Leadership and management

Question 1

Definitions of leadership

Answer 1

Grint 2011

Leadership as Person – who leaders are; their personality traits, skills and standards of personal effectiveness

Leadership as Process – how leaders get things done; this is defined by social interactions, attempts at influence, communication, empathy, empowerment and coaching

Leadership as Position – where leaders operate; as defined by organisational leadership roles, position, authority and/or professional status

Leadership as Results – what leaders achieve.

Question 2

Timeline of contemporary leadership theories

Answer 2

A brief timeline of key contemporary leadership theories is given below:

1840s – 1930s: ‘Great man’ theories: Leadership is an innate ability with which you are born.

1930s: Group theory: Leadership emerges and develops in small groups.

1940s –1950s: Trait theory: There are universal traits common to all leaders.

1950s –1960s: Behaviour theory: Key behaviours result in leadership.

1960s – 1970s:
Situational theories: Leadership style should vary with the person or group being influenced and the task that needs to be accomplished

Contingency theory: Focuses on adapting situational variables to better suit a leader’s style

1977: Greenleaf suggests that great leaders serve the group they lead by creating and maintaining an environment which encourages and supports everyone in maximising their potential
1978: Burns describes transactional and transformational leadership (see below); he suggests that followers are central to leadership and that successful leaders transform groups in ethically and morally uplifting ways

Transactional leadership:

Views leadership in terms of an exchange between leader and follower; at its most basic this transaction involves the exchange of reward (psychological or material) for work.
Promotes compliance through threat of punishment

Transformational leadership involves:

Challenging the status quo to create new visions and scenarios

Initiating new approaches

Stimulating the creative and emotional drive in individuals to innovate and deliver excellence.

1980s: Excellence: What combination of group facilitation, traits, behaviours and key situations enables people to lead organisations to excellence?

Management Theory: Key rules: Obeying the leader is fundamental; ensure a clear chain of command; use rewards and punishment

1990s: Relationship theory (also known as transformational theory): Successful leaders are passionate about the work and able to energize others

2000-2010s: There are many emergent leadership theories, the most illuminating of which are:

Adaptive Leadership:

Considers leadership as a practice to be used in situations without known solutions (Heifetz & Laurie, 2011).

Authentic Leadership:

Highlights transparent and ethical leader behaviour; encourages open sharing of information required to make decisions while accepting followers’ inputs (Avolio et al, 2009).

Complexity Leadership:

Relates concepts of complexity theory to the study of leadership and considers leadership within the framework of a complex adaptive system (Uhl-Bien et al, 2007). A complex adaptive system is composed of:
‘interdependent agents who are bonded in a cooperative dynamic by common goals, outlook, need, etc. They are changeable structures with multiple, overlapping hierarchies, and … are linked with one another in a dynamic, interactive network’ (Uhl-Bien et al, 2007).
Examples include the National Health Service, foundation trusts and mental health teams.

Question 3

Transactional leadership

Answer 3

Views leadership in terms of an exchange between leader and follower; at its most basic this transaction involves the exchange of reward (psychological or material) for work.
Promotes compliance through threat of punishment

Question 4

Transformational leadership

Answer 4

Challenging the status quo to create new visions and scenarios

Initiating new approaches

Stimulating the creative and emotional drive in individuals to innovate and deliver excellence.

Question 5

Wicked problems

Answer 5

Wicked problems are complex rather than just complicated (i.e. they are highly relational and cannot be removed from their environment, solved and returned without affecting the environment) (Grint, 2011). There are no obvious answers; typically a number of ‘solutions’ have been applied in an attempt to resolve the problem without achieving sustained success. Wicked problems are common and tend to be socio-political, chronic and ‘messy’. There is a high degree of uncertainty and no clear relationship between cause and effect.

Examples of wicked problems in psychiatry include:

the contestable nature of professional knowledge; alternative views can be found (even in the same team) on the interventions which practitioners might use
limited understanding of disease
lack of suitable or available treatments
paucity of appropriate teams and facilities
mental health laws which are either overly liberal or overly coercive
improving mental capacity and wellbeing
substance misuse
protecting the public and risk management while promoting recovery, wellbeing and community participation
maximising the quality of care whilst minimising the cost of care
being accountable to patients whilst being accountable to a population
meeting the needs of patients and the needs of the organisation
addressing central concerns (government, trust boards) as well as local needs
working with the short-term whilst working toward the long term.

