Transformational leadership in care homes can improve staff job satisfaction and retention, and enhance the delivery of effective care for residents
Care home managers have a significant influence on staff morale and care delivery. Training methods underpinned by transformational leadership theory (TLT) have been used successfully to develop their leadership skills. Twenty-five care home managers in the north-east of England took part in a preliminary study aimed at establishing which aspects of TLT were apparent in their leadership philosophies. Elements of TLT (such as supporting frontline employees to engage in education and establishing trust) were found to be embedded in participants’ philosophies of leadership, but gaining the support of senior management when attempting to apply a philosophy of leadership in practice was not present enough. To develop leadership skills, managers may benefit from training programmes that involve both structured teaching and guided learning through experience.
Citation: Rippon D, James IA (2015) Leadership philosophy of care home managers. Nursing Times; 111: 7, 12-16.
Authors: Daniel Rippon is assistant psychologist; Ian Andrew James is head of Newcastle psychology and challenging behaviour teams; both at Tyne and Wear Foundation Trust.
- This article has been double-blind peer reviewed
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Leadership styles that are used in healthcare settings can determine employee job satisfaction, organisational commitment, wellbeing, productivity and staff retention (Cummings et al, 2010) - all of these can have an impact on how healthcare is delivered to patients or residents. Leaders need a philosophy that can be understood easily so a standard of practice, organisational purpose and a clear direction of how to achieve shared goals can be effectively communicated to colleagues (Leboeuf, 1999).
Burns (1978) identified two contrasting styles of leadership:
Transactional leaders are task orientated; they tend to view their relationship with employees as providing rewards when tasks are completed and discipline when goals are not achieved. Transformational leaders place greater emphasis on developing employees as a means to achieve group goals. A wealth of research has indicated that leaders who display the attributes of a transformational rather than a transactional leader are most effective in leading healthcare staff (Cummings et al, 2010) and improving patient care (Thyer, 2003). A transformational leader uses idealised influence, inspiration, intellectual stimulation and individualised consideration in their leadership style (Avolio et al, 1991).
Effective leadership in care homes is vital for resolving challenges such as improving or maintaining the skills of frontline staff, ensuring that residents receive optimum levels of care and adhering to continual changes in health and social care policies (Royal College of Nursing, 2012). In the field of nursing, training programmes that have been underpinned by transformational theory have been shown to improve leadership skills and increase the independence of leaders in service development (Large et al, 2005). However, there is also a notion that leadership is a skill that is attributed to personal qualities that develop through practical experience, rather than formal training alone (Adair, 1998).
Based on the literature, our research question was “What is the philosophy of leadership of care home managers?” Our aim was to establish which attributes of a transformational leader were apparent within the philosophies of care home managers.
We used transformational leadership as a framework of this service evaluation to observe whether there were similarities between care home managers’ leadership philosophies and the attributes of a transformational leader. We used a qualitative research design and gave participants questionnaires that consisted of five questions (Box 1). A convenience sample of 25 care home managers from the north-east of England were recruited while attending a one-day training workshop on dementia care, which was funded by the local authority.
Box 1. Questionnaire
Participants were asked to answer the following questions:
- How would you describe your philosophy of running a care home?
- How did you develop your philosophy (background, history etc)?
- Has your philosophy changed over time?
- What advice would you give to a manager?
- Would you like to say anything else?
The training day was delivered by the Newcastle Challenging Behaviour Service. Participants were asked to complete the questionnaire as part of an exercise on the day. They were informed that the data from their responses would be analysed and submitted for publication, and consent would be indicated by handing in the completed questionnaire at the end of the exercise. Twenty-three participants returned questionnaires.
The questionnaire data was analysed using a six-stage thematic analysis (Braun and Clarke, 2006). The study was granted approval as a service evaluation project by Northumberland, Tyne and Wear Foundation Trust’s research and development department.
Three themes emerged from the thematic analysis of the data:
- Development of philosophy;
- Interpersonal impact (Fig 1, attached).
Development of philosophy
This theme is defined by the responses that indicated how care home managers had developed their philosophies. There is a notion that gaining experience of working in a particular setting is required for the development of leadership skills (Adair, 1998); practical experience in frontline care gave care home managers opportunities tocorrect the bad practices of previous managers, which informed how the participants should conduct themselves as leaders.
“I worked with a manager who the clients were not happy to be around, nor were the staff. What she said went! Got to the point where staff stayed at home. Started as a carer, saw a lot of bad practice.” (Participant G)
“My first job was as a care assistant in a care home and this showed me how not to care for people.” (Participant K)
Study participants also suggested that working in care homes gave them experience of observing good practice that had been incorporated in their leadership style.
