An exploration of how the concept of the ‘well led’ hospital Trust is defined and understood by NHS staff across a range of organisational managerial levels

By

Denise Chaffer

THESIS

Submitted for the degree of Doctor of Philosophy

Faculty of Health and Medical SciencesUniversity of Surrey

June 2018

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Statement of originality This thesis and the work to which it refers are the results of my own efforts. Any ideas, data, images or text resulting from the work of others (whether published or unpublished) are fully identified as such within the work and attributed to their originator in the bibliography or in footnotes. This thesis has not been submitted in whole or in part for any other academic degree or professional qualification.

Name: Denise Chaffer

Signature:

Date: June 2018

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Acknowledgements

I would like to thank the following for their support during my study: the participants from the NHS

Trust studied, who generously gave up their time to meet with me and share their views and

experiences with me. Without their contributions, this research would not have been possible. I

would also like to thank my supervisors, formally Dr Jane Hendy and latterly Professor Simon de

Lusignan, as well as Dr Carin Magnusson, for their support, guidance, and advice over the research

journey. Also thanks to Professor Paul Hodkinson for supporting me with my methodology and in

particular my approach to using grounded theory. Thanks also to Dr Debbie Cooke for providing

additional support during the last few weeks in providing feedback on final drafts.

I would also like to thank my employers, initially NHS England, who supported my application and

some study leave, and for the final three years my current employer NHS Resolution for supporting

me with both generous funding and also study leave.

I would also like to thank my husband Rob, many of my colleagues, and, in particular, Ray Field, and

Dr Suzette Woodward who have acted as critical friends and supported me particularly through

some of the more challenging times.

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Abstract

The aim of this PhD study was to gain greater understanding of staff experience of being well led

within a NHS Hospital Trust rated ‘well led’ by the Care Quality Commission (CQC), to better

understand the potential contribution leaders could make to improve quality of patient care.

A qualitative case study method was utilised to explore staff experiences in the ‘well led’ Trust. A

theoretical framework was developed to underpin the methodological process, incorporating

components of learning organisational theory (Argyris 1995 & Senge 1990) and an interpretive

grounded theory approach was applied (Charmaz 2006).

Four main themes were identified:

A sense of ‘family’, particularly a focus on shared values and behaviours that prioritised

both patient and staff wellbeing.

A strong preference for a distributed leadership model that was balanced against a need for

a hierarchical model.

A learning approach was balanced against a robust commitment to sanction behaviours

outside the values of the organisation.

A clear ambition to build resilience and embed these values to sustain the ‘well led’

approach in the face of significant financial pressures and work force challenges.

Many of the principles of learning organisation theory, identified by Argyris (1992) & Senge (1990),

were visible across all four themes.

However, there were also some important differences. In particular, there were challenges related

to the organisational requirement to balance strategies to both promote staff commitment, as well

as compliance. Furthermore, there were similar challenges linking parallel, but disparate models of

distributed and hierarchical leadership.

The findings identified both the features of a well led NHS Trust and also some challenges. These

new insights contribute to our current understanding of ‘well led’ Trusts, which can be used to

improve Trust level leadership more broadly in the NHS, and also provide a framework for further

research in this area.

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Contents

An exploration of how the concept of the ‘well led’ hospital Trust is defined and understood by NHS staff across a range of organisational managerial levels..............................................................1

Statement of originality.........................................................................................................................2

Acknowledgements...............................................................................................................................3

Abstract.................................................................................................................................................4

Chapter 1: Introduction – Policy context and rationale for the study...........................................11

Introduction.....................................................................................................................................11

Context and rationale for undertaking the study............................................................................11

Leadership as a social construct?....................................................................................................13

Aim of the study..............................................................................................................................14

Research question...........................................................................................................................16

Key objectives of the research.........................................................................................................16

Research design...............................................................................................................................17

Reflexivity........................................................................................................................................17

Reflexivity (Box 1) regarding reflection on my views and assumptions and experience prior to undertaking this study.....................................................................................................................18

Risk of bias.......................................................................................................................................19

Table 1: Types of potential bias (adapted) (Tvesky & Kahnmean, 1974).........................................20

Theoretical framework....................................................................................................................20

Conclusion.......................................................................................................................................21

Chapter 2: The NHS policy context and the emergence of the ‘well led’ concept for NHS organisations.............................................................................................................................................................22

Introduction.....................................................................................................................................22

Policy context..................................................................................................................................22

Background to the Francis inquiry and the government response..................................................23

Table 2: Timeline regarding commissioned investigations into safety concerns in hospitals 1998–2017.................................................................................................................................................25

Reflexivity (Box 2) regarding reflections on my views and assumptions about the reports on failings in hospital............................................................................................................................27

Development of the CQC inspection criteria of being ‘well led’ as the solution..............................28

Table 3: CQC state of care report (2017 a): 152 NHS Provider Trusts: CQC overall inspection ratings (hospitals)........................................................................................................................................29

Emergence of leadership and governance of NHS Trusts and the concept of ‘well led’..................31

The concept of NHS Foundation Trusts...........................................................................................32

Table 4: Timeline relating to NHS Policy changes 1999–2017.........................................................33

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Measurement of NHS Acute Trust quality performance and the concept of the ‘well led’ Trust....34

The call for leadership and the development of bespoke leadership courses.................................36

Reflexivity (Box 3) regarding my views, and reflections about the policy context, leading to emergence of the CQC concept of being ‘well led’..........................................................................37

Chapter 3: Preliminary literature review of the ‘well led’ concept relating to health care and quality care delivery........................................................................................................................................40

Introduction.....................................................................................................................................40

Literature review approach and search terms.................................................................................40

Search process followed..................................................................................................................41

Reflexivity (Box 4) in relation to preliminary literature review........................................................42

Brief history of the concept of leadership.......................................................................................43

Leadership as a social construct?....................................................................................................45

Influential contributions to leadership concepts.............................................................................46

Concept of the learning organisations.............................................................................................47

Concept of followership..................................................................................................................48

Effective leadership in relation to successful organisations.............................................................49

Relationship of leadership effectiveness to culture.........................................................................50

Relationship of effective leadership and the concept of subcultures..............................................52

Distributed leadership and leadership effectiveness.......................................................................54

Relationship of leadership effectiveness and delivery of quality care.............................................56

Summary of chapter........................................................................................................................58

Gaps in the literature regarding effective NHS leadership...............................................................59

Conclusion.......................................................................................................................................60

Selecting a theoretical framework to underpin this research study................................................62

A shared understanding of what defines a learning organisation...................................................62

Rationale for selection of learning organisational theory to underpin study..................................62

Table 5: Showing a range of publications relating to learning organisation principles from dates 1978 to 2017 inclusive.....................................................................................................................64

Exploring some of the components underpinning learning organisational theory..........................66

Components of learning organisations..............................................................................67

Compliance versus commitment.....................................................................................................67

Table 6: Example of compliance versus commitment (Argyris, 1998)/Control versus open learning systems continuum (Senge, 1990)...................................................................................................69

Mental models and creating the environment for learning and commitment................................69

Double-loop learning.......................................................................................................................69

Theories in action and espoused theory..........................................................................................69

Systems thinking..............................................................................................................................70

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Blending the theories to design the methodology tool...................................................................70

Table 7: Combining the common key components of learning organisations (Argyris, 1992; Senge, 1990)...............................................................................................................................................71

Reflexivity (Box 5) in relation to my personal views and beliefs regarding utilising the theoretical framework.......................................................................................................................................72

Conclusion.......................................................................................................................................72

Chapter 5: Research methodology chapter.........................................................................73

Introduction.....................................................................................................................................73

Rationale for undertaking study......................................................................................................74

Research question...........................................................................................................................74

Key objectives of the research.........................................................................................................74

Methodological consideration and approach..................................................................................75

Paradigm/Worldview.......................................................................................................................75

Ontology and epistemological approach.........................................................................................76

Reflexivity (Box 6) regarding my views and assumptions influencing the methodological approach to study............................................................................................................................................77

Considerations for the most suitable methodological approach.....................................................78

Grounded theory.............................................................................................................................79

Consideration of other research approaches..................................................................................80

Phenomenology...............................................................................................................................80

Ethnographic...................................................................................................................................80

Theoretical framework....................................................................................................................80

Selecting the chosen methodological approach for the study.........................................................81

Research design – case study..........................................................................................................82

Sampling strategy – defining population to be studied...................................................................82

Seeking permission/Gaining access to undertake study..................................................................83

Reflexivity (Box 7) regarding my views and assumptions influencing the sampling approach to study................................................................................................................................................85

Sub-sampling within selected NHS Trust.........................................................................................86

Ethical considerations......................................................................................................................87

Data collection tools........................................................................................................................88

Developing the semi-structured interview questions......................................................................89

Piloting of interview questions........................................................................................................89

Reflexivity (Box 8) regarding my views and assumptions about selecting interview questions.......89

Semi-structured interviews.............................................................................................................89

Observation of staff meetings.........................................................................................................90

Reflexivity (Box 9) regarding: reflections from the interview and observations process.................92

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Data analysis....................................................................................................................................93

Applying the analysis process..........................................................................................................94

Second stage focused coding process..............................................................................................95

Third stage of coding.......................................................................................................................95

Reflexivity (Box 10) regarding reflection during the analysis process..............................................96

Table 8: Example of Theme 1 – Family............................................................................................98

Table 9: Distributed leadership with some hierarchy......................................................................99

Reflexivity (Box 11) regarding reflections on the analysis process................................................100

Conclusion.....................................................................................................................................101

Chapter 6: Presentation of findings.............................................................................................102

Introduction...................................................................................................................................102

Final themes..................................................................................................................................102

Sub-themes...................................................................................................................................102

Theme 1: Family............................................................................................................................103

Setting and translating the vision..................................................................................................108

Recruit to fit the family and shared values....................................................................................109

Not fitting in the family..................................................................................................................110

Striving for excellence...................................................................................................................122

Summary of theme........................................................................................................................122

Theme 2: Distributed leadership with some hierarchy..................................................................124

Hierarchy and chain of command..................................................................................................124

Informality.....................................................................................................................................125

Competence..................................................................................................................................127

Commitment to deliver.................................................................................................................129

Summary of theme........................................................................................................................130

Theme 3: Learning.........................................................................................................................130

Talent management......................................................................................................................133

Summary of theme........................................................................................................................135

Theme 4: Sustainability responding to current and future challenges and pressures...................135

Increasing activity..........................................................................................................................136

Succession planning for executive team........................................................................................139

Summary.......................................................................................................................................141

Reflexivity (Box 12) regarding reflections on presentation of findings..........................................141

Conclusion.....................................................................................................................................141

Chapter 7: Discussion and conclusions chapter..........................................................................144

Introduction...................................................................................................................................144

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Research question.........................................................................................................................145

Ontology and epistemological approach.......................................................................................146

Grounded theory...........................................................................................................................146

Sub-themes...................................................................................................................................147

Theme 1: Family............................................................................................................................147

Shared values and expected behaviours.......................................................................................150

Delivering on what is promised.....................................................................................................152

Pursuit of excellence......................................................................................................................153

Not fitting with the family..............................................................................................................154

The right culture............................................................................................................................155

Compliance with CQC....................................................................................................................158

Summary of theme........................................................................................................................159

Theme 2: Distributed leadership/with some hierarchy.................................................................160

Table 10: Example of compliance versus commitment (Argyris, 1992)/Control versus open learning systems continuum (Senge, 1990).................................................................................................162

Table 11: View of the participants regarding distributed leadership with some hierarchy...........162

Hierarchy versus distributed leadership........................................................................................162

Military style chain of command...................................................................................................164

Polarities to manage regarding hierarchy......................................................................................165

Staff first........................................................................................................................................165

Table 12: Investors in People – Improving, leading, and supporting (source: https://www.investorsinpeople.com/)..........................................................................................166

Summary of theme........................................................................................................................166

Theme 3: Learning.........................................................................................................................167

System learning.............................................................................................................................168

Investing in developing leadership capability................................................................................170

Summary of theme........................................................................................................................171

Theme 4: Sustainability: responding to current and future challenges and pressures..................172

Pressures and challenges...............................................................................................................173

Executive team behaviors changing in response to pressures.......................................................174

Succession planning for the executive team..................................................................................175

The ‘leader centric’ concept..........................................................................................................176

Succession planning.......................................................................................................................178

Summary of Theme 4....................................................................................................................180

Summary and combining the four themes....................................................................................180

Theoretical considerations emerging from study..........................................................................181

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Contribution of new knowledge to gaining greater understanding of the ‘well led’ concept.......182

Table 13. Alignment of findings with learning organisation key components from research study with the common key components of learning organisations. (Argyris 1992) & (Senge 1990).....184

Shared values and clarity regarding expected behaviors important to participants......................184

Pursuit of excellence, clarity of vision, purpose and expectation also important..........................184

Executive leaders creating right environment important to participants......................................184

Commitment important but balanced with some elements of compliance..................................184

Participants valued military style chain of command....................................................................184

Participants valued investing in developing leadership capability.................................................185

Participants valued investment in staff education and training and importance of valuing staff. .185

Participants valued System learning approach, this was consistent across all levels of participants.......................................................................................................................................................185

Table 15 - Framework for developing a well led organisation founded on learning organisational principles.......................................................................................................................................187

Reflexivity (box 13) re reflecting back to my motivation to undertake this research....................189

Strengths and limitations of the study...........................................................................................190

Sample selected and theoretical saturation..................................................................................191

Theoretical framework..................................................................................................................192

Reflexivity (Box 14) regarding reflection of use of theoretical framework....................................193

Evaluation of the grounded theory approach................................................................................194

Table 15 - Evaluation of grounded theory approach to study.......................................................195

Reflexivity (box 15) Reflections on conclusions of study...............................................................197

Recommendations.........................................................................................................................199

Recommendations for NHS provider organisations.......................................................................199

Recommendations for the CQC and other NHS Arm’s Length bodies, e.g. NHS Improvement and NHS England..................................................................................................................................199

Recommended areas for further research....................................................................................200

Conclusion.....................................................................................................................................202

References.........................................................................................................................................204

Appendix 1: Letter to organisation seeking permission to undertake research................................218

Appendix 2: Letter to participants.....................................................................................................219

Appendix 3 Participant Information Sheet (re Individual interviews)................................................220

Appendix 4: Participant information sheet (regarding observations of meetings)............................222

Appendix 5: Consent form.................................................................................................................224

Appendix 6: Research semi-structured interviews protocol..............................................................225

Appendix 7: Interview questions.......................................................................................................226

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Chapter 1: Introduction – Policy context and rationale for the study

IntroductionThe purpose of this research study was to explore how the concept of the ‘well led’ hospital Trust (as

assessed by the Care Quality Commission (CQC)) was defined and understood by a range of staff

within an NHS hospital Trust across a range of organisational managerial levels. An in-depth case

study was undertaken within a Trust rated as ‘good’ or ‘outstanding’ in terms of the ‘well led’

assessment undertaken by the CQC. The aim was to gain deeper understanding of the concept of

leadership within the organisation, and explore how the assessment of an NHS Trust being assessed

as well led impacted on the quality of care delivered. The overall objective was to consider how the

findings from this research could help inform the wider NHS in improving its leadership capability

and subsequently improve the quality of care delivered to patients.

This chapter describes the rationale for selecting the concept of the ‘well led’ NHS Trust as the focus

for my research. The proposed research aims and objectives are outlined, together with the

methodological approach chosen for exploration of these issues. The theoretical framework of

learning organisational theory used to support the study will also be briefly described.

Context and rationale for undertaking the study The last few years have seen a number of public inquiries commissioned by the government in

response to a range of serious failings in patent care within NHS settings (Kennedy, 2001; Francis,

2013; Berwick, 2013; Kirkup, 2015). All of these reports make recommendations highlighting the

need to prevent these failings by tackling leadership and culture within NHS organisations. The

presumed assumption being that improving the quality of leadership within NHS organisations

will lead to improvements in care to patients and reduce the possibility of serious failings within the

NHS. The CQC introduced the concept of being ‘well led’ as a key component of their inspection

regime following the publication of the Francis report (2013) and this has become widely accepted

as a part of assessing NHS provider Trusts (Monitor and the NTDA Care Quality Commission/Monitor

(2014) . However whilst the various regulators have worked together in developing criteria for

assessing the concept of being ‘well led’, the theoretical concepts that define and underpin these

are less clear. Despite this a small number of NHS provider Trusts have achieved a CQC assessment

of ‘good’ and in some cases ‘outstanding’ in the ‘well led ‘component which suggests there may be

something to be learnt from the way in which these organisations have achieved this.

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This purpose of this research was to gain greater understanding of how staff experience the ‘concept

of being ‘well led’ within one of these NHS organisations. The overall rationale was that by

exploring, better defining and identifying some of the key components, including any underpinning

theoretical concepts, this may be useful towards driving improvements in NHS care delivery.

A key aim of this research was to explore and identify underpinning theoretical concepts which could

potentially contribute to development of wider theories of leadership literature and be applied to

other organisational settings beyond health care.

Relevance of the concept of learning organisations in relation to the ‘well led’ concept Common across the various reports (Kennedy, 2001; Francis, 2013; Berwick, 2013; Kirkup, 2015) are

references to the need to develop a learning culture. Berwick, in his report responding to the Francis

(2013) findings, in recommendation 6 stated that ‘the NHS should become a learning organisation,

and that its leads should create and support the capacity for learning’ (Berwick, 2013, p. 4) across

the NHS. This was followed by a speech by the Secretary of State for Health stating his vision for the

NHS to become the world’s largest learning organisation (Hunt, 2016). Implicit across the range of

failings identified in the above-mentioned reports is an assumption of an important relationship

between good or poor quality health care being attributable to the quality of leadership. Becoming a

learning organisations is viewed as a potential solution to help in addressing these failings. There is

however, limited detail within these reports that define what a learning organisation is or how this

could be best achieved.

The concept of the learning organisation is well described within leadership theories from the 1960s

but is less evident within the literature from after the 1990s (Argyris, et al., 19985 Gronn, 2003; Yukl,

1999). The reason for this is not clear, but this coincided with a whole range of leadership theories

being described, with just some studies (for example, Ancona, et al. 2007; Gronn, 2003; Yukl, 1999),

containing within them some of the principles from Argyris‘s, et al. (1985) work.

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A range of policy developments were subsequently introduced by various governments in response to a number of the hospital investigations reports (please see Table 4 in Chapter 2). One such example included the establishment of the NHS regulator Care Quality Commission in 2009, who subsequently developed an (CQC) assessment framework from inspections for NHS Trusts. Incorporated within the inspection process was a section that related to an NHS organisation being assessed as being ‘well led’. Chapter 2 describes in more detail the development of this assessment framework used by CQC, and explores how the roles of the former National Trust Development Authority (NTDA) and Monitor (who more recently merged to form NHS Improvement) have aligned with this approach. This has led to a commonly accepted assumption ( unchallenged by NHS policy leaders), that the ‘well led’ Trust as defined by the CQC could be effectively assessed against a range of criteria, and where an assessment of ‘good’ or ‘outstanding’ is achieved for being ‘well led’ the outcomes from quality care delivery will be improved. Despite a lack of evidence to support improvements in leadership effectiveness post Mid Staffordshire and more recently Morecambe Bay (Francis, 2013; Kirkup, 2015), the development of the ‘well led’ concept has emerged as the solution. It is difficult to pinpoint exactly where the term emerged from, other than that it began to feature as part of the assessment process between 2009 and 2013. The emergence of the ‘well led’ criteria appeared to be based on an assumption that if the issue of poor leadership and culture were not addressed, then NHS Acute Trusts will continue to fail to meet the quality standards expected and further failings would continue to be seen (CQC, 2015). While few would disagree with the need to prevent further failings, there is limited evidence to suggest how this could be best achieved. This research study was interested in exploring the assumption that Trusts being assessed by the CQC as ‘well led’ would directly lead to delivery of higher quality care to patients, and conversely whether participants may believe that not being well led would result in a lower standard of care.

Leadership as a social construct?Defining the concept of leadership itself can be viewed as elusive, and raises questions of whether it

can be seen more as a social construct, that is, a shared idea or understanding that is widely

accepted by society developed from a society view that leaders are necessary to bring order to

organisations (Fairhurst & Grant, 2010; Gemmill & Oakley, 1992). A number of deeply held

assumptions can be found within social constructs (Gemmill & Oakley, 1992; Elder- Vass, 2012).

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These include an unquestioning belief that leaders are required for the functioning of organisations.

It could be argued this belief is based on an unconscious assumption that their leader will be able to

solve all problems, or that effective leaders will emerge to do this (Gemmill & Oakley, 1992).

The recommendations from the Francis report (2013) are based on an assumption that improved

leadership offers the best solution, but places little emphasis on the role of the followers within this

(Uhl-Bien, et al., 2014). Leadership within NHS organisations is particularly complex, with many of

the staff in leadership roles also being simultaneously in followership roles. Examples of these can

be seen within clinical teams, where junior staff frequently can hold leadership roles for periods of

times, e.g. for a number of shifts and the same time be followers of their more senior leaders. A

further complexity is the relationship between leaders and managers, where in health care these

roles are frequently merged. For example nurses leading a ward, holding 24 hour responsibility for

patients within their care, and line management of a range of staff can be viewed as both as a

nursing leader and a ward manager. The importance of the differences between the two roles are

debatable, it could be argued that the differences between staff who hold leadership rather than

managerial roles is an artificial and unhelpful differentiation, as leaders will usually have some

degree of managerial responsibility within their roles (Mintzberg, 2017). In a similar way viewing

leadership theories in relation to transformational versus transactional leadership (Bass, 1990). as

either or, creates the possibility of an artificial differentiation and the concept of these being

mutually exclusive where the reality particularly when applied to health care is the need for aspects

of both. Where there is significant focus on the skills of a transformational leader this can fail to

recognise the role of the follower, who can be seen as subservient in their contribution to that of the

effective leader (Uhl-Bien, et al., 2014).

The concept of the ‘well led’ Trust has been generally accepted by the NHS without question. This

has been implemented as part of key policy by leaders and regulators, such as the CQC and Monitor,

as the believed solution to improve quality across the NHS. A further commonly held assumption is

the aspect of causality, in the belief that organisational outcomes are attributable to leadership, that

leadership can be observed, and that leaders are in control of events (Gemmill & Oakley, 1992;

Fleetwood & Ackroyd, 2004). Unravelling this range of assumptions was felt to be key to gaining

greater understanding of how good leadership could be better understood. However, views about

the concepts of social constructs are not without their critics; the theory of social constructivism is

complex, attracting a range of views (Fairhurst & Grant, 2010).

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Aim of the study The aim of this research was to explore this phenomenon, and seek to gain greater understanding of

these assumptions with the intention of generating new theories to help better define the concept

of being ‘well led’. This would enable NHS organisations to give greater consideration to

implementing a range of leadership actions, which if found to be beneficial could contribute to the

development of future health policy.

This study was interested in exploring and gaining understanding of how staff within an NHS Trust

defined and understood the concept of the ‘well led ‘organisation as defined by the CQC, and how

this impacted on the delivery of quality care. To gain a better understanding, a preliminary literature

review was undertaken to explore the concept of ‘well led’ organisations and how this term had

emerged and become broadly accepted by the NHS. This is presented in Chapter 2 and Chapter 3.

Following the collection and analysis of the data collected, a secondary literature review was

undertaken, as recommended by Charmaz (2014), to support a grounded theory approach.

The purpose of this study was to seek greater understanding of the concept of the ‘well led’ Trust

and explore whether deeper analysis of a Trust that had scored well in the CQC well led domain

could generate greater understanding of how staff define what being ‘well led’ meant to them. This

exploration would have the potential to develop a more evidence-based approach towards

understanding the concept of ‘well led’. This could have the potential to support NHS organisations

by providing more of a theoretical framework to support them towards improving their leadership

overall.

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Research questionThe research question was: how is the concept of the ‘well led’ hospital Trust defined and

understood by staff across a range of organisational managerial levels? Further sub questions within

this included:

What does the concept of ‘well led’ mean to staff?

What do staff understand by the concept of being ‘well led’ within their NHS Trust?

How does the concept of ‘well led’ translate across their organisation?

What were staff views on the impact their hospital’s leadership has on the quality of care

delivered to patients?

Key objectives of the research The key objectives for the study were to:

Explore through semi-structured interviews across three levels of NHS staff (executive, middle

management, and front-line clinical staff) within a single acute Trust (assessed as well led), what

these groups understood by the concept of the ‘well led’ Trust.

Explore how these staff defined and experienced the concept of ‘well led’ within their

working environment.

Explore staff’s views on how their experience of leadership moderated organisational/care

quality outcomes – from the perspectives of the staff interviewed.

Contribute new knowledge and gain greater understanding of the concept of ‘well led’ in

terms of how it is defined and measured and how it relates to the delivery of quality care to

patients.

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Research design The ontological approach for this research was one of exploration and interpretation of how the

‘well led’ concept was defined and experienced by staff in an NHS Trust. The approach taken was to

explore this concept through the lens of the staff’s views and experiences and gain greater

understanding within the organisation in which they worked. This was in response to a gap in the

literature that related to gaining greater understanding of an insider’s view of the ‘well led’ concept.

This study’s focus was on discovery and gaining greater understanding, rather than testing a

hypothesis, and therefore a qualitative methodological approach was selected. An inductive

interpretive grounded theory approach was selected to analyse the data collected as it was

captured, to grow my understanding and knowledge as a researcher and develop an emerging

theory of the experiences of staff in relation to the concept of ‘well led’.

Reflexivity One aspect of using a grounded theory approach included consideration of my role in the process of

being an ‘inside researcher’ and how best to make this visible to the reader throughout the research

process (Charmaz, 2006). It was important to show the relationship between myself as the

researcher with the participants I interviewed – both in terms of my position within the study and

also the potential impact this could have throughout the process of the study (Yu Ching Ko 2008;

Berger 2015). My aim was to make visible my views and assumptions throughout the entire research

journey. To achieve this, I followed a structured process of critical reflective note taking during each

phase of the research, which has been illustrated throughout each chapter in the form of reflexivity

text boxes. The text boxes represent a summary from these notes and are presented to demonstrate

the reflective journey I experienced and to make visible to the reader my positioning within the

entire research journey. This structured approach of reflective bracketing is supported by Ahern

(1999) and similar to an approach recommended by Rae & Green (2016). This process required me

to identify and write down my personal belief systems, expose my assumptions and biases, and

recognise the influence I may have on the participant’s responses and the need to make areas of

potential bias visible throughout (Ahern, 1999).

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Reflexivity (Box 1) regarding reflection on my views and assumptions and experience prior to undertaking this study Reflexivity box 1 shows my views and assumptions prior to

undertaking the study.

I have worked in the NHS since the mid-1970s. My first role was

as a cleaner in the Accident and Emergency Department when I

was at college. My second role was as a nursing auxiliary in an

elderly care ward before starting my nursing training in 1978. I

qualified as a registered nurse in 1981, and as a registered

midwife in 1987, and have held a range of roles in nursing,

midwifery, education, and senior management over the last few

decades. I have held the post of Director of Nursing in two acute

provider NHS Trusts and have experienced first-hand the

leadership challenges of prioritising the delivery of quality

throughout an NHS hospital while balancing this with the need

for achievement of financial and performance targets. I also

have experience of the CQC inspection ‘regime’ as both a

provider and commissioner of NHS services. During this time, I

had seen examples of wide variation across the NHS, particularly

in relation to the quality of care delivered and clinical outcomes

experienced by patients and their families. I have also observed

this variation in relation to the staff in terms of leadership,

culture, and support for ensuring learning across the NHS

system.

Following the publication of the Francis report (2013), I

experienced a range of emotions, in particular one of great

sadness that this could have happened within the NHS of which I

was so proud to be a part. My personal experience has been of

working with good staff, who were committed and came to work

to give the best care that they could. These failings were not new nor unique to the Francis report

(2013) and seen again in the Kirkup report (2015) and led me to question why these had occurred,

which further led me to explore this in more detail, including interviewing a small number of key

leaders related to health care. This resulted in my book being published in 2016. Having published

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Reflexivity Box 1

My reflections and assumptions prior to undertaking the study:

Worked in the NHS since 1977, holding a variety of clinical roles.

Held director roles in provider Trusts, commissioning, and at time of research – director within a national NHS organisation.

Clinician (nurse and midwife), still with live professional registration.

Passionate about driving improvements in patient care.

Personal experience as director of a provider NHS Trust receiving CQC inspection.

Personal experience of both very good and very poor leaders.

Emotional response to Francis report (2013) led me to:

Publish a book in 2016 on effective leadership which included interviews with some key health-care leaders (therefore alert to potential risk of confirmation bias).

Wanting to discover more about the components of good leadership.

Committed to multi-disciplinary learning and working together.

Strong sense of justice and fairness.

Desire to address variation in standards across NHS.

Passion for improving leadership in the NHS.

the book I felt the need to explore the concept of being ‘well led’ in more detail, believing that

developing a greater understanding of how this could be better defined would be helpful in making

many of the improvements needed in leadership within the NHS. Whilst I felt it was very important

to respond to the Francis report (2013) I believed such responses should be considered,

proportionate and based on good evidence as to what would be most effective in addressing the

issues raised. I believed this required developing a far greater understanding of why these failings

had occurred, to avoid the NHS system taking a range of actions and interventions which may not be

either evidence based or seen to be effective.

At the time of undertaking the study I held a senior leadership role within a national organisation

and was passionate about the need to make improvements across the NHS. I recognised that my

current role brings power and influence, but I try wherever possible to remain connected with the

front line, and continued to practice clinically when time allows. I also recognised that these roles

were situated within organisations that were perceived as having power and influence. This in turn

could have inhibited staff from speaking to me or sharing the truth with me. It was important,

therefore, for me to gain trust with the participants and to assure them that their contributions

would not adversely affect them personally or their organisation. Highlighting my views and beliefs

was important to illustrate as a frame for this research showing where I sat in the system, and

bringing into the open who I was, and what I stood for within the research journey.

The emerging assumption by the CQC (and supported by the Department of Health and Monitor and

latterly by NHS Improvement) was that by designing and assessing hospitals as being ‘well led’ led

and applying a range of interventions where this was not the case, would lead to improved quality

care delivery. This assumption led me to question how a well led organisation was defined and

understood by its staff and whether there was evidence to support what the components of a well

led Trust may be. There were some inherent risks of being an ‘inside researcher’ (Hibbert, et al.,

2014), which related to subjectivity, validity and bias, as well as how participants may view me as the

researcher. However, I believed my pre-existing knowledge and experience had the potential to

serve as an advantage to exploration of this concept in more depth (Charmaz, 2014).

Risk of biasI was aware that there were a large number of biases that researchers need to take into account and

I used a framework developed from a paper by Tvesky & Kahneman (1974) to help identify potential

areas of bias to help guide my research journey. The framework suggests a number of areas of bias I

needed to continually challenge myself on, and I used the framework throughout and draw

reference to the various categories within the reflexivity sections where I was aware that there was

20

potential for bias at a number of stages that could impact on this research study. Table 1: Types of

potential bias (adapted) (Tvesky & Kahnmean, 1974)

Availability heuristic: I may have seen something similar, so I may

overestimate its importance and overlook the other information

less readily available.

Belief bias: I may believe what I am hearing based on the strength

of the argument or the believability of the conclusion.

Blind-spot bias: I may view myself as less biased than others.

Clustering illusion: I may overestimate the importance of small

patterns in large data.

Confirmation bias: I may focus on information that only confirms

my existing preconceptions.

Courtesy bias: I may give an opinion that is viewed as more socially

acceptable so as not to avoid causing any controversy.

Illusion of validity: I may overestimate my prediction as accurate

and finally getting to a coherent truth.

Ostrich effect: I may avoid negative information and assume a

person has characteristics because they are a member of a group.

Theoretical framework To support this study a theoretical framework was selected that related to learning organisational

theory. The rationale for using this related to recommendations given within the report referenced

earlier (Francis, 2013; Berwick, 2013; Kirkup, 2015) for organisations to have a greater focus on

learning as a way of addressing some of the failings identified. The work from Argyris (1992) and

Senge (1990) were blended together to develop a theoretical framework to underpin this study. This

theoretical framework was used to help inform the methodological approach and give structure to

support analysis of the data collected. This is described in more detail in Chapter 4.

The findings from the study are presented in Chapter 6. Chapter 7 includes discussion of

this data alongside findings from a secondary review of the literature. Chapter 7

concludes the research study and provides a summary of the key findings from this

research. It presents a summary of the contribution to current knowledge that this study

21

offers. The strengths and limitations of the study and recommendations for further

research are also presented.

Conclusion This chapter described the aims of this research study together with the objectives and desired

outcomes from the study. The rationale for selecting the concept of the ‘well led ‘NHS Trust as the

focus for my research was described together with the methodological approach chosen for

exploration of these issues.

The next chapter describes the context of the NHS in relation to leadership and the emergence and

development of the ‘well led’ concept in more detail.

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Chapter 2: The NHS policy context and the emergence of the ‘well led’ concept for NHS organisations

Introduction This chapter presents a review of the NHS policy context leading to the emergence of the ‘well led’

concept for NHS organisations. A range of published papers, reports, and commentaries were

reviewed, which included the Francis report (2013), the Berwick report (2013), and the Kirkup report

(2015), together with an exploration of the influence and development into health policy alongside

the reports. The emergence of leadership and governance of NHS acute provider Trusts (hospitals) is

described together with the introduction of new public management and the drive for organisations

to achieve Foundation Trust status. The emergence of a call for improvements into health-care

leadership (Martin & Learmouth, 2012) together with the need to improve leadership capacity and

capability within the NHS is also discussed.

Policy context The Francis (2013) public enquiry into the Mid Staffordshire Hospital drew attention to examples of

poor health care, high mortality rates, and a culture of bullying. Many of the themes of the Francis

report (2013) had been previously highlighted in a range of similar investigation reports, such as

investigations into Bristol paediatric cardiac services (Kennedy, 2001), learning disability abuse

(Department of Health National response to Winterbourne View Hospital, 2012) and serious

safeguarding children failings (Laming, 2003). The significant failings from the Mid Staffordshire NHS

Trust were exposed in 2010 when the Health Care Commissioner (HCC 2009) undertook an

inspection into the quality of care provided at the Trust in the previous year. The criticism at the

time was that the Trust had prioritised the need to achieve financial balance and performance

targets above the requirement to deliver high-quality standards of care. Following the publication of

the findings, and after pressure from patients and their families, the government commissioned Sir

Robert Francis to undertake an independent inquiry into the failings of the Mid Staffordshire NHS

Trust. Sir Francis QC, a barrister, had previously chaired a number of high-profile inquiries into

failings in health care. Francis (2013) criticised both the leadership of the Trust and the external

partners, such as commissioners and regulators, for their lack of focus on quality, and highlighted

the importance of addressing ‘organisational culture’ and the need for more effective leadership at

every level.

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Subsequently, commentators on the Francis report (Health Watch, 2013; RCN, 2013; Leys, 2013)

cited the need to make improvements to ‘effective leadership’, ‘accountability’, and organisational

culture as being the key solutions to the issues raised within the report. Commentating in the

nursing press, Leys (2013) questioned the use of these terms being used interchangeably without

clear definition. This risked the potential for a range of actions being implemented without sufficient

attention being given to clarity of definition, understanding, and measurable benefit of both

effective leadership and culture change.

The question widely asked by members of the public (Health Watch, 2013), politicians, and the

Department of Health (Department of Health, 2013 a) was whether the Mid Staffordshire NHS Trust

scandal was an isolated incident, or whether the same level of failure could be occurring across the

whole NHS (Department of Health, 2013 b). The concerns were that NHS leaders had focused their

attention on finance and performance rather than on delivering a safe, quality service. This was

supported by David Nicholson, the then chief executive of NHS England, who gave evidence to the

House of Commons Health Committee hearing (Health Select Committee, 2013). On the failings of

the Mid Staffordshire hospital, he stated that, at that time, quality was not the organisational

principle of the NHS, and instead prioritisation had been given to performance and financial balance.

Nicholson believed this had created an environment where the leadership of the NHS lost its focus

(Health Select Committee, 2013). The Francis report (2013), and the subsequent comments by David

Nicholson, raise important questions as to what was understood by the phrases ‘effective

leadership’ and ‘organisational culture’, and whether it was possible to successfully balance

priorities that equally addressed quality of care, financial balance, achievement of performance

targets, and staff satisfaction. If the recommendations relating to leadership and culture given by

Francis (2013) were to have the impact expected on quality improvement in NHS hospitals, then it

was important to have confidence that the terms are interpreted and understood by those

responsible for making the changes needed.

Background to the Francis inquiry and the government response In 2008, the Mid Staffordshire NHS Trust was authorised as a Foundation Trust, having satisfied a

range of rigorous criteria to become self-governing organisations with oversight and performance

monitoring by the regulator known as Monitor (subsequently known as NHS Improvement). The

following year the Trust underwent a Health Care Commission (HCC) review following reports of high

levels of mortality and poor standards of care. A national inquiry was established chaired by Robert

Francis, QC. The final report was published in 2013 (Francis, 2013).

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The Chief Nurse for England (NHS England) in anticipation of the likely recommendations from the

Francis (2013) report prepared a response that linked many of the failings at Mid Staffordshire to the

nursing profession (Ford, 2013). The Royal College of Physicians (2012) took a different view,

emphasising the failures of senior medical leadership and, in particular, the role of the lead named

consultant responsible for care. Both responses to Francis (2013) advocated the need to change the

culture of the health service, and both the government and Royal Colleges responses suggested

implementing a top-down approach – in particular with an emphasis of directing staff to be more

compassionate (Royal College of Physicians, 2012; Department of Health, 2013 b).

The Francis (2013) report was not the first to expose concerns about NHS leadership and culture.

Back in 2001 Sir Ian Kennedy (2001) published the Bristol inquiry, which was set up in response to a

cluster of children’s deaths following heart surgery. The report called for a change in the culture of

the NHS and led to the setting up of the Commission of Health Improvement (CHI), which was

established in 2001. This was subsequently replaced by the Health Care Commission (HCC) in 2009,

who published a report into the failing of the Mid Staffordshire Hospital in 2009. The HCC were

replaced by the CQC in 2009.

Since the publication of the Francis (2013) report a further hospital scandal (Morecombe Bay NHS

Trust) was reported, this time highlighting significant failings within a maternity unit (Kirkup, 2015).

The investigation report once again revealed significant concerns, which called for the need to

address leadership, culture, and learning within the key recommendations. Table 2 illustrates a

range of commissioned safety investigations over the last few years where concerns relating to

leadership and culture with NHS hospitals were identified and feature within many of the

recommendations. The table also shows the relationship with government policy and the

establishment of the various improvement and regulatory bodies to help address some of these

concerns.

25

Table 2: Timeline regarding commissioned investigations into safety concerns in hospitals 1998–2017Table 2: Timeline of commissioned investigations into safety concerns in hospitals

1998 Sir Ian Kennedy Bristol Inquiry set up in response to deaths in children following heart surgery.

2001 Sir Ian Kennedy Bristol Inquiry reported significant failings in care and called for a change in the culture of the NHS. A range of reforms for doctors and professional bodies were recommended.

2001–2004 Commission of Health Improvement (CHI) established 2001. Review clinical governance engagement. Review and monitor progress against the National

Service Framework. Carry out investigations into serious failings.

Greater focus on quality and away from measuring performance based on financial and activity targets.

2004–2009 Health Care Commission (HCC) established to assess standards of care provided by the NHS.

2009 Health Care Commission report investigation into high rates of mortality at the Mid Staffordshire NHS Hospital – findings the Trust did not develop an open learning culture.

2009–current Care Quality Commission (CQC) established to regulate and inspect health and social care.Replace HCC and Commission for Social Care inspections and Mental Health Commission.

2010 First Francis report published.2010 Secretary of State announces public inquiry into the Mid

Staffordshire Hospital.2013 Partnership agreement between CQC and NHS commission

board (known as NHS England) – statutory duty to cooperate, common purpose of shared outcomes for patients.

2013 The Francis full public inquiry report is published. The report shows significant failings and neglect of patients.

2013 Government responds to Francis Inquiry.2013 Don Berwick invited by the prime minister to review the Francis

report. Berwick’s (2013) Commitment to Learn published. Recommendation that the NHS should become a learning organisation, and its leads should create and support the capability for learning.

2015 The Morecambe Bay Investigation Report is published. It was an independent public inquiry conducted by Bill Kirkup on behalf of the government into maternity and neonatal services and care at the hospital. The report stated the deaths of eleven babies and one mother at FGH were avoidable and a result of a 'lethal mix' of failings. Highlighted problems with the leadership and culture of the unit and stated that lessons should be learned from serious clinical incidents.

2017 State of care report. A report on the outcomes from CQC inspections, including progress in relation to the ‘well led’ domain aspect of inspections.

Sources include: Nuffield (2017); Dr Foster (2012); Dyer (2001); Patterson (2003); Health Care Commission (2004); NHS England & Care Quality Commission (2012); Kirkup (2015); CQC (2017 a)

26

The table illustrates the timeline for the Bristol, Mid Staffordshire NHS Trust, and Morecambe Bay

NHS Trust inquiries. Common to each are changes made to the various organisations responsible for

the oversight of NHS Trusts and the government responses in relation to establishing CHI, replaced

by HCC and subsequently replaced by CQC. Common also to each report are references to leadership

and cultural issues and the need to focus on learning. The timeline shows the government policy

change to address the issues, which arrives at the creation of the CQC as a semi-independent

inspectorate body as the solution to the problem. This suggests a national centralist policy, albeit

situated at arm’s length body to the Department of Health, which ran contrary to the ambition

within the Health and Social Care Bill (Department Of Health, 2012 c), which was to deliver a

devolved from national to local oversight system governed by individual clinical commissioning

groups across England. These contradictions run throughout the last decade where debates about

NHS failings being tackled by various governments but not seen to be successful in the prevention of

these events occurring.

Following the Mid Staffordshire scandal, the CQC replaced the Health Care Commission with a

greater focus on inspection of Trusts in relation to evidence of quality of care delivery. NHS Acute

Trusts were required to meet a number of quality standards to be rated as ‘high performing’. The

NHS Trust Development Authority (2014), along with Monitor, developed an accountability

framework for NHS Trusts. This included technical guidance with a range of metrics of how Trusts

would be assessed. The new model described how Trusts would be held to account and how the

indicators would be used to assess whether the organisation was delivering high-quality care. The

model was divided into two parts: 1) quality and delivery and 2) finance and sustainability. The

quality and delivery component was based on the CQC five domains, which include: caring, effective,

responsive, safe, and well led. The technical guidance included a range of performance, workforce,

and financial indicators, each of which was scored, and the total scores brought together to provide

the overall assessment of the organisation readiness to progress to Foundation Trust status. In a

similar way the Foundation Trusts were expected to meet all standards, and would experience

interventions from Monitor if they have significant failings.

Prior to the implementation of the Health and Social Care Bill (Department of Health, 2012 b), the

Secretary of State (Department of Health, 2012 b) had declared that all National Health Service

(NHS) Trusts would become Foundation Trusts (FTs) by April 2014. The aim of Foundation Trusts was

to achieve the status of becoming self-governing organisations overseen by ‘Monitor’ (regulator for

Foundation Trusts) (Department of Health, 2012 b). Concerns had been previously expressed

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(McGauran, 2002) as to whether the push to drive all Trusts to become FTs was achievable, in that

many organisations would find it difficult to demonstrate the improvements required.

All NHS Acute Trusts striving to become a Foundation NHS Trust were required to meet a range of

criteria across a quality matrix, which includes quality, finance,

performance targets and positive staff feedback on the

organisation (Department of Health, 2012 a) In 2014, a further

change was introduced by the Care Quality Commission (CQC) in

the style of a ‘hospital inspection regime’ (Department of

Health, 2014). These inspection reviews became colloquially

known as ‘Keogh reviews’ (named after the chief medical officer

at the time, Bruce Keogh), and were designed to target hospitals

with known problems in areas such as high patient mortality

rates, patient surveys rated as poor, and where there were

significant areas of concern.

Reflexivity (Box 2) regarding reflections on my views and assumptions about the reports on failings in hospital Reflexivity Box 2 shows my reflection journey on the reports on

failing in hospitals (1998–2017), and my views and beliefs that

motivated my beginning this research journey.

My thoughts when I have read these reports over the years

have been trying to gain a greater understanding as to why

good staff would go to work and deliver poor care (Chaffer,

2016). Without deeper analysis of understanding why these

failings occurred, recommendations may not adequately result

in preventing the issues from reoccurring. The other issue is that

the reports show that the Trusts’ internal governance systems

and also external bodies responsible for monitoring the quality

of care provided did not prevent these failings. In two of the

hospitals of concern it was the patients and their carers that

brought the failings into the public domain. Francis (2013)

highlights this as a key issue and recommends the protection of

staff who raise concerns and support of ‘whistle-blowers’. It was

important to gain greater understanding of what needed to be

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Reflexivity Box 2

My reflections and assumptions about the reports on failings in hospitals (1998–2017)

None of the reports identified why, and how these failings were allowed to happen in an NHS that is supposed to be the envy of the world.

Personal experience in past as senior leader experiencing the significant impact on staff and patient care where leadership in organisation is perceived to be the very opposite of well led

My experience over 30 years of nursing/midwifery is that the majority of NHS staff are committed to give best care.

Yet these staff did not act when they saw poor care. Needed to explore why this would be – what were the systems that prevented them from speaking up.

The failings in two of the reports of concern were exposed by patients and carers rather than staff speaking up. Need to also understand why this would this be.

I felt it to be important to ensure a system that encourages and fully supports staff in raising concerns.

Failure to learn is a common feature throughout the various reports.

Scrutiny from external stakeholders didn’t prevent the failings.

Focus on performance targets and finance prioritised over quality.

Calls to address leadership and learning culture feature on all reports.

in place in NHS Trusts to support staff in speaking up, and how a culture of learning could be

developed and achieved.

In addition, the governance systems that surround organisations in terms of commissioning and

regulation failed, and opportunities to learn from complaints and incidents were lost.

All of the reports recommend the need to address issues of leadership as well as to change the

culture within NHS organisations; however, recommendations that focus specifically on how this can

be best achieved are less obvious.

Development of the CQC inspection criteria of being ‘well led’ as the solution The CQC were introduced in 2009 in response to the Francis (2013) report with the expectation that

their inspection regime would offer greater oversight of NHS providers and highlight early those who

were failing in maintaining standards in quality care delivery. The CQC introduced a criterion of being

‘well led’ to their inspection regime as a way of addressing the need to improve NHS Trusts

leadership. However, the ‘well led’ concept was based across a range of process measures rather

than specifically on patient outcomes (CQC, 2017 a). For a Trust to achieve an overall assessment of

being outstanding they need to score well across all five domains, that is, safety, effectiveness,

responsiveness, caring, and well led.

During this time the CQC have developed what is known as an ‘intelligent monitoring tool’, more

latterly known as an ‘insight tool’, which brings together a wider range of quality measures about an

organisation with the aim to be able provide a risk rating for a Trust. The tool forms an integral part

of CQC inspections (CQC, 2015). However, this still leaves questions regarding the objective

judgement of the members of the CQC inspection team, particularly in determining what they

observe as being either good or poor leadership of organisations (Lilley, 2015). The judgement the

inspection teams make in relation to whether a Trust is deemed to be ‘well led’ are assessed using a

range of methods published in a joint framework by Monitor, CQC, and the NTDA with the aim of

committing to a single view of what good leadership looks like (Monitor, 2013). Their aim was to

agree an aligned framework that would look at leadership, governance, and culture. The framework

continues to have a greater focus on process as opposed to outcome measures; for example, the

assessment is based on the organisation’s strategy, vision and values, processes and structures.

