www.bradford.ac.uk/management

‘An investigation of the impact of leadership and team working on staff morale and wellbeing, and team performance, among mental health teams

within the Yorkshire & The Humber Strategic Health Authority’

University Researchers: Beverly Alimo-Metcalfe, Principal InvestigatorMargaret Bradley, Research Project Manager & Honorary Researcher

Dr John Alban-Metcalfe & Alice Locker, Honorary Researchers

Research Champions: Val Berry, Priyanka Bichala, Joann Gibson, Julie Sheldon, Mark Wilbram, Nick Turner, Dave Rainforth, Lisa Connor, Wayne Reece-Gorman

Overall Project Co-ordinator: Maggie Bell, SWYPFT

Steering Group Chair: Alan Davis, SWYPFT

Steering Group: Penny Petrie & Angela Ross (BDCT); David Harling (Humber NHS FT); Eddie Devine, Alison Thompson & Nick Turner (LYPFT), Chris Payne (NAViGO);

Rosie Johnson (RDASH); Maggie Bell and Christine Symonds (SWYPFT)Frank and Tula Naylor

Rebecca Smith (Yorkshire and the Humber SHA).

Team Leadership, Team Working and Outcomes in CMHTs

Overall Aim:

To bring about real & sustainable change and improvement in leadership and team working, for the

benefit of service users & carers

1. To understand how leadership behaviour enables multi-professional teams to function most effectively in working to promote and sustain improved health

outcomes for service users and carers

2. To devise and develop a set of guidelines, and a series of developmental activities, that will enable mental health professionals and others, to improve the

quality of provision for service users and their carers.

Research objectives

Identify the particular processes within teams that ensure engagement and wellbeing of TMs, enabling them to deliver high quality care

Identify how leadership of the team lead has an impact on team functioning and performance

Develop in-house research capacity by involving local researchers in the trusts

Investigate what service users & carers regard as high quality care; develop a diagnostic tools for measuring their perceptions of quality of care; gather data on perceptions of quality of care

Develop materials to support the increased effectiveness of multi-professional teams, and their leadership behaviour, & staff engagement and wellbeing, that can be used across a wide variety of health and social care contexts

Disseminate the research findings to inform improved practice both within mental health services and more widely in health and social care.

Why needed?

Effective Team working & leadership are essential for high quality care, staff wellbeing, and productivity

Leadership is critical for the NHS – Innovation, Quality, and Improvement (SHA Workforce Ambitions strategy)

92% of NHS staff work in teams - only 42% work in ‘genuine’ teams (Healthcare Commission, 2006)

Chief Executives are committed to service user and carer involvement in defining what constitutes ‘high quality care’

Previous research (CRTs) found evidence of a causal link between engaging leadership and team productivity (Alimo-Metcalfe et al., 2007,2008)

How the LTQ research builds on, and extends the CRT research

Close involvement of service users and carers in determining what constitutes ‘high quality care’

Wider range of MH teams & contextual factors

Employs the leadership dimensions that emerged in the CRT research proven to significantly affect productivity, staff engagement & wellbeing

Deeper analysis of the nature of team working processes – also Inter-team & Inter-agency working

Closer analysis of how leadership affects team working & inter-agency work

Quantitative Data Collection LTQ

Team Leadership

Leadership Capabilities

Engaging with Others

Visionary Leadership

TEAM PROCESSES

Intra- team Processes

Inter-team & Inter-agency Processes

Outcomes of Effectiveness

Users’ & Carers’ perceptions

Professionals’ perceptions

Professionals’Engagement &

Wellbeing

Other Performance Measures

CONTEXTUAL FACTORS

Quantitative collected at Time 1 – Cross-sectional model

The I-P-O Model of Team working

INPUTTeam

ProcessesOUTPUT

The I-M-O-I Model of Team working

INPUTTeam

Processes(Behavioural)

OUTPUT

Affective states(eg motivation, interest in task,

perceived value of the task)

Cognitive states(free exchange of knowledge & experience leading to a shared

understanding of how to improve quality of service)

