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The theories that circulate
around notions of leadership, while hardly new, are firmly rooted within the
structures of socio-psychological development, being essential to the organisation
of various aspects of humanity ever since the dawn of intelligent lifeforms
(Van Vugt 2006). Defining leadership, however, is not an easy task; it remains
a fluid concept, often shaped by the social ethos of its time, and to attribute
one 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). The
importance of leadership, specifically within the National Healthcare System
(NHS) cannot be understated (Storey and Holti 2013). The release of recent
publications such as the Francis Report has exhibited this (The King’s Fund
2013). In its publication, the Francis Report outlined how a dangerous culture
and weak leadership – one based upon command and control – lead many failures
in the hospital trust (King’s Trust 2013). Consequently, Francis, in
corroboration with the King’s Trust, recommended that a new form of leadership
be implemented, one that placed the patient and their experience at the
forefront (King’s Trust 2013). This essay, therefore, will explore the concept
of what a positive patient experience is, and analyse different leadership
theories, investigating how these may be applied to healthcare to ensure that
the vision of the optimal patient experience is achieved, and that failures
such as those at Mid-Staffordshire never occur again.

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In recent years, there has
been a shift with regards to how the performance of the NHS is perceived, from those
of clinical efficacy and its outcomes to that of patient experience (Wolf et
al. 2014). Patient experience is a concept not bound by one overarching
definition but instead varies widely within research (Wolf et al.  2014). The Beryl Institute defines it as ‘the
sum of all interactions, shaped by an organisation’s culture, that influence
patient perceptions across the continuum of care’ (Wolf et al. 2010). Whilst
this definition does, condense the main themes of patient experience, it fails
to outline what constitutes a positive patient experience, and its application
to the NHS is therefore limited as it provides no precise guidance. Without
specificity, such a definition would open to subjective interpretation (Wolf et
al. 2010). The National Institute for Health and Care Excellence (NICE) avoided
limiting patient experience to one definition, instead producing a guidance on
best practice (NICE 2012). The guideline outlines five main features of
positive patient experience. These include knowing the patient as an
individual, acknowledging essential requirements of care, tailoring healthcare
services for each patient, ensuring continuity of care and relationships and
enabling patients to actively participate in their own care (NICE 2012).

Despite the existence of such guidelines, individuals’ subjective experiences
of the care in which they actively received are essential, according to the British
Medical Association (BMJ), to informing improvement on both a micro and macro
level (BMJ 2014). In an evidence review carried out by De Silva, it was found
that surveys were the most common form of patient feedback (2013).  Surveys, whilst being highly convenient and
generally more representative, are also problematic, as they are merely superficial
in their representation and may thus suffer from social desirability bias and
selection bias (De Silva 2013). Subsequently, both NICE and De Silva identify
that not only is a more multidimensional approach necessary to measure patient
experience, but there needs to a be a change whereby feedback is also used
effectively in order to improve healthcare (NICE 2012, De Silva 2013). Thus, in
order to ensure that positive patient experience not only remains a central
outcome, but is implemented and measured through all levels of the NHS, the BMJ
proposed effective leadership improvements are essential (BMJ 2014).


In his seminal work published
in 1978, Burns identified the vital characteristics of leadership, coining the
term ‘transformational leadership’ (1978). According to Burns, such leadership
is a process where the goals of the leader and the followers are fused “in a
mutual and continuing pursuit of a higher purpose” (Burns 1978). Therefore, the
essence of transformational leadership is where the inspiration of a shared
vision inculcates motivation within individuals and empowers them to strive
towards the vision until it comes to fruition (Burns 1978). This results not
only in the level of human conduct being raised, but also broadening the aspirations
of the leader and inspiring those who follow to strive beyond achieving the
status quo, hence having a transforming effect (Burns 1978). Marshall and
Broome expanded upon the work of Burns, expanding the scope of what it means to
be a transformational leader (2010). According to Marshall and Broome, it is
not enough for such leaders to inspire others, as such leaders must have a
strong belief in themselves – one cannot lead if they lack self-belief (2010).

Additionally, transformational leaders are in their truest form innovators, and
as such should revel in change, continuously striving for improvement using creative
strategies and appropriate evidence to inform best practice (Marshall and
Broome 2010). Moreover, such leaders should not be afraid to take risks, and
where failure does occur, the leader should accept this, having the knowledge
that 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 at
Mid-Staffordshire are to be learned from, a significant shift must take place,
where the patient is placed at the centre of all priority and asserted
leadership is the most influential factor in shaping this culture (2013).