“Working as a nurse in care homes, I worked for good and bad managers. I have incorporated areas of practice that I thought worked well and disregarded any poor practice.” (Participant P)
“I developed my philosophy through working at various organisations and reflecting on what works and what does not - mainly through observation of the service user, staff and previous management.” (Participant F)
The data also indicated that working in different roles in care home settings can be helpful in developing a leadership style. When they were asked how their experiences had influenced their leadership philosophies, participants said that this had occurred by:
“Working in care in various positions, working towards managing a home of my own with a better understanding of client groups and their needs.” (Participant A)
“Gaining the experience from working as a carer, deputy manager to manager, identifying what is important to individuals.” (Participant M)
This suggests that experience of frontline working in care homes gives potential leaders the opportunity to:
- Correct any bad practice observed;
- Gain knowledge of the various roles that are important to the delivery of healthcare to residents.
Experience of frontline working in care home settings may also allow certain personal attributes - such as drive, motivation, caring - to flourish and could therefore be critical to the development of leadership style. However, leadership training programmes have also been shown to be beneficial in developing leaders in healthcare settings (Large et al, 2005). Participants also recognised this.
“My philosophy always changes with experience and more knowledge gained through training.” (Participant L)
“Philosophy has changed as I have developed as a person due to training received and evaluating the importance of dignity, respect and choice.” (Participant M)
This indicated that formal methods of training can contribute to developing a philosophy of leadership in care home managers. However, the RCN (2012) has reported that there is still a lack of training being made available to care home employees. This notion was mirrored in at least one participant’s response.
“There should be more training for home managers to attend with regards to the philosophy of care in general and not just read the company’s policies and procedures.” (Participant E)
Both practical experience and formal methods of teaching were viewed as influential in the development of the philosophies of leadership. This suggests care home managers could benefit from leadership training programmes that incorporate both formal/theoretical teaching and learning through practice.
This is concerned with the opinions of the care home managers, in terms of what they should do to develop and empower their workforce as a means to improve working processes. Developing frontline employees through education appeared to be embedded within the participants’ philosophies.
“Understand your staff, their strengths and development requirements.” (Participant J)
“To have a well-developed and highly trained team who feel supported in their role.” (Participant P)
These responses reflect elements of individualised consideration by valuing the importance of developing individual members of staff and meeting their educational needs.
Frontline care home staff who receive high standards of work-related training report higher levels of job satisfaction and are less likely to consider leaving their post than those who have received inadequate levels of education in their jobs (Castle et al, 2007). Transformational leadership theory states that a leader should apply individualised consideration and identify the areas where employees require development and support through education (Avolio et al, 1991). However, concerns have been raised about the shortage of opportunities for care staff to engage in work-related training, which can lead to high levels of turnover and inconsistent practice (RCN, 2012).
Attributes of a transformational leader include the ability to empower employees through intellectual stimulation, to encourage them to be innovative and actively involved in establishing strategies to improve practices (Avolio et al, 1991). Engaging in educational programmes has been shown to increase the likelihood of frontline employees becoming involved in decision-making processes about healthcare delivery in care homes (Sikorska-Simmons, 2005) and there are lower levels of staff turnover in care homes where frontline employees are able to influence how services are delivered (Donoghue and Castle, 2009).
“Creating and maintaining a team of staff who are confident enough to question ‘routines’ in an appropriate way in order to provide for the diverse needs and wishes of those we provide services for and their loved ones.” (Participant U)
This indicated that responses were in line with transformational theory, in that leaders should intellectually stimulate their employees by being receptive of their opinions and encouraging their independence.
This idea relates to responses about the working relationships that leaders must establish with colleagues so their philosophies can be applied in the care home setting.
It has been observed that trust between leaders and employees must be established before frontline employees can feel empowered enough to voice their opinions about service delivery (Wong and Cummings, 2009). A hallmark of a transformational leader is to possess idealised influence over both frontline carers and senior management by being a professional role model, which can lead to being respected and perceived as trustworthy (Avolio et al, 1991).
Leaders who have the skills to engage in the same tasks as frontline staff can establish reciprocal trust by being a visible role model from whom frontline staff can learn (Avolio et al, 2004). Within healthcare settings, it has been observed that frontline staff are more likely to voice their opinions if their manager is perceived to be trustworthy (Wong and Cummings, 2009). A method for leaders to establish trust is to work alongside employees and be a visible role model (Avolio et al, 2004), something that was apparent within the philosophies of the participants as illustrated by the following quotes.