PSYCHOLOGICAL SAFETY

TRUSTING & BONDING

SOCIAL SUPPORT

TEAM POTENCY

VALUING DIFFERENT

PERSPECTIVES

INTRA-TEAM WORKING

SUPPORTING A DEVELOPMENT

CULTURE

INFORMATION GATHERING

ROLES & RESPONSIBILITIES

UPDATING

COLLECTIVE EXPERIENCE

ADAPTING

PLANNING

STRUCTURING & LEARNING

TEAM WORKING

TEAM LEADERSHIP

ENGAGING WITH OTHERS

BUILDING A SHARED VISION

ENABLING THE TEAM

LEADERSHIP CAPABILITIES

INTER-TEAM RELATIONS

INTER-TEAM COLLABORATION

INTER-TEAM WORKING

TEAM OUTPUT

TEAMENGAGEMENT

WELLBEING AT WORK

INNOVATION

FOCUS ON QUALITY

IMPROVEMENT

IMOI MODEL OF TEAM LEADERSHIP AND TEAM WORKING

IMPACT ONTEAM

MEMBERS

TEAMPROCESS

OUTCOMES

Proposed Methodology

Gather both quantitative and qualitative data

Identify factors affecting (1) the effectiveness of teams & (2) leadership within them

Develop (1) case studies and (2) workbooks toolkit for use in mental health and more widely in health & social care.

Build internal capacity - Identify Local Research Champions (conduct rep grid interviews with users/carers; encourage colleagues to participate)

Adopt an iterative process as the project progressed requiring continual reflection and evaluation to take account of experiences and changing circumstances over the 3 years

Be advised by a Steering group (Service users, carers, the SHA, Trust, PCT)

Research stages

Research Championsconduct R/Grid Int.

Distribute ‘Engaging Teams 360’ Qs

Data analysis of QCQ & Engaging Teams 360 Q

Produce Case studies

Create Leadership & Team working

W/books

Distribute Qs & gather data from SU & Carers

Develop Quality of Care Questionnaires

Identify link between L’ship, TW & Outcomes

FINAL REPORT& trust reports

Research Champions’

Experience, Learning & Benefits

Why volunteered?

New experience and opportunity

Research - ‘dip toe in’ with support

Personal & professional development

Service user, carer and staff involvement

Research ‘real and grounded’ – leadership, teamwork, care quality, values and improvement

Make a difference

Validate personal beliefs

Val Berry, Team Manager, Humber, NHS FT

Training Training day

Opportunities to meet other Research Champions

Underpinning theory

Demonstration: opportunities to practice in safe environment; opportunity to ask questions and get feedback

Peer support

Overview of process

Appreciative inquiry approach

Qualitative and quantitative methods

Julie Sheldon, Acting Team Manger, RDaSH

Experience/Practicalities

Recruitment of service users and carers

‘Putting it out there’

Conducting the interviews

Service user and carer perspectives

‘Liberating’ to gather information but not to do/act

Perceived therapeutic benefit

Dr Priyanka Bichala, Perinatal Mental Health

Benefits for service users

Positive impact on practice

Therapeutic benefits: listened to, being valued and treated as an equal

Very current service user voice

Same values as professional

Independence allowed for honesty with Research Champions interview

Benefits for Carers

Using carers as a resource

Increased understanding from the carers’ perspective

Carers spoke freely without being defensive

Aided in clarifying expectations

Benefits for Research Champions

Insight from the honesty and receptiveness of service users and carers

Enhancing practice through increased self-awareness and personal insight

Acknowledging when things are not right

Skill development leading to a wider application of the technique

Research skills can be utilised by the organisation

Networking beyond the Trust

Joann Gibson, Team Manager, SWYPFT

Service Users’ & Carers’ notions of ‘high quality care’ –

Key Findings

Methodology – Stage 1Identifying themes in Service Users & Carers’ constructs of high quality care

Research Champions conduct (n = 65) interviews

450+ constructs of ‘High Quality Care’

Translated into Q items

Content analysis Produced 24 major themes

Workshop to check face & content validity & determine final items

(RCs, SU/C reps, S/Group, researchers, academic MH advisor)

Service users’ & Carers’ constructs of Quality of Care

Treated as an equal - work collaboratively and in partnership

Treated as an individual; staff get to know me and my needs

Staff are open-minded & non-judgemental; genuinely care

Staff are reliable; consistent; knowledgeable

Care is holistic; care is seamless

Supported in achieving my goals; strengthen my self-efficacy

Involve me in my care planning; & involve family & relevant others

Access to information re services; offered choices about my care;

Good communication within team and between teams/agencies

Methodology – Stage 1 (contd.)