Marshall corroborated with this, stating that the transformational leader and
their commitment to rousing innovation has never been needed more greatly
within the NHS, and may be the figure through which this change can be
instilled, 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 a
positive emotional contagion, fuelled by the shared desire to enhance the
patient experience (Kings Fund 2015). Such a contagion may result in strategic
decisions and the implementation of policies which enhance patient experience
(Kings Fund 2015). For instance, the presence of strong and focused goals that
specifically target areas where many trusts require improvement, such as timely
discharge, may allow for more consistent improvements in levels of performance
across trusts (Kings Fund 2015). Whilst the King’s fund agreed that focused
goals were important, the organisation also asserted that leaders must be aware
of the ceiling effect, where the absence of differentiation between trusts may
have a demotivating effect. Transformational leaders should, therefore,
innovate, and attempt to not only utilise the data from surveys effectively to
improve experience within their trusts, but also find new ways to measure
experience (Kings Fund 2015). Such leaders should also be aware that within the
current climate of the NHS, many of the failures regarding patient experience
are not simply due to the lack of a shared vision or motivation, but instead
are the result of wider pressures (Mcintosh 2017). Thus, in order to ensure that
patient experience is improved, transformational leaders should go beyond
inspiring individuals who follow them and attempt to remove these pressures
(Wolf et al. 2014).


Proceeding on from this, Menzies
Lyth identified the anxiety nurses are put under as affective to the overall
patient experience, as they have to deal with the most concentrated impact of
stress that arises from taking care of patients, and outlined the viability of
healthcare organisations is connected to the ability in which it has to contain
anxiety (Lyth 1960). Whilst this study may be argued as being outdated, its
fundamental argument is still very much applicable to the NHS. The main issues
lie within its suggestion that the main problem with the NHS was its inability
to change while, in fact, it is the uncritical promotion of change that has led
to an overloading of the system, distracting leaders from the main purpose of
the NHS. This consolidates the necessity for a transformational leader who
reasserts these values and provides a clear vision (Campling 2015). Campling
also asserts that the unkind behaviour seen in nurses, such as those at
Mid-Staffordshire, is the result of the absence of a supportive environment, leasing
to the subsequent implementation of defensive styles of coping and reduction in
capacity for empathy (Campling 2015). The presence of a transformational
leader, however, may allow for the creation of a more supportive environment
(Campling 2015). Through inspiration by the leader, individuals may feel more
empowered to pursue and fulfill the shared vision of patient centred care. The
feeling of empowerment may potentially enhance the sense of worth felt by each
individual, therefore stimulating them to reach a heightened quality of care
(Rokstad et al. 2015). Such an environment may lessen the likelihood of
developing such defensive styles of coping, hence leading to staff who are
kinder and more likely to know the patient as an individual, thus being more
attuned to their emotional, physical and social needs (Campling 2015).

Additionally, the establishment of a more supportive environment has been shown
within 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 heightened
continuity, which is significant at the organisational level, potentially
lessening the turnover of NHS chief executives (The king’s fund 2011). Lowering
this turnover may aid in the maintenance of strategic direction and the effect
on wards may be that they possess more experienced staff, have fewer issues
with understaffing and be less likely to rely on bank staff – all factors which
have been shown to not only increase the quality of healthcare, but also
heighten the experience in which a patient has (Robbins 2007, NICE 2012).


The potential impact that a
transformational leader may have on patient satisfaction is obvious, and the
efficacy 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 transformational
leaders within care homes led to both leaders and staff having a clear vision,
one based on providing care that was individualised (2015). Staff felt
encouraged to deliver care that was of the highest standard and act
autonomously, possessing a deep understanding of what it meant to ensure a
positive patient experience, and often reflected upon their performance. This
was viewed in contrast to nursing homes with more traditional modes of
leadership (such as transactional leaders), where goals or aspirations for the
home were unknown, and staff felt unsupported and unmotivated (Rokstad et al.

2015). Whilst this study exhibits the real-life impact that a transformational
leader may have, it is important to consider the low external validity of this
study. The study was carried out in a care home, which is a completely
different environment when compared to, for example, an acute care unit.

Furthermore, it only considered the impact of transformational leadership from
the staff’s perspective, not considering the viewpoint of the receivers of
care. Ultimately, in order to deepen the understanding of how transformational
leadership has an impact on the positive patient experience, longitudinal
studies need to be administered within a variety of settings, with a more
diverse sample of both staff and patients needing to be utilised. (Kings Fund


