COVID-19 has shown that compassionate leadership is essential for the future of the UK’s health and social care

• NHS staff

• socio-economic inequalities

The crisis in NHS and care staffing dates back to before the pandemic struck – but COVID-19 has heightened levels of staff stress and sickness to such an extent that a whole new approach to leadership is now required

Michael West

Even before the COVID-19 pandemic took hold in early 2020, the UK health and social care sector had been facing the biggest crisis in staffing since the introduction of the welfare state in 1948. This is a crisis related to vacancies, sickness absence, staff turnover and stress levels.

Staff stress had been steadily increasing, with more than 40% of staff in the NHS reporting they had been unwell in the previous year because of work stress, and one in four nurses leaving the NHS within three years of joining.

Not surprisingly, this has damaging consequences not only on staff health but their performance, and thus for patient/service-user safety levels too. The causes of these difficulties include: inadequate staffing levels; work overload and inflexible work schedules; moral distress, bullying, harassment and violence; discrimination; and poor pay. Collectively, these problems revealed a crisis of leadership for all health and care services in the UK.

And then the pandemic struck, triggering dramatic increases in work and other demands on staff in the health and social care sectors – not least the fear that many felt about the threat to their own lives, the lives of their loved ones, and the lives of those they provide care for.

The impacts of COVID-19 on health and care staff

Among NHS staff in England, there was a 10% increase in levels of staff stress overall. Some groups, such as staff working in intensive care, have experienced dramatic increases in symptoms of post-traumatic stress disorder (PTSD). Many staff will recover, but for some we know there are long-term difficulties.

There were also tragic losses of life among staff – of whom those from minority ethnic groups were disproportionately more likely to die. The effects on their colleagues will be long-lasting.

It is currently unclear what the full impact of COVID-19 on staff turnover will be, but anecdotal reports suggest many more staff are considering quitting. Recent emphasis has been placed on the need to catch up the backlog of work created by the pandemic, just as there is another large surge in cases and hospitalisations. Many health and care staff are exhausted, and tired of being exhausted. Nurses and midwives have been particularly hard hit. We have to transform health and care organisational cultures for the long-term future – indeed, all public sector organisations.

The key factor determining levels of staff stress in health services, our data show, is chronic work overload. It is the main predictor of staff stress, intention to quit, staff turnover and patient dissatisfaction.  Chronic work overload is like the pattern on the wallpaper we know longer see. Yet it is the primary factor damaging staff health and wellbeing, organisational cultures, and the safety of those we provide services for.

The four elements of compassionate leadership

We can, though, find hope and inspiration from extensive evidence (see 1, 2, 3) which shows that compassionate leadership results in profoundly better staff wellbeing and commitment, improved care quality, and fairer, more transparent and kinder workplaces. The NHS national staff survey, which has run for 18 years and is completed by more than half a million staff each year, demonstrates clear associations between supportive leadership and care quality, staff wellbeing, financial performance and lower levels of patient mortality.

Research on fundamental human emotion regulation systems, and on the centrality of compassion to wellbeing and performance in different organisations, has shaped our understanding of the core elements of compassionate leadership (see references at end). Where leaders throughout a Health Service Trust exhibit these four elements – attending, understanding, empathising and helping those they lead – outcomes are dramatically better: higher levels of patient satisfaction in the NHS, better care quality, better financial performance, higher levels of staff retention, and in the acute sector, lower levels of avoidable patient mortality.

The role of leadership in developing compassionate cultures in health and social care is crucial. Compassionate leadership may sometimes be mistaken for a ‘soft’ and ineffective approach – yet far more courage and authenticity is required to lead compassionately than to lead using command and control. It is ultimately focused on providing high-quality services for patients, service users and those in the community that public sector organisations serve, which implies a very strong focus on performance and performance management. It is certainly not about adopting an easy consensus on the way forward.

The importance of inclusive leadership

While compassion is fundamental to health and social care, it is actually even more important than is often imagined. Much research evidence now describes:

• the importance of compassion as protective of health and life;
• the impact of clinician compassion on patient outcomes;
• the link between compassion and patient experience;
• how being compassionate also protects those providing care; and
• the effectiveness of compassionate leadership.

