Leadership has been described as the behavior of an individual when directing the activities of a group toward a shared goal. The key aspects of the leadership role involves influencing group activities and coping with change. A difficulty when considering leadership of healthcare professionals is that most theories were not developed within a healthcare context but were usually developed for the business setting and then applied to healthcare. Published researches provide little evidence that such leadership initiatives are associated with improvements in patient care or organizational outcomes when applied in the healthcare setting.
Leadership theory is dynamic and continues to change over time. The early Great Man theory assumed that certain people have characteristics that make them better leaders. Various behavioral theories were developed between 1940 and 1980 describing common leadership styles such as authoritarian, democratic and laissez-fair. Situational and contingency theories between 1950 and 1980 recognized the importance of considering the needs of the worker, the task to be performed, and the situation or environment. Interactional leadership theories (1970 to the present) focus on influence within the specific organizational environment and the interactive relationship of the ‘leader’ with the ‘follower’. An emerging theory involves supportive leadership, which states that supporting and building relationships with employees will increase the likelihood that they will be positively influenced and motivated to work towards goals. The theory is founded on organizational behavior studies that suggest that people are happier and more satisfied in their work when they have supportive leaders who empathize at a personal level.1,2
Healthcare systems are composed of numerous professional groups, departments, and specialties with intricate, nonlinear interactions between them; the complexity of such systems is often unparalleled as a result of constraints relating to different disease areas, multidirectional goals, and multidisciplinary staff. Within large organizations such as healthcare systems, the numerous groups with associated subcultures might support or be in conflict with each other. Leadership needs to capitalize on the diversity within the organization as a whole and efficiently utilize resources when designing management processes, while encouraging personnel to work towards common goals. A number of leadership approaches can be adapted to the healthcare setting to optimize management in this highly complex environment.3
The transformational theory goes beyond the more traditional style of transactional leadership (which focuses on supervision, organization and group performance) and emphasizes that people work more effectively if they have a sense of mission. The transformational theory requires leaders to communicate their vision in a manner that is meaningful, exciting, and creates unity and collective purpose; the manager who is committed, has vision, and is able to empower others can be described as a transformational leader. Transformational leaders are able to motivate performance beyond expectations through their ability to influence attitudes.4
Collaboration is an assertive and cooperative process that occurs when individuals work together towards mutual benefit, in a form of organizational symbiosis. Collaborative leadership involves communicating information to coworkers and associated organizations, to allow them to make their own informed decisions.5,6 Such collaborative communication strategies enhance healthcare management by: encouraging dialogue between multiple stakeholders; sharing knowledge and experiences; and reducing the level of complexity within healthcare organizations. Individuals with different levels of responsibility need to engage with the leadership process, so that they are actively involved in validating and communicating needs and identifying modifications in practices that may be required to address changing demands. Collaborative healthcare leadership requires a synergistic work environment, wherein multiple parties are encouraged to work together toward the implementation of effective practices and processes. Such collaborations promote understanding of different cultures and facilitate integration and interdependency among multiple stakeholders,7,8 individuals are unified by shared visions and values,7 and the resulting synergistic working practices can achieve outcomes that are greater than the sum of individual efforts. Leaders need to be the first to model collaborative behaviors, to raise levels of motivation, and nurture interdependency between different healthcare practitioners.9
Despite the recognized importance of collaborative working practices, only a small proportion of time is spent in true collaboration. Conflict can be a pervasive force within healthcare organizations and, as gaps in communication develop and are potentiated, failure in working practices can occur.10 The most common sources of conflict are recognized as the following: individualistic behavior within the organization, poor communication, organizational structures, and inter-individual or inter-group conflicts. Conflict usually develops from underlying latent issues (which implies the existence of antecedent conditions) and can progress to perceived conflict (where the issue becomes apparent) and subsequently to manifest conflict (the behavioral/action phase), with the last stage being conflict aftermath. The healthcare leader must adopt a suitable approach for handling conflict at all stages with the aim of creating a positive outcome for all involved. A leader can employ strategies such as competition, avoidance, compromise, accommodation, collaboration, bargaining/negotiation, mediation, facilitating communication, seeking consensus, and engendering vision to aid resolution of conflict.
