The heart of the matter

The NHS is said to need more energising and enabling risk-takers who challenge old ways of thinking. Emotional intelligence will lie at the core of any such revolution, as Matthew Limb explains

Fran Woodard is gearing up for quite a leadership challenge. A critical care physiotherapist and former therapy services manager, she is about to become director of a huge, healthcare modernisation project. Her job from April will be to redesign stroke, renal and sexual health services - from prevention to end of life care - to benefit patients across a large part of south London. She hopes it will be an apt example of 'transformational leadership in action'. 'I want to get back to the frontline and to demonstrate that all my leadership skills actually work,' she says. Ms Woodard will be working with staff in hospitals, primary care trusts, social services and the voluntary sector, who may be used to their own way of doing things. Hence, she sees a 'transformational' approach as crucial in order to inspire and empower colleagues to produce 'sustainable' service improvements. So what does that mean in practice? 'It's about giving people the tools and techniques to develop their own leadership skills. It's about clinical engagement. It's about trusting people - a lot of it is about bloody good delegation,' she says. Jan Freer is another physiotherapist who says she subscribes to the principles of transformational leadership in her work. As director of organisational development for Calderdale & Huddersfield trust, she believes the purpose of leadership is 'changing things to improve patient experience'. She says: 'Transformation means that this happens because the people who want to make the difference are enabled to do so - they are given the responsibility, authority and the resources.' She adds: 'You need to engender a sense of commitment and ownership from everyone so that people are clear about the direction of travel and can get on with it.' Transformational or transactional? The transformational leadership method or theory favoured here by both Ms Woodard and Ms Freer is often contrasted with what analysts in this field term 'transactional leadership'. Transactional models tend to be more didactic, relying on command-and-control type hierarchies to get things done, backed up by appropriate rewards. 'The army has to have transactional leadership because you don't want somebody saying, "we can do this differently", in the middle of a war,' says Ms Woodard. She adds: 'There's quite a lot of literature around which will use the word management for transactional, and the word leadership for transformational - I think that's too simplistic but it does help in some places.' Commenting on the differences between the two leadership styles, she notes: 'Transactional produces predictability, order, the known, whereas transformational produces change and leads to a culture of change.' The terminology itself came under scrutiny in a systematic review of leadership development, which was carried out for the NHS Leadership Centre by the Warwick Institute of Governance and Public Management. According to the review, transformational leadership is characterised by certain qualities or behaviours such as 'inspirational motivation and intellectual stimulation'. Transformational leaders, it says, give everyone in their organisations opportunities for developing and learning and engender trust and respect by 'doing the right thing'. Indeed the review suggested the NHS needs more leaders of this type because they are 'energising and enabling' - risk-takers who challenge 'old ways of thinking'. However, Ms Freer believes the labels for different leadership methods are themselves somewhat old-fashioned and that in practice, leadership style 'depends on what you want to achieve in a given project'. She sees the transactional style, based on 'tell and obey', as appropriate for crisis management but not for long-term sustainable system improvement. 'That needs leaders who engage, motivate, articulate, coach, inspire and are passionate about the patients they are responsible for,' she notes. According to Christina Pond, a programme director at the NHS Leadership Centre, capacity for leadership in the NHS is no longer defined by status and job title. 'It is a way of thinking and a way of behaving regardless of position or seniority.' She says staff at all levels, clinicians and non-clinicians alike, can develop and demonstrate leadership skills, adding: 'The challenge is in encouraging each individual to recognise when and where they can make a leadership contribution.' The NHS Leadership Centre developed a leadership qualities framework (LQF) to support leadership development in the health service. The framework highlights 15 qualities and 'competencies' that effective leaders possess. Jacqui Stewart, who is the programme director responsible for the LQF, comments: 'Many of the qualities are transactional, because of the nature of the work of leaders in senior positions in the NHS, but when you achieve the highest level of many of the qualities they become transformational.' Use your feelings Whatever type of leadership is performed, says Ms Stewart, another vital ingredient has to be present. And this key component? As Ms Stewart explains: 'You need emotional intelligence in whatever you are going to do.' Emotional intelligence (EI) is a concept which describes certain qualities, characteristics and positive