamless candidate experience, developing a successful employee referral programme and reducing bias (Stevens et al, 2022). A retention strategy would focus mainly on McGregor's theory Y (Madero-Gómez and Rodríguez-Delgado, 2018) and the facilitative method of Heron's intervention (Heron, 2001). It will include having a strong induction programme, regular appraisals and one-to-one meetings between managers and staff, listening to employee feedback and following through, recognition and appreciation, investment in employee growth opportunities and training and development, promoting work-life balance and providing a competitive pay package (Kanyumba and Msosa, 2020).
Experienced managers would be involved in setting up the recruitment and retention strategy to ensure its effectiveness. If possible, service users should also be involved during interview stages to promote service user involvement (Mazzei et al, 2020). Using Belbin's team model (Bednár and Ljudvigová, 2020), the knowledge and expertise of the knowledgeable experts of the MDT would be harnessed without alienating other MDT members using facilitative leadership, shared vision and clear goals, equality between members, encouragement of constructive challenges, and common access to information (Aranzabal et al, 2022). Possible domination by one faction of the MDT over another faction would be mitigated by providing clarity of responsibilities and roles and promoting respect for the views of others (Guerra et al, 2022).
The possible effects of professional loyalties affecting the balance in the MDT may include the wasting of resources and a poor experience of care for patients (Jennings and Evans, 2020). Negative professional loyalties may be mitigated by promoting a shared vision and clear goals and equality between members (Guerra et al, 2022).
Tribalism in an MDT refers to an attachment of health professionals to their respective professional groupings rather than collaborating and identifying as MDT members (Musitha and Mafukata, 2020). Professional tribalism might hinder recognition of other disciplines and may negatively impact on patients' care outcomes (Jennings and Evans, 2020). Tribalism in an MDT would be mitigated by understanding the underlying reasons that promote tribalism, reframing the workplace culture, and breaking down information and communication barriers (Musitha and Mafukata, 2020). For the ward-based MDT, appointing a leader should be considered, based on the Lewin democratic leadership style (Muller and Pelser, 2022). This is because effective leadership (such as when chairing team meetings), is important to ensure co-ordination, participation, equality, and inclusiveness to enable better decision-making (Alloubani et al, 2019).
Succession planning is also important because members of the MDT could be retiring or moving to another city or taking up jobs in another organisation. Succession planning would allow managers to be proactive and prepare successors for relevant positions in good time (Kanyumba and Msosa, 2020). Succession planning steps would include identifying potential successors, confirming if the candidates are interested in the future roles, creating a development plan for each potential successor and following candidates' progress (Stevens et al, 2022). As patients have become more knowledgeable about their health conditions, leading to the rise of the ‘expert patient’, health professionals may feel their professional status and authority has been eroded (Jennings and Evans, 2020). This issue may be mitigated by promoting professionalism, professional authority, and professional identities (Jennings and Evans, 2020).
Nursing accountability and economic perspectives
Accountability in nursing leadership and management refers to the willingness of nurses to accept responsibility for their actions (Harrison, 2018). Accountability is a key principle of nursing and involves four key areas: professional, legal, ethical and employment, against which clinical issues can be considered (Drach-Zahavy et al, 2018; Nursing and Midwifery Council (NMC), 2018). One of the ways of becoming an effective nurse leader and manager is to promote peer accountability (Drach-Zahavy et al, 2018). There are key primary principles required to implement accountability in nursing and these are the ability to make decisions, communicating effectively, defining expectations, managing innovation, embracing feedback and criticism, taking responsibility, embracing change, promoting safe and diverse work environments and striving for continuous improvement (Harrison, 2018).
Nurse leaders and managers need to be aware of the current political and economic climate within their organisation, locally and nationally because nurses can influence policy and politics at various levels and become advocates for improvement of the quality of care. One of the main current political issues that affects health and social care in the UK is the NHS Long Term Plan (NHS England/NHS Improvement, 2019; Alderwick and Dixon, 2019). Part of this 10-year plan (2019-2029), which sets out the NHS's commitment to spend at least £2.3 bn more a year on mental health care, help 380 000 more people get therapy for depression and anxiety by 2024, improve access to mental health services and reduce mental health assessment waiting times (Alderwick and Dixon, 2019). These ambitions were set before the COVID-19 pandemic and economic changes.
Other political and economic perspectives currently related to the health and social care sector include the persistent staff shortages in the NHS (Dean, 2018), with around 43 000 nurse vacancies across the NHS (Royal College of Nursing, 2023), besides shortages of doctors, care workers and other health professionals. Staff shortages in the NHS may be attributed to a failure to attract young people into nursing, lack of staff retention fuelled by poor working conditions, and the impact of Brexit (Dean, 2018). In recent years, nurses have taken strike action because of issues such as staff shortages, pay and poor working conditions. The major economic issues currently affecting the NHS is the general economic downturn in the country, with the problems of inflation and the cost of living crisis. An ageing population is also resulting in more elderly patients, some with several conditions.
