Although we know that leadership motivates workers and affects a workplace’s climate, leadership means different things to different people. The same is true for concepts such as patient care and organizational change. To understand how leadership inspires health workers to provide better patient care, we will first learn how these workers define and understand it, and how their definitions and perceptions mesh or conflict with one another. We will do this by conducting focus groups with staff and patients and pursuing relevant issues raised in these groups in questionnaires and one-on-one interviews. Finally, we will observe staff meetings to see how suggestions for improved patient care are made and responded to, and interview people responsible for implementing them. We will thus track the career of suggestions designed to improve patient care to see what affects their failure or success; for example, work climate, or styles of leadership.
By using different methods, we can compare our findings, and ask informants about new discoveries, while the research is still underway. This way, while keeping key questions in mind (e.g. about leadership), we can keep the study sensitive to what we find rather than shaping it according to a rigid set of concerns. This will give us a fuller understanding of the complex workings of NHS organizations as their staff try to improve patient care, and of the role of leadership in encouraging or discouraging their attempts.
To identify the circumstances under which leadership can be an effective engine for change in the organization of health care, especially for patient care and service delivery, we will study three NHS organizations with different star ratings over a three-year period: a primary care trust and a teaching hospital in South West London, and a district hospital in Surrey. We will choose two units per hospital, and include patients, nurses and professions allied with medicine, non-clinical managers, and senior managers in all phases of data collection.
As a process occurring within an organization seeking change, and as part of the management of an organization’s meaning and emotion, leadership strongly influences worker motivation and organizational climate. On an empirical level, however, leadership, as well as better patient care and organizational change, are not facts, but social constructions. Thus, to understand how leadership is constructed, achieved and transmitted in our sites, we will examine how our informants define and understand it, and how these different definitions and perceptions reinforce or undermine each other. To capture the full range of attitudes, definitions, personal histories, and practices related to leadership and improved patient care, we will adopt a multi-method approach. The qualitative data (focus group and interview transcripts, and field notes) will be coded through Ethnography and analysed using grounded theory, and the survey data will be analysed through SPSS.
We will:
(1) Conduct focus groups with members of the groups identified above, and use the data to gain insight into key questions and to help structure our survey and interview instruments.
(2) We will administer two surveys (one for patients measuring patient satisfaction, and one for staff, including a standardized measure of Organizational Climate). We will conduct random sampling from the different subgroups of staff represented in the focus group and interview data to arrive at our survey sample.
(3) To provide richer, more detailed narratives about the opportunities and constraints embedded in the work setting and the routines that prevail within it, we will conduct ethnographic interviews to pursue questions about leadership and patient care uncovered in the focus group and survey data. and elicit story-telling narratives about leadership through a second wave of semi-structured interviews.
(4) Engage in ethnographic observation in staff meetings at each site to see how ideas for change designed to improve patient care are suggested and responded to, and conduct follow-up interviews with those who have been charged with implementing them and with those overseeing their implementation. We will thereby track the career of an attempt at change designed to improve patient care to see how it is affected by the obstacles and opportunities previously identified by the research team. The outcome of our analysis of this rich, overlapping data set will be a fuller understanding of the impact of leadership on the experience and delivery of patient care in NHS settings, and the circumstances (e.g. organizational climate) that encourage or constrain them.
Project team
Emma Rowland, Professor Paula Nicolson (RHUL), Dr Paula Lokman (RHUL), Dr Rebekah Fox (University of Kingston), Professor Yiannis Gabriel (University of Bath), Dr Kristen Heffernan (New York University Brockport) and Christopher Howorth (RHUL)
Project funder
NIHR 08/1601/137