values that are rated highly by leaders purporting to promote change. The idea that a high EI quotient was a more telling indicator of successful leadership than a soaring intelligence quotient (IQ) was popularised in the 1990s by the author Daniel Goleman. Proponents of emotional intelligence claim that leaders who use their feelings in making decisions will be more effective, by demonstrating a better understanding of themselves and colleagues. Qualities such as self-awareness, empathy, altruism, integrity and motivation are prized as the basis for developing strong leadership skills. Whereas the personal values of effective leaders may be seen as inherent, it is said the skills and self-awareness necessary for good leadership can be learned and developed. Mrs Pond comments: 'The concept of emotional intelligence and its relationship to effective leadership has contributed considerably to the theory and practice of leadership and leadership development.' NHS learning and development programmes, she says, 'draw heavily' on emotional intelligence and transformational leadership qualities. Ms Stewart points out that many of the personal qualities identified in the LQF as requirements of good NHS leaders are 'key to emotional intelligence'. She says: 'To me, understanding who I am, how I feel, how much I believe in myself, how confident I am, are the absolute fundamentals of leadership. Because if you haven't got those, you can forget the rest.' Relationships are key The emotional intelligence model embraces both 'personal and social competence', that is, it recognises that how a person interacts with others is critical too. As Ms Woodard comments, physiotherapists who have clarity about their own moods and motivations will improve the way they manage their relationships with colleagues and patients. 'If you don't understand them yourself, you don't understand the effects on others.' She suggests people in leadership roles should be aware of how they come across to colleagues and patients - are they seen as too pushy, too brash, or under-confident? And they should know how to 'master their own emotions'. For example, someone who knows that they become controlling when stressed can adapt their behaviour accordingly. She says: 'It's about being comfortable with ambiguity, because you understand how you react and can manage how you react, so it doesn't bother you that there is lots of change.' Ms Woodard suggests another benefit of self-management is the knack of being able to suspend judgment, and to deal appropriately with patients' needs without making prior assumptions based on appearance, for example. Pursuing goals with integrity, energy and optimism is also put forward as evidence of emotional intelligence that can inspire people to produce change. As Ms Woodard notes: 'I think that it's not only phenomenally important in terms of how physios interact with patients but it's about the patient understanding you're truly committed to getting them better.' She highlights how people who have a high degree of empathy and strong social skills are good at building teams, developing staff and retaining talent. They are also adept at working with individuals from different cultures and may even attain what, to many might sound like the holy grail of leadership - being able to understand politicians. 'Empathy does lead you to be much more politically aware, to acquire more political nous,' she observes. Leaders at all levels Ms Woodard is particularly keen that physiotherapists should understand that leadership is important for all levels of staff. Physiotherapy assistants are as capable as more senior staff of developing their leadership capacity in terms of emotional intelligence, she says, adding, 'An assistant will often see what's wrong with a service far better than anybody else will and they can promote change.' On this topic, Ms Stewart notes that although original research for the LQF focused on senior managers, much work has been done since with clinicians and professionals at different levels of responsibility. 'We needed to see how relevant it would be to other parts of the NHS and we couldn't just assume those in charge were the leaders.' A 360 degree assessment tool was developed to help people think about the leadership qualities they need for the job they do. The qualities have been tested at 37 sites around the country by groups including allied health professionals, nurses and managers. Ms Freer's view is that much leadership theory is straightforward and need not be viewed as rocket science. She says: 'We make too many distinctions between managers/leaders and staff/followers or managers and clinicians. The goal is to create an environment where everyone is able to contribute to improving the patient experience of care and that's all our responsibilities.' As she notes of today's NHS, 'the only thing that isn't an option is not to change'. As she prepares for a new leadership situation, Ms Woodard agrees with this comment. On whether this next experience will be one that many can expect to find transformational, she says, with disarming self-awareness: 'I hope so. I don't know whether my new team will think that when they've met me.' Further information: Primal Leadership: Realising the power of emotional intelligence; Daniel Goleman, Richard Boyatzis and Annie McKee: Harvard Business School Press Leadership qualities framework
Matthew Limb

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