Improving services through leadership development. This is an extended version of the article published in Nursing Times; 104: 13, 58-59.
Gillian Janes, MA, PgCLTHE, BSc, RGN, is senior lecturer and CETL4HealthNE fellow, School of Health and Social Care, University of Teesside, Middlesbrough.
Janes, G. (2008) Improving services through leadership development. This is an extended version of the article published in Nursing Times; 104: 13, 58-59.
Background: The NHS is facing unprecedented reform. Effective leadership has been identified as crucial to the success of this modernisation,
Aim: To evaluate the perceived impact of a new module (Leadership With a Purpose - LWAP) from student, mentor/manager and service development perspectives.
Method: A descriptive, qualitative study was carried out using one-to-one semi-structured interviews and thematic analysis.
Results: All participants reported a positive impact following LWAP attendance, with students and practice mentors/line managers identifying similar effects. Its usefulness during periods of transition was an unexpected finding. Further themes indicated wide-ranging effects on students’ attitudes and skills. These included improved personal skills such as communication, assertiveness and self-awareness. Another key theme was students’ improved ability to work with others. There was evidence of applying learning in practice, as participants implemented service improvements.
Conclusion: This study supports the limited research showing a positive impact. Its main contribution is the evidence it provides of the application of learning in practice in terms of service improvement following attendance. This is a major gap in the current body of knowledge.
This article is based on an evaluation study examining the impact on practice of a new leadership development module (Leadership with a Purpose - LWAP) for health and social care staff.
Fig 1 identifies some of the factors driving today’s unprecedented reform of the NHS and responses to this. Developing effective leadership at all levels of the service is crucial for successful modernisation (Department of Health, 2004; DH, 2000).
Recognition of this has resulted in a plethora of leadership development programmes. In a climate of enhanced educational accountability, robust evaluation, particularly on the impact of education in practice, is vital (Williams, 2003).
The LWAP module is one of a range of short introductory programmes available to health and social care staff in the UK, some of which have been evaluated (Janes and Wadding, 2004; Cooper, 2003; Edmonstone and Jeavons, 2000). However, major academic reviews concur in recognising the limited empirical evidence of the impact of leadership development programmes on practice (Hartley and Hinksman, 2003; Williams, 2003). It was therefore important this new, local module was evaluated.
The aim of this study was to evaluate the perceived impact of the LWAP module in practice from student, mentor/manager and service development perspectives, in order to inform future provision.
A recognised model for the evaluation of training and development (Kirkpatrick, 1983) was used to demonstrate how this study adds value by enabling module evaluation at a deeper level (level 3, that is, behavioural change and indirectly level 4, namely impact on the organisation) than is usually the case.
A systematic review of the literature was undertaken. Key search terms used were: evaluation; evaluation in practice; evaluation of education; leadership; and leadership development. Systematic filtering resulted in 38 papers, of which 14 concerned short, introductory programmes.
Much of the literature on leadership is descriptive and theoretically or practically weak (Hartley and Hinksman, 2003; Williams, 2003) or concerned with much longer, more intensive programmes.
However, critical review of these 14 studies indicates strikingly coherent findings from around the world. This amounts to a small but significant body of fairly robust evidence that introductory programmes have a positive impact on participants in three domains. These encompass: personal behaviour and attitudes; ability to work with others; and improving services.
Although no universal framework for leadership development evaluation has yet been agreed, these three domains would appear to comprise the core of any such structure. However, only a very small proportion of studies have addressed the impact of introductory programmes on service improvement behaviour in practice (Janes and Wadding, 2004; Krugman and Smith, 2003).
As identified earlier, the main purpose of contemporary leadership programmes is to develop staff who can modernise and improve services. Although there is evidence of their impact in this area, it is very limited, making it the most crucial area for further research.
An action-orientated evaluation methodology was used, which combines the focus of process evaluation with the essence of action research. The real benefit of this method lies in taking action in the real world (Lathlean, 1994). The study used a qualitative interpretive approach to data collection, which aims to capture and interpret the meaning of in-depth, narrative data concerning the lived experiences of individuals.
Population and setting
The research was undertaken in the North of England. The potential study population comprised a purposive, initial cohort sample of nine module participants from a range of disciplines and of both sexes, plus a chain referral sample of the practice mentor and line manager for each student. Inclusion and exclusion criteria were developed, based on the study’s aims and resources available, to provide equal access in accordance with research governance (DH, 2005). All participants were female registered nurses and worked in one of two large acute NHS trusts.
