Team Leader

Workbook:

Leading to

quality

Positive and
Engaging
Performance
Management

Leading to

quality

Contents
Page
Section 1:

Introduction

Section 2:

What have we learnt from the Leading to Quality data?

Section 3:

Good Recruitment

Section 4:

Clarifying Performance Standards, Roles and Responsibilities

Section 5

Being Accessible and Acting as a Role Model

11

Section 6:

Creating a Culture of Psychological Safety

15

Section 7:

Genuine Commitment to Development and Performance

Improvement

19

Section 8:

Knowing Your Team

26

Section 9:

Giving Regular Feedback

28

References

Leading to Quality 2013 All rights reserved

32

Section 1: Introduction
Definition
This workbook is about leadership behaviours that strengthen an individuals ability to
manage performance in the team. It helps leaders to demonstrate to colleagues how their
individual contribution to the team is critical to its effectiveness in delivering the highest
quality service to service users and, as such, it is about celebrating good performance and
managing unsatisfactory performance so that it does not continue. It proposes ways of
combining clarity of expectations of performance standards, and attempting to engage the
individual in finding a solution to such problems, to increase ownership and responsibility for
future actions.
All trusts will have their own formal performance management policies and procedures. It is
not the aim of the workbook go into any depth about the formal/procedural management of
performance, as this information will be locally determined. This workbook is more focused
on creating a culture in which employee performance is managed positively within the team,
through looking at the leadership behaviours that enable this to happen.
Background
Armstrong and Baron define performance management as a process which contributes to
the effective management of individuals and teams in order to achieve high levels of
organisational performance. As such, it establishes shared understanding about what is to
be achieved and an approach to leading and developing people which will ensure that it is
achieved. They go on to say that it is a strategy which relates to every activity of the
organisation set in the context of its human resource policies, culture, style and
communications systems. The nature of the strategy depends on the organisational context
and can vary from organisation to organisation (Armstrong and Baron, 2004).
Effective performance management is essential to providing good quality care. The most
recent expression of the importance of this is evident from the report of the Francis Inquiry,
which examined the failures at Mid Staffordshire NHS Foundation Trust that led to
catastrophic consequences for users of the service (published February 2013).
Performance management is a vast and complex area of organisational management, with
large volumes written on it. It is not possible to focus on all elements of performance
management within this workbook. As such, this workbook, as mentioned above, will focus
on the leadership behaviours of the team lead that promote the positive management of
performance within individuals and their teams to reduce the risk of poor performance.
Contents of the workbook
The workbook begins by outlining the main findings from the Leading to Quality research
about performance management. These findings are also integrated throughout the
workbook.
The workbook is split into areas that contribute to positive and engaging performance
management; Figure 1 illustrates these areas.
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Page 1

Developmental Activities
The workbook comprises a number of Development Activities, which are designed to be
practical and helpful.
The development activities include a range of suggested exercises which adopt various
tools and techniques to enable you as a leader to Reflect on the current situation and
compare it to what you want to achieve. The next section suggests a number of activities
that you could use to create a plan for taking Action.
Finally, there are suggestions as to how you can Monitor the progress of your
development activities and evaluate the impact that you are having. It is hoped that doing so
will enable you to sustain the behaviours and practices that will help you strengthen your
leadership effectiveness.

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Section 2: What have we learnt from the Leading to Quality data?

Case study findings
Elements of positive and engaging performance management were consistent throughout
the Best Practice Case Studies and the findings are discussed throughout this workbook. In
essence, the team leads (TLs) managed performance through:

Setting direction

Role modelling appropriate behaviours

Supporting staff to improve performance

Having the positive relationships with staff and interpersonal skills to deliver
developmental feedback

Recognising good performance and appreciating staff efforts

Supporting a development and improvement culture within the team, including

prioritising team and individual development

TLs, to a greater or lesser extent, were willing to manage performance within the team. On
the whole, TLs were proactive at managing performance and were not afraid to have the
difficult conversations this requires.
It was clear from the interviews that the TLs ability and willingness to manage performance
in a timely and effective manner had a positive impact on the teams because it:

Promoted respect, confidence and reassurance in the TL because, as one of the team
members explained, you need to have confidence that managers will deal with things;

Promoted a sense of trust because TLs are considered to be open and honest, meaning
team members know where they stand;

Meant there were clear standards of acceptable behaviour within the team, which
promotes positive team functioning and positive service user experiences.

Quantitative findings - findings from the EngagingTeams360

Team members sharing knowledge and learning from each other was found to be
important for an improvement culture within teams.
Having clear roles and responsibilities was important for a focus on quality, improvement
and well-being at work.
Supporting a development culture within teams was important for improvement.

These areas of team functioning are covered within this workbook.

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Section 3: Good Recruitment

It makes sense that positive performance within teams will start with ensuring that people
recruited to teams have the desired knowledge, skills, attitude and values to do their job.
Good recruitment was one of the key findings from the Leading to Quality Best Practice
Case Studies. It was also one of the recommendations from the Francis Inquiry (2013),
where it was advocated that assessing candidates values, attitudes and behaviours towards
the well-being of patients and their basic care needs should be assessed at recruitment.
The increasing recognition that staff values and attitudes can have a major impact on quality
of care and the service user experience has led some organisations to develop a system to
formally assess these during the recruitment process. For example, Oxford University
Hospitals NHS Trust has embarked on a project designed to ensure that the Trusts values
are demonstrated in day-to-day care by designing a value-based interviewing initiative. This
initiative allows them to explore applicants work behaviours, rooted in organisational values
and behaviours. By incorporating this information alongside applicants skills, competencies
and experience, employers obtain a broader and more comprehensive view of the
applicants. The Trust also recognises that recruiting people based on their values ensures a
greater fit between employees and the organisation and, therefore, enhances staff
engagement.
Similarly, York Teaching Hospitals Trust have introduced values based recruitment for health
care assistants, prioritising values over experience, in order to improve the patient
experience. They feel that this is having positive benefits for patients (improved quality
indicators and fewer complaints), employees (happier staff) and the organisation (reduced
sickness and increased retention).
Recruitment is an important area of HR practice and how a team leader approaches the
process will largely be governed by local HR policies and procedures; as such, it is largely
beyond the scope of this workbook. Given the importance of recruitment, it is advisable that
team leads reflect and, if necessary, act on and monitor their recruitment processes.
Reflect
Thinking about your team, do all team members have the knowledge, skills,
behaviours and values that are consistent with the teams (and organisations)
philosophy and approach?