There is limited detail on how these translate across an organisation and how they can be effectively

measured. The focus was very much on assessing leadership at board level, an example of one

question being ‘whether the board shaped an open, transparent and quality focused culture’ (Care

Quality Commission / Monitor, 2014, p. 31), and ‘whether the board had the skills and capabilities to

29

lead the organisation’ (Care Quality Commission / Monitor, 2014, p. 29). There is little specific

reference within the framework to the importance of learning being a key component of effective

leadership, as defined by Senge (1990) and Argyris (1992). The framework included additional

questions, for example, ‘whether leaders at every level prioritise safe, high quality, compassionate

care’ (Care Quality Commission/ Monitor, 2014, p. 31). The approach to the assessment of this

standard placed greater emphasis on processes such as staff receiving appraisals and induction

processes. It also made reference to a small number of outcome measures, such as staff surveys, and

safety incident reporting levels. The approach given within the framework included some

triangulation of views from a range of stakeholders, for example, some patient user groups and staff

groups. However, linkages to the use of specific organisational and management theories and

assumptions to underpin their documentation and frameworks are not evident. The ‘well led’

framework has been further refined over time and more detailed criteria developed (NHS

Improvement, 2017), and closer partnership developed with NHS Improvement, which was formed

in 2016 and includes both Monitor and NTDA within it (see Table 3).

The report by CQC (2014) on their first year (2013–2014) of inspections of quality showed that out of

the 38 Trusts inspected, 1 rated as outstanding, 9 good, 24 required improvement, and 5 rated as

inadequate. While the CQC admits that the first sample of NHS Trusts inspected were skewed

towards targeting those with particular safety concerns, the report demonstrated the need for more

focused improvements, particularly in the area relating to the quality of board/executive leadership.

By 2017 there had been some improvements (please see Table) (CQC, 2017 a). However, out of the

152 NHS providers (hospitals) organisations, 43% required improvement in the ‘well led’ domain.

Table 3: CQC state of care report (2017 a): 152 NHS Provider Trusts: CQC overall inspection ratings (hospitals)

Outstanding 11 7%Good 52 34%Requires improvement 77 51%Inadequate 12 8 %

Hospital Trusts that are judged ‘inadequate’ by the CQC ratings are categorised within a failure

regime. This can include the imposition of intensive scrutiny with agreed time scales to evidence

rapid improvement via what is termed ‘special measures’ (Department of Health, 2014). These

special measures can include the removal of executive teams, closure or restrictions on services, or

30

take over by other organisations. The failure regime thus draws a clear association between poorly

performing Trusts and poor leadership, in particular by the executive team and the belief that

replacing these leaders would resolve the problems (West, et al., 2014). Conversely, Trust executives

from Trusts rated as high performing could attribute this to ‘good’ leadership (and culture) of their

top teams, that is, the Trust board and executive team. The CQC guidance (CQC, 2017 b) suggests

that it’s not possible to be assessed as well led if the intelligent monitoring tool used to inform the

assessment suggests poor patient outcomes. This suggests that an assumption is made that there is

a direct causal relationship between being well led and good patient outcomes that is worthy of

greater exploration. This assumption is further supported by the inclusion of a rating for the ‘well

led’ organisation within the CQC scoring for hospital inspection, where all of those Trusts rated as

‘good’ or ‘outstanding’ to date have scored well in the category.

However, developing an understanding of what defines ‘good’ NHS leadership, and its relationship

to quality of care delivery is complex. Difficulties range from problems with defining what is meant

by ‘good’ as opposed to ‘poor’ leadership in the NHS, how this could be measured, and, in turn, what

could be done to focus improvement in these areas.

It is important to consider whether the assessment of NHS Trusts against the ‘well led’ framework

would be enough to prevent the types of failings that were seen within the Mid Staffordshire Trust.

The ‘well led’ Trust in this context is judged by the CQC against a number of assumptions. The first is

that while the assessment of a ‘well led’ has been extended to leadership across various speciality

areas there is still considerable focus on the ‘top team’ level of the organisation with a specific

emphasis on the roles, capabilities, and skills of the executive team. The second assumption is that

this can be effectively assessed through a range of methods that favour process measures over

outcome measures. A further assumption by the CQC is that the use of this framework will assure

objectivity and consistency of measurement on behalf of the assessors. The fourth and most

significant assumption (but not stated within the framework) is the view that a Trust assessed as

‘well led’ will have improved quality outcomes for patients and significant failings, such as those

seen in the Mid Staffordshire Hospital, will be prevented. To date, few Trusts (see Table 3) have been

assessed as being ‘well led’ by the CQC (CQC, 2014), which raises questions of what, if this could be

recognised as an objective measure (the limitations of which have already been described), could be

done to drive improvements in the many Trusts who have been identified as either requiring

improvement or rate as ‘inadequate’.

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Emergence of leadership and governance of NHS Trusts and the concept of ‘well led’The call for leadership (Martin & Learmouth, 2012) in the NHS has underpinned many of the changes

introduced to the management of the NHS over the last few decades. Leadership has developed as a

concept that is more than just a function of management, and is believed to be in some way

universally beneficial. This concept has developed, gaining general acceptance, based on a wider

range of assumptions in not only the belief that leadership is the answer, but also that leadership

itself can be observed, and the benefit of its impact measured (Gemmill & Oakley, 1992). The terms

of leadership are used frequently in health policy documents and presented unchallenged as the

solution to address many of the problems in the NHS (Martin & Learmouth, 2012).

The NHS is one of the largest employers in the world and has been subject to many political changes

over the last few decades. The emergence of the concept of ‘new public management’ (NPM) to the

NHS (Goodwin, 2000), saw a shift from an administrative function at its inception in 1948 to one of

embracing principles of management more commonly seen in the private sector. The introduction of

‘managerialism’ or new public management (Goodwin, 2000) under the Thatcher government saw

the adoption of policies that sought to introduce the concept of ‘general managers’ with a clear

chain of command, to drive improvement in productivity, performance, and budgetary control. This

new public management approach clashed with the autonomous views of the professions, in

particular the medical profession, who felt their views were lost, and in turn the voice of the patients

and users were also lost in the process (Goodwin, 2000). The tensions between the professions, in

particular the perceived power of medicine, is well documented (Salvage, 1985; Grant, 2012)

through the history of the NHS, and is particularly illustrated in the breakdown in negotiations with

the British Medical Association (BMA) and the government over the proposed changes to junior

doctors’ contracts (BBC, 2015).

The drive by the conservative governments pushed further towards the concept of self-governing

Trusts, this included introduction of the provider purchaser split and embraced the power of the

market forces in an attempt to improve standards. The NHS in particular has been resistant

(Timmins, 2012) to the application of the business model, and the various government ideological

swings between the need to introduce a market model, for example, Sainsbury style of business

seen in the 1980s introduced by the Thatcher government. The labour government, although often

perceived as against a business model for running the NHS, introduced during their last term the

32

concept of ‘any willing provider’, which allowed the contracting out of NHS services to the private

sector (Timmins, 2012).

The concept of NHS Foundation Trusts The concept of NHS Foundation Trusts was introduced by the government in 2003 (Department of

Health, 2002) (please see Table 3) with the aim of decentralising control of NHS hospitals. The aim

was to give providers freedom from government control and introduce a new form of social

ownership where health services were accountable to the local people rather than central

government (Klein, 2004). In July 2002, the government produced guidance on their proposals for

NHS Foundation Trusts. the principle was that they would be free-standing entities and not under

direct control from the Department of Health, and they would be inspected by the Health Care

Commission and held to account by the local communities they served via performance contracts.

Applications from high-performing Trusts, that is, those that had achieved ‘three-star’ rated status in

the performance ratings, were invited to apply (Department of Health, 2002). A statutory duty for

quality was introduced under Section 18 of the Health Act 1999, which required NHS bodies to have

in place arrangements for monitoring and improving the quality of care they delivered. The Health

and Social Care Act 2006 included an additional requirement of a duty for the health service to

secure continuous improvement in the quality of the service they provided. The Health and Social

Care Act 2008 established the Care Quality Commission (CQC) (which replaced the Health Care

Commission). New Foundation Trusts would be regulated by a newly introduced independent body –

Monitor – and the quality of services would be monitored by the CQC. NHS Trusts needed to

demonstrate they had effective board governance in place to be eligible for FT Status, including the

requirement to demonstrate ‘good governance’ (Wells, et al., 2006), which was assessed via written

submission and a number of key events, for example, a ‘board to board’ meeting between Trusts

and the NHS regional Strategic Health Authority with Monitor.

Table 4 shows the NHS policy changes over the last few years, which relate the changes from star

ratings to assess hospital performance in 2001, the emergence of the Dr Foster hospital guide, to the

creation of NHS England and NHS Improvement and their support towards the CQC ‘well led’

inspection criteria.

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Table 4: Timeline relating to NHS Policy changes 1999–2017

1999 Health Act – Introduction of NHS Foundation trusts (FTs) established Monitor to oversee FTs.

2001 Dr Foster – first hospital guide – including mortality data (focus on outcome data).

2001 Introduction of star ratings to NHS Trusts.2008 Health and Social Care Act.2004–2009 Health Care Commission (HCC) established to assess

standards of care provided by the NHS.2006 Annual health checks for NHS Trusts introduced to

replace star ratings.2010 Abolition of primary care trust, replaced with clinical

commissioning groups.Abolition of strategic health authorities.

2011 National commissioning board was set up as a special health authority of the NHS in October 2011.

2012 Health and Social Care Act.2013 NHS England created with operating name of the NHS

Commissioning Board (and, before that, the NHS Commissioning Board Authority). It was renamed NHS England on 26 March 2013.

2013 Partnership agreement between CQC and NHS Commission Board (known as NHS England) – statutory duty to cooperate, common purpose of shared outcomes for patients.

2016 NHS Improvement created as operational name for bringing together Monitor, NHS Trust Development Authority, and Patient Safety (from NHS England).

2017 State of care report. A report on the outcomes from CQC inspections, including progress in relation to the ‘well led’ domain aspect of inspections

Sources include: Nuffield (2017); Dr Foster (2012); Dyer (2001); Patterson (2003); HCC (2004); NHS England & Care Quality Commission (2012); Kirkup (2015); CQC (2017).

The rationale for the gradual delegation of government control of health providers in particular

hospitals was for NHS Trusts to be more locally accountable. Alongside this the government imposed

a number of conditions for an NHS Trust to become a Foundation Trust, which had a focus on

meeting the standards developed by Monitor, in particular those related to the concept of self-

governance. However, while the government needed to impose a regulatory system for Foundation

Trusts to relinquish central control, these requirements for assurance can have perverse effects

(Fulop, et al., 2008). One such effect is the industry and infrastructure this creates to provide the

assurance required, which diverts the time of senior executives. The NHS Trusts need to have in

34

place complex risk and governance processes that can be sometimes be seen as more focused on

data collection than the lived involvement and experience of the local population served (Berwick,

2013).

The events of Mid Staffordshire highlighted the prioritisation of finance over quality and particularly

highlighted the reduction in nursing staff numbers as a major contributor to the failings within the

Trust (Francis, 2013), and the role of the CQC was significantly strengthened when the Keogh type

hospital inspections were introduced. Following the publication of the Francis report (Francis, 2013)

and the government’s response (Department Of Health, 2013 a), Don Berwick, an international

leader for the Institute of Health Improvement, was invited by the Department of Health to give

some support in responding to concerns. Berwick has been a commentator for IHI for many years,

and his report (Department of Health, 2013) highlighted the need to take more steps to engage the

clinical leadership of organisations and move more towards a learning organisation and away from a

culture of targets.

A learning organisation is one that identifies the system factors that support quality processes within

an organisation (Senge, 1990; Argyris, 1998). The aim is to design systems to prevent failure, by

recognising risk, redesigning the procedures, and building capabilities to reduce future harm

occurring (Senge, 1990). In response to the Berwick report (2013), the Secretary of State made

reference to the commitment to the NHS becoming a learning organisation (Department of Health,

2013 b), however, there is limited reference to this concept within the CQQ well led domain. This

omission appears significant, as if this was a significant ambition for the NHS, then a reasonable

expectation would be that this would better described. This is explored in more detail in the next

chapter.

Measurement of NHS Acute Trust quality performance and the concept of the ‘well led’ TrustSince the events of Mid Staffordshire (Francis, 2013), the CQC have developed a new approach to

their inspection to help develop understanding of the impact of good leadership on quality (CQC,

2014). In 2015, they developed a further document to support the assessment of the ‘well led’ Trust

in partnership with Monitor and the NTDA Care Quality Commission/Monitor (2014). The document

refers to having worked closely with Professor West, who more recently co-authored a review of

evidence in relation to leadership within health care (West, et al., 2014), but this does not include

detail of underpinning assumptions or theory regarding defining the term ‘well led’. The particular

35

area of ‘well led’ considers the quality of board/executive leadership, the vision and strategy of the

hospital, governance for safety, and quality and the culture of the Trust. Their technical guidance has

been further developed (CQC, 2017 b) and includes several lines of enquiry that is designed to test

criteria for whether a Trust is ‘well led’. The CQC inspectors triangulate this across a range of

methods, such as interviews with staff and patients, review of documents, for example, the insight

tool (CQC, 2014), and observation of staff.

The CQC have drawn some conclusions that they believe show a relationship between Trusts rated

as ‘well led’ and those rated as ‘good’ or ‘outstanding’ and those with more positive staff surveys

(Richards, 2017). This supports the findings of a study of eighty-six Trusts in 2008 by Shipton, et al.

(2008), who explored the impact of leadership and quality climate on hospital performance. They

found that the more positively that staff rated the leadership of the Trust the better the hospital

performance. The limitation of the CQC report (CQC, 2017) in drawing similar conclusions is both the

small sample and the lack of clarity regarding measurement for leadership and culture that is being

used. It is not clear from the CQC guidance (CQC, 2017) how the issue of potential subjectivity

leading to a lack of objectivity in the inspectors is addressed. The current pool of participants in the

inspection teams are drawn from a wide field of NHS staff, members of the public, patient support

groups and student nurses. Consequently, the potential for bias is high. This may be mitigated in the

selection and training methods for the group, but this is not detailed within the CQC report. Perhaps

not surprisingly this explains why the CQC has attracted a degree of challenge and criticism,

particularly from those Trusts rated as needing improvement, as some feel the impact of the political

consequences, particularly in terms of reputation and public confidence, if they receive a less than

good or outstanding rating (Lilley, 2015).

Currently, external regulators responsible for the rating of a Trust operate across a wide matrix of

standards (CQC, 2015) and report wide variation across England’s NHS Trusts. A study by Sherring

(2012) showed that participants felt that only 18% of Trust leadership created a high-performing

environment, with up to 49% leaders of creating a de-motivating environment. This compares well

with the very small number of Trusts that CQC have assessed as ‘well led’ (CQC, 2015). This also

further serves to illustrate what appears to be a widely held assumption by Monitor and the CQC

(CQC/Monitor 2014) that the success or failure of an NHS Trust in terms of performance can be

attributed to the leadership style of the executive team, and thus if this is addressed the

performance would improve.

36

The call for leadership and the development of bespoke leadership coursesThe various safety investigations described above have led to a general call for improvements in

leadership (Martin & Learmouth, 2012) as the solution to the problems in hospital, and have

included a variety of approaches. These include recognition that a different type of leadership is

required, and there is a shift away from what are perceived as outdated models of leadership of

‘top–down’ hierarchies and imposition of performance targets, performance frameworks, and

leadership by fear, towards one of greater collaboration, engagement of the workforce, and

alignment of common purpose (King’s Fund, 2011). The King’s Fund is a ‘think tank’ involved with

work relating to the health system in England, and publishes a range of papers commentating on the

NHS. In response to the need to build NHS leadership capacity, the NHS Academy have developed a

range of leadership courses (NHS Leadership Academy, 2015) that attempt to utilise a variety of

management and leadership theories to underpin their training on what makes an ‘effective leader’.

It is, however, difficult to determine which theories or research studies underpin these courses and

this is further compounded by limitations of these approaches to the way in which effectiveness has

been robustly studied and measured to significantly enhance overall performance of the

organisations studied (King’s Fund, 2011).

The NHS has developed a health-care leadership model (NHS Leadership Academy, 2013) that

includes areas such as leading with care, influencing for results, and developing capability.

Programmes are offered for NHS top leaders and a bespoke programme is provided to develop the

Healthy NHS Board. In a similar way to the assessment process for rating the ‘well led’ NHS Trust, the

criteria for determining objective measurement of these are limited, and not obviously underpinned

by a sound evidence base. The King’s Fund have a particular interest in the leadership of NHS

organisations and commission a range of key NHS leaders to contribute to these recently

commissioned works on the state of NHS leadership. They identified a need for a more consistent

approach to defining standards for NHS leaders (King’s Fund, 2011), however, they stopped short of

recommending a regulatory framework for NHS executives. Instead, they have recommended that

NHS leadership culture be subject to greater scrutiny by the existing regulatory bodies, such as Care

Quality Commission (CQC) and Monitor. The King’s Fund also supports the view that greater

attention needs to be given to the selection and monitoring of top teams and, in addition, the

development of top leaders needs to be mindful of the new models where there needs to be a

culture of shared leadership. The NHS Leadership Academy (NHS Leadership Academy, 2013) has

developed and delivers a number of courses designed to develop potential leaders, however, this

37

supports the concept of a leader as an individual. More recently, there has been some criticism of

this approach and recognition of the need to address wider team performance rather than a focus

on the development of individual leadership competencies (West, et al., 2014).

NHS Improvement has introduced during 2016 a national transformation improvement programme

for maternity and neonatal services based on the Institute of Health Improvement (IHI)

methodology. The programme includes a focus on leadership and organisational cultures is being

rolled out with local NHS Providers over a period of three years. The programme will be formally

evaluated in terms of impact which will help to inform future initiatives being developed.

Reflexivity (Box 3) regarding my views, and reflections about the policy context, leading to emergence of the CQC concept of being ‘well led’Reflexivity Box 3 illustrates some of my reflections

about the policy context that has led to the

development and introduction of the CQC concept of

being well led. It reflects a journey of my thought

processes as I explored this topic in more detail. It

highlights some of my feelings about the CQC being

viewed as the solution to a national problem and

some of the questions this raises. It also helped to

inform my research process as being focused on

trying to define what some staff’s experience of

being ‘well led’ feels like and what some of the

components of this could be. It highlighted the

importance of ensuring that my research is closely

focused on my research question regarding how the

concept of the ‘well led’ hospital Trust is defined and

understood by staff across a range of organisational

managerial levels with the aim of trying to explore

potential solutions.

I was particularly alert to a potential ‘courtesy’ as

well as confirmation bias. This related to a risk of

being reluctant to express a view about the CQC’s

‘well led’ concept when it was accepted as national

policy. This also related to the risk that I may be

selective in looking for data that confirmed my views.

38

Reflexivity Box 3

My reflections and beliefs about the policy context leading to emergence of the CQC concept of being ‘well led’

Many reports identify need for learning, improved leadership, and change of culture.

Despite this, examples of poor care continue, and some themes persist.

I am particularly interested in

the degree to which inspection offers a solution

what theory underpins the ‘well led’ concept

the consistency and reliability of the CQC inspection regime

based on previous policy interventions, for example, CHI and HCC, what would be different about the CQC

the national policy (that is, widely held view) that CQC assessment of well led is valid but appears to be based on minimal evidence

the lack of attention given to critics of the inspection system (for example, Berwick, 2013; Lilley, 2015).

I am alert to my personal view being at odds with national policy view (risk of courtesy bias).

I am alert to the risks of an alternative view not being well received by some stake holders.

Desire to discover what good leadership looks like, define it, bottle, and spread it.

Needing to be realistic about what one small case study can achieve in contributing new knowledge to this issue.

There was an added risk that my research may be seen as critical of the CQC and the Department of

Health, and I needed to try to adopt a neutral stance to this and remain open to what the

participants’ views were that were expressed (Tvesky & Kahnmean, 1974). I continued to refer back

to the potential bias framework, highlighting where these risks could emerge and the need to

acknowledge and therefore take deliberate action to avoid these from biasing the study.

It can be seen that many of the commentators since the Francis report (2013) in particular focus on

the area of the need to address effective leadership of NHS hospitals, but few have been able to

define what is really understood by the term. Similar problems exist in attempting to define what is

meant by ‘being well led’ and how this is best translated and enacted throughout organisations.

Without being able to effectively define what is needed to help address these problems, so too

exists a problem with both measurement and assessing which intervention would be the most

effective.

Monitor, NTDA, and CQC (Care Quality Commission / Monitor, 2014) and more recently CQC (2017

b) have attempted to both define and agree a common view of the ‘well led’ NHS Trust. Some

limitations of their approach are the key focus being more directed at top team/executive team and

boards, lack of guidance based on robust evidence to support these assessments, and the potential

for lack of objectivity within the inspection teams to reach these conclusions.

This chapter has shown the emergence of a significant ‘quality shock’ where a number of reports

exposed significant failings within NHS provider Trusts (Kennedy, 2001; Francis, 2013; Kirkup, 2015).

The reports show a common theme within the recommendations regarding the need to make

improvements to leadership and the importance of embedding a learning culture. In response to

these reports a number of health-care reforms have been introduced, which include transition of

various regulatory bodies, that is, the Commission of Healthcare Improvement (CHI) to the Health

Care Commission (HCC) to the Care Quality Commission (CQC). They are all aimed at making

improvements in health-care quality and leadership. The development of the CQC well led concept is

aimed at improving organisational leadership, however, specific references that draw a direct link to

learning and the development of learning organisations are less apparent, despite being part of a

key ministerial policy announcement to the NHS in 2016 (Hunt, 2016).

The next chapter takes a more in-depth review of the general literature related to the concept of

leadership and provides an overview of theories relating to leadership and also its relationship to

39

Reflexivity Box 3

My reflections and beliefs about the policy context leading to emergence of the CQC concept of being ‘well led’

Many reports identify need for learning, improved leadership, and change of culture.

Despite this, examples of poor care continue, and some themes persist.

I am particularly interested in

the degree to which inspection offers a solution

what theory underpins the ‘well led’ concept

the consistency and reliability of the CQC inspection regime

based on previous policy interventions, for example, CHI and HCC, what would be different about the CQC

the national policy (that is, widely held view) that CQC assessment of well led is valid but appears to be based on minimal evidence

the lack of attention given to critics of the inspection system (for example, Berwick, 2013; Lilley, 2015).

I am alert to my personal view being at odds with national policy view (risk of courtesy bias).

I am alert to the risks of an alternative view not being well received by some stake holders.

Desire to discover what good leadership looks like, define it, bottle, and spread it.

Needing to be realistic about what one small case study can achieve in contributing new knowledge to this issue.

organisational culture. The aim is to gain a greater understanding of some of the concepts that

underpin views and beliefs about good leadership and its impact on improving quality outcomes.

40

Chapter 3: Preliminary literature review of the ‘well led’ concept relating to health care and quality care delivery

Introduction This chapter examines in more detail a preliminary review of broader literature related to the ‘well

led’ concept. It provides an overview of how some of the concepts related to leadership and

organisational culture have developed. The literature review focuses on how the concept of ‘well

led’ is defined. It also examined how effective leadership was understood and had developed

particularly in relation to leadership concepts within the NHS. It also briefly describes the

development of the concept of leadership over the last few decades. It discusses the emerging shift

of focus from one of ‘top–down’ leadership to one of viewing the leadership’s role as a vehicle for

creating an environment for quality improvement. The relationship between leadership and culture

is also discussed together with the concept of subcultures and the importance of recognising their

significance within the NHS systems. Some of the more historical influential contributions from

theorists such as Argyris (1998), Senge (1990), and McMurry (1958) are discussed in relation to the

extent of their influence on how the concept of leadership is currently defined and understood in

relation to driving quality improvement in health care.

Literature review approach and search terms Undertaking a literature review ahead of data collection and analysis when using a grounded theory

approach is believed to be controversial as it risks potentially imposing the researcher’s view on the

interpretation of data and the identification of themes (Ramalho, et al., 2015; Strauss & Corbin,

1990). I felt that approaching a study without prior knowledge and assumptions, and not

undertaking any prior literature review was not realistic and also lost the opportunity to

acknowledge the contribution that some prior knowledge and experience could bring to the process.

I also wanted to identify gaps in the literature so that my study could be more focused on addressing

this. This is a view supported by Charmaz (2006), who argues against taking a more traditional

approach for grounded theory when relatively little is known about the subject, where the intent of

the research was to elicit the views and experiences to generate the theory (Lyons & Cole, 2007). I

opted to undertake a preliminary review of the literature ahead of the data collection as this helped

shape my methodological approach, and I recognised the need to be aware of the risks of the

potential influence of this knowledge during the data analysis processes. This is discussed in

41

Reflexivity Box 4. A secondary literature review was undertaken following final completion of the

data analysis.

The key focus for this study was learning about how the concept of the ‘well led’ hospital Trust is

defined and understood by staff across a range of organisational managerial levels. The literature

review needed to help in defining and understanding the concept of a well led health-care

organisation. The aim was to explore the relevance of the more recent literature in gaining greater

understanding of how the concept of effective leadership could be applied to NHS organisations. The

databases used for this literature review were MEDLINE and CINAHL (Cumulative Index to Nursing

and Allied Health Literature), plus health, psychological, and sociological databases via the online

library pro quest search engine, as well as Google scholar. The University of Surrey combines a wider

range of databases under the one search engine of ‘Surrey search’, which was helpful in terms of

accessing literature from a range of perspectives.

Search process followed The key phrases ‘well led’, ‘effective leadership’, and ‘effective leadership in relation to health care’

were searched followed by a process of refining and synthesis, and their relevance considered within

a framework. The search engine for the phrase ‘effective leadership in health’ revealed a large

number of publications, many of which were too broad or not relevant to the study. The search was

further refined, adding additional search terms to publications more relevant to my research. This

included examining who the authors of the papers were, dates of publication, purpose,

methodological approaches, their strengths and weaknesses, and relevance and limitations of

findings against the key focus of the ‘well led’ concept for this study (Gray, 2014). This process of

synthesis supported critical analysis of the literature reviewed, helped to refine and identify key

papers informing the research, and helped to identify some gaps in the literature. This was

particularly in relation to theory underpinning the concept of well led health-care organisations. The

dates for the search were initially limited to the last two to five years, to gain recent views and

understanding of the leadership concepts, however, recent papers with this specific focus that

related to my research question were limited in number. This led to the inclusion of a sub set of key

terms found across the broad leadership literature. The search was extended to include the more

general terms of good and effective leadership and while this showed a larger range of more

relevant studies, there was a need to further define leadership effectiveness in relation to quality

outcomes. However, defining the extent to which leaders could be viewed as effective and their

impact on the success of an organisation was problematic because it was highly dependent on what

was understood by the desired outcomes, as these ranged from financial performance and profits to

production, or delivery of a ‘quality product’.

42

The research subject area was therefore divided further to include a further number of key words;

these included the relationship of leadership to organisational culture, the concept of subcultures

within health-care organisations, and the relationship between leaders and followers. The scope of

the literature review included exploration of influential leadership theories and their development

and influence over a number of years. These included: ‘great man theories (Von Wart m 2003), trait

theories (Von Wart M 2003; Yukl 2008; Bennis & Nanus 1985), transformational leadership versus

transactional (Bass 1990), followership (Uhl- Bien, et al 2014), distributed leadership (Bennett, et al,

2003; Bolden 2011); Learning organisational theory (Argyris 1998; Senge 1990); and social group

identity theory (Turner & Tajfel 1986). The literature

review also identified a group of influential

researchers more commonly referenced within the

leadership literature who had influenced the more

recent perspectives and concepts, including the work

of Argryis (1998), McMurry (1958), and Senge (1990).

Having reviewed the literature a deeper exploration

was undertaken of the leadership terms in relation to

social construct theory, particularly as to whether

this would help support greater analysis and

understanding of the leadership concept.

Many of the leadership theories explored for this

study revealed some paradoxes and contradictions

within them which highlighted the complexities

involved in selecting a particular theoretical

framework to help guide this research study.

Reflexivity (Box 4) in relation to preliminary literature review Reflexivity Box 4 illustrates my views and

assumptions as I approached the preliminary

literature review, and the reflections I had during the

process. The literature review explored a range of

leadership theories from a number of perspectives.

Many studies used the terms of leadership and

culture interchangeably. Various investigation

reports recommended the need for organisations to

43

Reflexivity Box 4My reflections and assumptions influencing the approach to the preliminary literature review

I made a decision that a review of the literature would help guide the study but it was important to be cognisant of risks to bias with the grounded theory approach.

I felt that keeping a semi-ignorance of the literature was not realistic – in my current NHS role it was not possible to be isolated from the literature, thoughts, and ideas that already exist.

I have written a book on the subject and have some knowledge of the literature– I was therefore already aware of some of it.

But needed to consider the risk of bias by doing this. Is there a risk I have a blind spot? Need to be mindful of availability heuristic bias. Need to be careful not to overlook other information that may be less readily available.

Also need to be mindful of confirmation bias and explore the literature more widely.

Wide range of leadership theories available to review, and it felt quite overwhelming.

Needed to be more focused on research question but concerned about missing something critical to inform my study.

Various reports call for change of culture but …

Culture difficult to define and therefore difficult to measure – variety of opinions and different definitions of culture and a wide variety of measurement tools.

Various reports recommend the need for learning from harm.

Considering why so little attention given to importance of learning in recent leadership literature.

learn from harm. The importance of learning being more about learning organisations began to

emerge during this process. However, despite detailed searches I continued to find a gap in the more

recent literature in terms of linking the importance of learning to effective leadership and/or the

well led concept.

The preliminary literature review was an area that required particular attention in relation to

application of the framework of (Tvesky & Kahnmean, 1974). Areas of risk of bias needed to be

acknowledged during the search process to take care to explore the literature through a number of

lenses and also to continually question the value of undertaking a preliminary literature review

ahead of the data collection.

Brief history of the concept of leadership The concept of leadership has been widely studied, and includes a variety of definitions across a

range of concepts but continues to be little understood (Martin & Learmouth, 2012; West, et al.,

2014; Von Wart M, 2003; Yukl, 2008; Dixon-Woods, et al., 2014). Historically, (pre-1900s) leadership

was often described as the ‘great man theories’ and individuals such as George Washington and

Napoleon are quoted as men who exhibited powerful leadership and influenced history (Von Wart M

2003). Later leadership theories focus on ‘trait theories’ where leaders were thought to share a list

of similar features. Since the 1900s leadership theory has evolved from the ‘great man’ theory, to a

focus on servant leadership (Von Wart M, 2003). Traits of the leader are frequently described as

either being directive and focused on directing activities, or alternatively instrumental in creating the

environment that achieves the outcomes required (Von Wart Montgomery, 2003; Yukl, 2008; Bennis

& Nanus, 1985). These outcomes include anything from improved profits, productivity, through to

better quality products or services. Since then, there has been growing support for leaders who are

seen as transformational rather than transactional in their style of leadership (Bass, 1990). The

concept of transactional leadership is based on the setting of objectives and goals together with

rewards and sanctions. Transformational leadership focuses on creating a vision to achieving change

through the commitment of the members of the organisation (Bass, 1990). However,

transformational leadership can still be viewed as ‘leader centric’ where the focus remains very

much on the leader to set the vision for an organisation, while the role of the members of the

organisation continues to be viewed as subordinate within a hierarchical structure. With

transformational leadership there is a focus on improving the quality of the leader’s relationship

with their followers and increasing commitment. There is also significant focus on the skills of a

transformational leader that can fail to recognise the role of the follower, who are seen as

subservient in their contribution to that of the effective leader (Uhl-Bien, et al., 2014). The creation

of this vision requires a shift of the leaders from an imposition of their vision on an organisation to

44

one that seeks to create this from within the organisation (Bass, 1990). Another perspective is

viewing leadership as a practice rather than a position, with the responsibility being about creating

the right conditions and supporting others across an organisation to become leaders and thus share

the role of leadership and create empowered communities of staff (Ganz, 2015).

45

Leadership as a social construct?A brief review of the history of leadership reveals a general acceptance of the concept itself, and one

where the phenomenon of leadership is felt to be real but at the same time there is some

acknowledgement about the difficulties of leadership being effectively defined, observed, and

measured. Thus, leadership can be seen as an elusive concept, which raises the question of whether

it is a social construct that has been created to help make sense of how certain problems may be

solved. A social construct is a shared idea or understanding that is widely accepted by society

(Fairhurst & Grant, 2010). This further raises the question of whether leadership could be considered

as having developed from a view held that leaders are necessary to bring order to organisations

(Gemmill & Oakley, 1992). A number of deeply held assumptions can be found within this social

construct (Gemmil & Oakley, 1992; Elder-Vass, 2012). These include an unquestioning belief that

leaders are required for the functioning of organisations, and that only a few select people have the

skills to lead organisations. Historically, this was based on wealth and privileged positions and a

construction that supports social order and hierarchy (Gemmill & Oakley, 1992). The concept of the

‘well led’ Trust has been generally accepted by the NHS. This assumption has been taken without

question and implemented as part of key policy leaders and regulators such as the CQC and NHS

Improvement as the believed solution to improve quality across the NHS. The concept of quality

represents yet a further example of a social construct, in that it is a term that has developed over

time, is commonly used, with what is perceived to be a shared understanding of what the term

actually means (Griffin & Cook, 2009). A further commonly held assumption is the aspect of

causality, in the belief that organisational outcomes are directly attributable to leadership, that

leadership can be observed, and that leaders are in control of events (Gemmill & Oakley, 1992;

Fleetwood & Ackroyd, 2004). This is illustrated within the NHS ‘well led’ concept, where the CQC

attribute improvements in quality outcomes directly to whether or not a Trust is judged to be well

led (CQC, 2015). Unravelling this range of assumptions is key to gaining a greater understanding of

how good leadership can be better understood; however, views about the concepts of social

constructs are not without their critics. The theory of social constructivism is complex, attracting a

range of views (Fairhurst & Grant, 2010). Greater exploration of social construct theory requires

deeper analysis and a critical view of the concept itself (Fairhurst & Grant, 2010). The review of the

literature explored a range of leadership concepts that could be applied in different ways, and are

viewed from a range of perspectives, and linked to a variety of outcomes. Therefore, a range of

leadership theories have been considered as being potentially relevant to gaining greater

understanding of the concept of effective leadership.

46

Influential contributions to leadership conceptsEarlier theories of leadership focused on the characteristics or traits of the ‘leader’ (Von Wart & M

2003), and this perspective can be seen in the work of McGregor (1960) with a focus on that of the

role of the leader in the directing of followers. Within these theories the characteristics and style of

leaders are seen as key to success, and employees/followers as passive recipients of this process.

Some of the influential contributions to the development of leadership theory come from the work

of McGregor (1960) on leadership theory relating to X & Y theory, who described two opposing

leadership behaviours taken by managers. These were theory X, a traditional view of direction and

control, whereas theory Y was the integration of individuals with organisational goals (McGregor,

1960). Theory X is based on views of humans as being seen as needing to be coerced, controlled, and

directed to get them to work, as opposed to Theory Y, where humans see commitment to achieve as

beneficial and work could be a source of satisfaction. Later, McGregor (1960) began to question the

X/Y theory, and suggested the two categories being seen as either/or were not the solution, and

began to develop a hybrid model between the two models that was not completed before his death.

It was also believed that other variables were important, including understanding the attitudes and

needs of followers (McGregor, 1960). Subsequently, a hybrid model known as Theory Z was later

developed by Ouchi (1981), placing greater focus on views about leadership being about creation of

the right environment. Argyris & Schon (1978) further developed this thinking, believing employees’

views about work to have progressed from one of a primary need to receive wages to relieve hunger

and provide housing to one of higher expectations of job satisfaction, value, and promotion of self-

worth. Studies of organisational leadership models (Argyris, et al., 1985) tested the assumptions that

managers held about their staff, and suggested that leaders could create a learning environment

where learning outcomes were improved. They drew a number of conclusions from in-depth studies

across three organisations, which explored concepts such as control versus learning and growth and

closed systems of operating in contrast to open ones, and concluded that the main key to success is

an organisation’s ability to adapt and change. The findings from Argyris, et al. (1985) focused on the

need to differentiate between staff commitment versus compliance, believing commitment to be

key to success in organisations. The term ‘mental models’ emerged, which was seen as key for

leadership effectiveness (Argyris, et al., 1985 & Magzan, 2012) what they experience and observe.

Argyris, et al. (1985) concluded that significant relationships were ones that had to do with achieving

organisational objectives and that authoritarian directive leaders were the most likely to inhibit

participation. The impact on staff was higher absenteeism and higher turnover and a reduction in

motivation and therefore lower productivity (Argyris, et al., 1985). The concept of mental models,

47

and a leader’s responsibility for creating an environment for organisational learning, is further

supported by Senge (1990).

The relevance of the early work of Argyris, et al. (1985) and later Senge (1990) is the focus on the

leader’s responsibility in the creation of a climate of learning, and commitment from staff, rather

than one of direction and compliance. Their theories have been influential particularly in relation to

developing a learning organisational approach to improving safety within the NHS (Berwick, 2013).

Concept of the learning organisations The concept of the development of learning organisations has attracted considerable interest since

the early 1960s as a framework to improve safety in the health-care setting (Berwick, 2013). A

learning organisation is one that identifies system factors and supports an increase in the reliability

of the processes within an organisation (Senge, 1990). The work by Argyris dates back to 1985 where

the concept of learning organisations was explored within a range of research studies (Argyris, et al.,

1985). A set of principles that make up learning organisations are described by Argyris (1992) and

further supported by the work of Senge (1990) and supported by the earlier work of Von Wart M

(2003), and Bennis and Nanus (1985). These include a leadership that is less hierarchical, engaging,

and distributed, a focus on staff at all levels being seen as stewards of the organisations, system

leadership rather than individuals with an overall focus on the creation of an environment for

success that is inclusive. These principles also include the understanding of the ‘mental models’ of

staff and recognises the difference between espoused theory and theories in action (Argyris, 1992;

Senge, 1990; Phillips, 2003). An important aspect of a learning organisation is one where the staff

show commitment rather than compliance (Phillips, 2003) and the concept of a leader’s

responsibility for the creation of the right environment for organisational success aligns with the

work of an organisation. Significance is drawn between the relationship of leaders and followers and

the importance of full understanding of the social relationship between the two to achieve

organisational success (Argyris, 1992; Senge, 1990). However, there are limited references to the

concept of the importance of a learning organisation’s relationship to effective leadership over the

last few years. Yukl (2008) makes reference to the work of Argyris (1992), and Berwick (2013)

highlights the work of Senge (1990) in relation to system learning. However, in specific relation to

health-care leadership, the literature is relatively silent on the importance of learning organisations

until the Berwick (2013) report, which reignited an interest in the concept. This is despite the

number of health-care investigations highlighting the importance of development of learning (see

Table 1) to drive the improvements needed. Despite Berwick (2013) advocating for the use of

learning organisation principles in supporting improvement in health-care leadership, there is little

reference to this in the development of the criteria for the CQC’s well led domain. There are

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references within the criteria that link to organisational learning particularly in relation to clinical

harm incidents, but little attention is given to the broader principles of learning organisations

(Argyris, 1992; Senge, 1990). In recognising this gap in the development of the CQC criteria for

defining and assessing the ‘well led’ concept further exploration of the work of Argyris (1992) and

Senge (1990) was undertaken. The aim was the development and use of a theoretical framework

based on principles of learning organisation to help guide my approach to my research question. This

is described in more detail in Chapter 4.

Concept of followership While there has been much focus on leadership research, the concept of followership had received

less attention in the literature (Uhl-Bien, et al., 2014). The concept being for the construct of

leadership to exist, there needs to be followers and therefore creation of a social relationship

between leaders and followers (Uhl-Bien, et al., 2014; Fairhurst & Uhl-Bien, 2012). This builds on the

views of Argyris, et al. (1985) and Senge (1990) whose focus is on the leader’s responsibility to create

the environment for staff to grow. Followership was also considered a key variable by McGregor

(1960) to the success of leadership. However, this focus was still very much on the leader’s

responsibility with less given to the characteristics of followers themselves. There is much emphasis

on leaders’ influence on followers and far less on how followers influence the behaviours of their

leaders (Shamir, 2007). A range of frameworks have been proposed that categorise types of

followers (Uhl-Bien, et al., 2014), with Shamir (2007) proposing the most effective followership when

leaders and followers form constructive relationships and contribute to the organisation’s

effectiveness. However, individual follower’s mental models is also an important consideration in

consideration of their relation to their views on attachment security (Hudson 2013). This is based

upon attachment theory described by Bowlby (1973) where individuals are thought to base their

own self-worth on expectations and feedback given by others. This is further supported by Gemmill

and Oakley (1992) who go further suggesting that some followers demonstrate dependence on their

leaders, a concept that links back to their life within the womb and that followers adopt a state of

learned helplessness (Seligman, 1977). This is thought to be based on an unconscious assumption

that their leader will be able to solve all problems, or a leader will emerge to do this (Gemmill &

Oakley, 1992). This, however, portrays followers to be passive and dependant, in that secure leaders

are more able to focus on their followers, but also that leaders become more secure in their

behaviour dependent on active following by their staff (Hudson, 2013). The argument given is that

the interactions of leaders and followers are determined by each other’s internal mental models in

that secure leaders who are available are attentive and engage with their staff to enable followers to

actively support the organisation’s objectives (Hudson, 2013).

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One of the complexities of the followership concept as applied to health care organisations, is that many of the leaders within hospitals also consider themselves to be followers, as the structures of leadership both externally to national health care leaders as well as across a hospital are multifaceted and complex. There is a paradox that emerges across a range of theories where closer analysis of the followership concept shows that contradictions within the model exist (Zhang et al 2015). One example is the need to consider the individual needs of a follower at the same time ensuring a consistent approach with all staff. Another example may be where one member of staff is supported to be autonomous, where as another member of staff requires greater direction and monitoring is required (Zhang et al 2015).This therefore suggests that the followership theory of leadership cannot be considered as absolute in that leadership behaviours can be often be seen to be contradictory and inconsistent. The followership theory therefore needs to be considered through a more situational lens. This may frequently change in relation to both organisational structures, staff groups and individuals which can be complex and variable, and at different times in relation to other influences which may present. Whilst the traits of both leader and the follower can be seen as important and co dependant at times to the success of an organisation, in the health care setting in particular these can be fluid, with staff holding both roles at various times and needing to adapt their styles and preferences on an continuous basis. Effective leadership in relation to successful organisationsShifting the focus away from the individual traits of leaders from directing and controlling to one of

reframing leadership to support organisational learning, requires those in leadership roles to

develop a specific set of skills that focus less on the development of self and more on supporting the

environment for leaders to emerge (Yukl, 1999; Gronn, 2003; West, et al., 2014). A large study by

Collins (2001) reviewed more than 1,000 companies and identified a small number who were

assessed as being the most successful, in that they had made the most impact and delivered high

performance over a period of time. Within these companies, Collins (2001) further identified five

common features between the five companies. The belief was that where companies followed these

five principles they would increase their chance of being very successful. It is suggested that these

principles could be equally applied to public sector organisations, stating that the key to success is

one that is most relative to the organisation’s mission, and not necessarily focused on just its

financial results (Collins, 2001). Thus, the potential to utilise similar principles to supporting success

in effective leadership for health-care organisations. However, critics of Collins’ (2001) work have

since reviewed the success of the 11 companies and challenged these assumptions (Neindorf &

50

Beck, 2008), where some were subsequently in decline (Tilson & Heins, 2010). The reasons for this

decline in performance was further studied by Collins (2009) based on research over five years of

failing companies. Collins (2009) identified five stages of decline that led organisations to failure.

These include: hubris born of success; undisciplined pursuit of more; denial of risk and peril; grasping

for salvation; and capitulation to irrelevance or death. Collins’ (2009) study while having a focus on

the characteristics of the leader (that is, a leader-centric approach), also focused on the importance

of the leader recognising their limitations and recruiting the right people around them. All successful

organisations equally had the potential for failure if the above features presented (Collins, 2001).

Key elements of effectiveness are transformational leadership style (focus on the organisation),

recognition of the importance of followership (recruiting the right people and importance of core

values), and being able to change their strategy or direction when needed (Collins, 2001). This

recognises that the inherent complexity that exists is an important component of leadership

effectiveness (Gronn, 2003).

Relationship of leadership effectiveness to cultureAlongside the need to address NHS leadership, there are also references to the concept of culture

and the need for the NHS to change the culture (Kennedy, 2001; Francis, 2013; Berwick, 2013;

Kirkup, 2015). However, without clear definition, which needs to include some method of

measurement, culture risks being simply a catch-all term that means different things to different

people (Alvesson, 1995). There are differing views on the relationship between leadership and

culture, with researchers attempting to quantify organisational culture and culture change for which

little empirical evidence exists (West, et al., 2014; Silvester, Anderson, & Patterson, 1999). There are

also views that a transformational style of leadership will impact directly on cultural change and is

the most likely to bring about improvement (Bass & Riggio, 2006).

Some organisations make a deliberate attempt to adopt what they term a strong culture by stating

expectations of behaviours by staff in terms of beliefs and values (Robbins, 1996). These are

communicated to employees and subsequently enforced by a series of methods (Legge, 1994). While

this is seen to benefit management, a risk of this approach is that it places the employee in a passive

position of being required to serve the management (Schein, 1995). Examples include a range of

recruitment and appraisal systems that aim to fit the individual to the organisation (Pascale, 1985). A

functionalist perspective would suggest that culture is within the control of management and is

therefore created and imposed on an organisation (Ogbanna & Wilkinson, 2003). Aspects of top–

down culture (Ogbanna & Wilkinson, 2003) include use of intense selection processes, conducting

51

performance appraisals against the desired culture, and evaluating the fit of individuals against the

corporate culture. The rationale is the belief that development of a strong culture will result in

greater employee commitment and improved quality and that leading and driving a strong corporate

culture will secure additional effort of employees (Bagraim, 2001; Pascale, 1985). One example of

this can be seen in 2013 when the Chief Nurse for England launched a Compassion in Practice

strategy (Department of Health, 2013 a), commonly known as the six Cs, based on an assumption

that a nurse’s lack of compassion was the root cause of these failings. The strategy led by the Chief

Nurse for England was a top–down approach underpinned by a view that this would help to address

some of the leadership and cultural problems highlighted by Francis (2013). The proposal was that

all nurses would be selected, recruited, and managed against nationally set standards about

behaviours, values, and, in particular, compassion. However, this was based on two assumptions:

first, a belief that there was a general problem with a lack of compassion in nurses and, second, that

this could be resolved by taking this approach. Neither of these assumptions appeared to have been

tested before the implementation of this top–down strategy and the strategy attracted a range of

criticisms from the nursing profession (Middleton, 2013).

This top–down strategy adopted by the Department of Health is an example of the imposition of a

top–down culture change. A policy decision was taken by the Chief Nurse for England at national

level to impose a set of national standards in relation to nursing across the NHS with the aim of

imposing a change of culture. This example used an imposed strategy to address a lack of

(perceived) compassion in the nursing workforce. The problem with imposed culture change is that

its focus is on achieving a degree of compliance as opposed to the creation of an environment to

create ownership and development of commitment from staff. The leader’s role in creating the right

conditions for change include engaging workforces to generate this commitment, which is supported

by Argyris (1998), Senge (2006) ,Von Wart M (2003), Yukl (2008) and Bennis and Nanus (1985).

However, attempts to win the hearts and minds of staff can be considered manipulative, and can

constrain individuality, particularly for those who can’t necessarily survive in an organisation with a

strong culture where the values and norms do not allow an individual to choose between sets of

values (Parry, Proctor -Thomson, 2003). The risk is that strong cultures may lead to staff feigning

belief for the organisation’s ideology as necessary to obtain organisational needs (Bagraim, 2001). A

top–down imposition of an expected change can also be viewed by staff as manipulative (Parry,

Proctor - Thomson (2003), particularly where it is not always clear what the benefits to the individual

employees are. This is particularly where the imposition of a strong top–down culture fails to both

recognise and engage the range of subcultures that exist in any organisation (Alvesson, 1995). This

52

approach also raises some potential ethical concerns as it could be seen as contriving by the top

management, and it denies the importance of individuality (Alvesson, 1995). This is supported by

Ogbanna and Wilkinson’s (2003) study of middle managers in the grocery industry. The study was

interested in measuring the impact of a culture change introduced within a supermarket chain.

Ogbanna and Wilkinson concluded that improvements could be more likely attributed to an increase

in surveillance, managerial control, and sanctions rather than a change in organisational culture.