A critical and personal reflection
Reflection is the thought process through which health professionals assess their professional experiences to gain insights (to aid learning and identify opportunities) about their practice (Adeani et al, 2020; NMC, 2018). The Gibbs' reflective cycle (Gibbs, 1988) was used for this reflection, although other commonly used models include the Atkins and Murphy model, Boud's triangular representation and Johns' model of structured reflection (Ingham-Broomfield, 2021). The Gibbs' reflective cycle gives structure to learning from experiences using six stages (description, feelings and thoughts, evaluation, analysis, conclusion and action plan) (Adeani et al, 2020). The model has been chosen because it is easy to understand and use, it allows learning over time based on experiences, it gives a balanced and accurate judgement over time and allows learning and planning from things that either went well or did not go well (Ingham-Broomfield, 2021).
The model has received some criticisms. The model uses a reactive approach rather than a proactive one to improve learning, and it may result in a superficial reflection with less potential for personal or professional development since there are no deep, probing questions (Adeani et al, 2020). Besides, the model does not refer to assumptions that a person might make or encourage critical thinking and does not challenge the user to analyse the situation from a different perspective (Adeani et al, 2020). Despite these disadvantages, the model can provide an appropriate framework to structure the critical reflection discussed in this article.
Description
As a mental health nurse, I was part of a project team of 13 colleagues who were asked to develop a new clinical area as part of a service expansion and present recommendations to the Trust's Executive Board at the end of 6 months. The team was formed by the Service Improvement Manager and the team members were selected from a range of professionals (doctors, nurses, psychologists, social workers and occupational therapists) from within the Trust. At the first team meeting, I took responsibility for co-ordinating the group and was eventually nominated to lead the group. As a result, I took the leadership role for the team throughout the project's lifespan.
Throughout the 6-month period, I chaired and co-ordinated the monthly meetings, prepared meeting agendas, ensured time keeping and the achievement of goals. I used Lewin's democratic leadership style (Alloubani et al, 2019) to ensure that all members participated in decision-making processes. I also used the management style of McGregor's theory Y (van Diggele et al, 2020) and focused on motivating and encouraging team members to approach tasks without direct supervision. The team's tasks were designed and delegated using the context of Belbin's team roles (Bednár and Ljudvigová, 2020):
- Resource investigator, team worker and co-ordinator (the ‘social’ roles)
- Plant, monitor-evaluator and specialist (the ‘thinking’ roles)
- Shaper, implementer and completer-finisher (the ‘action’ or ‘task’ roles).
The team members worked together by contributing to the team tasks to achieve the desired goal. As the team leader, I took the leading role of co-ordinator (Bednár and Ljudvigová, 2020), and stepped in to cover for a group member who was absent during the presentation to the board.
Feelings and thoughts
Before the task began, I felt that the goals of the team would be straightforward to achieve within the available time. I was confident that the majority (about 70%) of the members would make appropriate contributions to the team. I also thought that other team members were confident about getting the tasks done. This was based on informal conversations with team members. However, during the task, my feelings began to change as events started to unfold. I began to think that we might struggle to achieve the team's objectives within the time frame. During this period, it was not clear to me how the other team members were feeling. On reflection, I realised that I was wrong to assume that the majority of the team members (9-10) would make appropriate contributions to the team. I also realised that I was wrong to compare this work to previous teamwork in which I had been involved.
Evaluation
In this experience, some things went well. Two team members were exceptionally dedicated to their tasks. They played the roles of team-worker, implementer and finisher of Belbin's team roles (Aranzabal et al, 2022). They volunteered to pick up outstanding tasks not completed by other team members and demonstrated reliability. After the presentation to the board, the feedback was very positive. However, some things did not go well. Although we passed through all the five stages (forming, storming, norming, performing and adjourning) of Tuckman's team model (Kiweewa et al, 2018), we found the first two stages very challenging. There was an initial reluctance of team members to agree to the first meeting. Some team members did not make appropriate contributions to the team tasks. Only six out of 13 of the team members made significant contributions. Initially, it was decided that six members would make the presentation, but this was reduced to three. However, on the day, only two people made the presentation. I had to step in to cover because one team member was unavailable to take part in the presentation to the board.
Analysis
The teamwork was challenging because most of the team members did not make sufficient contributions. This is partly because they were not motivated and because there was no additional reward. Motivation and reward are very important to achieve team goals (Monderna and Voinarovska, 2019). It takes a lot of energy from the leader to get team members motivated when they have little or no motivation/reward for their efforts (Monderna and Voinarovska, 2019). Using Heron's model (Heron, 2001) of intervention (authoritative and facilitative), I persuaded and motivated members to contribute to the tasks. Leaders must be able and willing to ‘rescue’ the team (Specchia et al, 2021). I was always prepared to cover for any team member just to ensure that we were able to achieve our targets.
