1.1This report will provide evidence of the application of leadership knowledge to the role of the Health visitor’s practice. The report will look at my leadership style and skills in relation to developing and implementing an evening well baby clinic. When implementing this clinic I will aim to address and discuss past leadership experience and how I will use this within my team to achieve the best outcomes for families within my practice area.

Attention will be made on relating this to improving the quality of care as highlighted in the Nursing and Midwifery Council (NMC) Standards of proficiency for specialist community public health nurses, 2004. The standards also state that I, as a Specialist Community Public Health Nurses (SCPHN) must work in partnership with all team members and clients. I will apply my existing and newly developed leadership skills when managing my evening well baby clinic (NMC, 2004 and DOH, 2009). This report will include a discussion on my best practice and the use of evaluation and reflection in learning from experiences. The report will also include issues related to the quality of care and how my leadership can maintain or improve it.

The aims and objectives of this report are to provide a clear expression of the quality issues in clinical care. To analyse my understanding of the process of change and my leadership styles can influence the quality of care. I will then look at change theories, management and leadership styles within my practice area and consider what the strengths and weaknesses are. Consideration will also be given to conflict management and my style of leadership within the team in order to promote effective working.

2 Critical analysis and review of own individual knowledge and competence of leadership practice within health visiting practice.

2.1Whilst undertaking the SCPHN course I have had many opportunities and experiences to developed my leadership, and reflect on the kind of leader I aspire to be. There are two types of leaders, transformational and transactional. I feel that I am currently a transformational leader as I try to motivate staff members, encourage vision and ideas and inspire team members and clients to achieve the best possible outcomes. As identified by Huber (2010) Vision is a key aspect of any leadership activity. I feel that my evening well baby clinic has shown my vision through the ideas and implementation of activities within the group. I shared my vision with fellow team members, this promoted motivation and inspiration. Transactional leadership is a more direct approach setting out clear goals and offering rewards to staff members in order to meet objectives (Hartley and Benington, 2010). I adapted aspects of this approach but felt that a transformational approach was more appropriate for my team and my practice. Whilst the transformational model of leadership may be seen as dynamic and therefore appeal to change agents, in this scenario the proposed change is largely transactional. The evening clinic will not provide staff with new skills or knowledge and it is unlikely to be seen as a particularly innovative as it is simply expanding an already existing service within the practice area. However, it is important to recognise the need for transactional change, in this instance practical concerns of an evening well baby clinic are being addressed. The evening clinic will not only benefit service users, it will improve service delivery and help achieve both local and national requirements.

2.2 I feel that in order to look at management and leadership theories, it is important to understand the differences between them. Warren (2005) differentiated between management and leadership by stating that the main difference is vision. Leadership is concerned with vision, communication and values whereas management is primarily concerned with analysis, planning and problem solving. Kotter (1990) also suggests that both leadership and management are needed within complex organizations in order for them to run smoothly. This is supported by Marquis and Huston (2006) who state that the roles of the manager and the leader can and should be integrated and that it is essential for both approaches to be present within nursing. I believe that it is vital for leaders to have the ability to be both managers and leaders at the same time in order for quality of care to take place. It is important to remember that management and leadership are very different but have overlapping functions (Ellis and Hartley, 2005, Gopee and Galloway 2009). To have aspects of leadership and management skills are an essential part of the SCPHN role. Gopee and Galloway (2009) support Huber (2010) about the key importance of a visionary approach to leadership. It is important to reflect on the differences between leadership and management, to have the ability to utilise management in order to enhance my leadership and promote flexible, positive and appropriate team development. Christian and Norman (1998) build on this by arguing that management and leadership are so different that they sometimes can be conflicting.

2.3In my leadership experience I believe that having an effective working relationship with you team can influence the outcomes of a project this is identified by Hartley and Benington (2010), as being a key leadership quality. Kotter (1990) states that leadership is about setting directions, motivating people, inspiring people, having the ability to adopt a visionary position, setting a direction, and anticipating as well as coping with change. I have adapted this approach by undertaking regular team meetings where ideas and goals were set. Then time was given for the team to feedback there own personal vision which promoted self esteem and ownership of the project to enhance team motivation towards a common goal. Team members through this feedback time were able to identify there own strengths and interests to bring to the project, any areas of weakness that were identified were discussed and any relevant training was given. Cooperation and collaboration from other agencies was resourced to provide the best quality service for staff and service users alike. This enabled learning from each other where any potential conflict would be avoided due to staff working within there capability within there role and recognising that each member of staff is accountable for there own practice. This links with Malcolm et al (2003) who argues that leaders within the clinical area should stay focused on quality of care and professional issues and not cross over to the other side, which is management.