Their findings challenged the concept that the imposition of ‘organisational culture’ was a valid

method for organisations to improve performance, and instead posited that it was simply an

indication of instrumental compliance and not a change of culture. The relevance of this study is that

its conclusions don’t reject the use of value setting, rewards, and sanctions as a way in changing the

ways that staff behave, but do reject that this results in a ‘change of culture’. While they did succeed

in getting the front-line ‘check out’ staff be nicer to the customers, they didn’t change the views the

front-line staff held of customers. Thus, the conclusion was that a behaviour and compliance model

can achieve desirable results, but this should not be attributed to a change of culture. Accepting

these points, it is, however, worth further consideration of whether the imposition of a top–down

strategy of expected values and behaviours (not labelled as imposed culture change) can result in

improved service to customers. If this is achievable then this could prove relevant to health-care

delivery as well, which leads to a further question of the extent that it is necessary to change the

internally held views and mental models of front-line staff to achieve desired results.

This leads to questions as to whether it is really possible to design and develop a strategy to improve

the culture of health-care delivery as currently being proposed post Francis (2013). While being

actively promoted, the concept of effective leadership as a vehicle to driving culture change of the

NHS fails to acknowledge the lack of evidence and understanding of how this could be achieved and

where any robust evidence to support this is either measurable or achievable is at best limited. The

concept also fails to acknowledge the relationship with culture and also the importance of

understanding the existence of subcultures within organisations and understanding how various

groups may view leadership as impacting on their contributions. However, the findings of the

Ogbanna and Wilkinson (2003) study suggests that while changing culture may not be possible,

achieving staff compliance appears to be achievable. This leads to a further question to consider of

how important the commitment of staff is in comparison to achieving compliance. Studies by Argyris

(1998) suggest that sustainable improved organisational performance requires the latter, and that

over-reliance on compliance as a tool to drive improvements is likely to fail.

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Relationship of effective leadership and the concept of subcultures Subcultures within health care include a range of professional and non-professional groups across

various department and directorates and tend to form around any stable social unit (Schein, 1993).

Examples of subcultures within hospitals include the various professional groups, support services,

different racial groups and religious groups, and gender. Understanding these subcultures and the

various interdependencies within an organisation are key to bringing them together to share a

common set of values and beliefs which takes skilled leadership (Rollenhagen, Westerlund, &

Naswell, 2013). Some professional clinical groups, for example, medical staff, may work to a different

set of values (Grant, 2012) and wish to preserve their own distinct identity, which is often

traditionally separate from the perceived ‘dark side’ of management. It is suggested that doctors

frequently believe their primary focus to be exclusively on the patient in front of them and they have

little interest in the objectives of the management (Grant, 2012). They also wish to maintain their

position in the medical hierarchy, which they see as separate to the wider organisation (Grant,

2012). Frequently, subcultures fail to be acknowledged in corporate strategies, and are therefore not

communicated with adequately. This subsequently leads to a loss of opportunity to encourage

investment and high-profile clinical leadership and to involve staff collaboratively. This is further

supported by Siriwardnena (2013), who highlights three areas in relation to the cultural divide

existing between clinicians and managers, including a culture of fear running through management,

the low levels of clinical engagement in improvement of science between clinicians and managers

bringing about change. This perceived culture of fear arises from a threat of reputational damage

through potential job loss of executives who they believe focus on targets over clinical care. Thus,

lack of engagement with medical staff, in particular those working in the front line, can lead to

managers disenfranchising or even alienating clinical leaders and can lead to a breakdown in

relationships between the two groups of staff. Examples of this can be seen as a theme within a

number of health-care investigations, for example, Kennedy (2001), Francis (2013) and Kirkup

(2015), where there was a disconnect between management and the front line, to such an extent

that the clinicians, both medical and nursing staff, had given up raising concerns as they viewed

management as only interested in achieving targets at the expense of the patients’ experience.

Exploring the concepts of leadership and culture in more depth is complex – a view supported by a

study (Maben, et al., 2012) that explored the relationship between patients’ experiences of care and

the influence of staff motivation, affect, and well-being. The research included four separate case

studies with the aim of examining what they term the ‘micro-systems’, which appeared to exist

across the various departments of a hospital and community service. The areas included maternity,

54

elderly care medicine, community matron service, and a rapid response team. The differences

between the staff group were stark, where the elderly care unit found staff reporting high demand

and poor control and viewing managers as autocratic, arrogant, and unsupportive compared to the

staff in the maternity service who perceived themselves to be high performing but seeing the Trust

top management as irrelevant. This study illustrates the importance of considering the impact of

subcultures, or ‘microsystems’ as Maben, et al. (2012) describe. Despite the study taking place

within one organisation it shows significant differences that demonstrate the complexities of

perceived effective leadership at a number of levels. The study also illustrates the staff views as

followers, and shows the difference in terms of speciality and department and the level of which

they felt they felt empowered to act, or conversely felt helpless and unable to influence other levels

of leadership in the organisation. The narrative from the participants of the study are very powerful

and give depth to this research compared to other studies where the methodology has been focused

on surveys and questionnaires. The relevance of this study to the concept of the ‘well led’ hospital is

that it illustrates the differences of how staff views leadership between various departments even

within the same organisation.

Social group identity theory The concept of social identity theory (Tajifel &Turner 1982) could also be considered in terms of staff

identifying themselves to one group within the hospital system which had some key differences to

other departments. Social identity theory is where individual’s sense of who they are is based on

sharing similar characteristics of a particular group (Tajifel &Turner 1982). The components of group

social identity theory include social categorisation, identification and social comparison. Members

of a social group share a range of common beliefs , views which can feel supportive to a group

member, but can also be seen a potentially prejudiced towards those that are not seen to be part of

the group. This can lead to a perception of in and ‘out groups’, and members of the ‘in group’ can

hold negative views towards those that are not seen as members of their group. Thus it could be

argued the concept of subcultures and social group identity are based on similar theories in they

both have the potential risk associated where negative views towards ‘out groups’ which may be

held towards other groups within the same organisation (West, 2012). Within Maben et al’s (2012)

these views were held at various levels of the organisation which included viewing ‘management’

negatively and as an ‘out group’. This suggests it to be important to consider the potential influence

social group identity theory may contribute to the well led concept of an organisation at a range of

levels.

55

Distributed leadership and leadership effectivenessThe importance of actively engaging and empowering the clinical leaders within the NHS is viewed as

an important aspect of effective leadership (Berwick, 2013). The need for leadership to be

considered in a more shared or dispersed form with less reliance on a single individual has arisen out

of dissatisfaction with a ‘leader centric’ approach based on individualism (Gronn, 2003; Yukl, 1999).

The theory of distributed leadership provides a further lens to explore the concept of effective

leadership. Distributed leadership is one where rather than the focus being on one leader, a group of

leaders work and share between them aspects of the organisation’s leadership, rather than through

the actions of just one individual (Bennett, et al., 2003). Growth in support for this concept is

supported by Bolden (2011) who views the holding of complete power and control by senior leaders

in large complex organisations as problematic. The perceived benefits of distributed leadership are

they take into account the work of all individuals who contribute to the successful performance of

an organisation rather than those who have the designation of leader in their title (Bolden, 2011). A

variety of frameworks have underpinned the concept of distributed leadership, which include Gronn

(2003), Leithwood, Harris, and Hopkins (2008), MacBeath (2005), and Spillane (2006). Terms such as

‘collaborations’, ‘alignment’, and ‘collective distribution’ are key components of the frameworks.

However, the concept is not without its critics, with views that while leadership may be distributed,

often the power is not (Martin, et al., 2015), and is therefore potentially subject to abuse by senior

management who, while aiming to encourage engagement and inclusivity, don’t relinquish their

power. This can give an illusion of distributed leadership that is signalled as staff engagement that

may not be real (Young, 2009). Engaging and empowering staff at a number of levels within an

organisation can give the illusion of distributed leadership, but can also be viewed as a shifting of

blame if expected outcomes are not achieved (Gemmill & Oakley, 1992). The need for a more critical

approach and further research to support the promotion of a distributed leadership model,

particularly linked to measurable outcomes of an organisation’s success, is also supported by

Leithwood, Harris, and Hopkins (2008) and Harris (2009).

The application of a distributed model of leadership to the health care setting appears an attractive

one. Hospital leadership structures can be complex and have a variety of levels and distribution of

leadership roles. These can be seen at executive and operational levels, as well as at function level,

e.g. leading maternity services, or leading elderly care services, as well as various professional

groups. Executive teams need to balance a central control and command model against a

distributive leadership model throughout the multifaceted layers of a complex organisation. The

56

model of a hospital leadership structure could be viewed as be both hierarchical and distributed at

the same time and the level of the distribution of leadership will be dependent on the effectiveness

of expected outcomes being delivered. Where an outcome is not delivered there is a risk of blame

be applied from the more senior leadership, and / or the distribution of leadership being reduced

and moved back to a more central control (Gemmill & Oakley, 1992). This suggests the distributed

model of leadership can be viewed a preferred model which supports greater engagement and

ownership by staff across and organisations, it also runs to risks of distributed leadership being more

fluid and at risk of being relinquished under certain circumstances. The question of who decides the

where an executive level centralised approach might need to be applied, whether this is a conscious

considered decision and how best to balance between applying a hierarchical or distributed model

situations is complex and an area which suggests the need for greater exploration.

Relationship of leadership effectiveness and delivery of quality careThe relationship between effective leadership and delivery of quality care has been explored

through a range of studies, for example, Firth-Cozens, Firth, and Booth (2003), Hindle, et al. (2008)

and Grant (2012), where again the terms of leadership and culture are used interchangeably. Some

studies explore the relationship between a focus on patient safety and the raising of concerns by

staff, including Firth-Cozens, Firth, and Booth (2003), Hindle, et al. (2008) and Grant (2012). An

exploration of the relationship between senior management team culture and hospital performance

by Davies, et al. (2007) used the ‘Competing values framework’ that articulated four basic

organisational culture types adapted from Cameron and Freeman (1991). The limitations of the

study were that the results were based on perceptions from the senior managers and there was a

reliance on a solely quantitative approach. The study did not include any in-depth follow-up of the

front-line staff’s views of the culture, nor did it discuss the potential impact of subcultures within the

organisations.

Defining and measuring culture is recognised to be complex, however, the concept of organisational

culture continues to be considered important in relation to impacting on delivery of quality care,

despite the lack of consistent definition and therefore difficulty in measurement. A study by Saleem,

et al. (2014) supports this view, where organisational culture was considered to be a determinant on

the outcome of hospital care. A literature review by Scott, et al. (2003), reviewing ten studies, sought

to answer whether organisational culture affected overall health-care performance. They felt that

some evidence existed, but proving the nature of this association was not really possible. Drawing

conclusions based on measurable impact was problematic due to difficulties with determining

57

specific measurement of the concept. The main limitations of the studies were the underlying

assumptions relating to the concept of leadership and addressing culture being seen as a solution,

often using the terms interchangeably but without a clear definition of measurement.

A more recent study (Dixon-Woods et al., 2014) examined behaviours and cultures in the NHS in

relation to quality care delivery. The study was one of a large mixed methods approach, which

included interviews, ethnographic observation, surveys, and review of team performance data plus

organisations minutes, and reports. The study’s results highlighted variability across the areas

studied in relation to high-quality care delivery. They found that the majority spoke about

commitment to the ideal, alongside values and behaviours relating to compassion and care at the

heart of their mission. The study’s main focus was on NHS senior leadership and gives a range of

recommendations for senior leaders to create positive cultures. The views of the front line were not

sought in the study (although their care delivery was observed), which risked a possible lost

opportunity to discover their perspectives and their responsibilities in relation to improving quality.

The study’s results highlighted variability across the areas studied in relation to high-quality care

delivery. They found that the majority spoke about commitment to the ideal, alongside values and

behaviours relating to compassion and care at the heart of their mission. The interviews focused on

the top team leaders, in particular executive teams and boards, and concluded the need for them to

set clear goals and enable staff front-line teams to innovate and address system problems. The study

also found areas of misalignment of goals, which led to quality and safety problems, and observed

senior staff in some areas blaming front-line staff for poor care delivery (Dixon-Woods, et al., 2014).

Their analysis of outcome data from the organisations studies showed a correlation between higher

levels of staff engagement and lower levels of patient mortality. These findings support the work of

Senge (1990) and Argyris (1995) regarding the importance of embedding learning organisational

principles, with a focus on learning as opposed to blame.

The conclusion of the study did not give sufficient challenge to the limitations of implementing a

top–down/strong culture and instead reinforced the responsibility for creating a vision and

objectives lying with the executive teams and board. This focus on the assumption of the high level

of influence that top executives have on impacting quality care outcomes fails to acknowledge the

range of variables that exist within organisations, some of which include the behaviours of the

leaders and the followers, and particularly within NHS trusts where organisations may have multiple

leaders at various levels (Yukl, 2008). However, this focus on the role of the top teams continues to

58

dominate as being key to achieving improvements to quality care delivery in organisations, as seen

in the CQC and Monitor’s definition of a ‘well led Trust’ (Care Quality Commission /Monitor, 2014). A

preference for a more transformational and inclusive type of leadership approach has become

broadly accepted by the NHS (West, et al., 2014). There is still a disconnect with a continued focus

on the leadership style and in particular the behaviours of the top team. Studies on leadership

effectiveness share a common range of characteristics, such as clear vision, shared objectives,

engagement, and inclusiveness, most of which have gained this knowledge from studies of senior

managers rather than front-line clinical staff.

Summary of chapter To help inform this research study and the best approach to be taken, a preliminary literature review

relating to effective leadership was undertaken. This included a brief overview of the history of the

concept of leadership and some of the influential contributions to leadership concepts that can be

seen as relevant to this study. The concept of leadership as a social construct was also explored,

raising questions about whether leadership itself could be observed and whether there was a need

to unravel basic or hidden assumptions (Gemmill & Oakley, 1992). This was particularly applicable to

this study in relation to an assumption of causality and the relationship between effective

leaderships’ impacts on improving quality outcomes.

Further areas explored included concepts about learning organisations’ followership and distributed

leadership, alongside studies related to effective leadership in successful organisations, the

relationship of leadership effectiveness to culture, and subcultures. The limitations of the literature

reviewed relate to the multiple concepts used in the definition of ‘effective leadership’, which range

from studies of leadership traits, styles, types, relationship to organisational culture, and relationship

of leaders to followers. Many of the leadership theories explored illustrated a range of paradoxes

within them. The various theories have within them some contradictions which suggest difficulty of

being able to ‘pin down’ one definitive theory of how exactly the ‘well led’ concept could be defined

and understood. To compound the problem further, the literature reviewed in relation to health

care and the concept of being ‘well led’ lacks particular focus on the possible impacts of effective

leadership on health-care outcomes. While the wider literature infers a relationship between

effective leadership and improved productivity, this direct relationship for health-care leadership is

less developed. Another area felt to be worthy of further exploration is where many of the studies

relating to health care have mostly focused on the views of senior leaders and the executive team

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and much less so on the views of the staff within the organisations of how they define and

understand good/effective leadership.

Gaps in the literature regarding effective NHS leadership The literature reviewed highlighted the complexities and limitations in defining and measuring the

concept of being ‘well led’. It revealed a range of theories, many of which can be seen as

components and sub-categories of the well led concept. The relevance of the early work of Argyris,

Putnam, and Smith (1985) and later Senge (1990) places the focus on the leader’s responsibility in

the creation of a climate of learning, and commitment from staff, rather than one of direction and

compliance. The complexities of the role of followers and the limitations described in defining and

measuring culture in relationship to leadership together with the possible influence of subcultures

within a hospital setting gives a further dimension to consider in relation to defining the components

of a ‘well led’ organisation.

This led me to question how the concept of being well led in relation to the NHS could be better

understood and conceptualised and whether undertaking greater exploration through the views of

staff in different managerial roles and levels could give a different perspective to help understand

the relationship between leadership and quality care delivery. Studies to date have been

predominantly quantitative in approach and have relied on self-completed questionnaires or surveys

by members of executive teams, the limitations of which have been previously described.

There was a significant gap in the literature relating to how these problems could be best addressed.

The various investigations into health-care failings (Kennedy, 2001; Francis, 2013; Kirkup, 2015)

highlighted the need to specifically address leadership and culture within the NHS to prevent further

failings occurring on the scale that triggered the commissioning of the investigations. This led to a

commonly accepted assumption that the ‘well led’ Trust as defined by the CQC can be assessed

against a range of criteria, and where an assessment of good for ‘well led’ is given the outcomes

from quality care delivery will be improved. Despite a lack of evidence to support improvements in

leadership effectiveness, an industry of potential NHS leadership solutions has emerged that include,

for example, the establishment of the NHS leadership academy, the development of leadership

materials, and the dissemination of NHS leadership competencies. Many of these were based on an

assumption that if the issue of poor leadership and culture was not addressed, then NHS Acute

Trusts would continue to fail to meet the quality standards expected and further failings such as

those reported about safety issues in hospitals will continue to be seen. While few would disagree

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with the need to prevent further failings, there is limited evidence to suggest how this could be

achieved.

ConclusionAccepting the significant gaps in the literature, and the limitations of some of the current existing

literature, there is some evidence that emerged from the preliminary literature review that

developing a learning organisational approach may improve the quality and safety of health-care

organisations. This is explored further in Chapter 4 where some of the theoretical concepts that

underpin learning organisations are explored with the aim of taking this concept further to develop a

theoretical framework to help guide the study and answer the research question being posed.

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Chapter 4: Selecting a theoretical framework to underpin this research study

Introduction

This study was interested in gaining greater understanding of the concept of being ‘well led’ within

an NHS Hospital and considering whether by gaining greater insight through the lens of some of the

staff in leadership roles working within a Trust, organisations could be helped to improve their

leadership capability.

The research question was: how is the concept of the ‘well led’ hospital Trust defined and

understood by staff across a range of organisational managerial levels?

The gaps in the literature review were highlighted in the previous chapter and the proposal to

construct a theoretical framework to guide the study is described below.

Limitations of literature reviewed

The literature reviewed highlighted a range of complexities and limitations in defining and

measuring effective leadership. It revealed a range of theories, many of which could be seen as

components and sub-categories of the concept of effective leadership. The relevance of the early

work of Argyris, et al. (1985) and later Senge (1990) and more latterly Berwick (2013) and Doyle,

Kelliher, and Harrington (2016) places the focus on the leader’s responsibility in the creation of a

climate of learning, and commitment from staff, rather than one of direction and compliance. This

led to the question of how the concept of ‘well led’ in relation to the NHS could be better

understood and conceptualised, and also whether undertaking greater exploration through the

views of staff in different managerial roles and levels could give a different perspective to help

understand the relationship between leadership and quality care delivery. Studies to date, for

example, Davies, et al. (2007) and Saleem, et al. (2014) have been predominantly quantitative in

approach and have relied on self-completed questionnaires or surveys by members of executive

teams, which have the advantage of targeting greater numbers of respondents but do not include in-

depth follow up of the front-line staff’s views. In comparison, Argyris’s (1992) approach to

developing a theory of learning organisations was based upon case study organisational research

approaches that included directly observing what is termed as ‘leadership in action’, which was

refined and developed, underpinning theory over a period of time. This approach enabled greater

exploration of the emerging components of learning organisational theory within a range of

organisations utilising a case study approach.

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Selecting a theoretical framework to underpin this research study From a review of a range of literature relating to leadership concepts and theories, a theoretical

framework emerged bringing together a range of the above concepts and its potential to inform the

research aims of the study. The purpose of applying a theoretical framework was to aid analysis,

explain meaning, challenge assumptions, avoid generalisations, and help generate further theory

(Laberee, 2009). A blending of learning organisational theory from Argyris (1992) and Senge (1990)

was selected as a theoretical framework of the learning organisation to underpin this study. The

rationale for this selection will be described, and the limitations of this approach highlighted.

A shared understanding of what defines a learning organisation A learning organisation is described as one where a group of people continually enhance their

capacity to create what they want to create, facilitates learning of all of its members, and seeks to

continually transform to keep the organisation in a healthy state (Argyris, Putnam, and Smith, 1985;

Senge, 1990). Learning organisations are those with the ability to anticipate, respond to change, and

manage complexity and uncertainty (Malhotra, 1996). Learning organisations view all staff as

learners, and the concept of system-wide thinking is critical to help staff understand the context in

which they work (Senge, 1990). The leader’s role is viewed as one of instilling an organisational

sense of commitment by the agreement of shared visions and purpose and also advocates

empowerment, system thinking, and commitment to the wider system. The importance of the

concept of learning organisations has become increasingly relevant in view of increasing complexity

(Senge, 1990), hence the relevance of the theory to the NHS. There is a need to be responsive and to

transform in order to respond to some of the issues felt to underpin the issues raised by Kennedy

(2001), Francis (2013), and Kirkup (2015) in relation to making significant improvement in NHS

leadership.

Rationale for selection of learning organisational theory to underpin study The concept of the learning organisation is well described within leadership theories from the 1960s

but less evident within the literature from after the 1990s (Argyris, et al., 1985; Gronn, 2003; Yukl,

1999). The reason for this is not clear, but it coincided with a whole range of leadership theories

being described (Ancona, et al., 2007; Gronn, 2003; Yukl, 1999) which contain within them many of

the principles from Argyris‘s et al. (1995) work. These include the need for leadership to be

considered in a more shared or dispersed form with less reliance on a single individual – something

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that has arisen out of dissatisfaction with a ‘leader centric’ approach based on individualism (Gronn,

2003; Yukl, 1999). The importance of engagement of staff on empowering the clinical leaders within

the NHS is viewed as an important aspect of effective leadership (Berwick, 2013). The publication of

the Francis report (2013) and the subsequent commissioning of the Berwick report (2013) has

attracted considerable interest in the concept of a framework to drive improvements for safety in

the health-care setting. Berwick (2013) credits the significant influence of Senge (1990) to driving the

concept of system learning within learning organisational theory as a key component to improving

safety within the health-care system (Berwick, 2013). Berwick first established the Institute of Health

Improvement in 1991, following work aimed at redesigning health care into a system without errors,

waste, delay, and unsustainable costs. The first decade focused on the reduction of errors in

microsystems, such as the emergency department or the intensive care unit, with the aim for

subsequent spread of best practices (IHI, 2016). The Secretary of State for Health in 2013 (Jeremy

Hunt) resurrected significant interest in the concept of learning organisations after the events of the

Mid Staffordshire NHS report (Francis, 2013) and following a trip to the USA and gaining greater

understanding of the aims of the IHI, commissioned Berwick (2013) to give advice to the government

in the UK on how to make the NHS safer. Following an engagement exercise with a range of leaders

in health care and some front-line staff, a report was provided to the Department of Health with a

number of recommendations. One of the report’s key recommendations was ‘The NHS should

become a learning organisation; its leaders should create and support the capacity for learning at

scale within the NHS‘(Berwick, 2013, p. 4).Berwick (2013) having reviewed the various responses

which followed the publication for the Francis (2013) report was advising the government to focus

on the creation of an environment that was more engaging with front line staff and supportive of

the wider health care system to learn. This was in contrast to the government’s previous response to

the Francis (2013) report which had introduced a range of compliance initiatives which included

increasing the inspection regime of the CQC. This was followed by a speech by the Secretary of

State for Health stating his vision for the NHS to become the world’s largest learning organisation

(Hunt, 2016). The table below shows a timeline illustrating the various publications referring to

learning organisational principles.

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Table 5: Showing a range of publications relating to learning organisation principles from dates 1978 to 2017 inclusive.

1978 Argyris, C and Schon, D. (1978) published Organizational Learning: A Theory of Action Perspective.

1985 Argyris, C., Putnam, R. and Smith, D. (1985) published Action Science.

1990 Senge (1990) published his theory regarding driving the concept of system learning within learning organisational theory as a key component to improving safety within the health-care system.

1991 Berwick (1991) established the Institute of Health Improvement (IHI) with the aim of redesigning health care into a system without errors

1992 Argyris, C. (1992) published a book entitled On Organizational Learning.

2013 Berwick, D. (2013) produces a report responding to the Francis (2013) report: A Promise to Learn, A Commitment to Act.

2016 Hunt, J. (2016) Commitment for NHS to become largest learning organisation in the world.

This aspiration can be seen as a common thread across a range of NHS policy documents and NHS

arm’s length bodies (Berwick, 2013). However, the relationship link between the concept of ‘well

led’ and the ambition for all NHS Trusts to become learning organisations is not specifically

articulated, which is suggestive of a potential significant policy gap. It is not clear why the CQC do

not reference the concept of ‘learning organisations’ within criteria for their well led concept (CQC,

2015), particularly given the commitment from the minister for the NHS to become the largest

learning organisation in the world. There have been a range of policy development directions to the

CQC to measure for this within the inspection regime and in particular the concept of measurement

of the well led domain. More latterly, the CQC have added an increased focus on the concept of ‘well

led’ to their inspection regime, and have worked with NHS Improvement on agreeing joint criteria on

the components of ‘well led’, which will guide their key lines of inquiry when undertaking

inspections (CQC, 2017 b). However, specific linkage with the key components that contribute to the

concept of a learning organisation is not included, which leaves a potential gap in understanding

how this ambition could be best aligned, achieved, and subsequently measured.

Why this should be the case poses a number of possible explanations, which could range from a

simple lack of understanding by both the policy leads and the CQC in defining and exploring the

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relevance of the concept of learning organisations. Alternatively, it may relate to the specific

regulatory role that the CQC hold (CQC, 2015), where their focus is explicitly one of inspection,

assurance, and compliance with quality standards. In addition, Berwick (2013) warns against using

regulation alone to solve the problems highlighted by Mid Staffordshire in responding to the Francis

(2013) report. The CQC’s focus on compliance does not fit well with the learning organisation’s

concept where the key focus is on commitment in preference to compliance. However, the CQC

have been given a key role in assessing whether or not an organisation is well led. This apparent lack

of congruence has the potential to further call in to question the validity of the assessment of the

‘well led’ concept, and the need for greater exploration of its relationship to effective leadership

within NHS organisations.

The concept of learning organisational theory is not without its critics, which relates mainly to the

terminology of learning itself, which can be seen as abstract (Doyle, Kelliher, & Harrington, 2016;

Eldor & Itzhak, 2016). Various definitions include individual learning, team learning, organisational

learning, and learning climate, all of which can be seen to link together, but not necessarily (Doyle,

Kelliher, & Harrington, 2016) and (Eldor & Itzhak, 2016). The IHI (2016) references to learning

focuses primarily on the work of Senge (1990) in relation to system learning and error management

and less on the wider organisational learning as described by Argyris (1992). One key limitation of

utilising learning organisational theory as a theoretical framework for this study is ambiguity in

relation to the term ‘learning’. The above reports use the term ‘learning’ in relation to improving

safety in hospitals and this research is interested in exploring this concept from a wider perspective.

A further limitation relates to both the definition and subsequent measurement of impact which

have been constant factors across much of the leadership literature (Doyle, Kelliher, & Harrington,

2016). The term of learning suggests one of a continuum that further compounds the ability to

measure, as a limitation of study impact would relate to a moment of time. There remains a general

lack of clarity and understanding in relation to any agreed definition, underpinning principles, and

measurement of what constitutes a learning organisation (Doyle, Kelliher, & Harrington, 2016). This

lack of clarity is similar to that seen with the term of ‘culture’ where agreed definition and

subsequent measurement which presents some difficulties. A further limitation relates to the use of

this learning theory as described by Argyris (1992) being viewed as significantly dated and could

represent a challenge in relation in its application several decades later.

While recognising the limitations given, the attraction of utilising learning organisational theory for

this study is that it includes within its components other models of leadership theory, such as

distributed leadership and staff engagement (Ancona, et al., 2007). This gives the opportunity within

the research study to capture aspects of these that may emerge as dominant themes in their own

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right as the analysis of data progresses. This would also have the potential to aid greater

understanding of both the concept of being ‘well led’ and to develop a framework that incorporates

a range of components to help NHs Trusts to self-assess against and support improvement.

The learning organisation potentially offers a theoretical space to explore with staff their

understanding of a ‘well led organisation’ and may include a range of the components contained, for

example, commitment versus compliance, shared vision, and system learning within the learning

organisational theory. Conversely, staff studied within the organisation having been assessed by the

CQC as well led, may not include components contained within this theory. Exploration of the theory

has the potential to highlight the lack of congruity between the ambition ‘policy aspirations’ of

government for the NHS to become the largest ‘learning organisation in the world’, if it is not seen to

be reflected in the staff of Trust understanding what is constituted as ‘well led’. This study would

give the opportunity to highlight where there may be differences in understanding the concept of

being well led, and would contribute to the development of theory to support the aim of improving

leadership and in terms of improved quality of care. The theory of a learning organisation offers a

conceptual framework that includes a range of underpinning principles and beliefs to begin to

explore leadership in a more systematic way. These principles and components of learning

organisational theory are explored in more depth below.

Exploring some of the components underpinning learning organisational theoryThe term of learning as described by Argyris (1992) relates to the ability of organisations to

continually learn, adapt and successfully transform and grow. The term also applies to individuals

employed within organisations.

The principles of a learning organisation include leadership that is less hierarchical, that is engaging

and distributed, and a focus on staff at all levels being seen as stewards of the organisations (Senge,

1990). Hence, system leadership rather than individuals are important with an overall focus on the

creation of an environment for success that is inclusive. These principles also include understanding

the ‘mental models’ (see below) of their staff and recognises the difference between espoused

theory and theories in action. This is where leaders state their theories and assumptions about their

organisation, something that is known as ‘espoused theory’, that is, what the leader’s state, as

opposed to theory in action, that is, how they actually act (Argyris, 1992; Senge, 1990; Phillips,

2003). Later contributions to the components of the learning organisations come from Marsick and

Watkins (2003), Bass and Riggio (2006), Rowe (2010), and Eldor & Itzhak (2016). All are very similar

where they focus on themes that include staff engagement, commitment, and system-wide learning

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as key components of a learning organisation that they believe essential to their success. The early

work of Argyris, Putnam, and Smith (1985) and later Senge (1990) focus particularly on the leader’s

responsibility in creation of a climate of learning, and commitment from staff, rather than one of

direction and compliance. The leader’s role is viewed as one of instilling an organisational sense of

commitment by the agreement of shared visions and purpose and also advocates empowerment,

shared vision, system thinking, and commitment to the wider larger system (Senge, 1990). These

components are explored in more detail below.

Components of learning organisationsThe alignment of staff to the creation of a shared vision is a key component of learning

organisational theory. This is where the vision for the organisation’s core purpose and strategic

positioning is created from staff’s individual visions, with the aim of the vision being owned and

developed and not imposed upon the organisation. This shared vision is developed and contributed

to by all staff and commitment of individuals to the vision is critical to its success (Senge, 1990).

However, the theory of shared vision makes an assumption that conflict between competing views

can be resolved through the development and sharing of common interests (Brown, 1996), and also

there is room for disagreement and ways of resolving competing priorities.

Compliance versus commitment A further component of the learning organisations is a focus on the need to differentiate between

staff commitment versus compliance (that is, staff are motivated to deliver for an organisation

because they want to rather than because they have been told to), believing commitment to be key

to success in organisations (Argyris, 1998; Argyris, Putnam, & Smith, 1985; Phillips, 2003). This

concept is discussed in more detail below. Argyris (1992) and Senge (1990) also describe a process

that an organisation needs to undergo to move from traditional ways of working (see Table 5 below

for described features of traditional versus learning), to one of a learning organisation. Key to this is

the movement from a traditional organisation that exerts control from the central team, and expects

compliance from staff (Dixon Woods 2014). The vision is imposed on the organisation and the staff

are expected to implement it. In comparison, Argyris (1992) and Senge (1990) believe that where

staff engagement and development of shared vision and values are core to the way an organisation

is led, this will generate commitment from staff. The theory is that committed staff will engage with

the organisation as they feel part of its growth and success as opposed to being controlled and

expectations of compliance (Senge, 1990).

Argyris’s (1998) theory is based on the premise that the less power people have to shape their lives,

the less commitment there will be. In applying this to the work setting, compliance is defined as

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external commitment, where staff have very little control of their work and objectives, as opposed to

internal commitment where staff are encouraged to develop their own goals and values. How

achievable this really is in practice is questionable, and Argyris (1998) does concede that most

organisations will need to have a blend of both external and internal commitment approaches.

Table 6 shows the combined views of Argyris (1998) and Senge (1990) of the differences between

traditional and learning organisations in relation to their focus on commitment and compliance.

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Table 6: Example of compliance versus commitment (Argyris, 1998)/Control versus open learning systems continuum (Senge, 1990)

Traditional organisations Learning organisations

Vision imposed on organisation Shared vision and values

Managing and organising Staff engagement

Control and compliance Staff commitment

Mental models and creating the environment for learning and commitmentThe concept of mental models is an important component of learning organisation identified by both

Senge (1990) and Argyris (1992). These represent the assumptions and accepted norms that

influence the way staff interact and views from their own experiences and observations. These

assumptions can be deeply engrained and not easily recognised and understood and therefore

acknowledged within leadership team. Acknowledgement of these are seen as key for creating

change and enhancing leadership effectiveness (Argyris, Putnam, & Smith, 1985; Magzan, 2012;

Hudson, 2013). The concept of mental models, and a leader’s responsibility for creating an

environment for organisational learning, is further supported by Senge (1990).

Double-loop learning The ability to lead organisations effectively depends on leaders’ capability and capacity undergoing

double-loop learning (Argyris, 2004; Witherspoon, 2014). The theory is that critical to success is an

organisation’s ability to adapt and change (Argyris, 1992). ‘Double-loop learning’ is defined as a

process where an organisation is not only responsive to correct their problems and learn (known as

single-loop learning), but go one step further in having the ability to reframe the purpose of the

organisation and adapt and change (Argyris & Schon 1978). This requires a more sophisticated form

of leadership, where leaders focus on the root cause of their problems and are prepared to modify

the whole organisation’s underlying strategy, objectives, and policies (Argyris & Schon 1978).

Theories in action and espoused theoryBased on considerable research undertaken in the 1970s, Argyris & Schon 1978) assert that leaders

use two theories, these are espoused theory and theories in action. Espoused theory is described as

the words leaders use to convey what they do and what they would like others to do (Argyris &

Schon, 1978). They identified multiple examples of what they termed as ‘espoused theory’, as

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opposed to ‘theory in action’, which compares what leaders said they believed, how they made

decisions, their behaviours, and how they run their organisations, as opposed to how they were

observed to work in practice.

Systems thinkingAnother component of leaning organisation theory is the concept of system thinking. The view is

that leader’s need to view their organisations as a whole with systems throughout which are

interlinked and have connected processes. (Butcher, 2011). This requires leaders to improve

organisational reliability and outcomes by designing a system to prevent failure, making failures

obvious before they occur by undertaking proactive risk assessments, and designing the procedures

and building capabilities for mitigating harm caused by the failures when they are not detected or

intercepted (Senge, 1990). System thinking has been the key driver to increasing greater

understanding in improving clinical safety in health, and underpins the work of Reason (1997) whose

seminal work underpins the work of IHI (2016) in error management.

Blending the theories to design the methodology tool For the purpose of this study the theories of learning organisations from Argyris (1992) and Senge

(1990) were blended together to develop a theoretical framework to underpin this study. Combining

the components from both creates an opportunity to underpin the study with a framework and

inform the methodological approach and gives structure to support analysis of the data collected.

Blending of theories can give greater opportunities for insight and potential for generating new

theory. Conceptual blending refers to the combination of more than one theory, with the aim of

providing an alternative perspective, enabling the researcher to explore an issue through an

additional lens (Cranfield, et al., 2015). For example, while the theories of both Argyris (1992) and

Senge (1990) are similar, there are some differences. Senge (1990) places greater emphasis on

system thinking and learning and development of staff, whereas Argyris (1992) focuses more on

espoused and theories in action and the concept of double-loop learning. Both state the importance

of organisations moving from a leadership position of compliance to commitment. Conceptual

blending enables the researcher to focus on the issue, by including both theories, observing

similarities and differences, as well as which components emerge more prominently and give the

opportunity to create new theories (Cranfield, et al., 2015).

Selecting a smaller number of key components from both for this study was tempting, and could

have the potential to give greater depth and exploration of these concepts, however, the limitation

of this would be attempting to apply theory ahead of the data collection and it could potentially

introduce some bias into the study. Caution is needed in approaching the study in being too

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immersed in the literature and risks analysis of the data restricted to fitting the theoretical

framework (Gioia, Corley, & Hamilton, 2013). The need to be open to emerging theory that may not

fit the given components is important, hence a decision was taken to include a blending of the two

theories with the aim of the potential to limit bias and enable new theoretical concepts to emerge

(Gioia, Corley, & Hamilton, 2013).

Table 7: Combining the common key components of learning organisations (Argyris, 1992; Senge, 1990)

1. Building shared vision/Aligning vision and values (Argyris, 1992)

2. Leader installs organisational sense of commitment (Argyris, 1992)

3. Commitment to wider larger system (Argyris, 1992; Senge, 1990)

4. Staff commitment versus compliance (Argyris, 1992)

5. Less hierarchical/Distributed leadership (Senge, 1990; Ancona, et al., 2007)

6. Engages with staff/Empowerment of staff (Argyris, 1992)

7. Identifies system factors and supports reliability of processes/Designs systems to

prevent failures (Senge, 1990; Reason, 1997)

8. Builds capacity/Individual skills (Argyris, 1992; Senge, 1990)

9. Promoting a culture of learning and development (Senge, 1990)

10. Double-loop learning /Reframing Argyris (1992)

The review of the literature demonstrates the complexities that exist within definition and

measurement for both leadership and culture theory, and goes some way in an attempt to validate

an approach utilising a theoretical framework approach.

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Reflexivity (Box 5) in relation to my personal views and beliefs regarding utilising the theoretical framework Reflexivity Box 5 illustrates my views and beliefs regarding the

selection of a theoretical framework and the reflections I had

during the process. I was concerned that the use of the

framework could impact on my epistemological approach, and

risk the introduction of potential bias ahead of the data

collection. While concerned about this, I felt I needed to take the

risk but challenged myself continually throughout the process

regarding the rationale for using this as a framework, and staying

alert to where the risk of bias could occur.

I continually highlighted areas of potential bias using the Tvesky

and Kahnmean (1974) framework. I reflected on these potential

types of bias and challenged myself to take a more critical

approach, identifying and illustrating my views and assumptions

to ensure they are visible to the reader throughout the research

process within the reflexivity boxes.

Conclusion In conclusion a learning organisational theoretical framework

was developed that blended together theories from Argyris

(1992) and Senge (1990) and was elected to underpin this study. The relevance and usefulness of the

framework is discussed in Chapter 6

The next chapter describes the methodological approach adopted to undertake this study.

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Reflexivity Box 5My reflections and assumptions influencing approach to use of theoretical framework:

I was concerned about using a theoretical framework not compatible with the grounded theory approach.

I needed to balance risk against using a framework to help guide study.

Risk of shifting epistemological approach from an interpretive process to a more positivist approach.

Needed to recognise where I was at risk of introducing bias to study by using a theoretical framework.

Important to acknowledge this and take steps to mitigate risk through the methodological process.

Ensuring my views are visible throughout the study via reflexivity boxes.

Chapter 5: Research methodology chapter IntroductionThis study was undertaken to answer the research question:

How is the concept of the ‘well led’ hospital Trust defined and understood by staff across a range of

organisational managerial levels?

The aim was to gain greater understanding of the concept of being ‘well led’ within an NHS hospital

and to give consideration as to whether by gaining greater insight through the lens of some of the

staff in leadership roles in various levels working within a Trust organisations could be helped to

improve their leadership capability.

The rationale for the selection of an interpretive grounded theory methodological approach research

process for this study will be described. The research process will be outlined, which includes the

approach taken towards sampling, data collection, and the coding and analysis process followed.

Gaps identified in the literature reviewed regarding effective NHS leadership The literature reviewed highlighted a range of complexities and limitations in defining and

measuring the concept of ‘being well led’. It revealed a range of theories, many of which could be

seen as components and sub-categories of the concept of being ‘well led’. This led to the question of

how the ‘well led’ concept in relation to the NHS could be better understood and conceptualised,

and also whether undertaking greater exploration through the views of staff in different managerial

roles and levels could give a different perspective to help understand the relationship between

leadership and quality care delivery. Studies to date, for example, Davies, et al. (2007) and Saleem,

et al. (2014), have been predominantly quantitative in approach and have relied on self-completed

questionnaires or surveys by members of executive teams, which have the advantage of targeting

greater numbers of respondents but have not included in-depth follow-up of the front-line staff’s

views. In comparison, Argyris’s (1992) approach to developing a theory of learning organisations was

based upon case study organisational research approaches that included directly observing what is

termed as ‘leadership in action’, which was refined and developed underpinning theory over a

period of time. This approach enabled greater exploration of the emerging components of learning

organisational theory within a range of organisations utilising a case study approach.

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There was a significant gap in the literature relating to how the issues of poor NHS leadership raised

by Francis (2013) can be urgently addressed to prevent further hospital failings occurring. This had

led to a commonly accepted (and mostly unchallenged) assumption that the ‘well led’ Trust as

defined by the CQC and Monitor (2013) could be assessed against a range of criteria, and where an

assessment of ‘well led’ was given this would deliver improvement in quality care delivery. Despite a

lack of evidence to support recommendations for improvements in leadership a conclusion has been

reached that if the issue of poor leadership and culture is not addressed, further ‘failings’ such as

those reported about the Mid Staffordshire Hospital would continue to be seen. While few would

disagree with the need to prevent further failings, there was limited evidence to suggest how this

could be best achieved.

Rationale for undertaking study The aim of this study was to gain greater knowledge of what ‘well led’ meant to staff and how they

believed this translated to quality care delivery. The rationale was that by undertaking an in-depth

study of a hospital rated by the CQC as ‘good’ it may be possible to discover the views of staff about

how they experience leadership, and make recommendations from how best practice could be

captured and shared more widely with the NHS.

Research questionThe research question for this study was to explore how the concept of the ‘well led’ hospital Trust is

defined and understood by staff across a range of organisational managerial levels.

Further sub-questions within this included: What does the concept of ‘well led’ mean to

staff?

What do staff understand by the concept of being ‘well led’ within their NHS Trust?

How does the concept of ‘well led’ translate across their organisation?

What were staff views on the impact their hospital’s leadership has on the quality of care

delivered to patients?

Key objectives of the research The key objectives for the study were to:

Explore through semi-structured interviews across three levels of NHS staff (executive, middle

management, and front-line clinical staff) within a single acute Trust (assessed as well led), what

these groups understood by the concept of the ‘well led’ Trust.

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Explore how these staff defined and experienced the concept of ‘well led’ within their

working environment.

Explore staff’s views on how their experience of leadership moderated organisational/care

quality outcomes – from the perspectives of the staff interviewed.

Contribute new knowledge and gain greater understanding of the concept of ‘well led’ in

terms of how it is defined and measured and relates to the delivery of quality care to

patients.

Methodological consideration and approach At the heart of the objectives of the project was the aim to provide an in-depth understanding of

perspectives of the well led concept. Many studies had taken a quantitative approach that gave

some helpful perspectives through which to view the concept. However, I found the work by

researchers such as Argyris (1992) and later work by Dixon-Woods, et al. (2014) (who had taken a

more ethnographic/case study approach), provided a helpful approach to gain greater

understanding of the concept of effective leadership through the lens of staff. It felt important to

look beyond the tip of the iceberg (James, 2015) and explore what may lie beneath to help gain

greater insights into better understanding the concept of effective leadership. The iceberg analogy

(James, 2015) provided a helpful framework to consider the best methodological approach to

examine this problem. The framework includes the following components:

Paradigm/Worldview, for example, the position from which the policy speaks

Ontology and epistemology

Methodology

Methods

The ‘ice berg' framework (outlined below) was utilised to help determine the best approach to

conduct the study. I was particularly interested in what this framework offered to the study in terms

of exploring the concept of being ‘well led’ in greater depth, as well as how this research could be

best focused.

Paradigm/Worldview The NHS policy direction is an example of what could be considered a shared ‘worldview’/‘accepted

view’ (or more specifically the view from Department of Health policy) via their policy documents

(CQC, 2015). At a simplest interpretation of this is that effective leadership within the NHS needs to

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improve and the use of the CQC definition of well led underpinned by the work of West (cited CQC

2015). This was given as providing the definition, and assessment against this given criteria as a

proposed solution. As highlighted within the literature review there were a number of studies

reviewed, many of which had taken a quantitative approach that included large-scale samples using

methods such as surveys/questionnaires. There were less examples of researchers having combined

this with taking a more in-depth approach at the individual level to seek to understand what it felt

like for employees from their own lived experience of what they saw and observed and examining

how these experiences impacted on the way they examine their own leadership effectiveness. This

study did not specifically seek to challenge the NHS policy but instead sought to gain greater insight

from some staff within one hospital of their lived experience of what ‘well led’ felt like for them.

Ontology and epistemological approachThe ontological approach was one of deeper exploration and interpretation of this concept through

the lens of the staff’s views, experiences, and understanding within the organisation in which they

worked. This led me to consider which epistemological approach would be preferable to select

where the data collected could be viewed through a different lens and new knowledge could be

gained to contribute to a greater understanding of the concept of being well led. I wanted to

understand what was knowable, and also worth knowing (James, 2015) from the staff’s perspective

and gain greater insights into the staff’s lived experience.

The complexities of achieving this level of understanding presented a considerable challenge in

selecting the best approach to undertake this study. One approach considered was that of a

positivist quantitative design, the potential benefits being that by designing a carefully constructed

and measurable hypothesis for the study, the concept of well led could be tested across a range of

NHS Trusts. The strength of this approach could be in terms of being more systematic, the scale, the

size of respondents, and the generalisability of findings. However, this approach could potentially

miss more in terms of gaining some deeper insights from key individuals, and also the opportunity to

gain narrative from those whose views could reveal more detail in relation to their understanding,

experience, and interpretation of the concept of being well led. More importantly, consideration

needed to be given to whether this approach would sufficiently address the gaps found in the

literature review. Therefore, consideration of a qualitative approach gave the opportunity to enable

a greater in-depth exploration and understanding of how staff viewed and experienced the ‘well led’

concept.

This study’s focus was on gaining greater understanding of the staff’s views, rather than testing a

hypothesis and therefore the qualitative approach offered a greater chance of viewing the research

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questions through the lens of the staff who experience leadership within their organisation. The

approach enabled deeper level study and the ability to draw interpretation and meaning from data

collected. However, some critics of this approach could challenge the potential lack of objectivity of

the researcher and the relationship of the research to the data leading to the belief that results

could be biased and therefore not valid (Gray, 2014). In addition, qualitative data collection could

lead to a vast amount of data, which required detailed content analysis, as well as being very time

consuming, and the approach used to group data could also be subject to bias from the researcher.

Recognising these possible limitations, I took care to consider the best way to mitigate potential

risks. I felt the benefits of being an ‘informed insider’ (Charmaz, 2014) in terms of this being visible

within the data analysis balanced well against the possibility of the findings being viewed as biased.

In relation to managing the data I utilised a Microsoft software macros package (Peach, 2014) to help

organise and manage the data and help with content analysis to help avoid becoming overwhelmed

with the amount of data collected.

Reflexivity (Box 6) regarding my views and assumptions influencing the methodological approach to study.Reflexivity Box 6 illustrates my views and assumptions that influenced

my planned methodological approach. I have more than 30 years of

NHS experience both from clinical and managerial perspectives so the

complete suspension of preconceived views was not possible, nor

necessarily desirable in terms of the benefits I could bring as an ‘insider

researcher’ to the study in terms of making sense of some of the data

(Gioia, Corley, & Hamilton, 2013). It was, however, important that my

own contribution in terms of interpretation of the data was visible

throughout the research process. This gave the opportunity to

strengthen the research design rather than deny its existence. Within

this it was important to consider other aspects of my social

background, education, ethnicity, clinical background, ethical views,

political views, and religious views, all of which could be relevant to

the contribution of conscious and unconscious bias (Lyons & Coyle,

2007). Recognising these potential biases up front was essential to

expose and deal with them openly rather than pretend they did not

exist (Lyons & Coyle, 2007). I worked within the NHS system (in a

national role) and therefore it was important to be aware of the existence of my own assumptions,

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Reflexivity Box 6 My reflections and assumptions influencing methodology approach to study:

It was important to give voice to staff’s views and experiences.

Important to acknowledge it’s not possible to suspend preconceived views.

Reflexivity Box 1 previously highlighted my preconceived views as an inside researcher.

