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www.bradford.ac.uk/management
‘An investigation of the impact of leadership and team working on staff morale and wellbeing, and team performance, among mental health teams
within the Yorkshire & The Humber Strategic Health Authority’
University Researchers: Beverly Alimo-Metcalfe, Principal InvestigatorMargaret Bradley, Research Project Manager & Honorary Researcher
Dr John Alban-Metcalfe & Alice Locker, Honorary Researchers
Research Champions: Val Berry, Priyanka Bichala, Joann Gibson, Julie Sheldon, Mark Wilbram, Nick Turner, Dave Rainforth, Lisa Connor, Wayne Reece-Gorman
Overall Project Co-ordinator: Maggie Bell, SWYPFT
Steering Group Chair: Alan Davis, SWYPFT
Steering Group: Penny Petrie & Angela Ross (BDCT); David Harling (Humber NHS FT); Eddie Devine, Alison Thompson & Nick Turner (LYPFT), Chris Payne (NAViGO);
Rosie Johnson (RDASH); Maggie Bell and Christine Symonds (SWYPFT)Frank and Tula Naylor
Rebecca Smith (Yorkshire and the Humber SHA).
Team Leadership, Team Working and Outcomes in CMHTs
Overall Aim:
To bring about real & sustainable change and improvement in leadership and team working, for the
benefit of service users & carers
1. To understand how leadership behaviour enables multi-professional teams to function most effectively in working to promote and sustain improved health
outcomes for service users and carers
2. To devise and develop a set of guidelines, and a series of developmental activities, that will enable mental health professionals and others, to improve the
quality of provision for service users and their carers.
Research objectives
Identify the particular processes within teams that ensure engagement and wellbeing of TMs, enabling them to deliver high quality care
Identify how leadership of the team lead has an impact on team functioning and performance
Develop in-house research capacity by involving local researchers in the trusts
Investigate what service users & carers regard as high quality care; develop a diagnostic tools for measuring their perceptions of quality of care; gather data on perceptions of quality of care
Develop materials to support the increased effectiveness of multi-professional teams, and their leadership behaviour, & staff engagement and wellbeing, that can be used across a wide variety of health and social care contexts
Disseminate the research findings to inform improved practice both within mental health services and more widely in health and social care.
Why needed?
Effective Team working & leadership are essential for high quality care, staff wellbeing, and productivity
Leadership is critical for the NHS – Innovation, Quality, and Improvement (SHA Workforce Ambitions strategy)
92% of NHS staff work in teams - only 42% work in ‘genuine’ teams (Healthcare Commission, 2006)
Chief Executives are committed to service user and carer involvement in defining what constitutes ‘high quality care’
Previous research (CRTs) found evidence of a causal link between engaging leadership and team productivity (Alimo-Metcalfe et al., 2007,2008)
How the LTQ research builds on, and extends the CRT research
Close involvement of service users and carers in determining what constitutes ‘high quality care’
Wider range of MH teams & contextual factors
Employs the leadership dimensions that emerged in the CRT research proven to significantly affect productivity, staff engagement & wellbeing
Deeper analysis of the nature of team working processes – also Inter-team & Inter-agency working
Closer analysis of how leadership affects team working & inter-agency work
Quantitative Data Collection LTQ
Team Leadership
Leadership Capabilities
Engaging with Others
Visionary Leadership
TEAM PROCESSES
Intra- team Processes
Inter-team & Inter-agency Processes
Outcomes of Effectiveness
Users’ & Carers’ perceptions
Professionals’ perceptions
Professionals’Engagement &
Wellbeing
Other Performance Measures
CONTEXTUAL FACTORS
Quantitative collected at Time 1 – Cross-sectional model
The I-P-O Model of Team working
INPUTTeam
ProcessesOUTPUT
The I-M-O-I Model of Team working
INPUTTeam
Processes(Behavioural)
OUTPUT
Affective states(eg motivation, interest in task,
perceived value of the task)
Cognitive states(free exchange of knowledge & experience leading to a shared
understanding of how to improve quality of service)
PSYCHOLOGICAL SAFETY
TRUSTING & BONDING
SOCIAL SUPPORT
TEAM POTENCY
VALUING DIFFERENT
PERSPECTIVES
INTRA-TEAM WORKING
SUPPORTING A DEVELOPMENT
CULTURE
INFORMATION GATHERING
ROLES & RESPONSIBILITIES
UPDATING
COLLECTIVE EXPERIENCE
ADAPTING
PLANNING
STRUCTURING & LEARNING
TEAM WORKING
TEAM LEADERSHIP
ENGAGING WITH OTHERS
BUILDING A SHARED VISION
ENABLING THE TEAM
LEADERSHIP CAPABILITIES
INTER-TEAM RELATIONS
INTER-TEAM COLLABORATION
INTER-TEAM WORKING
TEAM OUTPUT
TEAMENGAGEMENT
WELLBEING AT WORK
INNOVATION
FOCUS ON QUALITY
IMPROVEMENT
IMOI MODEL OF TEAM LEADERSHIP AND TEAM WORKING
IMPACT ONTEAM
MEMBERS
TEAMPROCESS
OUTCOMES
Proposed Methodology
Gather both quantitative and qualitative data
Identify factors affecting (1) the effectiveness of teams & (2) leadership within them
Develop (1) case studies and (2) workbooks toolkit for use in mental health and more widely in health & social care.