Importantly, if leadership is not inclusive, it is not compassionate. Inclusion was a founding value of the welfare state in the United Kingdom, but organisational cultures in health and social care continue to reflect the widespread and pathological discrimination within wider society. The pandemic shone a spotlight on the effects of discrimination on health in society, with far higher proportions of those with disabilities and those from minority ethnic groups dying from COVID-19.

Inclusive leadership promotes equity, cultures that value diversity in all its forms, and ensures inclusion in practice. Compassionate leadership offers a means by which inclusive leadership can be achieved, including the compassionate management of conflict, and developing strategies that ensure all individuals, teams and leaders take responsibility for sustaining inclusive cultures.

Traditional approaches to leadership have important limitations, with their emphasis on developing individual capability while neglecting the need for developing collective leadership capability. They are also limited in that they can hamper the dialogue, debate and discussion that enable shared understanding about quality problems and solutions.

In contrast, compassionate leadership enables all to feel they have leadership responsibility, rights and accountability, effectively ensuring the skills of all are harnessed in the delivery of high-quality care. Compassionate leadership offers a practical means for ensuring the resources of the largest, most skilled and motivated workforces in the whole of industry (public sector staff) are effectively utilised.

Compassionate leadership in practice

This approach is now being implemented in many places – including Health Education and Improvement Wales’ (HEIW) 10-year strategy for developing compassionate leadership across the whole of health and social care in Wales. This strategy was developed (with my input) after consultation with staff from the whole of health and social care in Wales, consultations with key leaders across the system, and case studies of outstanding practice from all over the UK.

The strategy includes seven leadership principles which are espoused in development courses offered by HEIW:

• Enable safe, trusting and engaging systems and cultures;
• Strengthen respect, voice, influence and choice;
• Improve equality, inclusion and diversity, consciously removing barriers and boundaries;
• Develop supportive and effective team and inter-team working;
• Manage behaviour positively, openly, courageously and ethically;
• Establish the conditions for our workforce to reflect, learn, continually improve and innovate; and
• Create environments where collective leadership thrives.

The commitment to alleviate and prevent suffering requires wisdom, humanity and presence that enables us to take wise and caring action. Compassionate leadership is not hidden behind a mask of organisational titles, hierarchical positions or formulaic phrases that inhibit authentic connection.

Rather, it is a courageous leadership that embodies presence – being present with ourselves and others; using the core values of compassion, inclusion, kindness and caring that must be woven into the genetic structure of our health and social care workplaces.

Professor Michael West is the author of Compassionate Leadership: Sustaining Wisdom, Humanity and Presence in Health and Social Care (Swirling Leaf Press), on which the HEIW’s compassionate leadership development courses are based.

References on core elements of compassion and compassionate leadership

• Gilbert, P. (ed.).(2017): Compassion: Concepts, Research and Applications. London: Routledge.
• Rynes, S. L., Bartunek, J. M., Dutton, J. E., & Margolis, J. D. (2012): Care and compassion through an organizational lens: Opening up new possibilities. Academy of Management Review, 37(4), 503-523.
• Atkins, P.W.B., & Parker, S.K. (2012): Understanding individual compassion in organizations: The role of appraisals and psychological flexibility. Academy of Management Review, 37(4), 524–46.
• Lilius, J.M., Kanov, J, Dutton, J.E., Worline, M.C., & Maitlis, S. (2011): Compassion revealed: What we know about compassion at work (and where we need to know more), in K. Cameron & G. Spreitzer (Eds.): The Oxford Handbook of Positive Organizational Scholarship. New York: Oxford University Press.
• Dutton, J. E., Workman, K. M., & Hardin, A. E. (2014): Compassion at work. Annual Reviews of Organizational Psychology and Organizational Behaviour, 1(1), 277-304.
• West, M., Eckert, R., Collins, B., & Chowla, R. (2017): Caring to change. How compassionate leadership can stimulate innovation in health care. London, UK: The King’s Fund.
• West, M. A. & Chowla, R. (2017): Compassionate leadership for compassionate health care. In Gilbert, P. (ed.): Compassion: Concepts, Research and Applications. (pp. 237-257). London: Routledge.