Management Issues and Practices

James Strong, the former CEO and managing director of Qantas Airlines, twice sat on the panel convened at the Sydney office of CPA Australia to select those who would be recognized for the annual 40 Young Business Leaders list. Strong believed in the importance of nurturing young talent and threw himself wholeheartedly into leading much of the discussion among prominent leaders from all over the globe. Criteria for entrants included “the ability to land a top job, develop others and get the most from a team, and leading by example was also a must-have attribute” (“CPA Australia,” 2014). To provide the scope and depth of the list-building endeavor, it is informative to explore the names of other participants on the panel, and to match them to the criteria they articulated for entrant evaluation. Here is a quick run down: James Strong looked for entrants who had “done well from a tough start” (“CPA Australia,” 2014). CPA Australia’s president, John Cahill, emphasized “a sense of integrity,” while the company’s CEO stressed the importance of “having passion and the courage to fail. The executive chair of Women on Boards, Ruth Medd, was on the lookout for “professionally well-rounded” entrants (“CPA Australia,” 2014). Chris Cuffe, philanthropist and financier considered entrants who demonstrated early that they “have the get up and go to experiment” evidenced emerging leadership traits. In concert with Cuffe’s criteria, public practitioner Jason Cunningham was watchful for “young leaders who were likely to be ahead in sports, volunteering and other activities” (“CPA Australia,” 2014). From these proven leaders and their insights on leadership, it is possible to distill the attributes and propensities that are essential for strong leadership and good management practices (“CPA Australia,” 2014). A discussion of these dynamics follows.

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Leadership, Management, and Teams

The business management literature is replete with studies intended to discover and articulate the differences between leaders and managers (Cummings, et al., 2010). Operating a business is a like a sojourn on unmapped territory, fraught with known hazards and unknown risks, and a destination that seems continually just out of reach on an indistinct horizon. Leaders tend to set the company compass, determining what direction to travel, how fast to travel, and what to jettison when the load has grown too heavy, and create the necessary overlap to get the whole caravan moving in yet another direction. Managers are more typically engrossed by activities such as what to do when a wheel comes off, or the river can’t be forded, or which short cut to recommend when another caravan threatens to overtake the travelers. Leaving this simile, a more formal definition of leadership is getting people to work efficiently and effectively toward a common goal, such that the work is accomplished through the agency of people other than oneself. W hat, then is management? In 1997, a book written by leadership guru Warren Bennis, was titled, “Managing People Is Like Herding Cats.” The origin of the phrase “herding cats” has not definitively been established, but Bennis (1997) wrote, “Cats, of course, won’t be herded. And the most successful organizations in the 21st Century won’t be managed!” This phrase doesn’t stand well on its own, and though Bennis wore out his own simile, he does clarify elsewhere in his book, adding: “Management is getting people to do what needs to be done. Leadership is getting people to want to do what needs to be done. Managers push. Leaders pull. Managers command. Leaders communicate.”

Retaining some of the most talented people in an organization is not an easy feat. Highly intelligent and highly creatively people synthesize information in a way that can produce insights that are difficult to wrap oneself around. Add to this: highly capable people may find it difficult to be patient while others catch up. They want to take action and are often compelled by a sense of urgency. So these capable “cats” don’t take being herded, nor do they herd others well. Highly talented people may find the constellation of skills that enable one to or productively coach others a mystifying conundrum. If enough disgruntled people register complaints, the organization may find it easier to push out the rare talent than try to figure out how keep the wheels turning smoothlywithout overly squeaking.

From this, one is reminded that diversity is more than ethnicity, race, gender, age, and primary language. Diversity also includes a rather large spectrum of talent, education, and areas of specialty — any one of which can function to undermine or support to teamwork.

Team members and teamwork. The team members include a senior facility manager, middle managers in areas of specialty, and back-office staff. The role of the senior manager is a combination of oversight and troubleshooting, which is done in conjunction with the middle managers. In a company of any large size — with multiple facilities — communication is one of the primary concerns: the more layers a message needs to travel, the more opportunity that the meaning will be misconstrued. Even when communications are written, there will be times when the rationale behind a decision or the participation of the parties engaged in deliberation will not be clear to those who receive only the written message. The chaos, conflict, and confusion that can ensure ensured from a reduction in force are a perfect example of the importance of inclusive communication, in which critical information is shared across stakeholders.

The role of leadership and management is crucial to ensuring good stewardship of scarce resources. Absent informed and timely leadership there is a danger of the following scenarios occurring in the healthcare setting:

The continued growth of healthcare expenditures will reach such high levels that they are not sustainable;

Care that should be provided and is justified from every consideration will not be provided;

Care that is not of certain value will be funded.