Build internal capacity - Identify Local Research Champions (conduct rep grid interviews with users/carers; encourage colleagues to participate)
Adopt an iterative process as the project progressed requiring continual reflection and evaluation to take account of experiences and changing circumstances over the 3 years
Be advised by a Steering group (Service users, carers, the SHA, Trust, PCT)
Research stages
Research Championsconduct R/Grid Int.
Distribute ‘Engaging Teams 360’ Qs
Data analysis of QCQ & Engaging Teams 360 Q
Produce Case studies
Create Leadership & Team working
W/books
Distribute Qs & gather data from SU & Carers
Develop Quality of Care Questionnaires
Identify link between L’ship, TW & Outcomes
FINAL REPORT& trust reports
Research Champions’
Experience, Learning & Benefits
Why volunteered?
New experience and opportunity
Research - ‘dip toe in’ with support
Personal & professional development
Service user, carer and staff involvement
Research ‘real and grounded’ – leadership, teamwork, care quality, values and improvement
Make a difference
Validate personal beliefs
Val Berry, Team Manager, Humber, NHS FT
Training Training day
Opportunities to meet other Research Champions
Underpinning theory
Demonstration: opportunities to practice in safe environment; opportunity to ask questions and get feedback
Peer support
Overview of process
Appreciative inquiry approach
Qualitative and quantitative methods
Julie Sheldon, Acting Team Manger, RDaSH
Experience/Practicalities
Recruitment of service users and carers
‘Putting it out there’
Conducting the interviews
Service user and carer perspectives
‘Liberating’ to gather information but not to do/act
Perceived therapeutic benefit
Dr Priyanka Bichala, Perinatal Mental Health
Benefits for service users
Positive impact on practice
Therapeutic benefits: listened to, being valued and treated as an equal
Very current service user voice
Same values as professional
Independence allowed for honesty with Research Champions interview
Benefits for Carers
Using carers as a resource
Increased understanding from the carers’ perspective
Carers spoke freely without being defensive
Aided in clarifying expectations
Benefits for Research Champions
Insight from the honesty and receptiveness of service users and carers
Enhancing practice through increased self-awareness and personal insight
Acknowledging when things are not right
Skill development leading to a wider application of the technique
Research skills can be utilised by the organisation
Networking beyond the Trust
Joann Gibson, Team Manager, SWYPFT
Service Users’ & Carers’ notions of ‘high quality care’ –
Key Findings
Methodology – Stage 1Identifying themes in Service Users & Carers’ constructs of high quality care
Research Champions conduct (n = 65) interviews
450+ constructs of ‘High Quality Care’
Translated into Q items
Content analysis Produced 24 major themes
Workshop to check face & content validity & determine final items
(RCs, SU/C reps, S/Group, researchers, academic MH advisor)
Service users’ & Carers’ constructs of Quality of Care
Treated as an equal - work collaboratively and in partnership
Treated as an individual; staff get to know me and my needs
Staff are open-minded & non-judgemental; genuinely care
Staff are reliable; consistent; knowledgeable
Care is holistic; care is seamless
Supported in achieving my goals; strengthen my self-efficacy
Involve me in my care planning; & involve family & relevant others
Access to information re services; offered choices about my care;
Good communication within team and between teams/agencies
Methodology – Stage 1 (contd.)
