Identity prototypicality.

Identity prototypicality refers to when leaders represent what it means to be a member of the group [9, 13]. Specifically, it refers to not only how leaders represent the ‘average’ group member, but also how leaders represent what it means to be an ‘ideal’ group member [14, 15]. This appraisal of prototypicality comes from group members assessing whether leaders represent the values, behaviours, and goals that are normative of the social group [13].

Leaders who demonstrate prototypicality are perceived more positively than non-prototypical leaders. For example, leaders who demonstrate identity prototypicality tend to be rated as more effective [15, 16]. Ratings of leadership effectiveness were also found to drop less following leadership failure when leaders were perceived as prototypical [17, 18]. In addition, prototypical leaders facilitate greater support from followers to achieve group goals [19], including group members demonstrating greater endorsement and support for unfair leadership when these leaders are viewed as prototypical [20]. Finally, leaders perceived as prototypical group members facilitate greater feelings of trust from group members compared to non-prototypical leaders [19, 21]. This association was recently explored within an NHS hospital, where increased perceptions of leadership prototypicality were linked to increased reported trust in leaders to appropriately handle the COVID-19 situation [22].

Identity prototypicality not only contributes to positive appraisals of leadership but can also encourage followership and safe behaviour. For example, research exploring predictors of COVID-19 adherence has found significant associations between trust in leadership, or trust in government, and people’s willingness to adhere to COVID-19 restrictions imposed by government [23–25], where this trust in leadership can be facilitated by leaders demonstrating group prototypicality [19]. Thus, prototypical leadership within hospitals could be key to promoting staff adherence to safety guidance. Finally, the social identity approach to leadership highlights that leaders can be influential in guiding group behaviour through demonstrating group prototypical behaviours, which followers can look to when inferring how they are supposed to act [13]. Within the current context, leadership engaging in COVID-19 safety guidance could indicate both (a) leadership group membership and (b) how staff are supposed to act (by adhering to guidance). Thus, leaders who demonstrate identity prototypicality facilitate both positive appraisals of their leadership and followers’ engagement in behaviours important to the group.

Identity advancement.

Identity advancement refers to leaders being seen to be acting on behalf of and standing for the group [5, 9]. Identity advancement involves leadership promoting the values and goals of the group, as opposed to promoting outgroup goals and values [26], where leaders are seen to be getting things done for the benefit of the group as opposed to acting upon their self-interests [9].

Leaders who demonstrate identity advancement have also been found to be perceived more positively compared to leaders who do not. For example, leaders seen to be prioritising the group’s goals above their own (e.g., by sacrificing their time to advance the group) are rated as more effective by group members [27]. Similarly, leaders seen to be displaying group-oriented attitudes and behaviours are endorsed more than leaders who display self-orientated attitudes and behaviours [28]. Additionally, leaders who are perceived to be acting upon the goals and interests of the group are rated as more authentic leaders [29]. Finally, within the validation of identity leadership scales, significant associations were found between identity advancement and followers’ feelings of trust in leadership [21].

Similar to identity prototypicality, identity advancement results in both positive appraisals of leadership and routes to promoting followership and safe behaviour. First, as discussed with identity prototypicality, identity advancing leaders can facilitate greater feelings of trust from followers [21] which is associated with promoting adherence to COVID-19 safety guidance [24]. Further, leaders who promote the interests of the group above their own facilitate group members engaging in supportive behaviours towards that leader, including voting for these leaders [29] and supporting leaders’ policies [26].

Both identity prototypicality and identity advancement contribute to positive appraisals of leadership and facilitate followership and engagement in behaviours important to the group. Thus, within the NHS, identity leadership could be relevant to both positive evaluations of hospital leaders and increased adherence to COVID-19 safety measures.

Credibility strategies.

First, a broad variety of viewpoints were evaluated by including staff from different departments across two hospitals, including those in leadership positions. Second, peer debriefing was adopted wherein a staff working group associated with this project evaluated whether our findings were consistent with their understanding, alongside consultations with hospital management. Third, we adopted reflexivity by looking back on our theoretical assumptions and our positionality towards healthcare workers and their experiences throughout the pandemic.

