Leadership Links With Care
How leadership behaviour matters to health and social care, based on the key themes highlighted in this learning activity
You need to engage your colleagues in a dialogue about what you as a leader could do to enhance your leadership approach based on what the evidence tells us.
What difference leadership makes to what people achieve together.
how leadership makes a difference
links between leadership and quality care
why leadership matters in health and social care.
it is very hard to know how what I do as a leader will make things better for patients.
How is leadership linked to healthcare improvement?
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there was very little convincing evidence to show whether leadership made a difference to care and if it did, how this happened
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the actions and behaviours of leaders were very difficult to directly attribute to the quality or improvement of care.
Key aspects of leadership
Influence up to 30% of a team’s performance
Leadership style has a critical influence (up to 70%) on a team’s climate and the team climate accounts for 30% of the team’s performance.
In 2000, the Performance and Innovation Unit at the Cabinet Office undertook a broad review into Public Sector Leadership and the importance of team climate was clear.
Affect patient care and satisfaction
Jenny Firth-Cozens and Derek Mowbray from the University of Northumbria did one of the first reviews into how leadership affects the quality of healthcare and their conclusion was: “It therefore seems that leaders are able directly to affect the safety of their teams’ actions and outcomes — an extremely important finding for patient care.” (2001, pp ii3–ii7).
Create lower stress and higher quality patient care
In their book exploring the downsides of charismatic leaders, American psychologist Robert Hogan and his colleagues identified that the prime cause of stress in the workplace is the boss. This links with other evidence to suggest that good team leadership produces good teams with lower stress and higher quality patient care.
Impact on patient satisfaction with services
In a study into client satisfaction among mental health service users, US-based researchers Patrick Corrigan and colleagues found that the way staff rated the quality of team leadership independently accounted for 40% of the total variance in client satisfaction. Those teams where the staff were happier with the way the team was led had better satisfaction ratings from service users.
Be critical to high performance
Sandra Leggat and her colleagues from La Trobe University, Melbourne, Australia completed a review of the literature on factors associated with high performance in healthcare organisations and other industries. Unsurprisingly, leadership consistently emerged as a necessary factor for high performance. The more pertinent finding was that the difference made by leaders was specifically in the influence they could have on setting the tone for the rest of the team or organisation.
Affect engagement of staff and team performance
Within an NHS context, Margaret Bradley and Beverly Alimo-Metcalfe investigated whether and how leadership contributed to the effectiveness of 24-hour mental health crisis resolution teams. Data reported by team members showed that the only significant factor positively associated with improved team performance was the extent to which team members thought their leader was engaging.
Positive emotional environment
Doug Pugh from Virginia Commonwealth University in the USA has researched the importance of recognising that providing a service to others is emotional work, known as emotional labour.
The crucial point concerning leadership in healthcare settings is that leaders need to help create a climate which supports professional carers in their emotional labour and recharges their emotional bank account. Generally this activity is left to chance - leaders or team members may well recognise and support each other informally. However a growing evidence base suggests that a structured approach to supporting staff in their emotional labour yields genuine user/carer and patient benefits.
As is pointed out by John Storey & Richard Holti (2013), “this work is of clear relevance to healthcare and seems especially relevant to current concerns about compassion and caring and of their neglect and/or presence.”
Engagement
Studies have consistently shown that engaging staff has an important impact on care. Of the many definitions of engagement, the King’s Fund report Together We Can (2012) selects the most straightforward from MacLeod and Clarke (2009): “The business values the employee and the employee values the business”. In common with other definitions, this recognises that every member of staff chooses whether to do the minimum required, or to go further.
A range of suggestions are made in the literature about why engagement raises performance. For example, a study by Marisa Salanova and colleagues at the University of Jaume I in Spain suggests that engaged staff are more likely to put energy into interactions with clients; their positive approach may in turn motivate other staff; and this creates a more engaged workplace. The King’s Fund Report Together We Can (2012) proposes another explanation: that “engaged staff are likely to exert more influence over the use of standard processes, teamwork and the degree to which there is a culture of improvement, all of which are factors influencing patient outcomes.” (p.3).
What can leaders do to support engagement?
Leaders can support engagement in a number of ways. Saijo Mauno and colleagues from the University of Jyväskylä in Finland undertook a study of Finnish healthcare staff. They found that people having control over how they did their jobs was the best predictor of engagement, even more than management quality. This and other studies (for example, Jari Hakanen and colleagues from Finland) suggest that leaders in healthcare wishing to engage staff need to think carefully about how jobs are designed to ensure:
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a manageable workload
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a sense of autonomy
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staff are involved in understanding resource availability
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self-esteem is promoted
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a positive climate is created.
Doctors who are engaged are less likely to make mistakes
A study by Dutch academic Jelle Prins and colleagues used data from a survey of 2,115 resident physicians in the Netherlands and found that doctors who scored more highly on engagement were less likely to make mistakes.
Safer patient care is linked to nurses feeling engaged
A study of more than 8,000 hospital nurses by Heather Laschinger and colleagues from Acadia University in Canada found higher engagement was linked to safer patient care.
A lack of engagement can be a cause of poor care
The Commission on Dignity in Care for Older People in 2012 identified top-down cultures lacking engagement as a cause of poor care. It states: “If senior managers impose a command and control culture that demoralises staff and robs them of authority to make decisions, poor care will follow” (p.16).
