Leadership in Health and Social Care Education_Literature Review for FDTL Leadership Project

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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