Managers who are engaged with their staff create well-being and better care. Margaret Bradley and Beverly Alimo-Metcalfe explain how to achieve this

Managers and workers on the front line of service delivery are bombarded with instructions and targets. Accompanied by continual change and service reconfiguration, this demoralises staff.

Despite increases in spending, the NHS is experiencing disappointing performance, and ineffective leadership and team working have been identified as partial causes for this. However, research has shown that multiprofessional team working can lead to improvements in productivity and service provision.

A big challenge for leaders in the NHS is the ability to cope with the relentless forces for change, so that the teams they manage are highly effective and sustain high morale, job satisfaction, and well-being. Can this be achieved? Our research into leadership and change management in multiprofessional mental health crisis resolution services provides some vitally important answers.

Crisis resolution teams were introduced as an alternative to hospital admission for people experiencing acute mental health problems. A central aim was to cut inpatient admissions. The purpose of the research project, funded by the Department of Health and conducted in collaboration with King's College London and the Sainsbury Centre for Mental Health, was to investigate whether leadership contributed to the teams' effectiveness, and if so, how.

The model we used for our research was based on our three-year investigation of "engaging" transformational leadership. Unlike the US "heroic" models of distant leadership, our research was based on staff views of nearby, day-to-day leaders.

A 360-degree transformational leadership questionnaire was developed, which has been shown to predict high levels of morale and well-being in staff. The study involved questionnaires, interviews, case studies and hospital admissions data. We also included questions about staff attitudes to work and staff well-being.

Dimensions of leadership

Analysis of data from 46 teams and 763 team members revealed three dimensions of leadership culture: leadership capabilities, visionary leadership and engaging with others.

Leadership capabilities refer to the competence of the leader in developing the team in a goal-directed way, geared to developing processes and systems. They can be regarded as the "what" of leadership. Visionary leadership and engaging with others relate to the way leadership competencies are used and can be regarded as the "how" of leadership. Visionary leadership refers to having a clear and inspiring vision for the team, both internally and externally. Engaging with others refers to being supportive and accessible to staff and promoting a learning culture in which staff are empowered to take the lead where appropriate.

All three dimensions positively and significantly affected some aspects of staff attitudes to work and their well-being, but only "engaging with others" significantly affects all aspects of positive attitudes to work, and all aspects of well-being.

When it came to predicting the performance of the teams, leadership capabilities did not have a significant effect. It was only the degree to which the team displayed engaging leadership that significantly predicted the teams' productivity. This is defined in terms of meeting the government target of reducing inpatient bed occupancy by treating patients in their own homes.

This is one of the first studies to provide evidence of a cause and effect relationship between leadership behaviour and organisational performance.

Our findings raise serious questions about how the NHS and other organisations are building leadership capacity. Many still base leadership development activities on competency frameworks, despite increasing criticism of this approach. Our research takes this debate further, since competencies did not predict productivity, only engagement did.

For engagement to be sustained, it is crucial to embed the leadership behaviours that promote it in the culture of the organisation. Any interventions designed to create this kind of culture must start at the top. Focusing interventions only at lower levels may well create more problems than it alleviates.

Our experience is that people find the model of engaging leadership instantly appealing. We have witnessed extraordinary changes in the behaviour and attitudes of people towards colleagues, patients and others with whom they work, and to their approach to their job, in the NHS and other contexts. It is our experience that one of the greatest frustrations for staff is when this is approach is not adopted by those at the top of the organisation. Such dissonance can be extremely demoralising and stressful for staff, so much so that we now believe that not involving senior managers in this kind of intervention might be ethically questionable.

The findings are clear: the NHS will only be able to handle the formidable challenges it faces by creating cultures of engagement - its staff deserve it. The private sector is leading the way on investing tens of millions of pounds in increasing engagement because recent studies have shown an indisputable link between engagement and profitability, and reduced turnover.

Our research identifies the particular leadership behaviours that affect successful change and productivity, and our data suggests such behaviours could make the NHS 4 per cent more productive while significantly increasing staff morale and well-being.

Characteristics of engaged leaders

  • Teams that succeeded in developing an engaging leadership culture displayed the following characteristics:

  • Engaging stakeholders from the outset to shape the service This formed the basis of continuing strong relationships necessary for the teams to succeed.

  • Shared vision of good quality service Team leads ensured the vision of the team was shaped by team members to create a sense of ownership of their work.

  • Non-hierarchical teams A culture of devolved leadership encouraged people to take the lead where it was appropriate for them to do so.

  • Supportive culture Informal support from colleagues and the team lead, and formal support in the form of supervision, ensured people felt comfortable in seeking advice and sharing work-related problems.

  • Successful change management Members were consulted on impending changes and their response taken into consideration. The result was a collective team response to top-down changes and the formulation of a joint action plan for addressing such changes.

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