If yes, why is this the case? Is part of this due to recruitment practices? What
do you do to ensure that new recruits have the right fit for the job, team and
organisation?

If no, do you feel there is one area that stands out as being lacking in these
staff? (e.g. knowledge, skills, behaviours or values?)
Did the recruitment process assess all relevant knowledge, skills, behaviours
and values? It might be that more development needs to be done in one of
these areas?

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If no, do you think you assessed all the knowledge, skills, behaviours or
values relevant to the job but then once appointed the applicant failed to
demonstrate these in the workplace?

Essentially, if you have been responsible for the recruitment of staff that you feel fail to
demonstrate the necessary knowledge, skills, behaviours or values once in post then action
should be taken to improve the recruitment process. This leads on to the next section.

Act

The next time you are recruiting someone to the team, think about what is important
in the role with regards to knowledge, skills, behaviours and values.

Think about how you could assess all these elements, considering a range of options
such as job-specific and critical incident scenarios pertaining to the areas that you
have identified as important.

The next time you are recruiting a person to the team seek advice from HR. They are
very experienced in this area and will be able to offer helpful suggestions. It is also
important to liaise with HR because recruitment processes are generally very much
controlled by HR policies and procedures to ensure the process is fair, equitable and
procedurally correct.

Considering the vital importance of good recruitment, it might be useful to undertake

some training and development in this area. Contact HR to see if there are any
opportunities available for this or the possibility of some coaching.

Also consider whether there are any colleagues you can speak to within the
organisation to learn from their practice.

Monitor

Monitor the success of attempts to enhance recruitment by looking at the

performance of those you have recruited into the team.

Does their performance reflect the potential identified at the recruitment stage? If not,
consider what other changes can be made to the recruitment process.

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Section 4: Clarifying Performance Standards, Roles and

Responsibilities
A clear theme from the performance management literature is that staff need clarification of
performance standards, roles and responsibilities, objectives and priorities. Part of this is
ensuring that staff have a clear understanding of the part they play in achieving the teams
and the organisations goals (NHS Staff Council, 2010).
The literature notes that while most staff in the NHS work in teams, less than 50% of these
teams are authentic or genuine as opposed to pseudo teams. Authentic teams are
characterised by clear goals, well-defined roles and responsibilities, working
independently, and having regular meetings (updating). This enables the maximisation
of the resources within the team - in the form of the members knowledge, skills, experience
and expertise and reduces the inefficient duplication of effort.
The actions of genuine teams are associated with high quality healthcare. The actions of
pseudo teams have been shown to result in high levels of errors, accidents and poor staff
wellbeing at work. In other words, to result in incompetent, or even dangerous behaviour,
with important consequences for quality of healthcare, and team confidence.
The general research literature on workplace factors that impact on individuals levels of
work-related stress, indicate that, combined with autonomy, clarity of responsibilities and
objectives play a major role in reducing stress. Analysis of the 590 team members
ratings of roles & responsibilities in the Leading to Quality research, corroborated these
findings. That is, behaviours relating to this scale significantly predicted team members
wellbeing.
Not only did this dimension of team working predict wellbeing of team members, it also
significantly predicted a culture of improvement, and a focus on quality.
The Role of the Team Leader/Line Manager
Team leaders play a critical role in ensuring that standards, objectives, roles and
responsibilities are discussed and agreed with staff. The standard of work should be
explained, with staff being clear about what is expected of them. Similarly, job descriptions
should accurately describe what is expected of staff with regards to roles and
responsibilities, knowledge, skills, behaviours, attitudes and values. Team leaders need to
communicate these effectively and check that they are understood it is not enough to
present them in a written document and accept that as sufficient to inform staff of what is
expected of them. Standards, objectives, roles and responsibilities should be communicated
once people are new in post through induction and conversations with line managers.
Following this, clinical/managerial supervision, performance appraisals and team
development opportunities provide team leaders with the forums to communicate and
discuss these in a structured manner. Being accessible to staff generally and acting as a role
model gives team leaders the opportunity to do this more informally. These areas are
discussed in greater depth in other areas of this workbook.
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Two-Way Conversation
When having conversations about standards, objectives, roles and responsibilities, these
need to be two-way conversations i.e. a discussion between team leaders and
individuals/teams, rather than leaders telling and individuals/teams listening. For example,
team leaders need to involve staff in setting their objectives, rather than telling them what
these are. This will lead to objectives that are more rewarding and motivating for staff,
leading to greater ownership of the objectives, greater goal accomplishment and staff
engagement.
The discussion on setting objectives should also focus on what support (e.g. learning,
development, resources) are required to help staff achieve their objectives.
When agreeing objectives, it is important it is important that they are SMARTIES:
S
Specific
M

Measurable

Achievable/Attainable

Relevant (i.e., does it relate directly to the overall goals of the service, team, and/or
organisation?)

Time scale

In what way is it Intrinsically motivating to the person responsible for achieving it?
(encourage the individual to reflect on the benefits to that person of achieving the
goal)

Economic (i.e., Is it the best use of the individuals time, efforts, skills, other
resources required, etc., in relation to their other priorities?)

Celebrate success along the way (this encourages regular reflection and positive
reinforcement as the individual makes progress in achieving the goal)

Approaching objectives using SMARTIES helps provide a framework for reviewing progress
towards achieving objectives.
Reflect

Ask team members to complete the short diagnostic questionnaire below. It is

probably advisable to assure individuals that individuals ratings will remain
anonymous maybe have a box in the office for people to put their completed forms
in.

