Two foundation trusts developed an innovative approach to management training using coaching and partnership working to boost the performance of clinical leaders
Ward managers are the largest management group in the NHS, and have an important leadership role in creating and sustaining excellent performance. Two London foundation trusts developed a unique frontline leadership programme for these staff.
Citation: Castillo C, James S (2013) How to turn ward managers into leaders. Nursing Times; 109: 9, 18-19.
Authors: Cavette Castillo is ward manager; Sarah James is associate director of education and development; both at King’s College Hospital Foundation Trust, London.
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Hospital-specific management practices are strongly related to the quality of patient care and productivity (Dorgan et al, 2010), and to teamworking and patient mortality (West, 2002).
King’s College Hospital Foundation Trust (KCH) and Guy’s and St Thomas’ Foundation Trust (GSTT) are two of the four organisations that make up the academic health science centre King’s Health Partners (the others are South London and the Maudsley, and King’s College London). KCH and GSTT have 7,000 and 12,500 staff respectively; with such large workforces, improvements could not be driven solely through top-down or large-scale strategic programmes but have to be delivered at the front line. This was the inspiration for our Improving Frontline Leaders programme, which was designed and delivered jointly and aimed to turn managers into leaders.
Developing the programme
Initial analysis of staff development needs revealed that frontline leaders struggled to link their work to the organisational vision. They also lacked the confidence to articulate and deliver the service-level change required to achieve that vision. To tackle this, we set out to develop a multidisciplinary programme that modelled and promoted partnership working for clinical and corporate leaders from both hospitals. With the help of performance development consultancy Lane4, we created a training programme aimed at ward and departmental managers. It ran for 12 months; there were eight cohorts.
Our key objective was in line with former health minister Lord Darzi’s vision for frontline managers to “offer leadership… step up, work with other leaders, both clinical and managerial, and change the system where it would benefit patients” (Darzi, 2008). We sought to introduce new accountability in line with his High Quality Care For All paper (Darzi, 2008), which described accountability to patients and the community rather than the hierarchy; this requires a culture shift in the thinking of frontline leaders.
The principles underpinning this project were to:
- Involve stakeholders (participants, managers and sponsors) in design, delivery and evaluation;
- Focus on creating a high-performance environment;
- Develop coaching to improve skills to lead sustainable change;
- Use KCH values to develop leadership behaviours;
- Use evidence-based content;
- Enable application and embedding of learning;
- Thorough evaluation to ensure people and organisations have benefited.
The programme was designed to be delivered in eight cohorts to 120 staff at the two trusts (including therapists, ward managers, senior nurses and midwives, school nurses, health visitors and other managers) between December 2009 and November 2010. We targeted a large number to create momentum, and to deliver sustainable change through embedded learning. Each cohort’s training was spread over eight months (Box 1).
Box 1. Improving Frontline Leaders programme contents
- Pre-course 360° feedback* to build self-awareness
- Half-day launch event
- Three one-day leadership development modules: definition of leadership styles; coaching and feedback skills; delivering and sustaining change
- Three half-day action learning sets using a practice-based project as a vehicle for learning
- A half-day close event to review learning and receive a 360° “re-measure” feedback and plan the next steps
* 360° feedback increases people’s awareness of their role as leaders by asking the opinion of their colleagues and superiors. At the end of the project, the 360° feedback tool was used to evaluate change
Evaluating the programme
The programme was evaluated using levels of reaction, learning, behaviour and results (Kirkpatrick and Kirkpatrick, 2006):
- Reaction: Workshop evaluation was used to refine programme content, particularly during the first four cohorts;
- Learning: We set tasks between the three modules to create and improve skills - for example coaching a high performer and a low performer - and encouraged reflection and learning through projects. Achievement of learning objectives was evaluated by asking participants after each module if they had learnt skills and were putting them into practice; they consistently scored over 4 out of 5, increasing to an average of 4.5 for cohorts 5-8;
- Behaviour: Change in behaviour was measured through a 360° feedback “re-measure” at the end of the programme and a survey one year later;
- Results: These were demonstrated through service improvement projects.