Research governance and ethical issues
The study was approved by the relevant university research governance committee, NHS trust R&D departments and local research ethics committees. Being a member of university academic staff and module leader presented a potential ethical dilemma in the form of a dependent relationship between researcher and participants (DH, 2005). To minimise this, recruitment to the study began after the students received assessment results.
This comprised the development and piloting of a semi-structured interview guide to ensure a degree of continuity and focus for the interviews. One-to-one tape-recorded interviews were then carried out with students, practice mentors and line managers to ensure a range of perspectives were captured. The practice mentors and line managers were identified by each student. Each interview was transcribed verbatim as soon as possible and participants given the opportunity to verify their transcript.
A recognised framework (Burnard, 1991) guided the thematic analysis of each transcript and provided a transparent audit trail. Data analysis was undertaken independently by the researcher and a colleague who had no involvement in the project, before discussion to confirm the resulting themes. Participants were able to verify the final themes and research report.
Results and discussion
All participants were female - six nurses and one midwife. Of the seven interviews conducted, four were with students and three with people fulfilling the dual role of practice mentor/line manager for students (they will be referred to as mentors here). The mentor for student 1 did not participate. The students attended the module approximately nine months before interview and had been in their current roles from a few months to almost 20 years. Although not specifically asked about years of professional experience, it was apparent during interviews that all were very experienced practitioners.
Development of themes and sub-themes
Four broad themes emerged from the data. These were: the context of LWAP attendance; impact on the individual; impact on ability to work with others; and impact on service. Each theme comprised a number of sub-themes.
All participants reported a positive impact following module attendance. In contrast to some previous studies (for example, Krugman and Smith, 2003), mentors and students reported broadly the same impact with very few differences. Therefore, variations between groups are highlighted.
Theme 1: LWAP in context
The importance of contextual influences on impact in this study was not new. However, the usefulness of leadership development during a period of either personal or organisational transition was an unexpected finding and has not been identified previously in the literature. All participants were experiencing transition, either personal or organisational.
Similarly, transition was the motivating factor identified by all mentors for recommending the module. The mentor for student 4 said:
‘-I thought it would be good for her-there [are] a lot of issues within that department that we’re wanting to look at and there is a need for a lot more change in there- she knows clinically there isn’t a problem - it’s- the leadership skills we’re wanting to develop.’
Despite mentors’ common reasons for recommending the module, there was wide variation in their expectations.
However, all mentors claimed students had gained from attendance and planned to continue recommending LWAP. This emphasis on transition is a feature of the current practice context and shows the impact of reform and modernisation policy on NHS staff (Wanless, 2004). Mentors in particular saw the module as a means of helping staff to cope with new roles and changing work practices, and to lead NHS transformation.
Theme 2: Impact on the individual
The findings demonstrated evidence of impact on individuals in terms of personal attitudes, skills and knowledge. This theme is broken down into three sub-themes.
Sub-theme 1: Changed attitudes
Subtle but important changes in attitude were the most frequently cited differences by students and mentors alike. For example, a changed attitude to leadership was common:
‘-I’d have just normally said no-you do that-but because it’s changed my thinking it doesn’t always have to be that senior person’s responsibility and that has changed me, you know, my way of thinking.’ (Student 1)
This underpinned different attitudes to service improvement, resulting in students seeing this as part of their role, leading to increased confidence, motivation and passion for patient-centred care:
‘I definitely think from doing the module it gave her a boost, it gave her something to work towards and it gave her the encouragement to really go and work towards making things happen rather than just thinking about it.’ (Mentor for student 3)
Interviewees consistently identified increased confidence and self-esteem as a result of LWAP attendance. In addition, mentors highlighted the association between this and participants’ increased risk-taking behaviour and willingness to learn from mistakes. This is an important finding as attitudinal change is the most difficult educational outcome to achieve (Ramsden, 1992). Increased confidence, self-esteem and risk-taking underpin self-belief, which is identified as central to leadership effectiveness in the NHS (DH, 2002).
Sub-theme 2: Improved skills
All interviewees highlighted development of several key leadership skills following the module. These were: increased self-awareness; influencing skills including assertiveness and communication; and delegation.