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Strongly
agree

Agree

Disagree

Strongly
disagree

I am clear about the teams goals & sense of

direction
I am clear about the standards I need to
achieve with regards to:
Knowledge
Skills
Attitudes
Behaviours
Values
I am clear about my roles & responsibilities
The team has clearly defined objectives that
they are committed to
The team has measurable objectives
I have clearly defined objectives that I am
committed to
I have measurable objectives
I know how my objectives relate to the teams
success, and to delivering the highest quality
of care
Collate the responses and identify where the main areas of lack of clarity are. It is likely the
exercise will provide invaluable feedback to the team lead, in relation to how they can
strengthen their leadership role and support the team
Act
At the next team meeting/opportunity for team development, facilitate a team discussion on
the findings of the questionnaire.

If an area for development emerged in relation to the teams clarity of understanding

of the teams goals and sense of direction and clarity of acceptable standards of
behaviour, attitudes and values, this is a fundamental responsibility of the team
lead. The Striving for Quality workbook in this series focuses specifically on this are so
it would be advisable to undertake the activities contained within this workbook.

There are other aspects of roles & responsibilities that might need to be addressed,
which can be greater understood through the following activities.

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Having identified a specific aspect of the questionnaire that would benefit most, if not all
members of the team, ask people to work in small groups to discuss (1) their particular
experience in relation to the topic; (2) what effect it has on them; and (3) what they would
find helpful support from the team, a colleague, or the team lead, if s/he is their line
manager. Some of the issues might be of a personal nature, and some might relate to
the whole team. Emphasise that the discussion should not use the names of individuals,
if criticism is involved, and that the focus is on how to move forward, rather than to spend
time criticising the past or current situation.

Ask each group to record what emerges from the discussions, and to prepare to
summarise back to the whole team those points/issues that are appropriate to share with
the team without naming people together with suggestions for addressing the current
situation.

Share the feedback in a plenary session, including suggestions that were identified in the
small groups, as this might stimulate thinking across the team.

Discuss the themes with the team, and identify specific topics/issues worth working on,
and transforming into a plan of action.

If there is a general sense, for example, that there is a lack of clarity around individual
standards, objectives, roles and responsibilities, it is advisable that the team lead
explores this with team members individually during supervision, or another one-to-one
meeting. It is important that team members feel comfortable to have an open discussion
about this with the team lead (see section 6).

During a one-to-one meeting between a manager and a member of staff, it would be

useful for the team lead to have supplementary materials, including the job description
for the person concerned and the mission, vision and values of the team/organisation. It
may be that it emerges that this documentation is not very informative, which is an action
for the manager to consider.

When clarifying and discussing objectives, ensure that they are SMARTIES.

Work towards an agreed action plan, and a timescale. If relevant, and possible at the
time, identify individual responsibilities, ensuring that the people involved feel confident
and clear about them.

Monitor

Each team meeting should include a review of progress on team goals, and an
opportunity for each team member to feedback their progress, and any
concerns/challenges they have experienced, or are experiencing. Take time as a team to
support the individual.

Team goals and priorities change, as environmental and contextual factors change, so
expect there to be regular reviews of team members understanding of the vision and
goals, and encourage proactivity in the team, in relation to challenging whether goals,
practices, or responsibilities are still the most appropriate for maintaining, and improving
quality of services offered by the team.

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Individual goals should be reviewed regularly (informally on an on-going basis and

formally on a quarterly basis); clinical supervision/managerial supervision and the
performance appraisal process provide good opportunities for the review of individual
goals. Your trust will have a formal system in place for the performance review and
appraisal process, which you will be expected to adhere to.

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Section 5 Being Accessible and Acting as a Role Model

Being accessible to staff and acting as a role model are critical elements of leadership
behaviour that contribute to positive performance management. This, again, was one of the
key findings from the Francis Inquiry, where it was recommended that nurse managers:

Should not be office-bound

Should make themselves visible to patients and staff alike, and be available to discuss
concerns with all, including relatives.

Should work alongside staff as a role model and mentor, developing clinical
competencies and leadership skills within the team.

Being accessible and acting as a role model were key themes to emerge from the Leading to
Quality Best Practice Case Studies. With regards to being accessible, team leaders were
approachable and made themselves available to staff, helping them to problem solve and
offering advice. The following comments illustrate this supportive approach:
His/her door is always open. If s/hes not got the time s/he will make time. S/he will
always listen.
Managers are under more and more pressure but s/he is always there for you. S/he
will drop anything. S/he will problem solve with you.
The accessibility and physical presence of team leaders is also important because it gives
team leads the opportunity to get to know their staff, including strengths and areas for
development.
With regards to acting as a role model, the best practice case study team leaders had a
hands-on leadership approach and were integrated within the team, giving them the
opportunity to act as a role model for team members. This hands-on leadership approach
was very important for credibility and respect from the team. The team leads would role
model clinical skills and also passion and determination, a strong work ethic and the type of
behaviours that nurtured a supportive culture within the team. The following quotes illustrate
the importance of role modelling positive behaviours:
S/he is excellent. Very knowledgeable. S/he has a good grounding in EI and you know
what s/he says has substance to it.
If no ones willing to do anything s/hell do it. S/hes very persistent, very proactive and
acts as a role model.
His/her engagement skills are brilliant with clients.
S/he has credibility and respect through working hard, acting as a role model, and
practicing what s/he preaches.

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The importance of being accessible and approachable

The importance of being accessible and approachable cannot be underestimated. Being in
regular contact with staff and making yourself available to staff on an on-going basis has
many advantages including:

Getting to know staff and the team, including strengths and areas for development

Provides the opportunity to give feedback to individuals and the team on an on-going
basis

Knowing what is going on in the ward/team including the standard of care being
delivered, and the difficulties/frustrations being experienced by the team and team
members

Creates a sense that you are part of the team/belong to the team

Creates a sense that you are genuinely concerned about the well-being of team
members at work

Increases a sense of psychological safety as, when done appropriately, it is likely to

build-up a sense of trust in the team

Approachable for support and advice people feel they can readily turn to you, which
leads to improvement and the avoidance of mistakes

You will be more likely to spot when someone needs support and can offer this when
required.

The Importance of acting as a role model

Acting as a role model is critical because it gives the team leader the opportunity to:

Role model excellence, at best, and the minimum required standards, at least, of
behaviour, skills, knowledge and standards in relation to service user care

Reinforces the valued behaviours in relation to team working

Gain credibility and respect from team members.