Results of the evaluation
Improved confidence has been key to delivering KCH’s strategy for a high-performance environment. This was the most commonly stated result in the 12-month post-programme evaluation. Participants related their new confidence directly to improvements in areas such as managing staff, managing change, handling conflict and taking projects forward.
Achievements have included developing the partnership aspect of King’s Health Partners - before the programme, many staff did not know where the other trust was. One year on, participants’ managers noted an improved understanding of organisational contexts and service constraint at both organisations.
Leadership behaviour change
Highest-ranking behaviours in the first 360° feedback questionnaire concerned individual performance; those ranked most improved on the 360° feedback after the programme were:
- Acts on feedback;
- Asks of other people’s point of view;
- Effectively provides positive feedback.
Skills to lead change
These were demonstrated through participants’ personal development and service improvement projects, most of which improved care by redesigning a process or improving a pathway. For example, a KCH procurement manager reduced clinical inventory value in day surgery by 10% (amounting to over £60k in savings) in just four months; in GSTT, introducing a discharge lounge for three surgical wards halved the patient wait for discharge from five to 2.5 hours in three months, released 1,000 hours of nursing time, reduced complaints and improved patient satisfaction.
A large proportion (70%) of KCH participants said that developing skills to lead change had had the greatest impact on their practice. One of the most improved behaviours reported in the 360° feedback re-measure was asking questions that prompted others to think about how they deal with situations (for example, encouraging nurses to solve problems and knowing when and how to involve colleagues and senior staff during difficult situations with service providers and patients).
Coaching increases problem-solving skills and decreases dependence on senior staff. As staff potential is realised, confidence grows and they are able to see for themselves how things can be done differently. During evaluation a participant said: “coaching my team members to optimise their performance has enabled me to delegate more appropriately and free up time for service development”. Nursing managers are using their new skills to role model and encourage critical thinking.
The benefits of the programme
The programme’s benefits have been felt at individual and team levels, as well as at organisation/service-user levels, through the delivery of work-based improvement and personal development projects. It has improved KCH staff understanding of the working pressures and patterns of colleagues at GSTT. Working in partnership enabled the trusts to invest more, which allowed more leaders to participate. Organisational culture has changed, with more constructive use of feedback to challenge poor performance, and better communication between colleagues.
In the one-year post-programme evaluation, participants reported higher levels of satisfaction. There was a high standard of mutual accountability and we identified no slippage or underachievement against the plan or standards of delivery.
Leadership improved at both trusts. Nursing managers have an eclectic toolkit to aid management, mentorship and leadership skills, which benefits service providers and users. Communication skills have improved and acquiring practical ideas has been useful for staff development. This transfers directly into patient care.
The programme demonstrates the need to provide structure and support to frontline leaders in the future if we are to create a productive and efficient organisation. One participant summed up her success by stating: “I have a greater appreciation of the NHS… and our role within it. We have common values, work under similar constraints and share a vision for the future”.
- The performance of frontline clinical leaders is strongly linked to the quality of hospital services
- Large-scale development cannot be achieved through top-down programmes; it must be delivered at the front line
- Simultaneous development of staff in different disciplines helps them to understand each others’ work
- Frontline clinical leaders often lack the confidence to promote trust values and to delegate
- Increasing staff confidence in their leadership skills can help to improve organisational culture and staff satisfaction
Darzi A (2008) High Quality Care for All: NHS Next Stage Review Final Report. London: DH.
Dorgan S et al (2010) Management in Healthcare: Why Good Practice Really Matters. London: McKinsey & Company.
Kirkpatrick DL, Kirkpatrick JD (2006) Evaluating Training Programmes: The Four Levels. San Francisco, CA: Berrett-Koehler.
West MA (2002) The link between the management of employees and patient mortality in acute hospitals. International Journal of Human Resource Management; 13: 8, 1299-1310.