Wicked problems don’t need leaders to give the right answers, but to ask the right questions

Question 6

Tame problems

Answer 6

Tame problems may be complicated but can be solved by the application of logic and clear pathways or protocols. They are likely to have occurred before and engender a limited degree of uncertainty. Medical students and trainees are primarily taught to solve tame clinical problems. Examples of tame problems in psychiatry include:

diagnosing clinical depression
Mental Health Act 1983 assessments
a quality standard drifting outside of control limits
dealing with complaints
supporting a colleague who is underperforming
workforce planning
job planning
training.

Question 7

Define management

Answer 7

getting things done well through and with people, creating an environment in which people can perform as individuals and yet collaborate towards achieving group goals and removing obstacles to such performance’. (Royal College of Psychiatrists, 2012)

Question 8

Distinguishing leadership from management

Answer 8

Leadership- established direction, aligns people, motivates and inspires, implement and manage change

Manager- planning and budget, organisation and staff, controlling and problem solving, bringing order

Question 9

Clinical leadership vs medical leadership

Answer 9

Medical leadership is delivered by a doctor

Question 10

Why psychiatrists make good leaders

Answer 10

Psychiatrists are perhaps well placed to provide leadership through enhancement of the skills required to be a good psychiatrist including:

an understanding of severe disturbance, interpersonal dynamics and pathological and healthy processes, particularly projection, splitting, and mourning

the ability to think in systems and groups

expertise in managing boundaries, overcoming barriers and motivating and supporting others

skills in assimilating diverse and conflicting evidence.

Question 11

Imperatives of leadership should include

Answer 11

it is suggested that the imperatives of leadership should include:

clinical decision-making in multidisciplinary contexts
the management of dynamics in team settings
the professional development of colleagues
service improvement
ensuring equity of access
an ambassadorial role for health services
an acceptance of wider roles outside the employing organisation
horizon scanning, to anticipate developments in policy and practice, and then encourage evolution in service delivery.

A consultant doctor cannot usually see every patient (the money and the time are simply not there) or be personally responsible for every patient seen by a member of the team that they lead. However, a doctor can, and indeed is uniquely positioned to lead a team in such a way that practice and outcomes for patients are good and are continuously improving. A doctor can be accountable for this leadership role.’

Question 12

The healthcare leadership model

Answer 12

The Healthcare Leadership Model comprises of nine ‘leadership dimensions’:

Inspiring shared purpose:
– Valuing a service

– Being curious about how to improve services and patient care

– Behaving in a way that reflects the principles and values of the NHS.

Leading with care:
– Having the essential personal qualities for leaders in health and social care

– Understanding the unique qualities and needs of a team

– Providing a caring, safe environment to enable everyone to do their jobs effectively.

Evaluating information:
– Seeking out varied information

– Using information to generate new ideas and make effective plans for improvement or change

– Making evidence-based decisions that respect different perspectives and meet the needs of all service users.

Connecting our service:
– Understanding how health and social care services fit together and how different people, teams or organisations interconnect and interact.

Sharing the vision:
– Communicating a compelling and credible vision of the future in a way that makes it feel achievable and exciting.

Engaging the team:
– Involving individuals and demonstrating that their contributions and ideas are valued and important for delivering outcomes and continuous improvements to the service.

Holding to account:
– Agreeing clear performance goals and quality indicators

– Supporting individuals and teams to take responsibility for results

– Providing balanced feedback.

Developing capability:
– Building capability to enable people to meet future challenges

– Using a range of experiences as a vehicle for individual and organisational learning

– Acting as a role model for personal development.

Influencing for results:
– Deciding how to have a positive impact on other people

– Building relationships to recognise other people’s passions and concerns

– Using interpersonal and organisational understanding to persuade and build collaboration.