Leaders rely on specific engagement behaviours when improving care services
Jeanne Hardacre and colleagues from the University of Warwick explored which leadership behaviours were most associated with service improvement in the NHS. These were all found to be behaviours which engage others, namely:
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valuing the skills and expertise of others
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seeking, understanding and valuing the viewpoint of others
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building confidence and trust in others
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facilitating cooperation and collaboration.
Better patient experience is evident in organisations where staff engagement is higher
In 2012, Michael West and Jeremy Dawson compared engagement scores given by staff in an NHS staff survey with a wide range of organisational data about outcomes. They showed that where there is strong staff engagement, patient experience improves, inspection scores are higher and infection and mortality rates are lower. They suggest leaders need to give staff autonomy, enable them to use a range of skills, ensure jobs are satisfying and give staff support, recognition and encouragement. They also propose that some of the personal qualities associated with engagement that managers should nurture include optimism, resilience and self-belief.
Relationships between clinicians and managers
Clinical innovation stems from blending clinical and managerial skillsets
In their paper for the Open University, John Storey and Richard Holti (2013a) identified that successful clinical leadership requires collaborative working with a wide range of non-clinicians, including managers, IT staff, project managers, estates and many others. This suggests that there is an important need for non-clinical leaders to connect up with clinicians to understand their perspective, and vice versa.
Innovations are more likely to be successful if they are built on good manager-clinician relations
Several studies have emphasised that when innovations are founded on trusting and well-established relationships, there is more likelihood of problem-solving and more effective adaptation of innovative ideas to local circumstances e.g. research in 2007 by Louise Fitzgerald from Said Business School in Oxford and colleagues, and also a study in 2009 by Trisha Greenhalgh, a GP and Professor of Primary Care in London and colleagues.
Partnership between clinical leaders and experienced managers is a key leadership factor
Ross Baker from the University of Toronto did a study in 2011 to examine several high-performing but contrasting health systems in the USA, Sweden, England and Canada. His findings highlighted the importance of clinical leaders working in partnership with experienced managers in combining their knowledge about improvement with their clinical expertise. A video presentation of his full findings can be viewed on the King’s Fund website.
Conclusions
The evidence base to illustrate how leadership matters to care continues to develop and evolve all the time, and is increasingly an area of interest for academics and for practising leaders. Understanding the themes emerging from research studies can help us to focus our leadership energy into work which has been shown to have an impact on the quality of care provided to patients. What is clear is that how you choose to lead can make a real difference to the impact you have on those around you and ultimately on people being cared for by our health and social care services. A curiosity to learn what works well, and why it does so underpins all good leadership practice, and this can be based on experience as well as on research findings and reading.
Conclusions
Jean Hartley and John Benington summarised the findings from their review of leadership in healthcare. “The evidence from leadership studies and experience in healthcare is that there is no ‘one best way’ of being an effective leader… this takes us back to the critical importance of accurately reading the context in which leadership is exercised. Leadership benefits from an approach that is not uniform or universalistic, but that asks key questions: what will work, in what circumstances, why and how?” (p.129, original emphasis).
Based on research in healthcare environments, which three of the following aspects of leadership have been shown to be associated with quality care?
Correct, research shows that leaders who create a climate of care, engage staff and create strong partnerships with clinicians positively influence patient care. There is evidence that command and control cultures do not have this effect.
References
Essential reading Baker, G.R., 2011. The Roles of Leaders in High Performing Healthcare Systems. [online]. Available at: www.kingsfund.org.uk/leadershipcommission Bradley, M. & Alimo-Metcalfe, B. 2008. Best actors in a supporting role Health Service Journal no. 6105, 8 May, 28-29 Available at: https://anderson.leadershipacademy.nhs.uk/mod/resource/view.php?id=573 Commission on Dignity in Care for Older People (2012). Delivering Dignity: Securing dignity in care for older people in hospitals and care homes. A report for consultation. London: Local Government Association/NHS Confederation/Age UK. Available at: https://anderson.leadershipacademy.nhs.uk/mod/resource/view.php?id=575 Corrigan, P.W. (2000) Mental Health Team Leadership and Consumers’ Satisfaction and Quality of Life Psychiatric Services Vol. 51 No. 6 781-785 Available at: http://bit.ly/17aHG7H Firth-Cozens, J., Mowbray D.,(2001) Leadership and the Quality of Care Quality in Health Care 10 (Suppl II):ii3–ii7 Available at: http://bit.ly/16efTpQ Fitzgerald, L., E. Ferlie, et al. (2007). ‘Service improvement in healthcare: understanding change capacity and change context.’ Clinician in Management. 15(2): 61-74. Available at: http://bit.ly/13SKUPg Greenhalgh, T., et al. (2009). ‘How Do You Modernize a Health Service? A Realist Evaluation of Whole-Scale Transformation in London.’ Milbank Quarterly. 87(2): 391-416. Available at: http://bit.ly/17aIqK7 Hakanen JJ, Bakker AB, Demerouti E (2005). ‘How dentists cope with their job demands and stay engaged: The moderating role of job resources’. European Journal of Oral Sciences, vol 113, pp 479–87. 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