Compare Service Users’ & Carers’ constructs with NICE Quality Standards
Construct themes compared with NICE ‘Quality Standards for Service Users Experience in Adult Mental Health’
Suggested 3 ‘missing’ dimensions of high quality care:
- ‘Strengthens my self-efficacy’;
- ‘Good communication & (intra/inter- team, & interagency working)
- Importance of ‘holistic care’
Extract : Comparison of NICE Quality Standard forService User Experience with SUs’ constructs
Stage 2 - ‘Quality of Care Questionnaires’ - Service Development & Structure (1)
‘Quality of Care Questionnaires’ – 2 versions produced (for Service Users & Carers)
Distributed throughout the region – Responses from 451 Users + 148 Carers
Factor analysed – producing 4 factors for SUs (consistent with ‘Recovery’):-Strengthens my self-efficacy & control over care-Personal relationships-Respect for me as a person-Aspects of delivery of care
And 2 factors for Carers (consistent with ‘Triangle of Care’):-Provides support for Carer-Respect for the Service User
Stage 2 - ‘Quality of Care Questionnaires’ - Service Data analysis (2)
Mean scores of Service Users’ responses indicated that:They were very satisfied with the care they receive
Most positive items were:
-Personal relationships with the professionals-Professionals’ respect for service users as individuals
And lowest scoring (though still positive) was:
-Strengthens my self-efficacy
Important to note that this was one of the strongest themes in SUs’ notions of high quality care, and the Recovery model
Stage 2 - ‘Quality of Care Questionnaires’ - Service Data analysis (3)
Mean scores of Carers’ responses indicated that:They were also positive, but less positive than were the Service Users
Most positive items were in relation to professionals being:
-Approachable-Communicate in a way that the carer understands-Treat the person for whom they care as an individual
And lowest scoring was:
-How involved in, and how informed they were in relation to the care given to the person for whom they care
Important to note that this is at the heart of the ‘Triangle of Care’ model
Observations& Implications of datafrom Service Users & Carers
The Repgrid interviewing process produced a rich, diverse, and extensive range of constructs – due to outstanding skills & commitment of the Research Champions
The constructs from service users were virtually identical to those elicited from carers They revealed 3 important additional dimensions of what constitutes ‘high quality
care’, compared with NICE Standards, and should be publicised widely The factor analysis of the responses from service users reinforced the critical
importance to them of care which strengthens their self-efficacy The 4 factors to emerge should form the basis of key elements in supporting MH
professionals’ development, personal reviews, supervision, and team reviews These factors reflect the value of the ‘Recovery’ approach to care Service users were very positive about the care received; this should be fed-back to
professionals & celebrated Although still positive, it was disappointing that the ‘strengthening self-efficacy’
items were rated lowest Carers were less positive, but identified what was important to them in feeling
supported The dimensions they rated lowest, reflect the ‘Triangle of Care’ and should form the
basis of discussions by teams for generating ideas for improvement & regular reviews The skills acquired by the Research Champions which could be utilised in a wide
range of trust situations & activities; their commitment was outstanding
Team Leadership, Team Working, & Outcomes – the Key Findings
Rank order of Average scores for Team Leadership & Team Working
(N = 590 Team
members)
Highest ratings by team members
Team Engagement (Impact on team members)
Social Support and Team Potency (Trusting and Bonding – affective states)
Updating (Planning – behavioural)
Collective Experience and Adaptability (Structuring and Learning – cognitive states)
Innovation (Team process outcome)
Lowest ratings by team members
Wellbeing at Work (Impact on team members) Improvement and Focus on Quality (Team process
outcomes)
Roles and Responsibilities (Planning – behavioural)