Present leadership demonstrating prototypical group behaviours.

Staff positively appraised leaders who were present and engaged in the same prototypical tasks as frontline staff:

Our immediate line manager has been fairly visible. It’s kind of been doing what we’ve been doing. There’s not been any reluctance to go and get stuff done

(Extract 1, RE, hospital B)

After being asked about whether RE (extract 1) felt their relationship with leadership was a feeling of being ‘in it together’, RE highlights how their immediate line manager was seen to be on an equal level as themselves by doing the same prototypical tasks as frontline staff, where this leader demonstrated a willingness to share these responsibilities. This lack of reluctance to engage in frontline tasks is viewed by RE to demonstrate that the leader was one of the team. Within this conceptualisation, leaders who are present and perform the same prototypical tasks as staff are viewed more positively than leaders who are seen as absent or not engaging in the same work as staff.

This is also discussed by OC (extract 2) when asked about their own relationship with leadership at line manager and senior management levels, but OC further shows how leadership engaging in prototypical staff tasks was a signal of group membership. OC highlighted their own positive experience before moving on to discuss their perceptions of the relationship between frontline staff and leadership on other wards who were not present:

[Staff on other wards] mistrust was maybe ‘I’m feeling like a lamb to slaughter’ wasn’t really like directed at their line management say but sort of further up the chain or like hospital management, potentially even government. Yeah I think from what I understand most of their line management were like sticking right in as well and doing whatever they could too and were doing as much clinical work as they possibly could

(Extract 2, OC, hospital A)

OC discusses feelings of mistrust and abandonment being created by those higher in the leadership hierarchy, i.e., leaders who are non-present and distant. In contrast, OC views line managers who are seen to fully engage (‘sticking right in’) in frontline tasks as a positive and distinct group from upper management. By comparing how line managers and upper management engaged with staff, OC removes line managers from being responsible for feelings of mistrust towards leadership or abandonment from leadership. Instead, the presence and performance of shared tasks by leadership are antecedents to feeling part of a group with the leader, because they signal that those leaders are equal.

Non-present leadership lacking shared views.

In contrast to present leaders being seen as prototypical, more distant leaders were seen as not sharing the same views as frontline staff and therefore lacking prototypicality:

I think it very much felt like those on the ground versus those in the ivory towers… we’re the ones on the front line with PPE that didn’t work and other people [leaders] were, you know, complaining that people were going off sick with covid or similar

(Extract 3, AE, hospital B)

In extract 3, AE creates a category of non-present leadership. First, AE crafts a categorisation of non-present leadership as ‘other’ through describing them as being in the “ivory towers”, symbolising these leaders as further up the hierarchy with a lack of awareness of the issues faced by people lower in this hierarchy. Second, AE further categorises the group membership of these leaders by describing non-frontline staff as “other people”, attributing a category definition to those who are not present as outgroup compared to the ingroup of present frontline staff. In this conceptualisation, leaders are viewed as being distant not only physically, but distant from the experiences of frontline staff. The lack of understanding of the frontline staff experience AE perceives from leadership (through complaining about staff going off sick) is attributed to this distance and separation between frontline staff and leadership.

By being perceived as non-present, and therefore lacking an understanding of the challenges faced by frontline staff, any relational connection between hospital leadership and frontline staff is seen to be lacking. Thus, there are limited antecedents to shared social identity through leadership distance. Further, given staff feel there are barriers to adhering, such as a lack of working PPE, leaders who are not present and therefore lack an understanding of the views of frontline staff are seen as unlikely to update guidance to remove these barriers.

