Leadership in Mental Health Nursing: Integrating the Current Knowledge into Interdisciplinary Practice Strategies

Life is fluid. Change is an inevitable in health care because of multiple factors including development of new technology (Atter, 2008), clinical practice changes (Callaly, & Minas, 2005; Piat, Sabetti, & Bloom, 2010), changing client demographics (Atter, 2008), scarce financial resources (Erwin, 2009), staff shortages, and many others. Mental health nursing in the hospital setting is a prominent area of change because of the shift from the custodial care model prevalent in the early and mid part of the 20th century, to a client-centered recovery-oriented approach that gained popularity in the latter part of the century.  This shift required a drastic paradigm shift from caring for to caring with patients and their families.  Compounded by the additional workplace stress of de-institutionalization, the result was fewer inpatient mental health beds and shorter lengths of stay (Lloyd, et al, 2009).  Unfortunately, change can be a major cause of workplace stress (Olson, 2008; Yu, 2009) which may foster staff resistance to both leaders, and the chosen strategies for innovation (Atter, 2008).  The purpose of this article is to explore the reasons for staff resistance in health care and remedies rooted in strong leadership styles that may be applied to overcome resistance.  The discussion will focus on organizational change in the mental health hospital setting, and how leadership strategies that emphasize and develop collaboration, communication and stress management, counteract resistance. The transformational leadership model is used to illustrate a specific framework that can be utilized to help ameliorate staff resistance and facilitate organizational change.

Organizational Changes in Mental Health Care

The care delivery model in mental health has changed from custodial care, meaning focus on institutionalized, to a community-based recovery oriented approach that emphasizes holistic care (Lloyd et al, 2009). Recovery concepts have guided the formation of health care policy and services in many countries including the United Kingdom, Australia, New Zealand and the United States (Lloyd et al, 2009). This requires a philosophical shift from the dominant medical model that has guided both past and current practice of mental health which are illness oriented and conceptualize the client as inevitably and persistently impaired by their diagnosis (Craig, 2008; McAllister, 2003). Within this new model, clients are admitted to the hospital setting for short periods of time only for stabilization in acute crisis.


Mental health nursing requires the integration of broader health and wellness information (Hughes, 2008). There must be considerations made in order to provide good care, like taking time because the opportunity to establish a therapeutic relationship is lost when close, personal encounters with clients are rushed and mechanistic (Hughes, 2008). In mental health nursing, Registered Nurse staff has the opportunity to support clients living in vulnerability (Hughes, 2008). Unique to the mental health field is the requirement of skill in working with multiple plans for multiple purposes, for example recovery, clinical, discharge, risk and relapse plans (Hughes, 2008). Registered Nurses on inpatient mental health units or in hospital services have to manage numerous demands and documents both plans and interventions (Hughes, 2008). Thus, mental health nurses need strong leadership, direction, mentorship, guidance, and support from their own professional body (Hughes, 2008). Mental health can be an extremely stressful environment in terms of crisis situations like suicide intervention or interventions with client aggression and violence. Lobbying for more favourable working conditions with employers and agencies is a necessary part of the work environment (Hughes, 2008).


In order to do clinical work mental health professionals need a well-functioning organizational context (Callaly & Minas, 2005). Callaly & Minas (2005) argued that only those who provide care can fundamentally change care for the better as clinical decision making drives 75% of the cost of health care. Further, the decisions of clinicians are vital in the policy development process to ensure decisions are made on the basis of relevance rather than political expediency and ideology or practical and economic convenience (Callaly & Minas, 2005). There is a need for clinicians to possess qualities that are aligned with the needs of clinical staff, necessitating treatment with greater respect and have work valued not only by peers but at management levels.


In the profession of nursing, the transformational leadership model has been typically used to understand the role of nursing leaders, most significantly in times of organizational change. There is a tendency to rely on outdated methods that have little evidence-based support, for example, use of restraint and seclusion rooms and institutionalization because they are well established and entrenched in the ward culture.  It is also congruent with the values and interpersonal nature of working inclusively with mental health consumers (Cleary, Horsfall, Deacon, & Jackson, 2011).


Resistance and Organization Culture


Resistance may be part of a cultural component of a particular organization. It is important to recognize that organizations have their own individual cultural context in which they function (Maurer, 2005). Leaders in nursing face the challenge of overcoming resistance to change. Some strategies are by exercising power and control, however, effective leaders learn that there are more effective strategies to overcome resistance to change. The key is achieving a voluntary commitment to shared values. Leaders must brother the needs of followers both within and outside of an organization which necessitates sensitivity to the needs of many stakeholders as well as a clear sense of the organization’s mission. Good leadership and a sense of direction may help relieve the pressure of change by contributing to the development of systems that adds value to the clinical endeavor and reduce unnecessary duplication of effort (Callaly & Minas, 2005). Leaders in nursing must be prepared to gather disparate stakeholders around a common table and facilitate dialogue and planning toward a common vision to create a dynamic partnership. Leaders are responsible for setting the ethics and norms that govern the behaviour of those within an organization.