Belief I can add value to the study utilising my knowledge and experience.

Recognising the risks of introducing confirmation bias and the need to be open to alternative views.

prejudices, and perspectives held and to surface these into my own consciousness (Hibbert, et al.

2014). This was not just applicable to the collection and interpretation of data but included the

selection of the research topic, the focus of the literature review, as well as development of the

research questions. In recognising that I was not able to completely suspend belief systems for the

purpose of the research but instead was required to unpack and scrutinise the ways my position may

have affected the research process. Reflexivity is seen as the key to both reveal and challenge pre-

existing assumptions about the subject matter being studied (Alvesson & Sandberg, 2014). In

addition, utilising a model of analysis such as that proposed by Gioia, et al. (2013) used alongside

Charmaz (2006) provided a potential mitigation to this dilemma and offered a methodological

approach that fitted well with the research aims of this study. Gioia, et al.’s (2013) together with

Charmaz’s (2006) grounded theory approach was felt to be flexible and allowed for consideration of

the presence of the researcher in the process and also a degree of interpretation of the data, with

the potential for the generation of new theory. I felt this combined approach best supported my

plan for undertaking the analysis process and was attracted by their support for value of the ‘inside

researcher’ in terms of this being beneficial in terms of adding value to the study, so long as this was

clearly visible throughout the process (Gioia, et al., 2013; Charmaz, 2014).

The methodological approach needed therefore to acknowledge and address the gap of knowledge,

be open about the experience of the researcher, and effectively address the key aims of the study.

Considerations for the most suitable methodological approach The overall aim of this study was to answer the research question:

How is the concept of the ‘well led’ hospital Trust defined and understood by staff across a range of

organisational managerial levels?

The research methodology would be to undertake an in-depth case study within a Trust currently

rated as ‘good’ or ‘outstanding’ in terms of the ‘well led’ assessment undertaken by the CQC, to gain

deeper understanding of how the well led concept was understood by a range of staff within the

organisation, and also how this impacted on the quality of care delivered. It was hoped that gaining

greater understanding would give the opportunity to contribute to further development and

understanding of the concept of the ‘well led’ Trust.

The choices within the qualitative paradigm most relevant to this study included selecting from a

grounded theory approach, a more phenomenological study approach, or using an ethnographic

methodological approach.

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Grounded theory The use of a grounded theory approach for this was considered, however, some (Strauss & Corbin,

1990) suggest starting the study without prior assumptions or hypothesis. Instead it is recommended

to use the interplay between analysis and data collection to produce theory, build complexity by

breaking down constructs into theories (Straus & Corbin, 1990; Gray, 2014). I felt that approaching a

study without prior knowledge and assumptions, and particularly not undertaking any prior

literature review was not realistic and also lost the opportunity to acknowledge the contribution that

some prior knowledge and experience could bring to the process. This is a view supported by

Charmaz (2006) who argues against taking a more traditional approach for grounded theory when

relatively little is known about the subject, where the intent of the research was to elicit the views

and experiences to generate the theory (Lyons & Coyle, 2007). A component in this process was the

absence of the researcher in terms of prior knowledge, for example, not undertaking a full literature

review prior to undertaking the research. The data collected would be analysed against the

framework but not interpreted, and instead reported as sourced. I felt this approach to be too rigid

(Glaser, 1998) and I needed to move to a more flexible and more open to an interpretive approach

(Evans, 2013). These more flexible approaches have become more acceptable (Breckenridge, et al.,

2012) and include acknowledgement that a researcher can bring a useful perspective to the area

being studied. This is a view supported by Breckenridge, et al. (2012) in giving consideration to

whether adapting grounded theory to a more flexible approach, that is, including some prior review

of relevant literature, risked losing the original model of grounded theory or whether this is a natural

evolving of an approach that needs to adapt as research approaches develop.

The focus of this research was in seeking deeper exploration of the views of how staff defined and

understood the concept of well led within their organisation and the issues related to the existing

knowledge and experience of the researcher have been previously described. However, the

advantages of being an inside researcher included being in a unique position to provide explanations

and some sense making of the data. This approach is supported by Charmaz (2006) who believes the

researcher needs to be visible in the process of the research. This is view is also supported by Gioia,

Corley and Hamilton (2013), who also stress the importance of the researcher’s presence being

visible during the interview process, analysis, and presentation of findings stage. This approach

offered a method of enquiry that supported the aims of this study, but would have to be balanced

against also mitigating the potential risks of this approach.

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Consideration of other research approaches

PhenomenologyRecognising my presence as the researcher and the appeal of a more interpretive methodology, a

phenomenological approach was also explored. Phenomenologists collect data from subjects and

describe their lived experience, and this approach tries to both explain meanings as expressed by the

participants and seeks to attribute meanings (Lyons & Coyle, 2007). It is felt to be more inclusive and

enables the findings to emerge. Theory emerges from philosophy and aims to describe ‘lived’

experiences from the perspective of the participant. The researcher gains rich data, usually limited

to the in-depth interview, and does not include other methods of research to support the data

(Gelling, 2011). It aims in addition to include additional data gained from other methods, such as

observation, and other literature to either challenge or support theory emerging from the data. This

approach was rejected on the basis that the aim of this study was more focused on gaining greater

understanding of the views of a number of staff on the concept of being well led, rather than a

specific focus necessarily on deeper interpretation of a smaller number of staff’s lived experiences

and perspectives.

Ethnographic Undertaking an ethnographic methodological approach was also considered for this study. The

advantages of this approach were that it offered the opportunity to immerse myself within one

organisation, observing the staff in action, to gain a greater understanding of the lived experience

and cultural phenomena that existed over a period of time (Gray, 2014). The disadvantages were the

potential difficulties in gaining access, which would include observation of a larger number of staff in

their daily activities, which may include activities related to patients. Therefore, gaining consent

from staff and patients and achieving ethical approval represented a challenge. A further challenge

related to my being a part-time student with a busy full-time job and being able to commit enough

time working within the organisation to gather enough meaningful data over a longer period of time.

After careful consideration of the three possible approaches, I opted for the grounded theory

approach as I felt that this offered the opportunity to interview a range of staff from across the

organisation, and included within it some observations of staff within meetings.

Theoretical framework For the purpose of this study the theories relating to the concept of ‘learning organisations’ from

Argyris (1992) and Senge (1990) were blended together to develop a theoretical framework to

underpin this study. The rationale for the use of this framework was previously described in Chapter

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4. This theoretical framework was used to help inform the methodological approach and give

structure to support analysis of the data collected. The limitation of using a framework was

previously acknowledged (see Chapter 4) (Elliott & Higgins, 2012), as this could have the potential to

introduce some bias into the study. Caution was taken in approaching the analysis to avoid

becoming too immersed in the literature and risk the temptation to attempt to fit the data to the

theoretical framework (Gioia, Corley & Hamilton, 2013). It was important to ensure a clear

distinction between an inductive and deductive approach as the epistemological lens for this study

was one of induction, and there was a risk of moving the analysis towards a more deductive

approach by use of a theoretical framework. This could potentially be viewed as incompatible with a

process of induction. There are, however, some differing views of whether grounded theory can be

both inductive and deductive (Elliott & Higgins, 2012). I felt that Charmaz’s (2006) approach to

grounded theory offered a more flexible approach and I focused on, first, giving voice to the

participants and considering as the meanings emerged how closely the theory commentary aligned

with the theoretical framework. I worked hard to avoid trying to align the narratives to the

framework and instead used it in the background as a guide. Having initially selected a more flexible

method of analysis to explore emerging theoretical concepts from the data collected I felt

comfortable (subject to acknowledging the limitations of this approach) to remain with my chosen

inductive process for the analysis phase.

Selecting the chosen methodological approach for the study An interpretative framework of grounded theory as described by Gioia, Corley and Hamilton (2013)

and Charmaz (2006) was selected as I felt that this offered a methodological approach that best

fitted with the research aims of this study. The study required a grounded theory approach that was

flexible and allowed for consideration of the presence of the researcher in the process and also a

degree of interpretation of the data, but stayed close to the aim of attempts to generate new

theory. The components believed to best generate theory included two aspects (Gioia, Corley, &

Hamilton, 2013), that of the knowledgeable agent (the research subjects), and the ‘knowledgeable

people’ (the researcher). It was important to ensure this inductive study had qualitative rigour, and

the framework supported a methodology that enabled this to be more transparent as it was

constructed. This included undertaking some limited review of the literature ahead of data collection

(Gioia, Corley, & Hamilton, 2013; Charmaz, 2006). The strength of this approach was the attention

given to the methodological aspect of the research study. This included the interview protocol and

detailed process of analysis. This provided a rigorous link between data and a concept of sense-

giving to the data (Gioia, Corley, & Hamilton, 2013).

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Research design – case study A qualitative case study approach was selected to enable the researcher to interview and observe

staff within their work setting and explore with staff in depth their lived experiences of leadership

and how they felt this impacted on the delivery of quality care to patients. A case study method was

chosen to support the position of an explorative approach and allow for expression and exploration

of ideas (Yin, 1993; Polit & Hungler, 1991). This study was concerned with the phenomenon of

leadership in context, which supported the research aims of obtaining the views of staff within their

work setting (Cresswell, 2007). The overall aim was to generate meaningful theory by gaining greater

understanding of the staff’s experience of the ‘well led’ concept (Meridith, 1998). The aim was to

seek depth rather than seek comparisons or look for specific generalisability (Bryce Hoflund, 2013).

The case study approach allowed for the consideration of the views of staff in a given setting and

gave the opportunity to undertake an in-depth study within an individual setting. One advantage

that the case study approach offered was the opportunity to bring the issues to life and tell the

staff’s story, the strength of this approach being the opportunity to test the views of key staff on

effective leadership (Edwards & Talbot, 1994). However, it was recognised that the use of the case

study approach was not without its critics; some have argued that it lacks rigour, objectivity, and

reliability (Gray, 2014; Remnyi, et al., 1998). However, as the case study approach was not intended

to test a hypothesis it was felt to be better suited to this area of research, which required the

development of in-depth understanding of the concept of being ‘well led’ (Flyburg, 2006). Some of

the limitations highlighted were mitigated to a degree by the risks being planned for, and this

required a set of disciplined skills to successfully address the areas where focus and discipline of the

approach needs to be very robust (Yin, 1993). This was addressed specifically through consistent and

coherent study design, which included clear research objectives, and careful sampling. These tools

included semi-structured individual interviews with a range of staff (multiple key informants),

together with observation of some key staff meetings. This approach utilised a qualitative and

interpretive method to gather meaningful data that explores the process by which participants

define effective leadership and their views of how this translates within their organisation. This

provided an excellent opportunity for examining the views of staff at various levels across the

organisation.

Sampling strategy – defining population to be studiedA criterion-based sampling approach was selected to identify rich data that could be studied in

depth (Patton, 2002), and, therefore, it was necessary to select the units of study that met set

criteria and study the organisations in depth. One acute hospital Trust was selected for this study

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from the group of those currently rated as ‘good’ or ‘outstanding’ by the CQC. There were a number

of hospitals that had received the rating of ‘good’ or ‘outstanding’ by the CQC, including a category

having been judged as ‘well led’. The rationale for using the CQC rating as selection criteria was

based on the CQC having been given a key role in assessing whether or not an organisation is well

led. These assessment were publicly available as national ratings, and judged against nationally

agreed standards and criteria I did however fully acknowledge the limitations of using CQC

assessments of NHS Trusts being well led. This was previously discussed in the earlier chapters which

explored the validity of these assessments. This aim of this research was not to investigate the

validity of the CQC assessment and it was important to be careful to be as objective as possible,

whilst also recognising the potential bias based on my earlier criticisms of the methodology used for

CQC assessment.

I chose to anchor the research study in one such organisation gave a unique opportunity to explore

the staff views on the concept of the ‘well led’ organisation in more depth. The rationale for

selecting a Trust having been assessed as ‘good’ in the well led category was that it offered the

potential to identify some of the key components of being ‘well led’ with the aim of sharing this with

the wider NHS. An alternative could have been to study a Trust in the ‘needs improvement’

category, but I felt that this would have less potential to develop a theory of what ‘well led’ looked

like to take forward.

After careful consideration, an in-depth qualitative case study method was selected from within the

small number rated as ‘good’ or ‘outstanding’ by the CQC. The rationale was that by exploring how

the concept of being ‘well led’ was defined and understood by a range of staff in an NHS Trust

assessed as ‘good’/‘outstanding’ there would be the potential to identify some of the key

components that could be taken forward to develop theory in supporting wider improvements in

leadership across the NHS.

Seeking permission/Gaining access to undertake study Out of the nine NHS Trusts that met the criteria of having been rated by the CQC as ‘good’ or

‘outstanding’ two organisations were excluded from the group for selection. This was following a

number of ethical considerations that included excluding those within the geographical location of

where I had previously worked, and ensuring no previous working relationship with the Trust

selected. A small number of NHS Trusts were contacted via e-mail, asking whether they would be

prepared to be involved in the research study.

After one positive response from one of the Trusts that expressed interest (there was only one

positive response), a follow-up e-mail was sent to the medical director that described the purpose of

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the research, what this would involve for the Trust, how the research would be conducted, the

number of staff involved, and the estimated time commitment required. Following this, they agreed

and subsequently gave approval from their research and development committee. Permission was

subsequently given.

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Reflexivity (Box 7) regarding my views and assumptions influencing the sampling approach to study Reflexivity Box 7 illustrates my views and assumptions about my sampling

approach for the study. I questioned my own assumption that focusing on

an organisation assessed as well led by the CQC was the right approach. I

was also concerned that due to the small number of NHS Trusts to select

from there was a risk of none of them agreeing to participate in my study.

I felt there was more to learn from a Trust that was rated as ‘good’ or

‘outstanding’, but challenged myself as to whether this assumption was

valid, and whether this assumption risks bias, for example, confirmation

bias, or conversely a risk of courtesy bias (see Table 1) if the results did

not align with the CQC assessment and if findings showed the need to

present an opposing view. I was also mindful of my position and whether

this would affect the Trust’s willingness to participate either positively or

negatively. As it transpired one of the Trusts was very keen to participate,

and I was also then concerned as to whether this willingness to participate

could also bias the findings. On reflection this willingness to participate

appeared to be directly linked to the Trusts leadership’s sense of pride

they held about their organisations success and a desire for others to see

their achievements. I however remained mindful of the inherent risks,

particularly as there was a very small sample to select from and remained

alert to this possible risk of bias throughout the process.

The selected NHS Trust was a medium-sized district general hospital that

operated across two sites, separated geographically by several miles,

having undergone a merger a few years earlier. The organisation

employed about 8,000 staff, and had accident and emergency services as

well as sizeable maternity units on both sites. The Trust was led by an

executive team and the Trust was managed across three directorates. The executive team and the

three directorates operated across the two sites (a merger had taken place three years earlier). Each

directorate was led by a clinical director and a lead nurse and supported by a general manager. The

Trust was one of nine in the country that had historically merged with a military hospital, several

decades earlier.

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Reflexivity Box 7

My reflections and assumptions influencing the sampling approach to study:

I believe there was more to learn from a Trust rated as ‘good’ or ‘outstanding’ in the ‘well led’ CQC domain.

I questioned myself whether this was a reasonable assumption.

However, only very small numbers of Trusts met the criteria of being assessed as ‘outstanding’ in the well led CQC domain.

I had concerns about my perceived ‘position of power’, that is, in the national NHS role and whether a Trust would be willing to participate.

This could work either in a negative or positive way.

I was surprised by the selected NHS Trust enthusiasm to participate, and also whether this willingness risks bias.

Very mindful of current pressures on the Trust and not wanting to increase burden on their time.

Sub-sampling within selected NHS Trust The sample size needed to be sufficient to gain depth of data to achieve the aims and objectives of

the study. The sampling method of a case study approach was to reach a saturation point in the

collection of the data where no new major concepts emerged from the observations and the

interviews conducted (Latham, 2013). Determining the best sample size in advance of the data

collection risked that if the sample was too small, failure to reach saturation, and of losing focus

from the research aims. It also risked wasting the time of the participants if their contributions are

not used. Estimations for best sample size for case studies vary, but some suggested a sample size of

15 to 20, with 15 being the minimum (Latham, 2013); others suggested the need for more or less

depending on the richness of the data captured (Guest, Bunce, & Johnson, 2006; Crouch &

Mckenzie, 2006). A sample size of up to 25 people was planned, with the addition of some

observations of meetings across the NHS Trusts.

The participants were selected from both the corporate (cross Trust, that is, executive team and

senior management operational staff) together with participants from three directorates

(departments), including emergency care, elective care, and maternity services. The Trust leadership

structure was divided into three directorates, each with a medical lead, nursing lead, and

operational lead, and all were approached via letter (see Appendix 2) that was distributed via a

secretary who worked for the executive team. The executive team were also approached via the

same process. The rationale was to capture views from staff across a range of services. Within the

four areas the sample included staff operating within a range of leadership levels, and included

participants who were doctors and nurses, executive team members, and middle managers. I

recognised one key limitation of my sampling approach was the willingness of this organisation to

participate which could potential lead to a degree of bias and was cognisant of the need to remain

alert to this risk. A further limitation was the selected sample excluded a range of different groups of

staff, such as administrative, diagnostic and support staff who may hold different perspectives.

However the focus of this research was to explore the views of clinical and managerial staff at this

stage, recognising the potential for further research across wider staff groups in a future research

study. These limitations are discussed in further detail in chapter 7.

I was given a key administrative contact from the Trust to help coordinate and arrange the

interviews, a process of setting up interviews that took considerable time. The context of this was a

very busy hospital and one experiencing severe ‘winter pressures’ (a term given to describe a range

of pressures, for example, hospital beds at full capacity), lack of capacity in the emergency

department, and staff shortages. There was a need for me to be both understanding (I am familiar

with working in similar situations) and patient. In recognising the Trust’s generosity of giving their

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time in supporting my project I tried to ensure as much flexibility as possible, which included fitting

in interviews at a time that would be least intrusive to the Trust’s core business. Consequently, the

interviews took place over a period of several months.

All agreed to be interviewed and they were a mixed group in terms of age, ethnicity, and gender. A

balance was struck to ensure the minimum of interviews were conducted that ensured a diverse

sample from across the three directorates and central corporate teams, as well as at the three levels

of management within the Trust.

The initial analysis sample aimed to capture a range of views from staff in key leadership positions

across the Trust to provide data that effectively answered the research question. As the data

collection progressed the need to continue and conduct interviews was regularly reviewed until

reaching a stage of where no further new ideas were emerging (Charmaz, 2014). At this point of

saturation, the researcher discontinued further data collection to avoid the collection of data that

may not be used or add value and to avoid wasting the time of participants (Francis, et al., 2010).

Ethical considerations An ethical framework was adhered to throughout the study, incorporating three principles of

anonymity, confidentiality, and consent (Patton, 1990). I was aware that I had a greater

responsibility to protect the rights of the research subjects than in the pursuit of gaining new

knowledge to seek to answer the research question (Gilbert, 2004).

The research needed to be seen by the organisations to be studied as worthwhile (Gilbert, 2004).

The nature of the case study approach was that I needed to be invited into the research subject’s

workplace, which is an NHS hospital whose fundamental purpose is to provide health care to its

patients. I was asking subjects to commit their time for the researcher with an expectation that the

results will be meaningful and serve in some way to inform the wider NHS. The subjects would not

expect to personally gain from the experience, so they were fully briefed about the purpose of the

research.

It was essential that subjects gave their full informed consent to participate, which (please see

Appendices 1–5 where further details of this are provided), included the participant information

sheet and consent form, which meant research subjects were fully aware they were being

‘researched’, the purpose of the study, and how the results would be communicated. Equally, it was

important that any subjects approached who did not want to participate were able to articulate this

and for this to be fully accepted as their right. Once participants had consented to being involved

with the research, they were reassured that they could withdraw if they changed their minds, and

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equally they had a right to privacy, not to be asked or expect to answer questions they may find

intrusive. This is particularly important in qualitative research; as if a participant wishes to withdraw

they can simply not complete a questionnaire, or not return a survey. However, when they are being

observed or interviewed subjects will be supported to withdraw from the study if they wish to (Gray,

2014).

The participants were informed that their data would be anonymised and non-attributable to them

personally, and they would not be identifiable when the research is published. In this study the

responsibility extended to the whole organisation, as well as individual participants who would be

anonymised. The data collected was stored in a secure, locked environment and password

protected.

This study received favourable ethical approval from the university’s ethics committee prior to

conducting the study .Examples of participant’s information sheets and consent forms are provided

within Appendices 2, 3, and 4 for further detail). Additional permission was also sought and

subsequently given by the NHS Trust being studied from their own research committee.

Complete anonymity presented a possible challenge in relation to the sampling technique of the

selected as the numbers of Trusts in the two categories are small, however, all possible safeguards

were taken to anonymise and protect the Trust from being identified. How anonymity of the

participants and confidentiality of their responses would be protected were described within the

consent process and a section was included assuring participants that data collected will not be

individually attributable. Some of the early risks identified with this included:

Ensuring I had no previous working relationship in the selected NHS Trust. This was

addressed through the sampling process.

Gaining ethical approval, in particular where the number of NHS Trusts in the ‘good’ and

‘outstanding category’ are small numbers and there was a small risk of their being identified

(the study was subsequently given approval). To mitigate this risk, I ensured that I would

take additional care to anonymise the Trust during the presentation of the findings, which

included making limited reference to the organisation’s size and geographical location and

details of the Trust that could lead to it being identified.

Data collection toolsThe research tools used included the use of semi-structured interviews, plus observation of clinical

governance meetings in the four directorates identified above.

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Developing the semi-structured interview questions The combined theories of learning organisations from Argyris (1992) and Senge (1990) were blended

together to develop a theoretical framework to underpin this study (see the previous chapter) and

helped to develop the interview questions. The questions used (please see Appendix 6) were framed

to be open ended, seeking staff’s knowledge, experiences, opinions/ beliefs, and understanding of

leadership.

Piloting of interview questionsI took the opportunity of piloting the interview questions with a clinical colleague, and found that

the process felt very stilted and false, and did not flow as a conversation as well as I had anticipated.

I transcribed and analysed the pilot interview, resulting in a lack of depth in the data collected. This

highlighted the need to take a more flexible approach and adapt the questions to use them more of

a prompt for a conversation to promote free discussion rather than a question and answer session.

This was an important learning point for the process as I felt this adjustment in the approach to the

interviews enabled the collection of greater richness in the data.

Reflexivity (Box 8) regarding my views and assumptions about selecting interview questions Reflexivity Box 8 shows my views and assumptions in relation to the

piloting of the interview questions. This was a very important

learning point in the process as this highlighted that to encourage

open, free-flowing conversations I needed to say very little and ask a

very small number of open questions (less than four) with an

occasional need for a prompt.

Semi-structured interviewsIndividual semi-structured interviews were undertaken with staff in

key leadership roles to enable exploration of individuals’

perspectives. The aim was to explore individual constructs in

defining and understanding leadership and to analyse these to help

generate theory. Wherever possible, interviews were conducted in a

private room (two interviews were conducted in a shared area in a

private space within a communal area, for example, the library), at a

prearranged time with the staff member concerned. Information

sheets were provided ahead of the interviews (but not all had received them). The participant was

given time to read the information sheet and to give consent (see Appendix 5), the interviews were

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Reflexivity Box 8

My reflections about selecting the interview questions to use:

Piloting of questions with a colleague gave greater insight about the need to improve my interviewing technique.

Needed to create an environment that invited free-flowing expressions of views.

Interviews needed to be a ‘conversation’ with the focus on the participant and my resisting any attempt of agree/disagree with views expressed.

recorded, and the average length of an interview was 1 hour. The meetings observed were all of

about 1.5 hours duration. Field notes of what was observed were also taken to accompany the

recording, mostly as a reflection after the interview was completed (Charmaz, 2006).

The questions were used only as a gentle prompt to stimulate discussion and once the first question

was asked to invite the participant views I maintained a listening role to enable them to speak freely

without interruption, only referring back to the questions referenced in Appendix 6 as an occasional

prompt. This worked well, and by encouraging the participants to share their views the conversation

flowed easily and in a very relaxed way. An example of this was where some interviewees wanted to

continue to chat as they were very interested in the study. A small number were more rushed as the

participants needed to get back to work. Meticulous records were kept throughout the whole

process.

All the interviews were audio recorded with the consent of the participants and a diary was used to

record field notes as a supplement to the recordings. These were used to check accuracy of the

recordings and also give the opportunity to note other aspects of the interview process, for example,

the setting, non-verbal exchanges, and general observations of the participants during the data

collection. The tapes, notes, and written transcripts were stored securely, and password protected

on my own personal computer.

Observation of staff meetings Data collection In addition to the interviews some staff meetings were observed, including one

executive team meeting and three directorate meetings. This research method involved observing

and recording the interactions of the staff in these group settings. The purpose of including these

observations in addition to interviewing staff was to add another lens to the data collection and to

observe examples of the well led concept (as defined and described by the staff interviews). I took

extensive field notes during the meeting and afterwards, to capture the context, surroundings,

conversations, and behaviours during the meeting. The risks of using this method included the

participants changing their interactions due to my presence, which could have presented potential

limitations to the data. This was also a consideration in relation to the interviews where there was a

risk of participants telling me either what they thought I wanted to hear or what the Trust expected

them to say. I gave close consideration to this effect during the interviews, observations, and

subsequent analysis, throughout the whole process continually challenging myself about this

possibility. However, I was aware that this could be something the CQC inspectors had also needed

to be aware of during their assessment processes, so I continued to be keep an open mind to this

possibility.

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The data gathered through the observation of staff meeting was helpful in confirming the data

gathered through the semi structured interviews. This was particularly helpful in relation to risk of

concerns I had held regarding the risk of participants telling me what they thought I had wanted to

hear. One particular example of this was the views expressed by participants experience when

involved in clinical incidents, and not feeling they were being blamed. The various departments

approach to incidents were discussed in all three directorate meetings where they discussed a range

of clinical incidents that occurred, their discussions very much confirmed the views expressed within

the various interviews of a learning approach and staff not being blamed.

The semi-structured interviews were undertaken over a period of time and included staff in a

leadership role in the following areas:

Corporate: this included staff who held leadership roles across the whole organisations,

including a range of staff, including executive directors (chief executive, human resources,

medical, nursing, operational management) and other corporate function leads, for

example, patient experience lead and professional leads.

Directorate: this included clinical directors (medical leads), nurse leads, and operational

managers, from medical directorate (included A&E and acute medicine), maternity unit, and

surgical unit.

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Reflexivity (Box 9) regarding: reflections from the interview and observations processReflexivity Box 9 summarises my reflections from the interview and

observation process. Out of the first 20 staff interviewed only 1 gave any

negative comments about the leadership of the Trust. My initial

impression was on how consistent the views of staff were and the

possibility they may simply be giving a ‘party line’ was considered, that

was, was this ‘too good to be true’. This was something I had anticipated

and was sensitive to and was concerned that my background of holding a

senior role within the NHS was driving this. After conducting about 20

interviews over a period of three to four months, I made a decision to

interview more staff from the second site (the Trust has two sites, with a

geographical difference of 20 miles), and also to include some interviews

with some front-line junior medical staff and nurses (all of whom have

leadership roles) to gain greater understanding of staff’s views.

Selection of further participants to interview

I contacted the key administrator person who had been supporting me

with contacting staff to ask them if they would be willing to participate in

my study. I was given some additional contacts, 7 of them from the

second site and 3 from site 1. The additional participants comprised of

staff working in clinical roles, a mixture of junior doctors (Foundation year

2 doctors as well as specialist registrars and also registered nurses at

various levels of seniority. The rationale for conducting these staff was to

help mitigate the risk that participants had in someone way been

influenced to give a more positive view of the organisation. These staff volunteered at fairly short

notice, some only agreeing to be interviewed on the day of the interviews, which I felt significantly

reduced the risk of there being any influence. They spoke very openly and appeared genuinely

interested in sharing their views. While continuing to use the same lines of interview questions I

finished all interviews with an open question inviting anything else they would like to add. The views

continued to be consistent. After 30 interviews were completed across both sites, no new themes

emerged, and I felt that theoretical saturation had been reached. In addition, four meetings were

observed, one per segment of the study, which continued over a few months following the initial

interviews, which provided additional insights in terms of supporting the analysis and interpretation

phase of the data.

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Reflexivity Box 9

Reflections from the interview and observations process:

Consideration of whether my senior NHS position was introducing bias; however, most participants were not aware (despite information sheet).

Concerns as to whether participants were giving views they thought I wanted to hear (risk of confirmation bias and also the effect of my senior positon in an NHS role).

Consideration of whether participants in meetings behaved differently due to my presence.

As more participants were interviewed from varying departments across the two sites consistent views continued and my concerns regarding this lessened.

Data analysisThe process of analysis followed the framework provided by Gioia, Corley and Hamilton (2013) and

Charmaz (2006). This process followed a systematic approach incorporating what Gioia, Corley and

Hamilton (2013) describe as first and second labelling, that of the informants (research subjects) and

the researcher.

The first stage of the process the data included identifying the terms used by the informants and a

large number of categories were generated. As this progressed differences emerged and an axial

process was used to reduce to a smaller number of categories. The second stage was then applied

where the knowledgeable informant (myself as the researcher) began to make sense of the data and

helped describe the phenomena emerging from the data. When all the concepts and themes were in

place then, in the third stage, I attempted to aggregate the dimensions. Once all three stages were

completed the data structure allowed for the raw data to be displayed in a more manageable form

and to in effect see the whole of the data displayed on one page. At this stage, the emerging data

was studied alongside the literature, at which point the data transitioned from inductive to

abductive research and the two sources of data were viewed in ‘tandem’. This data then provided

the emerging theory, which attempts to begin to answer the research question. The importance of

this emerging theory was then captured in the writing up of the findings with the emphasis on

assisting the reader of the study in being able to observe the data connections between the three

stages of analysis.

The stages of analysis described by Gioia, Corley, and Hamilton (2013) and Charmaz (2006) were

utilised to support analysis and interpretation of the data. This was based on their learning from

criticisms of the possibility of perceived lack of rigour and reproducibility of research such as case

studies using grounded theory approaches. One limitations of this approach was a deliberate

departure from classical grounded theory models (Strauss & Corbin, 1998) and the inclusion of an

interpretive component. This could be viewed as a hybrid between grounded theory and

phenomenology and therefore be open to criticism for a possible lack of the rigour needed to

generate meaningful theory to address the aims of the research. However the counter to this was

the provision of a relatively simple framework to follow that could be shared with others to help

demonstrate how analysis of the data has generated the theory and lends itself to be reproduced.

The process lent itself to be an inductive and adaptive process, which was explorative and flexible in

nature, and highlighted the importance of being able to accurately describe the process of analysis,

including providing the reader with information regarding the coding process and details of how final

codes and subsequent codes were arrived at and the researcher’s knowledge and interpretation

being visible throughout.

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Applying the analysis process All of the recordings were listened to several times, before being transcribed. Each interview was

coded and anonymised to ensure confidentiality. Each interview was transcribed verbatim and was

double spaced and reviewed line by line (these were individually numbered), in order to break down

the text, and ensure detailed analysis. This was to support open coding, and sections of passages

from the interview were selected. Memos were also kept for each interview to support the context

for each interview. The focus was trying not to become overwhelmed by the number of emerging

codes.

A long list of codes were allocated to areas of text, and comments and text extracted using a

Windows Macro, transferring the data to an Excel sheet. This enabled each of the 30 interviews to

be further analysed individually, collectively, and also by directorate area.

Initial codes for each interview were numerous, up to 90 on the first level of coding. The extracted

comments were then reviewed to reduce the number to a more manageable set of codes, and used

a range of approaches. These included frequency of terms used, areas they had particularly

emphasised, unexpected findings, patterns in the data, and a range of clusters of perspectives as

well as individually held views (Charmaz, 2006; Gioia, Corley, and Hamilton 2013). I was supported

during this process by two professional colleagues (experienced in qualitative research), the codes

and the process of the 3 stage were shared and discussed who provided critical challenge

throughout the coding process. This process was a very useful stage which helped increased

confidence in the interpretation of the data and the final themes that emerged.

The process included:

First stage - open coding Listening to recordings several times.

Transcribing and coding each interview, anonymising to ensure confidentiality.

Verbatim transcripts were double spaced and reviewed line by line (these were individually

numbered), in order to break down the text, and ensure detailed analysis to support open

coding

Memos were also kept for each interview to support the context for each interview.

A long list of codes were allocated to areas of text, and comments and text extracted using a

Windows Macro, transferring the data to an Excel sheet. This enabled each of the 30

interviews to be further analysed individually, collectively, and also by directorate area.

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Extracted comments were reviewed to reduce the number to a more manageable set of

codes, and a range of approaches were used. These included frequency of terms used, areas

they had particularly emphasised, unexpected findings, patterns in the data, and a range of

clusters of perspectives as well as individually held views (Charmaz, 2006; Gioia, Corley, &

Hamilton 2013).

Second stage focused coding process The second stage of coding used a combination of grouping themes as they emerged and the

application of a degree of my own interpretation (Gioia, Corley, & Hamilton 2013; Charmaz, 2006) as

to how these could be best grouped, including reducing in excess of 90 codes to a smaller number,

by:

Combining and grouping themes as they emerged and making some initial interpretation of

the data in terms of seeking explanations of what the participants were expressing (Gioia,

Corley, & Hamilton 2013; Charmaz, 2006).

Checking grouping against my own interpretation, continually challenging, contrasting the

data between the interview transcripts, and checking alignment with the research question

with the aim of trying to reduce the potential for bias (Charmaz, 2006).

Third stage of coding The third stage of coding reviewed the second level codes as a collective to ask the question of what

this data seemed to be saying. This process included:

Checking back to the original interview transcripts whether I had omitted to include any data

from the participants that gave additional insights after the initial analysis.

Scrutinising areas where there were some unexpected findings, or where there were clear

differences in views and returning to the original transcripts to revisit analysis and

interpretation.

Reduction of codes to a smaller number of key themes.

Re-checking against my own interpretation with my two professional colleagues to try to

reduce the potential for bias (independent of the study). They provided challenge

throughout the coding process and we debated and considered a range of other possible

options before agreeing on the final 4 themes which had emerged from the data.

Application of relevance of wider theoretical concepts, including the learning organisation

organisational framework, but not until after the final four themes had emerged, and

subsequently undertaking a further literature review in seeking to understand what the data

was telling me.

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Throughout the process the theoretical framework of learning organisational theory was used as a

framework to help guide the study, however, being vigilant in allowing the themes during the

analysis to emerge in advance of any comparison with the theoretical framework. I was also

cognisant (Gioia, Corley, & Hamilton, 2013) throughout the analysis process of the need to resist

where possible application of knowledge of prior reviews of the literature, to allow the data to speak

for itself. It was also important to acknowledge my own health-care experience in the field, and

rather than try to believe I could resist applying this lens, I needed to be very reflective in terms of

understanding my own possible biases and acknowledging them and having them out in the open.

The study sought to hear the views of the participants’ understanding of leadership, and I took care

to ensure that I resisted the temptation to not simply try to fit the data to the framework without

having considered a range of other possible theories. I repeatedly challenged myself on this as I

arrived at a smaller group of themes emerging from the coding.

In general terms the views were very consistent with one another. One example of a key difference I

found was where staff appeared to view themes such as ‘hierarchy’ from quite different

perspectives. This is discussed further in Chapter 6.

Reflexivity (Box 10) regarding reflection during the analysis process Reflexivity Box 10 summarises my views and assumptions during the

analysis process. I revisited the three stages, and asked myself what I

believed the data was telling me, including trying to seek alternative

explanations in relation to the following data emerging from the

interviews. I reflected on my own experience of the NHS over the past

30 years, which had been one of observing significant variation

between NHS organisations in terms of quality of leadership and

quality outcomes. My previous roles had included oversight of a great

many Trusts, which had involved working in a variety of levels, and

included working (and continuing to work) as a front-line clinician, as

well as holding executive director positions. I had both chaired and

participated in numerous Trust meetings, which gave me experiences

with which to compare when undertaking the observation aspect of

this research. I therefore entered the data collection stage of my

research as an experienced and knowledgeable insider, which risked

the potential of bias during the analysis and interpretation phase of the study. This was an important

aspect to openly acknowledge and be aware of and something that I continually challenged myself

about during these stages. At the same time the benefits of being an ‘insider’ gave the opportunity

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Reflexivity Box 10

Reflections during the analysis process:

Took care to ensure analysis process undertaken with no reference to theoretical framework or prior literature review to try to reduce bias.

All views from participants were considered valid.

Attention was given to represent all views and with aim to avoid selection with bias.

Included unexpected findings, to limit risk of confirmation bias.

to offer insights that may not have been possible without my level of previous knowledge and

experience. To mitigate the risk of this potential bias I asked two professional colleagues to review

my analysis process – one was a health-care professional and one worked outside the health-care

sector.

A further mitigation to the process of bias occurring was to present the findings using the voices of

the participants, therefore each theme was analysed adhering closely to the interviewee’s voice to

illustrate and evidence the data described. One challenge to this process was making the decision of

what not to include, and the risk of providing a biased account by not including differing views from

the participants that were presented. However, the data collected did not demonstrate a wide range

of differences in the views that were expressed. I had expected to see this variation present at both

the varying levels of staff in leadership interviewed and also between the directorates. This was not

the case, and despite adding additional interviews and ensuring I had included staff from both sites,

and further additional interviews with front-line staff, the majority of staff spoke about the Trust’s

leadership in very positive terms. Prior to finalising the final codes I reflected on an overall consistent

positive narrative given from 29 participants of the 30 about their experience of good leadership

within the Trust, which led me to question whether these results were almost ‘too good to be true’.

There was only one participant (medical consultant) interviewed who provided a less positive

perspective they attributed to them having just had a very busy weekend on call.

The final set of codes were grouped following the grounded theory process described by (Charmaz

2006). Two examples illustrating how final themes emerged are shown in the examples below:

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Table 8: Example of Theme 1 – Family

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Initial codes

FamilyValuesBehavioursEngagementExpectationsTeamIn it togetherExcellenceFitting/Not fitting the familyCulture

Focused codes

In it togetherCollegialityShared values and behaviours

Emerged theme

Family

Table 9: Distributed leadership with some hierarchy

Relevance of the theoretical framework

During the process I revisited the three stages and continually reviewed the data to determine and

challenge myself in what data I believed the findings were revealing. There was consistent narrative

throughout the majority of the interviews. On reflection, having revisited the selected theoretical

framework, I initially considered rejecting it as I had questions as to how the themes related.

However, after some careful consideration I reviewed the applicability of the framework alongside

the components of the final themes that emerged and found it supported a deeper analysis of the

data. This helped guide the interpretation of the data at a more macro level, and based on this the

final set of codes were grouped and four themes are presented in the following chapter in greater

detail.

At this stage there was still a risk of having simply described the data without considering the wider

theoretical concepts, and the need to seek to understand what the data was telling me. I reviewed

other suggestions for analysing using a grounded theory approach to check whether they may be a

superior method to analyse the data. I explored further an approach to a more classical grounded

theory, as to whether this would help to construct the bridge from descriptive codes to analytical

ones. I became more confident in the work of Charmaz (2006) in terms of revisiting the data, greater

use of my field notes, and tried to take a step back from the data in an attempt to seek to

understand where the data related more specifically to my research questions.

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Initial codesHierarchy

Informal chain of commandOrganisedMilitaryAccessibleFriendly

Focused codes

Distributed leadershipInformal vs. formalChain of command /Hierarchy

Emerged theme

Distributed leadership with some hierarchy

This was a helpful process to explore in more depth whether existing theories helped with making

sense of the data, most of the literature reviewed helped give further insights, with the strongest

emerging theory being linked to the concept of family. However, I remained cognisant (Gioia, Corley,

& Hamilton, 2013) of the need to suspend where possible knowledge of prior reviews of the

literature, and to try to stay ‘semi ignorant’ of the various theories to allow the data to speak for

itself.

Reflexivity (Box 11) regarding reflections on the analysis process Reflexivity box shows my reflections during the process of analysis of the

data. It was important to acknowledge my own health-care experience in

the field, and rather than try to believe I could resist applying this lens, I

needed to be very reflective in terms of understanding my own possible

biases and acknowledging them and having them out in the open. The

study was seeking to hear the views of the participants’ understanding of

leadership, and I was taking great care to ensure that I resisted the

temptation to not simply try to fit the data to the framework without

having considered a range of other possible theories. On reflection I placed

too greater emphasis on this, and at one stage concluded that the

theoretical framework I had selected for the study was not relevant. I

challenged myself on this as I arrived at a smaller group of themes

emerging from the coding.

In addition to working with 2 professional colleagues during the analysis

process and also sought advice and support from a professor (from

University of Surrey) who was recommended to me as having expertise in

grounded theory methodology. I shared the detailed process I had

followed during the analysis process with the professor, his feedback and

advice gave me increased confidence that I had given a sufficient level of

scrutiny and attention to the process and that I was at risk of being too

cautious and potentially over thinking the details of the process. The risk

of overthinking was an important aspect of my research journey to overcome, which once

recognised and understood gave me increased more confidence in the quality of the data collected.

I subsequently undertook a secondary review of the literature, and the final stage of the analysis

included the application of these additional insights to help make sense in supporting the

interpretation of the views of the participants as the final categories emerged, which were

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Reflexivity Box 11

Reflections on the analysis process:

I had placed too much emphasis on avoiding consideration of data alongside the theoretical framework.

Analysis process showed the components of the framework in some areas supported the findings.

Referring back to preliminary literature review after data analysis was completed was helpful and supported some aspects of the findings.

Secondary review of literature was a more helpful process and more targeted specifically to findings as more focused.

Working with two professional colleagues as critical friends was really helpful, challenging and supported the process.

subsequently confirmed as the four overarching themes. The rationale for this approach was to

allow the theory from the data to emerge and to then seek greater understanding as suggested by

Charmaz (2006) and Gioia, Corley, & Hamilton (2013) and to then use the secondary review of the

literature to support the final stage of interpretation of the findings.

ConclusionThis chapter has described the area of focus of the study and the rationale for why this was an

important area to undertake research. The research methodological approach to this issue has been

carefully considered and described and rationale given as to why the case study method selected

was best suited to attempt to gain an in-depth lived experience of how staff understand effective

leadership and how they see it enacted across their organisation. The following chapter presents the

findings that emerged from this study.

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Chapter 6: Presentation of findings

Introduction This chapter presents the findings from this research study, which includes the data collected from

both the semi-structured interviews and the observations from meetings. The previous chapter

described the methodological approach selected for the study and the analysis process that was

followed. A synopsis of the findings is presented, followed by an explanation of the key findings.

The final four themes that emerged are as follows:

Final themes 1. Family

2. Distributed leadership with some hierarchy

3. Learning

4. Sustainability

The four themes are presented below and illustrated with quotes from the participants and notes

taken from the observational aspect of the study. The quotes have been labelled with a letter

attributed to them that relates to their directorate specialty, that is, C = Corporate functions, S =

Surgical, M = Medicine, and O = Obstetric department. The participants from within these areas

include directors both at executive and clinical level, lead clinicians, that is, doctors and senior

nurses, middle managers, and some front-line clinicians. The purpose of the allocated letters is to

avoid the risk of participants being identified. There are, however, references to the speciality area

in which they work. There was little difference in the views given between the front-line clinicians

and the senior managers and directors. Where there were specific points focused on then these

have been highlighted. It was not within the scope of this study to compare the views between the

two sites, although the voices of the participants used a number of comparisons of the two during

the interviews. The Trust was led by one overall integrated executive and clinical leadership team

operating across both the Trust’s sites. Most staff worked regularly across both sites with the

exception of some of the clinical leaders.

Sub-themes Within the four themes a number of sub themes ae presented that represent the process of the

analysis where the focused codes emerged (see Tables 7 and 8 in the previous chapter). The tables

represent an illustration of the focused codes and initial codes but do not show the full list that

applies to each theme. Each theme presented is supported by a range of quotes from the

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participants, which have been categorised through this process to provide supportive evidence that

underpins the selected codes.

Theme 1: Family The family theme emerged through the initial and focused code theme, as it was the term that was

used by staff to describe their connection with the corporate/wider organisation and their own

departments and the way they referred to patients. I considered whether the theme of ‘team’ was

more prominent but this did not reflect the range of connections. The participants used the term

‘family’ in relation to their experience of the concept of ‘well led’. I also considered whether instead

the theme should be ‘culture’, as this was a term frequently used by the participants. However, the

term ‘culture’ was used in many different contexts and I concluded, as was supported by the

literature (Alvesson, 1995), that the wide and differing interpretations that could be given to the

term could not be adequately reflected using this term.

The family theme emerged from the staff interviewed who described their feelings of being ‘part of

one family’, which was frequently termed as the ‘X (Trust name) family’. Participants used this term

when they were describing what they felt to be a commonly shared view of being ‘in it together’.

These terms incorporated a number of sub themes within this category. These included how the

staff described experiences of the way they felt the executive leadership team instilled in its staff an

organisational sense of commitment. The staff interviewed gave examples of the executive team’s

visibility and accessibility and how they engaged with staff across the organisation. Staff felt that the

executive team clearly communicated expectations of staff with a focus on the organisation visions

and values. When the participants were discussing the Trust’s shared values they did not explicitly

describe them or define them. They talked about the values in a broad sense, which encapsulated a

patient-centred approach, and about being supportive and valuing staff. The way the staff described

being part of the ‘family’ incorporated these components alongside a feeling of all being ‘in it

together’ and was consistent across the four directorates regardless of seniority.

Many of the participants highlighted the positive aspects of feeling part of the Trust family. Some

spoke about the importance of doing things the ‘Trust x way’. The chief executive and their team

were referred to by one of the participants as the ‘parents’ of the organisation and viewed as setting

out the rules of the organisation. This was illustrated by one participant who said:

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‘The X [chief executive] and his senior management team are like parents with a large family who set

very clear ground rules and he does that by example … It’s just a way of behaving really. It is like

being in a family because nobody writes down family rules but it is how you treat each other’ (14 S

operational manager).

This quote illustrated the way that some of the participants referred to the family rules, and spoke

about the staff knowing what they were without the need for them to be written down. The use of

the family concept term was a feature through many of the interviews. Some of the participants

talked about Site two as being their ‘sister’ site and other staff were referred to by some as ‘siblings’.

This use of family terminology was unexpected but something that was consistent throughout the

majority of the interviews.

Many of the staff described how much they valued being part of the Trust family and the support

that this gave them. While many of them spoke about this in a positive way, there were also some

negative aspects to this given as well. Some felt that at times the ‘family’ could also be seen as

dysfunctional. They said:

‘It is like a family because everybody tends to get on and it’s an artificial family because the

people who work at x have selected people in their own image quite often … it is slightly

dysfunctional at times but it holds together because it understands where it is going.’ (14 S –

operational manager)

This was further illustrated by another participant who saw this aspect of the ‘family’ being

dysfunctional as beneficial, as it meant that they could disagree without necessarily falling out:

‘It’s like being part of being family and it is understanding each other’s pressures really … it is

also something that you feel, so you might argue with your siblings but it doesn’t mean to

say that actually that you are never going to talk to them again.’ (11C – senior nurse)

Many of the participants described a feeling of camaraderie with others with whom they worked, as

well as with the top team. Many of the staff spoke about the concept of family, team working, and

supporting one another interchangeably and they highlighted how important working together was

for the staff. This was a common theme across the various directorates. One participant illustrated

this, saying:

‘We appreciate how we are all in the same boat really and we are all in it together and what

we can do to support each other.’ (8 M – senior nurse)

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Another member of staff further supported this and said:

‘There is a sense of camaraderie.’ (4C – senior nurse)

This sense of togetherness and camaraderie was often attributed to the chief executive and team as

setting clear expectations to staff and giving priority to putting patients first. The use of the term

‘culture’ was commonly mentioned but not specifically defined. One example of this from one

participant was:

‘It has been very much about setting the right culture and a real we are in it together

approach.’ (2 C – senior manager)

The term of ‘culture’ was used frequently throughout many of the interviews, appearing to mean

different things to different staff. These views supported the work of Alvesson (1995), who warns

about the risk of the term of ‘culture’ being a catch all, which means different things to different

people. This difficulty in defining the term of culture is well documented (Patterson, 2003) and is

discussed in more detail further in this chapter. Many of the participants used the ‘culture’ term

when discussing the shared vision and values of the Trust. The staff views suggested that a key

aspect of being part of the Trust family was holding the same set of values, these particularly

including being patient focused and giving support to front-line staff. However, it wasn’t clear from

the participants how the values had been created. Some staff talked about the values of the Trust

being visibly displayed across both the hospital sites and I saw many posters displayed when I

conducted the interviews. Just one of the executives referred to the creation of the values, saying:

‘a set of values and behaviours which we have developed with our staff so a few years back

we tried to express in writing what our culture is all about so we did that with using about

800 people and we came up with a strapline “committed to excellence, working together,

facing the future” and underneath each of those straplines are a set of behaviours we would

like our staff to display.’