SA (extract 4) further exemplifies viewing non-present leaders as lacking shared views with frontline staff when discussing the ability to talk to leadership about the issues staff are facing:

With higher management it got a bit trickier just because obviously they are all working from home and not actually in the department and, you know, not actually seeing what we’re seeing on a daily basis so I think at times there was a bit of butting heads shall we say […] we’re not, you know, complaining for the sake of complaining. We are complaining because we cannot do our jobs […] when it reaches a point where you can’t actually do your job safely, that’s when you know we’ve really had to fight this

(Extract 4, SA, hospital A)

Leaders who are not present on the floor are seen as unable to recognise the challenges faced by frontline staff, where contrasting views of what challenges staff are facing results in clashes between frontline staff and leadership, contributing to an overall negative perception of leadership. Recognising others as ingroup members is, in part, attributed to seeing others as sharing the same goals and values as us [14]. In this example, non-present leaders are seen to have different viewpoints and expectations to frontline staff. This, in turn, contributes to a lack of shared social identity between frontline staff and leadership and limits the ability of staff to adhere to safety guidance by leaders not being there to listen and act.

Present leadership having shared experiences with frontline staff.

Non-present leadership also contributed to views of leaders having different experiences of the pandemic response:

I don’t think the challenges there [in the leader’s office block] is anything like they are in the ward setting in terms of space and distancing and numbers and even things like silly things that don’t really seem to affect him [leader] over there is like the temperature when you’re wearing the PPE all day every day. I mean obviously they are wearing masks as well but they’re not wearing gloves and gowns all day every day in the office block. And so I think it is hard for them to kind of really appreciate exactly how tough it is on the ward

(Extract 5, NO, hospital B)

NO (extract 5) provides an example where a leader who worked within a separate environment to frontline staff was seen to have different experiences of the PPE challenges faced on the wards. Prior literature demonstrates the role of shared experience in recognising others as part of the same social group [38]. Here, recognising a lack of shared environment and therefore lack of shared experience between frontline staff and leadership renders the leaders in the office block as “other” to frontline staff on the ward.

Perceived lack of shared experience between leaders and frontline staff was also seen to contribute to the ability for staff to adhere to safety guidance. AE (extract 6) demonstrates this in the following example, where they were asked to further discuss why they felt that emails communicating guidance were not effective, where AE was unaware of who these emails were coming from:

I think a lot of people that write those emails have never actually done the job, or they say ‘you should do this for this situation’ but the ward doesn’t have a sink, or the room that you’re in doesn’t have a sink or doesn’t have an alcohol gel dispenser in it […] it’s just that the guidance that comes down from wherever it comes from doesn’t seem to have ever, people don’t seem to have applied it or tried to apply it […] It’s often very irrelevant from what’s going on on the ground

(Extract 6, AE, hospital B)

AE provides an example where guidance was felt to be challenging to adhere to because the work environment did not have the resources required to follow the guidance (for example, a lack of hand sanitiser or environmental restrictions), leading to the guidance being viewed as impractical. AE attributes this impractical guidance to non-present leadership who were unable to understand or appreciate the working environment due to a lack of shared experience with frontline staff. AE thus demonstrates a view that in order to facilitate staff adherence to safety guidance, leaders need to be present and have a shared experience as to provide guidance that is practical to adhere to within the constraints of the hospital or specific ward environment.

Notably absent from AE’s comments on leadership is feeling part of the same group as them. In line with the prior literature that a sense of common experience can lead to shared social identity among the people facing the situation, AE’s comment on distant leadership lacking shared experiences demonstrates how the antecedents to feeling part of a group with leaders are missing when leadership are physically and psychologically separate. Moreover, they show the subsequent implications this can have for non-adherence to safety guidance. In contrast, AE (extract 7) positively appraises the suggestion of having a single, present person responsible for translating and providing safety guidance (which was the situation in both case study hospitals):

I think the best thing about that [having a single point of contact for covid guidance] is that person translates what is the kind of senior management policy into something that is actually do-able. And it needs to be someone that’s close to the ward that’s doing that as well

(Extract 7, AE, hospital B)

Importantly, AE highlights that for guidance to be practical, applicable, and thus adhered to, they feel it needs to come from someone who is present on the floor and who has engaged in shared experiences with frontline staff. As presence and engagement with frontline tasks have been viewed as demonstrating leadership prototypicality (i.e., sharing the experience and acting as the group should), there is a suggestion that guidance should come from those viewed as prototypical to ensure the guidance is practical and able to be adhered to. Further, AE highlights a viewpoint that a present single point of contact for guidance is perceived as someone who acts on behalf of the group. Thus, this suggestion of a single leader in charge of guidance communication, who could ensure practicality and applicability via their presence, could promote both positive appraisals of these leaders as identity advancing, alongside facilitating the ability for staff to adhere to COVID-19 safety guidance by providing practical guidance that can be adhered to.