Valuing Different Perspectives and Supporting a Development Culture (Trusting and Bonding – affective states)
Building Shared Vision (Team leadership)
DFAs for scales – showing which scalesuniquely predict which outcomes
DFAs for scales – showing which scalesuniquely predict which outcomes
DFAs for items – showing which specific
behaviours uniquely predict outcomes (1)
DFAs for items – showing which specific
behaviours uniquely predict outcomes (1)
DFAs for items – showing which specificbehaviours uniquely predict outcomes (2)
DFAs for items – showing which specificbehaviours uniquely predict outcomes (3)
PSYCHOLOGICAL SAFETY
TRUSTING & BONDING
SOCIAL SUPPORT
TEAM POTENCY
VALUING DIFFERENT
PERSPECTIVES
INTRA-TEAM WORKING
SUPPORTING A DEVELOPMENT
CULTURE
INFORMATION GATHERING
ROLES & RESPONSIBILITIES
UPDATING
COLLECTIVE EXPERIENCE
ADAPTING
PLANNING
STRUCTURING & LEARNING
TEAM WORKING
TEAM LEADERSHIP
ENGAGING WITH OTHERS
BUILDING A SHARED VISION
ENABLING THE TEAM
LEADERSHIP CAPABILITIES
INTER-TEAM RELATIONS
INTER-TEAM COLLABORATION
INTER-TEAM WORKING
TEAM OUTPUT
TEAMENGAGEMENT
WELLBEING AT WORK
INNOVATION
FOCUS ON QUALITY
IMPROVEMENT
IMOI MODEL OF TEAM LEADERSHIP AND TEAM WORKING – VALIDATED
IMPACT ONTEAM
MEMBERS
TEAMPROCESS
OUTCOMES
Contextual factors found to significantly influence outcomes
Size of team
Ratio of OTs & Social Workers/ Nurses
Caseload size (NB caution in interpretation because of varying complexity of cases)
Implications for multi-disciplinary MH teams – 1
Rich source of insights into team leadership, working & effectiveness Not surprising: crucial importance of Roles & Responsibilities, incl. well-defined goals,
processes & procedures, & sense of direction (especially important for quality, improvement & wellbeing) – BUT this was an area of weakness
Not surprising: crucial importance of Inter-team/inter-agency Working (especially important for innovation, quality & improvement) – BUT only moderately high rating – need to strengthen. Users stressed its importance
Surprising: crucial importance of Trusting & Bonding – the social, emotional aspect & cultural/supportive aspect of team working (especially important for improvement, team engagement & wellbeing) – HIGH on social support & self-belief, but LOW on Valuing Different Perspectives & Supporting a Development Culture – implications for team leadership
Emphasises: crucial importance of Structuring & Learning – free exchange of knowledge & experience, resulting in shared mental models, and delivery of quality healthcare (especially important for improvement and team engagement) – GOOD NEWS, these were among the highest ratings
Observations & implications for multi-disciplinary MH teams – 2
1. Unexpected: Team Leadership does not impact directly on Team Engagement and Wellbeing at Work – rather, its influence is exerted through the way the team functions (Intra-team and Inter-team Working)
BUT Building Shared Vision was one of LOWEST ratings
2. We have EVIDENCE that there is an OPTIMAL… Size of MH teams Ratio of OTs & SWs/Nurses Case load
IMPLICATIONS for the structure, content and rationale of Team Leadership Development interventions, and the context in which they are delivered
IMPLICATIONS for focus of Team working Development interventions – we know which Specific behaviours result in greater team effectiveness
IMPLICATIONS for Planning size, staffing & case load of MH teams
Results from the Case Studies of high-performing teams
STRONG AND PASSIONATE
VISION OF PROVIDING
GOOD QUALITY CARE
INTRA-TEAM WORKING
TEAM WORKING
TEAM LEADERSHIP
INSPIRING OTHERS
SUSTAINING SHARED VISION
BALANCING NEEDS
PERFORMANCE MANAGEMENT
RELATIONSHIPS WITH OTHER
TEAMS/AGENCIES
INTER-TEAM WORKING
TEAMENGAGEMENT
WELLBEING AT WORK
QUALITY OF CARE
IMPACT ON TEAM MEMBERS
IMPACT ON SERVICE USERS AND CARERS
MODEL OF TEAM LEADERSHIP AND TEAM WORKING BASED ON THE CASE STUDIES
EFFECTIVE CHANGE
MANAGEMENT
TEAM FOCUSED
GENERAL LEADERSHIP
STYLE
TEAM COMPOSITION
POSITIVE RELATIONSHIPS
WITHIN THE TEAM
EFFECTIVE COMMUNICATIO
N
CULTURE OF INNOVATION,
IMPROVEMENT &
DEVELOPMENT
ADAPTING TO CHANGE
TEAM PROCESS OUTCOMES
INNOVATION & IMPROVEMENT
Case Studies: Effective Team Working
Strong and passionate vision for providing good quality care
Why? Recruitment; clearly defined service; leadership.