2.4 I believe, as dose Mulally (2001) that leadership for nurses is essential for the success of the Department of Health’s NHS plan (2000). Over the past decade accessibility has been a consistent factor in governmental policy. The white paper; The New NHS: Modern Dependable (DH, 1997) advocated improvements to the quality, range and accessibility of services available within the community. Shortly after the Acheson Report (Acheson, 1998) highlighted that within primary care it is important that services are not only effective but readily accessible. Acheson concluded that the NHS should be aiming to provide equitable access to effective health care for all. The project that I have implemented is aimed to improve the quality of existing services. Research into inequalities in health and anecdotal evidence from parents who have or are due to return to work has highlighted a current deficit in service provision. Service users have indicated general dissatisfaction at there being no clinic available at a time accessible to working parents. When discussing inequalities it is easy to focus on disadvantaged families living in deprived areas, however, it is important to acknowledge that working parents experiencing difficulties accessing services only available during the working day are also experiencing inequality. Therefore as a leader I have identified a gap in service provision and an opportunity to reduce inequalities in health by providing this service. The NHS Plan continued the trend of encouraging a greater range of services and recommended that primary care providers offer services from shared modern premises (DH, 2000). Recently, Our health, Our care, Our say (DH, 2006) was published which aims to improve services in the community, it promised more co-ordination between services and greater consistency across the health service in order to reduce inequalities. It also advocated more flexible services to increase accessibility and recommended involving service users and the local population in decision making.

3. Critically analyse leadership styles and apply them to the complexity of the delivery of care.

3.1 In the last year as a SCPHN I have been able to observe many different leadership styles, on reflection I believe that I have chosen aspects of these styles to develop my own style. One theorist suggests that leadership in a clinical setting influences followers to bring about improvements in care (Welford, 2002). Through research I have found that there are many different leadership styles, Hersey et al (2008) identified these styles as authoritarian, laissez-faire and democratic. Within my career I have encountered many of the leadership styles, this has enabled me to choose aspects of these styles within my own practice. I found the laissez-faire approach of no interference and lack of decision making and a lack of structure to be confusing and unclear. The advantages of this approach with groups are that they are fully independent and promote professionals working together (Huber, 2010). The authoritarian approach from previous leaders has been very directive and not team focused. I found this approach did not encourage togetherness and therefore I would not want to promote this within my team. In conflict situations I can see how it would be an efficient approach. I aim to be a democratic leader who works with there team, sharing responsibility and decision making although this may be a long drawn out process I believe it will facilitate an improved project. Huber(2010) stated that the challenges of a democratic style are getting people with different professional backgrounds to work together and decide on a plan of action. To overcome this I ensured that the team shared common goals. I created motivation within the team to examine working practices. This was confirmed to me as many of the staff showed their interest by their offering of ideas to meet this challenge. By tapping into the moral dimension of a proposed change i.e. promoting the need to contribute in order to protect the safety and health inequalities for those children and families who would not otherwise be in a position to attend a “well baby clinic” during the day. It was also recognised that there may be resistance to working unsocial hours. As two health visitors will be required for each clinic and there are currently in excess of 20 health visitors employed by the trust they may only be expected to cover one clinic every 10 months. Some staff may even volunteer to work more often providing relief for those staff who aren’t keen to cover the clinic while providing a benefit to themselves if they can start work later in the day, therefore demonstrating that the democratic leadership style further inspired staff to change by motivating followers to transcend their own self-interest for the sake of the team and organization (Bass 1985).

3.2 Situational leadership was developed by Hersey and Blanchard (1977) and assumes the leader adapts their style according to a given situation. Encouraging team input and facilitating problem solving are key features of the supportive behaviours exhibited by the situational leader (Northouse 2004). This style has two main types of intervention: those which are supportive and those which are directive. The effective situational leader is one that adjusts the directive and supportive dimensions of their leadership according to the needs of their subordinates (Northouse 2004).As most team members were highly motivated in the project, freely offering suggestions and ideas, a directive role was not needed. The supportive behaviours I employed encouraged a participative approach characterised by the use of finely tuned interpersonal skills such as active listening, giving feedback and praising (Marquis and Huston 2000) which can be likened to a Skinnerian approach of positive reinforcement.

