Emergency Staff O Task Structure example essay topic

This essay is based on the work experience at a busy children's department (CD) in urban India. The essay focuses on two aspects of the CD- the organisational culture and leadership issues. Let us describe the CD before we analyse these issues. The children department is a busy 40 bedded facility with an in built Paediatric Accident and Emergency Unit. The two roles of the organisation are 1) to provide a health care to a city and semi urban population and 2) to train junior doctors thorough a three year clinical programme.

There are two main areas of activity. There is an emergency department which contributes in part to the work load on the inpatient unit. The inpatient unit has two main sections - general care and cancer care The workforce is headed by the Head of Department (HOD) and 2 Associate Professors (Assoc P), 8 Assistant Professors (AP) and 20 resident doctors. The eight permanent staff (PS) members work in small teams comprising of a mixture of year ones to year three residents. The permanent staff, especially the HOD held overall responsibility for the activities of the unit and essentially provided leadership and clinical training. They were also responsible in evaluating the work of the junior staff and make decisions regarding their promotion through various levels of training.

The CD is further divided into teams headed by Assoc Ps or APs. Schein, one of the foremost researchers into organisational culture, defined it as: 'A pattern of shared basic assumptions that the group learned as it solved problems of external adaptation and internal integration, that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think and feel in relation to those problems' 1 Each organisation develops its own 'way of working' or 'culture'. Handy asserted that organisations evolve specific structures and thereby structure- specific cultures and leadership types suited to their objectives. Let us look into the two main areas of CD work and explore these issues. 1. Inpatient care: Most care pathways within the inpatient ward rely upon pre set procedures and protocols to deliver health care.

For example, children with cancer are treated using a national protocol of drugs with pre- determined care pathways of using drugs and monitoring treatment. This work is repetitive and demands accuracy and the use-standardised methods. There is little scope for individuality apart from ones manner in talking to the families in question or manual dexterity in simple procedures such as placing drips. One could describe the unit as having a role culture 2 or bureaucratic culture 3.

The main features of this system are the reliance on formal procedures and managerial hierarchies 1, 2. Power is distributed down the hierarchy and efficiency is achieved by following of pre-determined procedures and guidelines 2. The predictability provides a safe and secure environment for the workers. Developing individual potential and ability (especially relevant for doctors in training) is not a priority and is at risk of being sacrificed in order to sustain the 'assembly line' or machine like manner of working. The features of this culture, however, suit the requirements of the task - precision, predictability and consistency. 2.

Emergency Care: Emergency care of patients, especially with injuries, requires 'thinking on the feet' and calls upon innovative skills and high risk decision making. The onsite team needs and is allowed to make autonomous, innovative and 'lateral thinking' decisions whilst working in the broader remit of the guidelines. Difficult or complex decisions are referred to the next step in the hierarchy. In practice, a PS member or yr- 3 resident is the team leader and expert who is available to provide for on the spot decision making and leadership. Power with the small team is distributed along lines of individual expertise and ability and not via a hierarchical network. This can be described as having an entrepreneurial culture 3 or club culture 2 where there is usually has a central figure that provides the initiative and expertise.

The leader takes risk and initiative and the team around the person are heavily dependent upon him / her. Control is exercised through the centre. There are few rules and little bureaucracy - and the entrepreneurial structure is maintained where major decisions require flair and skilled judgement rather than reliance on procedure and measured weighing of alternatives 3. Problems could arise if the leader is inept or weak. Success depends upon finding the right people who can blend with the team 2. At the CD, teams cannot be selected by the leader and every resident has to go through emergency posting.

The team efficiency and effectiveness can therefore, unacceptably, vary over time. Teams go through stages of growth - forming (creating identity), storming (assertiveness, challenging the shape or purpose of the team), nor ming (settling in, becoming comfortable) and performing (maturation, effective delivery of goals) 2. The resident postings rotate on a 4 monthly basis - which in my opinion, is insufficient time for the team to start performing. I would suggest the posting should be rotated 9 monthly, if not yearly. The backbone of the structure of the CD is bureaucratic (see below) with further divisions into relatively autonomous teams, which in turn have different work cultures.

Let us look at issues regarding leadership and how changes can be incorporated to improve the efficiency and effectiveness of the team. One can analyse leadership using the traits approach - which assumes leaders are born and not created (focuses on the individual and not the task); the behavioural approach (focuses on observable behaviour that makes a leader effective); the leadership styles approach (the way functions of the leader are carried out- focuses on the behaviour of leaders towards subordinates - autocratic, democratic and laissez -faire styles); using contingency models (No single style is appropriate to all situations) web) or the using the transformational leadership model (Leaders broaden and elevate the interests of their followers, generate awareness and acceptance of the purposes and mission of the group web Research shows that having a range of different leadership styles and knowing which to apply in which sort of situation is closely associated with success. We shall use Fielders contingency model to explain the leadership situation at the CD. Fiedler's model assumes that group performance depends on: 1. Leadership style, described in terms of task motivation and relationship motivation. He devised a device to measure leadership style which indicated the degree to which a person described favourably or unfavourably their least preferred co-worker (LPC).