The positive impact that a
transformational leader may have for patient experience is, therefore, evident,
and it is argued that it should be more integrated into the NHS (Campling
2015). The question that remains, however, is how. Robbins suggests that
leaders require education with regards to transformational leadership qualities
(2007). However, in the midst of the current financial crisis of the NHS, this
begs the question as to whether formal training would be viable (McIntosh
2017). Additionally, to be a transformational leader and perpetuate any kind of
innovative vision requires intense charisma, and the ability to have effects on
followers which can be considered as extraordinary (Tourish & Pinnnington
2002). The reality is simply that there is not a readily available supply of
individuals who have the ability to convey such a vision, whilst also being
able to maintain routine such as upholding the NHS, or running the wards
(McIntosh 2017). Moreover, Campling expresses that transformational leaders
cannot be taught, and the ability to be a transformational leader is often
innate (2015). Transformational leadership may also have a negative impact on
its followers, resulting in numerous personal sacrifices being made in their
commitment to achieving the shared vision of their leader (Tourish &
Pinnington 2002). This was exhibited by Neilsen, who found that in Danish
Postal workers, transformational leadership was linked to the promotion of
self-sacrifice, where individuals would go into work whilst ill in order to
achieve the shared vision, leading to heightened absence levels in the long
term (2016). Whilst this study has its limitations – for instance, it was not based
in healthcare, nor in the UK – it outlines the potential dangers of such a
leadership style. Working in healthcare is inherently stressful, as already
outlined, and the pressure to achieve a positive patient experience may lead to
negative consequences for individuals, such as increased absence- or
potentially, anxiety and depression (Tourish & Pinnington 2002). Thus,
while transformational leadership has a significant amount of potential within
the NHS, particularly for enhancing patient experience, as exhibited by studies
by 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 that
transformational 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, a
distributed model of leadership is a more viable framework for the enhancement
of patient experience (Fitzgerald et al 2013), despite there being no
universally contingent definition of distributed leadership. However,
Fitzgerald et al provides a concise definition, explaining that distributed
leadership comprises of a system of senior leaders at the national level, with the
middle level comprising of clinicians who also act as leaders i.e. sisters and
consultants, and individuals who may not possess the label of leader, but act
with leadership qualities to aid in the enactment of change (2013). Turnbull
outlines that distributive leadership must engage every individual, and that
individuals are not leaders because they are exceptional nor inspirational in
any way, but instead they observe what needs to change and work with others to
achieve this vision – innovators, who disseminate information (2011). Expanding
upon this patient experience may be compromised because individuals notice
issues, such as patient’s operations being consistently delayed and thus
remaining nil by mouth for a number of days, but fail to exercise leadership in
order to enact change (Turnbull 2011). Distributed leadership may therefore
give clinicians a heightened sense of responsibility and thus empowerment. Increased
empowerment is linked to innovation and more effective clinicians, and as a
result, better care can be implemented and tailored to the individual, hence
advancing patient experience (Turnbull 2011). 
Fitzgerald et al provide further support for this, finding that the
effective implementation of national mandates was dependent upon a good
relationship existing between senior leaders and clinicians who acted as
leaders. They were found to be critical in adapting such mandates to the meet
their local agendas – indeed, Fitzgerald et al linked poor quality of care in
diabetes clinics with limited boundary spanning, where leaders and clinicians
had poor relationships (2013). Furthermore, effective implementation of patient
survey data regarding patient experience was linked to distributed leadership
(Kings Fund 2015) Conversely, distributed leadership has also been linked to
poorer quality of care and thus poorer patient experience, as well as slowed
decision making, fragmentation within organisational structures and divergent
strategic priorities. This may result in the national mandates to enhance
patient experience not being efficiently implemented across the NHS, and lack
of constancy (Fitzgerald et al 2013). Research has made it clear that there is
a link between patient experience and distributed leadership (King’s fund 2011,
McIntosh 2017, Fitzgerald et al 2013). Limiting who can be a leader to specific
senior individuals can undermine the importance of clinicians and the
complexity of the NHS; success is founded upon a collective dynamic (King’s
Fund 2011). The main issue with this, however, is the lack of research
regarding the actual implementation of distributed leadership, and the impact
which it has on patient experience. If distributed leadership is to be
implemented more widely across the NHS, more research needs to be carried out
in order to understand the effect it may have, whether it be positive or
negative, and how to manage these effects (Fitzgerald et al 2013).


The NHS was created following
a major war, and reflected the core value of compassion felt by society at the
time where all individuals, despite their social status, age, or gender deserved
and felt the need for an optimal patient experience and the highest quality of
care (King’s Fund 2011). However, the complex constraints faced by the NHS has
led to some losing sight of this core value, instead placing emphasis on
finances and meeting targets, with the impact of this being evident in
Mid-Staffordshire (King’s fund 2013). Such failures outlined the need for
reformations in leadership within the NHS. Within this essay, two leadership
theories and their impact on patient experience have been explored. However, it
is not a matter of which theory should be the overriding model for leadership
within the NHS. To designate only one theory as truth would be reductionist; it
is 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 the
optimal experience is to be achieved, more research needs to be carried out in
order to better understand how models of leadership influence patient
experience, and how these models can intersect to ensure that the NHS can return
to its core values.

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