Engaging Transformational Leadership is an approach to leadership that is conducive to good-quality care because it nurtures staff’s confidence, motivation, ability to work with others and willingness to innovate
Pressure on NHS staff has never been greater, stemming from factors including increased workload, major changes to how service provision is organised, greater uncertainty and complexity, and increased interdependence of teams and organisations. Leaders in nursing have a significant role to play in minimising the impact of these factors on staff, including by reducing stress and improving teamwork, innovation and collaboration. This article explains how a specific approach to leadership, called Engaging Transformational Leadership, provides a framework for nursing leaders to rise to these challenges.
Citation: Alban-Metcalfe J, Alimo-Metcalfe B (2018) Engaging Leadership – a better approach to leading a team? Nursing Times [online]; 114: 6, 21-24.
Authors: Juliette Alban-Metcalfe is chief executive officer, Real World Group and adjunct associate professor at the Centre for Sustainable Business and Enterprise, University of Southern Queensland, Australia; Beverly Alimo-Metcalfe is emeritus professor of leadership studies at the University of Leeds and founding director of Real World Group.
- This article has been double-blind peer reviewed
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In 2018, there can be no doubt the acronym VUCA – volatile, uncertain, complex, ambiguous – applies to the context in which the NHS provides care. This context means leaders in the NHS must enable others to be adaptable and innovative in the face of rapid change, and ensure that both they and their staff are psychologically resilient. How can nursing leaders rise to that challenge, and how can they be supported to do so?
With evidence of unsustainable stress levels (Royal College of Physicians, 2015; Boorman, 2009), there is a growing need to protect the wellbeing of the healthcare workforce. Nurses’ rates of physical illness, mortality, psychiatric admissions and suicide have been found to be higher than the national average for working adults (Clegg, 2001; Kirkcaldy and Martin, 2000). Putting aside its cost to nurses’ personal mental wellbeing, stress can have a significant negative impact on the quality of care nurses provide (Mark and Smith, 2012). Ultimately, this can endanger the health, if not the lives, of patients, as shown so vividly by the Mid Staffordshire inquiry (Francis, 2013).
Stress-causing factors such as workload and uncertainty may be unavoidable in the short-to-medium term, but some factors that are known to reduce stress can easily be put to good effect. One of these is the leadership approach of the line manager or supervisor (Harms et al, 2017). A leader can reduce or increase the stress experienced by staff, and their style of leadership is influenced by their own experience of work-related stress (Hunter et al, 2011; Day et al, 2004). Breaking the cycle of stressed leaders resorting to a stress-inducing “command-and-control” approach is key.
There is an increasing need for innovation in healthcare, not just to implement new practices but also to improve efficiency and adapt to major changes, such as integration with social care. Innovative behaviour relies on staff being engaged with their organisation and its values (Sonenshien and Dholakia, 2012; Woodward and Hendry, 2004). Staff need the autonomy and confidence to experiment with new approaches, including some latitude to make mistakes (Edmondson, 2011; Zhang and Bartol, 2010). They also need to know they will not be rebuked if they come up with new ideas – a culture of “psychological safety” is key (Edmondson, 1999).
Effective working within teams is essential to the quality of care and the effective use of resources. Effective collaboration between teams is required because of the increasing need to work with multiple agencies and stakeholders, and the increased emphasis on patient-centredness. According to the 2013 NHS Staff Survey, most employees (97% across all professions) reported being a member of a team, but only 53% said they worked in a well-structured (“genuine”) team (NHS England, 2013). “Genuine” teams are defined as:
- Having shared objectives;
- Working in interdependent ways;
- Regularly meeting to discuss effectiveness.
In contrast, in “pseudo” teams and teams with a strong medical-based hierarchy, there are:
- High levels of errors and accidents;
- Poor staff wellbeing;
- Slower adoption of innovative practices (Dawson, 2007; Feinmann, 2006; Edmondson et al, 2001).
There are several ways in which leadership style can deliver positive outcomes for organisations, staff and patients (Laschinger et al, 2014). However, to ensure effective leadership, we need to challenge the enduring myth that a good professional is a good leader (Alban-Metcalfe and Alimo-Metcalfe, 2009; Alban-Metcalfe et al, 2009). The distinction between a good leader and a good professional is that the former is not only competent in their job, but also able to exert a positive influence in their interactions with others.