(24 C – executive director)

It wasn’t clear from the interview how long ago this had been or whether the values had been

revisited. However, the participants were consistent in saying how much they shared the values of

the Trust and how important they believed these to be.

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Many of the participants described the Trust as a friendly place to work. This was reflected in both

the way staff worked together and the way they took time to get to know staff. Participants

particularly valued the use of their first names by senior staff, which they felt had made it easier to

ask for support and advice. The approachability and support of medical consultants was highlighted

by many staff, in particular the junior doctors. One said:

‘they are very patient orientated and they want to help the patient and they have not lost

that reason for why they went into the profession in the first place.’ 16S (junior doctor –

surgery)

Some talked about the uniqueness of this at this Trust compared to their previous experiences, and

those of their medical trainee colleagues working on other neighbouring Trusts. Junior medical

trainees in particular were all very positive about their senior medical colleagues without exception

(on both sites of the Trust), regardless of seniority. Another junior doctor illustrated this point by

saying:

‘because the team are really friendly, all the senior nurses, and all the senior consultants are

very approachable … the seniors are very likeable, approachable and friendly; everyone goes

by first name terms.’ (18 M – junior doctor – medicine)

The experience of friendliness was felt to be unique to the organisation particularly when compared

to experiences that staff had had in other hospitals. This was particularly commented on by a junior

doctor:

‘previous hospitals I have been at have been unfriendly and staff can sometimes be

obstructive.’ (16 S – junior doctor surgery)

This view was also supported by the majority of the nursing staff interviewed who valued positive

team working with their medical colleagues. While some of the staff interviewed had worked at the

Trust for many years (some for more than thirty years), others who were newer commented during

the interviews that the longer serving staff did not realise how good the Trust was, particularly when

compared to other places they had worked.

One exception to this was given from just one participant who was nurse staff member from Site

two:

‘the consultants are very old fashioned here and they are 10 years behind places like X

[previous large teaching hospital.’ (27 M – senior nurse medicine).

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This particular example was unusual and stood out from the other interviews in its criticism of the

medical staff compared to other participants.

Family concept as applied to patients The staff description of the concept of family in relation to being well led was also extended to

include the approach taken by the Trust in caring for patients as if they were members of their own

family. The focus on patients was felt to be key to the success of the organisation. This was

consistent across all of the interviews and related to expectations given to staff by the chief

executive and the wider executive team. The application of the ‘family term’ and use of ‘family

language’ was equally applied to patients as well as staff. One participant said:

‘X [chief executive] talks a lot about treating patients as though it was a member of your

family.’ (11 C – senior nurse)

Another participant supported this in saying;

‘I like to think that well-led is about giving everyone to treat people as if it is their own mum

and dad that are standing in front of them.’ (24 C – clinical director)

Many of the staff spoke about viewing patients in this way. This family perspective was very

important to the staff interviewed and was key to the shared vison and values of the organisation.

Visibility and access to senior staff The importance of role modelling by senior staff and consultants was frequently mentioned, many

appreciating both the visibility and accessibility of not just the chief executive but also the top team,

particularly when the Trust was under severe pressures, such as bed shortages and A&E being

overwhelmed with patients. The staff interviewed valued this level of visibility and felt it gave a

positive message to staff of the concept of being ‘in this together’. The executive team were

described as approachable, with an ‘open door policy’, and many commented on how they

appreciated the importance of what they described as a lack of informality and being able to easily

access senior staff.

Staff particularly valued both access to the senior team and managers and felt the visibility of the

executive team to be a key aspect of being well led. One said:

‘senior managers and clinical leads spend a lot of time over there, they were highly visible

and one of CEX’s strengths is that everybody knows who he is because he walks around the

wards and talks to people, he is a normal bloke’ (14 S – surgical consultant)

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This concept of the chief executive being seen as a ‘normal bloke’ supported the impression of

friendliness and informality that was described by many of the participants. One participant said

they felt the Trust to be:

‘visibly well led in that x [director of nursing] is seen a lot on the ward, the Chief Executive is

seen wandering around and you can stop him and I will stop him and lobby or whatever I

need to do to get what I want and that works well’ (13M – senior nurse medicine)

This ease of access to the senior team was seen as very important to the participants, and staff

valued the lack of formality and ability to communicate with the senior management in this informal

manner.

Setting and translating the vision As well as having access to the executive team for support and advice or to lobby, another common

aspect of the interviews was the importance of the executive team setting and translating the vision

for the organisations. Thus, the importance of a two-way communication was valued by the

participant. Clarity of vison and expectations of staff were felt to be very important in the context of

being well led, as well as being able to translate these so that staff knew what they were expected to

deliver. One participant said:

‘To set a really good vision that is easily translated into services, so again it feels real and I

think that is a strength of the leadership here in terms of being able to translate strategic

objectives and what it means for the services and staff’ (4 C – senior nurse)

Critical to the translation of the vision was the importance of feeling connected. One participant in

particular highlighted the importance of having an emotional connection:

‘It’s a heart and soul thing … with the organisation an emotional connection with the

organisation … I think through line management, appraisals, all of that, we have got a real

sense of connection … a kind of connection between the Board, senior management team

and the front line.’ (1C – senior nurse)

Common within the family theme, was the importance of access to the ‘parents’, that is, the

executive team, visibility of leaders, and clarity of what was expected of the staff. The concept of

feeling connected to the organisation’s core purpose and values, particularly in an emotional sense,

emerged as a strong theme in the interviews.

Many of the staff during the interviews expressed concerns about the impact on the Trust having

merged with another organisation (which had occurred three years earlier) in terms of a reduction in

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visibility of senior staff. Some of the senior staff had based themselves for a couple of days a week

on Site two, which had inevitably led to a reduced presence on Site one. One member of the

executive team said:

‘I think you have to be on the two sites at different times and people need to know whatever

day I am going to be here that I am and am visible, approachable and contactable.’ (10 C –

executive director)

However, most of the staff accepted this as inevitable and some thought this had created greater

opportunities for deputy staff to become more visible. One participant who had been recently

appointed said:

‘from what I see is that they do have good deputies here and they do think about succession

planning and think about who could be coming into those roles.’ (22 O – clinical midwife)

Throughout the interviews there were many concerns given about the impact and influence that the

merger with the second site had had on the original site. The merger had happened some years

earlier, but the differences between the two sites were frequently referred to during the interviews.

This was with particular reference to the strategy the executive team had taken to impose the way

on working in relation to shared values on Site one on to Site two. Gaining greater understanding of

the concept of ‘well led’ in relation to the merger was outside the scope of this study, however, it

emerged as an important area of concern for staff and these findings are included where they relate

to the concept of being ‘well led’ within the four themes that emerged from the data collected.

Recruit to fit the family and shared valuesThe importance of staff being seen to live the Trust’s values and the Trust culture being central to

the experience of being well led was a key aspect of the interviews. The values had been launched a

few years previously. One participant referred to the launch and said:

‘a few times in the first year that they were launched would people have the confidence even

in an e-mail to say: this isn’t really in line with the value of working together is it.’ (2 C –

senior manager)

This quote illustrated how staff felt confident to challenge when they felt staff were not seen to be

‘living the values’ that were expected from working within the organisation. The terms used to refer

to Trust x culture and family were often used interchangeably. One common finding from the

participants was a view about the need to fit within the family and therefore the importance of

selecting the right staff who would share the same values of the Trust staff. One participant said:

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‘when someone has the same values and principles and can communicate that effectively

and can meet their objectives then I see that as well-led.’ (27 M – senior nurse medicine)

Participants talked about the importance of recruiting the right staff who they believed would

support the family culture of the organisation. One participant spoke about the building of this

family culture and gave an example of how this worked within the executive leadership team. The

belief was that by selecting staff who fitted the Trust family this helped to ensure that the way of

working would still continue if the current leaders were absent:

‘they tend to appoint people who do things similarly, they will tend to build that culture in

the kind of leadership team and as a result even if they are temporarily absent some of that

culture and some of that positivity can sustain’ (25 O – obstetric consultant)

Not fitting in the family Some staff clearly articulated what a good Trust fit would be; for example:

‘X trust fit is somebody who is hardworking’ (6C – director)

Others talked about the problems they encountered with staff ‘not fitting in’ and some went further

and spoke about how staff who didn’t fit in were unable to stay. Examples of these were:

‘People who are self-opinionated and self-directed might not fit.’ (20 0 – senior midwife)

It wasn’t clear what exactly the participant meant by this, and on reflection it would have been

helpful to probe further, but the comments suggested this behaviour to be outside the ways that the

‘family’ operated, which was more collegiate and a case of working together.

One of the participants supported this and said:

‘I have seen people come and go because they didn’t really fit in.’ (10 C – executive director)

Many of the participants commented that they felt that some of the staff on Site two didn’t fit the

‘family’ culture, predominantly due to their view that the staff didn’t share the same values as Site

one. One participant’s view was:

‘The main reason they don’t fit is because they don’t have the same values or that they think

they are in charge, and things will change to be done their way whereas that is not how it

works … a few people that didn’t buy into it have resigned because they didn’t fit in and they

weren’t going to play by the rules and so people who were clearly going to be disruptive –

the view was that we were better off without them.’ (14 S – consultant surgeon)

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The literature reviewed in Chapter 3 highlighted the risks of imposing a top–down culture that could

be considered manipulative, and some staff wouldn’t be able to survive in an organisation with a

strong culture that set values and norms that do not allow an individual to choose between sets of

values (Parry, Proctor - Thomson, 2003).

The focus on being ‘patient centred’ was a key feature within many of the interviews and

throughout the meetings observed. Examples were given of this across all the staff interviewed, one

participant describing the:

‘patient as being pinnacle to everything that we do.’ (20 O – senior midwife)

Another participant described being patient centred as being core to the success of the Trust, saying:

‘Our teams know that the patient is core to our business, they are the person we have to

keep safe. We do want them to come back to us and we want them to recommend that their

friends, family and colleagues to come here as well.’ (21 M – senior nurse)

This focus on patients being core to the business was a central feature across all of the interviews.

The executive team and managers (plus clinical directors) held leadership roles across both sites of

the hospital, and they talked about the differences in terms of patient care delivery and staff

behaviours between the two sites. This was despite the merger having occurred some years

previously. While staff talked very positively about Site one, many examples of previous problems

were given related to the staff and care delivery on Site two. Some attributed this to the different

pressures and challenges that the two sites faced, particularly in relation to staffing and the different

type of population they served. One participant gave the following view in relation to receiving

patient feedback:

‘two different populations so here [Site one] often written complaints are very eloquent but

often 5/6/7 pages long, over at site they will often come in by e-mail, very short paragraphs

and English may not be the first language.’ (11 C – senior nurse)

In addition to acknowledging the difference between the patient populations, there were also

observations shared about the differences in the workforce, particularly in relation to challenges

with recruitment and retention of staff on Site two. One participant said:

‘They tend to have far more difficulties with their staffing levels so it may be that the system

of management has evolved because of that, but certainly accessibility I don’t see the

management team out and about on the shop floor and interacting with the staff in perhaps

the same way that I do here.’ (22 O – clinical midwife)

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This participant felt the problems with staff were directly linked to the visibility of and access to the

middle and senior management, and many of the participants thought that Site two needed to

adopt a similar approach to that seen on Site one. As discussed earlier in this chapter there was wide

support from those interviewed (from both sites) of imposing the expected values of behaviours of

leaders on to Site two.

This had generally been welcomed by staff based on Site two who were very welcoming of the

values that they felt the merger has brought.

‘I was here for a year when it was x trust before it merged with Site one and now they have

the right Director of Nursing in, the right Chief Exec, Head of Operations so they all have the

same values and principles that I have, when someone has the same values and principles

and can communicate that effectively and can meet their objectives then I see that as well-

led.’ (27 M – senior nurse medicine)

Many of the interviewees commented on what they felt was a tough approach taken to dealing with

poor behaviour either towards patients or to another member of staff. Some of the participants felt

that the Trust as a whole was much quicker to take action since the merger. This approach to taking

tough action when required was in particular attributed to the style of the chief executive. One

participant observed:

‘he is very supportive but when things aren’t right he will address it and he can be fierce, very

occasionally’ (14 S – consultant surgeon)

One participant in particular expressed the view that they felt the senior leadership (since the

merger) ‘had their back’ and they could count on their support if they needed to take difficult

decisions with poorly performing staff. They said:

‘We do performance management and you have got to have the people to back you. I have

people backing me higher up that would support me because as soon as you start

performance management there are grievances and you have got to have that support to be

able to manage people’ (27 M – senior nurse medicine)

This statement highlighted the view of this member of staff that being ‘well led’ was related to

having the backing of senior management when they needed to tackle performance of staff and

action needed to be taken.

Another example was given where action had been taken by the directorate lead (supported by the

executive team) who felt that a member of the medical staff was exhibiting poor behaviour. The

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example given related to a medical staff member who were not following the Trust policy of

following the WHO checklist in theatre (a nationally accepted and adopted surgical checklist that is

used within NHS hospital operating theatres). Poor compliance of adherence to the checklist was

highlighted prior to the merger, and the senior leadership adopted a strong line with the staff,

stating:

‘pre-merger the CQC had said that there was very poor compliance with WHO checklist so ultimately

if you don’t do it that’s absolutely fine, 1. You don’t work for us and 2. I will share that with your

private provider that you don’t think that is what is considered best practice, that you don’t think it is

good for the patients … so in many ways it is trying to find the levers to make people change.’ (5 C –

executive director)

Examples were given by some of the participants of a commitment to take tough action where

medical staff in particular have been resistant to adopting the expected values and behaviours of the

staff. One participant said the message to these staff had been:

‘if you don’t want to be part of this then you are going to go … So we exited 5 consultants in the first

year and the background that my predecessor here hadn’t got rid of anybody in 13 years.’ (5C –

executive director)

Many of the participants supported this tough approach being taken to manage the participants, this

was despite the terminology used of ‘got rid of ‘.This participant added that this was enacted with a

degree of compassion, and said the Trust had:

‘A habit of trying to land people gently, so when dealing with Site two there were four divisional

directors, two remained and two were not kept on but we found them some roles to do in the interim

to try and give them a soft landing so as to not completely alienate people.’ (5 C – executive director)

None of the participants spoke about where these displaced staff went to. It appeared from the

interviews that they were exited from the organisation, but it was not clear whether they had been

given employment elsewhere in the NHS.

The participants from the executive teams also spoke about the negative language used by some of

the clinical leaders on Site two, where they were observed to be visibly criticising their own service

without recognising that it was within their own gift to change. They observed the lead clinicians,

saying:

‘you know this is terrible, that’s terrible, the other’s terrible when they are talking about their own

service’ (5 C – executive director)

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The position taken by members of the executive team was a recognition of the need to engage the

clinical leadership in taking ownership of the problems within their service and support them in

driving improvements.

The focus of the interviews was very much on the Trust’s expected behaviours being about

supporting staff and in ensuring a ‘no blame’ culture, and they described some of the behaviours of

staff on Site two as not fitting with this approach. They gave examples of previous medical staff on

Site two being blamed for clinical errors and a culture of blaming and reporting one another. One

participant said of Site two in relation to the medical staff:

‘They used clinical incidents to have a go at each other and report each other to the GMC [General

Medical Council]. 10% of the consultants at Site two went in front of the GMC because they reported

each other and they used clinical issues to have a go … so we took action to deal with some really

difficult medical HR issues that have been going on for several years so really tackling the really

thorny issues because those are things that from the medical establishment they want dealing with

and the upside is that when we did.’ (5 C – executive director)

The participants felt that this behaviour of staff in terms of the expected approach to managing

patient safety incidents had significantly improved over the last couple of years, and this was

credited to the action that had been taken to change the culture. Many of the staff interviewed on

both sites without exception described their experience of a ‘no blame’ culture. This was a term

used to describe the way in which they felt the Trust supported staff when serious incidents or

errors occurred. Many discussed examples of this as being measured in the high levels of reporting

incidents from staff, the openness within investigations, and the way staff felt supported through the

process, which included patient involvement and apologies given. One participant said they really

welcomed the:

‘opportunity to apologise to the patient if they feel that actually I didn’t do so well on that day.’ (7O –

senior midwife)

Another example was given from a front-line nurse, who said:

‘If I have an incident with medication I have to make sure that the patient is safe, do the observations

and I have to tell the doctor and reassure the patient and also fill out the paperwork online. The main

priority is to make sure the patient is safe.’ (26 M – junior nurse – medicine)

A further example was given from a junior doctor:

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‘my priority is to make sure that the patient is safe, so if I am involved in an incident unintentionally I

report it and normally I get feedback, so it is a learning process.’ (9 O – obstetric middle grade)

These examples demonstrated the focus on using the clinical incident reporting system to keep

patients safe, and supported the earlier views expressed in the study of a patient-focused approach.

This approach was consistent between both nursing and medical participants, showing they

recognised the expectation of them in putting the patient’s safety needs first. This did lead me to

question whether the participants were telling me what they thought I wanted to hear. However,

this approach was consistently described by many of the participants and was also reflected in some

of the meetings I observed. While this risk needed to be acknowledged as a possibility, the

participants were from different speciality areas, and spoke in very positive terms with regard to

how this Trust was different to others they had worked in, or to the experience of their colleagues

working elsewhere. The participants expressed the view they were confident of the organisation

supporting them to speak up and report and without fear of being blamed. This participant

illustrated this approach, saying:

‘Our teams know that the patient is core to our business, they are the person we have to keep safe.

We do want them to come back to us and we want them to recommend that their friends, family and

colleagues come here as well.’ (21 M – junior nurse medicine)

These views demonstrated a consistent approach to patient safety and why they felt it was

important to the Trust. None of the staff interviewed discussed their experience of being involved in

errors in negative terms. There was no evidence of any fear of being blamed for safety incidents, and

instead a focus on support and learning. In addition, some staff spoke about examples of where staff

had been supported in reflecting and learning from serious incidents. Participants still felt there

were more improvements to be made in this area within Site two and some of the participants

compared what they felt was good practice on Site one with historic practice on Site two. One of the

participants interviewed offered this insight regarding what they had experienced on Site two:

‘there was quite a history of consultants being suspended and blamed for things which were perhaps

outside their control, or even if they weren’t outside their control they certainly didn’t go and do

them deliberately and instead of trying to understand why they happened and building a system to

stop that from happening again.’ (25 O – consultant obstetrician)

This again supported the views that things had significantly improved since the merger. One example

included measurable improvements in a low reporting of incidents on Site two, which were now

more aligned to that seen in Site one. Another improvement related to the experiences of what

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participants described as a ‘blame’ culture previously observed in Site two, in particular consultants

blaming one another for errors that in referrals to their regulatory body. There was a consistent view

given by many of those interviewed that a ‘no blame’ culture was important to them. This was

important not only in keeping patients safe, but also ensuring that staff felt supported when errors

occurred. One participant observed:

‘Since I come from a country where there was a bit of a blame so yes I know the difference between a

blaming environment and a non-blaming environment, so there is no blame and I was involved in an

incident at this hospital before but they tried to find solutions to what would make it better and yes

they tend to do that.’ (16 M – medical junior doctor)

Another junior doctor’s comments supported this, saying:

‘and we have very supportive seniors at X so generally they would sit down even it’s a small error

what you could have done better and what you do in the future, but they don’t every criticise.’ (16 S –

surgical junior doctor)

There were also views expressed about a recognition of the difference between blame and

accountability. Clarity of knowing what they were accountable and responsible for was felt to be

important to participant’s views about the Trust being ‘well led’. This aligned well with learning

organisation principles that place an emphasis on system learning without blame (Chaffer, 2016;

Senge, 1990). This also relates to the importance of this learning being translated into ensuring safer

services as a result. This was highlighted by a number of the participants across the various

directorates, examples of which included the view that:

‘Non-blame means it is a non-blame culture but at the same time that doesn’t mean no

accountability or no responsibility.’ (8M – senior nurse – medicine)

Another participant in a different directorate said:

‘there are people who I know are accountable and responsible but I also know that I am accountable

and responsible so the buck stops with me within my role.’ (12 O – senior midwife)

While another compared the way the Trust managed safety incidents positively compared to other

Trusts they liaised with, saying:

‘when I go to other organisations and they seem more chaotic and there doesn’t seem to be a clear

line of responsibility and accountability, then I think that probably doesn’t help.’ (22 O – clinical

midwife)

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A similar approach was seen in the management of complaints. The process of managing complaints

viewed a patient-centred approach as integral to their approach, and this included meeting with

families early in addressing complaints to avoid them becoming more serious and difficult to resolve.

One participant said:

‘I think our biggest philosophy around things like complaints is that we try to deal with them at

source … matrons will meet with the person immediately and try and diffuse the situation and deal

with it at source.’ (20 O – senior midwife)

There was a clear expectation of staff that they would resolve complaints at source wherever

possible and training was provided to support this approach. One participant illustrated this saying

there is an:

‘expectation of the nurse in charge and that has come in through the training, is that actually they

will be trying to seek out those issues and resolve them with the patients and families.’ (11 C – senior

nurse medicine)

Another aspect to the management of complaints was viewing them as a way for the organisation to

learn and gain feedback from patients. There were a number of ways that the Trust encouraged

feedback from patients, including offering opportunities to complain via the Trust website. They

were invited to e-mail the executive directors directly and the Trust had put in place a system to

provide a rapid response to patients.

One of the executives said:

‘‘if you are an in-patient and you are not happy with the care I can actually do something about it if

you email me even though it might be a weekend or a night, I will get it sorted and that sometimes

shocks a few people but in terms of the response, but I think it is important that you can do that and

there aren’t many Chief Executives that you can email directly in my experience although it is a pain

in the neck … We all learn from complaints and unfortunately we do get them and anyone can make

a complaint or comment to me which goes on our website and I usually respond within a few hours

and that is quite important for me.’ (24 C – executive director)

This example demonstrated the commitment from the top of the organisation to live the values of

being patient centred. This was, however, acknowledged to require commitment to be able to

respond in a timely way, and could be seen as a significant burden on one individual. The comment

about this ‘being a pain in the neck’ illustrated this commitment despite this. This also further

supported the findings that related to polarity of the views expressed regarding the support for

distributed leadership as well as the need for a clear hierarchy. While the executive team spoke

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about a preference for distributed model of leadership, this stance from the executives appears to

contradict this in terms of being seen as the only people that respond to directly e-mailed

complaints. This burden could possibly have been mitigated if the nominated executive had

suggested there was a rota to respond on their behalf, but they said the requirement to respond sat

with that person. However, other staff spoke about a range of methods of receiving patient

feedback, and the responsibilities on all of the staff to respond in a timely manner. One of the staff

interviewed who talked about how they supported this approach to inviting patient feedback

illustrated this saying:

‘Any comments that come back in, anything that comes back positive either as a result of those

surveys, anything positive on NHS Choices, any tweets, anything like that, the matron in ED [the

Emergency Department] will send that out to the whole of the department. In the same way if

something negative comes in that as well gets shared with the whole department because you

cannot have one and not the other, if you are there and able to accept the praise then you have to be

able to accept the criticisms and work with those.’ (21 M – senior nurse medicine)

These examples demonstrated the importance that participants gave to giving feedback to staff, and

how they tried to balance both positive and negative feedback with the aim of motivating staff to

drive improvements.

Some of the staff interviewed expressed significant concerns about some of the staff’s experience

working on Site two. Some blamed the behaviour of a small number of consultants on Site two for

the problems the organisation had faced in terms of the previous poor quality of CQC care

assessment that was received prior to the merger.

‘Poor old x [Site two] when we acquired them, they had had something like 15 different Board

directors in the space of 18 months … we were told by x [external regulator] that the consultants at

Site two were feral.’ (6C – executive director)

Others interviewed felt it was the consultants themselves on Site two that had lacked support from

their senior management:

‘when I went to the other site I spent a lot of time talking to the consultants and they had been

bullied, undermined and intimidated by people who were in management above them … here was

quite a history of consultants being suspended and blamed for things which were perhaps outside

their control, or even if they weren’t outside their control they certainly didn’t go and do them

deliberately and instead of trying to understand why they happened and building a system to stop

that from happening again.’ (25 0 – senior obstetrician)

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These comments illustrated a range of views that show the perspectives staff held about compliance

with how they expected staff to behave in terms of living the Trust values, particularly on Site two.

This highlighted a degree of polarity between views about commitment versus compliance (Argyris,

1992). The staff interviewed believed that the values of Site one were the right ones and that led to

an expectation that all staff needed to comply with them. The significant problems of Site two were

highlighted by many of the staff interviewed who felt these had been effectively addressed in

particular by adopting a strategy to ‘transplant the culture’ from Site one to Site two. They felt that it

had been important to be very clear about expected values and behaviours, particularly about what

would and would not be tolerated by the organisation. To address this the executive team made a

decision to move a number of their senior staff to make the improvements needed on Site two. One

participant interviewed said:

‘the decision was taken to parachute most of the Site one leaders in over to Site two and support the

leaders that were over there.’ (6C – executive director)

Another said:

‘We transferred or moved about 50 people to try and infect the process at Site two… we are still

outnumbered 40-1.’ (5C – executive director)

The Trust executive team had made a deliberate decision to impose the culture of Site one on to Site

two. This was based on a belief that by moving senior staff across they would be able to change the

culture of Site two and improve the quality performance of the Trust. The decision was seen as

successful, and some of the executive team interviewed believed that by taking this action they had

managed to change the culture on Site two by aligning it with the values and behaviours of Site one.

In addition, the executive team had focused specifically on making improvements in the

effectiveness of senior clinical leadership. The rationale for this was given by one participant, who

said:

‘We wanted to change the culture and we used our values and behaviours as the benchmark, people

latched on to that and unlike other transactions where you have new leadership at the top, the

success of this one revolved around the chiefs of service, so the clinical leadership.’ (24 C – executive

director)

The participants from the executive team believed that empowering the clinical directors (medical

staff in leadership roles for the directorates) leading this clinical change had been key to changing

the culture on Site two. The comments illustrated an imposition of what the participants terms a

good culture on to Site two, and aligned to areas referenced in the literature reviews (see Chapter 3)

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that references where some organisation had made deliberate attempts to adopt what they term a

strong culture by stating expectations of behaviours by staff in terms of beliefs and values (Robbins,

1996). These expectations were communicated to employees and subsequently enforced by a series

of methods (Legge, 1994). The rationale for this approach is based on a belief that development of a

strong culture will result in greater employee commitment, improved quality, leading to a strong

corporate culture (Bagraim, 2001; Pascale, 1985). The risks of this type of imposition on an

organisation were highlighted earlier in Chapter 3 in a study within a supermarket chain by Ogbanna

and Wilkinson (2003). While they saw measurable improvements, they concluded that rather than

an imposition of ‘organisational culture’ being a valid method for organisations to improve

performance. It was instead labelled as simply an indication of instrumental compliance and not a

change of culture. The conclusion was that introduction of a behaviour and compliance model could

achieve desirable results, but this could not be attributed to a change of culture. Once again the

comments from the participants illustrated a focus on compliance as a tool to drive improvement

rather than necessarily creating a climate for commitment (which is seen as a key component of a

learning organisation) (Argryris, 1992)

There was, however, wider spread acknowledgement from those interviewed about how difficult it

had been for Site two. Some participants talked about how they felt they had taken a supportive

approach, but with a strong message within it stating the way forward was to work in the same way

as Site one. One of the executive team said this was:

‘not telling them off and telling them that they are rubbish, but just going listen guys you have had

terrible management, we are now going to show you how we do it the x [Site one] way.’ (5C –

executive director)

While the approach appeared to be one of imposing Site ones culture on Site two, there was a view

from one member of staff who spoke about the importance of also acknowledging that there were

areas that Site one could learn from Site two:

‘I also think this site [Site one] need to go over and see what is good about the other site as well as

there is good on both sites.’ (12 O – senior midwife)

Throughout the interviews some of the findings suggested a degree of ‘group think’ (Janis, 1982)

where the problems of Site two which was presented at as having been a problem. This had been

evidenced by the previous CQC inspection, and during the merger process. Conversely, the above

comment from 12 O acknowledged the positive aspects of Site two. However, the views of the

participants were that the strategy of ‘infecting Site two with their culture’ had worked and they

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highlighted examples of improvements in patient experience that included a reduction in patient

complaints. One participant also observed the improvement in the staff well-being on Site two as a

consequence, and said:

‘there was a fall in complaints and there was a definite rise in positive feedback and the staff seemed

to be sort of standing a little bit more upright and I think there was a bit of a kind of bounce because

the loop had been taken off people’s necks and people were a bit more happy to speak out.’ (25 O –

senior obstetrician)

One measurable outcome of the changes imposed was a significant improvement of Site twos CQC

rating. It was moved from being rated ‘inadequate’ to ‘good’. These improvements confirmed to the

participants the validity of the approach that has been taken to the imposition of the Trust

expectations regarding values and behaviours on to Site two. Few if any of the participants

questioned or challenged the approach that had been taken, and believed the results spoke for

themselves, which was that the site had improved and the evidence for that was clearly

demonstrated in the improved CQC rating.

There were, however, some concerns raised about the CQC inspection regime and the negative

impact this had had in relation to Site two. One participant described the impact they felt the

process had on both patients and staff. This senior lead clinician reflected on their recent experience

following the recent inspection:

‘it was desperately important that the CQC inspection was better than the last and a lot of effort

went into making it better than the last but sustainable change isn’t about a few inspectors who

come round on a day and actually I don’t personally find the CQC a particularly a good way to assess

an organisation.’ (25 O – senior obstetrician)

They went on to say:

‘I think the CQC has enormous power of harm. I have been into a number of organisations not least

trust x … where the CQC has created destruction and harm and damaged patient care because I don’t

think they have any idea in the amount of destruction that a poor CQC rating brings to staff morale,

to the way the patients speak to the staff. The public will say “well I know this is a terrible place to

come and have care so I don’t trust you and I’m going to be rude to you” … and I just think that’s very

destructive and I think people who are constantly told how terrible they are stop trying.‘ (25 O –

senior obstetrician)

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These observations from this member of staff raised questions of the impact the CQC regime had on

the Trust and in particular Site two. The outcome of the inspection had concluded the site had

improved and was well led. While many of the staff had concluded that their actions of ‘infecting Site

two with the culture’ had produced this outcome, this participant expressed a degree of reservation

in terms of sustainable change.

Striving for excellence The Trust’s ambition for excellence was described by many of the participants and this need to

continually strive for excellence was mentioned mostly in positive terms. However, a few

participants expressed some reservations stating they felt the Trust has pushed this agenda too

hard. This was related to the increasing pressures the staff were feeling and they were looking to the

leadership to support them in not increasing expectation on them to continue to do more. One

participant said:

‘we don’t say no to things so the work keeps coming.’ (3M – senior doctor medicine)

Another participant said:

‘sometimes I feel we should take a step back and say actually we can’t do that right now’ (12 O –

senior midwife)

This risks of ‘over reaching’ (Collins, 2009) is included within his theory of the ‘five stages of decline’,

which can potentially lead to an organisation’s failure, relating to where there is a strategy for

pursuit of more. Parallels can be seen from the views given by the staff raising their concerns about

being over-ambitious in terms of what can be delivered.

Summary of theme In summary, the concept of family was a key theme where staff described their experiences of the

way the executive leadership team (top team) instilled a sense of commitment, shared vision, values

and empowerment of staff. This theme encapsulated a number of components from the learning

organisation theoretical framework but there were also aspects that were less in congruence with

this, such as the examples given of an ‘imposed’ culture on Site two, and some of the views

expressed by the staff towards Site two.

This theme focusing on values and behaviour included examples of where the Trust leadership had

addressed particular issues with poor behaviour related to Site two. It included examples of where a

tough approach had been taken in addressing poor behaviour, particularly where staff were not seen

to be working within the expected values held by the organisation. This theme included examples of

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how the Trust managed safety incidents and how the approached complaint management by inviting

feedback, being responsive, and dealing with complaints at source. The concept of not blaming staff

for errors and learning from both safety incidents and complaints was core to this theme.

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Theme 2: Distributed leadership with some hierarchy The second theme that emerged entitled distributed leadership with some hierarchy, encapsulated a

number of components from the learning organisation theoretical framework. The theme also

included within it a view by some of the participants of a military influence in relation to their

experiences of the concept of being well led.

Hierarchy and chain of commandThe interviews revealed a polarity around the term of hierarchy that was referred to in many of the

interviews. Some staff spoke about how much they valued a ‘flat structure’ and felt the Trust to be

‘non-hierarchical’, by which they meant they felt that staff could approach anyone regardless of

seniority for advice and support. Conversely, others talked about the importance of a clear chain of

command approach and how important is was to be clear about who was ‘in charge’.

One participant said:

‘being well led, it very much feels like there is not much difference from the top to the bottom’ (8 M –

senior nurse)

Another from the executive team talked about the need to:

‘break down hierarchy’ (5 C – executive director)

This was not, however, a view shared by some of the other participants who spoke about the

importance of hierarchy. One said:

‘it is actually quite important to have a hierarchy and to know as a staff member at which point you

need to approach the person in that hierarchy’ (22 O – midwife)

Another participant supported this view in saying:

‘You need to have leadership, there needs to be a certain hierarchy team profile and it is about

making sure you get the right people in the right job, because when we have had 2 people in the

wrong job it caused mayhem.’ (27 M – senior nurse medicine)

The participants’ mixed views on hierarchy presented a confusing picture regarding the relationship

between hierarchy and views about being well led. One of the participants talked about hierarchy in

relation to career progression, saying:

‘There are actually only 7 grades, 7 steps if I wanted to progress that way, there are only 7 other

people who I would have to jump up above before I get to be chief exec.’ (17 M – junior nurse)

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Another participant talked about hierarchy in terms of access to senior staff and how much they

valued being able to approach the executive leadership team. Many examples were given in relation

to where the senior leadership team were viewed as having an ‘open door’ policy and staff felt they

could approach them at any time. One said:

‘their door is always open and you could just walk in.’ (14 S – surgical consultant)

While many of those interviewed highlighted how much they valued access to senior staff this

appeared to conflict with the importance they placed on a visible perceived ‘chain of command’, the

importance of knowing who was in charge, and staff knowing their place in the system, one

participant going further, saying:

‘actually the safest thing is a chain of command.’ (4 C – executive director)

The staff frequently used terms such as ‘chain of command’, the importance of knowing who was in

charge, and how well the service was organised. Some also attributed this to the military influence

and felt this visible clarity benefited staff in knowing who to ‘go to’ when they needed advice or

support.

During the interviews some staff spoke about the problems they had in the past where both clinical

staff and patients were not able to identify who was in charge of the in-patient wards. One initiative

that had been introduced was a ‘red badge’ system, which was where the nurse in charge of each

shift wore a magnetic red badge to denote that they were in charge. This was believed by the

participant to be a successful initiative to address this issue:

‘that one person has full accountability of the ward so we have a little red magnet that says nurse in

charge … everybody in charge of a ward wears a red badge.’ (4 C – executive director)

This reference to this symbol of authority demonstrated the importance the participant placed on a

visible chain of command and again the possible influence of the military staff’s strong focus on

symbolic labels to demonstrate the ranking of their staff (Bell, 2013).

Informality In contrast to the focus on a visible chain of command many of the staff spoke about their

appreciation of informality. One said:

‘This is a very friendly organisation to work in, even if you go to some of the higher level meetings it is

a very friendly environment.’ (7 O – senior midwife)

Some of the staff interviewed spoke about how much they appreciated the lack of bureaucracy in

terms of meetings being informal, absence of agendas, and being given the freedom to ‘just get on

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with things’ without having to go through formal business case development processes to make

changes in their department. One participant said that what they appreciated was that the:

‘meetings are very informal and for the executive we don’t really have minutes.’ (5C – executive

director)

I observed a range of meetings during this study, and my observations very much supported this

view of informality. I found the majority of the meetings to be fairly chaotic in nature, none of the

meetings started on time, staff arrived at different times, and frequently disrupted the meetings as

they moved chairs around to accommodate late comers. The executive meeting I observed was run

in a very informal way. It was not possible for me to establish who was chairing the meeting (the

chief executive was on leave) and members of the group had side conversations, took phone calls,

checked e-mails, and interrupted one another throughout the meeting. There was no formal agenda

or obvious action points and it was not possible to ascertain what decisions had been taken. The

meetings I observed across the organisation, which included medicine, surgery, and maternity, were

similar although they did have agendas, minutes, and some action points. Staff seemed to be very

relaxed, eating their lunch, and most of the participants were seen to be engaging in the meetings at

various points. Across all four areas where the meetings were observed discussion appeared to be

friendly (lots of laughter), open, with mostly equal contributions from the participants, but not very

action focused.

Many of the staff interviewed valued the informal approach within the Trust. One participant said

they really liked:

‘that informal way of getting things done, that personal I’ll pop round and have a chat with …

however, we’ll have a face to face discussion and try and find that balance between a structured kind

of formal way of getting things done and the informal quick yeah let’s just get on with it. I would be

really sad if we lost that.’ (1C – senior nurse)

However, again a contrast was given between the informal approaches experienced at Site one

compared to that of Site two. One participant commented:

‘it was a mess whereas x [Site one] if you wanted to do something you didn’t have to ask permission,

you didn’t have to write a business case, you just made it happen because it was good for patients.’

(14 S – consultant surgeon)

The importance of this concept of informality was a deliberate strategy of the executive team where

they prided themselves on giving freedom to the various directorates. In particular, they provided

clinical leaders with what they felt was just the right level of support, for example, finance and

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business support. They felt this process of clinical engagement to be very important in empowering

the clinical staff to give the freedom to be allowed to get on and do their jobs. One of the executive

team said:

‘what we have not done is given the clinicians the budget because my feeling is that you have got a

general manager and they can manage your £70 million budget, what I want you to do is lead on the

clinical strategy … we have given them the opportunity to lead change and more importantly giving

them a wow factor of the satisfaction of delivering something.’ (24 C – executive director)

The importance of supporting clinical leadership and engagement was felt to be an important aspect

of the success of the Trust, and the success of this was seen in the success they had in both

attracting and recruiting to clinical leadership positions and the success in taking clinical services

forward.

Competence The Trust was one of a small number of hospitals that had incorporated military services and merged

with a military hospital several years ago. Many of the staff interviewed commented on the impact

of the military leadership and how they felt this influenced the way the hospital was run. Staff

expressed the view that the military influence was a key aspect that had contributed to the Trust

being well organised. Some participants reflected on the way they had observed the military staff’s

strong focus on the well-being of staff and the importance they placed on supporting their teams.

One of the members of the executive team reflected during the interview what they had observed in

the military staff’s strong primary focus on staff well-being.

One participant commented:

‘There is obviously a military aspect here (and I am not military) but whether or not, the fact is that

the military branch feeds in to being well organised.’ (18 M – junior doctor – medicine)

Another said:

‘Everyone in the military is very efficient and very goal orientated.’ (16 S – junior doctor surgery)

A further participant commented about how they had observed the approach of the military staff’s

key focus on the importance of working together and compared the running of the trust to leading a

military team:

‘the army will pull together and make it work.’ (13 M – senior nurse medicine)

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One of the executive participants reflected on what they felt they had learned from the military. This

was recognising the importance of putting the staff first, who in turn would provide better care for

the patients. They said:

‘if you were to ask me a couple of years ago what is the role of the ward sister or the shift leader,

people would talk about looking after the patients. What we learnt from our military colleagues is

that they go out on an expedition or they have a task in hand, the task is secondary to leading the

team.’ (4 C – executive director)

This shift in focus from patient to team and subsequently the staff aligned strongly with the concept

of family and the importance of working together as a team. Another participant supported this,

giving the following example:

‘we know that she is if you like been in the trenches taking grenades with us.’ (17 M – junior nurse

medicine)

This illustration of the experience of camaraderie aligned strongly with those illustrated within

Theme 1 relating to the concept of ‘family’ and being ‘in it together’, however, there were also some

interesting contradictions in some of the views given. Whereas some focused on the team aspect,

there were also other comments that spoke about the military in terms of hierarchy and the visibility

of a chain of command.

Some of the staff spoke also about the importance of staff competency in relation to being well led.

The term ‘competence’ was discussed both in terms of front-line staff and also of the top leadership

team. One participant said:

‘Well-led looks like somebody who is competent in their role. As an overall Board – competent

people, confident, know their job, fair, good leaders and good managers.’ (27 M – senior nurse

medicine)

Another interviewee shared a similar view:

‘a competency of what it is to be in charge and actually with that it’s about how you manage

incidents, how you manage someone that is upset with their care, so really trying to standardise

some of the expectation and the response and that has gone down really well, particularly for our

Band 5 and 6’s that may be in charge of a shift.’ (4 C – executive director)

Another participant firmly linked the concept of being well led with competency, and the importance

of competency to running a ward. They said:

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‘some people that you see who are not competent to do a job, so therefore cannot lead well … when I

first came in I had 5 band 7 vacancies so the areas weren’t well-led.’ (27 M – senior nurse medicine)

They described a range of actions that had been taken to rectify the issue, which included dealing

with a ward manager they felt was not competent and recruiting a new ward leader who they felt

demonstrated the competence and values required to make the improvements needed.

‘This ward a year ago was under an action plan, we have 3 serious incidents in the space of a month

and x just happened to come along at the right time. When you get the right person in the right job it

thrives because she has the communication skills, the knowledge, the empathy, the patient care.’ (27

M – senior nurse medicine)

The issues with the ward were resolved and the vacancies filled. They went on to say:

‘this is now a delightful ward and the patients are happy, the staff are happy, the doctors are happy

and that’s what well-led looks like.’ (27 M – senior nurse medicine)

Thus, the strategy of directly dealing with issues in this way was felt by the participants to be

successful and in particular reflected in improvement for both patients and medical staff.

Commitment to deliver As well as the participants’ focus on the importance of the competence of staff, they also frequently

used terms such as the importance of delivering on what is expected, highlighting the importance of

doing what you say you will, and being seen to deliver. This focus supports the work of Argyris

(1992) in relation to the learning organisation. This relates particularly to the concept of ‘espoused

theory’, which is where leaders can be seen to say one thing and, in reality, behave in a completely

different manner. This concept of delivering was illustrated by one of the executives who said:

‘if we make promises or pledges or we have a strategy/set of Board objectives we say to everyone

this is what we are going for … the employees look at what the leadership delivers.’ (6C – executive

director)

This was further supported by one of the participants who said:

‘we know what we are expected to deliver and then given the support and headroom to do that.’ (21

M – senior nurse medicine)

The importance of engagement of staff on empowering the clinical leaders within the NHS is

considered an important aspect of effective leadership (Berwick, 2013). This approach of

empowering staff in various leadership roles to be supported and given headroom to deliver aligned

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with the concept of distributed leadership was discussed in Chapter 3 (Bolden, 2011). The benefits of

distributed leadership were highlighted where individuals contributed to the successful performance

of an organisation rather than those that have the designation of leader in their title (Bolden, 2011).

Concerns raised within the literature review also included some cautions of this approach, which

risked giving an illusion of distributed leadership displayed as staff engagement that may not be real,

that is, the power to make decisions is not necessarily delegated (Young, 2009). These concerns

were not raised by the participants during the interviews – many were very positive about the level

of clinical engagement – but it is possible that some of the clinicians that had left the organisation

due to not fitting in may have held a different view. While their views of the staff that had left sat

outside the scope of this study it is an area worthy of further discussion and is considered further in

the next chapter.

Summary of themeThis theme’s focus has been on the views of the participants in relation to a distributed leadership

approach and also a desire to ensure some degree of hierarchy with a clear chain of command. The

participants expressed views that suggest they want both. They valued informality and being

allowed to get on with their job, but they also recognised a need for clarity in terms of knowing who

was in charge, particularly in relation to the in-patient wards. The influence of the military, with a

focus on being organised, competent, and focused on team performance was mentioned by many of

the participants, and the staff valued being supported to take ‘tough action’ where it was needed to

make improvements to care delivery. The participants gave examples that illustrated a deliberate

strategy to impose what they termed as the ‘right culture’ on Site two, and they believed this had

resulted in significant improvement, that is, improved CQC rating.

Theme 3: Learning The third theme focused on the concept of learning, which was a common term used across all of

the interviews. The term was used to describe a number of aspects in relation to the concept of

being ‘well led’. The term was used consistently when discussing patient safety incidents, and the

importance of learning from harm in terms of prevention of future incidents (Reason, 1997). The

concept of system learning was referred to by many of the participants in relation to incident

investigation and a recognition that safety incidents were rarely attributable to a single individual

(Reason, 1997). The importance of identifying system factors leading to safety incidents is well

recognised as a key component in the importance of designing out errors and supporting more

reliability of processes to prevent safety incidents occurring (Senge, 1990) and (Reason, 1997).

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The concept of a developing a learning and no blame culture was described by many of the

participants. One participant said:

‘We try to have a no blame culture, if there was something that we had to learn from we learnt from

it, and it wasn’t a case that you just said that’s what we are going to do, we went back and

checked … we try to create a culture of learning.’ (10 C – executive director)

This focus on learning was supported by another participant, who said:

‘I think that we really are a learning hospital.’ (4C – executive director)

This focus on the term ‘learning’ was a common theme throughout all of the interviews and

supported by a belief that the organisation was very much focused on using learning as a way of

driving improvements in patient care.

Another participant said:

‘we have learned as much from where we fail.’ (8 M – senior nurse – medicine)

This focus on learning was discussed specifically in relation to learning from clinical incidents. One

participant illustrated this, saying:

‘clinical incidents were seen by people a constructive way at looking at learning from things they do

learn from them and then they can see that things will be better for the patient and outcomes will be

better.’ (14 S – consultant surgeon)

Another participant commented on how important it was to:

‘learn from experience of certain cases which might have gone wrong, medicine by definition,

although we aim to give the best care, mistakes are made.’ (18 M – junior doctor medicine)

This was further supported by another participant who said:

‘I think where mistakes do happen and they do, as long as people learn from them that is the key bit.’

(24 C – clinical director)

This approach to learning from specific incidents was illustrated by another participant who gave a

particular example of some actions that had been taken to prevent a repeat drug error occurring.

They explained that the aim of this was to:

‘prevent it from happening again and we went through a system of having the purple box on the

trolley for the drugs so it is quite a systems approach to instant management.’ (13 M – senior nurse

medicine)

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Another participant went further stating how learning from incidents could be used to make

improvements and in turn improve care, saying:

‘the way you learn, we tend not to beat people up badly about it but try and make it developmental

and if everybody is striving towards doing it as well as they can it’s the way you learn.’ (14 S –

consultant surgeon)

This approach to learning was supported by a set of agreed governance processes that were felt to

be an important feature of being well led. One participant said:

‘Important to have the right governance framework, ensuring what they do is safe and centre stage

is the patient … governance arrangements are all about openness, transparency and again some

really good clinical leadership and that takes time to build.’ (24 C – executive director)

Many of the participants made references to how the Trust senior team had invested in training and

development, which served to illustrate the importance given towards organisational learning. This

investment and access to training was viewed as very important to the staff at all levels, and was in

particular highlighted by a number of the executive team. Some of the participants gave examples of

where there had been successful bids for additional external investment to develop the leadership

capacity of the clinical staff in addressing some of the issues that the merger has surfaced.

