An awareness of the impact of leadership is central to the challenge of understanding and upholding the delivery of compassionate patient care. An increasingly ageing population with multiple complex health conditions, together with a rise in patient expectation and a target-driven work culture, is creating considerable pressure on staff working in general practice. The aim of this article is to discuss and critically analyse the influence of leadership style on staff morale and burnout through the exploration of three key themes in relation to leadership: the individual, the team and the workplace culture.
Defining emotional exhaustion
Work-related stress is prevalent within the NHS (2020) and if not acknowledged and resolved may lead to burnout. Burnout can be defined as a syndrome of emotional exhaustion, cynicism and negative thoughts towards patients and colleagues, together with reduced personal accomplishment (Maslach and Jackson, 1981). In 2018, Monsalve-Reyes et al undertook a meta-analysis of 1430 research studies on burnout in primary care nurses and found reduced personal accomplishment was present in 31% of participants, emotional exhaustion in 28% and depersonalisation in 15%. Emotional exhaustion used in this context could be a similar term to compassion fatigue, a related but separate concept to burnout (Yoder, 2010). Valent (2002 in Yoder 2010) proposed that both concepts are failed survival strategies: compassion fatigue as a response to indirect trauma when caring for patients, for example in a palliative care, termed a rescue-caretaking response, while burnout is an assertiveness-goal achievement response.
This links burnout to the reduced personal accomplishments found by Maslach and Jackson (1981), where work-based stress may result from deficits in leadership and breakdown of team working. Burnout is not only important on an individual basis but effects job performance (Yoder, 2010; NHS, 2016). The link between feeling undervalued and stress, and a lack of compassion has been highlighted in the media and government reports over recent years following the Mid Staffordshire NHS Trust failures (Cummings and Bennett, 2012; Francis Inquiry, 2013; Department of Health (DH), 2015).
Defining compassion
Compassion is the core NHS value (West et al, 2017), one of the fundamental principles and values of nursing professional standards (Nursing and Midwifery Council, 2018) and one of the six core values of the NHS Constitution (DH, 2011). However, defining and understanding the meaning of compassion can be complex. West (2016) outlines four components: listening, understanding, empathising and helping; while de Zulueta (2015) discusses kindness and sensitivity. These are values and skills that nurses traditionally associate themselves with, yet they are not easily measured by the performance-based targets used in the modern NHS to define and quantify success. Financial and operational pressures on the NHS have resulted in targets which are more difficult to achieve with constrained resources, resulting in increased staff stress (NHS Improvement, 2016). However, the focus of this article is not on compassion shown to patients directly, but that shown to staff. West et al (2014: p10) succinctly phrase this as:
‘If we want staff to treat patients with respect, care and compassion, then leaders and staff must treat their colleagues with respect, care and compassion.’
Leadership and the individual
Compassion has recently been used in reference to leadership qualities and behaviours (NHS, 2014a) and is consistent with the phrase intelligent kindness or emotional intelligence. Cadman and Brewer (2001) define emotional intelligence as empathy, self-awareness and self-control; all central to effective nursing practice but also characteristics of compassionate leadership. The NHS Leadership Academy (2013) recognise that since compassion is felt at a personal level, the way we manage ourselves is a central part of being an effective leader, supporting the ideology that anyone can be a leader regardless of position and title (Barr and Dowding, 2012; NHS England, 2014a). An understanding and recognition of our personal attributes and values will impact on our behaviour at work and our interactions with colleagues. Optimistic, affirming and motivated individuals will raise morale in a team and prevent an increase in ‘toxic’ behaviour (NHS Leadership Academy, 2013). Therefore, a mindful awareness of behaviour and self-control will allow an individual to recognise signs of burnout and to seek help.
An effective leader
Dewar and Christley (2013) identify that embedding a culture of compassionate care for both staff and patients requires the involvement of all staff. Traditionally seen as interconnected with management, leadership is no longer allied to seniority (Barr and Dowding, 2012) but instead should be demonstrated by staff at all levels (Goppee and Galloway, 2014). Early leadership theories developed from hierarchical organisations in manufacturing industries are irrelevant to the collaborative, team work approach of the modern NHS (Sullivan and Garland, 2010). Contemporary theories focus on leadership behaviour styles that may be used interchangeably depending on the required task, to maintain the team and/or to meet the needs of individual team members, eg Adair's action-centred leadership (2010 in Barr and Dowding 2012) or situational leadership (Grimm, 2010). Based on the work of Lewin et al (1939) leadership styles or traits fall into three main classifications – autocratic, democratic or permissive – each of which can be developed or learnt. An effective leader can have significant influence on a team and work environment by using several leadership styles and traits in different situations. For example, a leader may use a transactional or autocratic approach when consistency or reliability are necessary, for example during an emergency or when managing a budget (Barr and Dowding, 2012). However, a democratic or transformational approach would work better when interpersonal relationships are central to the achievement of a shared vision (Sullivan and Garland, 2010).
Developing self-awareness of our own leadership styles is vital to effective, compassionate leadership. In an aspiring culture of openness and learning, introspective observation and understanding of our behaviour is essential to facilitate personal development. Self-tests are available online to help individuals explore their personality traits and the potential impact of these on leadership behaviours, for example the Myers-Briggs MMD personality test (Team Technology, 2018) and Cherry's (2020) Leadership Style test. However, in order to develop a positive leadership style, it is necessary to reflect on the strengths and weaknesses indicated by these quizzes.