Team composition: Multidisciplinary; experienced; stable.
Positive relationships within the team: Harmonious, supportive, respectful.
Effective and engaging communication: Formal and informal.
Culture of innovation, improvement and development:
Reflection; sharing ideas; thinking ‘outside the box’; team and
individual development; commitment to supervision.
Case Studies: Effective Team Working cont’d
Relationships with other teams and agencies: service user
centred; networking and building relationships; link people.
Difficulties: Pressures on other teams and agencies; different
perceptions of risk; service transformation.
Approach to resolving difficulties: Face-to-face meetings;
flexibility; depoliticising the situation.
Adapting to change
Case Studies: Effective Leadership
Sustaining Shared Vision
Inspiring others: Vision and values; passion and determination;
strong work ethic; acting as a role model.
General leadership style: Democratic but decisive; situational
leadership; open and honest; positive; hands-on; empowering.
Team focused: Developing a team culture; understanding team
members; valuing team members; supportive; team development.
Performance Management: setting direction; role modelling;
supportive; light hearted; prepared to pull rank; adhering to policies.
Case Studies: Effective Leadership cont’d
Balancing needs of team with needs of organisation:
Compliance; acting as an advocate.
Effective change management: Open; supportive; positive; local
ownership; team development; advocate; practical support.
Case Studies: Staff Engagement & Wellbeing Positive staff engagement and wellbeing
Why?
Intrinsic motivation
Nature of the work
Leadership
Team working
Factors that detract from staff engagement and wellbeing:
Nature of the work
Perceived business culture
Organisational changes
Case Studies: Quality of Care
Teams felt they did provide good quality care
Methods of collecting feedback:
Service user feedback: informal and formal feedback; feedback
from service user events; lack of standardisation.
Observing service user recovery
Service user events
Outcome tools
Case Studies: Quality of Care cont’d
What facilitates good quality care?
Previously mentioned elements of team working, leadership, staff engagement and wellbeing.
Good quality staff
Barriers to providing good quality care?
Time: administrative demands; geographical area to cover; size of caseload
Relationships with other teams
External agencies/interfaces with other services.
Recommendations for Practice
&
Project Achievements
Recommendations for Practice Case studies - useful source of reference and for development
Team and leadership development in situ – scales offer framework for development, & regular review (individual, team, organisational)
Findings suggest need for a stronger focus: on Quality, Valuing Different Perspectives; Supporting a Developmental Culture, & Clarity of Roles & Responsibilities
Note the wide-ranging effect of effective inter-team/agency working
Try to find ways of reduce administrative demands, where possible
Important to note’ ‘Quality of Care Questionnaires’ findings – use Qs
Collect standardised service user and carer feedback
Repertory Grid Interviews - extend expertise & use
Recommendations for Practice
Implications for service reorganisation and transformation
Size of the team
Importance of multidisciplinary team working
Stability of team membership
Importance of a shared sense of purpose
Change in the nature of the work as a result of service redesign
Supporting team leaders
Project achievements (1)
In-depth understanding of quality of care
Development of 2 new Quality of Care Questionnaires
Developing internal research capacity
Positive benefits to service users/carers of participating in interviews
A new evidence-based model of the relationship between team
leadership and team working, and team outcomes
In-depth understanding of leadership and team working
Project achievements (2)
Reports: team, trust and overall report
Practical toolkit for team and leadership development
Leading to Quality Final Event
Professional and academic articles
Further Information
The following website:
www.southwestyorkshire.nhs.uk/LTQ
Contains the following downloads:
The Leading to Quality full report
The Leading to Quality Toolkit
The Service User and Carer Quality of Care Questionnaires