One of the primary roles of healthcare leadership in the company has been to facilitate the contemporary shift away from providers and toward patients and their families (Graetz, et al., 2011). The important changes that managers have had to address deal primarily with alterations in the Australian system of healthcare financing so that it does not subsidize the health inputs, so to speak (Graetz, et al., 2011). This radical change has helped to focus system resources on outputs — that is to say, on measuring and monitoring patient outcomes as they reflect quality healthcare (Graetz, et al., 2011).

Some of the roles of the people in the company could be improved by using action research as a format to address the changes of practice that are required in order to be an agile organization (Graetz, et al., 2011). The company is organizing its effort to improve team building around the theory of caring. The transformation of the healthcare sector from a provider focus to patient-centered healthcare providers is mirrored in the company’s initiative to demonstrate that through their clinical activities and professional transactions, nurses care about patients as well as care for them — and that both of these are important to the well-being of their patients (Tonges & Ray, 2011). The plan is to use action research to study how caring theory can be manifested by integrating routine interventions to connect healthcare processes, care expectations, and nursing actions (Tonges & Ray, 2011).

The team building initiative and the action research are modeled after the Carolina Care Model that was developed at the University of North Caroline Hospitals (Tonges & Ray, 2011). The Carolina Care Model includes a performance framework for ways to actualize the caring theory and to support nursing practices that promote patient satisfaction (Tonges & Ray, 2011). Embedded in this initiative and essential to the Caroline Care Model are efforts to transform cultural norms in order to sustain the model implementation (Tonges & Ray, 2011).

The Carolina Care Model has enabled the Swanson Caring Theory to be operationalized and fostered change of practice that enhances the hospital experiences of patients and their families (Tonges & Ray, 2011). The Carolina Care Model also demonstrates the linkages between caring theories and the development and implementation of evidence-based methodologies (Tonges & Ray, 2011).

The tasks and protocols that comprise nursing rounds practice are designed to analyze patient needs, anticipate those needs as much as possible, and ensure regular, personalized contact between the patients and the nursing staff (Tonges & Ray, 2011). In the process of anticipating and meeting those needs, patients increase their trust in the nurses and in the hospital procedures and policies that influence the quality of care that they receive (Tonges & Ray, 2011). These actions, taken together, foster trust in the patients, which is closely linked to patient satisfaction, assuming that patient needs are adequately or superbly met (Tonges & Ray, 2011). In addition to patient satisfaction, there are benefits to nursing staff of conducting practice in a manner that reflects the influence of caring theory (Tonges & Ray, 2011). Nurses gain professional satisfaction from providing safe, high quality care results in satisfied patients (Tonges & Ray, 2011).

It should be said that the rationale for deciding on a particular model of care is to organize the nursing work, to provide a common language and formal structure for the work, and to describe processes for delivery of optimal services and patient care (Hedges, et al., 2012). The basic structure of a care model articulates the responsibilities, communication pathways, work streams, and decision-making authority of the people working in the healthcare context (Hedges, et al., 2012). The care model selected promotes a relationship-based approach to nursing that can function as a driver to achieving a higher level of quality patient care (Hedges, et al., 2012). Importantly, the model an also serve as a mechanism for transitioning the facility unit to a new cultural norm (Hedges, et al., 2012). Integrating a new care model into practice at a facility requires that all aspects of nursing care be addressed in the change model, including criteria for success, core nursing principles, leadership and administrative manager roles and responsibilities, nurse roles and responsibilities, policies and processes, and tools (Hedges, et al., 2012).

An effective approach to team building that would work in tandem with the transition to a new care model is action research (Lewin, 1952). The action research would entail implementation of a professional practice model that is grounded in caring theory, with the action research component focused on evaluating the knowledge that staff have about nursing on five different levels: 1) Do the staff have the capacity to be caring — to provide caring nursing services to patients? 2) Is the nurse committed to relating to patients in a caring manner evocative of the caring model adopted by the facility? 3) Does the healthcare facility support the activities and actions of staff committed to caring nursing practice? 4) Does the nursing practice provide evidence of behaviors that are based on these actions: a) Knowing the patient, b) being with the patient, c) doing for the patient, d) enabling the patient, and e) maintaining belief in the patient? (Tonges & Ray, 2011).

Swanson established a middle-range theory that identified five integrated caring processes that exemplify her of nursing: “informed caring for the well-being of others” (Swanson, 1993). The caring processes are represented by the following statements:

1. Maintaining belief and sustaining faith in the capacity of other people to have meaningful lives and make the transitions through their own effort, when necessary. To achieve meaningful lives;

2. Working to understand events so as to know them from the perspective of the other person for whom the events have meaning;

3. Being emotionally present to the patient whenever contact is made or communication transpires;

4. Doing for the patient the things that they cannot do for themselves, but would do if they could;

5. Empowering others, and facilitating for others when necessary, the ability to care for themselves and their family members (Swanson, 1991; Watson, 2005).