These comments illustrate some of these changes:
‘-because I learned to look at myself I found it easier to implement the change and I do look at my work differently and I do plan things differently.’ (Student 2)
‘I have been more assertive and taken people to one side rather than just letting it go, which is a fault of mine, I am too passive. So the course made me recognise that and I’m dealing with it.’ (Student 3)
The second example shows how enhanced assertiveness enabled effective accountability, which is another key leadership skill for NHS staff (DH, 2002). These support the findings of previous studies (Janes and Wadding, 2004; Cooper, 2003; Edmonstone and Jeavons, 2000).
Sub-theme 3: Increased knowledge
LWAP students’ increased knowledge was evident in three areas: leadership theory; tools and strategies; and the broader context of leadership practice. First, gaining an understanding of contemporary views on leadership appeared to have the most wide-ranging effect on participants, completely changing their approach to the topic and its relevance to them.
Students’ lack of knowledge regarding contemporary leadership approaches was not surprising as this was the first programme most had experienced. However, this raises an important issue, as recent key health and social policy documents emphasise the importance of leaders adopting a transformational approach (DH, 2004; DH, 2000). This study’s findings suggest that it is unwise to make assumptions about the understanding of this concept by key service staff.
Secondly, increased knowledge regarding practical tools and strategies for leaders also had an important personal impact on students. In particular, the circle of influence and win/win thinking and assertive communication were highlighted by students. Mentors generally took a broader view, identifying students’ improved ability to adapt their behaviour to different people/situations and enhanced ability to implement change as key personal developments.
These findings support strong evidence from previous studies (Janes and Wadding, 2004; Cooper, 2003; Krugman and Smith, 2003; Tourangeau, 2003; Edmonstone and Jeavons, 2000).
Theme 3: Ability to work with others
Sub-theme 1: Attitudinal changes
Enhanced recognition and appreciation of the contribution of others and ability to motivate them were frequently and consistently identified by students and their mentors/line managers alike, although there were slight differences. This reinforces the need to use other forms of data in addition to self-reporting to ensure the study is trustworthy. Valuing the contribution of others led to an increased willingness to ask for and accept support as this comment by student 3 illustrates:
‘My attitudes have changed definitely in that I can rely on people-. I don’t have to do it all myself. That’s less stressful for me. I do leave time for the other things for me to do with the audit and the extra jobs that you do.’
Sub-theme 2: Skills development
In terms of enhanced collaborative working skills, the ability to develop and influence others was identified consistently by both groups. Some examples of developing others included encouraging colleagues to problem solve for themselves, plan their own work and develop areas of specialist interest, then share these skills with others. This commonly led to enhanced job satisfaction for colleagues. This finding supports previous work (Hill, 2003; Krugman and Smith, 2003).
However, time constraints due to poor staffing levels were identified as a potential barrier, although this was not considered insurmountable.
Enhanced ability to influence others was also identified consistently by both groups and attributed to enhanced communication/empathy, which underpinned the development of more trusting relationships with colleagues. This is illustrated by student 2:
’ -the consultants, I think the management people find it hard to get [them] to change their mind on things, they’re quite a powerful force and quite hard to win over but, if things are put to them in a way that they can view it more positively, we just chip away- small changes and I think it’s them gaining confidence in us as people that can make changes.’
This is consistent with a number of other studies. The positive impact on students’ ability to work more effectively with others is underpinned by the development of personal skills already discussed above.
Theme 4: Impact on service
Sub-theme 1: Project characteristics
There was clear evidence of the application of learning in practice as illustrated by the service improvements participants implemented. Student projects had a number of common characteristics. These were: service user focus, multiple stakeholder involvement, unexpected spin-offs and the catalytic effect of module attendance. Projects included the introduction of: telephone follow-up for orthopaedic patients; reducing the number of inappropriate referrals to a regional antenatal unit; a daily rest period for post-ICU surgical patients; and improving access for antenatal scanning. User-centred evaluation of projects was a module requirement, resulting in comments such as:
‘The feedback we had from the patients is that they think it’s excellent.’ (Student 3)
The multi-stakeholder nature of student projects illustrates the complexity of modern health and social care as well as the application of enhanced collaborative working attitudes and skills by students. This also resulted in a balanced scorecard approach to evaluation. For one project, benefits for clients, administrative, sonography, medical and nursing staff were identified:
‘It has had a huge impact and will in future on clinic times [and] consultant time so from the service point of view that’s absolutely excellent.’ (Mentor for student 2)
Following this success, although roll-out was desirable, the student was aware of the implications of this for other staff, demonstrating her increased knowledge of the broader context of practice.