Conclusions
Using this reflective model helped me to gain deeper insights into my personal self-awareness and how to use it to improve my participation in teamwork. During this team project, I have learnt that our society (including health and social care sector) requires strong and effective leadership in order to achieve meaningful success (Bush et al, 2021). It is better when leadership is delegated rather than acquired. This will promote co-operation among all the team members since the choice of leader has been by consensus. The leadership style should not be rigid but flexible and situational (Thompson and Glasø, 2018). Most of the time, I used the democratic leadership style but at other times, I used autocratic and/or laissez-faire leadership styles (Gandolfi and Stone, 2018). To be specific, when another member was missing during our presentation, I stepped in without consulting the team members on what to do next using the autocratic method (Thompson and Glasø, 2018). On the other hand, when trying to agree on meeting times, I would normally step back to let the majority of the team members decide the most convenient time using democratic and/or laissez-faire leadership styles (Thompson and Glasø, 2018).
Action plan
I would choose to work with those people I have worked with in the past who have shown commitment, motivation, and passion to make appropriate contributions to teamwork. The main reason for this is their dependability and reliability (Syed Kholed et al, 2021). Working with people who have previously shown themselves to be reliable would definitely give me a good level of confidence that these people would contribute adequately to the teamwork. I would also wish that there is a reward attached to the task. Knowing there will be a reward at the end of a task is one of the sources of motivation for people to work towards achieving a goal (Vörösmarty and Dobos, 2019). In this case, the reward could be financial such as gift cards, vouchers or non-financial such as certificates or Trust-wide recognition.
The role of emotional intelligence
Emotional intelligence is the ability to identify, assess, and manage the emotions of one's self and of others to help guide behaviour and thinking towards achieving collective goals (Fteiha and Awwad, 2020). Nurses use emotional intelligence to demonstrate sensitivity towards their own and other people's psychological health and wellbeing and direct others towards achieving common goals (Prentice et al, 2020). I used emotional intelligence to recognise and manage my emotions and the emotions of the group members to positively influence my leadership and management practices to achieve the team's goals (Prentice et al, 2020). I achieved this by using my emotions to help direct team members' attention and critical thinking to achieve team goals, by taking time to reflect and review my thoughts to give me better control over my emotions (Fteiha and Awwad, 2020). Following Goleman's emotional intelligence theory (Fteiha and Awwad, 2020), I used five components: self-awareness, self-regulation, motivation, empathy, and social skills to direct the team to achieve team goals. Using emotional intelligence was beneficial because it allowed effective team working, helped to deal with change easily, helped to handle tough conversations, helped to manage challenging situations with a lower level of stress and fewer unintended consequences and also helped me to develop strong leadership skills (Prentice et al, 2020).
Implications for future practice
The first lesson learnt is that strong leadership is essential to deliver effective, efficient, and person-centred healthcare (Alloubani et al, 2019). This is because leadership styles (whether autocratic, democratic, laissez-faire or otherwise) particularly affect the quality of care and nurse performance (Gandolfi and Stone, 2018). Secondly, for nurses to become effective leaders, they need to develop essential skills such as emotional intelligence, integrity, critical thinking, dedication to excellence, communication skills, respect for others, mentorship, and professionalism (Alloubani et al, 2019).
I have also learnt that management in nursing means that nursing managers have to take responsibility for managing the day-to-day operations on the wards and nursing departments and for supervising nursing teams (Madero-Gómez and Rodríguez-Delgado, 2018). This is because effective management is important to ensure the overall success of the wards and departments, to ensure safe and healthy work environments, and to contribute towards achieving team goals that deliver effective patient care while promoting professional growth (Hasanpoor et al, 2019). As nurse managers, McGregor's theory Y would be useful to get the best results (Madero-Gómez and Rodríguez-Delgado, 2018).
Based on the lessons learnt from my experience of this project and from my study of leadership and management practices, I will apply these to my future practice by listening and learning, communicating clearly and effectively, taking responsibility, striving for excellence and authenticity, setting a strong example and modelling, including every staff member, delegating according to skill, and engaging in consistent mentorship (Alloubani et al, 2019).
Conclusion
Based on a critical evaluation of personal leadership and management experience gained from participating in a project work and across health and social care sector, the following lessons are relevant to future practice as a registered nurse:
- Strong leadership and management are extremely important to provide person-centred care and to deliver successful healthcare
- Nurses need to become effective leaders and managers by continuously developing essential leadership, management and teamwork skills
- Nurses need to be aware of the political and economic issues affecting health and social care as nurses have the potential to influence policy and politics at many different levels.
KEY POINTS
- Efective leadership and management of teams are important to provide person-centred care
- Nurses should develop essential leadership, management and teamwork skills
- Nurses should be aware of political and economic issues because they have the potential to influence policy and politics at various levels to benefit healthcare
CPD reflective questions
- Reflect on the leadership and management knowledge and experience you have gained while participating in multidisciplinary team
- As a nurse, how do you intend to become a more effective leader and manager?
- Are you aware of the political and economic issues affecting health and social care? Reflect on those that most affect your clinical area