Reflect

Think about the extent to which you are visible to staff? Do you sit within the same
office, or do you work in a separate office?

If you work in a separate office, do you have your door open most of the time or do
you predominantly have the door closed. Thinking about the last fortnight, write a list
of the occasions in which a member of your team has called in to your office,
unannounced, to talk about work matters of concern to her/him. If this does not
occur can you identify reasons why colleagues do not call in to your office in this
way? Are there obvious barriers?

Do you consider that a member of staff at any level could approach you, without
feeling intimidated? Do they do this?

How often to you work alongside the team/members of the team?

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Is this enough to demonstrate the standards of care you expect from staff?

Is this enough to get to know the quality of your teams work?

When you work alongside staff, do you take the opportunity to give feedback on their
performance, both positive and negative?

Are there regular formal opportunities for you to meet with the team so problems and
difficulties can be discussed (e.g. team meetings)

Do you create the opportunities to have informal social sessions so that you have
the opportunity to talk informally to staff so that you develop a comfortable
relationship?

Reflect on the last month and if you feel that you have not been accessible and
approachable to staff, take the decision to rectify this;

Unless necessary, try to work with your office door open, making sure staff know you
are available to discuss issues or problems;

When staff do approach you, communicate to them verbally and non-verbally that
you are available for a conversation/discussion;

Make sure that when staff do approach you that you give them your full attention dont be distracted by checking emails or checking your mobile phone.

If you do need to concentrate and have to work with the door closed, let the team
know you will be doing this in advance, with an explanation as to why try to keep
these times to a minimum

Throughout the day, join the team in the communal areas of the workplace (e.g. in
the open office or on the ward) to make sure things are running smoothly and that
you are happy with what you see;

When you are walking about and talking to staff, ask how they are feeling about their
work, if they are experiencing any frustrations or anticipating problems. Try to
empathise with them, acknowledge their efforts and achievements, invite them to ask
questions of you. Make a note for yourself of what you learned and reflect on it.

Consider incorporating opportunities to co-work with members of your team. For

example, if you work in a community setting, is it possible to spend a day with each
member of your team once every six months? This will give you the opportunity to
role model your expectations of staff

Consider joining staff on lunch breaks/tea breaks so that you get the opportunity to
talk informal setting, which should help to develop a comfortable relationship and
also create a sense that you are part of the team.

Act

Monitor

Keep a diary of which colleagues come to talk to you, how frequently, and about what
issues. Identify those individuals who still do not come and talk, and, if you judge it

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appropriate, invite them to come for an informal chat, or better still drop in and see
them in their workplace.

Ask a colleague whom you trust and respect to observe your behaviour, and let you
know of any changes that they notice in yourself or in others in your team.

Evaluate the quantity and the quality of the additional information that you have
gained as a result of being out of your office. Determine whether to adjust the
amount of time you spend, and/or the kind of questions that you ask.

Ask yourself what insights you have gained (a) into the day-to-day and long-term
running of your department or organisation, and (b) into the thoughts and feelings of
your staff, and what motivates them.

Monitor the contributions of staff/colleagues to sharing information at

team/department meetings. Is anyone not providing enough information? If so,
reflect on why this might be the case. It may be your manner. If you are not sure of
the reason, consider discussing the matter with them.

Listen to what they say carefully; noticing not just the information they provide, but
also they way in which they say it. Do you get any sense of concern, irritation,
frustration or anxiety? Can you respond in a way that reduces the negative aspects,
and perhaps increase the positive ones?

Analyse any important decisions that you have taken, and evaluate the outcome(s).

Consider finding a mentor with whom you can meet regularly (e.g. 3 monthly) to
review progress.

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Section 6: Creating a Culture of Psychological Safety

Positive performance management in teams is enhanced by a trusting and supportive
culture that exists within the team, which creates a sense of psychological safety in team
members (Edmondson, 2002). In psychologically safe environments, people believe that if
they make a mistake others will not criticise or think less of them for it. They also believe that
colleagues will not resent or penalise them for asking for help, information or feedback. A
psychologically safe culture leads to reflection and improvement. The leadership behaviour
of the team lead is critical to promoting this culture.
The Leading to Quality Best Practice Case Studies found that the leadership behaviours that
supported a psychological safe culture were ones in which leaders:

Were accessible and approachable to team members to seek support and advice
from (as discussed previously)

Promote a learning and development culture within the team in which asking for help
and support is acceptable, and providing help and support is the norm;

Promoting a culture where people are willing to share ideas freely;

Demonstrated genuine concern for the welfare and wellbeing of team members;

Had a no blame culture so that people would feel comfortable to admit mistakes;

Were prepared to admit their own mistakes and areas for development, reflecting on
this with their team.

When someone makes a mistake it is important to1:

Identify the cause (e.g., lack of motivation, or lack of clear understanding of the
objective, or lack of training and experience, or lack of support, etc.), and try to
rectify the situation so that it does not re-occur;

Separate the intentions of the person to perform effectively, from the mistake that
was made; praise the intention, but encourage the individual to reflect on their
behaviour and its consequence, such that they can identify what they could have
done differently in retrospect; provide guidance if needed;

Clarify with the individual how they will behave if a similar situation arises in the
future;

Accept, if appropriate, that some of the responsibility for the mistake lies with the
organisation, or with the line manager (who may be yourself), or factors out of
their control;

ensure that any lessons for the organisation are implemented as soon as is
possible;

consider what you might learn from the experience that would increase your
effectiveness.

There will be a formal policy on dealing with mistakes and poor performance you will need to
adhere to this
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It is crucial that the manner in which mistakes/misjudgements are dealt with does not have
the effect of reducing the individuals confidence, and/or of affecting their motivation, and
that of their colleagues. If this were the case, this could negatively affect their level of
engagement, and future performance, and their willingness to be proactive in thinking of
ways in which they, and/or their team, can improve effectiveness. Clearly some serious
mistakes will need to be dealt with by utilising trust policies and procedures for dealing with
such events (e.g. serious untoward incidents), which are important to adhere to.
The activities in this section of the workbook focuses on creating the psychologically safe
culture in which there is a just culture so that mistakes or misjudgements can be admitted
and learned from, where ideas are encouraged and freely shared, and where people feel
safe to ask for help and support.
Inform

How reflective are people in your team on their own performance or on the performance
of the team?