Changes in the Health Care System

The National Health Reform Agreement (NHRA) will increase transparency and accountability in Australia’s health care systems, leads to more efficacious care, and improve the overall health of Australians (Willis, et al., 2012). The switch to Activity Based Accounting appears to a solid business move that will make it easier to track patterns in expenditures on which to base future decisions about allocation, spending, and the fulfillment of social responsibilities related to healthcare (Willis, et al., 2012). As with nearly every other developed country, the tension between the rising costs of healthcare and the public sentiment that taxation and governmental costs are already too high can press people at all levels of the system to make changes that do not benefit the public, but are directed more at preserving the public’s coffers (Willis, et al., 2012). Where unions are prominent in employee negotiations, there will be strong resistance to increasing costs to members and to any proposal that is designed to restrict access to quality health care (Willis, et al., 2012). Juxtaposed against the pressure from the union are the cost-cutting exigencies of the employers (Willis, et al., 2012).

The provision of services for people with disabilities or elderly people within the healthcare system is widely seen as an ever-growing burden at individual, business, and government levels (Willis, et al., 2012). It is unlikely that the pot of available resources will get any larger in concert with the demand for services. Companies will need to add competencies, and perhaps entire divisions, in order to ensure that they can grow into the areas where there is demand (Braithwaite & Mannion, 2011). These changes will impose demands on leaders that encompass a range of activities, including: 1) The establishment of leadership frameworks that support current leaders and develop new leaders with competencies in the areas where demand is expected; 2) to develop and implement educational preparation and training programs that align with anticipated workforce needs; 3) to establish models of care that are in step with current and anticipated future demand — such as in care of the aged or disabled; 4) to increase opportunities for , mentorship, and traineeship positions; and 5) to provide models of are that enable sustainable and broadened Allied Health coverage (Podger & Hagan, 1999).


The theory of caring and care models are the threads that run through this discussion. Indeed, an examination and fitting of a model of care to a healthcare context serve as the basis for an action research project to be carried out with the aim of building a stronger, more effective team. The healthcare system is never static: change is a constant in healthcare as it is in most sectors. A healthcare system must figure out ways of working that enable an agile system with the potential to optimize healthcare services. To accomplish this, effective leadership and management must be resident in the healthcare system.

References 13

40 young business leaders. In the Black. 2014 CPA Australia Ltd. Retrieved from

Bennis, W. (1997). Managing people is like herding cats. Covey Leadership Center.

Braithwaite, J. & Mannion, R. (2011). Managing change. In K. Walshe & J. Smith, Healthcare Management, pp. 830-861. New York, NY: McGraw-Hill Education.

Cummings, G.G., McGregor, T., Davey, M. Lee, H., Wong, C.A., Lo, E., Muise, M. & Strafford, E. (2010). Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review. International Journal of Nursing Studies, 47(3), 363-385. doi: 10.1016/j.jnurstu.2009.08.006.

Graetz, F., Smith, A., & Lawrence, A. (2011). Managing Organizational Change (3rd ed.). Sydney, AU: John Wiley & Sons.

Hedges, C.C., Nichols, A., & Filteo, L. (2012). : transitioning to a new care delivery model in maternity units. Journal of Perinatal — Neonatal Nursing, 26(1), 27-36. doi: 10.1097/JPN.0b013e31823f0284

Lewin, K. (1952). Field Theory in Social Science: Selected Theoretical Papers. London: Tavistock.

Podger, A. & Hagan, P. (1999, March). Reforming the Australian health care system: The role of government. Department of Health and Aged Care Occasional Papers: New Series No. 1. Retrieved from$File/ocpanew1.pdf

Swanson, K. (1991). Empirical development of a middle range theory of caring. Nurse Research, 40(3), 161-166.

Swanson, K. (1993). Nursing as informed caring for the well being of others. IMAGE, 25(4), 352-357.

Tonges, M. & Ray, J. (2011, September). Translating caring theory into practice: The Carolina Care Model. Journal of Nursing Administration, 41(9), 374-381.

Watson, J. (2005). Caring theory as ethical guide to administrative and clinical practices. Nurse Administrative Quarterly, 30(1), 48-55.

Willis, E., Reynolds, A., & Keleher, H. (2012). Understanding the Australian Health Care System (2nd Ed.). Sydney, AU: Elsevier.