The The importance of leadership, specifically within the

The theories that circulatearound notions of leadership, while hardly new, are firmly rooted within thestructures of socio-psychological development, being essential to the organisationof various aspects of humanity ever since the dawn of intelligent lifeforms(Van Vugt 2006). Defining leadership, however, is not an easy task; it remainsa fluid concept, often shaped by the social ethos of its time, and to attributeone definition to it would be reductionist (Metcalfe and Metcalfe 2000).

Despite this, leadership may be recognised as a tripod of certain features,such as a leader/leader, followers, and a unified goal (Bennis 2007). Theimportance of leadership, specifically within the National Healthcare System(NHS) cannot be understated (Storey and Holti 2013). The release of recentpublications such as the Francis Report has exhibited this (The King’s Fund2013). In its publication, the Francis Report outlined how a dangerous cultureand weak leadership – one based upon command and control – lead many failuresin the hospital trust (King’s Trust 2013). Consequently, Francis, incorroboration with the King’s Trust, recommended that a new form of leadershipbe implemented, one that placed the patient and their experience at theforefront (King’s Trust 2013). This essay, therefore, will explore the conceptof what a positive patient experience is, and analyse different leadershiptheories, investigating how these may be applied to healthcare to ensure thatthe vision of the optimal patient experience is achieved, and that failuressuch as those at Mid-Staffordshire never occur again.

 In recent years, there hasbeen a shift with regards to how the performance of the NHS is perceived, from thoseof clinical efficacy and its outcomes to that of patient experience (Wolf etal. 2014). Patient experience is a concept not bound by one overarchingdefinition but instead varies widely within research (Wolf et al.  2014). The Beryl Institute defines it as ‘thesum of all interactions, shaped by an organisation’s culture, that influencepatient perceptions across the continuum of care’ (Wolf et al. 2010). Whilstthis definition does, condense the main themes of patient experience, it failsto outline what constitutes a positive patient experience, and its applicationto the NHS is therefore limited as it provides no precise guidance. Withoutspecificity, such a definition would open to subjective interpretation (Wolf etal.

2010). The National Institute for Health and Care Excellence (NICE) avoidedlimiting patient experience to one definition, instead producing a guidance onbest practice (NICE 2012). The guideline outlines five main features ofpositive patient experience. These include knowing the patient as anindividual, acknowledging essential requirements of care, tailoring healthcareservices for each patient, ensuring continuity of care and relationships andenabling patients to actively participate in their own care (NICE 2012).Despite the existence of such guidelines, individuals’ subjective experiencesof the care in which they actively received are essential, according to the BritishMedical Association (BMJ), to informing improvement on both a micro and macrolevel (BMJ 2014). In an evidence review carried out by De Silva, it was foundthat surveys were the most common form of patient feedback (2013).

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  Surveys, whilst being highly convenient andgenerally more representative, are also problematic, as they are merely superficialin their representation and may thus suffer from social desirability bias andselection bias (De Silva 2013). Subsequently, both NICE and De Silva identifythat not only is a more multidimensional approach necessary to measure patientexperience, but there needs to a be a change whereby feedback is also usedeffectively in order to improve healthcare (NICE 2012, De Silva 2013). Thus, inorder to ensure that positive patient experience not only remains a centraloutcome, but is implemented and measured through all levels of the NHS, the BMJproposed effective leadership improvements are essential (BMJ 2014).  In his seminal work publishedin 1978, Burns identified the vital characteristics of leadership, coining theterm ‘transformational leadership’ (1978).

According to Burns, such leadershipis a process where the goals of the leader and the followers are fused “in amutual and continuing pursuit of a higher purpose” (Burns 1978). Therefore, theessence of transformational leadership is where the inspiration of a sharedvision inculcates motivation within individuals and empowers them to strivetowards the vision until it comes to fruition (Burns 1978). This results notonly in the level of human conduct being raised, but also broadening the aspirationsof the leader and inspiring those who follow to strive beyond achieving thestatus quo, hence having a transforming effect (Burns 1978).

Marshall andBroome expanded upon the work of Burns, expanding the scope of what it means tobe a transformational leader (2010). According to Marshall and Broome, it isnot enough for such leaders to inspire others, as such leaders must have astrong belief in themselves – one cannot lead if they lack self-belief (2010).Additionally, transformational leaders are in their truest form innovators, andas such should revel in change, continuously striving for improvement using creativestrategies and appropriate evidence to inform best practice (Marshall andBroome 2010).

Moreover, such leaders should not be afraid to take risks, andwhere failure does occur, the leader should accept this, having the knowledgethat they may, in fact, be closer to achieving their vision (Marshall &Broome 2010). The King’s Fund asserted that if the shocking failures of care atMid-Staffordshire are to be learned from, a significant shift must take place,where the patient is placed at the centre of all priority and assertedleadership is the most influential factor in shaping this culture (2013).Marshall corroborated with this, stating that the transformational leader andtheir commitment to rousing innovation has never been needed more greatlywithin the NHS, and may be the figure through which this change can beinstilled, thus enhancing patient experience as a consequence.