In our experience, many organisations fail to achieve the right balance between management and leadership skills because:
- When leaders are selected, recruiters tend to value “human capital” (experience, qualifications, track record) over “social capital” (the ability to enhance the effectiveness of others);
- Professional or managerial competences still dominate leadership frameworks to the exclusion of essential leadership behaviours;
- Performance appraisals tend not to pay sufficient attention to leadership successes – such as strengthening the leadership skills of others – and focus too much on the achievement of more tangible targets.
A leader can acquire human capital, be a competent manager and/or achieve targets, largely without enhancing their social capital – however, when social capital is enhanced in the process, the outcomes are likely to be far better for the organisation.
If an organisation accepts the above points, it must:
- Adapt its leadership selection methods and criteria, including leadership frameworks;
- Help individuals who are recruited in leadership positions to complement their competences with effective leadership behaviours;
- Promote a culture valuing a type of leadership that enhances social capital through formal and informal feedback.
Validity of leadership frameworks
Given that leadership style makes a difference to the quality of care, we need to test leadership approaches in the same way we test clinical procedures or drugs. This means selecting a leadership model on the basis of its proven validity and scrutinising the research underpinning it.
It appears that many leadership frameworks used in the health service have not been tested for their impact on care. Neither we, nor other researchers consulted by us, could find peer-reviewed or other published evidence of the validity of the Department of Health’s Healthcare Leadership Model in spite of it (NHS Leadership Academy, 2013).
Engaging Transformational Leadership
There are leadership models that have been shown to have a positive impact on staff motivation and job satisfaction (Alimo-Metcalfe and Alban-Metcalfe, 2008; Avolio et al, 2009). One such model, known as Engaging Transformational Leadership (Fig 1), originated from a UK empirical study in 2001 investigating what distinguishes leaders who have a positive impact on staff motivation, morale and wellbeing from those whose impact is less positive, or even negative (Alban-Metcalfe and Alimo-Metcalfe, 2016; Alimo-Metcalfe and Alban-Metcalfe, 2001).
The principles of the model are:
- “Servant leadership” – supporting others, enabling them to become leaders themselves and displaying transparency and integrity – as opposed to “heroic leadership”;
- Partnership working and the removal of barriers to the communication and sharing of ideas, both within teams and with external partners;
- A respect for other people’s views, concerns, experience and perspectives, and a willingness to take them on board;
- An environment that encourages people to challenge the status quo, to come up with new ideas, to innovate and experiment;
- A culture that supports personal development – one in which the leader is a role model for learning and mistakes are used as learning opportunities.
Evidence suggests the model assesses those leadership behaviours that have a positive impact on employees’ motivation, job satisfaction, self-esteem, commitment and stress levels (Alimo-Metcalfe et al, 2008; Alban-Metcalfe and Alimo-Metcalfe, 2007, 2000; Kelly et al, 2006; Dobby et al, 2004). To ensure that wellbeing, openness to change, improvement and engagement are sustained, the leadership approach needs to be embedded in a team’s culture.
Impact of engaging leadership
Two longitudinal research studies were undertaken by us and colleagues at King’s College London and the University of Bradford to explore the impact of a culture of engaging leadership on the effectiveness of mental health teams in the NHS (Alimo-Metcalfe et al, 2013, 2008). The aim was to identify the characteristics of teams that had not only high levels of readiness for change and ability to innovate, but also high levels of wellbeing and positive attitudes to work.
To investigate what distinguished higher- and lower-performing teams, both studies used psychometric diagnostic tools to assess competences and behaviours, the Leadership Culture and Change Inventory and the Engaging Team 360. They also used a statistical technique called structural equation modelling to understand the contribution of different teams’ characteristics to the outcomes.
In the earlier study (Alimo-Metcalfe et al, 2008), a direct link was found between an engaging leadership culture and performance, staff engagement and wellbeing. This is one of the rare pieces of published evidence showing a causal link, and not just a correlational association, between leadership approach and productivity or performance.