How proactive are each of your staff in suggesting ways in which they/the team can
improve the effectiveness of what they do?

Try to think of a suggestion from a member of staff that may have seemed a bit off the
wall what was your response to that suggestion/what was the teams response to that
suggestion?

Thinking about events over the last 6 months - have members of your team readily
admitted to you when they have made a mistake or a misjudgement?

Do you feel you find out about mistakes/misjudgements (from, for example, service users
or other members of staff) rather than from the staff responsible?

What is your response when people have made a mistake/misjudgement?

How often do you reflect on your own performance with staff? Do you openly admit when
you have made mistakes/misjudgements?

It is not enough to reflect on your own behaviour with regards to psychological safety, you
need to seek input from your team members. Ask your team to complete the following short
questionnaire so that you gain more awareness in this area. It is a good idea to ask people
to complete it anonymously by providing a box for them to put their completed questionnaire
into.
Psychological Safety for Performance Improvement
Score on a scale of 1-5, with 1 being not at all and 5 being very much so
The culture of this team makes me feel
Comfortable reflecting on my own performance
Safe to admit a lack of knowledge and expertise

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Comfortable suggesting ways in which I can improve my performance

Comfortable reflecting on the performance of the team
Comfortable suggesting ways in which the teams performance could be
improved
My suggestions for improvement are taken on board
Able to ask for help and support
Able to admit when things are getting on top of me, and Im losing a sense of
being able to cope with a particular challenge, or my job
Able to express my anxieties and concerns
Able to admit mistakes/misjudgements, without being ridiculed
Mistakes are learnt from to minimise the chance of them happening again

Act

Collate the responses and have a team discussion, ideally with an independent
facilitator. It is important that everyone gets a say and that no one person/group
dominates.

Being sensitive and mindful of the general feeling about psychological safety in the team,
as represented by the team members scores, decide whether it would be better to work
a whole team, or whether it would be more productive to break into small groups to
discuss a specific theme, or combination of themes, in relation to how the team could
strengthen a culture of safety. That is, focus on a future desirable state, rather than on
past negative aspects of culture.

Before doing so, ask the whole team to identify the principles (ground rules) by which the
discussion should take place. For example, that personalised criticism of an individual is
not acceptable; that the aim is to identify how the team will function from now on.

Invite members of the team to reflect on the collated team scores for the team, and to
comment for example, as to whether there are any surprises.

Working as a team, identify themes that appear to be reflected in the way in which
members have scored the questionnaire, ensuring that the focus at this stage is in trying
to describe the data, and not to make evaluative or judgemental comments.

Ensure that the team does not only focus on potentially negative areas at the expense of
recognising where there are areas of positive feedback for the team

If you were working in sub-groups, come together as the whole team, and report back to
the group, (1) the rationale behind your action plan the issues that it set out to address,
(2) the action plan itself, and (3) the criteria for judging a successful outcome.

Invite questions and comment from other team members.

After each of the presentations, identify any themes that emerge, and as a whole group,
reflect on the potential value of each of the action plans proposed. Always include

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reference to the ultimate purpose of the exercise, which is to increase the effectiveness
of the team in delivering the highest quality of care to service users and carers.

Agree your group action plan. Ensure that all members agree the values, principles,
behaviours, that will form the basis on how you intend to work together (and perhaps
with other teams) for the future. Pay particular attention to personal/inter-personal versus
systemic factors, and to a combination of both.

Develop and agree a team contract of how each member will accept personal
responsibility for supporting the strengthening of the teams future effectiveness.

Agree how you intend to address situations that threaten to affect negatively a culture of
psychological safety in the team.

It is important that as a team, you also consider the criteria that could be used to judge
the success of your action. Make sure that these are as specific as possible and stated
in behavioural terms. For example, rather than agreeing that: In team meetings, we
shall be respectful of each others contributions, it might be more helpful to state more
explicitly, that we shall listen respectfully to colleagues contributions, not interrupt each
other; and, if we do disagree, not phrase our remarks in personally critical terms, but
relate them to ideas.

Consider asking members to volunteer to champion certain aspects of how the team
creates a psychologically safe environment for each other, and for any other individuals
or groups with whom you work, and to feedback observations (including, importantly, the
positive ones) at the end of meetings, or other relevant situations.

Monitor

Once a whole team action plan has been agreed, agree criteria (including a time scale)
for achieving each of the agreed actions.

Consider at the end of each team meeting (and on a one to one level during
supervision), spending some time reviewing how effectively you worked as a team, and
what went well/better; what you have learned as a team about how to work more
effectively; identify what the team could do differently at the next meeting.

Celebrate success, even small ones, as you increase the teams effectiveness in
creating a culture of psychological safety, and remember to identify the benefits

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Section 7: Genuine Commitment to Development and Performance

Improvement
It is crucial that team leaders display a genuine commitment to development and
performance improvement at the individual and team level through making opportunities
available for both.
Importance of one-to-one development opportunities
A clear finding from the Leading to Quality Best Practice Case Studies was that formal
elements of the performance management process were embraced and valued, such as the
performance appraisal process and the clinical supervision/management supervision
process. Team leaders and team members found these activities to be extremely useful.
Whilst supervision is a requirement for most teams, there can be a tendency for some to
regard it as going through the hoops, which was certainly not the case for the case study
teams. The case study teams found supervision an excellent opportunity for reflection,
problem solving, and an opportunity to give and receive feedback.
Importance of team meetings
Another of the key findings form the Leading to Quality study was that there were regular
opportunities made available for team development which were prioritised and valued by the
teams. For some teams these were weekly meetings, whereas for others they were twice
weekly, or even daily.
During the team meetings individual service users were discussed, with everyone becoming
aware of what was happening for each service user. These meetings were an opportunity for
the team to actively engage with each other and the teams work by evaluating progress,
sharing ideas, problem solving and planning for the future. They provided a forum for all
disciplines to work together and to provide their specialist knowledge and experience. They
were considered to be very useful from a positive risk taking perspective as it gave team
members a sense of shared decision making and shared responsibility, rather than one
person being solely responsible. These team meetings were considered to be very beneficial
for a positive service user experience. The value of team meetings is well established in the
literature on team working, with a caveat that they are well structured and well managed,
with their usefulness and effectiveness regularly reviewed (West et al, 2012).