Question 13

Limits of competency frameworks

Answer 13

Competency frameworks and lists of leadership skills are based on what strong performers have done in the past and thus may not be relevant in rapidly changing circumstances. It is unlikely all leaders within an organisation must possess the same set of competencies to be successful or make the organisation successful. There is also a risk of embedding one particular group of attitudes and not seeking out the right skills and attitudes for new ways of working.

An extensive list of knowledge, skills and attributes may be overwhelming and appear unachievable. It also suggests that leaders can move seamlessly between styles and approaches. Furthermore, by listing individual competencies, frameworks can imply to readers that leadership resides in a single individual, whereas notions of contemporary shared leadership argue for leadership as an embedded characteristic of organisations.

Leadership is related to context and your choice of approach will depend on what is required; it is not simply a matter of choosing the model with which you have the strongest affinity.

Question 14

Transformational leadership skills

Answer 14

Bass 1985
 modelling integrity and fairness
setting clear goals
holding high expectations
encouraging others
providing support and recognition
stirring the emotions of people
enabling people to look beyond their self-interest
inspiring people to reach for the improbable.

In mental health service teams, transformational leadership is positively associated with a cohesive organisational culture and negatively associated with burnout. It is superior to transactional leadership styles (Corrigan et al, 2002; Rodenhauser, 1996).

Question 15

Leadership as a position

Answer 15

1. Team leader-> often team manager
2. Clinical lead-> may advise managers about the needs within the service. Does not normally have operational management responsibilities
3. Clinical director-> normally responsible for part of a mental health service and has budget, typically work in partnership with a professional manager
4. Medical director-> executive, medical baord, medical input for development of strategies, communicates to trust and clinicians, supports work of clinical directors, professional lead, assumes coporate role

Question 16

Importance of feedback

Answer 16

It is critical that frontline staff have a platform upon which to challenge the status quo and feed information up the management hierarchy so that colleagues in higher levels of the organisation are sensitive to what is happening. Without this platform, there is disconnection between managerial and clinical practice at the expense of patient care. Leaders should be prepared to listen to feedback, consider it in a broader organisational context and adapt their strategies accordingly. Channels of communication must be transparent and are akin to the circulatory systems that feed the heart; when a channel is blocked the organisation ceases to function. Unfortunately, a common marker of success for leaders is the degree of compliance of the workforce rather than an ability to respond to feedback.

Those who follow you construct your identity as a leader; encouraging and receiving feedback about how you are perceived is vital as the last thing a leader wants is a colleague talking about them behind their back!

Question 17

Individual learning styles

Answer 17

Honey and mumford 1982
Individual learning styles. Honey and Mumford (1982) describe four different styles of learning:
Activist: learning by doing
Reflective: learning by observing and thinking
Theoretical: understanding the theory behind the actions
Pragmatic: seeing how to apply the learning in the real world

Question 18

Leadership courses

Answer 18

Purchasing on an individual basis one of the plethora of two or three day leadership courses may potentially improve a learner’s knowledge of healthcare systems, processes, structures and governance and develop the ‘soft skills’ of management and leadership, including time management, delegation and presentation skills. However, the ‘piecemeal’ approach often adopted is unlikely to have a positive long-term impact on an individual’s leadership behaviours particularly upon their return to work. Likewise, they are unlikely to catalyse large-scale service improvement because crucially such courses do not provide the opportunity for participating organisations and services to develop alongside them. It is also very difficult to judge the quality of brief leadership courses given a paucity of published outcome measurements.

Brief, and in particular commercial, leadership courses frequently purport to offer ‘quick fixes’ to some of the wicked issues of organisational life. However, leadership and its multiple facets are too complicated to be captured within a specific ‘5 steps’ or ‘top 10 tips’ style approach; it is impossible to reduce a concept as complex as leadership to a series of simple steps and persuade busy clinicians that they can become a competent leader with a few days of experience.

Question 19

Questions to ask as a reflective leader

Answer 19

Future-orientated questions

These help us to change our perspectives by focussing on possibilities we would like to see, enabling a shift from being problem to solution focussed.

Examples include:

If this meeting ended in a satisfactory way what would be happening?
How would I recognise a successful outcome?
What do I want to achieve in the short / long term?