Strong evidence emerged regarding the role of LWAP as a catalyst for service improvement. Student project ideas were not necessarily new but, in all cases, module attendance created the opportunity, motivation and commitment for implementation:
‘She’s probably thought about this for a long time and this has just given her that go-ahead to start it.’ (Mentor for student 3)
The notion of LWAP as a driver for improvement was an unexpected finding and has not been noted by other authors. It provides a strong argument for the provision of formal programmes incorporating compulsory implementation of a service improvement project.
Sub-themes 2 and 3: Factors affecting project success
Key contextual and policy drivers for service improvement were highlighted as facilitating project success, particularly by mentors. In addition, support from immediate colleagues and managers and a positive organisational culture were strongly associated with effective project implementation by all participants, further supporting the literature on this subject. One feature of this issue is the provision of leadership development as part of a trust-wide strategy, which is the case for LWAP and has been recommended in respect of another short, introductory programme (Cooper, 2003; Edmonstone and Jeavons, 2000).
Both groups of respondents consistently felt students’ ability to apply the enhanced knowledge and personal skills gained from module attendance had an impact on project success.
Factors such as the multidisciplinary nature of practice and financial constraints were, not surprisingly, identified as barriers to project implementation by both groups, although these were not considered insurmountable. Students but not mentors identified cultural issues such as tradition and custom as inhibiting improvement.
The following comment provides one example summarising the wide-ranging impact that module attendance appears to have had on participants and, more importantly, on service delivery:
‘At first I thought, it’s such a short course, how valuable is that [service project] going to be? But it’s demonstrated to me that that was an excellent way to look at it because it’s increased [her] self-belief, it’s had an impact on the team, it’s had an impact on the service and will do in the future. It’s just going to grow and grow and, from one module of introduction, I think what she’s achieved is tremendous and it’s only reflecting back now that I’ve probably realised just how far she’s come.’ (Mentor for student 2)
One limitation is that none of the students who failed to submit the module assignment participated. This may have been for a number of reasons including: they had a negative experience of the module; they did not value the academic credits attached; were too busy to take time out of practice to participate; or assumed the invitation had been sent in error. In addition, all participants were women.
In conclusion, a review of the literature revealed limited evidence of the impact of introductory leadership development programmes on participants and practice.
In addition, the absence of an agreed evaluation framework is apparent despite massive recent investment in development opportunities for health and social care staff. The nebulous concept of leadership in health and social care practice requires a multi-faceted approach to evaluation. Despite some differences, the findings are strikingly similar to those of previous studies evaluating the impact of short programmes across the world.
This study’s main contribution to the literature is its focus on the application of learning in practice through the implementation of service improvement projects. This enabled us to explore the impact of LWAP at level 3 (behavioural change) and indirectly at level 4 (impact on the organisation). This is a major gap in the current body of knowledge, which this study addresses by providing evidence of service improvement following module attendance.
While recognising the study’s limitations, this research indicates that this leadership development programme is an effective organisational development strategy. It can simultaneously drive the modernisation of service delivery and empower the workforce to deliver this.
Thus, based on the study findings and the limited empirical research, the following structure for a universally applicable leadership development evaluation framework is proposed. This should explore programme impact in three domains: impact on the individual; ability to work with others; and service improvement. It should use a mixed methods approach, incorporating formal or informal 360-degree feedback from service users, colleagues and managers.
- Testing of the proposed evaluation structure incorporating three domains (impact on the individual; ability to work with others; and service improvement) on a larger sample and other leadership development programmes;
- Quantitative evaluation of the impact of LWAP service improvement projects on service costs, staffing levels, skill-mix and patient satisfaction;
- Evaluation of the service improvement impact of such programmes with no compulsory service improvement project;
- Evaluation of the impact of LWAP on non-nursing participants, for example allied health professionals, and administrative, technical and support staff;
- Evaluation of its impact on participants who did not complete the module.
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