Striving for quality

There was a sense that teams were striving to be the best they could be for the benefit of
service users. This commitment to improvement for service users helps team leaders frame
performance management in a positive manner, with there being a clear goal that all staff
are committed to. Recent research found that the framing of performance management was
important in determining how it is accepted by staff (Haines and St-Onge, 2012), it would
makes sense that performance management with the goal of improved service user care
should be accepted by most people working in the NHS.

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Having regular opportunities for development at the individual and team level gives team
leads the opportunity to:

Reinforce the vision, mission and philosophy of the team;

Reinforce performance standards, roles

performance objectives (discussed below);

Celebrate good performance;

Manage unsatisfactory performance;

Get to know staff in greater depth, including their strengths and areas for
development, including the identification of training needs and areas where extra
support is required;

Understand in depth the care plan and progress for each service user, providing
them with the knowledge and opportunity to intervene if necessary.

and

responsibilities,

and

discuss

Inform
There are three main areas in which the team leader should inform themselves about their
teams and their own attitudes and perceptions:
1. Attitudes towards team meetings and their perceived effectiveness
2. Attitudes towards clinical/managerial supervision and its perceived effectiveness
3. Attitudes towards the performance review process and its perceived effectiveness
Thinking about these three areas, for each one think about how your team approaches them:

Are they enthusiastic, or is there a level of reluctance in their participation? Is there a

sense that people are just going through the motions?

Are you enthusiastic about formal development opportunities, or do you feel that time
could be better spent?

Do you and the team do the level of preparation required for these activities?

Are action plans made as a result of meetings and reviews? Are those actions
agreed followed up by the relevant parties? Are team members held to account for
completing actions?

Is the team clear about how these activities contribute to the team goals and
improving the quality of service?

Do you as the team leader feel that you know enough about your staff and the team,
including strengths, areas for development, and aspirations?

Do you as the team leader feel that you know enough about what is going on with the
teams caseload?

If you are in doubt about the effectiveness of your team meetings, ask a trusted
colleague that you know to be effective in such areas if you can observe how they
conduct team meetings.

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Ask if the same trusted colleague can observe one of your team meetings and offer
feedback (with consent from the team, of course).

Act Team meetings

If, following your reflection you feel that there are areas for development with regards to the
three areas, consider how this can be acted on.
With regards to team meetings:
Effective Team Meetings for Performance Improvement

Communicate
the importance
and goals of
team meetings

Make sure you communicate the need for team meetings positively and
why they are time well spent. It is highly likely that staff will feel they dont
have the time to attend due to clinical priorities. However, conducted well,
team meetings will support staff to meet these clinical priorities.

As part of this, reiterate how team meetings contribute to high quality

care/the goals of the team.

The purpose and goal of the meeting should be reiterated at the start of
the meeting

Prioritise team
meetings

Make sure you stick to the agreed time and date, showing that you
prioritise this activity and that it is important to you; Ensure that other staff
prioritise these meetings

Well structured

Ensure that the meetings have a clear and realistic agenda, and that the
meetings are chaired well in order to get through the agenda in the
agreed duration of the meeting

Ground rules

It is important to discuss the ground rules for meetings so that there are
acceptable levels of behaviour. These rules could include things such as
turning mobile phones off or not talking over other staff when they are
talking. It is important that the person chairing the meeting reinforces
these ground rules

Participation in
team meetings

Observe participation in the meetings with regards to who speaks too

much and who never or rarely speaks. The table below outlines the
different types of behaviour you may encounter in team meetings and how
you overcome these

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Actions

Ensure that actions from team meetings are recorded and allocated to an
individual/group so that they are owned. They should also be time
specific. Actions should be followed up at the next team meeting. Ideally
actions should be written down and sent to all the team following the
meeting.

Suggestions for
improvement

A consistent part of the agenda for team meetings should be suggestions

for improvement. These should be actioned (as above) and followed-up at
the next meeting.

Support
required

It is also useful to have an item on the agenda about the support team
members require to fulfil their role; again, where necessary, this should be
actioned.

Celebrating
success

Another part of the team agenda could be celebrating success, where the
team lead or other members of the team recognise and celebrate
success.

Responding to Different Types of Behaviour in Team Meetings

Silent, Shy, Inhibited

Know-all, Opinionated

Ask the person directly, "What do you think of that,

Chris?".

Give them a task to do, like writing on the flipchart.

Praise any contribution and thank them for the idea look for something positive to say about it.

Encourage other people to be assertive and stand up

to them.

Give each person in the team one minute to give

their ideas in turn.
Introduce a topic that you know is of interest to the
person.
Split into pairs and ensure the shy person is paired
with someone supportive, who is not overbearing.

Scornful or Puts Others Down

Low Motivation, Reluctant

Set clear ground rules, e.g. 'We want everyone to

have a say, but there's no point in just moaning - it's
got to be constructive'. One technique that can help
is to only allow a disagreement if something positive
is said first: "What I like about your idea is... however,
I'm not sure about ...".

Encourage and praise contributions.

Give them some responsibility.
Pair up the reluctant person with a friendly and
enthusiastic team member.

Confront the person immediately: "I don't think that's

a helpful attitude".
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 Praise people who do not put others down: "That's a

really helpful comment, thank you".

Too Dominant or Talkative

Joker - Inappropriate or Damaging Humour

Give everyone time to talk in turn.

Confront behaviour: "I think that has probably hurt

Pat's feelings".

Pair them up with people like themselves!

Discuss the use of jokes in the group; point out that

some people are more sensitive than others.

Act Performance Development Reviews (PDRs)

Performance appraisals and development reviews have the potential to be extremely
beneficial to staff, team leaders and the service. The purpose of PDRs is:

For line managers to acknowledge the success and progress of staff; and thank them
for their contribution.