One of the participants said:

‘we had a bit of integration funding for bringing the organisations together and we have been able to

use some of that in leadership training for nursing.’ (1C – senior nurse)

A participant from another department also spoke about a recent successful bid to deliver some

leadership training, saying:

‘we managed to get £60,000 from a bid to HEE [Higher Education England].’ (7O – senior midwife)

This investment in delivering this training had been very well received and the participants felt that it

had been beneficial. One of the senior executive team commented:

‘that investment in people’s leadership has really paid off.’ (4C – executive director)

This approach was also supported by a front-line nurse who had worked in the Trust for a couple of

years and compared their experience to their previous Trust. They spoke about how access to

funding for external courses had become more difficult due to a reduction in national funding. In

response to this, the Trust had taken the initiative of developing their own courses and was running

them internally for their staff. This nurse from Site one said:

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‘the thing that is different here is that you kind of explain it to the guys here who haven’t worked

elsewhere is that we have internal courses to try and make up the difference.’ (17 M – junior nurse

medicine)

Another senior nurse from Site two supported this view in saying:

‘We have the best education team that I have ever worked with. They really work hard, they are a

great team, and they do training in house now which is great.’ (27 M – senior nurse medicine)

Both of these quotes showed how the participants appreciated the focus the Trust gave to

supporting education. The participants from the executive team felt the investment in training had in

particular resulted in improved cross-site working and had helped staff in leadership positions to

drive a range of quality improvement within the hospital. There was also a view given from the

participants about how open the Trust leadership was to supporting staff in applications for funding

for training. One of the executive team said:

‘for training and development it is quite rare for us to say no to anything.’ (6C – executive director)

Another from the executive team spoke about the importance the leadership team gave that

‘guaranteed that they would never be cancelled.’ (4C – executive director)

The Trust had been previously successful in achieving ‘investors in people’ (IIP) accreditation and had

been awarded ‘bronze status’, which is where an organisation is assessed against a number of

standards that align closely to those within learning organisation theory. One particular component

that aligns is where training and development of staff takes priority, and a recognition of where

there are pressures on an organisation that the need to increase access to training becomes even

more important (Argyris, 1992). The above example given by one of the executives of the Trust

showed the commitment to training aligned well with the learning organisational theoretical

framework used to support this study.

Talent managementThe participants also spoke about the process they had used to select staff to go on courses, in

particular the leadership programmes. The importance of ‘talent management’ was mentioned in

relationship to identifying staff with potential to be encouraged to take up leadership positions. The

importance of building both individual skills of staff and overall capacity of the leadership are key

components within the learning organisational framework underpinning this study (Argyris, 1992;

Senge, 1990).

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Having an organisational focus on ‘talent management’ is a key standard within IIP accreditation and

again aligns well with learning organisation principles. Some positive examples of how the leadership

teams had identified and selected these staff were given by one participant, saying:

‘we came up from the 40 with the same 20 names individually that we thought were really talented

and we were amazed at the talent that was in the organisation already.’ (4 C – executive director)

Another said how they felt:

‘that is important and I think people learn on the job and we try and spot talent and where there are

opportunities and we have got gaps then we encourage people to fill them.’ (24C – executive

director)

One reason given for why the staff thought this was so important related to succession planning and

ensuring that there were staff ready to step into leadership positions when required. One participant

said:

‘so if god forbid I was to win the lottery rather than get run over by a train, X [deputy] would be able

to step in. If something happened to x then y [their deputy] would step in.’ (8M – senior nurse

medicine)

Another reason given for supporting the focus on talent management related to commitment to

continuous improvement. This comment was given in the context of how the participants felt that a

key component of being ‘well led’ was about raising the overall standard of staff. They illustrated

this point saying:

‘part of the trick that the good leader’s got to pull off is pulling those people who are below average

to average and pulling those people who are average to above average and if you can just do those

two things you cooking on gas and humming along.’ (24 C – executive director)

This comment supported the ambition of the Trust to push for excellence. The participants

expressed the views that they weren’t content to be average; they wanted to be the best. This point

was illustrated in one of the meetings I observed where the clinicians were discussing the results of a

national audit in relation to a specific surgical clinical speciality. The results had shown some

progress by the Trust, but they had scored as being average within the audit. The collective response

from the participants was that this wasn’t good enough for them and they wanted to be the top

performer in the country and not in the middle scoring group. There was no challenge given to this

view expressed at the meeting, and there was overall commitment to give greater focus to making

the improvements necessary.

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One particular comment given by one of the executives was their reflection of the need to focus on

continual improvement by remaining ‘energised’, and gave the following example of how they keep

themselves motivated so they can continue to motivate others.

‘I have gone through several of these where you have to reinvent yourself particularly if you stop in a

role for a significant period of time because if you don’t re-energise yourself you just go flat in terms

of performance.’ (24 C – executive director)

This comment reflected an interesting insight into their views about continual improvement and

how this is balanced against the risk of being in the same role long term. This point around the

longevity of post holders in leadership positions is discussed in more detail within Theme 4.

Summary of themeThis theme focused on the concept of learning, which incorporated aspects of its application to

patient safety incidents and investment in education and training, which has included a specific

emphasis on developing and building leadership capability. There was also a focus on building

leadership capacity as well as leaders taking responsibility for improving the overall performance of

staff, moving some of the staff from average to good. The focus of the Trust on this concept of going

from ‘good to great’ supports the work of Collins (2001) who views the investment in staff as being

key to this ambition. However, further follow-up to Collins’s (2001) research describes the issue of

sustaining this effort, and this is explored in detail in the following theme.

Theme 4: Sustainability responding to current and future challenges and pressures Theme 4 is entitled ‘sustainability’, which captured the concerns raised by many of the participants

of the need for the Trust to be able to respond to both the current pressures and future challenges

they were facing. This theme was labelled as sustainability to reflect these challenges and pressures.

While the staff overall were very positive about the leadership within the Trust, there were frequent

references to the pressures and challenges the Trust was facing. These concerns related to the staff’s

concerns about the ability of the organisation to maintain its position of being well led and delivering

high standards of patient care in the longer term due to the increasing pressures and challenges

many of the participants shared.

These challenges related to a number of key areas, one of which was the increasing pressure of

increasing workloads. Another was the financial pressures where staff felt that the continual

requirement to make continuous savings were not possible. There were also significant concerns

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raised about succession planning for the executive team alongside concerns for the longer term

sustainability for the Trust in terms of the way they felt it was currently being led.

This point was illustrated by this participant who reflected:

‘I think it deserved the well-led title at the last CQC inspection but I don’t know if we will get it this

time.’ (27 M – senior nurse medicine)

This comment illustrated the concerns of staff as to whether the concept of well led was sustainable

in the light of the increased pressures on the hospital.

Increasing activity The Trust alongside many across the NHS was facing considerable financial challenges at a time

when the activity appeared to be growing. One participant said:

‘the hospital is very busy and getting busier and busier.’ (9O – trainee middle grade obstetrician)

Many of the participants supported this view and reflected how they were feeling the growing

pressures and were concerned that the good reputation the Trust had enjoyed was at significant risk

of being lost as they felt they were beginning to fail in meeting the needs of the patients. One

participant said:

‘at the moment because you can’t actually do what people need or want and you can’t do what’s

right by patients because there isn’t any money and the reality is that means that people are a little

more demoralised again and I think there has been a little of that kind of back sliding of some of the

positive changes and some of them are continued but I think there is a bit less of.’ (25 O – consultant

obstetrician)

The impact of these pressures on the staff were felt to be significant. Examples were given of the

continual pressures to manage the flow from the emergency department when there were no beds

to move the patient to the wards. This was described as being on ‘black alert’, which is a status

hospitals use when the pressures on the service have reached a critical point, that is, when the

service is felt to be unsafe. Declaration of a black alert was previously a rare event. Staff described

the frequency of this situation and continual demands on staff to react and respond. One of the

medical leaders said:

‘Being told every single day that you are on black alert, you have to go and see another patient here

and squeeze another 2 or 3 into clinic, people just get tired.’ (3 M – consultant physician)

Another supported this, saying:

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‘Everybody is doing everything they can, all the capacity we possibly can open has been opened, and

it is just good to share the pain sometimes.’ (21 M – junior nurse medicine)

This participant felt the situation was not sustainable and was impacting significantly on both

themselves and their teams. The majority of the participants were concerned about pressures on

staffing numbers. This was a main agenda item on the four meetings that I observed. The pressures

on both nursing staff with high-level vacancies and unfilled shifts were causing considerable

concerns. The same pressures were observed across all medical specialties, in particular at middle

grade (senior registrar speciality grade). These pressures were leading to significant overspending on

temporary staff within the various directorates and the senior clinical leads were required to take

financial recovery plans to the executive team, referred to as ‘those upstairs’ to show how they

would regain financial balance.

‘I think we are used to being asked to work that extra bit harder and we all do but there are many

things currently that make it very difficult and very challenging – bed pressures, notes pressures, 18

week pressures and you can only keep working 120% for a short period of time, you can’t do it

forever, it just seems that there is no light at the end of the tunnel.’ (3M – consultant physician)

Another participant described how the pressures particularly in the emergency department (A&E)

was:

‘running the risk sometimes of it tipping the wrong way that the breaches can be more important

than the patient and I would say probably two or three times there have been occasions where the

staff have said to me in ED that it is starting to feel like the breach is more important than the

patient.’ (8 M – senior nurse medicine)

This participant was highlighting the risk of breaching the A&E target (which is externally reported)

becoming more important than the care of the patients as the pressures on the services increased.

This observation was significant in terms of placing the importance of achieving targets above

patient care, which was a key criticism within the events of the Francis (2013) report.

The participants generally spoke about the executive team with respect, recognising the problems

they were facing externally. During the interviews they referred to positive working relationships

with external partners. One participant said:

‘we are working with all our external partners as we, so I think as a well led organisation there are

very good expectations and communications with our external partners.’ (21 M – senior nurse

medicine)

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However, during the four meetings I observed there were a number of negative comments directed

towards external NHS stakeholders, for example, clinical commissioning groups (CCGs), NHS England,

NHS Improvement, and CQC. One example was during a meeting I observed where the participants

at the meeting were discussing about expecting a visit from an external organisation. There was

confusion as to who they were and they referred to them as:

‘NHS E &NHS I or whatever they are called these days … and we are being pushed from above in a

heavy manner, and at risk of being told how to run our department.’ (memo notes emergency care

meeting)

The context of this related directly to the increasing financial pressures, and demand on services,

particularly in A&E. It was interesting to observe the participants referring to external stakeholders

in this way, and this focus of considering others outside of the Trust as ‘out groups’ is a concept that

has been previously described by West (2012). This concept can equally be applied internally within

organisations where staff refer to other departments as ‘out groups’ such as ‘management’ or

‘Human Resources department’, but this was not reflected in the participants’ comments, who

instead appeared to direct blame for the challenges and pressures on external groups. This further

supported the comments from Theme 1 of how the participants demonstrated loyalty to the ‘trust

family’, and despite the level of the pressures described the participants remained supportive of the

‘parents’ of the Trust, that is, the executive team and other leaders in the Trust. There was a

recognition that the chief executive recognised the pressures they were feeling, and being heard and

listened to was key to the staff feeling valued. One participant said:

‘He gauges the temperature of the organisation, understands their pressures, talks to the staff and I

think the staff feel that he listens.’ (11 C – senior nurse)

While acknowledging the issues were key to staff so too was an expectation of the executive team

taking action to reduce the pressures. As was described earlier in Theme 1 relating to the continual

striving for excellence there were some risks highlighted by some staff that this had been pushed too

far. This raised the issue of whether the loyalty of the participants towards the executive team

would weaken if effective actions from them to reduce the pressures staff were feeling were not

taken.

While the meetings observed appeared to be informal and light-hearted in the main, I observed

some aspects particularly within the executive team meeting where the staff made a number of

negative comments in response to the pressures the Trust was experiencing. One example of was a

negative comment made about patients’ visitors use of the hospital carpark. The Trust has

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experienced some break down with payment machines leading to visitors failing to pay for their

parking. This had an impact on the Trust’s need to income generate to mitigate some of the Trust’s

financial pressures. Although the comments appeared to be light-hearted ones made in passing, this

was an example of a less patient-centred approach that appeared to be emerging in response to the

financial pressures. This was also observed when the executive team were reviewing overspending

by the directorates on non-pay items, and recommending a shift from the preferred delegation of

budgets to one of central control. There were discussions about the need for members of the

executive team being required to sign off agency requests, and a view from the team that this was

not a road they wished to go down. These comments reflected a shift from what had been the top

team’s espoused theory of demonstrating a distributed leadership model of behaviour (that is, being

seen as ‘well led’) to one of demonstrating more of a central command and control approach. Hence

the risk to the sustainability of the ‘well led’ leadership approach to one where the nature of the

pressures being to change the behaviours of the top team. For the moment, though, this shift of

approach appeared to have gone unnoticed by the participants who were interviewed.

Succession planning for executive team Concerns about both succession planning and the importance of talent management were discussed

by many of the interviewees. The chief executive was mentioned by first name by virtually all of the

participants interviewed. He was held up as an important role model for the Trust, in terms of their

visibility, clarity of expectations, accessibility, and openness and, in particular, their visible

commitment to both putting patient first and for supporting staff. While the merger with the second

site had lessened the visibility of staff on Site one, there was an appreciation of the need to be

visible on both sites and it was felt that this had given greater opportunity to develop more leaders

and encourage deputies to be more visible. While many felt that the Trust was paying attention to

both, many expressed concerns about potential changes in the top team, in particular the chief

executive. One participant said:

‘X [chief exec] is the glue, he spends a lot of time ironing out the wrinkles between people’ (5 C –

executive director)

The participants were overwhelmingly positive about the chief executive in terms of their role in the

Trust being seen as well led, some attributing this specifically to the stability of them having been in

post for many years. One participant relayed a conversation they had had with the chief executive,

saying they were confident that the leadership and culture of the organisation was sustainable in the

Trust and not dependent on him as an individual:

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‘“if I walk out tomorrow it would still carry on” and he says that publicly and I often reflect privately

and think is that true … the culture is not one man or one lady, it is a culture and I would like to think

that if eventually I do pack it in that the culture will remain’ (5 C – executive director)

Others felt differently; one participant said:

‘I think you cannot be the Chief Exec of an organisation for 20 plus years and it not to a certain extent

be about his leadership and him as an individual and the relationships that he has and has made.’ (11

C – senior nurse medicine)

Another participant highlighted the importance of others supporting such staff in chief executive

positions (the average tenure of a chief executive is currently 18 months (Nicholson, 2012)).

Reflecting on the risks of having a chief executive take up a role and then leave within a short period

of time, they said:

‘Anyone can make a decision or a set of decisions on a two year time frame and then leave a wake

because they are all wrong decisions and cause a lot of distress within an organisation.’ (24 C –

executive director)

There was also a view offered in relation to the importance of the chief executive being supported in

these roles:

‘We have one of the longest standing Chief Executives in the NHS and there must be some lessons for

the NHS in trying to support people to stay in those positions.’ (10 C – executive director)

The participants spoke about the wider executive team in similar terms but many expressed

concerns about the possible impact of the chief executive leaving. One participant illustrated these

fears, saying:

‘we will go through a period of challenge, a bit like a bereavement’ (10 C – executive director)

Another participant articulated this fear in terms of what they felt the risks may be of a poor

appointment:

‘if a new CEO comes in and is very different, autocratic, not communicative, you can disenfranchise a

workforce quite quickly I think so it takes a long time to get there but it doesn’t take long to fall down

and once people start getting fed up with how they are being treated they will work to rule, they will

become picky.’ (14 S – consultant surgeon)

While some saw a potential change of senior leadership as an opportunity, others expressed

concerns. During the data collection one of the members of the executive team had left to take up a

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post in another hospital. The process that was followed to recruit their replacement was positively

commented on by one of the participants:

‘I wouldn’t say that I am worried about who is going to fill her role because we have spoken with the

chief exec has asked what we want to see in our next Director of Nursing.’ (23 S – senior surgical

nurse)

This example of staff engagement from the executive team was viewed very positively by this

participant, and demonstrated involvement of front-line staff and giving them an opportunity to

contribute to the selection of future leaders for the Trust. There was also confidence in attracting

staff across the organisation into clinical leadership positions. One participant observed:

‘We have never had a situation where there has not been anyone to succeed a clinical director and

mostly we have had a choice’. (8 M – senior nurse medicine)

This showed the leaders in the Trust were paying a significant amount of attention to succession

planning, which they felt had been successful.

Summary This theme focused on the concept of sustainability, challenges, and pressure and incorporated a

number of key areas, including increasing workloads, financial pressures, and significant concerns

regarding succession planning for the executive team alongside concerns for the longer term

sustainability for the Trust in terms of the way they felt it was currently being led.

Reflexivity (Box 12) regarding reflections on presentation of findings Reflexivity Box 12 shows my reflections on the presentation of the

findings. It was important to present the views of the participants as

they were captured, and presented in a verbatim way. I was mindful to

use full sentences for quotes wherever possible and not edit text, to

ensure the context of the views was not altered in any way. The

findings were presented to represent the voices of the participants and

illustrate their views and experiences of being ‘well led’.

Conclusion This chapter has presented the findings from both the semi-structured

interviews and the range of meetings that were observed with the aim

of seeking to achieve the research objectives. The purpose of this

research study was to gain greater knowledge of what the concept of

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Reflexivity Box 12

Reflections on presentation of findings:

I felt it was important to present findings accurately and within context given.

It was also important to make sure views given were equally represented.

It was important that the voices of the participants speak for themselves.

Need to make sure equal representation of views and avoid risk of confirmation bias.

‘well led’ meant to staff and how they believed this translated to delivery of high-quality care to

patients. An inductive grounded theory approach was used to give voice to the participants who

described in their own words their views about what the term ‘well led’ meant to them and how this

translated to a drive to improve care to patients. The findings were presented utilising four themes

that emerged during the anaysis of the data. These included: Family, Distributed leaderhship with

some hierarchy, Learning, and Sustainability. The concept of learning organisational principles as a

theoretical framework was used to help guide the study, and the findings considered against the

various components as described by Argyris (1992) and Senge (1990).

Theme 1 presented the concept of family where staff described their experiences of the way the

executive leadership team (top team) instilled a sense of commitment, shared vision, values, and

empowerment of staff. This theme incorporated a number of components from within the learning

organisation theoretical framework utilised, but there were also aspects that were less in

congruence with this, such as the examples given of the top team’s deliberate strategy of the

imposition of a prescribed culture change on to Site two. This theme also included the participants’

views regarding the values and behaviour in relation to the Trust leadership, and gave examples of

where they welcome a tough approach being taken to address poor behaviour, particularly where

staff were not seen to be working within the expected values held by the organisation.

Theme 2 focused on the importance of distributed leadership with some degree of hierarchy. The

themes revealed some conflicting views in relation to the extent of the presence of hierarchy, which

ranged from an appreciation of what they saw as a flat structure as well as a desire and support for a

clear and visible chain of command. This theme also surfaced recognition from one of the

participant’s thinking that suggested shifting a focus from being focused on the well-being of

patients to focusing more on the staff.

Theme 3 focused on the concept of learning, which incorporated aspects of understanding system

learning as applied to patient safety incidents, and investment in education and training, which has

included a specific emphasis on developing and building leadership capability.

Theme 4 presented findings that described the concept of sustainability, challenges, and pressure

and incorporated a number of key areas, including increasing workloads, financial pressures, and

significant concerns regarding succession planning for the executive team alongside concerns for the

longer term sustainability for the Trust in terms of the way they felt it was currently being led. This

theme raised a question for me of whether the Trust could maintain the view held of it of being ‘well

led’ and the extent to how resilient the Trust would likely be as the impact of pressures and

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challenges increased, and particularly as individuals in key leadership position take the decision to

retire or leave.

The themes gave an overall picture of the positive view of the experience of leadership within the

Trust, and in particular how they felt this achieved overall improvements to patient care. While the

findings focused on the positive aspects of being part of the ‘family’ and shared values, expected

behaviours, and commitment towards improvement, these themes also showed a potentially darker

side when staff were seen to ‘not fit‘ within this concept of family as described.

While in some aspects many of the components within a learning organisation were seen, such as a

commitment to learning, avoidance of blame and system learning, there were other aspects that

appeared to conflict with the theoretical framework used.

The next chapter will discuss these themes in more detail using a grounded theory approach

(Charmaz, 2006) and considers what this means in terms of staff’s understanding about leadership in

their organisation and explores in more depth what this research could contribute to the debate of

how ‘well led’ could be best defined and applied across the wider NHS.

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Chapter 7: Discussion and conclusions chapterIntroduction The purpose of this research study was to gain greater understanding of the views and experience of

staff of the concept of being ‘well led’ within an NHS hospital. The rationale was that by undertaking

an in-depth study of a hospital assessed by the CQC as being ‘well led’ it may be possible to discover

the views of staff about how they experience leadership, and make recommendations for how best

practice could be captured and shared more widely with the NHS.

Chapter 2 presented a review of the NHS policy context in response to a number of health-care

failing reports leading to the emergence of the ‘well led’ concept for NHS organisations. This chapter

referenced a range of published papers, reports, and commentaries, which included the Francis

report (2013), the Berwick report (2013), and the Kirkup report (2015).

Chapter 2 also explored emergence of leadership and governance of NHS Trusts together with the

introduction of new public management and the drive for organisations to achieve Foundation Trust

status.

Chapter 3 presented an initial review of the literature related to the ‘well led’ concept and an

overview of how some of the concepts related to leadership and organisational culture had

developed over time. It discussed the emerging shift of focus from one of ‘top–down’ leadership to

one of viewing the leadership’s role as a vehicle for creating an environment for quality

improvement. The concept of effective leadership, as well as ‘followership’ and ‘distributed

leadership’, were also explored. The relationship between leadership and culture was discussed

together with the concept of subcultures and the importance of recognising their significance within

the NHS systems. Some of the more historical influential contributions from theorists such Argyris

(1998), Senge (1990), and McMurry (1958) were described in relation to the extent that their

influence had impacted on how the concept of leadership could be defined and better understood in

relation to driving quality improvement in health care. There was some evidence that emerged from

the preliminary literature review that developing a learning organisational approach may improve

the quality and safety of health-care organisations. This was explored further in Chapter 4 where

some of the theoretical concepts that underpin learning organisations were explored with the aim of

taking this concept further to develop a theoretical framework to help guide the study and answer

the research question being posed.

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Chapter 4 presented the theoretical framework selected to support the study. A blending of learning

organisational theory from Argyris (1992) and Senge (1990) was selected as a theoretical framework

of the learning organisation to underpin this study.

This chapter revisits the research question and the methodological approach used for this study and

explores four themes that have emerged from the research.

A secondary literature review was undertaken following the analysis process to support the

grounded theoretical approach (Charmaz, 2006). This secondary review focused specifically on the

four themes and the subthemes that emerged from data during the analysis process. This was

combined with both the preliminary literature review presented in Chapter 3 and the theoretical

framework (learning organisational theory as described in Chapter 4) with the aim of seeking greater

interpretation of views and experiences expressed by the participants.

The strengths and weaknesses of the study are explored in this chapter with the aim of identifying

where conclusions can be drawn and recommendations made, as well as recognising and

acknowledging limitations of the study and where further research is needed.

The contribution of new knowledge this study brings towards developing new theory in increasing

understanding of the well led concept is presented. The chapter concludes with recommendations

to be taken forward to support NHS organisations in improving their approaches to leadership with

the aim of improving the quality of patient care delivered.

Research questionThe aim of this study was to explore how the concept of the ‘well led’ hospital Trust was defined and

understood by NHS staff across a range of organisational managerial levels. Further sub questions

within this included:

What the concept of ‘well led’ meant to staff.

What staff understood by the concept of being ‘well led’ within their NHS Trust.

How the concept of ‘well led’ was translated across their organisation.

What the staff views were on the impact their hospital’s leadership has on the quality of

care delivered to patients.

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Ontology and epistemological approachThe ontological approach taken to answer the research question was one of exploration and

interpretation of how the concept of effective leadership was defined, and the degree to which the

concept of being ‘well led’ could be viewed in reality. The commonly accepted NHS policy view

(example of world view held James (2015)) was that the CQC ratings were a valid method to rate

NHS Trusts and assess the extent they were considered to be ‘well led’. The aim was to explore this

view through the lens of the staff experiences and understanding within the organisation in which

they worked. This study’s focus was on discovery and gaining greater understanding, rather than

testing a hypothesis. Therefore, selection of a qualitative approach offered an opportunity to view

the reponses to the research question through the lens of the staff that experience leadership within

their organisation. This approach enabled deeper level study and the ability to draw interpretation

and meaning from data collected. The iceberg analogy (James, 2015) framework (as described in

Chapter 4) was applied to the methodological approach to seek greater undersanding for the

concept of being ‘well led’.

Grounded theoryAn interpretative framework of grounded theory (Gioia, Corley, & Hamilton, 2013; Charmaz, 2006)

was applied to support the process of both sampling and data analysis for this study. The study used

a grounded theory approach that was flexible and allowed for consideration of the presence of the

researcher in the process. This approach also allowed for a degree of interpretation of the data, but

stayed close to the aim of generating new theory. It was important to ensure that this inductive

study had qualitative rigour, and the framework supported a methodology that enabled this to be

more transparent as it was constructed. This recognised that I had the potential to bring some

insights to the research and focused on rather than hiding this from the study, exposing it within the

analysis process.

The data collection included interviews from 30 members of staff, including staff in leadership roles

across the whole organisation, which included a range of staff, including executive directors (chief

executives, human resources, medical, nursing, and operational roles) and other corporate function

leads, for example, patient experience lead and professional leads. The data collection also included

notes taken from observing four meetings over the course of several months from each directorate.

The data was analysed following a grounded theory framework (Gioia, Corley, & Hamilton, 2013;

Charmaz, 2006) to make sense of the data and describe the phenomena emerging from the findings.

The emerging data was studied alongside the literature using an inductive approach and this data

provided the emerging theory, with the aim of answering the research question. The importance of

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this emerging theory was captured in the writing up of the findings with an emphasis on the reader

of the study being able to observe the data connections between the three stages of analysis. The

final four themes that emerged are further explored and discussed in this chapter, including:

1. Family

2. Distributed leadership with some hierarchy

3. Learning

4. Sustainability

Sub-themesWithin the four themes a number of sub-themes from the data collected are also presented,

representing the process of the analysis where the focused codes emerged (see Tables 7 and 8 in the

previous chapter). The tables represent an illustration of the focused codes and initial codes but do

not show the full list that was applied to each theme. Each theme presented was supported by a

range of quotes from the participants, which have been categorised through this process to provide

supportive evidence that underpins the selected codes.

Theme 1: Family The concept of the family theme emerged from the data and included participants describing

feelings of being ‘in it together’ and a sense of camaraderie in relation to how they defined and

understood the concept of ‘well led’. They described how they felt the executive leadership team

(top team) instilled a sense of commitment, shared vision, shared values, and a focus on the

importance of the empowering of staff. Parallels can be drawn from the literature previously

reviewed (Von Wart M, 2003; Yukl, 2008; Bennis & Nanus, 1985) with the participants’ responses.

These related to them viewing the role of their chief executive and executive team as having created

the right environment for success. The participants’ use of language associated with family was

unexpected and was a feature throughout many of the interviews. Examples of this included one

participant referring to the top team as ‘parents’, another as the ‘mothership’, and to other staff as

siblings. Another aspect of the family language used was observed where participants referred to

the second site as our ‘sister site’, although interestingly the first site was sometimes referred to as

the ‘parent site’ by some. This illustrated the way that staff viewed Site one at times as in some way

superior to Site two.

The leadership literature was further explored to help explain the significance of the family concept

as described by the participants in relation to leadership and their experiences of ‘well led’. One

theory presented by Wilkes, Jared, and Viglione (2015) defined a concept of a ‘corporate family

model’, which drew comparisons between components of a family with that of a corporate

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organisation. The ‘family system’ as described by Kerr (2000) was explored together with further

work by Wilkes, Jared, and Viglione (2015), who suggested that parallels could be drawn between

the functioning of a family unit and applying this theory to the way that an organisation’s leadership

team functioned. Some aspects of this theory did offer a helpful perspective through which to view

the concept of ‘family’. This was in particular the exploration of various relationships and the

identification and management where there were some dysfunctional issues between staff.

However, this theory was not reflective of the emphasis given by the participants of this study,

where the focus was more on the aspect of togetherness and camaraderie in relation to being well

led.

The concept of social identify theory (Turner & Tajfel 1986) was also explored to consider whether

the concept of social group identity was helpful in increasing understanding of the participant

references to their feeling of being part of a family. There were some elements within the data that

suggested some similar features. These included the way the participants described the Trust and

their views expressed that they belonged to one organisation, and referred to those outside the

group, i.e. commissioners and regulators as not being part of their group identity. They also

compared themselves with other Trusts, and felt they were doing better than others in some areas,

for example their commitment to education and training as well as the good relationships junior

doctors had with consultants. This aspects supports areas believed to be integral to social identity

theory, i.e. adopting the identity of the group which included defining acceptable values and

behaviours, as well as comparisons with other groups (considered as ‘out group’ , i.e. who are

different (Tajfel & Turner 1986), & Hogg and Abrams 1988) . In some cases these features could be

seen in some of the examples given where participants on site 1 felt that staff on site 2 were judged

less favourably and this being attributed to them not holding the same values. Thus not fitting the

family could be explained by staff holding negative views towards those they judged negatively and

being part of a perceived ‘outgroup’. It could be argued that this categorisation of in and out groups

could be viewed as a form of prejudice, i.e. site 1 considering themselves to be superior to those

that work on site 2 (Tajifel &Turner 1982). Whilst application of social identity theory appears to be

helpful in offering a framework that begins to explain the concept of family, there are some

limitations of its applicability to the participant’s use of this term in this study. One limitation is the

staff described elements of the family in hierarchical terms, e.g. executive team being the parents,

and site one being the ‘mothership’. Social identity theory as described by Tajifiel & Turner (1982)

suggest group members hold similar characteristics, and categorisation being key to the group’s

identity. Also participants from the study identified some key staff as holding particular individual

characteristics i.e. chief executive and director of nursing , and some staff being members of

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different professional groups, for example medical and nursing staff. In addition many of site 2 staff

believed themselves to be part of the Trust family, whilst the categorisation of the social groups and

sub groups offer some helpful insights, the family concept seems to have less clear boundaries

around the segmentation of the group membership that the social group identity describes (Tajifel &

Turner 2002).

Another area explored in seeking to understand the ‘family concept’ was examination of the term

‘collegiality’. This is a term used to describe where people work together for a common purpose and

where there is an acceptance of shared values (Hargreaves, 1994). Aspects of collegiality

encompassed a desire for non-hierarchical relationships, collaboration and coordination (Hanson,

1995). This resonated with some of the findings from this study, for example, a positive view

expressed of a perceived flat hierarchy, shared values, and working together. However, this didn’t

fully encapsulate the emphasis on the experience of staff working for what they described as the

‘Trust family’. The use of the ‘family’ term was frequently linked to participants’ views about being

well led, and included within it the use of family language that was used for both staff and patients

interchangeably. The concept of feeling part of the Trust ‘family’ being closely aligned to

participants’ views on being well led emerged as a key theme to take forward in its own right.

Many of the participants referred to the ‘Trust family’ and ‘the family’ and used the terms

interchangeably. This suggested the Trust and the family were viewed by staff as the same thing.

One participant made the point that staff work ‘for’ not ‘at’ the Trust, and the findings suggested a

high level of allegiance to what they termed as the “Trust family’. Closer exploration of this concept

showed that many of the components the participants associated with the ‘family’ concept aligned

well with aspects from learning organisational theory (Argyris, 1992; Senge, 1990). Examples of this

included reference by participants to key components of the family concept, which included the

importance of shared vision, shared values, and commitment, all of which aligned closely with the

work of Argyris (1992) and Senge (1990). There was, however, an emphasis given by participants

that some degree of hierarchy was present, one example being how the executives were viewed as

parents of the organisation. Additional aspects of the family included a sense of togetherness and

camaraderie. A few participants attributed this sense of camaraderie to the presence and influence

from a number of military staff who worked within the organisation (the Trust had merged with a

military hospital some years earlier). Some parallels could be seen when reviewing some literature

related to military theory, in particular the creation of feelings of belonging and comradeship that

become more tangible during periods of crisis and combat (Akwah, 2017). These examples of

camaraderie can also be seen within police forces or other emergency services. These describe how

this could at times be experienced to the exclusion of their own families, who found it difficult to

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understand this workplace cohesion and could be difficult to break in to (Akwah, 2017). Some of

these features resonated with the staff’s description of the family concept in the context of this

study, particularly where they referred to some staff’s difficulty in ‘breaking in’ to the Trust family.

However, unlike the military or emergency services the participants of the Trust family concept was

not attributed to a particular period of crisis or conflict. It was instead attributed to more of the day

to day leadership of the Trust. The extent to which general feelings described by staff of camaraderie

could be directly attributed to a degree of military influence within the Trust was also not clear.

Many of the staff talked about a sense of togetherness as being linked to feelings of being well led.

However, the terms of ‘being in it together’ were frequently cited by the participants, which

suggests this to be a very important aspect of their beliefs about the organisation. Some of the

components of the family concept and the staff’s views about how staff therefore fit into the Trust

family are explored further below.

Shared values and expected behaviorsThe family theme included a focus on the importance of staff owning the Trust values and

behaviours in relation to staff’s experience of being well led. This was a key finding and while the

values were visibly displayed on notice boards throughout the Trust, it was not clear from the staff

how long ago these had been agreed or whether there was any plan to review them. The

participants talked about the Trust’s focus on being patient centred, supporting staff, the

importance of working together, and a no blame culture. The participants spoke about having an

emotional connection with the Trust and what they felt were expected ways to behave. It was not

clear how these had been explicitly communicated to them, even though many of them spoke about

clarity of expectation of them. It was more a case of a strong belief that this was simply the way the

Trust was. During the interviews the participants confessed to not being able to actually pinpoint

how the values and expected behaviours were communicated. They made reference to the values

being displayed around the buildings but suggested it was more than this, and felt this was an

organisation that put patients first and this was demonstrated at every level. In particular, they

made reference to role modelling of the senior executive team who they felt lived the values of

being patient centred in the way they led the organisation, and these values matched those of their

own. The participants aligned their experience and understanding of the concept of ‘well led’ to this

shared vision and their belief that focused on being patient centred was core to their values.

Therefore, it was a given expectation that all staff would be signed up to delivering on this. One

example of this was how staff approached improvements in patient experience, which included

inviting feedback, being responsive, and dealing with complaints at source. This approach was one

that was led by the chief executive, who invited direct e-mail feedback from patients on a 24/7 basis

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and there was an expectation that all staff were aware of the responsibilities in being proactive and

responsive to patient feedback and complaints.

These shared values also extended to the way they felt the Trust supported staff, and made

particular reference to their experience of a no blame or just culture. By this the participants were

referring to the way the organisation responded to clinical incidents and errors, by not blaming staff

for errors but focusing on seeking to support staff to learn from harm and drive safety

improvements. The participant’s experiences were consistent in relation to how the organisation

responded to a patient harm event, for example, serious clinical error, and very closely aligned to a

system learning process rather than a focus on an individual’s (Senge, 1990). Participants gave

examples of how such safety incidents were managed, and where the focus was on learning and not

blame. This approach aligned strongly with Argyris’s (1992) and Senge’s (1990) learning

organisational framework, and this was consistent throughout all of the interviews.

A further finding that emerged related to the views of junior doctors in relation to their consultant

colleagues. When sharing their experiences of how they defined being well led, the junior doctors

made little reference to the executive leadership during the interviews other than to refer to

photographs they had seen on a wall somewhere. Instead, they saw their consultants as their

leaders when discussing their views on being well led. These findings aligned well with a previous

study by Grant (2012) whose research found that doctors believed their primary focus to be

exclusively on the patient in front of them and had little interest in the objectives of the

management. They also stated that while they wished to maintain their position in the medical

hierarchy (which they saw as separate to the wider organisation) (Grant, 2012) their values in terms

of being patient centred and supporting staff were completely aligned with that of the executive

team. Grant’s study (2012) described a concept of subcultures within a Trust and had found that

some professional groups, in particular, medicine, wished to preserve their own distinct identity

traditionally separate from what they perceived as the ‘dark side’ of management. While

acknowledging that the sample of doctors interviewed from this research study were small, the

findings did not support this view. They, instead, suggested that while the junior doctors looked

towards their consultants in terms of describing their views about being ‘well led’, there was no

suggestion of any perception of a ‘dark side’ of management or that they felt the medical staff held a

different set of values. The way the junior doctors described their consultant colleagues was very

positive, particularly when the junior doctors drew on previous experience and comparisons with

other Trusts. The junior doctors interviewed were in a unique position to draw these comparisons as

they moved regularly between hospitals, and they felt that this Trust was different in terms of the

positive support they received from their consultant colleagues. This related specifically to access to

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seniors, and feeling able to contact them for advice when needed, and there was no suggestion

emerging from any of the interviews of a bullying culture or lack of support in their roles.

These findings suggest a different experience for these junior doctors compared to others training

elsewhere (Royal College of Surgeons, 2017) who reported working within a bullying culture. There

was also no evidence of a clash of views with the medical staff who have been traditionally

recognised as guarding their autonomy in the face of new public management approaches

(Goodwin, 2000). The tensions between the professions, in particular the perceived power of

medicine, have been well documented (Salvage, 1985; Grant, 2012) through the history of the NHS,

and this was particularly illustrated in the breakdown in negotiations with the British Medical

Association (BMA) and the government over the proposed changes to junior doctors’ contracts (BBC

2015).

In contrast, the participants from this study described positive relationships with their consultants,

together with the Trust executive participants who spoke about the importance they gave to

recruiting doctors who had trained with them. This was reflected in the way the Trust approach

recruiting their own trainees into consultant posts. These findings signify a difference in findings

from previous studies together with experience of the junior doctors in this Trust compared to the

experience of their colleagues working elsewhere (Grant, 2012; Siriwardnena, 2013).

These findings were significant in discovering a key aspect of the concept of being well led when

compared to the experience of doctors working elsewhere. However, this needs to be viewed with

some caution in relation to the small sample size of doctors who were interviewed. While the

participants didn’t specifically refer to the executive leadership teams in relation to their experience

they, alongside other participants interviewed, described working within a supportive and learning

environment where staff were committed to delivering high-quality care.

Delivering on what is promised Clarity of expectations was a common finding during the study, alongside staff being seen to deliver

on what was promised. Particular reference was given when discussing their expectations of the

executive team. Some of the views included their observation of the executive team, in particular

them being visible, accessible, and being seen to offer support in the clinical areas when they are

under pressure, for example, the A&E department. Other examples included the executive team

being seen to live the values and the importance of staff delivering on what they have committed to

do. These views from staff aligned well with the component described within the learning

organisational framework in relation to espoused theory. Espoused theory relates to the words that

leaders use to convey what they do and what they would like others to do (Argyris & Schon, 1978).

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Examples of this include comparing what leaders said they believed, how they made decisions, their

behaviours, and how they run their organisations, as opposed to how they were observed to work in

practice. A common theme running through many of the interviews was the participants’ views of

how important this was to them in relation to the concept of ‘well led’. Argyris and Schon (1978)

focused their research on observing leaders in an organisation in what they term as theories in

action. They analysed the behaviours of leaders of how they communicated their preferred

approach to actions and what they were observed to do in practice. The findings from this study

suggested that staff particularly valued observing their leaders role modelling what they had

communicated their expectation of staff to be. Some examples were where the executive team were

visible, accessible to staff, and seen at times of crisis to give physical support where needed. Another

example was the chief executive making themselves available directly to members of the public via

the Trust website on a 24/7 basis to feedback concerns so they could be immediately resolved.

Pursuit of excellence One of the key components of the Trust values that emerged was a commitment to the pursuit of

excellence, this was interpreted by staff as the organisation’s ambition relentless drive to be the

best. This included providing the best care possible and a feeling by the participants to continually

push the boundaries, and not be content with being average, and striving to be the best. The

language of ‘family’ extended to include patients and staff encouraged to view their care delivery

through the eyes of their patients and to treat everyone as though they were a member of their

family. This was a view expressed particularly by the executive team, and the expectation of the

organisation’s priority to ensure continual focus on putting patients first was a consistent finding

throughout all of the interviews. This expected focus of being patient centred and providing the best

possible care was never questioned throughout the interviews, however, there were views

expressed about how this could be best achieved. This was amid a range of increasing pressures and

challenges and many of the participants feeling they couldn’t be continually expected to do more

with less. These feelings of the continual pursuit of excellence from the executive aligned with the

work of Collins (2001) who reviewed more than 1,000 companies with the aim of identifying what

some of the components of success were. Many of these components were present within the Trust

studied, which included, for example, leaders focusing on the organisation rather than on

themselves and recruiting the right people. However, some of the successful organisations when

studied a few years later showed a decline in performance. This led to a further study of this

phenomenon to understand the reasons for the decline (Collins, 2009) and five stages of decline

leading organisations to failure were identified. One stage relevant to this study was the

‘undisciplined pursuit of more’, which aligned well with the views being expressed by the staff who

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felt they were being pushed too far. They felt that there was a risk of there being too high

expectations, which would lead to a consequence of poorer care being delivered. While the staff

were supportive of the executive team’s transformational leadership style (that is, one that focused

on empowering staff within the organisation), they also felt that the top team would need to

acknowledge the reality of these pressures and be able to change their strategy or direction where

needed (Collins, 2001). One example of this would be not taking on more business/work that the

staff would not be able to deliver, which was commented on particularly within the maternity

service. There was a particular concern expressed that related to the good reputation of the

maternity unit having resulted in attracting more patients than they were resourced to care for.

Recognising the inherent complexity in the pursuit of more is believed to be an important

component of leadership effectiveness (Gronn, 2003).

The participants were expressing significant concerns in relation to the organisation’s ambitions, and

a belief that whilst the Trust was seen as successful there were warning signs of being at ‘tipping

point’ and the risk the organisation could experience significant decline and possible failure as

described by Collins (2009) unless they paid immediate attention to the risks being described. The

impact of the challenges and pressures the participants expressed is discussed further within Theme

4, which focuses on sustainability of the Trust in relation to these issues.

Not fitting with the family The participants felt the concept of family was a key component relating to well led, however there

were two aspects of this theme which I felt required a degree of caution with interpretation. The

first was the need to continually challenge myself as to whether the views expressed were simply

‘too good to be true’. To seek to address this concern I took great care to interview a broad selection

of staff and despite this the view remains consistent throughout all of the interviews. The second

aspect related to what could be viewed as a potentially less positive interpretation that the family

concept which could be viewed as a clique or a cult, and that some form of indoctrination has taken

place with the staff. Cults can be defined as social groups who are defined by a common set of belief

or share a common interest, however they can sometimes be seen as having extremist views and

exclusive. Cliques can be viewed as close knit groups who do not welcome others people into the

group. The interpretation of the data did not seem to suggest the presence of extremist views or

exclusiveness, the participants very much supported the concept of shared values and beliefs, but

took a strong positions with those that did not support and live the values of the organisation. Many

of the Trusts’ staff had been in post for a considerable number of years, and there was some

acknowledgement of how some new staff could find it difficult to fit in, and this was explored further

during the interviews. There were some deliberate actions by managers taken to recruit to ‘values’

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and to ensure that both the recruitment and appraisal system included clear expectations of staff in

terms of behaviour, and the participants gave examples of the type of behaviour that would not be

acceptable. This approach is similar to those described by Robbins (1996), Legge (1994), and Pascale

(1985) and there have been similar approaches adopted across the NHS. One example is the ‘6 Cs’

strategy, which was led by the Chief Nurse for England with the aim of recruiting nurses against a

range of nationally set standards (Middleton, 2013). The rationale for adopting this approach was

linked to a belief that development of a strong culture would result in greater employee

commitment and improved quality and that this would lead to increased commitment from

employees (Bagraim, 2001; Pascale, 1985). However, this approach was not without its critics, for

example, Schein (1995), who described the risk of a higher focus on the benefits to the organisation

than those of the employee. Many of the participants went further in relation to their views of the

importance of ‘fitting the family’, and gave examples of how some behaviours of staff would not fit,

and how the organisation would respond to dealing with what they perceived to be negative

behaviours. The participants gave examples of how new staff would be expected to know what

constituted the right fit, including in addition to their approach to select and recruit to values, linking

this to the appraisal system. When the participants were probed on other ways they thought the

values were communicated to staff, they used terms such as role modelling and the need to take

swift and at times tough action when staff were not seen to be living the values. The participants

supported this approach and did not express a view of whether new staff difficulties breaking into

the Trust family could potentially be perceived as a clique, that is, a close-knit group of staff who do

not readily allow others to join them.

The right culture There have been many references to the concept of culture and the need for the NHS to change the

culture (Kennedy, 2001; Francis, 2013; Berwick, 2013; Kirkup, 2015). These have led to a call for

improved leadership and the need for the NHS to change its culture being promoted as key areas for

attention. Frequently, the two terms are used interchangeably (West, et al., 2014) and without clear

definition, the culture term risks being a catch-all term that means different things to different

people (Alvesson, 1995). The use of the term ‘culture‘ was frequently used throughout the

interviews and illustrated the views of Alvesson (1995) that the term represented a range of

different possible interpretations. There were a number of examples of this given in relation to Site

two and the need to ‘infect the staff with the right culture’. The participants held strong views about

the importance of taking swift action when some staff exhibited behaviours that were not

acceptable within the shared values held by the organisation. The use of the term ‘infect’ was

unexpected and led to consideration of whether this approach could potentially have a ‘darker side’.

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For example, what if aspects of this ‘right culture’ were challenged by some staff, and instead of the

intention of creating a sense of commitment from staff it was instead seen as the imposition of a

compliance model. This approach was not questioned by any of the participants, or any suggestion

given that this could be viewed in this way. However, this raised questions in relation to

interpretation of the data about some of the potential risks where the concept of shared values

shifted to one of imposed values. This imposition of ‘right’ culture was a deliberate strategy based

on the shared belief that this would leave to the improvements needed. The Francis report (2013)

made recommendations that included a call to action to address NHS leadership and made a number

of references to the concept of culture and the need for the NHS to change the culture. The views

from the participants frequently used the term of ‘culture’ change, which risked this being used as a

catch-all concept without a clear and measurable definition of what culture is (Alvesson, 1995). The

findings from this study supported the continuing differing views with researchers attempting to

quantify organisational culture and culture change for which little empirical evidence exists (West, et

al., 2014; Silvester, Anderson, & Patterson 1999).

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Pursuit of excellence Some of the participants in the study believed that the Trust approach to imposing the culture on to

Site two had been successful in changing the culture. They evidenced the success of this approach in

their references to the measurable improvements that had been achieved since adopting this

approach. Some critics of imposing a specific culture on an organisation (Ogbanna & Wilkinson,

2003) would challenge this view, and question whether this actually represents change of culture at

all. Instead, they attributed this change to one of simply achieving staff compliance through a range

of behaviour control and compliance methods. This leads to a further question to consider the

extent to which commitment of staff is achieved where it is sought through the use of a behavioural

compliance method. Studies by Argyris (1998) suggest that sustainable improved organisational

performance requires a focus on commitment, and that over-reliance on compliance as a tool to

drive improvements is likely to fail. However, the findings from this study suggest the Trust’s

approach of an ‘imposed culture’ had been successful and the improvement in relation to reduction

of complaints and improved CQC ratings support this approach as being the right one. This finding

suggests a key contradiction in terms of driving a compliance model and the imposition of what the

participant viewed as a strong culture. The participants’ comments suggested they believed they had

identified what a ‘good’ culture was, and they had achieved the improvements needed for Site two

by imposing this on the staff and this had achieved the desired results. For them it was simply a case

of showing Site two what good looked like and ensuring compliance to this expectation. The success

of this approach had been further reinforced by the improved assessment by the CQC of Site two,

which the participant viewed as a demonstration that this approach had been successful.

The success of this approach focused on a compliance model to impose culture change directly and

contradicted with the need to focus more on commitment from staff to achieve desired results

(Argyris, 1992; Senge, 1990). This runs contrary to the views from Ogbanna and Wilkinson’s (2003)

study that suggest that changes achieved through what is framed as imposed culture is more likely

to be due to the imposition of a behaviour compliance model than a true cultural change. In

addition, this suggests a centralist approach from the senior executive team rather than a

distributed leadership model that participants valued and attributed to the concept of being ‘well

led’. This presents an area worthy of further exploration as to whether this represents a true polarity

or whether both commitment and a degree of compliance are needed in terms of how the concept

of being well led can be better understood.