Observer-perspective questions

These are useful in conflict resolution and enable a person to be less emotionally involved, adopt a neutral position and see the bigger picture.

Examples include:

How do others see my approach to leadership?
Are they able to tell me?
What do I do that others most appreciate / dislike?
In having the angry discussion with me, what do I think was important to him?

Unexpected context-change questions

Helpful in seeing other perspectives.

Examples include:

When is the conflict not present?
What would I notice if the conflict had gone?
If the situation changes, what do I not want to change?

Normative-comparison questions

Help to define a person’s position in comparison to his or her peer-group.

Examples include:

Do I think that I meet more or less often with my managerial colleagues compared to other consultants?
When I think of someone who is a good leader, what does he or she do? How is this different to my performance?

Question 20

Role of the psychiatrist in a team

Answer 20

‘delivery of mental healthcare is a team activity in which all members make important contributions to improving mental health and service provision. The ability to unite this diversity of talent and perspectives to meet organisational aims is a hallmark of a successful psychiatrist’ (Hobkirk et al, 2011).

The professional requirement for consultant psychiatrists to be leaders in teams is clear. Consultant psychiatrists are expected to:

demonstrate leadership competencies as described in the Healthcare Leadership Model (NHS Leadership Academy, 2013) which identifies multiple areas of competency relevant to team and group working (see the box below)

show competency in team working and leadership at annual appraisals via 360-degree feedback and reflection; this is a requirement for revalidation and is discussed further in Leadership And Management For All Doctors (GMC, 2012)

complement and respect the vital roles played by clinicians from other professional backgrounds:

Question 21

Evidence based effective leadership models

Answer 21

There are numerous models of leadership, but only a few with evidence of effectiveness in groups or teams, principally:

shared leadership
‘an interactive influencing process among individuals in groups where the objective is to lead one another to the achievement of group and organisational goals, or both.’

engaging leadership
Engaging leadership aims to bring leaders and followers together to understand existing conditions and how they can collectively address these (

values-based leadership
Values-based leaders focus on ‘core values’, the enduring guiding principles that capture an organisation’s strengths and character. They communicate these values in order to fulfil the organisation’s aims. As core values represent the soul of the organisation, these are likely to remain steadfast in the face of changing market trends and fads.

transformational leadership*.

Question 22

Disadvantages and barriers to shared leadership

Answer 22

Potential drawbacks include:

encouraging individuals to abdicate their responsibility to act and think independently (in the belief that others will act for them)

limiting the impact of highly creative and driven people who are perhaps better working as individuals (Locke, 2002)

failure to positively harness disagreement and conflict (e.g. around vision and strategy) to the detriment of creative thinking and progress.
Negotiating shared leadership between agencies can be highly challenging. A report on transforming the mental health of London (King’s Fund, 2014) found that barriers to creating a shared plan of action included:
different political and historical agendas among key stakeholder groups

unconstructive communication between stakeholders (e.g. stakeholders adopting the position that current problems should be solved by them taking the lead, blaming other stakeholders for providing inadequate supports for efforts to improve mental health)

limited knowledge and acknowledgement of the strengths, weaknesses and access to resources for each group.

Question 23

Approach to enhancing medical engagement

Answer 23

Leadership-> top level leadership, lead by example, stable

Selecting and appointing the right doctors to leadership and management roles-> appoint on the basis of competency

Promoting trust and respect between doctors and managers-> creating shared goals around quality

Clarifying roles and responsibilities-> working together doctors and nurses shape and develop services

Effective communication-> developing relationships through open and honest communication

Setting expectations about professional behaviour-> ensuring issues relating to unprofessional behaviour and patient safety are dealt with quickly and decisively

Providing support and development

Developing a future focused and outward looking culture

Question 24

Evidence for values-based leadership

Answer 24

The bulk of evidence for values-based leadership lies in the educational field, as described by Bratton & Gold (2003), who give 10 case studies of ‘outstanding’ school principals. Values-based leadership is associated with a high level of follower motivation and above-average organisational performance, especially under conditions of crisis or uncertainty (Pillai & Meindl, 1998; House et al, 1995; Waldman et al, 2001).

