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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
The psychiatric profession must ensure that its next generation of leaders has the appropriate skills to provide mental health services in the face of globalization and urbanization, new technologies, and competing demands for shrinking resources. Developing leadership skills and leaders is critical in order to optimise the use of resources, their application, service planning and delivery of services for patients and their families.
This is the first book on leadership (rather than management skills) to focus on psychiatry and mental health care. Contributions from international experts with clinical and non-clinical backgrounds pull together the theories and practical skills required to be a successful leader. The aim is to guide mental health professionals in general and psychiatrists in particular on how to gain the relevant skills and on how to utilise these skills and training to take on leadership roles in clinical and organisational settings.
The book covers the role of the leader and the skills required for leadership, including chapters on communication, decision-making, team development, mentoring, gender issues in leadership, burnout and more. It includes a section on assessment tools and learning material. Essential reading for all those who aspire to lead in psychiatry!
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Seitenzahl: 587
Veröffentlichungsjahr: 2013
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Contents
Cover
Title Page
Copyright Page
List of Contributors
Preface
Part A: The Role of the Leader
Chapter 1: What is Leadership?
Introduction
What is leadership?
Skills needed in and for leadership roles
Leaders: born or made?
Psychodynamic understanding of leadership
Key qualities of successful leaders
Conclusions
References
Chapter 2: What Makes a Leader? Skills and Competencies
Leader and leadership
Management versus leadership6
Power, authority and leadership
Leadership and charisma
Personal skills in leadership: traits of a leader
What sets up a leader?
Leadership styles
The impact of leadership on the organization
References
Chapter 3: Medical Professionalism, Leadership and Professional Judgement
Introduction
Historical account
Professionalism
Professional judgement
Conclusions
References
Chapter 4: Leadership Theories and Approaches
Introduction
Definition of leadership
Leadership versus management
Classical leadership theories and approaches
Modern leadership theories and approaches
Summary
References
Further reading
Chapter 5: Clinical Leadership
Definitions of leadership
What is clinical leadership?
Clinical leadership and group dynamics
Clinical leadership and decision-making
Personality and leadership
Leaders as change agents
Can we measure success?
Education and training for clinical leadership
Compassion and personality attributes
Conclusion
References
Chapter 6: Leadership and Clinician Engagement in Service Development
The medical model and psychiatric services
Ambiguity, uncertainty, insecurity and multidisciplinary team-working
The nature of clinical leadership
Clinical leadership and service development
Conclusions
References
Part B: Skills Required for Leadership
Chapter 7: Communication
Introduction
The importance of communication for a psychiatrist
Interpersonal communication in the clinical setting
Verbal and non-verbal communication in the clinical setting
Communication turning into therapeutic alliance in the clinical setting
Communication skills for effective leadership by a psychiatrist
Conclusion
References
Chapter 8: Leadership and Decision-Making
Introduction
Decision-making versus problem-solving
Psychology of decision-making
Clinical decision-making
Experts and expertise
Conclusions
References
Chapter 9: Team-Building in Psychiatry
Introduction: leaders in psychiatry – as team builders and team leaders
Team characteristics and team dynamics
Methods and requirements for team leaders in team-building and team development
Future perspectives
References
Chapter 10: Coaching and Mentoring
Introduction
Definitions
Using coaching and mentoring
The impact of coaching and mentoring
Coaching for health
Diversity and equality
Models for coaching
‘The time for mentoring is now’
References
Chapter 11: Leadership and Factions
The benefit of using planned political interventions
Lead your service from the understanding that it is within a system
Make best use of time and relationships
Develop the most effective personal communication style
Designing for successful implementation of change
Acknowledgement
Further reading
Chapter 12: Leadership Outside the Clinical Team
Shared leadership
Extended teams in healthcare settings
Leadership and values
Leadership in society at large
References
Chapter 13: Leadership in Academic Psychiatry
Introduction
Mission of academic medicine
From physician-researcher to leader
Research
Knowledge dissemination
Healthcare
Management and administration
Increasing diversity in academic medicine
The Four Capabilities Leadership Framework
Attributes important for success
Conclusions
References
Chapter 14: Taking People With You
Introduction
Which people?
Valuing your team
Taking the mentally ill patient with you
Building partnerships with families and the community
Building partnerships with NGOs
Building partnerships with the local administration and government
Looking beyond borders
References
Chapter 15: Leaders and Managers: A Case Study in Organizational Transformation – the Sheppard Pratt Experience, 1990–2011
Introduction
The evolution of the psychiatric hospital in the United States
Sheppard Pratt in 1990
Changing vision and strategy
Lessons in leadership over the past 20 years – a personal reflection
Lean times ahead
Conclusion
References
Chapter 16: Burnout and Disillusionment
Introduction
The concept of burnout
Doctors in distress
Stress and burnout in mental health workers
How to deal with burnout?