(Marshall  and Broome 2010). At the organisational level,the presence of transformational leaders may result in the enactment of apositive emotional contagion, fuelled by the shared desire to enhance thepatient experience (Kings Fund 2015). Such a contagion may result in strategicdecisions and the implementation of policies which enhance patient experience(Kings Fund 2015). For instance, the presence of strong and focused goals thatspecifically target areas where many trusts require improvement, such as timelydischarge, may allow for more consistent improvements in levels of performanceacross trusts (Kings Fund 2015). Whilst the King’s fund agreed that focusedgoals were important, the organisation also asserted that leaders must be awareof the ceiling effect, where the absence of differentiation between trusts mayhave a demotivating effect. Transformational leaders should, therefore,innovate, and attempt to not only utilise the data from surveys effectively toimprove experience within their trusts, but also find new ways to measureexperience (Kings Fund 2015). Such leaders should also be aware that within thecurrent climate of the NHS, many of the failures regarding patient experienceare not simply due to the lack of a shared vision or motivation, but insteadare the result of wider pressures (Mcintosh 2017). Thus, in order to ensure thatpatient experience is improved, transformational leaders should go beyondinspiring individuals who follow them and attempt to remove these pressures(Wolf et al.

2014).  Proceeding on from this, MenziesLyth identified the anxiety nurses are put under as affective to the overallpatient experience, as they have to deal with the most concentrated impact ofstress that arises from taking care of patients, and outlined the viability ofhealthcare organisations is connected to the ability in which it has to containanxiety (Lyth 1960). Whilst this study may be argued as being outdated, itsfundamental argument is still very much applicable to the NHS. The main issueslie within its suggestion that the main problem with the NHS was its inabilityto change while, in fact, it is the uncritical promotion of change that has ledto an overloading of the system, distracting leaders from the main purpose ofthe NHS. This consolidates the necessity for a transformational leader whoreasserts these values and provides a clear vision (Campling 2015).

Camplingalso asserts that the unkind behaviour seen in nurses, such as those atMid-Staffordshire, is the result of the absence of a supportive environment, leasingto the subsequent implementation of defensive styles of coping and reduction incapacity for empathy (Campling 2015). The presence of a transformationalleader, however, may allow for the creation of a more supportive environment(Campling 2015). Through inspiration by the leader, individuals may feel moreempowered to pursue and fulfill the shared vision of patient centred care. Thefeeling of empowerment may potentially enhance the sense of worth felt by eachindividual, therefore stimulating them to reach a heightened quality of care(Rokstad et al. 2015). Such an environment may lessen the likelihood ofdeveloping such defensive styles of coping, hence leading to staff who arekinder and more likely to know the patient as an individual, thus being moreattuned to their emotional, physical and social needs (Campling 2015).Additionally, the establishment of a more supportive environment has been shownwithin research to reduce staff turnover; simply put, when staff are satisfied,they want to stay in their positions (Robbins 2007). The effect of this is heightenedcontinuity, which is significant at the organisational level, potentiallylessening the turnover of NHS chief executives (The king’s fund 2011).

Loweringthis turnover may aid in the maintenance of strategic direction and the effecton wards may be that they possess more experienced staff, have fewer issueswith understaffing and be less likely to rely on bank staff – all factors whichhave been shown to not only increase the quality of healthcare, but alsoheighten the experience in which a patient has (Robbins 2007, NICE 2012).  The potential impact that atransformational leader may have on patient satisfaction is obvious, and theefficacy of transformational leadership has been supported by numerous studies,such as those by Rokstad et al. (2015).

Rokstad et al.  found that the presence of transformationalleaders within care homes led to both leaders and staff having a clear vision,one based on providing care that was individualised (2015). Staff feltencouraged to deliver care that was of the highest standard and actautonomously, possessing a deep understanding of what it meant to ensure apositive patient experience, and often reflected upon their performance. Thiswas viewed in contrast to nursing homes with more traditional modes ofleadership (such as transactional leaders), where goals or aspirations for thehome were unknown, and staff felt unsupported and unmotivated (Rokstad et al.

2015). Whilst this study exhibits the real-life impact that a transformationalleader may have, it is important to consider the low external validity of thisstudy. The study was carried out in a care home, which is a completelydifferent environment when compared to, for example, an acute care unit.Furthermore, it only considered the impact of transformational leadership fromthe staff’s perspective, not considering the viewpoint of the receivers ofcare. Ultimately, in order to deepen the understanding of how transformationalleadership has an impact on the positive patient experience, longitudinalstudies need to be administered within a variety of settings, with a morediverse sample of both staff and patients needing to be utilised. (Kings Fund2015).