Key findings of the second study (Alimo-Metcalfe et al, 2013) include:
- Leadership competences are one aspect of effective team leadership, but competences that relate to social capital were more varied and contributed more overall to things such as actively engaging with others, building a shared vision and enabling the team to achieve their maximum performance;
- Team leadership contributes to the overall output based on how the leader enables the team to function, which supports the notion that social capital is more important than human capital;
- Inter-team relations and collaboration are essential aspects of effective teams;
- The higher-performing teams exhibited characteristics such as:
- Genuinely interdependent working;
- Members feeling psychologically safe to express their ideas;
- Members supporting each other;
- Clarity of roles and expectations;
- A genuine learning culture featuring: learning from experiences, including mistakes; reflection facilitated by sharing experiences; a respect for each other’s contributions and the generation of ideas.
These findings contradict the notion that there needs to be one indispensable person who has overall control; instead, this is replaced by a notion of “distributed leadership”. Effective leaders create a culture that exploits the wealth of perspectives, experience, strengths and potential within their teams – and team members reflect this approach in their interactions with others, both internally and externally.
Advances have been made in recent years towards more effective leadership, with two examples being the inclusion of:
- Values-based leadership in recruitment processes;
- Leadership behaviours in formal frameworks.
Another positive development is the introduction of revalidation for doctors and nurses. Both at the General Medical Council and Nursing and Midwifery Council, the revalidation model formalises what is expected of professionals – something that was previously absent. The requirement for individuals to gather and reflect on feedback from others encourages them to lead more effectively.
Having said that, both the GMC and NMC revalidation models could include more of the aspects of effective clinical leadership described in this article. These are leadership behaviours that apply to everyone, not just people in formal leadership roles. The NMC could enhance individual effectiveness by encouraging nurses in leadership roles to seek more specific multi-source feedback. In our experience, while some leaders can be described as “naturally” adopting the more effective behaviours described in this article, these can successfully be developed among managers who have not had the same exposure to positive role modelling or have not been encouraged to adopt more effective leadership. Box 1 lists some suggested reflection points for nurse leaders.
Box 1. Reflection points for nurse leaders
- When you recognise that you are experiencing high levels of stress, stop and think about how this may be affecting your leadership behaviour. Once you have spotted what, in your behaviour, might be stress inducing for others, could you modify it?
- Ask your team members individually and confidentially whether they feel safe to make suggestions, admit having made a mistake, or not having the answer to a problem. If they do not feel safe, what can you do to change this? Is your own behaviour creating the problem? Do you need to challenge unsupportive behaviour from other team members?
- Does your team meet the criteria of a genuine team? If not, could you and your team members learn to become one by speaking to, and observing, genuine teams?
- Regularly meeting with your team to review progress is a powerful tool. At each meeting, you could ask one person to share what has gone well, what they feel could be improved, what did not go according to plan, and what they have learned. Lead by example – particularly if this is new to your team
- Reflect on how positive your team meetings are, for example, by keeping a tally of positive, neutral and negative comments and body language. Are negative behaviours allowed to prevail? It is not helpful to be overly positive, but are there things you can do to redress the balance?
- When you cannot attend a meeting, could the team hold it without you?
- When you are unable to communicate face-to-face with your team or colleagues, could you find a better alternative than email? A telephone call or videoconference will reduce the chance of miscommunication and bring important emotion into the relationship
- How much do you encourage your team members to collaborate with other teams? Could some of your team members take responsibility for bridging the communication gap with other teams? What coaching could you provide to increase their confidence in that respect?
- Are there people or groups with whom you can talk about the challenges you face? You cannot do this alone, so joining professional groups and spending time with peers will help
One key to improving and sustaining the effectiveness of health sector organisations is to provide work conditions that attract and retain staff, maintain their wellbeing and enable them to realise their potential. Given the influence of leadership on wellbeing and performance, organisations need to enable reflection through some form of multi-source feedback based on evidence-based approaches. This would signal that they are treating leadership with the seriousness it deserves and allow the most effective approaches to healthcare provision to thrive.
- The leadership style that is adopted in a healthcare organisation makes a difference to patient care
- A good professional or manager is not necessarily a good leader
- Organisations need to focus more on their leaders’ ability to enhance the effectiveness of others – their “social capital”
- Good leaders are not people who have overall control and are indispensable, but are people who engage with staff
- Effective leaders create a culture that exploits the wealth of perspectives and strengths within their teams
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