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The creation of a shared vision and a sense of commitment from staff are recognised to be key

components of the learning organisational theory (Argyris, 1995; Senge, 1990) (see Table 6), and

these were a key feature that emerged from analysis of the participant’s interviews. In particular, a

focus from the executives was on the creation of commitment from staff in terms of being patient

centred and striving for excellence rather than driving a sense of compliance. However, despite this

focus on staff commitment emerging from the interviews there appeared to be a polarity between

the two. While the family values concept focused on staff’s motivation on being patient centred,

supporting staff and an ambition for excellence in terms of staff’s commitment to the success of the

organisation, there was also evidence of the application of a compliance model. Examples of this

were the evidence of tough action taken when staff exhibited poor behaviours (that is, outside the

shared values of the organisation) and where in some cases they were encouraged to leave the

organisation (or dismissed). One feature of this tough action was that it was taken specifically in

relation to dealing with poor behaviour, examples being where staff were not seen to be sharing the

Trust values of being patient centred, and supporting staff and also where there were issues relating

to being competent to undertake their role. The comments from the participants supported this

view and expressed appreciation of the support they had from senior managers within the

organisation to take tough action when necessary in the interests of improving patient care and staff

well-being. The approach showed a preference for a compliance model in terms of dealing with poor

behaviour and while the participants spoke in broader terms about the experience of well led being

related to the creation of an environment that encourages commitment, this showed they also

supported the use of a compliance model when required to support the improvements they

believed to be necessary.

Compliance with CQCThe organisation had a regulatory requirement imposed (nationally) to be compliant with the CQC

standards for inspection. This showed that even if the Trust leadership wanted to focus more on

commitment, the Trust was still being inspected against a compliance model imposed by the CQC as

part of the national regulation framework. One of the participants gave an example of their view of

the potential for harm that they believed the CQC brought to the organisation (see previous

chapter). This demonstrated that while staff spoke about their emotional connection with the Trust’s

vision and values the framing of this commitment, they believed this would always need to be within

a model of compliance, that is, what is and isn’t acceptable in terms of both behaviour and

compliance related to the standards set by the CQC. This raised the question of whether the

concepts of commitment versus compliance were true polarities and whether a choice of one or the

other needed to be taken in order to align with the learning organisation framework. Another

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perspective could be the need to embrace both and to manage the polarity rather than suggest that

compliance is not a significant component of staff commitment (Johnson, 1998). The findings from

this study suggest an integral part of a being a learning organisation to be about staff commitment

with some rules. Alternatively, whether this polarity could be considered as commitment with

consequences, of which the majority of the staff share, for example, taking tough action to manage

what they see as poor behaviour, rather than a compliance model. Perhaps the solution is one of an

accepted need for compliance by staff in order to stay close to the shared values of the organisation.

It was also not evident from the interviews the extent that peer pressure contributed to staff either

adhering to or living the Trust values. For example, it is possible that the impact on some of the staff

working within Site two would be to change their behaviour to conform, particularly when they

witnessed colleagues being encouraged to leave the Trust (or subsequently dismissed). One further

aspect for consideration is where the staff who left went to (or were dismissed) and whether they

were recruited to other NHS Trusts and continued with their behaviour (outside of the family values)

elsewhere, and the potential for negative impact on future patients and staff they encounter.

Further exploration of this was outside the scope of this study, but nevertheless would be an

important area to gain greater understanding of these possible impacts to the wider NHS.

Summary of theme When the participants were asked to share their understanding and experience of the ‘well led’

concept in terms of what it meant to them, they referred to the concept of family and the

importance of being ‘in it together’. This focus on family from the participants was an unexpected

finding and not a concept that was specifically evident within the previous literature reviewed for

this study. The participants viewed their chief executive and executive team (the parents) as having

created the right environment for success and central to this was staff’s shared values. Common

terms related to family, such as parents, siblings, and sisters, were given to various staff and there

was also an expectation that patients would be cared for as if they were members of the staff

families. In seeking to interpret how this concept of family related to staff’s view about being well

led, further review of the literature was undertaken. Exploration of related theoretical concepts such

as collegiality, the corporate family, and camaraderie captured some of the experiences given by the

participants, but the views given described a family concept that had some key elements that were

quite distinct to their experiences. Viewing the executive team as parents suggested some degree of

hierarchical model, where staff looked upwards for setting of vision, direction, and clarity of

expectations. At the same time, the staff shared this vision, which was one of being patient centred

and supportive of staff and values that were shared and communicated across the organisation. The

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findings from some of the junior medical staff interviewed suggest they shared similar values in

terms of being patient centred and the importance of supporting staff, but views of being well led

were directly related to their consultants rather than the executive team. Their experiences of being

supported in their role was highlighted, and differed from their experience in other NHS trusts.

Critical to this concept of family included components such as comradeship, togetherness, a sense of

commitment, and shared vision and values. Thus, the concept of family closely included many of the

components of the learning organisation framework (Argryis, 1992; Senge, 1990) but there were

some differences, in particular in relation to the concept of commitment versus compliance. Some

polarities emerged between this sense of commitment and the degree of compliance that was

expected in supporting and living the Trust values. An example of this is where there could be a

potentially darker side of the family concept where staff may not fit the ‘family’ or share the Trust

values. Examples of this were given where the Trust deliberately attempted to improve the

leadership on site by imposing compliance of these family values on to Site two. While the

management of the merger of the two sites was outside the scope of this study’s research aims, the

strong emphasis given by the participants on the success they had had from improving the

leadership on the second site was relevant, in that there was a strong belief that this approach had

been very successful in achieving the urgent improvements needed.

There was a strong view that emerged from the participants that their experience of being well led

related to the Trust staff, and in particular the executive team delivering on what they promised.

This concept of espoused theory (Argryis, 1992) was important to the participants, and there was a

real sense during the interviews that they observed this happening in practice. There were, however,

also some concerns emerging from the participants interviewed, expressing views of being pushed

too far, and the risks of this leading to a potential for the Trust to see a decline in the quality of care

delivered. This is discussed in more detail in Theme 4.

Theme 2: Distributed leadership/with some hierarchy The second theme that emerged was one of distributed leadership with some hierarchy and

incorporated a number of components from the learning organisation theoretical framework utilised

to help guide this study. Key components of a learning organisation include a leadership that is less

hierarchical, is engaging, and has a focus on distributed leadership (Argyris, 1992; Senge, 1990;

Phillips, 2003).

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The findings from this study suggested an approach taken by the executive leadership of this Trust of

a transformational leadership approach that focused on the creation of an environment driven by

shared values and staff commitment works to provide the best care to patients. This aligned well

with transformational theory as described by Bass (1990). However, one criticism of this theory is

the risk of this approach being viewed as ‘leader centric’ where the focus is on the leader to set the

vision for an organisation, while the members of the organisation’s role continues to be viewed as

subordinate within a hierarchical structure (Uhl-Bien, et al., 2014). The reference to the executive

team as parents illustrated a hierarchical perception by some of the participants in the study.

The responses from the participants of this study raised some interesting perspectives in relation to

a desire for some degree of hierarchy alongside a desire for a focus on distributed leadership. This

suggested a second polarity that is explored in more depth within this theme. The creation of an

organisation that is less hierarchical and uses a distributed model as a key component of staff’s

views of the concept of being ‘well led’ was evident through many of the participants’ responses.

Participants used terms such as ‘empowerment’ and ‘engagement’ and talked about the importance

of being given freedom to get on with their job and lead their departments. They also spoke about

how much they valued access to senior staff, and the degree of informality and friendliness that they

felt were key aspects of the concept of ‘well led’. However, the participants also spoke about the

importance of a clear chain of command and a visible hierarchy, and one example given was the use

of symbols, for example, use of red badges for nursing staff on wards to show who was in charge.

Many of the respondents expressed these differing views within the same interview. In addition, the

influence that the military presence had on the leadership within the Trust was also mentioned by

some of the participants. Terminology used to describe the influence of the military were terms such

as ‘well organised’ and ‘efficient’ and there was discussion of delivering what has been promised

(espoused theory), all of which were valued by the participants in relation to the participants sharing

their views on what they felt to be components of being ‘well led’.

Table 10 gives an example of a learning organisational theory framework from Argyris (1992) and

Senge (1990), which is suggested for organisations’ ambition to encompass learning organisational

principles there is a need to move to the right of this table.

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Table 10: Example of compliance versus commitment (Argyris, 1992)/Control versus open learning systems continuum (Senge, 1990)Traditional organisations Learning organisations

Vision imposed on organisation Shared vision and values

Managing and organising Staff engagement

Control and compliance Staff commitment

In contrast the table below (Table 11) shows the views expressed sometimes from the same

participants in relation to hierarchy, some valuing flat hierarchy and informality at the same time as

believing a clear chain of command was a key component of being well led.

Table 11: View of the participants regarding distributed leadership with some hierarchy

Hierarchy Lack of hierarchy

Hierarchy with clear rules

Clear chain of command

Empowerment – distributed leadership

Military style chain of command – efficient, goal

orientated, competent

Symbols of who is in charge

Using relationships to get things done/

having a chat

Easy access/Open door

Clear accountability Chaotic/Informal processes

Hierarchy versus distributed leadership Hierarchy is defined as a system in a society or an organisation, in which people are organised into

different levels of importance from highest to lowest (Oxford, 2017). Most NHS provider

organisations display versions of their managerial structures and include details in particular of their

Trust board/top team on their public websites, but it is unlikely that they would explicitly refer to

these in terms of their importance. Most likely they are describing an accountability structure that

shows where the ultimate accountability for the Trust remains and, as such, the chief executive is

known as the ‘accountable officer’ for the organisation. Distributed leadership, also sometimes

termed as shared leadership, aims to empower and engage the workforce by giving freedom, and

devolving responsibility to staff to get on with their job and lead their departments with limited

interference from the top team. Within an NHS Trust accountability inevitably remains with the chief

executive. Hence, the two cannot necessarily be viewed as mutually exclusive. However, while a

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definition of what respondents meant by the term ‘hierarchy’ was not explicitly given, the findings

suggest the staff saw the need for both. The respondents valued clarity and knowing who was in

charge, who to go to when needed and, in particular, certainty around accountability and

responsibility. This was seen as particularly important in relation to the management of a ward and

provision of this clarity to staff, patients, and their relatives. At the same time, they valued the

visibility of senior staff, as well as easy access to and informal discussions with them, and freedom

and support to make decisions. This perspective aligns well with the work of Kotter (2014) who

highlights the limitations that a traditional hierarchy can have on an organisation in terms of the

need to be responsive to change. Kotter (2014) advocates a dual operating model where an

organisation alongside a traditional hierarchy develop a network approach where staff are engaged

across an organisation regardless of role to work across boundaries to deliver wide-scale change.

This view is supported by Reinelt (2010) who describes a concept of network leadership being similar

in nature to that of distributed leadership, with a focus on a bottom–up and collective approach.

There can, however, be an assumption given that a hierarchical model of leadership is associated

with a top–down, directive, transactional, and controlling approach that was not necessarily the

case, and were not the views expressed by the participants.

Whether a hierarchical structure can be seen to have a positive or negative impact on an

organisation is open to debate and may be more dependent on a number of contributory factors. A

study by Anderson and Brown (2010) identified a number of key factors to this, which included the

type of leaders employed, the kinds of tasks required, whether the hierarchy affected motivation of

the staff, and how the possession of power influenced the leaders and the staff. Their conclusion

was that the steeper the hierarchy the less commitment there was from staff, and the more

centralised control there was the poorer the overall performance of an organisation. The findings

from this study suggest that the participant’s use of the term ‘hierarchy’ could be interpreted in

different ways; for example, the results showed that some felt that a degree of hierarchy was helpful

as was also a clear chain of command. At the same time, they valued access to senior staff and

freedom to make decisions, which suggested where they viewed hierarchy positively. This was as

long as this was not linked to a perception of power and control remaining with the senior

leadership team, and the staff were being empowered to take up leadership responsibilities of their

own. These findings support the view of Bolden’s (cited in Gosling, Bolden, & Petrov, 2009) review of

shared leadership who concludes that leadership that is shared had the potential to complement

rather than replace hierarchy and that both can exist alongside. Bolden, et al.’s (2009) study in

relation to higher education (HE) further supports this view, and concluded that HE required a

combination of both (Bolden, et al., 2009). The findings from this study suggest that the participants

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valued autonomy and freedom to manage their own areas, but recognised the importance of clarity

and hierarchy in some areas. The findings suggest the balance between the two being much higher

in the distributed leadership emphasis, with less in the hierarchical space. Further refining the

specific views of staff in relation to the areas and situations they would attribute to requiring a clear

hierarchy was beyond the scope of this study but emerged as an important area for further research

to gain greater understanding of this finding.

Military style chain of command Some of the participants discussed the influence they felt the military style of leadership had on the

way the organisation was led. This was mentioned by a number of the participants from across the

sample of those interviewed. This was an unexpected finding as there were no obvious signs of links

to the military in terms of the Trust’s website, or visible signage indicating the organisation as having

links with the military. Some studies relating to the military culture support these comments of

military cohesion and commitment to a common goal (Bell, 2013; Bondy, 2004; Keller, 2014). This

concept of ‘camaraderie’ was illustrated in a case study by Bell (2013) who highlighted that these

teams had a ‘camaraderie’ that no one understood outside the military. A quote from one of the

participants in this case study by Bell (2013) illustrated the point, saying: ‘it’s like a big family’ (Bell,

2013, p. 3). Historically, armed forces are recognised as operating within a traditional hierarchical

structure, often characterised by their ranks being visibly displayed through their uniforms and other

visible signs (Bell, 2013). However, on closer examination of the literature related to military

leadership, it is suggested that armed forces particularly when engaged in dangerous activities utilise

more of a distributed model of leadership (Grenier, 2012). The military are required to be adaptable

and to train and empower teams to go into conflict prepared for the possibility of their leader being

killed. They, therefore, place an active focus on succession planning and make preparations for

anyone of the team to be able to take a leadership role at short notice (Grenier, 2012). Thus, the

military training has a focus on self-managed teams, and is able to transform quickly from a central

control and command with a rigid hierarchy to one of shared leadership that is able to respond to

what could be a rapidly changing environment (Ranthun & Matkin, 2014). This is different to the way

in which the NHS traditionally approaches succession planning for leading teams, where there is

more usually a focus on preparation of deputies, but not an approach that extends to wider teams’

requirement to step in to a key leadership position at short notice. While the data collected didn’t

specifically highlight the influence of the military presence in terms of succession planning, they did

give a view that suggested that the military influence contributed to their sense of the concept of

being ‘well led’. The relationship between the military influence and the staff concept of being well

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led was outside the scope of the focus for this study and it would be an area worthy of further

detailed study in the future.

Polarities to manage regarding hierarchy Many of the participants expressed positive views about the importance of a clear chain of

command, and also at the same time valuing a flat hierarchy. Closer exploration of the differences in

these views shows that it could be legitimate to value both, and they were not mutually exclusive.

However, the findings suggested that while the participants accepted the value of some degree of

hierarchy, they rejected this being aligned to a central power and control model. This aligns well

with the learning organisation theoretical framework used for this study (Argryis, 1998; Senge,

1990). The principles of a learning organisation include a leadership that is less hierarchical,

engaging, and distributed. The model does not suggest a need for a total absence of hierarchy but

more a rejection of traditional hierarchy. This desire for distributed flat structure and at the same

time a valuing of the hierarchy (where some attributed this to what they viewed as a positive

military influence) highlighted an important polarity where the participants expressed both elements

to be important to the concept of being well led. This was an important and unexpected finding

which suggested the need to explore whether there was an optimum balance between distributed

leadership and hierarchy which could be found.

Staff first One participant made reference to the need to give greater focus on supporting the well-being of

staff, whereas in the past they had favoured an approach of putting patients first. The participant

was not suggesting that the two were mutually exclusive but had observed how their military

colleagues reflected this approach. This is supported by some of the literature related to the military,

which highlights the purposeful focus the armed forces give to preparation and development of

staff. Some (Keller, 2014) suggest the military to have a number of purposes, for example, to engage

in military action and when not in action to prepare staff for battle. Hence, the military approach to

invest in training and development of teams in readiness for combat if needed, particularly at short

notice. This participant had concluded that the concept of well led was directly related to investment

and support of staff. This was based on a belief that this would lead to the delivery of improved

commitment by staff and consequently higher quality care delivery. This approach aligns well with

the organisation’s ambition in achieving Investment in People (IIP) accreditation, which dated back

to 2013. The Trust had been successful at achieving bronze level achievement a couple of years ago,

which is awarded to organisations that meet a number of standards aimed at investing in staff to

improve performance of an organisation (see Table 11). The exact detail of the theory that

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underpins the IIP accreditation is difficult to establish, and has evolved to incorporate a wider range

of components over the last few years (Smith, 2011). The initiative is not without its critics (Higgins &

Cohen, 2006) and questions have been raised in terms of its tangible benefits, and enthusiasm for

uptake of the initiative has reduced over the years. Within this study I did not observe many signs of

the IIP accreditation stamp within the organisation. There was one patient information leaflet I

observed where this was displayed. Only one of the participants made reference to the Trust having

achieved this and it was not possible to establish from the data the importance the participants gave

to having gained IIP accreditation. The relevance of reference to the concept of staff first and IIP

accreditation was the similarities that could be drawn with the themes emerging from this study in

relation to the views of staff in relation to the concept of being well led. These are illustrated in the

following table, which shows a set of standards that are assessed within the IIP framework. There

are no direct references given to IIP within the CQC criteria for assessing whether an organisation is

well led. Given the underpinning theory that led to the development of the IIP framework it is

difficult to determine, it is therefore difficult to conclude how these standards have emerged. The

table below illustrates the IIP standards:

Table 12: Investors in People – Improving, leading, and supporting (source: https://www.investorsinpeople.com/)

1. Leading and Inspiring people

2. Living the organisational behaviours and values

3. Empowering and involving people

4. Managing performance

5. Recognising and rewarding high performance

6. Structuring work

7. Building capability

8. Delivering continuous performance

9. Creating sustainable success

These components align well with the learning organisation framework (Argryis, 1992; Senge, 1990)

used for this study, and together with the data collected suggests the potential for the development

of a framework that focuses on investment in staff as a key component in offering a more granular

approach in defining the criteria of what the concept of ‘well led’ means to staff.

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Summary of theme The participants when speaking about their experiences of well led talked about how important

elements of shared or distributed leadership (Bolden, et al. 2009) were in terms of being

empowered to take responsibility for their own areas, and given the freedom to be innovative and

make decisions without being overburdened with bureaucratic processes. They associated well led

with there being easy access to senior staff, a degree of informality, and friendliness. At the same

time that they spoke about valuing a flat hierarchy, they also talked about the importance of the

need for clarity in relation to a clear chain of command. Further review of the literature suggested

that these potential polarities were not necessarily mutually exclusive and theories in relation to

learning organisational principles (Agryris, 1992) and distributed leadership (Bolden, et al., 2009)

accept some degree of hierarchy as being necessary. The Trust operated a model of a less traditional

steep hierarchy and one of distributed leadership, and at the same time clarity of expectation and

knowing who to go to regarding certain issues was important to the staff.

The influence the participants felt the military had on the concept of being well led was another

unexpected finding. There was little visible evidence of a military presence within the Trust. Further

exploration of theory in relation to the military showed that while there was a clear chain of

command and some symbolic examples of being in charge, for example, the red badge was

associated with the armed forces influence; there was also an aspect that had a very strong focus on

investment in the well-being of the staff. Alongside this, the Trust has gained accreditation of the

‘Investors in People’ standards, which focused specifically on investing in staff to drive improved

performance. While there have been a number of critics of the IIP process, the standards again

aligned well with the components of the learning organisation framework used to support this study

(Argyris, 1992; Senge, 1990).

This theme linked strongly to the previous one of family, and in particular supported the model of a

family governed by a set of parents as a common thread in terms of some degree of hierarchy but

less traditional in terms of a shared/ distributed leadership approach.

Theme 3: Learning The theme of learning emerged as a common thread running through all of the themes, and aligned

well with the theoretical framework for learning organisations was used to guide the study. This

theme considers learning in its own right and explored how the term of learning was used to

describe a number of aspects in relation to the concept of being ‘well led’. This includes references

to system learning, managing patient safety incidents, and the importance of learning from harm in

terms of prevention of future incidents (Reason, 1997). The participants also discussed the

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importance they felt the Trust had given in terms of investment to training and education in relation

to improving the leadership capability of their staff.

The participant’s comments on learning related mainly to the management of safety incidents and

investment in education and development for staff. They did not comment on how learning or

improvement was specifically measured within the organisation, only that the investment was

valued by staff and in broader sense in relation to a sense of a learning as opposed to blame

approach for staff involved in safety incidents. Some of the participants made references to

evidence (rather than actual measurement ) of the organisations improvement as being related to

reduction in patient complaints, and improved reporting of serious incidents, as well as achieving

CQC ratings as being good or outstanding. They also discussed improvements in leadership

behaviours, performance and succession planning, a particular example of medical staff increased

willingness to apply for clinical director roles was given as evidence of the changes that had been

achieved.

Learning organisational theory as described by Argyris (1992) considers the concept of learning in

wider context and relates to an organisation’s ability to improve its overall leadership by embracing

a system wide commitment to learning. The participant’s interviews did however include many of

the components (see Table 13) of learning organisations in relation the ‘well led’ concept, but they

didn’t necessarily use the term ‘learning’ when describing these.

System learning The concept of system learning was discussed by many of the participants in relation to incident

investigation and a recognition that safety incidents were rarely attributable to a single individual

(Reason, 1997). Participants referenced during their interviews the importance of identifying system

factors leading to safety incidents. This is well recognised as a key component in the importance of

designing out errors and supporting more reliability of processes to prevent safety incidents

occurring (Senge, 1990; Reason, 1997). Systems thinking is considered a key component to being a

learning organisation (Senge, 1990), and has been seen as a key driver to increasing greater

understanding in improving clinical safety in health, and has underpinned the work of Reason (1997)

and IHI (2016) in error management. The findings from this study supported participants connecting

experiences of being well led to working within an organisation that did not blame staff for clinical

errors. There were a number of examples given from staff who supported this view and described

their expectations of both themselves and others when they are involved in a safety incident.

Without exception they described the priority of ensuring the safety of the patient being their prime

responsibility, followed by an environment that supported open disclosure, early reporting, and

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support of both the patient/family affected, as well as the staff involved. There was no suggestion

emerging from any of the interviews of staff fearing to speak up, which differed from the

experiences of many other NHS organisations (BMA, 2017). Patient safety incidents were viewed by

the participants as an opportunity for the organisation to learn, and high level of incident reporting

actively promoted. Low levels of incident reporting were viewed as a problem, and examples of

measurable improvements in leadership on Site two were cited as where incident reporting levels

had improved. The approach taken by staff in relation to openness with families was a further

indication of the deliberate focus on learning, and included meetings with families at the earliest

opportunity, and including them within investigation processes.

Support for staff who had been involved in a clinical incident was considered very important to the

participants, and there were examples given by both doctors and nurses of where they felt this had

been given. This approach was evidenced during one of the meetings I observed as part of this study.

This was illustrated in both the tone of discussion about a significant error that had occurred, and

the care taken to ascertain and ensure the doctor involved was not blamed and considerations of

how best the learning could be shared. This was again observed when they discussed a nurse’s drug

error. There was no suggestion of blame, or fear of reporting, which supported the findings from the

interviews that this level of openness and support to staff was viewed as very important to staff in

relation of what they viewed as being led. This was a significant finding from this study when

compared with the experiences of staff working in other organisations across the NHS, where staff

report a fear of speaking and a bullying environment (BMA, 2017).

The Trust’s approach to supporting wider system learning included references to the importance of

accountability, and there were views expressed within the interviews about the importance of staff

being accountable for their actions, but this was not interpreted in terms of blame, and staff

expressed the view that there was an important distinction. The difference between blame and

accountability has become an important area for discussion as the NHS progresses towards greater

openness in relation to managing patient safety incidents, and the supporting of staff has emerged

as an important consideration in driving improvements. The experiences of the participant

supported best practice in this area, and supported the views of a range of patient safety leaders

across health care (Chaffer 2016).

The participants when discussing system learning in relation to patient safety incidents made a clear

distinction between the way the Trust supported staff involved in safety incidents in comparison

with how they managed staff who displayed poor behaviour. The participants’ views of those who

would not fit the Trust family focused specifically on those who were not patient centred and whose

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behaviour was not acceptable to the organisation. This was an important distinction as the

participants’ advocated very swift action to address poor behaviour. They made reference to where

some consultants on Site two had been reporting one another to the General Medical Council (GMC)

for patient safety incidents, and their view of how unacceptable this was. This finding supported the

importance of distinguishing between blame and accountability and the importance of system

learning to improving safety (Senge, 1990). This approach did not, however, shy away from taking

action where poor behaviours of individuals can lead to an organisation that is driven instead by fear

and lack of transparency.

The importance of embedding system learning throughout an organisation is felt to be important

and not limited to the management of patient safety incidents when they have occurred (Senge,

1990). Leaders need to view their organisations as a whole with systems throughout that are

interlinked and have connected processes (Butcher, 2011). Embedding this requires leaders to

improve organisational reliability and outcomes by designing a system to prevent failure. This

includes undertaking proactive risk assessments and designing the procedures and building

capabilities for mitigating harm caused by the failures when they are not detected or intercepted

(Senge, 1990). While the participants discussed their experiences in relation to the management of

patient safety incidents, and the importance of learning, limited reference was made to the

proactivity needed to anticipate errors and to design systems to prevent these. This was not

unexpected as the focus of the interview questions was specific to their experience of being well led,

and was not the focus of the interview; however, this would be an area worthy of further

exploration. System learning in its broader sense is considered to be an important component to a

learning organisational framework (Argyris 1992; Senge, 1990).

Investing in developing leadership capability Many of the participants made reference to the focus that the Trust gave to investing in training and

development. In particular, they made reference to their appreciation of an investment in leadership

development. This had been a particular strategy in terms of supporting the merger of the two sites

(which had occurred a few years previously), and had brought many of the staff in key leadership

positions together. Focusing on succession planning in terms of identifying staff with the potential to

take up leadership positions was discussed by some of the participants. This focus on building both

individual skills of staff and overall capacity of the leadership aligned well with key components

within the learning organisational framework underpinning this study (Argyris, 1992; Senge, 1990).

The Trust’s approach to ‘talent management’ was a key standard within IIP accreditation and also

aligned well with learning organisation principles.

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The priority given to investing in staff was valued by many of those interviewed, a focus that was

seen as coming from the top of the organisation, and some participants commented on how

successful and innovative the Trust had been in accessing additional funds. Views about this

investment and valuing staff related directly to staff views of being well led, and the importance the

organisation placed on learning and the development of its staff. This correlated well with the

learning organisational framework used to support this study (Argyris, 1992; Senge, 1990) in terms

of the focus on continued learning. This commitment to learning was also viewed as different to

some of the participants’ previous experience in other NHS organisations. They gave examples of

how the organisation was creative in terms of continuing to offer training in the context of increasing

pressures on funding available. The view from one of the executive team supported this top-level

commitment, stating that even when there were financial pressures they did not cancel training.

This also further supported the learning organisational principles, believing at times of pressure and

crisis, training becomes even more important not less (Argyris, 1992)

A further aspect within the theme of learning related to the Trust’s ambition to strive to be the best

and a continual push for excellence. Many of the participants expressed views of what they

perceived from the organisation was an expectation on them to do more with less, and some

expressed some reservations with this in relation to the increasing pressures the Trust was facing.

There was a risk in relation to what was perceived by staff as overreaching and risking a negative

impact on the organisation has been previously discussed (Collins, 2009). However, some of the

executive team credited their success to their ability to be adaptive to change, to continually

improve, and remain energised. They attributed this to the organisation’s success and believed this

was an important aspect of leading the organisation. The ability of an organisation to adapt to

change in this way related well to a component within Argyris’s (1992) concept entitled double-loop

learning. This theory is believed to be a key component of learning organisations and describes an

approach taken by leaders in organisations that focused on questioning, exploring, and a reframing

of a work situation. A leader’s ability to adapt in this way is associated with greater success for the

organisation – instead of reacting by implementing an immediate solution. These leaders take time

to analyse issues in depth to examine the root cause and address the changes at this level (Argyris &

Schon, 1978).The findings from this study gave examples in relation to learning from clinical

incidents, for example, a focus on system learning to improve. However, while some of the

participants attributed the success of the organisation to its ability to adapt to change, there were

no other examples given to support this evidence of double-loop learning in practice. On reflection,

this in an important area that would have been helpful to explore in more depth during the

interviews and an area that would benefit from further research.

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Summary of theme The concept of learning as a theme emerged as being key to the participants’ experience of being

well led, which incorporated many of the findings arising from this study, and aligned well with the

theoretical framework for learning organisations used to guide the study.

Specific to this theme was the concept of system learning and understanding particularly in the

managing patient safety incidents application of a no blame approach to staff with an aim of learning

and the prevention of future incidents (Reason, 1997). This approach showed some level of

application of double-loop learning (Argyris & Schon, 1978) where staff took a system learning

approach, to reflect and learn from harm to support the improvement of safety for patients. The

support to staff was also a key aspect of the promotion of a no blame approach. The participants

were also proactive when responding to patient complaints, and described the expectations of staff

to implement a range of early interventions to improve the patient experience.

The participants also discussed the importance they felt the Trust has given in terms of investment

to training and education in relation to improving the leadership capability of their staff. This

investment was viewed as important to the development of the leadership capability of the

organisation, and staff expressed views about feeling valued and supported. Succession planning

was a key aspect of this development, and the participants recognised the importance of identifying

and developing future leaders to the continued success of the organisation.

Theme 4: Sustainability: responding to current and future challenges and pressures Theme 4 considered the concept of the sustainability of the Trust that was required to adapt and

respond to a range of significant pressures and future challenges being encountered. While the

organisation was very proud to have achieved a label of being ‘well led’ there were many concerns

raised during the interviews about whether this was sustainable. There were many comments that

related the increasing pressures being put on the staff to achieve targets, financial balance, and

continue to improve quality of care delivered to patients. The responses suggested a view that the

organisation was reaching a tipping point, for example, where there were risks of more focus being

given to achieving the A&E target and less on the experience of the patient. These concerns related

specifically to the organisation’s ability to continue to deliver high standards of patient care in the

longer term if these challenges were not addressed. These financial and workforce pressures were

felt to be very real by the participants and dominated the four meetings that were observed.

One particular challenge the Trust had faced was the management of a merger with site 2. Although

this has occurred several years earlier, it was referred to by nearly all of the participants and

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appeared to continue to take up a considerable amount of the senior leadership’s time. However

many of the participants viewed the merger as a success particularly in relation to the significant

improvements that has been achieved for site 2. There was a sense of pride expressed by some of

the participants relating to this, but at the same time acknowledgment of the impact this has had in

relation to less access and visibility to senior leaders on site 1. There were also further discussions

taking place with the chief executive in relation to future NHS structure changes that related to new

models of care being proposed (e.g. the possibility of further integration of services) and sense of

weariness and resistance to further change expressed by some staff who believed the organisation

was as ‘tipping point’ and any further expansion in service would not be sustainable.

Pressures and challengesThe pressures facing the Trust were felt to be very real by the participants of the study, but they also

recognised these to be issues that were facing the wider NHS. These challenges included concerns

about increasing pressure of increasing workloads and some criticism was expressed at what they

perceived as the organisation’s continued ambition to do more. There was a recognition that the

chief executive recognised the pressures that were feeling and being heard and listened too was key

to the staff feeling valued. However, one of the participants made reference to the executive team

holding meetings that gave encouraging and rallying messages to staff to do more but without

recognising the reality for staff of being expected to do more with less. The risks of an organisation

over-reaching has been explored earlier in relation to the importance of the executive top team

acknowledging the reality of these pressures and being able to change their strategy or direction

where needed (Collins, 2001). However, many of the concerns were pressures on the Trust related

to current work rather than taking on more and concerns about maintaining a quality service,

performance targets, and ensuring financial control. Discussions on how to address the workforce

shortages, particularly in relation to middle-grade medical posts, dominated the meetings observed.

The staff expressed concerns about the continual requirement to make continuous savings that they

felt were not possible without having significant negative impacts on patient care delivery.

Despite these significant pressures being faced, the participants remained supportive of the

executive team. While some frustrations around unrealistic expectations were expressed, there was

also acknowledgement of the external pressure the executives were facing from other stake holders.

The loyalty of the ‘family’ concept was played out in the discussions in the meetings, using

expressions such as all ‘being in this together’. Some of the clinical leaders made jokes about being

summoned to meetings with ‘them upstairs’ to explain how they were planning to recover financial

balance for their directorate. The participants demonstrated support to the ‘Trust family’, and

despite the level of the pressures described the participants remained supportive of the ‘parents’ of

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the Trust, that is, the executive team and other leaders in the Trust. Conversely, criticism was

directed at external bodies, such as the commissioners, NHS Improvement, and the CQC about what

were perceived as unrealistic expectations. It was interesting to observe the participants referring to

external stakeholders in this way, and this focus of considering others outside of the Trust as ‘out

groups’ is a concept that has been previously described by West (2012). This concept can equally be

applied internally within organisations where staff refer to other departments as ‘out groups’ such

as ‘management‘ or ‘human resources department’, but this was not reflected in the participants’

comments, who instead appeared to direct blame for the challenges and pressures on external

groups.

While this finding suggested some considerable support for the executive team in directing much of

their frustration to external bodies, this could potentially test the extent of the loyalty the

participants held towards the top team. This was felt particularly if effective actions were not taken

by them to reduce the pressures staff were feeling were not taken. The findings also suggested some

potential risks in terms of the Trust addressing some of the risks associated with their views towards

‘out groups’ and the potential to improve relationships with external stake holders (West, 2012).

This could potentially negatively impact on the organisation in terms of planning its strategic future.

The views expressed by participants suggested they viewed external stakeholders as ‘outgroups’

supports the concept of some of the risks associated with strong social group identity (Tajifiel &

Turner (1982). The findings suggest the concept of family was strong, they believed themselves to be

a very successful organisation and that the problems they were facing were attributed to the

pressures such as financial, work force shortages brought by external bodies i.e. other’s outside the

organisation.

The participants expressed great pride in the success of the organisation but did not discuss the

risks of not engaging more with external stakeholders in terms of their future survival. Some

examples were given from the chief executive about constructive meetings with external partners

about future possible changes to services. There were also some examples given regarding joint

working with others to help manage to demand on the emergency department and reducing length

of stay for patients. However many of the participants expressed negative views of some external

bodies, and this lack of positive engagement could potentially prove to be a risky strategy as the

survival and growth of the organisations and its responsiveness to change in the longer term (Collins

2001).

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Executive team behaviors changing in response to pressures The value the participants placed on a distributed leadership approach was previously discussed, and

the participants particularly valued the freedom they were given as leaders to manage their own

function areas. They felt empowered to make changes without being restrained by bureaucratic

processes. During an executive team meeting observed, the participants discussed a range of

measures that related to changing to a more central control approach. This related in particular to

concerns about the various directorates overspending and one example of this was about replacing

additional restrictions on the use of agency staff. This suggested change had the potential of losing

some of the positive aspects of a distributed leadership approach that many of the participants

associated with views about being ‘well led’. This suggested that the executive team would need to

further explore their need to exert greater control on spending but not lose what their leaders really

valued about the leadership approach that was attributed to the success of the organisation to date.

The findings from the study suggested a preference for a distributed leadership model and could

potentially face resistance from staff if a move to a more central control and command approach

was adopted by the executive team.

During one of the meetings observed as part of the study, the executive team when seeking to

address financial pressures the Trust was facing discussed the costs of the visitors parking and some

lost income due to a breakdown in the payment machines. This was followed by some light-hearted

comments expressing some frustrations about some visitors not paying for their parking, and was an

example of a less patient-centred approach that appeared to be emerging in response to the

financial pressures. These comments ran contrary to the way that core to the Trust’s values was

always about putting patients first, and suggests the risk of these pressures when behaviours may

change in response to these. These responses to the current pressures suggested some shift in terms

of the executive team’s leadership approach to one that is more centralised. This shift raises the risk

of significantly changing some of the features that staff viewed as being well led. This also raises the

question of whether the well led concepts as described by the participants were resilient enough to

these pressures, or whether resilience was only possible while the Trust was performing well. This

leads to a further question about whether the Trust’s positive quality outcomes that the staff

attributed to the ‘well led’ approach could continue to be sustained during times of significant

pressures and challenges. Or whether these pressures risked a deterioration of the success, as the

approach to leadership adjusted to address the financial challenges.

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Succession planning for the executive team Concerns about both succession planning and the importance of identifying and developing future

leaders were discussed by many of the interviewees. The chief executive was held up as an

important role model for the Trust, in particular what participants viewed as their visible

commitment to both putting patients’ first and supporting staff. Both the chief executive and the

wider executive teams were positively viewed by staff and many expressed concerns about the risks

to the organisation were they to leave. Others were confident that the leadership was sustainable in

the Trust and not dependent on the chief executive as an individual. Many attributed the length of

service the chief executive had given to the organisation in terms of continuity as being key to well

led, while others felt this was more attributable to the individual themselves.

The ‘leader centric’ conceptThe findings from the study suggest the participants held positive views about the executive team

and in particular the chief executive, and this was illustrated where one of the participants in

particular referred to the team as the ‘parents’. The fears expressed by some of the participants if

one of these ‘parents’ (in particular, the chief executive) were to leave was that the organisation

would go through a period of bereavement. The findings suggested that the participants’ experience

of being well led were intrinsically linked to the individuals who were in the executive team posts.

One possible conclusion could be that some of the staff were looking up to the executives as ‘great

men’, as described in early leadership theory (Von Wart M 2003). However, the staff’s views on the

concept of being ‘well led’ did not really support this view. The overall findings suggested the staff’s

experience of being well led related to more of a transformational style of leadership. What they

particularly valued about the executive team was rather than them being transactional in their style

of leadership there was a focus on the development of shared values. This worked by achieving

change through the commitment of the members of the organisation (Bass, 1990). Some critics of a

more transformational leadership approach suggest that this can still be viewed as ‘leader centric’

with a focus remaining on the leader to set the vision and values for an organisation. This leaves the

other members of the organisations as being subordinate within a hierarchical structure. The

apparent polarities of the participants’ views about hierarchy were previously discussed within

Theme 2 where participants supported some degree of hierarchy, as long as the greater focus was a

distributed leadership approach. These findings suggested that the staff wanted some direction from

their executive team, but particularly valued a transformational leadership approach that focused on

improving the quality of the leader’s relationship with their followers and increasing commitment.

There was a fine balance to be found between an imposition of their vision on an organisation, to

one that seeks to create this from within the organisation, very much supporting the views of Bass

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(1990). Many of the participants in the study made no reference to viewing themselves as followers,

and while the findings did not specifically suggest they viewed themselves as subservient in any way

to the executive team, they did ‘look up’ to them in terms of clarity of purpose, expectations, and

role modelling. This was an interesting finding and suggested the staff worked in what could be

framed as a ‘permitted’ hierarchy, meaning that the staff would support and permit some degree of

hierarchy but not one related to a central command and control model. The findings suggest they

wanted both; they valued the leadership of the top team, but at the same time valued being leaders

in their own right. The process of distributed leadership is recognised to work for those who could

be defined as ‘followers ‘(Uhl-Bien, et al., 2014), however, the participants in this study were also

working within leadership roles themselves and this supported the views of both Argyris, et al.

(1985) and Senge (1990) who believe it is the leader’s responsibility to create the environment for

staff to grow. The findings suggest a further polarity relating to the participants’ preference to ‘be

led’ and to be empowered ‘to lead’, the balancing of which would seem to be critical in terms of how

staff perceived the well led concept.

The theories related to followership are suggested as being a key variable by McGregor (1960) in the

success of leadership. However, the findings suggested participants shared the values and

behaviours that were believed to be key to the success of the organisation. The main concern for

staff was what the impact may be if the leader (the chief executive) they looked up to was to leave.

The findings suggested the staff’s concerns related in part to some emotional connections, for

example, suggestions the staff would go through a period of grieving, as well as fear for the success

of the organisation should a successor be appointed who did not lead in a similar way. This sense of

an emotional response could possibly be explained in relation to staff experiencing a level of

attachment as described by Bowlby (1973) and further supported by Gemmill and Oakley (1992),

suggesting that some followers form a dependence on their leaders, which can be linked back to

their life within the womb and that followers adopt a state of learned helplessness (Seligman, 1977).

However, the findings from this study did not suggest that the participants viewed themselves as

passive and dependent followers. Conversely, they appeared confident in their own leadership

approaches and their loyalty towards the chief executive post holder is possibly better explained by

the argument suggested by Hudson (2013). They suggest that secure leaders who are available are

attentive, engage with their staff, and enable followers to actively support the organisation’s

objectives.

The findings from the study suggested that some of the participants believed their experience of

being ‘well led’ was directly related to the length of time the chief executive and the wider executive

team had been in post. They said that continuity within the leadership team were key and had

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resulted in stability of the organisation. There were also comments made about lessons for the

wider NHS about the importance of supporting chief executives to remain in post, particularly as the

average length of tenure for chief executive posts was less than three years (Barnes, 2015). Some of

the literature suggests differing views about the effect of length of service in terms of effectiveness

of the organisation. Some suggest that the longer a chief executive is in post relationships and

engagement with employees improve but external relationships can deteriorate. There is a risk that

chief executives can become insulated over time, and pursue outdated strategies (Craik, 2015;

Xueming, et al., 2013). There is also a risk their deputies may leave where they see no prospect of

being promoted. Craik (2015) suggests the solution may lie in a middle ground, giving long enough in

post to deliver a strategy and build a team, but short enough to support successful succession

planning and attract new ideas. However, many of the well-known large businesses such as Amazon

and Virgin have had the same leaders for many years and have experienced significant growth and

profit. There is limited research in terms of explaining why this should be the case, however, some

studies have suggested that one of the common features of successful companies is the absence of a

‘celebrity’ chief executive (Drucker, 2003). These companies are known more for their brand than

the name of their leader, and these leaders have ambition for the success of the company and

surround themselves with the right people to deliver this ambition (Collins, 2001). One successful

long-serving NHS chief executive was recognised and rewarded for his contribution to the NHS in

2016 (Birch, 2016). The expert judging panel attributed his success to having been a chief executive

for more than 20 years and suggested that this continuity, his innovative approach, and style of

supportive leadership had created an environment in which trying different things was permissible.

Similarities can be seen between the citation given here and the findings from this study in relation

to views expressed about the chief executive. However, it would be difficult to definitively attribute

the leadership approach with the length of service; it could equally be the case that it was the

leadership approach that had led to success of the organisation and the post holder remaining in

post long term.

The interview with the chief executive revealed a quietly spoken person who was very committed to

the success of the organisation, both in terms of being patient and staff centred and proud of the

achievements of the whole organisation. They attributed some of their success not so much to the

long time they had been in post, but to their ability over the years to adapt to change as new

challenges presented. They had confidence in both the executive team and wider organisation’s staff

that the Trust was not dependent on them and there were many leaders who had been developed

who were ready to step into the role. Some of the participants supported this view and saw a

potential change of senior leadership as an opportunity. They gave an example of how another

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member of the executive team had left to take up a post in another hospital. The process that was

followed to recruit their replacement was positively commented on by one of the participants. This

had included involvement of front-line staff in giving them an opportunity to contribute to the

selection of future leaders for the Trust. This suggests the organisation had the resilience and the

processes in place to continue to recruit to the family values the participants shared that would

ensure the continuity of approach.

Succession planning The military approach to succession planning is one that has a continual focus on developing their

next leaders. Their approach of preparation and training for conflict is aimed at ensuring that if their

leader falls in battle there are other leaders to immediately take their place. Grenier (2012)

comments that the military don’t have time to undertake extensive searches of executives and time-

consuming recruitment processes; instead they rely on the ability of any of their teams to take up

these roles at short notice. However, most organisations are ill-prepared for succession (Harrell,

2016) and in contrast this planning can take some considerable time, and deputies need to be given

the opportunities and exposure to the responsibilities of a chief executive over a period of time to

ensure they are prepared to take on the role. The findings from this study suggest that succession

planning had been given some attention and was a key component of the IIP accreditation process.

Some of the executive team were confident of the abilities within the organisation to be able to step

up and take more senior roles when required. The participants did not give views about whether

there was a preference for internal or external post holders when recruiting to executive positions.

They did, however, make reference to a preference to appoint their own trainee doctors to

consultant posts. One of the participants made reference to this in terms of their belief about

growing their own consultants and the importance of nurturing their trainees.

While there was a focus on succession planning to manage the impact of the chief executive or the

members of the team leaving, the findings from this study suggested the approach of recruiting to

the values of the Trust was key to managing any risks of not appointing the right person to lead the

Trust.

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Summary of Theme 4 This theme focused on the concept of sustainability, challenges, and pressure and incorporated a

number of key areas, including increasing workloads, financial pressures, and significant concerns

regarding succession planning for the executive team alongside concerns for the longer term

sustainability for the Trust in terms of the way they felt it was currently being led. These pressures

and challenges had led the executive needing to consider adjusting their leadership approach from

one of distributed leadership to one moving towards greater central command and control. This was

in response to the need to take improved financial control. These pressures also suggested the need

for the Trust to be more proactive in engaging with external stakeholders. The findings suggested a

high degree of an internal focus on the organisation and identified and the need be more strategic

and responsive to future opportunities and threats to sustain the current success. When the CQC

have assessed an NHS provider as being ‘outstanding ‘and ‘well led’ they subsequently reduce their

frequency of inspections with the organisation, potentially moving these assessment from annual to

3 yearly. However there is a risk that where a provider has achieved this rating there is a potential

for overreaching leading to a loss of sustainability and potential decline or failure (Collins 2001).

Therefore the CQC may need to consider whether some interim review may be warranted to detect

early signs of decline particularly in relation to quality service delivery and staff feedback.

This theme also explored the risk associated with the potential changes to the executive leadership

team, in particular, the chief executive. The relationship between views of being ‘well led’ and the

length of service of the chief executive was considered, which raised a question of whether the

success of the organisation related to the leadership approach of the chief executive had led to them

being in post for many years, or whether being in post for this length of time was the reason for the

perceptions of being well led. The rationale for this was more related to continuity of approach from

the same leader over a period of time. This is an area that would benefit from further research.

Summary and combining the four themesThe four themes that emerged from the analysis of the staff’s views on the concept of being ‘well

led’ included participants describing a sense of feeling part of a wider family, particularly in relation

to the importance of a focus on shared values and behaviours and putting both patients and staff

well-being at the core of these. Second, there was a strong preference for a distributed leadership

approach that retained a degree of hierarchy with a clear chain of command. The third theme

highlighted importance of a system learning approach particularly in relation to the absence of a

blame culture but alongside a commitment to take tough action when behaviours fell outside the

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shared values of the organisation. The fourth theme related to the need to build resilience and

embed shared values in order to sustain the ‘well led’ approach during times of significant financial

pressures and workforce challenges. The underpinning principles of learning organisational theory

as described by Argyris (1992) and Senge (1990) could be seen as a connecting thread through each

of the themes , with different elements present throughout (see table 13 below ). There were also

with some contradictory findings which suggested a number of polarities to be considered, balanced

and managed (please see table 14).

Theoretical considerations emerging from studyThe theoretical considerations emerging from the findings from this study have the potential to offer

some key insights in contributing to a greater understanding of the concept of being ‘well led’. Some

additional areas of exploration and research into this area are also suggested. These relate to the

degree a well led organisation would need to prioritise commitment over compliance. This relates in

particular to the way the participants viewed the imposition of the Trust’s values and expected ways

of behaving on their organisation. The participants supported the imposition of what they termed

‘good culture ‘on the organisation (in particular Site two) which included taking tough action on staff

who did not comply with the Trust values. This was particularly notable when compared with the

supportive and learning approach given to staff in relation to be involved with clinical errors. Whilst

some of the literature challenges an imposition of a particular culture on an organisation (Ogbanna

& Wilkinson 2003) , the participants fully supported this approach and attributed it to the concept of

being ‘well led’ and it having enabled the organisation to achieve the quality improvements needed.