Compare Service Users’ & Carers’ constructs with NICE Quality Standards

Construct themes compared with NICE ‘Quality Standards for Service Users Experience in Adult Mental Health’

Suggested 3 ‘missing’ dimensions of high quality care:

- ‘Strengthens my self-efficacy’;

- ‘Good communication & (intra/inter- team, & interagency working)

- Importance of ‘holistic care’

Extract : Comparison of NICE Quality Standard forService User Experience with SUs’ constructs

Stage 2 - ‘Quality of Care Questionnaires’ - Service Development & Structure (1)

‘Quality of Care Questionnaires’ – 2 versions produced (for Service Users & Carers)

Distributed throughout the region – Responses from 451 Users + 148 Carers

Factor analysed – producing 4 factors for SUs (consistent with ‘Recovery’):-Strengthens my self-efficacy & control over care-Personal relationships-Respect for me as a person-Aspects of delivery of care

And 2 factors for Carers (consistent with ‘Triangle of Care’):-Provides support for Carer-Respect for the Service User

Stage 2 - ‘Quality of Care Questionnaires’ - Service Data analysis (2)

Mean scores of Service Users’ responses indicated that:They were very satisfied with the care they receive

Most positive items were:

-Personal relationships with the professionals-Professionals’ respect for service users as individuals

And lowest scoring (though still positive) was:

-Strengthens my self-efficacy

Important to note that this was one of the strongest themes in SUs’ notions of high quality care, and the Recovery model

Stage 2 - ‘Quality of Care Questionnaires’ - Service Data analysis (3)

Mean scores of Carers’ responses indicated that:They were also positive, but less positive than were the Service Users

Most positive items were in relation to professionals being:

-Approachable-Communicate in a way that the carer understands-Treat the person for whom they care as an individual

And lowest scoring was:

-How involved in, and how informed they were in relation to the care given to the person for whom they care

Important to note that this is at the heart of the ‘Triangle of Care’ model

Observations& Implications of datafrom Service Users & Carers

The Repgrid interviewing process produced a rich, diverse, and extensive range of constructs – due to outstanding skills & commitment of the Research Champions

The constructs from service users were virtually identical to those elicited from carers They revealed 3 important additional dimensions of what constitutes ‘high quality

care’, compared with NICE Standards, and should be publicised widely The factor analysis of the responses from service users reinforced the critical

importance to them of care which strengthens their self-efficacy The 4 factors to emerge should form the basis of key elements in supporting MH

professionals’ development, personal reviews, supervision, and team reviews These factors reflect the value of the ‘Recovery’ approach to care Service users were very positive about the care received; this should be fed-back to

professionals & celebrated Although still positive, it was disappointing that the ‘strengthening self-efficacy’

items were rated lowest Carers were less positive, but identified what was important to them in feeling

supported The dimensions they rated lowest, reflect the ‘Triangle of Care’ and should form the

basis of discussions by teams for generating ideas for improvement & regular reviews The skills acquired by the Research Champions which could be utilised in a wide

range of trust situations & activities; their commitment was outstanding

Team Leadership, Team Working, & Outcomes – the Key Findings

Rank order of Average scores for Team Leadership & Team Working

(N = 590 Team

members)

Highest ratings by team members

Team Engagement (Impact on team members)

Social Support and Team Potency (Trusting and Bonding – affective states)

Updating (Planning – behavioural)

Collective Experience and Adaptability (Structuring and Learning – cognitive states)

Innovation (Team process outcome)

Lowest ratings by team members

Wellbeing at Work (Impact on team members) Improvement and Focus on Quality (Team process

outcomes)

Roles and Responsibilities (Planning – behavioural)

Valuing Different Perspectives and Supporting a Development Culture (Trusting and Bonding – affective states)

Building Shared Vision (Team leadership)

DFAs for scales – showing which scalesuniquely predict which outcomes

DFAs for scales – showing which scalesuniquely predict which outcomes

DFAs for items – showing which specific

behaviours uniquely predict outcomes (1)