3.3 I can identify my correct use of the democratic leadership style by working with and alongside team members encouraging participation. This is achieved by assessing worker’s competence and commitment to completing the task. The member of staff that appeared to take little interest and was not able to offer ideas displayed a lower developmental level compared to other team members and hence I directed her more using the coaching behaviours advocated by Hersey and Blanchard (1977). This coaching promoted inclusion and participation by: giving encouragement, soliciting input and questioning the participant on what they thought of the proposal and the changes they would like to see. This was done to increase levels of commitment and motivation (Northouse 2004) and thus integrate that team member into the change process. On reflection this can also be identified as an example of reducing the resisting factors to the change within the force field as by adapting to the needs of that team member, she was encouraged to take part and share ideas rather than hinder progress and potentially thwart the change. I aim to develop my leadership style further by gaining feedback from my team members and by reflecting on what have been positive and negative experiences, whilst maintaining a link with best evidence based practice.

3.4 When implementing my evening well baby clinic and introducing my new leadership style, it was important to remember that change would be needed. When proposing change it must be recognised that if a structured process is not used the process could easily fail (Keyser and Wright,1998). It is important therefore, to acknowledge the complexity of the process. Lewin (1951) identified three stages in the process of change, these were ‘unfreeze, move and refreeze’. Within this scenario, the’unfreeze’ process would include communication and planning with both staff and PCT management in order to gain their backing and support for the evening clinic. The ‘move’ process would involve trying the evening clinic for a period of six months, and observing it’s effectiveness during this time. If the evaluation of the service proved it to be successful it would ultimately result in the clinic becoming established concluding the ‘refreeze’ process.

Through implementing the clinic I gained peoples thoughts and opinions and what they felt was needed, in Kassean & Jagoo’s study (2005), they identified the unfreezing stage as that of facilitating people’s thoughts on the current situation. Sheldon and Parker’s (1997) research found that people can only be empowered by a vision that they understand and that it is paramount that strategies are used to foster inclusion and participation so that all team members are fully aware of the impetus for change.

3.5 When improving care, two potential obstacles have been highlighted by Tait (2004), these were limited resources and the pace of change. With these in mind, a force field analysis (Lewin, 1951) has been completed to try and identify potential barriers. The issues I have identified are that it must be established early in the process the arrangements for the remuneration of staff time. Possible options are overtime payments or time owing. Staff will display individual preferences depending on their individual perception of the benefit of each option. As the decision on how time will be paid will lie with the PCT management team it is important to establish their response early as this issue is likely to be raised by the health visitors very early in the change process. Another issue identified was Health and Safety. As the building is already used for a family planning Clinic, any health and safety issues are already likely to have been addressed. I however considered it to be good practice to revisit and review the risk assessment. I identified a training issue around securing the health centre at the end of the evening, these locking up and safety procedures could be addressed with a short in house training session. After identifying the above issues it was my responsibility as a leader to consider resources and budgets available in order to achieve all my aims and objectives.

4. Identify and evaluate areas of leadership that enhance and benefit the quality of client care.

4.1 The Government has clearly outlined the need for nurses to develop leadership skills at all levels within the workforce in order to deliver the NHS modernisation programme (DH 1998; DH 1999). The leadership role expected of community practitioners is evident in ‘Shifting the Balance of Power’ (DH 2001a) and ‘Liberating the Talents’ (DH 2002) with the expectation that health visitors will lead teams which will deliver family-centred public health within the communities they work (DH 2001b). I strongly believe that by collaborating with other agencies when setting up my evening well baby clinic I have improved the quality of care for clients within my practice area.

4.1When implementing my project I took into consideration the felt and expressed needs (Bradshaw, 1972) of service users, and in line with both local Primary Care Trust (PCT) and government policy (Sec 2.3) regarding accessibility to services, it is proposed that an evening clinic be introduced for a trial period of six months. I made this decision as a leader of my team to ensure quality care and provision was implemented. To enable ongoing quality and evaluation change will be audited and evaluated in order to inform future practice and service delivery. In health visiting I believe that the emphasis should be placed on quality of care, providing and promoting access to health information and helping people make sense of the information so that they are able to make informed lifestyle decisions (DH, 2000).

4.2 A study investigating parents preferred sources of child health information found that when parents required advice on their child’s general health care needs, the child health clinic was the second most popular source of information and advice (Keatinge, 2005). Child health nurses were identified as a good source of information, parents felt comfortable talking to the nurse and advice was seen to be reliable. Attendance at the child health clinic was viewed as an opportunity to obtain regular information and advice (Keatinge, 2005). A study of parental satisfaction with the health visiting service found that approximately two thirds of health visitor contacts took place in the clinic and routine weighing and general advice accounted for a high percentage of recent contacts in one year old infants. Again the health visitor was viewed as an important source of advice (Bowns, Crofts, Williams, Rigby, Hall and Haining, 2000). The National Service Framework (NSF) for Children, Young People and Maternity services (DH, 2004), contains several standards. Standards 1-3 are particularly relevant when considering a well baby Clinic, they focus on promoting health and identifying needs, supporting parents and having services centred around the family. Each of these standards can be addressed in a well baby clinic. The NSF is intended to lead a cultural shift which will result in services designed around the needs of the family, not the needs of the organisation, thus resulting in quality of care for all (DH, 2004).