Approachable leadership.

Non-approachable leadership were negatively appraised, where staff believed that these leaders left their colleagues feeling abandoned and dismissed:

I think for us it was a two-way conversation [between staff and leadership] and we felt we were able to say what was right and what was wrong and voice our concerns, but a lot of people, my colleagues, others, didn’t have that at all, felt pretty let down […] staff were in tears, not just nurses but doctors too, because they were so scared and basically being made to feel like lambs in slaughter

(Extract 8, OC, hospital A)

OC (extract 8) highlights contrasting staff experiences of approachable leadership within the hospital. They report positive experiences of approachable leadership where they felt able to voice any concerns they had but acknowledged that this was not a universal experience, where non-approachable leadership was viewed as an experience shared by many. This lack of approachable leadership was viewed by OC to leave staff feeling highly dismissed and abandoned.

Beyond facilitating feelings of support, a recurring theme was that approachable leadership was also key to facilitating feelings of group membership between leaders and frontline staff, alongside providing the information required to allow staff to adhere to COVID-19 safety guidance:

The relationship’s great. Actually I have to say within my experience of the relationship between staff here and management here is very good, they’re very approachable. I don’t think everybody will tell you the same thing, but my relationship is that they’re very approachable and that, you know, they treat you almost as an equal as it were, so you get as much information as they’ve got

(Extract 9, IR, hospital A)

IR’s experience of approachable leadership (extract 9) further demonstrates the link between approachability and both positive appraisals of hospital leadership and the ability for staff to adhere to the guidance. The sense of solidarity described by IR between leaders and frontline staff was seen to create an avenue for sharing information, putting leaders and staff on equal footing and creating a sense of staff and leadership being in it together. Approachability was seen to facilitate this two-way interaction between leadership and frontline staff, which in turn allowed staff to be provided with the same level of information as leadership. Having up-to-date information was recognised by other participants as key to facilitating adherence to current guidance; for example IR (hospital B) highlighted that not having the most up-to-date information meant that being able to “keep on top of what we were meant to be doing was quite challenging”.

Further, approachable leaders were viewed positively, particularly for their availability to provide clarity to guidance to help staff, as discussed by IR (extract 10) when asked about their conversations with leadership on the ward:

It’s quite an open kind of conversation that you can ask questions if you’re unsure about anything, everybody is really approachable about it

(Extract 10, IR, hospital B)

IR assumed that this leader was consistently happy to help the group by being available to clarify the guidance, where this line of communication was seen as regularly available when required due to leadership approachability. Clarity of guidance was raised by other participants as key to facilitating adherence; for example, RE (hospital B) noted that they would adhere if “it [the guidance] was clear cut… if it was very linear and easy to understand”, and AE (hospital B) mentioned that they felt adherence was only possible because “it [the guidance] was clear”. Thus, the approachability of leadership was not only seen to have facilitated positive perceptions of leaders, but also enabled staff to adhere through clarifying guidance.

Finally, leaders who facilitated two-way conversations were seen to be invested in what was best for frontline staff, particularly when the benefits and goals of the group were emphasised:

We all knew that we were going into very uncertain times and nobody really knew the answer, so it was very much, you know [leadership saying] ‘if you guys think that you have an idea for a better way for us to be doing this, you know, no idea is a bad idea’. We’re all just trying to look after each other as best we can here and so, you know, you did feel comfortable raising ideas or saying ‘actually, I didn’t feel safe in this situation’

(Extract 11, SA, hospital A)

Here, SA (extract 11), a frontline member of staff, views leaders as demonstrating ingroup membership by engaging in two-way conversations that emphasised shared goals (i.e., ‘look after each other’) with staff and therefore inviting leaders and staff to be on an equal level. By leaders being seen to care about the group and wanting to keep each other safe, they define what it means to be a good (and ideal) group member [14]. Thus, SA recognises this leader as representing prototypicality. In addition, leaders who engaged in these two-way conversations were seen to be working with staff and for staff to achieve shared group goals (to keep each other safe). By leaders acting for the group through engaging in conversation and co-production with frontline staff, they are positioned as identity advancing leaders.