 The positive impact that atransformational leader may have for patient experience is, therefore, evident,and it is argued that it should be more integrated into the NHS (Campling2015). The question that remains, however, is how. Robbins suggests thatleaders require education with regards to transformational leadership qualities(2007). However, in the midst of the current financial crisis of the NHS, thisbegs the question as to whether formal training would be viable (McIntosh2017). Additionally, to be a transformational leader and perpetuate any kind ofinnovative vision requires intense charisma, and the ability to have effects onfollowers which can be considered as extraordinary (Tourish & Pinnnington2002). The reality is simply that there is not a readily available supply ofindividuals who have the ability to convey such a vision, whilst also beingable to maintain routine such as upholding the NHS, or running the wards(McIntosh 2017). Moreover, Campling expresses that transformational leaderscannot be taught, and the ability to be a transformational leader is ofteninnate (2015). Transformational leadership may also have a negative impact onits followers, resulting in numerous personal sacrifices being made in theircommitment to achieving the shared vision of their leader (Tourish &Pinnington 2002).

This was exhibited by Neilsen, who found that in DanishPostal workers, transformational leadership was linked to the promotion ofself-sacrifice, where individuals would go into work whilst ill in order toachieve the shared vision, leading to heightened absence levels in the longterm (2016). Whilst this study has its limitations – for instance, it was not basedin healthcare, nor in the UK – it outlines the potential dangers of such aleadership style. Working in healthcare is inherently stressful, as alreadyoutlined, and the pressure to achieve a positive patient experience may lead tonegative consequences for individuals, such as increased absence- orpotentially, anxiety and depression (Tourish & Pinnington 2002). Thus,while transformational leadership has a significant amount of potential withinthe NHS, particularly for enhancing patient experience, as exhibited by studiesby researchers such as Rokstad et al (2015), there are also clear limitations-limitations which cannot be ignored (King’s fund 2011).  The King’s Fund states thattransformational leadership is ill-suited to the current demands facing the NHS(Kings Fund 2011). It is argued that in a system as complex as the NHS, adistributed model of leadership is a more viable framework for the enhancementof patient experience (Fitzgerald et al 2013), despite there being nouniversally contingent definition of distributed leadership. However,Fitzgerald et al provides a concise definition, explaining that distributedleadership comprises of a system of senior leaders at the national level, with themiddle level comprising of clinicians who also act as leaders i.

e. sisters andconsultants, and individuals who may not possess the label of leader, but actwith leadership qualities to aid in the enactment of change (2013). Turnbulloutlines that distributive leadership must engage every individual, and thatindividuals are not leaders because they are exceptional nor inspirational inany way, but instead they observe what needs to change and work with others toachieve this vision – innovators, who disseminate information (2011).

Expandingupon this patient experience may be compromised because individuals noticeissues, such as patient’s operations being consistently delayed and thusremaining nil by mouth for a number of days, but fail to exercise leadership inorder to enact change (Turnbull 2011). Distributed leadership may thereforegive clinicians a heightened sense of responsibility and thus empowerment. Increasedempowerment is linked to innovation and more effective clinicians, and as aresult, better care can be implemented and tailored to the individual, henceadvancing patient experience (Turnbull 2011). Fitzgerald et al provide further support for this, finding that theeffective implementation of national mandates was dependent upon a goodrelationship existing between senior leaders and clinicians who acted asleaders. They were found to be critical in adapting such mandates to the meettheir local agendas – indeed, Fitzgerald et al linked poor quality of care indiabetes clinics with limited boundary spanning, where leaders and clinicianshad poor relationships (2013). Furthermore, effective implementation of patientsurvey data regarding patient experience was linked to distributed leadership(Kings Fund 2015) Conversely, distributed leadership has also been linked topoorer quality of care and thus poorer patient experience, as well as sloweddecision making, fragmentation within organisational structures and divergentstrategic priorities. This may result in the national mandates to enhancepatient experience not being efficiently implemented across the NHS, and lackof constancy (Fitzgerald et al 2013).

Research has made it clear that there isa link between patient experience and distributed leadership (King’s fund 2011,McIntosh 2017, Fitzgerald et al 2013). Limiting who can be a leader to specificsenior individuals can undermine the importance of clinicians and thecomplexity of the NHS; success is founded upon a collective dynamic (King’sFund 2011). The main issue with this, however, is the lack of researchregarding the actual implementation of distributed leadership, and the impactwhich it has on patient experience. If distributed leadership is to beimplemented more widely across the NHS, more research needs to be carried outin order to understand the effect it may have, whether it be positive ornegative, and how to manage these effects (Fitzgerald et al 2013).  The NHS was created followinga major war, and reflected the core value of compassion felt by society at thetime where all individuals, despite their social status, age, or gender deservedand felt the need for an optimal patient experience and the highest quality ofcare (King’s Fund 2011). However, the complex constraints faced by the NHS hasled to some losing sight of this core value, instead placing emphasis onfinances and meeting targets, with the impact of this being evident inMid-Staffordshire (King’s fund 2013).

Such failures outlined the need forreformations in leadership within the NHS. Within this essay, two leadershiptheories and their impact on patient experience have been explored. However, itis not a matter of which theory should be the overriding model for leadershipwithin the NHS. To designate only one theory as truth would be reductionist; itis instead more likely to be a fusion of differing models (Kings Fund 2011).Ultimately, if the goal of creating an NHS where patients consistently have theoptimal experience is to be achieved, more research needs to be carried out inorder to better understand how models of leadership influence patientexperience, and how these models can intersect to ensure that the NHS can returnto its core values.

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