Leadership Strategies for Organizational Change in Mental Health Nursing


Good leadership is necessary for the personal development of nurses and attainment of the strategic goals of an organization. Part of the role of a leader involves being involved in many levels which allows for continued improvement through utilizing the best evidence and being up to date with advances in MHN. Well developed roles are key as job ambiguity leads to increased stress and increases likelihood of attrition when job satisfaction decreases (Holm & Severinsson, 2010).


Holm and Severinsson (2010) found three themes that contributed to the knowledge of the mental health nurse leadership role in organizations: (1) clarifying role expectations and areas for development at the same time as increasing the influence on patients with mental health problems, (2) using evidence-based practice to implement improvements and organizational change in mental health and (3) employing communication skills as well as supporting, nurturing and empowering others. I argue that in order to specifically address the issue of staff resistance in mental health nursing there are three necessary components to leading successful organizational change which incorporate the themes identified by Holm and Seversinsson (2010), (1) communication, (2) collaboration and (3) stress-management.

Communication. Stress Management. When employees have a negative perception of organizational changes, massive work stress will arise (Yu, 2009). If efforts are not made to relieve this stress the attitudes and performance of employees will be impacted (Yu, 2009). The utilization of stress management strategies demonstrates a significant positive effect on organizational change-related stress (Yu, 2009). This exemplifies the importance of identification and management of stressful employee situations in organizational change as well as seeking measures to maintain trust such as being open about changes and using a collaborative approach that involves employees.


Collaboration and Team Coherence. The role of an organization should be to involving people who will be affected by change, helping them understand the importance of the change and giving them time to make the essential transitions to successfully implement change (Olson, 2008). Resistance to change is not malicious but may result from resistance to being controlled (Olson, 2008). Through addressing the concerns and using a collaborative approach leaders can create action plans are build momentum for moving forward (Olson, 2008).

Stress Management. 


Application of the Transformational Leadership Model in Mental Health Nursing


The transformational leadership model works well in mental health because it is aligned with nursing’s desires for collaboration and team coherence within a consumer centered recovery oriented approach (Cleary, et al, 2011). This is a positive leadership model that incorporates mutual respect, effective communication, ethical practice, valuing collaboration, and facilitating the development of a shared vision for better patient care in order to fulfill higher expectations, gain nurse autonomy., and improve practice (Cleary, et al, 2011).


The primary characteristics of transformational leadership are keeping promises, behaving consistently with these promises, and achieving the trust of staff. These processes result in greater job satisfaction, boosted worker morale, and increased organizational commitment with benefits extending to clients, employees, and employers. Much research in clinical nursing leadership reveals that nurses are not often not well prepared for leadership roles, as they have not experienced positive role models, feel overwhelmed, and view colleagues and nursing management structures as unsupportive (Cunningham & Kitson, 2000). There has been little research conducted on nursing leadership in mental health specifically with the existing body of knowledge exploring the nature of care rather than the learning and professional development needs of nurses (Holm & Seversinsson, 2010). The mental health leadership role is complex because of the constantly changing context of situations and the multiple tasks involve (Holm & Severinsson, 2010). The purpose of this paper is to identify the specific skills needed in the context of mental health.


Leaders who self-evaluated themselves as inspirational generated the highest level of patient satisfaction (Holm & Severinsson, 2010). Clients reported a higher quality of life when staff perceived their leaders as charismatic, inspirational and considerate (Holm & Severinsson, 2010). The community experience is identified as a unique setting because clinicians in these health settings have less opportunity for interdisciplinary collaboration between units, contract agencies and the community (Holm & Severinsson, 2010). Three specific attributes that allow a good quality of mental health nursing leadership are: (1) relating to patients, (2) relying on teamwork and (3) paying attention to the personal life of nurses.


In order to achieve structural change for the benefits of mental health consumers there are particular leadership qualities and actions that have emerged as central to making and maintaining clinical improvements such as personal authenticity and professional integrity when interacting with others, value relationships as the foundations of change processes, use an inclusive/team oriented approach, develop and maintain trust, see member contributions and value and build on them, draw on a repertoire of styles appropriate to the situations, influence people higher in the organization, future orientation, challenge routines, standard procedures, priorities, and thinking, support team members by coaching, teaching and facilitating learning,


One way to achieve collaboration, involvement and shared working practices is the concept known as shared governance, a system of leadership and management where staff are empowered by processes of inclusion and shared decision making promoting a decentralized collective accountability and clinician-owned decision making process (Lamont, Walker, & Brunero, 2009). The benefits are increased worker morale, job satisfaction, interpersonal relationships, and increase perceived worth (Lamont et al, 2009). They specifically focus on practice development because it is ways in which knowledge and skills development is used to provide better patient care. The practice development model emphasizes use of authenticity with personal qualities and creative imagination with practice skills and practice wisdom. This is a transformative practice as both individual and team practices are changed and sustained because the process and outcomes are embedded in the organizational strategy (Lamont et al, 2009). It is important for staff to actively take part in a collaborative approach rather than taking a passive role (Lamont et al, 2009). As transformational leadership empowers members of an organization a seemingly inflexible system can explore innovative ideas and visions in an inclusive manner while increasing organizational commitment. The PD approach did meet resistance despite the value that was demonstrated. Staff voiced opinions that these strategies were a waste of time, openly voicing their negative attitude toward the process.