Numerous studies have shown that autonomous healthcare workers with direct responsibility for their patients do not respond well to authoritarian leadership to lead highly qualified healthcare professionals.1,5,10,11 Leadership needs to focus on the development of effective collaborative relationships through support and task delegation, and this could be the basis for widespread implementation of the shared leadership model within the healthcare setting, as it encourages shared governance, continuous workplace learning and development of effective working relationships.12,13
Shared leadership is a system of team-level management/leadership that empowers staff within the decision-making processes.14 It offers the opportunity for individuals to both manage and develop within a team and is effective at improving the work environment and job satisfaction.15,16 Effective teamwork is key to the shared-leadership approach, with a focus on identifying team values and optimizing team efficiency to improve practices. Shared leadership ideally results in individual staff members adopting leadership behaviors, greater autonomy, and improved patient care outcomes. Barriers to developing shared leadership can include a poor team ethos, high workload and staff turnover rates, uninteresting work, lack of responsibility, and insufficient goal setting. Shared leadership is an ongoing and fluid process that requires continuous evaluation to be responsive to ever-changing healthcare challenges,5 and presumes a good working relationship between managers and staff.17 When organizational and group inter-relationships are developed and fostered to achieve defined goals, they can influence the practices of groups and individuals outside of the core team and also increase the standing of the group within the organizational hierarchy.18,19
Globalization necessitates that responsibility and initiative be more widely distributed and many large corporations have recognized this by becoming less hierarchical and more collaborative in their leadership approach. This distributed leadership approach requires 4 key characteristics19: sense making – the ability to understand the constantly changing business environment and interpret the ramifications of changes within an organization; relating – the ability to build trusting relationships, balance advocacy with inquiry, and cultivate networks of supportive confidants; visioning – creating credible and compelling images of a desired future that those in the organization can work towards; and inventing – creating new ways of approaching tasks or overcoming seemingly insurmountable problems. All four characteristics are interdependent and leaders need to identify their own capabilities, strengths, and weakness. The leader’s goal is to create an ethos whereby individuals can complement one another’s strengths and offset one another’s weakness, with leadership distributed throughout the organization.18,19
Practicing effective leadership can have a substantial impact on the working lives of healthcare staff, patient outcomes, and the fate of an organization. In some instances, the leader will need to influence group members by: (1) creating enthusiasm for risky strategies, (2) requiring a change in underlying beliefs and values, and (3) influencing decisions that favor some at the expense of others. However, by practicing such behaviors, in some instances, the leader can influence others to engage in crimes of obedience,11,20,21 which has led to declining public trust. A good leader must have intentions, values, and behaviors that intend no harm and respect the rights of all parties.
Functional Results Oriented Healthcare Leadership
The types of challenges that clinicians face when leading within the complex setting of a modern healthcare services include: diverse and changing needs, increasing patient expectations, and the high cost of new interventions and treatments. This requires clinicians to: consider the needs of the wider patient population; to take decisions that not only make the best of resources but also deliver clinical quality; and implement clinically-led service improvements that are likely to suceed.
The functional results-oriented leadership style focuses on the process of an organization implying leadership as having the specific role and skills necessary to deliver the desired results of the group based on and meeting the needs of three areas, namely; individuals, team, and tasks.22,23 It emphasizes in establishing the leadership role that facilitates effective and efficient healthcare provision. As indeed, results take a crucial center stage at this type model.22,23
Many theories, cases, and models have influenced the current leadership strategies that can be applied to the healthcare setting. Guidance for effective leadership should focus on the dynamic relationships between leadership values, culture, capabilities and the organizational context. The leader’s developmental journey must operate within this dynamic, supported by a high level of self, team and organizational awareness. Leadership development has clearly reached a critical crossroad, and the most important role of the leader could be described as ensuring a ready supply of replacement leaders to maintain organizational progress in the ever-changing healthcare environment.