Engaged leadership who act upon staff’s concerns.

Positive appraisals of leadership are also extended to leaders who are seen to act upon the concerns raised by staff:

The very first eye protection that we had, if you’ve never seen it, it was essentially like a cellophane sheet with a bit of coat hanger through it. And they fell off, and they didn’t work, and everyone complained about them. And I think we all had faith that the person that was giving us, immediately giving us the rules, was also the person that was fighting our corner to the chain of command. And I think that’s, yeah I think that would’ve persisted if there were any other things in that particular environment

(Extract 12, AE, hospital B)

AE (extract 12) describes an example where PPE inadequacy was raised as a concern to leadership, where leaders were viewed as demonstrating group advancing behaviours by acting upon these concerns on behalf of the group. AE raises an assumption that issues with inadequate PPE are a challenge faced by everyone and provides an example of the barriers to support their point. AE also poses that all frontline staff look to leadership to resolve these issues but AE assumes a conflict is required with higher-up management to resolve issues. AE implies a hierarchy and top-down approach to leadership which AE views as unhelpful for facilitating adherence. In contrast, AE positively views those providing frontline staff with guidance as those who would challenge upper management on their behalf. By demonstrating identity advancing behaviours of engaging in a difficult challenge on behalf of the group, these leaders were seen to facilitate feelings of trust that they would act for the group again in future, as seen within prior literature [21].

Leaders who were seen to not act on the concerns of staff were seen as dismissive and limited staff’s ability to adhere to COVID-19 safety guidance. LY (extract 13), who worked within hospital office spaces rather than a patient facing role, discussed an example where their line manager did not promote working from home:

So we had a number of discussions and they were still pushing for me coming into the office for one day to send emails just because everyone was doing it […] that’s one of the examples when I felt that they were not listening

(Extract 13, LY, hospital A)

In this example, LY views leadership as failing to act on their concerns and actively dismissing them by not listening or engaging with the concerns raised by staff, and justifying a lack of action by attributing it to what everyone else in the hospital was doing. A similar experience was discussed by NE (hospital B), who found that their line manager did not encourage working from home and instead was seen to perceive this “as an inconvenience” where “there’s no real, you know, conversation at all” regarding the concerns being raised by office staff. As a result, these leaders are perceived as non-identity advancing leaders as they are seen to be failing to act for the group by not encouraging or facilitating working from home (which was the Scottish Government’s guidance at the time [39]). These examples of leadership failing to act on staff’s concerns, therefore, limited staff’s ability to adhere to COVID-19 safety guidance.

In comparison, leadership who acted for the group by addressing the concerns raised by staff were both viewed positively and facilitated adherence to COVID-19 safety guidance as exemplified by SA (extract 14):

They were very useful for being able to sort of, even if they didn’t have the answers in there they would research into the trust to see if there’s any other kind of cleaning products that we could use that would be a lot safer on the equipment and being able to get that in for us instead. And that was really helpful

(Extract 14, SA, hospital A)

Here, SA demonstrates that leaders who are seen to be acting upon group concerns are appraised positively, where these engaged leaders do not leave staff feeling dismissed compared to leaders who are seen to be ignoring the views of the group as discussed previously. SA highlights an example where staff were unable to clean the equipment with the existing cleaning products as they would cause damage. By acting upon the concerns raised by staff regarding this, leadership found a solution that facilitated staff following the COVID-19 guidance. Thus, this highlights the importance of leadership acting upon group concerns (demonstrating identity advancement) not only for the positive appraisal of leadership, but also for facilitating the ability for staff to adhere to COVID-19 safety guidance.