A person who described his least preferred co worker in a relatively favourable manner tends to be permissive, human relations oriented, and considerate of feelings of men (high LPC). In contrast, a person who describes his LPC in an unfavourable manner tends to be managing, task controlling and less concerned with the human relations aspects of the job (low LPC) - Fiedler 1967. My own observations would place my HOD as having a high LPC. A proxy marker to this was the fact that she was felt to be quite sympathetic to the juniors when it came to the question of compassionate leave and tutorial support during examinations.

Most of the emergency team physicians, in my opinion, would have low LPC rating, whereas the cancer team leaders would have a high LPC rating 2. Situational favourableness, determined by three factors: o Leader member relations: How well is the leader accepted by the subordinates? I felt that the HOD was well accepted by the resident doctors in training - this is based on informal discussions with colleagues. One could define the relationship between the PS and the HOD as poor in general. The PS who were leaders for small groups varied in relations with the juniors -the cancer ward staff, in my opinion, better relations with the leaders as compared to the emergency staff. o Task structure: Are the jobs of subordinates routine and precise or vague and undefined? The task at the emergency department could be quite chaotic and undefined - requiring improvisation and quick thinking.

The work at the cancer unit was clear, precise and predicable o Position power: what authority does the leader's position confer? The regional state office (SO) determined major policy health care decisions and future direction. Staff appointments and the budget was largely the domain of the regional office. The HOD was responsible for ensuring the execution of the guidelines and for the 'management' of the workforce. The resource power (in this case money and budgets) therefore rested with the SO.

The HOD had position power (described as 'authority' -it is official and legitimate) over the rest of the team. To the TS in training he / she also had expert power (possession of knowledge and skills allowing one to influence others). The leaders influence on the two major groups differed (see table below Permanent staff (power of HOD over PS- Low) Resident staff (training) (power of hod and PS on RS-high) o Appointment by SO. Salary linked with time spent in the organisation and not performance linked o Promotions also time bound and depended upon the senior position falling vacant o Had negative power- as described by Handy- an unhappy work force can block, obstruct, or delay work thereby creating inefficiency. o Were experts in themselves and so did not see much difference between themselves and the HOD in terms of clinical expertise o Appointment by SO. Fixed appointment of 3 yrs. Progress from R 1 to R 3 depended upon appraisal by the PS o Had to appear for exit exams at end of R 3 - PS staff were part of the examination team o Not experts: depended upon PS for training According to Fiedler - Low LPC leaders are effective when the situation is either highly unfavourable or highly favourable.

High LPC leaders are effective in situations which are of moderate favourableness. Cancer department Permanent staff (leader is the HOD) Resident doctors (leaders are PS members and HOD) Leader member relations Poor Good Task structure High High Position power Weak Strong Overall position Moderately favourable Highly favourable Emergency department Permanent staff (leader is the HOD) Resident doctors (leaders are PS members) Leader member relations Poor Poor Task structure Poor Poor Position power Weak Strong Overall position Highly unfavourable Highly unfavourable Applying Fiedler's theory: 1. The High LPC style would be most effective with the PS staff at the cancer department and least effective with this group at the emergency department. At the emergency department, the effectiveness of the HOD could be improved if the task became highly structured, there was increase in power (of HOD), or the relations between the HOD and PS improved. The first two factors are relatively inflexible. Steps could, however, be taken to improve the leader member relationships and increase the influence of the leader.

It was felt that the HOD had a Laissez faire style of leadership when it came to dealing with the PS. They were often left to their own methods and means to sort out their work- and while this recognised the fact that they were experts in their own right, it also led to a situation where differences in opinion were ineffectively resolved for want of someone taking overall charge of the team. A democratic style, which is participative in nature, but where the leader retains overall control, would have been more appropriate. Fiedler argued that individual leaders have little chance of adopting a style which is more appropriate to the situation. This has been subsequently disputed by Blake and Mouton (1982) who developed a successfully tested the managerial grid -a device used for identifying leadership style of a team with an aim to either alter team membership to increase effectiveness or enable individual members to modify their personal style.

2. The leadership was not effective when dealing with resident doctors in either the emergency department or the cancer centre. The main problem in the emergency team was to do with the poor relationships of the RS with the PS. The PS were perceived as authoritative - this style is shown to be appropriate with novices (yr one resident) who have little experience and need direction and guidance. The failure to modify this style to match the increasing experience of the yr 2 and yr 3 residents was thought to be a reason for discontent. A democratic style would, perhaps, have been better suited for the group.

One could argue that the high task structure and good relationships between the PS and RS at the cancer department meant that the need for strong leadership was not felt and hence the overall effectiveness of the leader was reduced. 1. Schein, Edgar H. 1992 (12). Organisational culture and leadership. San Francisco: Jossey - Bass Publishers Of the best rulers, The people only know that they exist; The next best they love and praise The next they fear; And the next they revile. When they do not command the people's faith, Some will lose faith in them, And then they resort to oaths!

But of the best when their task is accomplished, their work done, The people all remark, "We have done it ourselves". -- Lao-Tzu (6th century B.C. ), Chinese philosopher. [13] The Wisdom of Lhotse, ch. 17 (ed. and tr. by Lin Yu tang, 1948). In The Columbia Dictionary of Quotations. Copyright (c) 1993 by Columbia University Press.