Leadership in Health and Social Care Education Literature Review for FDTL Leadership Project Introduction Continuous and rapid change in UK health and social care has meant that many professionals in the sector are undertaking new and challenging roles. Some of these professionals are not trained or experience in leading and managing these changes and it is therefore necessary that sufficient and dedicated education be provided. Within the NHS, clinical (medical, nursing and social) staff are increasingly being required to perform managerial duties, the responsibility of which is not necessarily part of their basic training (2002). Further, clinical managers often have difficulties in performing dual roles as they can be easily distracted by operational demands and conflicting priorities. Various generic and applied opportunities for management training are available – through formal educational institutions, in-house activities and private organisations. Alternatively, very few formal and dedicated leadership training opportunities exist. Leadership development in the NHS has always been ad hoc and incoherent with too few clinicians in leadership roles and too little opportunity for board members to develop leadership skills. That will now change ( 2000). This paper will argue that management and leadership are exclusive roles, with different (and sometimes contradictory) objectives and functions. (2000) propose that there are three avenues for learning to lead – through trial and error, developing relationships, and education. This paper focuses on formal educational activities. Formal leadership education needs to begin at medical school. “Tomorrow’s doctors must be fully equipped to take on leadership roles with enthusiasm and confidence” ( 2000). Some authors question whether leadership can be “taught” at all ( 1998;1977) “There is no known way to train great leaders” ( 1977). Regardless of this debate, the principles of management training cannot automatically be applied to leadership education. If leadership education is to emerge as a recognised developmental activity, considerable attention needs to be given to the differences between management and leadership and the role of, and challenges facing, leaders. This paper will examine some definitions and concepts of leadership and explore how leadership differs from management. What is leadership? (2002) suggests that leadership is often confused with concepts such as power, authority, management, administration, control and supervision. However, the essence of the leadership role and process is to inspire, develop and empower followers. Leadership is the process of influencing others to understand and agree about what needs to be done and how it can be done effectively, and the process of facilitating individual and collective efforts to accomplish the shared objectives (2002). The NHS Modernisation Agency (2002) states that the role of leaders in the NHS is to: Improve patients’ care, treatment and experience ! Promote a healthier population ! Enhance the NHS’s reputation as a well-managed and accountable organisation ! Motivate and develop staff. (2000) argues that there would be no leaders without followers, and the relationship between the two requires a sense of community. Successful leadership requires a clear strategic vision that resonates with the community. Leaders must be able to generate and sustain trust among the community, but also question the assumed objectives and processes (1997). Leaders are responsible for drawing attention to the cultural factors that impede organisational learning, to ensure that the organisation can avoid controlling the symptoms rather than underlying causes. Leaders need to create processes by which problems can be defined and ways in which organisational members can convey their reality and avoid dominant and culturally acceptable definitions of the problem ( 2001). (1980) suggests that emotions in organisational life are often repressed, suppressed or dismissed – seen to be taking away from the “real” business of the organisation. However, “the consequence of this attitude is that ritualistic activities and rationalization of behavior seem to be the norm and have become the more acceptable ways of dealing with the routines of management” (1980). The importance of emotions is exemplified through the manifestation of stress-related conditions, such as premature death of executives, output problems, work inefficiencies, labour turnover, strikes and absenteeism. There is a need for greater awareness of the reasons and motivations for individual and organisational action, and recognition of the emotional costs of corporate life. This might lead to recognition of the limitations of rationality in organisational life. ( 1980) argues that everyone has the capacity for this type of learning – however, there is a pressure to conform to previously learnt behaviours. This leads to a neglect of dependency, affection, hostility, shame and guilt. Competent leadership requires congruence between internal values and external reality – the greater the disparity, the greater the need to exercise power. Leaders have the potential to become paranoid – if this paranoia becomes pathological – through illusions of grandeur or delusions of persecution – it can be self destructive to both the individual and the organisation In a later work, (1984) propose that organisations can be neurotic – paranoid, compulsive or depressive. Sometimes these neuroses reflect the leadership style from the top, which permeates the entire organisation. The neuroses then threaten the well-being and ultimate survival of the organisation. Change management is an area where effective leadership is paramount to successful organisational development. More change requires more leadership – many organisations have difficulties adapting to change (1990). The ability to manage change is a key characteristic of a transformational leader. Transformational leaders must be visionary, proactive, creative, innovative and supportive of alternate viewpoints (2002). (2002) analysed a complex change management project, involving collaboration between five North London medical schools to develop community-based aspects of the undergraduate medical curriculum. Among other problems such as, organisational tensions, role boundaries and conflicting aims, leadership tension was one of the primary factors which mediated the success of the change management project. Leaders were confused about the aims of the project, which filtered through to the individual organisations – administrators were then confused regarding the priorities of the project. MacFarlane et al propose that at the commencement of a change management project, an innovative leader is required – a charismatic visionary. The necessary skills and abilities then change according to the subsequent development and maintenance of the project – attention needs to be given to this development otherwise the aims of the project can become confused and conflicts can arise (2000) research suggests that leaders who achieve the best results do not rely on one leadership style, but incorporate multiple styles seamlessly depending upon the situation. Leaders can achieve this by building a team with members who employ the styles that the leader lacks, or by expanding one’s own style repertoire. In different stages of organisation, different kinds of leadership are appropriate. In a mature or declining culture, such as the NHS, leaders need to overcome constraining cultural assumptions. Declining cultures may be based upon behaviours which were in the past appropriate, but are no longer so. Leaders must notice changes in external conditions, reflect on them and respond appropriately. If an organisation does not adapt to its changing environment it will die. A leader must are able to span boundaries, and be aware of marginal