To discuss areas for development;

To identify opportunities for development, including training;

To ensure job descriptions are up to date;

To review performance against SMARTIES objectives and to agree new objectives;

For staff to give feedback to their line manager about any issues or concerns relating
to work.

According to the NHS Staff Council, effective performance appraisal and staff development
contribute directly to improved patient outcomes, which is why regulators such as the Care
Quality Commission as well as the Department of Health regard it as so essential to ensure
that appraisal and development reviews take place (NHS Staff Council, 2010).
Your trust will have a formal system in place for the PDR process, including documentation,
which you will be expected to adhere to. This will also inform how often you undertake the
process.
However, having a policy and procedure is simply not enough to ensure the effectiveness of
the process. The NHS Staff Council suggest the following factors to increase the chance of
PDRs being effective:

The process is taken seriously and prioritised;

Both parties know and can articulate its purpose;

Both parties undertake the required preparation the appraisee should be given time
at work to be able to do this;

Time is devoted to it, even during severe operational pressures;

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The line manager has the information, skills and confidence to fulfil their
responsibilities in the process properly;

It is a dialogue rather than a form filling exercise;

The appraisee should be doing most of the talking, rather than the appraiser; to
encourage this the appraiser should ask open questions;

Positive elements of performance should be emphasised and celebrated;

It is not an isolated activity and is used to support a regular dialogue around

performance development and improvement and link the outcomes to the
organisations objectives

As such, there should be no surprises for the appraise during the process as they will
have had continual feedback in between formal appraisals.

Both parties deliver on the commitments involved to train, to develop and improve,
to perform.

If you feel that the PDR sessions are not as effective as they could be then you should act
on this by ensuring adherence to the principles above. If necessary, see what training is
available to help you with the process.
A very useful document to refer to in relation to conducting effective appraisals in the NHS
and incorporating the Knowledge Skills Framework is a document produced by the NHS
Staff Council Appraisals and the KSF made simple a practical guide (2010) (available to
download from:
http://www.nhsemployers.org/Aboutus/Publications/Documents/Appraisals%20and%20KSF
%20made%20simple.pdf).

ACT Effective Clinical Supervision

The importance of clinical supervision was supported by the Leading to Quality Best Practice
Case Study Studies/ It was considered to be essential for:

Improved patient safety and quality of care;

Supporting staff and, therefore, enhancing their levels of wellbeing;

Setting goals and objectives in relation to service user care, and in relation to staff
performance;

Giving staff the space to reflect on their own performance with an experienced
professional

Clinical supervision is a vast area, with no one model prevailing. It is highly likely that your
trust has a policy for conducting clinical supervision, which you will be required to adhere to.
However, as with PDRs, how you conduct the process is essential for how effective
supervision is. The same principles discussed in relation to PDR (above) should be taken
into consideration when undertaking supervision. Most of all, the process should be
supportive, facilitative and focused.

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As a line manager, you need to reinforce the importance of clinical supervision, make sure
that it is prioritised and that the time is made available. If you hear a member of your team
grumbling about having to do it, take this opportunity to reinforce the importance of the
activity.
If you feel you need to be more effective at delivering clinical supervision sessions, consider
undertaking some additional training and reading in the area.

Monitor

It is important for you to record and monitor your actions in relation to strengthening
the development and performance improvement culture within the team;

Set yourself some SMARTIES objectives (preferably with your line manager) and
review your progress towards these at specified time points.

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Section 8: Knowing Your Team

Several of the activities within this workbook have been geared to getting you to know your
staff better. Particular emphasis should be paid to the Being Accessible and Approachable
elements of the workbook. It should go without saying that in order to manage performance
in the team, it is essential that a team leader has a good understanding of their team
members.
Reflect

Think about each member of your team and reflect on how well you know them and their
strengths and areas for development it might help to complete the following diagnostic:
Topics

Person A

Person B

What are their major

strengths? (think of
examples)

How much opportunity

is there for them to use
these in their role? (1-10
scale)

What are their major

areas for development?

On a scale of 1 to 10,
how important is it for
them to work on this
area?
On a scale of 1 to 10
how engaged are they in
(a) their role; (b) team
working?

(a)

(b)

(a)

(b)

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ACT

If you have identified from the diagnostic that you have a lack of knowledge on team
members then it is important that you rectify this. Not knowing this information illustrates
that you are not engaging with your staff effectively.

It is recommended that you conduct all the activities within this workbook, especially in
relation to Being Accessible and Approachable, and Genuine Commitment to
Development and Improvement.

MONITOR

It is important for you to record and monitor your actions in relation to getting to know
your team;

Set yourself some SMARTIES objectives (preferably with your line manager) and review
your progress towards these at specified time points.

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Section 9: Giving Regular Feedback

Recognising Good Performance
The practice of employee recognition has deep roots in motivation theories. From the
perspective of such theories, employee recognition is considered as a reinforcement
contingency with the capacity to shape behaviour and improve performance. Recognising
good performance has traditionally been regarded in relation to monetary and career
development rewards. However, increasingly there is a realisation that social rewards (e.g.
acknowledgement in a team meeting) can be just as effective as and even more so than
monetary rewards (Gostick, 2003). The importance of recognising good performance is also
an integral part of an engaging leadership style (e.g. Alban-Metcalfe & Alimo-Metcalfe,
2010), with leaders praising their staff contribution having a motivating effect on staff.
Recognising good performance does not only serve to motivate staff, it is also a way of
reinforcing to teams and individuals the desired employee behaviours (Haines and St-Onge,
2012).
The recognition of good performance also allows for a smoother transition into difficult
conversations about unsatisfactory performance.
Recognising good performance was a clear theme to emerge from the Leading to Quality
Best Practice Case Studies. Team members felt their team lead appreciated their efforts at
work, which made the team feel valued and appreciated. The team lead demonstrated their
appreciation through regularly thanking team members for their hard work and commitment.
There are several ways in which good performance can be recognised. As indicated above,
these can be monetary and career development rewards, and social rewards. Whilst in the
NHS monetary and career development rewards are generally restricted to once a year and
within the confines of set pay scales, social rewards can be frequent and varied, including:

Everyday practices of saying thank you and appreciating staff efforts on a regular
basis;

A detailed acknowledgement of good practice during supervision and performance

appraisal discussions, based on examples;

A special mention at meetings;

A special endorsement in a trust newsletter (where relevant);

Entering a member staff into a Best Practice award, where relevant;

Recognising good practice in a practitioner journal, where relevant.