Conclusion

The purpose of this article was to explore the leadership issue of resistance to change in the specific practice area of mental health nursing. There are multiple organizational changes in mental health resulting from different factors. These multiple changes result in resistance to change because of comfort levels, and increased stress levels. The discussion will focus on organizational change in the mental health hospital setting, and how leadership strategies that emphasizing and developing collaboration, communication, and stress management counteract resistance. The transformational leadership model was used to illustrate a specific leadership model all healthcare leaders can utilize to successfully ameliorate staff resistance and facilitate organizational change.

References

Atter, L. (2008). Using creative transformational leadership in shaping our hospice's journey to


excellence. Practice Development In Health Care, 7(3), 134-142. doi:10.1002/pdh.261


Blegen, N. E. & Severinsson, E. (2011). Leadership and management in mental health nursing.


Journal of Nursing Management, 19, 487–497. doi: 10.1111/j.1365-2834.2011.01237.x


Callaly, T., & Minas, H. (2005). Reflections on clinician leadership and management in mental


health. Australasian Psychiatry, 13(1), 27-32. doi:10.1111/j.1440-1665.2004.02146.x


Cleary, M., Horsfall, J., Deacon, M., & Jackson, D. (2011). Leadership and mental health


nursing. Issues in Mental Health Nursing 32 (10), 632-639. Retrieved from


http://library.mtroyal.ca:2114/direct.asp?ArticleID=4B208F267668E6266FA2


Craig, T.K.J. (2008). Recovery: say what you mean and mean what you say. Journal of Mental


Health 17(2), 125-128. doi: 10.1080/09638230802003800


Ennis, G., Happell, B., & Broadbent, M. (2011). Rethinking leadership in mental health nursing.


Australian Nursing Journal, 19(4), 44.


Glisson, C., Schoenwald, S.K., Kelleher, K., Landsverk, J., Hoagwood, K.E., Mayberg, S., et al


(2008). Therapist turnover and new program sustainability in mental health clinics as a


function of organizational culture, climate, and service structure. Administration & Policy in


Mental Health 35, 124–133. doi:10.1007/s10488-007-0152-9


Holm, A., & Severinsson, E. (2010). The role of the mental health nursing leadership. Journal Of


Nursing Management, 18(4), 463-471. doi:10.1111/j.1365-2834.2010.01089.x


Hughes, F. (2008). Leadership in mental health nursing. Journal Of Psychosocial Nursing &


Mental Health Services, 46(9), 8-9.


Hughes, F., & Bamford, A.. (2011). Providing Nursing Leadership in a Community Residential


Mental Health Setting. Journal of Psychosocial Nursing & Mental Health Services: Online


Exclusive, 49(7), e35-e42. Retrieved February 9, 2012, from Research Library.


Lloyd, C., Deane, F.P., Tse, S., & Waghorn, G. (2009). Supporting recovery oriented services for


people with severe mental illness. Australian Journal of Rehabilitation Counselling 15(1), 1-


11. doi: 10.1375/jrc.15.1.1


Lamont, S., Walker, P., & Brunero, S. (2009). ‘Teaching an old dog new tricks’: A practice


development approach to organizational change in mental health. Practice Development In


Health Care, 8(2), 65-76. doi:10.1002/pdh.281


McAllister, M. (2003). Doing practice differently: solution focused nursing. Journal of Advanced


Nursing 41(6), 528-535. doi: 10.1046/j.1365-2648.2003.02564.x

McNabb, D., & Webster, M. (2010). Qualities and practices of professional social work


leadership in an interdisciplinary mental health service: an action learning approach. Action


Learning: Research & Practice, 7(1), 41-57. doi:10.1080/14767330903576846


Piat, M., Sabetti, J., & Bloom, D. (2010). The Transformation of Mental Health Services to a


Recovery-Orientated System of Care: Canadian Decision Maker Perspectives. International


Journal Of Social Psychiatry, 56(2), 168-177.


Yu Ming-Chu, (2009). Employees' perceptions of organizational change: The mediating effects


of stress management strategies. Public Personnel Management, 38(1), 17-33.Retrieved from


http://0-search.proquest.com.aupac.lib.athabascau.ca/docview/215950700?accountid=8408