sub-cultures and the over-riding cultural context. In order to develop as a leader, it is important that there is a learning culture where resources are allocated to development, and learning is rewarded (2002). Further, leaders within learning cultures must accept that their own wisdom and experience is limited and encourage a shared responsibility for learning. Hence, a leader needs to know a culture before trying to change it, have vision for it and yet be open to different perceptions of reality, embrace contradictions and acknowledge mistakes. (1996) proposes an eight stage process for leading change: ! Establish a sense of urgency ! Create a guiding coalition ! Develop a vision and strategy ! Communicate the change vision ! Empower employees for broad-based action ! Generate short-term wins ! Consolidate gains and produce more change ! Anchor new approaches in the culture (1985) proposes that organisational leaders create learning cultures by recognising and rewarding appropriate behaviour and through managing and containing anxiety. For this they must look inside themselves and question their own assumptions – the prevailing cultures may reflect a leaders’ own assumptions, including their neuroses. Schein believes that leaders must be comfortable within their own weaknesses and open to diverse experiences. We cannot achieve the cultural humility required to live in a turbulent culturally diverse world unless we see cultural assumptions within ourselves. In the end, cultural understanding and cultural learning start with self-insight.(1985). Analytical Imagination and creativity Listening Influencing Enabling Collaborative working Technical competencies CREDIBILITY Human behaviour Own role Internal environment External environment National issues Self-awareness Empathy Values Self-confidence Integrity Vision ( 2002) propose that effective leadership should incorporate various elements relating to knowledge, skills and competencies and personal characteristics and behaviours. Figure 1 outlines the specific traits within each of these elements, which are believed to relate to effective leadership. Figure 1. Effective leadership – The key elements ( 2002) (2001) propose that personal characteristics are a more important indicator of successful leadership than an actual job description. Personal traits, such as commitment to an issue and an ability to develop linkages between perspectives and objectives, have considerable influence on the effectiveness of a leader. There is an alternative argument that, although personal characteristics are important indicators of successful leadership, situational variables have the capacity to moderate and constrain the relationship between attributes and effectiveness. The characteristics of the followers, the nature of the work, the type of organisation and the nature of the external environment all influence what would be considered to be the most appropriate leadership style (2002). (2001) also proposes that personality is not necessarily an indicator of successful leadership. Leadership versus management Management and leadership are diverse roles which require different characteristics and functions. Although the roles are often contradictory, they are complementary – one cannot function without the other. Managers typically promote stability while leaders promote change (2001). Figure 2 outlines some of the key comparisons between management and leadership. Figure 2. Comparing management and leadership (1990) Management Leadership Creating an agenda Planning and budgeting Establishing direction Developing a human network for achieving the agenda Organising and staffing Aligning people Execution Controlling and problem solving Motivating and inspiring Outcomes Predictability and order Change (2001) suggests that leadership sets a direction and develops a vision for the future. However, management is more concerned with planning which is deductive and orderly, not a process of producing change. Planning should complement direction setting. Kotter proposes that most US organisations are overmanaged and underled. One of the most frequent mistakes that overmanaged and underled corporations make is to embrace long-term planning as a panacea for their lack of direction and inability to adapt to an increasingly competitive and dynamic business environment ( 2001) (2001) proposes that organisations cannot wait for leaders to emerge, but must seek them out and develop their potential. Therefore, formal leadership education and training should be of great importance to organisations. Leadership education and training Just as we need more people to provide leadership in the complex organizations that dominate our world today, we also need more people to develop the culture that will create that leadership (2001). (2002) suggests the following rules for successful leadership: ! Articulate a clear and appealing vision ! Explain how the vision can be attained ! Act confidently and optimistically ! Express confidence in followers ! Use dramatic, symbolic actions to emphasise key values ! Lead by example ! Empower people to achieve the vision. Most leadership training programmes are designed to increase generic skills and behaviours necessary for effectiveness and advancement. Effective training should involve clear learning objectives, clear and meaningful content, appropriate sequencing of content, appropriate mix of training methods, opportunity for active practice, relevant and timely feedback, enhancement of trainee self-confidence and appropriate follow-up activities. Many leadership training programmes utilise particular techniques such as, behaviour role modelling (demonstration and role playing in order to enhance interpersonal skills), case discussion, business games and simulation (analysis of complex problems and decision-making) ( 2002). However, (2002) states that the most essential leadership skills are learnt from experience, rather than through formal training programmes. However, learning from experience is affected by the amount of challenge, the variety of tasks or assignments, and the quality of feedback. proposes that action learning and multisource feedback (such as 360-degree appraisal) are useful methods of enhancing the learning from experience process. It has been suggested that the term “training” should not be used when referring to leadership education. “Training” implies the idea of receiving knowledge while a focus on “development” or “learning” demonstrates the autonomy of the leadership role ( 2000). Conclusion This literature review has identified that leadership involves conceptualising a course of action and influencing others to understand and agree on how it can be executed effectively ( 2002). This review has explained that leadership and management are exclusive concepts. While management is more concerned with promoting stability and following a directive, the role of leadership is to create a vision and promote organisational change. “Institutionalizing a leadership-centred culture is the ultimate act of leadership” ( 2001). There is some contention in the literature as to whether leadership can be taught or learnt – is effective leadership linked to specific personality characteristics, indicating that only certain individuals naturally make good leaders? ( 2001) proposes that effective leadership has little to do with inherent personality characteristics. (2002) further suggests that there is little evidence of a correlation between supposed leadership attributes and ultimate success. If it is assumed that leadership can be formally developed, the literature would suggest that leadership can not, and should not, be taught through traditional educational activities aimed at management, such as MBA programmes, but needs to be developed through dedicated educational activities.
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