References
Chapter 17: Gender Issues Related to Medical Leadership with Particular Reference to Psychiatry
Introduction – historical background
Present status
Psychiatric leadership
Surveys
Barriers
Strategies to move forwards
References
Chapter 18: Leadership for Good versus Good Leadership in Mental Health
Introduction
Issues in defining a ‘good’ and a ‘right’
Contemporary issues in defining the ‘right’ or ‘rights’ of individuals
‘Rights’ in healthcare
The ‘right’ to healthcare
Parallel ‘goods’ in healthcare
Leadership
‘Good’ leaders in medicine
‘Good’ leaders in mental health
Leadership for the ‘good’ in mental health
Conclusion
References
Chapter 19: Acquiring Leadership Skills: Description of an International Programme for Early Career Psychiatrists
Introduction
Selection of the participants
Structure and content of the courses
Outcome and follow-up of courses
Conclusion
References
Chapter 20: Leadership, Ethics and Managing Diversity
Introduction
What are human rights?
Dealing with diversity
Role of the leader and ethics
Conclusions
References
Part C: Learning Materials
Chapter 21: Assessment Tools
Uses of leadership assessment in a practice
What to assess
Tools for assessing leadership: selection, development and performance
How to use leadership assessment in your practice
Appendix 21.1 Sources of tools for assessing leadership
References
Chapter 22: Learning Materials
Introduction
Chapter 1: What is Leadership?
Chapter 2: What Makes a Leader? Leader Skills and Competencies
Chapter 3: Medical Professionalism, Leadership and Professional Judgement
Chapter 4: Leadership Theories and Approaches
Chapter 5: Clinical Leadership
Chapter 6: Leadership and Clinician Engagement in Service Development
Chapter 7: Communication
Chapter 8: Leadership and Decision-Making
Chapter 9: Team-Building in Psychiatry
Chapter 10: Coaching and Mentoring
Chapter 11: Leadership and Factions
Chapter 12
Chapter 13: Leadership in Academic Psychiatry
Chapter 14: Taking People With You
Chapter 15: Leaders and Managers: A Case Study in Organizational Transformation
Chapter 16: Burnout and Disillusionment
Chapter 17: Gender Issues Related to Medical Leadership
Chapter 18: Leadership for Good versus Good Leadership in Mental Health
Chapter 20: Leadership, Ethics and Managing Diversity
Chapter 23: Conclusions
Index
This edition first published 2013 © 2013 by John Wiley & Sons, Ltd
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Library of Congress Cataloging-in-Publication Data
Leadership in psychiatry / edited by Dinesh Bhugra, Pedro Ruiz, Susham Gupta. p. ; cm. Includes bibliographical references and index. ISBN 978-1-119-95291-6 (cloth) I. Bhugra, Dinesh. II. Ruiz, Pedro. III. Gupta, Susham. [DNLM: 1. Leadership. 2. Mental Health Services-organization & administration. 3. Communication.4. Medical Staff-organization & administration. 5. Professional Competence. WA 495] RC467.95 616.890068-dc23
2013015838
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not beavailable in electronic books.
Cover image: iStockphoto.com/Dmitry MerkushinCover design by Sarah Dickinson
List of Contributors
John P. Baker
Assistant Professor
Center for Leadership Excellence
Western Kentucky University
Bowling Green, Kentucky, USA
Dinesh Bhugra
Professor of Mental Health and Cultural Diversity
Institute of Psychiatry, King's College London
London, UK
Kenneth G. Busch
Psychiatrist
Chicago, Illinois, USA
Nicholas Deakin
Academic Foundation Year
Barts Health NHS Foundation Trust
London, UK
Klement Dymi
Research Assistant
Psychiatric Centre Ballerup
Hellerup, Denmark
Cindy L. Ehresman
Program Manager
School of Leadership Studies
Western Kentucky University
Bowling Green, Kentucky, USA
Wolfgang Gaebel
Professor, Department of Psychiatry and Psychotherapy
LVR-Klinikum Düsseldorf
Medical Faculty
Heinrich Heine University
Düsseldorf, Germany
Patrick Gatonga
University of Nairobi
Nairobi, Kenya
Maja Gawronska
Stein Institute for Research on Aging
University of California, San Diego (UCSD)
Department of Psychiatry
San Diego, California, USA
Susham Gupta
Consultant Psychiatrist
East London NHS Foundation Trust
Assertive Outreach Team – City & Hackney
London, UK
Denise Harris
Clinical Facilitator
Professional and Practice Development Team
Sussex Community NHS Trust
Zachary Merton Hospital
Rustington, West Sussex, UK
Dilip V. Jeste
Estelle and Edgar Levi Chair in Aging
Director, Sam and Rose Stein Institute for Research on Aging
Distinguished Professor of Psychiatry and Neurosciences
Director of Education, Clinical and Translational Research Institute
University of California, San Diego
San Diego, California, USA
Marianne Kastrup
Competence Center for Transcultural Psychiatry
Psychiatric Centre Ballerup
Hellerup, Denmark
Andreas Kuchenbecker
LVR-Academy for Mental Health
Solingen, Germany
Levent Küey
Associate Professor of Psychiatry
Istanbul Bilgi University
Istanbul, Turkey
Juan José López-Ibor
Departamento de Psiquiatría, Facultad de Medicina
Universidad Complutense, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC)
Fundación Juan José López-Ibor
Madrid, Spain
María Inés López-Ibor
Director, Departamento de Psiquiatría, Facultad de Medicina
Universidad Complutense, CIBERSAM (Centro de Investigación Biomédica en Red de Salud Mental)