Inform

When did your boss last thank you for your efforts? What effect did it have?

If you feel you are not thanked for your efforts, what effect does that have?

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How have you shown your appreciation for the efforts and contributions of each of
your staff? How easy/comfortable do you find it to thank people, or express your
appreciation to them?

Think of the ways in which you show your appreciation to your staff are there any
that you have found to be particularly effective? Be mindful that some staff prefer
written and others verbal feedback.

What effect did showing your appreciation have on your staff? Do different staff
respond in different ways?

Act

Ensure that you communicate to your staff that you value the work they do, by
praising or thanking them for their efforts and contributions. It, perhaps, comes
naturally to do this when someone has had a major achievement. It is, however,
equally important to communicate this in relation to the day-to-day possibly
unexceptional, but just as essential contributions of colleagues/team members.

Over the next two weeks, thank each member of the team for their contribution and
see how they respond to this. Ensure that you convey your appreciation in a genuine
way. Try to give specific examples.

Where appropriate, try to give positive feedback to staff when other members of the
team are around this is likely to help boost a persons sense of satisfaction, and will
also reinforce to other team members the desirable behaviours. Make sure that you
do not consistently favour particular individuals when giving this feedback.

As mentioned in relation to team meetings, it might be an idea to have a regular

agenda item that celebrates the success of the team and/or individuals within it.

Explore opportunities available to celebrate success beyond the team such as:

A special endorsement in a trust newsletter

Entering a member staff into a practitioner award

Recognising good practice in a practitioner journal

Monitor

Observe and monitor the effect of recognising good performance on your staff;

Tailor your future actions towards individual staff members preferred means of
recognition;

If you feel the actions you have taken have not been effective, seek advice from a
mentor/trusted colleague on actions you can take to improve the situation.

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Giving Developmental Feedback

It is important that regular constructive developmental feedback is given to staff on an
ongoing basis, with managers being prepared to address poor performance in a timely
manner. Developmental feedback should be given with sensitivity and honesty. Feedback
should not be given in a way that undermines staff confidence and/or negatively affects their
motivation and engagement. Giving developmental feedback is an area that managers do
generally find difficult (Haines and St-Onge, 2012).

Armstrong and Baron (2004) outline some basic principles for giving good feedback:

Provide feedback on actual events

Describe, dont judge

Refer to specific behaviours rather than general feelings or impressions

Ask questions rather than make statements (e.g. why did this happen? On
reflection, is there anything you could have done differently?)

Enable people to work things out for themselves (How will you tackle this sort
of problem in the future? What actions can be taken to avoid a similar situation?)

If there are several performance problems, select key issues to focus on

developmental feedback on too many issues at a given time may have a
demotivating effect.

Focus on aspects of performance that the individual can improve

Show understanding of factors that have been beyond the control of the
individual concerned

An additional area of giving feedback not specifically mentioned by Armstrong

and Baron is that the person giving the feedback should ask what support is
required to help the person address the situation.

Reflect

How comfortable do you feel in giving developmental feedback?

How willing are you to give developmental feedback?

How often do you give developmental feedback?

Think of a time when you have been given developmental feedback on your own
performance? How was it approached and how did it impact on your confidence
and motivation? Did your performance improve as a result?

Think about a time when you have given developmental feedback to members of
your team. How did you approach it and what impact did it have?

Act

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Using the principles of giving effective feedback described above, plan how you are going to
give developmental feedback to a member of your team that is in need of this feedback.

How are you going to describe the problem without being judgemental?

What are the specific behaviours that you are giving feedback on?

What questions will you ask to facilitate an open discussion on the reasons for the
problem?

What questions will you ask to identify how to avoid the problem in the future?

What are the key performance issues to focus on? Make sure these are ones that
can be improved

Recognise the factors beyond the control of the individual

Ask what support they need to resolve the difficulties they are experiencing

Also consider the most appropriate time and place to be giving the feedback

Set a time to review performance on the issues discussed

When you have given the feedback, reflect on how you think it went and what could
be improved for the next time you give feedback.

Monitor

Observe and monitor the effect your feedback had on the persons motivation and
performance;

If you feel the actions you have taken have not been effective, seek advice from a
mentor/trusted colleague on actions you can take to improve the situation. It may be
that you require training in this area.

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References
Alban-Metcalfe, Jtte.& Alimo-Metcalfe, B. (2010). Integrative leadership, partnership
working, and wicked problems: A conceptual analysis. International Journal of Leadership
in Public Services, 6, 3, 3-13
Armstrong, M. and Baron, A. (2004) Managing performance: performance management in
action. London: Chartered Institute of Personnel and Development).
Edmondson, A. C. (2002). Managing the risk of learning: Psychological safety in work
teams. In M. West (Ed) International Handbook of Organizational Teamwork, London:
Blackwell.
Gostick, A. (2003), A Heros Welcome: Improving Culture with Noncash Awards and
Recognition, Workspan, 46, 7, 4447.
Haines, V. & St-Onge, S. (2012). Performance management effectiveness: practices or
context?. The International Journal of Human Resource Management, Vol. 23, 6.
The Mid Staffordshire NHS Foundation Trust Inquiry. Independent inquiry into the care
provided by Mid Staffordshire NHS Foundation Trust: January 2005 March 2009. Chaired
by Robert Francis QC
NHS Staff Council, (2010). Appraisals and the KSF made simple a practical guide
(available to download from:
http://www.nhsemployers.org/Aboutus/Publications/Documents/Appraisals%20and%20KSF
%20made%20simple.pdf).
West, M., Alimo-Metcalfe, B., Dawson, J., El Ansari, W., Glasby, J., Hardy G, et al. (2012)
Effectiveness of Multi-Professional Team Working (MPTW) in Mental Health Care. Final
report. NIHR Service Delivery and Organisation programme.

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