University Researchers : Beverly Alimo-Metcalfe, Principal Investigator

1. ‘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 Rebecca Smith (Yorkshire and the Humber SHA).

2. 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 • 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 • 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.

3. 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 multi-professional 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.

4. 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)

5. 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 & inter-agency work

6. CONTEXTUAL FACTORS Team Leadership Leadership Capabilities Engaging with Others Visionary Leadership Outcomes of Effectiveness Users’ & Carers’ perceptions Professionals’ perceptions Professionals’ Engagement & Wellbeing Other Performance Measures TEAM PROCESSES Intra- team Processes Inter-team & Inter-agency Processes Quantitative Data Collection LTQ Quantitative collected at Time 1 – Cross-sectional model

7. The I-P-O Model of Team working Team Processes OUTPUT INPUT

8. The I-M-O-I Model of Team working Affective states (eg motivation, interest in task, perceived value of the task) Team Processes (Behavioural) OUTPUT INPUT Cognitive states (free exchange of knowledge & experience leading to a shared understanding of how to improve quality of service)

9. INTRA-TEAM WORKING LEADERSHIP CAPABILITIES PSYCHOLOGICAL SAFETY ENGAGING WITH OTHERS BUILDING A SHARED VISION ENABLING THE TEAM SOCIAL SUPPORT IMPACT ON TEAM MEMBERS TEAM LEADERSHIP TRUSTING & BONDING TEAM POTENCY TEAM ENGAGEMENT VALUING DIFFERENT PERSPECTIVES WELLBEING AT WORK SUPPORTING A DEVELOPMENT CULTURE TEAM WORKING TEAM OUTPUT INNOVATION PLANNING INFORMATION GATHERING FOCUS ON QUALITY ROLES & RESPONSIBILITIES INTER-TEAM WORKING UPDATING IMPROVEMENT STRUCTURING & LEARNING COLLECTIVE EXPERIENCE TEAM PROCESS OUTCOMES ADAPTING INTER-TEAM RELATIONS INTER-TEAM COLLABORATION IMOI MODEL OF TEAM LEADERSHIP AND TEAM WORKING

10. Proposed Methodology • Gather both quantitative and qualitative data • Identify factors affecting (1) theeffectiveness 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)

11. Research stages Research Champions conduct R/Grid Int. Distribute Qs & gather data from SU & Carers Develop Quality of Care Questionnaires 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

12. Research Champions’ Experience, Learning & Benefits

13. 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

14. 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

15. 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

16. 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

17. Benefits for Carers Using carers as a resource Increased understanding from the carers’ perspective Carers spoke freely without being defensive Aided in clarifying expectations

18. 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

19. Service Users’ & Carers’ notions of ‘high quality care’ – Key Findings

20. Methodology – Stage 1Identifying 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)

21. 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

22. 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’

23. Extract : Comparison of NICE Quality Standard forService User Experience with SUs’ constructs

24. 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

25. 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

26. 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

27. Observations& Implications of datafrom 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

28. Team Leadership, Team Working, & Outcomes – the Key Findings

29. Rank order of Average scores for Team Leadership & Team Working (N = 590 Team members)

30. 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)

31. 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)

32. DFAs for scales – showing which scalesuniquely predict which outcomes

33. DFAs for scales – showing which scalesuniquely predict which outcomes

34. DFAs for items – showing which specificbehaviours uniquely predict outcomes (1)

35. DFAs for items – showing which specificbehaviours uniquely predict outcomes (1)

36. DFAs for items – showing which specificbehaviours uniquely predict outcomes (2)

37. DFAs for items – showing which specificbehaviours uniquely predict outcomes (3)

38. INTRA-TEAM WORKING LEADERSHIP CAPABILITIES PSYCHOLOGICAL SAFETY ENGAGING WITH OTHERS BUILDING A SHARED VISION ENABLING THE TEAM SOCIAL SUPPORT IMPACT ON TEAM MEMBERS TEAM LEADERSHIP TRUSTING & BONDING TEAM POTENCY TEAM ENGAGEMENT VALUING DIFFERENT PERSPECTIVES WELLBEING AT WORK SUPPORTING A DEVELOPMENT CULTURE TEAM WORKING TEAM OUTPUT INNOVATION PLANNING INFORMATION GATHERING FOCUS ON QUALITY ROLES & RESPONSIBILITIES INTER-TEAM WORKING UPDATING IMPROVEMENT STRUCTURING & LEARNING COLLECTIVE EXPERIENCE TEAM PROCESS OUTCOMES ADAPTING INTER-TEAM RELATIONS INTER-TEAM COLLABORATION IMOI MODEL OF TEAM LEADERSHIP AND TEAM WORKING – VALIDATED

39. 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)

40. 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

41. Observations & implications for multi-disciplinary MH teams – 2 • Unexpected: Team Leadership does not impact directlyon 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

42. Results from the Case Studies of high-performing teams

43. PERFORMANCE MANAGEMENT GENERAL LEADERSHIP STYLE TEAM FOCUSED INSPIRING OTHERS SUSTAINING SHARED VISION BALANCING NEEDS EFFECTIVE CHANGE MANAGEMENT IMPACT ON TEAM MEMBERS STRONG AND PASSIONATE VISION OF PROVIDING GOOD QUALITY CARE TEAM LEADERSHIP TEAM ENGAGEMENT WELLBEING AT WORK TEAM COMPOSITION INTRA-TEAM WORKING TEAM WORKING IMPACT ON SERVICE USERS AND CARERS POSITIVE RELATIONSHIPS WITHIN THE TEAM QUALITY OF CARE EFFECTIVE COMMUNICATION INTER-TEAM WORKING TEAM PROCESS OUTCOMES INNOVATION & IMPROVEMENT CULTURE OF INNOVATION, IMPROVEMENT & DEVELOPMENT RELATIONSHIPS WITH OTHER TEAMS/AGENCIES ADAPTING TO CHANGE MODEL OF TEAM LEADERSHIP AND TEAM WORKING BASED ON THE CASE STUDIES

44. Case Studies: Effective Team Working • Strong and passionatevision 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.

45. 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

46. 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.

47. 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.

48. 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

49. 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

50. 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.