“Ensure that you are aware of what happens ‘on the floor’.” (Participant D)
“I would pass on my passion for caring for [older people] and not be all office based.” (Participant E)
“Hands-on, democratic style, giving ownership to staff and service users - role modelling.” (Participant O)
“Being visible, respecting others, encouraging others to see the work as a privileged profession and be democratic.” (Participant V)
“To develop and build trusting relationships with service users, families and staff.” (Participant P)
“Guide and support staff as much as possible by getting out on the floor.” (Participant M)
Participants’ comments suggested they acknowledged the importance of exerting idealised influence with employees by establishing trust, which, in turn, is achieved by engaging in tasks carried out on the front line.
Working processes in healthcare settings can also be determined by senior management through organisational policies (Oliver, 2006). For care home managers to apply their philosophies in practice in their workplace, they must also be able to also exert idealised influence over senior management. However, there was no indication in the dataset to suggest participants thought they should be able to exert idealised influence on senior management to implement their philosophies.
Mid-level managers can experience great difficulties implementing any organisational changes without the support of senior management (Leboeuf, 1999). This would suggest that unless they acknowledge the importance of exerting idealised influence with senior management, care home managers may find it difficult to implement practically their personal philosophies of leadership. This opens a debate as to whether care home services are governed purely by “top-down” policies or whether mid-level managers are able to influence their senior management teams to implement their philosophies.
Leaders must be able to articulate their philosophy to both frontline staff and senior management to clearly communicate a vision of how organisational goals can be achieved (Leboeuf, 1999). According to transformational leadership theory, a leader must be able to motivate and inspire colleagues when communicating their philosophies (Avolio et al, 1991). This was apparent in our data.
“Ensure that you have good staff who understand your vision and are on board with you to pursue that vision.” (Participant W)
“Be clear with your staff of what your philosophy is.” (Participant K)
“Philosophy is provided to staff through training and mentoring - show staff the meaning of [your] philosophy of care.” (Participant E)
For a philosophy of leadership to be implemented, it must be articulated in such a way that it is clearly understood by colleagues (Leboeuf, 1999). Our data indicated that care home managers acknowledge the importance of communicating their philosophy of leadership coherently so that it can be understood by their colleagues and implemented practically. However, it was unclear from our data whether those managers should have the ability to inspire senior management, as well as frontline staff, with their philosophies of care.
Strengths and limitations
Although there is extensive research literature to suggest transformational leadership style is the most desirable for healthcare settings, the majority of care home managers may not practise this method of leading (Donoghue and Castle, 2009). Caution should therefore be exercised when interpreting the results of this evaluation - responses provided could have been desirable statements that are consistent with organisational policy or related to what care home managers “should” do as leaders as opposed to what they do in practice.
In addition, as only a small sample size was used in this study, the data obtained may not be representative of care home managers across the UK. Therefore, the findings of this research may be valid only for the participants who took part in it rather than for care home managers in general.
Questionnaires pose the problem of providing participants with a finite and closed set of questions, and this could limit participants’ opportunity to elaborate and provide a more detailed response (Wakley, 2005). Conducting interviews with participants may have allowed us to explore the relationships between care home managers and their senior management; however, leaders and managers should be able to articulate their philosophy in a concise manner (Leboeuf, 1999) - this is why questionnaires were thought to be a useful method of data collection for this preliminary evaluation. The study therefore provides a good basis for future observational research to confirm that the philosophies highlighted in this study are evident within the practice of care home managers.
The findings of our study indicate that leadership training programmes which comprise both formal modes of teaching and practical placements could be helpful in developing the care home managers’ leadership philosophies. The data suggests the philosophies of care home managers reflected elements of transformational leadership theory. However, acknowledgement of the need to influence senior management in implementing their philosophies was not apparent in the data obtained. To maximise care home managers’ potential to apply their philosophies in practice, increased awareness of the requirement to be influential with senior management may be required.
The findings of this service evaluation are being presented at a series of workshops sponsored by Newcastle City Council. These sessions aim to improve the provision of care in care homes.
- Care home managers could benefit from leadership training programmes that include formal teaching and evaluation of their skills in practice
- Senior management must support managers’ philosophies before these can be applied in practice
- Managers’ philosophies reflect the importance of educating frontline staff to improve service delivery
- Managers must establish trust for frontline staff to feel they can voice their opinions
- Research is needed to find out whether care home managers’ philosophies are applied practically
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