‘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 Investigator
Margaret 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
www.bradford.ac.uk/management
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 multiprofessional 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 & interagency work
Quantitative Data Collection LTQ
CONTEXTUAL FACTORS
Team Leadership
Leadership
Capabilities
Outcomes of
Effectiveness
TEAM PROCESSES
Intra- team Processes
Engaging with
Others
Inter-team & Inter-agency
Processes
Visionary
Leadership
Users’ & Carers’
perceptions
Professionals’
perceptions
Professionals’
Engagement &
Wellbeing
Other Performance
Measures
Quantitative collected at Time 1 – Cross-sectional model
The I-P-O Model of Team working
INPUT
Team
Processes
OUTPUT
The I-M-O-I Model of Team working
Affective states
(eg motivation, interest in task,
perceived value of the task)
INPUT
Team
Processes
(Behavioural)
Cognitive states
(free exchange of knowledge &
experience leading to a shared
understanding of how to improve
quality of service)
OUTPUT
ENGAGING
WITH OTHERS
PSYCHOLOGICAL
SAFETY
BUILDING A
SHARED VISION
ENABLING THE
TEAM
LEADERSHIP
CAPABILITIES
IMPACT ON
TEAM
MEMBERS
SOCIAL
SUPPORT
TEAM POTENCY
TRUSTING &
BONDING
TEAM
LEADERSHIP
TEAM
ENGAGEMENT
VALUING
DIFFERENT
PERSPECTIVES
WELLBEING AT
WORK
SUPPORTING A
DEVELOPMENT
CULTURE
TEAM
WORKING
INFORMATION
GATHERING
INNOVATION
PLANNING
FOCUS ON
QUALITY
ROLES &
RESPONSIBILITIES
INTER-TEAM
WORKING
UPDATING
COLLECTIVE
EXPERIENCE
TEAM
OUTPUT
STRUCTURING
& LEARNING
ADAPTING
IMPROVEMENT
TEAM
PROCESS
OUTCOMES
INTER-TEAM
RELATIONS
INTER-TEAM
COLLABORATION
INTRA-TEAM WORKING
IMOI MODEL OF TEAM LEADERSHIP AND TEAM WORKING
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 Champions
conduct R/Grid Int.
Develop Quality of Care
Questionnaires
Distribute Qs & gather
data from SU & Carers
Distribute ‘Engaging
Teams 360’ Qs
Data analysis of QCQ &
Engaging Teams 360 Q
Identify link between
L’ship, TW & Outcomes
Produce Case studies
Create Leadership &
Team working W/books
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 1
Identifying themes in Service Users &
Carers’ constructs of high quality care
Research Champions
conduct (n = 65) interviews
450+ constructs of ‘High Quality Care’
Content analysis
Produced 24 major themes
Translated into Q items
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 for
Service 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 data
from 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 scales
uniquely predict which outcomes
DFAs for scales – showing which scales
uniquely 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 specific
behaviours uniquely predict outcomes (2)
DFAs for items – showing which specific
behaviours uniquely predict outcomes (3)
ENGAGING
WITH OTHERS
PSYCHOLOGICAL
SAFETY
BUILDING A
SHARED VISION
ENABLING THE
TEAM
LEADERSHIP
CAPABILITIES
IMPACT ON
TEAM
MEMBERS
SOCIAL
SUPPORT
TEAM POTENCY
TEAM
LEADERSHIP
TRUSTING &
BONDING
TEAM
ENGAGEMENT
VALUING
DIFFERENT
PERSPECTIVES
WELLBEING AT
WORK
SUPPORTING A
DEVELOPMENT
CULTURE
TEAM
WORKING
INFORMATION
GATHERING
INNOVATION
PLANNING
FOCUS ON
QUALITY
ROLES &
RESPONSIBILITIES
INTER-TEAM
WORKING
UPDATING
COLLECTIVE
EXPERIENCE
TEAM
OUTPUT
STRUCTURING
& LEARNING
ADAPTING
IMPROVEMENT
TEAM
PROCESS
OUTCOMES
INTER-TEAM
RELATIONS
INTER-TEAM
COLLABORATION
INTRA-TEAM WORKING
IMOI MODEL OF TEAM LEADERSHIP AND TEAM WORKING – VALIDATED
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
GENERAL
LEADERSHIP
STYLE
TEAM
FOCUSED
INSPIRING
OTHERS
SUSTAINING
SHARED VISION
BALANCING
NEEDS
PERFORMANCE
MANAGEMENT
EFFECTIVE
CHANGE
MANAGEMENT
IMPACT ON TEAM
MEMBERS
STRONG AND
PASSIONATE
VISION OF
PROVIDING
GOOD QUALITY
CARE
TEAM
ENGAGEMENT
TEAM
LEADERSHIP
WELLBEING AT
WORK
TEAM
COMPOSITION
POSITIVE
RELATIONSHIPS
WITHIN THE
TEAM
INTRA-TEAM
WORKING
TEAM
WORKING
QUALITY OF
CARE
IMPACT ON SERVICE
USERS AND CARERS
EFFECTIVE
COMMUNICATIO
N
CULTURE OF
INNOVATION,
IMPROVEMENT
&
DEVELOPMENT
INTER-TEAM
WORKING
INNOVATION &
IMPROVEMENT
RELATIONSHIPS
WITH OTHER
TEAMS/AGENCI
ES
ADAPTING TO
CHANGE
MODEL OF TEAM LEADERSHIP AND TEAM WORKING BASED ON THE CASE STUDIES
TEAM PROCESS
OUTCOMES
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