4.3As a leader it is essential to have an awareness of clinical governance to ensure health care organisations can develop cultures and ways of thinking in order to improve quality of care (Tait, 2004). I have considered the culture of the organisation within which the proposed change will take place as I felt it was important. In my experience of the health visiting service, individual health visitors cover individual caseloads and generally work independently. This is not to say that a team culture does not exist but communication is essential, and as a leader I can facilitate this as part of my role. In addition to this regular health visitor meetings and annual ‘away days’ encourage communication and help foster the wider team spirit. Clinical governance attempts to provide joined up policy development (Tait, 2004) so it is important to note that the issues highlighted are high on both local and national agenda’s. As a result of this it is hoped that the proposal, attempting to improve service provision with minimal resource implications is likely to be given serious consideration by service providers. Initial consultation with the management team was sought to identify if there is managerial support for the proposed evening clinic. Once this was achieved the process of consultation with health visitors and administrative staff began. It is hoped that by encouraging shared governance and shared leadership the proposal will be both practitioner owned and organisationally supported (Scott and Caress, 2005).

5.Demonstrate a dynamic and flexible approach to leadership issues.

5.1Within the project there is a mixture of cultures that have proved beneficial when planning the expansion of the well baby clinic. Managerial support was established early in the process, so that the change would be less opposed. However in addition to this staff were encouraged to contribute their ideas and concerns the change process may progress more smoothly. The implementation of this strategy reduced the risks of potential conflict. Barr and Dowding (2010) state that by being a dynamic and flexible leader who is able to resolve conflict effectively, high quality patient care can be achieved. Change can sometimes be viewed as a negative thing. A percentage of the team who will be affected by this change are established health visitors. There can at times be apathy to change and a tendency to continue with a certain practice because it has ‘always been done that way’ or because something has been tried and failed before.

5.2 If conflict was to arise within my team I would use a conflict resolution strategy as identified by Barton (1991). This approach can be adapted by leaders to help improve team moral and productivity (Huber 2010). I believe the important factors for the leader to implement are effective communication, assertiveness and empathy. If this technique is delivered effectively I believe can be resolved quickly and with minimal upset. If conflict arises and a leader avoids confronting an issue or withdraws from the situation this can be beneficial as it allows for a cooling off period between team members but I believe that this is not a solution as it will not resolve the conflict. Marquis and Huston (2006) support Huber’s research by saying that a leader should address conflict but also needs to recognise and accept an individuals differences and opinions. Therefore a flexible leadership style should be adopted whenever possible.

6 Conclusion and Summery.

6.1 In conclusion I feel that a model which places great importance on the needs, values and morals of others is transformational leadership (Northouse 2004; RCN 2005) and elements of this could be identified in my leadership. The goal of transformational leadership is to create a vision & change “what is” into “something better”. Although transformational leadership did not originate within the nursing profession, its usefulness is in its application towards implementing the proposed change in practice. Transformational leaders are accustomed to sharing power, using influence and developing potential and are seen as the only leader likely to implement lasting change (Marriner-Tomey 2004).

6.2 Before completing the process I was inclined to believe that a large proportion of change was dictated to staff by managers and that as an ‘individual member’ of a large work population I had a relatively little influence over work practices and few opportunities to lead other staff. The positive outcome of compiling this report has been gaining insight into the process of change and that different types of change and leadership are equally important. I have also benefited from actually completing the process and analysing the potential problems that may occur when trying to introduce a change in practice. I feel that the knowledge gained has influenced and inspired me to strive to become a motivational and beurocratic leader.

6.3 The negative points have been seeing how much work is required to bring about a relatively small change in practice. This process has taught me that in my career I will be unable to change everything I want to. It has also been difficult gathering the evidence base which has been frustrating as this appears to be a fundamental indicator in ensuring a proposal within practice is taken seriously. In the future I hope my new confidence in my ability to lead and empower will make me a valuable contributor to the health visiting service. I will carefully study those working practices I would like to change, ensure there is a good evidence base for any proposals and follow a structured process in order to maximise the potential success of future ventures.

6.4 Evidence based practice- leadership-SCPHN. AND CONTINUING REFLECTION OF SELF AND SERVICES.adapability and flexability.values