Leadership, compassion and the team
All leadership works in a group or organisation because all leaders must have followers. Bradberry (2015) takes a negative view of followers stating that they ‘do their jobs and that's it’ and only ‘see the limitations inherent in any given situation’. This viewpoint rejects the requirement of leaders to have followers and the reality that leadership is a two-way process based on the leader–follower relationship (Goppee and Galloway, 2014). Emotionally intelligent, compassionate leaders will need to be aware of their follower's needs. As Cummings and Bennett (2012) state, ensuring staff feel valued, cared for and communicated with is essential to good leadership.
Although difficult to distinguish, there is a distinction between a group and a team. Sullivan and Garland (2010) characterise a group as a collection of individuals who interact with, and influence, each other, while a team is characterised as a group who work co-operatively together to achieve a mutually agreed goal.
An effective leader needs to understand not only their own behavioural style, but that of everyone in the group, and how the group works together. Every individual in a team will have an identity or role with a mix of attributes and weaknesses, for example Belbin's team roles (2010). Barr and Dowding (2012) suggest that a transformational leader will use empathy skills and two-way communication to motivate their staff and promote cohesion, so building a successful team. However, as much as a team will impact on an individual, an individual will also impact on a team and a leader needs to identify negativity affecting the team dynamic and act accordingly for example by discussing concerns in a supportive one-to-one meeting.
Teamwork and kindness
A positive work team or group may provide the primary motivation for an individual to return to their job each day (Sullivan and Garland, 2010), having an enormous impact on their work-related quality of life. Ballatt and Campling (2011) advocate that kindness in a team generates attentiveness, which in turn inspires kindness. Borrill et al (2000) found that people working in effective, supportive teams had better mental health than those working alone or in groups, and they propose this is due to social support and increased role clarity. In addition, the way a team manages anxiety and work pressures can create a buffer against organisational administration and practices (Ballatt and Campling, 2011).
Leadership and organisational culture
Organisational culture has been defined as ‘the way we do things round here’ or the shared values, norms, assumptions and beliefs of a group of people working together in an organisation (Goppee and Galloway, 2014). Workplace culture has an impact not only on those who work in it but also those who use it. However, recognition of a harmful, destructive culture may only arise after an event, for example, the Francis Inquiry (2013), which highlights the failure to build a positive ethos and resulted in a demand for fundamental changes in NHS culture. The modern NHS is a market-driven workplace with a strong bias towards monitoring performance targets, audit and managing costs (Ballatt and Campling, 2011; West et al, 2014). It is difficult to quantify, or audit, compassionate care for staff, and therefore it may be identified as less valuable. It follows that the issues leaders or managers focus on, reward and seek to influence, inform employees of the organisation's values and standards (West, 2017).
Values and vision
Two influences on the culture of an organisation are its values or vision and the behaviour of its leaders. In 2012, the Department of Health published the ‘6Cs’ (care, compassion, courage, communication, competence and commitment) (Cummings and Bennett, 2012), as a response to high profile failures of care in the NHS (Francis Inquiry, 2013). The 6Cs were intended to be a unifying set of values for nursing and were allied to the NHS Five Year Forward aims (NHS England, 2014b) of better outcomes, better experience and better use of resources (Baillie, 2017). Nurses must also work within the NMC Code of Conduct (NMC, 2018) values and principles, and the NHS Constitution (DH, 2011) values, one of which is compassion. To be credible, leaders need to believe and clearly articulate these core values through role-modelling, as leadership is the most influential factor in shaping organisational culture (de Zulueta, 2016; West, 2017).
NHS England (2014a) emphasise the importance of engaging all staff to promote and safeguard a culture of compassionate care, and in 2013 the NHS Leadership Academy developed the Healthcare Leadership Model (NHS Leadership Academy, 2013) to help all staff understand the impact of leadership behaviour on culture. A study by Wong and Laschinger (2013) found that when nurses perceive their leaders to be open, truthful and inclusive in decision-making, they exhibit higher work engagement and place greater trust in management. Conversely, limited control in decision-making coupled with high work demands are key predictors of workplace stress (West et al, 2014).
Conclusion
The impact of low staff morale or burnout has been linked to a feeling of disempowerment. Recognising that leadership and management are two different entities can be reassuring, and to understand that everyone can be a leader whatever their role is inspiring.
Prior to reading for this article, I felt that low morale and cynicism was an inevitable reaction to unavoidable workplace stresses. However, I have recognised, through reading and reflecting, that everyone can lift morale not only in themselves but also for their colleagues. We can choose to present our authentic selves to our colleagues, using emotional intelligence to promote our personal values and challenge toxic behaviour. A mindful awareness of our behaviour and self-control can help recognise signs of stress and enable us to take measures to combat them.
The current environment of the NHS is target driven; largely by financial pressures and increasing public expectation. This has increased the stress and anxiety felt by skilled and caring professionals who are motivated by their compassion for fellow humans. As previously discussed, emotionally intelligent care can be difficult to quantify, leading to misplaced focus and resulting in the catastrophic failures in empathy and quality of care seen in recent years. The current attention and refocusing of values on compassionate care in the NHS have highlighted that the staff and patient experience of the NHS are inextricably linked. Engaged and empowered staff will believe and model the values of a culture, emphasising again that leadership is the catalyst for change.
KEY POINTS
- Emotional exhaustion, cynicism and negative thoughts towards patients and colleagues can be signs of burnout
- Compassion is a core nursing value but is not easily measured by the performance-based targets of the modern market driven NHS
- Leadership and management are two different entities. Leadership is not allied to seniority and can be demonstrated by all members of a valued and supportive team
- An effective leader can have significant influence in a team and work environment by using different leadership styles and traits
- A positive work environment will have enormous impact on an individual's experience of work, improving mental health and reducing anxiety
CPD reflective practice
- How would you define compassion in nursing?
- Think about your practice team. Would you say you have kindness in your team? How does this impact on morale?
- How would you define your own leadership style?