DFAs for items – showing which specific

behaviours uniquely predict outcomes (1)

DFAs for items – showing which specificbehaviours uniquely predict outcomes (2)

DFAs for items – showing which specificbehaviours uniquely predict outcomes (3)

PSYCHOLOGICAL SAFETY

TRUSTING & BONDING

SOCIAL SUPPORT

TEAM POTENCY

VALUING DIFFERENT

PERSPECTIVES

INTRA-TEAM WORKING

SUPPORTING A DEVELOPMENT

CULTURE

INFORMATION GATHERING

ROLES & RESPONSIBILITIES

UPDATING

COLLECTIVE EXPERIENCE

ADAPTING

PLANNING

STRUCTURING & LEARNING

TEAM WORKING

TEAM LEADERSHIP

ENGAGING WITH OTHERS

BUILDING A SHARED VISION

ENABLING THE TEAM

LEADERSHIP CAPABILITIES

INTER-TEAM RELATIONS

INTER-TEAM COLLABORATION

INTER-TEAM WORKING

TEAM OUTPUT

TEAMENGAGEMENT

WELLBEING AT WORK

INNOVATION

FOCUS ON QUALITY

IMPROVEMENT

IMOI MODEL OF TEAM LEADERSHIP AND TEAM WORKING – VALIDATED

IMPACT ONTEAM

MEMBERS

TEAMPROCESS

OUTCOMES

Contextual factors found to significantly influence outcomes

Size of team

Ratio of OTs & Social Workers/ Nurses

Caseload size (NB caution in interpretation because of varying complexity of cases)

Implications for multi-disciplinary MH teams – 1

Rich source of insights into team leadership, working & effectiveness Not surprising: crucial importance of Roles & Responsibilities, incl. well-defined goals,

processes & procedures, & sense of direction (especially important for quality, improvement & wellbeing) – BUT this was an area of weakness

Not surprising: crucial importance of Inter-team/inter-agency Working (especially important for innovation, quality & improvement) – BUT only moderately high rating – need to strengthen. Users stressed its importance

Surprising: crucial importance of Trusting & Bonding – the social, emotional aspect & cultural/supportive aspect of team working (especially important for improvement, team engagement & wellbeing) – HIGH on social support & self-belief, but LOW on Valuing Different Perspectives & Supporting a Development Culture – implications for team leadership

Emphasises: crucial importance of Structuring & Learning – free exchange of knowledge & experience, resulting in shared mental models, and delivery of quality healthcare (especially important for improvement and team engagement) – GOOD NEWS, these were among the highest ratings

Observations & implications for multi-disciplinary MH teams – 2

1. Unexpected: Team Leadership does not impact directly on Team Engagement and Wellbeing at Work – rather, its influence is exerted through the way the team functions (Intra-team and Inter-team Working)

BUT Building Shared Vision was one of LOWEST ratings

2. We have EVIDENCE that there is an OPTIMAL… Size of MH teams Ratio of OTs & SWs/Nurses Case load

IMPLICATIONS for the structure, content and rationale of Team Leadership Development interventions, and the context in which they are delivered

IMPLICATIONS for focus of Team working Development interventions – we know which Specific behaviours result in greater team effectiveness

IMPLICATIONS for Planning size, staffing & case load of MH teams

Results from the Case Studies of high-performing teams

STRONG AND PASSIONATE

VISION OF PROVIDING

GOOD QUALITY CARE

INTRA-TEAM WORKING

TEAM WORKING

TEAM LEADERSHIP

INSPIRING OTHERS

SUSTAINING SHARED VISION

BALANCING NEEDS

PERFORMANCE MANAGEMENT

RELATIONSHIPS WITH OTHER

TEAMS/AGENCIES

INTER-TEAM WORKING

TEAMENGAGEMENT

WELLBEING AT WORK

QUALITY OF CARE

IMPACT ON TEAM MEMBERS

IMPACT ON SERVICE USERS AND CARERS

MODEL OF TEAM LEADERSHIP AND TEAM WORKING BASED ON THE CASE STUDIES

EFFECTIVE CHANGE

MANAGEMENT

TEAM FOCUSED

GENERAL LEADERSHIP

STYLE

TEAM COMPOSITION

POSITIVE RELATIONSHIPS

WITHIN THE TEAM

EFFECTIVE COMMUNICATIO

N

CULTURE OF INNOVATION,

IMPROVEMENT &

DEVELOPMENT

ADAPTING TO CHANGE

TEAM PROCESS OUTCOMES

INNOVATION & IMPROVEMENT

Case Studies: Effective Team Working

Strong and passionate vision for providing good quality care

Why? Recruitment; clearly defined service; leadership.