The Joint Commissioning Panel for Mental Health has developed a guide about values-based commissioning in mental health, an approach where the commissioning process rests on three equal pillars:

1. patient and carer perspective or values
2. clinical expertise
3. knowledge derived from scientific or other systemic approaches.

The advantages of values-based commissioning include:

the delivery of more service user or patient-focused services

potentially improved cost-effectiveness

the achievement of key outcome measures

Question 25

Bias in teams

Answer 25

groupthink

escalation of commitment

emotional bias.

Question 26

Groupthink

Answer 26

Decisions in mental healthcare are often made by groups rather than individuals (e.g. in clinical reviews, multidisciplinary meetings and board rooms). Groupthink is the wish to achieve consensus and avoid disagreement in group discussions (Janis, 1982), and emerges when:

there is a lack of external influence for identifying the pros and cons of a particular course of action

there is a lack of systemic process for this

group members do not wish to challenge the decision of the majority or voice new ideas for fear of appearing to ‘rock the boat’.

It is interesting to note that doctors are more likely than other healthcare professionals to have their proposals challenged and to accept decisions contrary to their initial suggestions (Gair & Hartley, 2001). A study by Wright et al (2003) also found that in mixed-sex groups men consistently talk, interrupt and introduce new topics more frequently than female colleagues.

Symptoms of groupthink include:

rash, illogical or uncreative decisions

an illusion of invulnerability and morality

pressure on dissenters to agree

self-censorship of dissent

collective rationalisation

avoidance of alternative views

negative views of competitors (Janis, 1982).

Question 27

Escalation of commitment

Answer 27

This describes an irrational escalation of investment of resources (time, money or expertise), despite increasing evidence that outcomes are failing. The term ‘mission creep’ is sometimes used to describe escalation of commitment where original objectives are not clearly defined. In lay terms, it could be thought of as throwing good money after bad.

Question 28

Why do rational individuals invest their time and energy in unsuccessful strategies?

Answer 28

The impact of emotion in decision-making, leading to a build-up of commitment, is well recognised (e.g. Wong & Kwong, 2007). It will be considered in the next section.

Escalation of commitment can emerge in response to unconscious social demands such as the expectation that health systems, when run correctly, can prevent morbidity and mortality (Obhlozer, 1994).

Fotaki & Hyde (2014) suggest that defence mechanisms (splitting, blame and idealisation) play a role in maintaining commitment to unsuccessful strategies in the NHS, quoting instances of mental health service reform as examples.

Question 29

Individual patient choice? an escalation?

Answer 29

Individual patient choice is considered a cornerstone of mental healthcare (NHS England, 2014) and has shaped the design of clinical systems (e.g. the choice and partnership approach). It is highly valued by policy makers but, to date, has not emerged as a successful strategy:

Patients do not seem as strongly invested in the concept as policy makers, with only 35% of patients exercising choice of hospitals (Boyle, 2013).

Of greater value to patients is obtaining information about their treatment (Boyd, 2007), being involved in their treatment (Coulter, 2010) and a relational aspect to care (Mol, 2008).

Individual choice is in conflict with the collective goals of public mental health, and the ability to exercise choice is not equal across all groups of patients.

In clinical medicine, a main area of focus has been to avoid escalation of over-investigation and treatment in older people or those with terminal conditions (Redelmeier, 1995). Routine information on costs per case, including bed days incurred, could highlight potential escalation.

Question 30

Domains of performance

Answer 30

Safe
Effective
Caring
Repsonsive
Well led

Question 31

Ng et al 2018 on leadership

Answer 31

At the core of leadership is the quest to make sense of
unknowable and unpredictable situations; and in doing
so, to find meaning and direction

Central to creating an environment that fosters growth
in a leadership mindset is the belief that leadership can
be learnt. It is essential that our organisations value this
learning and provide active opportunities to undertake
development in this area. In this regard, we may ask to
give constructive feedback that promotes learning and
success. To realise our potential, we believe the profession
of psychiatry must be more intentional and proactive
in creating opportunities to develop a leadership
mindset across the career trajectory.