They felt this was further endorsed by the success of their CQC assessment.

A further key finding was the participant’s preference for a distributed leadership approach balanced

against the need to ensure some degree of hierarchy. The participants valued many aspects of a

distributed leadership approach and in particular the focus on informality, for example lack of formal

meetings and bureaucracy. They also highlighted the importance of a clear chain of command and

lines of accountability and the important finding was the need for both, that they are not mutually

exclusive but the balance favoured a higher percentage on a shared leadership approach.

The focus on support of staff and promotion of learning organisational approach was particularly

evident in the junior doctor’s views of being well led, which suggested a range of positive

relationships with their leaders, i.e. their consultants which they felt directly enhanced the quality of

care they delivered. This findings contrast with the experiences of many junior doctors in training

across the NHS and suggest an important aspect of being well led being directly related to the

support trainee doctors receive in the work place.

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Whilst acknowledging the limitations of this study, which are discussed in detail later in this chapter,

these key findings have the potential to provide a framework for further research in this area and

making a contribution to driving improvements to the leadership of NHS organisations. The findings

also suggest an organisation the was feeling the challenge of sustaining a ‘well led’ approach against

a range of significant financial and work place challenges and pressures. The findings suggest the

need to adopt a range of strategies which include investing in staff leadership capability, embedding

values, continued distributed leadership approach (avoid shifting the balance to one of central

command and control) and taking care to not be over ambitious nor hold unrealistic expectations of

staff. The experience from this case study in relation to achieving the improvements assessed by the

CQC in relation to Site two, suggest the participants believed the imposition of ‘the right culture’ had

been successful. However the findings from the study have also suggested an organisation that

describes itself as struggling at times to sustain the quality of care they desire. There may be risk that

the improvements achieved with Site two may not necessarily be sustainable if commitment of the

staff has not been achieved. As seen within the Ogbanna & Wilkinson (2003) study, whilst staff

maybe appear to be behaving more in line with the Trust values, if hearts and minds have not been

won, there is a risk that as pressure and challenges increase that staff will not be so willing to comply

and risked a reverse in the improvements seen.

Contribution of new knowledge to gaining greater understanding of the ‘well led’ concept The aim of this study was to answer the research question, which was to explore how the concept of

the ‘well led’ hospital Trust was defined and understood by NHS staff across a range of

organisational managerial levels.

The findings from this study revealed some new insights towards gaining greater understanding of

the concept of being ‘well led’ and what some of the key components might need to include. Many

of the principles of learning organisation theory (Argyris 1992) & Senge 1990) were visible across all

four themes and these are shown in Table 13 which combined components of learning

organisations as described by Argyris (1992) and Senge (1990). These are highlighted in the third

column of table 13 and summarised above where the findings from the participants support the

components of the learning organisational framework. There were however two key exceptions

(numbered 5 & 6) relating to polarities between compliance versus commitment and the desire for

some hierarchy versus a preference for distributed leadership. Polarities represent potential issues

that need to be solved, or alternatively problems that need to be managed (Johnson 1998) &

(Johnston 2014). By identifying issues that appear to be mutually exclusive it becomes possible to

consider how both ends of the polarity points can be best reconciled. In relation to the concept of

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being well led the participant’s responses suggested they saw a need for a balance between

distributed leadership and hierarchy and commitment and compliance. In terms of effectively

managing this balance the examples given by the participants suggest this to be situational. Their

views aligned with many of components of learning organisation (see table 13), but the findings

suggest that achieving balance in the areas below (in table 14) to be directly related to participants

views about the concept of being well led. They valued all four components, but in certain

situations, for example clarity of who was in charge of a ward, clear hierarchy was essential. Likewise

in situations where staff were not seen to be living the family values, a preference was given to

imposing a greater emphasis on compliance, and taking tough action to ensure poor behaviour was

addressed.

Table 13 shows considerable alignment of participants views regarding their understanding and

experience of the concept of being ‘well led’ with the components of learning organisational theory

as described by Argyris (1992) and Senge (1990) with two areas of difference. These relates to the

contradictory views expressed by the participants in relation to compliance and commitment, and

distributed leadership versus hierarchy.

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Table 13. Alignment of findings with learning organisation key components from research study with the common key components of learning organisations. (Argyris 1992) & (Senge 1990) Key components of learning

organisations

Alignment of themes with

learning organisation key

components from research

study

Components from the

four themes which

emerged from grounded

theory analysis

1. Building shared vision / aligning vision and values Argyris (1992)

Key finding within theme 1 - family

Shared values and clarity regarding expected behaviors important to participants

Pursuit of excellence, clarity of vision, purpose and expectation also important

2. Leader installs organisational sense of commitment Argyris (1992)

Key finding within theme 1 &4 – family and sustainability

Executive leaders creating right environment important to participantsCommitment important but balanced with some elements of compliance

3. Commitment to wider larger system Argyris (1992)/ Senge 91990)

Key finding within internal organisation’s structure, less evident with externally facing and wider stake holders

Commitment seen as important, but balanced against the need for some compliance

4. Staff commitment versus compliance Argyris (1992)

Key finding as potential polarity across themes 1 – 3,

Commitment versus compliance at variance within framework

5. Less hierarchical/ Distributed leadership Senge (1990) (Ancona et al 2007)

Key finding as potential polarity within theme 2

Participants valued military style chain of command

Versus

Participants value Informal / access to senior staff

6. Engages with staff / Empowerment of staff (Argyris 1992)

Key finding within theme 1 family and theme 2 distributed leadership

Participants values informal / access to senior staff ,lack of bureaucracy being empowered to make decisions

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7. Identifies system factors and supports reliability of processes /Designs systems to prevent failures (Senge 1990) Reason (1997)

Key finding in theme 3 – learning - system learning

System learning important to participants, in particular learning from patient safety incidents and not being blamed

8. Builds capacity / individual skills (Argyris) & (Senge 1990)

Key finding in theme 3 &4, learning and building sustainability

Participants valued investing in developing leadership capability

Succession planning for the executive team was viewed as important

9. Promoting a culture of learning and development (Senge 1990)

Key component in theme 3 learning, and across all themes

Participants valued investment in staff education and training and importance of valuing staff

This was evidenced by Investors in People approach, but the award was only explicitly referred to by one participant

Participants describe a consistent approach to learning from harm and not blame

Participants valued System learning approach, this was consistent across all levels of participants

10. Double loop learning / reframing Argyris (1992)

Some evidence of this seen in theme 3 but not strongly present across all four themes

Some of the executive team thought this was important, but this element was not strongly supported from findings

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Table 14- Balancing polarities for being Well Led

Table 14 shows that key to achieving the concept of being well led is a mixture of all 4 components

and critical to success is finding the right balance between them. The participants in this study

valued all 4 but the findings also suggest that the balance of the four components are not necessarily

equal. For example the participants attributed informality and access to senior leaders to being well

led, but still wanted a clear change of command and some degree of hierarchy. Likewise whilst the

family concept created commitment from staff and a focus on learning from patient safety harm

incidents they also felt it was important to have systems of compliance particularly where staff were

not seen to live the agreed values, and therefore not ‘fit the family’ and may in certain circumstance

been required to leave the organisation if they did not comply. Whilst the learning organisational

framework used for this study goes some of the way to offering a tool to underpin the well concept,

the four components of table 14 would need further research and to be tested with staff in a range

of different situations to explore and test how these four components could be effectively balanced.

Table 15 combines these four components and offers a theoretical framework to underpin the well

led concept based upon principles of learning organisations. This use of framework has the potential

to provide some theoretical underpinning to the ‘well led’ concept as currently assessed by the CQC.

The aim of the framework is to help organisations better understand how some of the components

contribute to being well led and could be used as a tool to assess themselves against and support

them on their leadership improvement journey. The use of this framework shown in table 15 could

also be used by the CQC and other regulatory and commissioning bodies to support assessment of

the ‘well led ‘concept and identify areas for improvement.

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Compliance Hierarchy

CommitmentDistributed leadership

Well led

Table 15 - Framework for developing a well led organisation founded on learning organisational principles

Components of well led learning organisation

Required Criteria

Leaders at all levels create the right environment based on concept of family, which includes agreeing and embedding a shared purpose for staff and creates a share sense of being ‘in this together’

Leaders engage with staff at all levels, in building vison and values which are patient centred and staff centredLeaders at all levels ensure they are accessible, visible, friendly and supportive

Leaders at all levels build a sense of commitment with staff through vision and values which balanced against the level of compliance needed

Leaders at all levels build a shared vision and values together with staff.They are seen as role models and live the valuesThey communicate clear expectations of staffThey ensure that systems of compliance are focused on staff living the values of being patient centred and supportive of each otherThere is zero tolerance to behaviours that run contrary to the agreed values

Leaders at all levels maintain the right balance between distributed leadership which is balances against the need for permitted hierarchy

Leaders at all levels empower staff , trust, and enabling freedom to leadThey create and maintain openness, ensure easy access to leaders, informality and minimal bureaucracyThey balance this against the need for:Clarity of reporting lines, organisational structures, accountability and necessary governance processes

Leaders at all levels embed a culture of system learning which achieves openness, trust with families and staff

Leaders at all levels ensure there is a focus on a learning as the key principle when managing clinical incidents, without blameThey build capacity and capability of staffThey invest in staff via education and trainingLeaders at all levels focus on succession planning

Table 15 combines the findings from this research study and shows the key components to support

NHS acute providers in their ambition to be well led. The tool is offered as a theoretical framework

for the CQC to use with other NHS Arms lengths bodies as well as for NHS acute provider Trusts to

consider in achieving the ambition of the ‘well led’ concept. The ultimate aim being to prevent

future failings within the NHS on the scale of those seen within the reports of Kennedy (2001),

Francis (2013) and Kirkup (2015).

The table offers a framework for both providers and the CQC which describes the components of

being well led. The left had column brings together the findings from this research which is

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underpinned by learning organisational principles. The right hand column describes the criteria to

be achieved which starts with engagement with all staff at all levels in building the visions for the

organisation. Leaders are present at every level across organisation and this view of leaders extends

from shift leader and ward leader to executive with a responsibility on all of them to act as role

models and live the values and behaviours agreed as important to the organisation. The success of

building vision and values for an organisation starts with a focus on working with all of the staff, the

focus is on staff and not structures. Implementing these changes takes time and commitment and a

willingness to engage with staff and make changes. Whilst this may prove time consuming the

findings from this study suggest they are worth devoting the time on.

Table 15 also shows some similarities to some of the components of the IIP accreditation framework

(see table 12 ) and suggests potential to consider the possibility of further integrating the two

models to support a more theoretical underpinning of the well led concept.

Wider contribution to leadership theory beyond health care.The findings from this study could also be applied in a wider context beyond health care. Learning

organisational theory is relevant to other settings, the framework could equally be useful to other

types of organisations. The findings suggest that elements from a range of leadership theories

described in chapter 4 help offer some insights to develop greater understanding the concept of

being well led, but none of them are absolute. Whilst learning organisational theory as described by

Argyris (1992) and Senge (1990) showed considerable alignment with participants views there were

some areas of key differences. These paradoxes and contradictions in leadership theory are

recognised (Zhang et al 2015) and this study has shown that the potential of deeper exploration with

research participants in identifying some of these areas. The theory which has emerged from this

research study suggests the need to give far greater attention to these areas and the need to explore

these polarities further. The right balance between compliance and commitment together with a

desire from staff for both distributed leadership balanced with hierarchy needs to be recognised as

being key components of organisation journey to improve its overall leadership.

Reflexivity (box 13) re reflecting back to my motivation to undertake this research Reflexivity 13 box reflects on my motivation in undertaking this

research study. My interest in undertaking this research was in part

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Reflexivity box 13

Reflecting back to my motivation to undertake this study:

Based in part on past personal experience as senior leader experiencing the significant impact on staff and patient care where leadership in organisation was

related to a past experience as a senior leader in one particularly challenged organisation and

experiencing the impact on both patients and staff where the executive leadership was perceived by

staff as the very opposite to well led. Subsequent experience as a Director in both provider and

commissioning NHS organisations over many years and more recently in national role has continued

to see wide variations in the quality of care delivered between NHS organisations. I was particularly

interested in the common themes that emerged from many of the previous enquiries Kennedy

(1991) Francis (2013) & Kirkup (2015) which recommended the need to move to a culture of learning

and improve leadership. I was particularly interested in the common themes that emerged from

many of the previous enquiries Kennedy (1991) Francis (2013) & Kirkup (2015) which recommended

the need to move to a culture of learning and improve leadership. However the recommendations

from these reports gave limited attention to the ‘how’ these improvements could be best made. It

was also apparent from reviewing the literature relating to ‘culture change’ there were wide

variations in agreed definition of the term and therefore being able to effectively measure this

change was limited. Some attempts to define the well led concept had been made by CQC and more

laterally NHS improvement but I confess to beginning this study with a degree of scepticism in

relation to understanding which theories underpinned the well led concept (as defined by the

CQC). I did however believe that by undertaking this research in an organisation that had been

assessed as being ‘well led’, and gaining greater insight into the views of some staff it may be

possible to better define the concept with the potential to better define and subsequently share

with other NHS organisations some of the underpinning concepts. I applied the iceberg framework

(James 2015) in determining the best approach to conduct the study. I first considered the research

paradigm related to this topic, which started with a need to explore the ‘world view’ and support

the approach to question the assumptions underpinning the accepted view of the CQC assessments

of ‘well led ‘were valid.

A preliminary review of the leadership literature identified a gap in the terms of exploration of staff’s

experience of the concept of being well led and the epistemological lens selected to undertake this

study was a qualitative interpretive approach. The ontological approach selected was one of

exploration and interpretation of what the concept of effective leadership was, and the degree to

the extent the concept of being ‘well led ‘could be viewed in reality. The aim was to explore this

concept through the lens of the staff’s views, experiences and understanding within the organisation

that they worked. A case study approach was selected to incorporate an insider’s view of leadership

within the hospital studied and with the expectation that a qualitative approach would give the

opportunity to enable a greater in depth exploration and understanding of the concept how staff

viewed good and poor leadership. I chose to use a grounded theory approach as I felt this would give

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Reflexivity box 13

Reflecting back to my motivation to undertake this study:

Based in part on past personal experience as senior leader experiencing the significant impact on staff and patient care where leadership in organisation was

the opportunity to explore the concept of ‘well led’ through the lens of the staff and allow the

theory to emerge through their own described experiences.

To assist me in a more reflexive approach I kept a diary and made notes (summaries of these are

illustrated within reflexivity text boxes within each chapter) throughout the process which captured

my own personal journey of changing perceptions. This helped me better understand how my own

understanding of the concept of well led changed though the research process. This was particularly

important during the data analysis stage and the need to continually refer back to the research

question and the objective of the study.

Strengths and limitations of the study

The research question focused on the views of staff operating at a number of managerial levels.

While this was helpful in selecting the participants to include in terms of the managerial structures

of an NHS hospital, on reflection it would have been more helpful to differentiate in more detail the

difference between staff holding managerial roles and leadership positions. While all of the

managers interviewed would consider themselves to be leaders, it would have been helpful to give

greater consideration to this, as there was a risk that some key staff views could have been excluded

from participating in the study if I had taken a more purist view and limited the participants to just

those in managerial roles. However, it could be argued that the differences between staff who hold

leadership rather than managerial roles is an artificial and unhelpful differentiation, as leaders will

usually have some degree of managerial responsibility within their roles (Mintzberg, 2017).

Sample selected and theoretical saturationThe NHS Trust used for this study was selected as having been assessed by the CQC as being well led,

and there was a small sample of NHS organisations from which to choose. I made an assumption

that exploration within one of these ‘well led‘ Trusts would have the potential to offer important

insights in gaining greater understanding of some staff’s views and experiences of the concept of

being well led. On reflection, it may have been useful to have undertaken the study in a second NHS

Trust, which could have the potential to improve validity of the data gained; however, in practical

terms this would have taken considerably longer to complete. Another approach that could have

been considered could have been a comparison study between Trusts that have achieved different

levels of being assessed as being well led. However, this would have changed the focus of the

research and would not have addressed the specific aims of this study, which was to look in depth at

the staff’s experience, and would instead have been a comparison study and would therefore have

leaned towards answering a different question. However, despite this being a small sample, some

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rich data was gathered from a range of participants across the organisation studied, which enabled

in-depth analysis of their views, which is recognised as a key benefit of undertaking case study

research (Yin, 1993).

The final sample size was 30 semi-structured interviews and observation of four meetings across the

organisation. In the context of an NHS Trust that employs several thousand staff this is a small

sample, but was also practical in terms of the time available for the study. The sample size was more

than the minimum, that is, a sample size of between 15 and 20 suggested by Latham (2013). Others

suggest the need for more or less depending on the richness of the data captured (Guest, Bunce, &

Johnson, 2006; Crouch & Mckenzie, 2006). However, the aim was to conduct in-depth interviews to

gain staff views, and while it would have been beneficial to conduct more interviews, theoretical

saturation in terms of new data emerging was reached during the study. At this point of saturation

further data collection was discontinued to avoid wasting the time of busy health service

participants and to avoid the collection of data that may not be used, or add value (Francis, et al.,

2010).

I had expected to find greater differences in the views of staff, but this was not the case, and this

applied regardless of level of position held within the hierarchical structure of the organisations, or

the speciality worked within. During the study the issue of the concerns relating to Site two was

raised within all of the interviews. It was felt to be important to ensure that participants were

interviewed from both sites. However, while findings from this study in relationship to validating

their views about imposing their values and behaviours on to Site two related to their beliefs about

being well led, I was careful to not be distracted by this. There was a risk of digressing away from the

main research questions and instead focusing more on issues concerning an organisational merger.

I was also initially surprised by the respondents’ consistently positive views of being well led, so felt

the need to test this further and ensure I included a number of clinicians delivering front-line care to

explore further if this view was supported by these staff. Reflecting on the consistency of the

positive views given by the staff regarding the Trust’s leadership I considered the possibility of

whether the staff had been providing me with a narrative of what they thought they should say and

what they thought I wanted to hear. I also considered whether my senior national role within the

NHS could have been an influencing factor. In addition, the positive responses given to me were very

similar to those found during their previous CQC inspection and I also considered the possibility of

whether staff had been briefed to give the ‘party line‘ to ‘outsiders’ in order to give a positive image

of the Trust. However, after careful consideration I felt this to be very unlikely, as despite my

providing information about my research to the participants prior to the interviews most of them

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had not read it in advance and were not aware of the context of my study. Nor were they aware of

who I was until I provided the information sheets again at the time of the interview. Also following

many of the interviews were frequently more relaxed informal discussions where staff continued to

speak in positive terms. This was also seen in the meetings that I observed. I reflected on my initial

scepticism in relation to the validity of the CQC assessment on the well led concept, and whether the

CQC inspectors when they had assessed this Trust had also considered the ‘too good to be true’

perception. This led me to consider whether this view by the participants in the study believing the

organisation as being well led would be consistent if a significantly larger sample were with a greater

cross-section of the Trust. However, the findings from this study suggested the participants did

believe their organisation to be well led. I was confident that the richness and the consistency of the

data collected was sufficient to be able to give these participants a voice in terms of generating some

theories relating to their experiences of being well led, but also accept that further interviews in

different departments, for example, ancillary and administrative staff, would have added greater

value to this study.

Theoretical framework The theoretical framework used a blended theories approach related to learning organisations from

Argyris (1992) and Senge (1990) to underpin the methodological approach used and to give structure

to support analysis of the data collected. There was a potential risk of introducing some bias into the

study (Elliott & Higgins, 2012). It was important to ensure a clear distinction between an inductive

and deductive approach, as the epistemological lens for this study was one of induction. I was aware

of a risk of moving the analysis towards a more deductive approach by the use of a theoretical

framework. Caution was taken in approaching the analysis to minimise the risk of a temptation to fit

the data to the theoretical framework (Gioia, Corley, & Hamilton, 2013).

Reflexivity (Box 14) regarding reflection of use of theoretical framework Reflexivity Box 14 shows my reflections on the use of the

theoretical framework. I found the framework to be useful in

terms of structuring the interview questions and I took great care

during the analyis and interpretation of the data to avoid

applying the framework and instead followed the grounded

theory process of analysis suggested by Charmaz (2006) to guide

this process. I focused on giving the voice to the participants and

as the meanings began to emerge I then considered how closely

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Reflexivity Box 14

Reflections of use of theoretical framework:

Initial concerns about using framework about bias helped me to keep continued awareness of this throughout process.

Framework was most useful following the analysis process of the data.

Its greater use was in helping to identify emergence of new theory from the data.

I concluded, despite my initial

the theory commentary aligned with the theoretical framework. I worked hard to avoid trying to

align the narratives to the framework and instead used it in the background as a guide. The

limitation of this was the extent to which I could realistically truly suspend knowledge of both the

initial literature review and avoid application of the theoretical framework together with being

confident that I was not biasing my interpretation. It was important to remain as close to an

inductive approach as possible to avoid imposing the framework on the data as it emerged. The

espistemological lens was focused on exploring the experiences from the participants’ perspective

and I took care to avoid the risk of trying to fit their responses into the framework and risk

misinterpeting their views. I considered where the emerging themes related to the theoretical

framework at the final stage of the process of the focused analysis, and at the same time undertook

a secondary literature review. The attention I gave to the rigour of this phase helped reduce the risk

of influencing the final themes. On reflection, the views from staff aligned with many aspects but not

all of the categories of the theoretical framework. The advantages of applying this level of rigour was

that it enabled the four themes to emerge and best represent the voices of the participants, and

consequently generated new ideas and theories in relating to being well led that could have been

missed if this discipline had not been rigidly adhered to.

Evaluation of the grounded theory approachThe use of the grounded theory approach fittted well with the case study approach and the aim of

eliciting the views and experiences of staff to generate the theory (Lyons & Coyle, 2007). Selecting a

less traditional and more interpretive grounded theory suggested by Charmaz (2006) and supported

by Breckenridge, Jones, Elliott, and Nicol (2012) felt less rigid and suportive of my intention of an

approach that was inductive, interpretive, and systematic. I did, however, find the process described

by Gioia, Corley, and Hamilton (2013) and Charmaz (2006) complex to follow, and studied at length

the process suggested by Charmaz (2006), in particular, in relation to making visible my own

interpretation witin the analysis process. On reflection, one limitation of this study was the level to

which this was visible to the reader. To mitigate this, I included the voices from the participants in

quotes in the findings to support the interpretaitons presented. The aim was to gain a deeper

understanding of how the concept of well led was defined and understood, which was likely to vary

between settings due to the wide number of potential factors present. The key findings from the

study suggest a number of areas worthy of further research. The findings also offer a range of

components of the ‘well led’ concept as described by the participant that would be helpful to test in

other organisations. The next steps would be to undertake further research in a range of settings to

explore whether the findings from the organisation are reproducible and also to explore further

what some of the variables may be. The strength of the study was its close alignment to learning

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Reflexivity Box 14

Reflections of use of theoretical framework:

Initial concerns about using framework about bias helped me to keep continued awareness of this throughout process.

Framework was most useful following the analysis process of the data.

Its greater use was in helping to identify emergence of new theory from the data.

I concluded, despite my initial

organisational theory as suggested by Argryis (1992) and Senge (1990) and a belief that further

research would be helpful to focus on the areas that demonstrated new theory in terms of the

contribution to the literature that this study brings.

An evaluation framework suggested by Charmaz (2014) was adapted and used to critically evaluate

the use of grounded theory approach in answering the research question:

How was the concept of the ‘well led’ hospital Trust defined and understood by NHS staff across a

range of organisational managerial levels?

The following framework below considered a number of questions in response to the outcomes of

the study to evaluate whether the research question had been effectively answered. Table 11 shows

my responses to the questions posed within the categories and the conclusions that emerged from

this process.

Table 15 - Evaluation of grounded theory approach to study Criteria Critical evaluation of grounded theory approach to the study

Credibility Has my research achieved intimate familiarity with the setting or topic?’

Yes, the participants openly shared their views and beliefs, and the research produced rich meaningful data

Is the data sufficient to merit the claims

Yes, but acknowledging the limitation of how these relate to this one case study the date collected was rich and the depth of findings support many of the components of learning organisational principles. Whilst it may have been beneficial to interview a wider group of staff, within the sample used rich data was collected and theoretical saturation was reached

Have systematics comparisons between the categories been made

Yes, there is a read across between the themes, with the concept of learning being a common thread across all four of the themes

Are there strong links between the data, argument and analysis

Yes, the analysed data has driven the argument and further theoretical understanding and underpinning of the ‘well led’ concept

Has the research provided enough evidence to allow reader to independently assess and agree with claims

Partially, the conclusion bring together an interpretation of the analysed data together with reflexivity from my research journey. Combining my views and experiences as an inside researcher the reader it is expected than similar conclusions could be drawn

Originality Are your categories fresh

Some of the categories are fresh, for example the family theme provide a different perspective from that given from the literature reviewed

‘Do they offer new insights?’

Yes the polarities between compliance and commitment as well as hierarchy versus distributed leadership offer new insights and a different perspective compared to that seen within the literature reviewed

195

What is social and theoretical significance

The significance of the polarities are they are new and demonstrate that staff desire to determine the balance of the 4 categories. This challenges the leadership organisational assumptions that learning organisations would not include preferences for hierarchy or compliance and these would be more likely be associated with traditional organisational characteristics (Argyris 1996)

How did grounded theory approach challenge, extend, refine current ideas and concepts

Using a grounded theory approach focused on the lived experiences of the participants generating the theory, it reflected and represented the voices from the staff, who were given the opportunity to freely express their views. The preferences for the need for some hierarchy and compliance as part of what they viewed as ‘well led’ was a new concept that the grounded theory approach enable to emerge

Resonance Do the categories portray the fullness of the studied experience?’

Yes, the four themes emerged during the data analysis and this enabled the data to be categorised within the themes. The interviews together with the observations of the meetings enabled a fuller experience to be studied. However a limitation previously acknowledged was that wider sampling over a longer period of time may also be beneficial

Does your grounded theory make sense to your participants or people who share their circumstances?

I had the opportunity to share some of the conclusions from the study with the senior leadership team at the study site. They were in agreement with the findings and fed back they valued the depth of analysis the study had revealed

Does your analysis offer them deeper insights about their lives and worlds?’

The conclusions provide deeper insights into understanding and defining the concept of being well led. However they also show that there is more to discover, and whilst this study was limited to one case study, it revealed rich data and shows the potential for further exploration

Usefulness Can the analysis spark further research into other substantive areas?’

Yes, more research would give the opportunity to test some of the theory generated from this study and explore in more depth the usefulness of the learning organisation , and the extent to which the polarities which emerged are a feature elsewhere

How does your work contribute to knowledge?

The concept of learning was a key theme throughout the various reports on health care failings, and it emerged from the study as a key theme throughout.

Contributions to new knowledge and theory relate to application of a refined and adapted and modified learning organisational framework to help define categories towards being able to define what ‘well led’ looks like to staff. This is one that pays particular attention to the balancing of the polarities shown in table 14. Table 15 provides a useful tool for organisations to explore this further.

Gaining greater understanding of how the balancing of the polarities described by staff as being part of the ‘well led concept’ is key i.e. the optimum balance between commitment and compliance, and hierarchy and distributed leadership impact on their views about being well led.

196

The above evaluation framework was helpful in asking a range of questions in terms of the study’s

conclusion and considering the extent to whether the research

question had been answered. Applying the framework helped me

to conclude that my study was able to contribute new knowledge

in terms of understanding how some staff within one case study

defined and understood the concept of the ‘well led’ hospital

Trust across a range of organisational managerial levels. However

the study also highlighted the need to take this research question

further with the need also to test the extent to which learning

organisational framework and further exploration of the polarities

could help to gain greater understanding of how the ‘well led ‘

concept could be better defined and understood. By gaining

greater understanding and consideration of the value of a

modified learning organisational framework to improving

leadership in an NHS Trust this could be further research and

tested in terms of exploring the relationship between a well led

organisation and measuring improvements and possible impacts

on the quality of care delivered to patients by improving the way

staff feel they are on the journey of being ‘well led’.

Reflexivity (box 15) Reflections on conclusions of study Reflexivity box 15 shows my reflections on the conclusions of this

study. It was a great privilege to be able to gain access to an

organisations where staff held a positive view of their

organisation during a time when the wider NHS is facing such

unprecedented pressures in relation to demand, insufficient

resources and work force challenges. I had not expected the

participant’s views to reflect those of the CQC assessment of

being well led and this led to me to conclude that this needs to be

further explored in other NHS organisations. However as

highlighted in chapter 2 it is difficult to identify the theoretical

underpinning of the CQC criteria for assessment of the well led

concept. This suggests that the concept has emerged overtime as

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Reflexivity box 15

Reflections of conclusions of study:

Participants expressed positive views about their organisation at a time when the NHS is facing unprecedented pressures

Findings suggested participants did believe their organisation to be well led – supports the CQC’s assessment findings

Findings challenged my initial scepticism re CQC assessment but needed to consider whether CQC methodology valid or whether this NHS trust unique?

Led me to consider would this be the case in another NHS provider Trusts assessed by CQC as ‘well led’ or could this be an exception, i.e. is this a one off?

However CQC assessment lacks theoretical underpinning framework and therefore challenges consistency and objectivity of their approach

Learning organisation principles which are modified to reflect the four polarities may offer a helpful framework (see table 15) for better defining ‘well led’

And have potential to support NHS organisations to make improvements by using of framework (table 15)

Potential to help organisations to respond to health care failings in terms of the need to improve leadership and continuous learning to improve

Potential for the CQC to use learning organisational theoretical principles to underpin and give more of a theoretical base to the their criteria for assessing the well led concept, am alert to risk of courtesy bias, risk CQC may not want to hear suggested criticism of their methodology

a response to seeking a solution to the current leadership challenges that NHS organisations face as

highlighted in various enquires have shown. Without this theoretical underpinning of what

constitutes ‘well led’ the CQC risks variation and lack of objectivity in their approach to assessment

and being subject to challenge. Whilst the findings in this study support the CQC assessment in this

particular case, this would need to be further tested with multiple organisation having been

assessed as well led to be able to confirm its validity.

The findings from this study offer potential for the CQC to use modified learning organisational

theoretical principles which reflect the 4 polarities described above to underpin and give more of a

theoretical base to their assessment process. The findings also offer insights to help NHS acute

provider organisations in helping them respond to some of reports of health care failings in

terms of the need to improve leadership and to make improvements by aligning modified principles

of learning.

198

RecommendationsThe following recommendations emerged from the study and are suggested in taking forward the

key findings from this study. These include recommendations for NHS provider organisations, for the

Care Quality Commission, other NHS bodies and also considerations for further areas of research.

Recommendations for NHS provider organisations and wider NHS It is recommended that NHS providers take forward an integrated framework as shown in table 15 to

support them in their journey towards being ‘well led’. It is recommended that NHS organisations

engage internally and with external partners to use the tool to self-assess themselves against the

framework and work through each area in detail. This framework incorporates the four themes with

the above tables (Argyris 1992) & (Senge 1992) and includes giving particular attention to the

following aspects:

Balancing commitment versus compliance: Acknowledging the importance of determining

and subsequently maintaining the right balance between commitment and compliance in

relation to organisation’s values and behaviours.

Distributed leadership with permitted hierarchy: Recognising the need for a distributed

leadership approach with some aspects of hierarchy, which considers the optimal balance

between a degree of informality, friendliness and lack of bureaucracy balanced against a

clear visible chain of command.

Recognise both the benefits and risks of the imposition of expected ways of behaving on the

organisation within a framework of compliance with the expected shared values and

behaviours (participants label this as ‘good culture’) which includes taking tough action on

staff who display behaviours that don’t reflect the agreed values.

Focus on supporting staff: Recognising the importance of staff in particular junior medical

trainees having access to and support from their senior staff. This includes:

Senior staff role modelling the shared family values.

The importance of investment in staff and succession planning

Building resilience and embedding shared values to manage pressures and challenges.

Recommendations for the CQC and other NHS Arm’s Length bodies, e.g. NHS Improvement and NHS EnglandIt is recommended in the light of the findings which have emerged from this study, the CQC and

other closely aligned NHS arm’s length bodies adopt a modified learning organisational framework

(as described in table 15) to give some theoretical framing of the well led concept (Argryis 1992 &

199

Senge 1990). This would support them in building a more consistent and objective approach to

assessment. This would give the CQC and other external partners the opportunity to encourage

providers in self-assessing themselves against the framework to help them focus on key areas to

address. This self-assessment from provider Trusts would also highlight the level of self-awareness

the organisation has in relation to quality of its leadership and could be triangulated against other

sources of data (as collected prior to inspections). This would enable more objective assessment of

the ‘well led’ concept and the degree to which a provider NHS trust could be viewed as a learning

organisation.

It is recommended the CQC and other NHS care arm’s length bodies engage in further discussions

with the wider NHS system together with NHS providers in proving greater support for organisations

in improving the leadership capabilities of NHS Trusts.

The CQC needs to consider whether some interim review may be warranted in Trust rated as

outstanding and well led (where inspection have been subsequently reduce to 3 yearly) to detect

early signs of decline particularly in relation to quality service delivery and staff feedback.

Recommended areas for further research Further areas for research should include:

Researching, testing and evaluating the modified learning organisational framework (table 15) on a

range of NHS Trusts.

Seeking to gaining greater understanding of how the balancing of the polarities described by staff as

being part of the ‘well led concept’ i.e. the optimum balance between commitment and compliance,

and hierarchy and distributed leadership impact on their views about being well led.

Researching, and evaluating the modified learning organisational framework (table 15) on a wider

range of organisations outside of health care setting to test, and further develop the framework on

its applicability of embedding learning organisational principles in other industries.

Further studies should also consider extending a case study approach to undertake:

Multiple case studies which explore the concept of ‘well led’ as assessed by CQC in other

NHS acute providers assessed as good or outstanding in the well led domain A study which focuses on exploring further the views of medical staff in relation to being

well led

200

A study which focuses on NHS support staff’s view of being ‘well led ‘( e.g. porters, domestic

staff, administrative staff) A study that compares the views of staff’s experience of being well led between those rated

as ‘outstanding versus those rated as ‘inadequate’ in this area Evaluates the impact of imposing Trust values on additional site post-merger or acquisition

of additional NHS organisations

201

Conclusion This study explored how the concept of being ‘well led’ was experienced and understood by a range

of staff within one NHS Hospital Trust (rated by the CQC as well led). These findings have the

potential to support the NHS in improving its leadership capability to help prevent further failings

occurring as those seen on the scale of the Mid Staffordshire hospital (Francis 2013), and

Morecambe Bay NHS Hospital (Kirkup 2015).

A theoretical framework was developed incorporating learning organisational principles to underpin

this study and support the methodological approach and analysis. The process of analysis and

interpretation utilised a grounded theoretical approach supported the generation of some new

theory to offer new insights into how the concept of ‘well led’ was experienced and understood by

staff. A qualitative case study approach was selected which explored through semi structured

interviews with a range of staff and observations their experiences of the ‘well led’ concept. A

theoretical framework incorporating components of learning organisational theory (Argyris 1995 &

Senge 1990) was used together with an interpretive grounded theory approach (Charmaz 2006) to

underpin the methodological process.

Four themes emerged from the analysis of the staffs views on the concept of being ‘well led’ , these

included participants describing a sense of feeling part of a wider family, particularly in relation to

the importance of a focus on shared values and behaviours and putting both patients and staff

wellbeing at the core of these. Secondly there was a strong preference for a distributed leadership

approach which retained a degree of hierarchy with a clear chain of command. The third theme

highlighted importance of a system learning approach was highlighted in terms of the absence of a

blame culture alongside a commitment to take tough action when behaviours fell outside the shared

values of the organisation. The fourth theme related to the need to build resilience, embed shared

values in order to sustain the ‘well led’ approach during times of significant financial pressures and

work force challenges.

Many of the principles of learning organisation theory (Argyris 1992) & Senge 1990) were visible

across all four themes. However the data suggested some important differences, these were in

relation to the degree a well led organisation would need to prioritise commitment over compliance.

Another was the preference distributed leadership balances with the need to ensure some degree of

hierarchy. These key findings revealed some new insights into the concept of being ‘well led’ and

have the potential to provide a framework for NHS acute provider Trusts to consider using and to

support further research in this area with the aim of driving improvements to the leadership of NHS

provider organisations.

202

A number of recommendations have been suggested for NHS the CQC and wider external

stakeholders to consider taking forward combed components of learning organisation principle

together with some key findings emerging from this study. This would enable the development of a

framework for NHS organisations to support them in their ambition to improve their overall

leadership capability to drive forward improvements in quality of care provided to patients, and also

increase support and value for the staff that deliver this care.

Learning organisational theory is also relevant to other settings, and this framework could equally be

useful to other types of organisations. Consideration needs to giving to test, further develop and

refine this tool for use on area beyond health care organisations. There is however an urgent need

to address the recommendations which have arisen from a rage of significant health care failings

with some evidence based action that will drive the improvements needed and prevent these from

reoccurring in the future. Achieving the secretary of state’s the ambition for the NHS to become the

largest learning organisation in the world requires a commitment from all that work within it to

make this a reality.

In the words of Berwick (2013), to effectively address and improve the safety of patients in England

requires from all that work in the NHS ‘ A promise to act and a commitment to learn’(Berwick 2013) .

An adapted learning organisational approach to provide a theoretical underpinning for the well led

concept offers one potential approach towards making this a reality.

203

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Appendix 1: Letter to organisation seeking permission to undertake research

Dear x

I am writing to ask whether you would be willing to agree to my undertaking a research study within your organisation.

I am currently a part time post graduate student registered for a PhD programme at University of Surrey. The purpose of my research is to try to gain a greater understanding on the how effective NHS leadership is defined, developed and enacted in relation to quality performance across different organisational managerial levels within the Trust.

The reason for approaching your Trust as it has received a rating as ‘good or outstanding ’ following a CQC hospital inspection, and I am interested in exploring in greater depth the concept of a ‘well led ‘ organisation, in understanding how this is defined, developed and enacted across an organisation.

The design of the research includes a ‘case study’ approach, which would involve spending some time within an organisation to gain greater understanding of the way leadership is transacted across the organisation. This time would include interviewing key staff, where possible in group meetings, and observing some team meetings to hear their views on effective leadership. I would anticipate undertaking this over a 2 -3 days’ timescale.

It is hoped by exploring these views to gain in depth and greater understanding how effective leadership is best developed within an NHS organisation. The findings from the study will be analysed and presented in the form of a doctorate study, The Trust will not be identifiable in the report and all responses will be anonymised and non-attributable to any individuals.

I would be happy to prepare a separate confidential report on the findings for the Trust’s own use if this would be helpful.

If you are interested in participating in this study please contact me via e mail denise.chaffer1@sky.com

I look forward to hearing from you

Denise Chaffer

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Appendix 2: Letter to participants

Dear x

I am writing to ask whether you would be willing to participate in relation to a research study I am interested in undertaking. I am currently a part time post graduate student registered for a PhD programme at University of Surrey.

The reason for approaching you is that you have a key role within your organisation and I would be interested to hear your views about effective leadership within the Trust. The reason for selecting your Trust is that it has received a rating as ‘good/ outstanding ’ following a CQC hospital inspection, and I am interested in exploring in greater depth the concept of a ‘well led ‘ organisation, in understanding how this is defined, developed and enacted across an organisation.

I would like to invite you to participate in an interview and also to ask whether you would also be willing to agree to me observing one of the meetings you attend. I have attached some further information which provides further detail of the study to hear your views about leadership in the Trust and how this relates to the quality performance of the organisation. All responses will be anonymised and treated as confidential and any contributions will not be attributable to any individuals participating in the research.

The interview will take no longer that 1.5 hours and will involve some discussion around your views of good leadership within the Trust. It is hoped by exploring these views to gain in depth and greater understanding how good leadership is best developed within an NHS organisation. The findings from the study will be analysed and presented in the form of a doctorate study.

If you are willing to agree to participate in an interview and / or agree to me observing one of the meetings you attend I will ask you to complete the consent form attached.

You would be able to change your mind and withdraw from the interview at any stage in the process

I look forward to hearing from you

Denise Chaffer

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Appendix 3 Participant Information Sheet (re Individual interviews)

PROJECT TITLE

An exploration of how the concept of the ‘well led’ hospital Trust is defined and understood by NHS staff across a range of organisational managerial levels.

Introduction

My name is Denise Chaffer and I am currently a part time PhD student at University of Surrey. I am a Registered nurse and Midwife and have been a senior manager in the NHS for the last 15 years.

I would like to invite you to take part in a research project. Before you decide you need to understand why the research is being done and what it will involve for you. Please take the time to read the following information carefully. Talk to others about the study if you wish.

What is the purpose of the study?

This study seeks to try and gain a greater understanding about effective leadership within an NHS organisation and how this relates to quality performance.

Why have I been invited to take part in the study?

Because you have a key role within your organisation and I would be interested to hear your views about leadership in relation to quality performance of the Trust. Your participation within the study will be confidential and your contributions will anonymised and not identifiable to colleagues in any dissemination of results from the interviews.

Do I have to take part?

No, you do not have to participate. Your employment will not be affected and there will be no adverse consequences in any way if you decide not to participate. You can withdraw at any time without giving a reason and your contribution to any of the data will be withdrawn and not used in the study

What will my involvement require?

You will be invited to participate in an interview to hear your views about leadership in the Trust and how this relates to the quality performance of the organisation. This will be held in a room at the Trust and will take no longer than 1 hour. If you decide to participate you will be ask for your consent to record the discussion using an electronic recorder. This will then be transcribed and you will be given the opportunity to accuracy check the transcription of the interview. If you decide to withdraw at any stage during the interview your contribution will be erased from the audio recording and any related notes taken will be destroyed

What will I have to do?

If you would like to take part you will be invited to take part in an interview responding to a small number of questions about your views on leadership.

What are the possible disadvantages or risks of taking part?

The disadvantage to taking part is giving up your time to participate. There are no real risks to taking part, except this will require you to take some time out of your working day

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What are the possible benefits of taking part?

It is unlikely that you will benefit directly but it is hoped that you may find the opportunity to give your views .

What happens when the research study stops?

A summary of the research study will be available for participants on request if you would like to receive this by contacting me directly by e mail up to a year (Dec 2018) following completion of the study.

What if there is a problem?

If you have any complaint or concern about any aspect of the way you have been dealt with during the course of the study will be addressed; please contact the investigator Denise Chaffer (denise.chaffer@surrey.ac.uk) you may also contact my primary supervisor Dr J Hendy (j.hendy@surrey.ac.uk) or telephone +44(0)1483 684743 or if you need to contact an independent third party please contact Head of School Professor Andy Adcroft, email a.adcroft@surrey.uk or telephone 01483 6822007

Will my taking part in the study be kept confidential?

Yes. Personal data will be handled in accordance with the Data Protection Act 1998. All of the information you give will be anonymised and not attributable so that those reading reports from the research will not know who has contributed to it.

Research Data will be stored securely for at least 10 years in line with University of Surrey policy

Contact details of researcher Denise Chaffer denise.chaffer@surrey.ac.uk

Who is organising and funding the research?

The research is part of a Phd programme run by University of Surrey. There is no funding attached to the study.

Who has reviewed the project?

The study has been reviewed and received a Favourable Ethical Opinion (FEO) from the University of Surrey Ethics Committee.

Thank you for taking the time to read this Information Sheet.

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Appendix 4: Participant information sheet (regarding observations of meetings)

PROJECT TITLE

A study of how effective NHS leadership is defined, developed and enacted in relation to quality performance across different organisational managerial levels

Introduction

I am currently a part time post graduate student registered for a PhD programme at University of Surrey. I am a Registered nurse and Midwife and have been a senior manager in the NHS for the last 15 years.

I would like to invite you to take part in a research project. Before you decide you need to understand why the research is being done and what it will involve for you. Please take the time to read the following information carefully. Talk to others about the study if you wish.

What is the purpose of the study?

This study seeks to try and gain a greater understanding about effective leadership within an NHS organisation and how this relates to quality performance.

Why have I been invited to take part in the study?

Because you have a key role within your organisation and I would be interested to hear your views about leadership in relation to quality performance of the Trust

Do I have to take part?

No, you do not have to participate. There will be no adverse consequences in any way if you decide not to participate. You can withdraw at any time without giving a reason.

What will my involvement require?

You will be observed by the researcher during your one of your usual Trust meetings, who will be observing how members of the group interact with each other where the content of the discussions links to leadership and quality performance across the organisation. Notes will be taken by the researcher during the meeting.

What will I have to do?

If you would like to take part you will be asked to participate in your Trust meeting in the same a way as usual.

What are the possible disadvantages or risks of taking part?

The disadvantage is you may feel self-conscious being observed but there are no real risks to taking part.

What are the possible benefits of taking part?

It is unlikely that you will benefit directly from taking part.

What happens when the research study stops?

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A summary of the research study will be available for participants if they would like to receive this.

What if there is a problem?

If you have any complaint or concern about any aspect of the way you have been dealt with during the course of the study will be addressed; please contact the investigator Denise Chaffer (denise.chaffer1@sky.com), you may also contact my primary research supervisor Dr J Hendy (j.hendy@surrey.ac.uk)

Will my taking part be kept confidential?

Yes. All of the information you give will be anonymised and not attributable so that those reading reports from the research will not know who has contributed to it.

Data will be stored securely in accordance with the Data Protection Act 1998.

Contact details of researcher and, where appropriate supervisor?

Denise Chaffer tel 07881 275305

Who is organising and funding the research?

The research is part of a PhD programme run by University of Surrey. There is no funding attached to the study.

Who has reviewed the project?

The study has been reviewed and received a Favourable Ethical Opinion (FEO) from the University of Surrey Ethics Committee.

Thank you for taking the time to read this Information Sheet.

Version 1 (15 May 2015)

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Appendix 5: Consent form Full title of Project:

An exploration of how the concept of the ‘well led’ hospital Trust is defined and understood by NHS staff across a range of organisational managerial levels.

Name, position and contact e mail of Researcher:

Denise ChafferPhD student University of Surrey E mail denise.chaffer1@sky.com

Please Initial Box

1. I confirm that I have read and understand the information sheet for the above study and have had the opportunity to ask questions.

2. I understand that my participation is voluntary and that Iam free to withdraw at any time, without giving reason.

3. I agree to take part in the above study.

Note for researchers:Include the following statements if appropriate, or delete from your consent form:

4. I agree to the interview being audio recorded

5. I agree to the use of anonymised quotes in publications

Name of Participant Date Signature

Name of Researcher Date Signature

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Appendix 6: Research semi-structured interviews protocol

Semi structured questions for semi structured individual interviews

1. Introduction – re aims of study and context

Introduction interviewer Details of how interview will be structured Time allocated to interview Checking participants how read information sheet, and consented to

participating Confirmation of confidentiality , consent, anonymity and data from interview

will not be attributable Confirmation of permission to electronically record interviews

2. Introduction and areas of topic to be covered Establishing brief background of participants and areas / level of responsibility in

organisation Outline of subject areas to be covered during the interview

3. Undertaking the interview (see attached interview schedule)

4. Closing interviews, inviting any questions, clarification, confirming next steps in terms of transcribing interviews and opportunity to agree accuracy

5. Thanking staff for their time.

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Appendix 7: Interview questionsResearch question?

How is the concept of the ‘well led’ hospital Trust defined and understood by NHS staff across a range of organisational managerial levels?

What does the concept of ‘well led’ mean to staff ?

What do staff understand by the concept of being ‘well led’ within their NHS Trust ?

How is the concept of ‘well led’ translated across their organisation ?

What are staff views on the impact their hospital’s leadership has on the quality of care

delivered to patients ?

Interview questions

Knowledge

How you would define good leadership within your organisation?

What do you understand by the term well led?

Sub probing questions - Please could you give some examples …

I would like you to think about your experiences of good leadership and how that significantly affect your interest, motivation, performance, please describe your experiences.

Sub probing questions - Please could you give some examples

Opinion or belief

Please describe your own views about how you see good leadership across the organisation impacting on quality care delivery?

Sub probing questions - Please could you give some examples

Behaviour or experience

I would like you to think about your own leadership role in the organisation, and your views about how other staff might best describe this?

Sub probing questions - Please could you give some examples

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