Team composition: Multidisciplinary; experienced; stable.

Positive relationships within the team: Harmonious, supportive, respectful.

Effective and engaging communication: Formal and informal.

Culture of innovation, improvement and development:

Reflection; sharing ideas; thinking ‘outside the box’; team and

individual development; commitment to supervision.

Case Studies: Effective Team Working cont’d

Relationships with other teams and agencies: service user

centred; networking and building relationships; link people.

Difficulties: Pressures on other teams and agencies; different

perceptions of risk; service transformation.

Approach to resolving difficulties: Face-to-face meetings;

flexibility; depoliticising the situation.

Adapting to change

Case Studies: Effective Leadership

Sustaining Shared Vision

Inspiring others: Vision and values; passion and determination;

strong work ethic; acting as a role model.

General leadership style: Democratic but decisive; situational

leadership; open and honest; positive; hands-on; empowering.

Team focused: Developing a team culture; understanding team

members; valuing team members; supportive; team development.

Performance Management: setting direction; role modelling;

supportive; light hearted; prepared to pull rank; adhering to policies.

Case Studies: Effective Leadership cont’d

Balancing needs of team with needs of organisation:

Compliance; acting as an advocate.

Effective change management: Open; supportive; positive; local

ownership; team development; advocate; practical support.

Case Studies: Staff Engagement & Wellbeing Positive staff engagement and wellbeing

Why?

Intrinsic motivation

Nature of the work

Leadership

Team working

Factors that detract from staff engagement and wellbeing:

Nature of the work

Perceived business culture

Organisational changes

Case Studies: Quality of Care

Teams felt they did provide good quality care

Methods of collecting feedback:

Service user feedback: informal and formal feedback; feedback

from service user events; lack of standardisation.

Observing service user recovery

Service user events

Outcome tools

Case Studies: Quality of Care cont’d

What facilitates good quality care?

Previously mentioned elements of team working, leadership, staff engagement and wellbeing.

Good quality staff

Barriers to providing good quality care?

Time: administrative demands; geographical area to cover; size of caseload

Relationships with other teams

External agencies/interfaces with other services.

Recommendations for Practice

&

Project Achievements

Recommendations for Practice Case studies - useful source of reference and for development

Team and leadership development in situ – scales offer framework for development, & regular review (individual, team, organisational)

Findings suggest need for a stronger focus: on Quality, Valuing Different Perspectives; Supporting a Developmental Culture, & Clarity of Roles & Responsibilities

Note the wide-ranging effect of effective inter-team/agency working

Try to find ways of reduce administrative demands, where possible

Important to note’ ‘Quality of Care Questionnaires’ findings – use Qs

Collect standardised service user and carer feedback

Repertory Grid Interviews - extend expertise & use

Recommendations for Practice

Implications for service reorganisation and transformation

Size of the team

Importance of multidisciplinary team working

Stability of team membership

Importance of a shared sense of purpose

Change in the nature of the work as a result of service redesign

Supporting team leaders

Project achievements (1)

In-depth understanding of quality of care

Development of 2 new Quality of Care Questionnaires

Developing internal research capacity

Positive benefits to service users/carers of participating in interviews

A new evidence-based model of the relationship between team

leadership and team working, and team outcomes

In-depth understanding of leadership and team working

Project achievements (2)

Reports: team, trust and overall report

Practical toolkit for team and leadership development

Leading to Quality Final Event

Professional and academic articles

Further Information

The following website:

www.southwestyorkshire.nhs.uk/LTQ

Contains the following downloads:

The Leading to Quality full report

The Leading to Quality Toolkit

The Service User and Carer Quality of Care Questionnaires