Fundación Juan José López-Ibor
Madrid, Spain
David M. Ndetei
Professor of Psychiatry
University of Nairobi
Director, Africa Mental Health Foundation
Nairobi, Kenya
Ahmed Okasha
Director of WHO Collaborating Center for Research and Training in Mental Health
Okasha Institute of Psychiatry, Ain Shams University
Cairo, Egypt
Zoë Reed
Director of Strategy and Business Development
South London and Maudsley NHS Foundation Trust
London, UK
Blanca Reneses
Deputy Director
Instituto de Psiquiatría y Salud Mental
Instituto de Investigacion Sanitaria (IdISSC)
Hospital Clínico San Carlos Departamento de Psiquiatría, Facultad de Medicina Universidad Complutense
Madrid, Spain
Robert Roca
Vice President and Medical Director
Sheppard Pratt Health System
Baltimore, Maryland, USA
Hugo Rodriguez
Head of Inpatient Unit
Institute of Psychiatry
National University of Asunción
Asunción, Paraguay
Wulf Rössler
Professor Emeritus, University of Zurich, Switzerland
Senior Professor, Leuphana University, Lüneberg, Germany
Professor of Post-Graduation, University of Sao Paulo, Brazil
Pedro Ruiz
Professor and Executive Vice Chair
Director of Clinical Programs
Department of Psychiatry and Behavioral Sciences
Miller School of Medicine – University of Miami
Miami, Florida, USA
Norman Sartorius
President, Association for the Improvement of Mental Health Programmes
Geneva, Switzerland
Steven S. Sharfstein
President and Chief Executive Officer
Sheppard Pratt Health System
Baltimore, Maryland, USA
Alex Till
Foundation Year 1
Leicestershire, Northampton & Rutland Foundation School
East Midlands Workforce Deanery
Northampton, UK
Julio Torales
Professor of Psychiatry
Professor of Medical Psychology
School of Medical Sciences
National University of Asunción
Asunción, Paraguay
Rebecca Viney
Coaching and Mentoring Lead
Associate Dean
Professional Development Department
London Deanery
Stewart House
London, UK
Hugo de Waal
Consultant Old Age Psychiatrist
Norfolk & Suffolk NHS Foundation Trust
South London & Maudsley NHS Foundation Trust
Associate Postgraduate Dean, East of England Deanery
The Julian Hospital
Norwich, UK
Sidney Weissman
Professor of Clinical Psychiatry
Feinberg School of Medicine
Northwestern University
Chicago, Illinois, USA
Noemi Wulff
LVR-Academy for Mental Health
Solingen, Germany
Jürgen Zielasek
Department of Psychiatry and Psychotherapy
LVR-Klinikum Düsseldorf
Medical Faculty
Heinrich Heine University
Düsseldorf, Germany
Preface
Clinical leadership is vital in looking after patients, managing resources and responding to the needs of families and carers of patients. However, only in the last few years has attention increasingly been paid to aspects of leadership and training. In medical schools, as well as other training environments, very limited exposure to leadership situations is made available. Hence, often those in clinical leadership situations learn on the job.
There is always a tension regarding whether leaders are born or made. The truth is somewhere in the middle. Certain leadership skills can be learnt, such as managing teams, managing resources and communication skills. On the other hand, certain personality skills are present from birth. This combination of nature and nurture can make a good leader who is capable of doing the best for their patients and making the most of the available resources. Leadership does not occur in a vacuum and leaders need followers. Why followers choose one leader rather than another depends upon a number of factors. Charisma, passion, courage and communication, along with technical competence, are some of the qualities possessed by successful leaders.
At the core of clinical leadership is the patient, whose clinical needs must be paramount. Services need to revolve around the patient, and the clinical leader has to take these into account in acquiring and managing resources. Clinical leaders must remain focused on clinical matters, but also on the social, political and economic context within which they may provide services.
Clinical leadership in mental health services carries with it certain responsibilities, and specific competencies and skills are required. Planning and delivering services, whether these are in the public sector or the private sector, is a critical aspect of the role the clinical leader plays. In addition, the task for the leader is to set the direction for the planning and delivery of services. This focus requires personal qualities such as self-awareness, self-management and self-development. Part of the continuing professional development must focus on these skills. Keeping up to date and being technically competent is vital for any clinical leader so that they can convey professional values and views with confidence. Any worker in a clinical setting must work with integrity and honesty.
Clinical leaders also need to have vision about the healthcare delivery, along with the passion to communicate their vision to the key stakeholders. Leaders also need the skills to mentor team members and support them when needed. Managing teams and resources is an important function of the leader's role. The leader must maintain professional standards and understand decision-making processes as well as theories of leadership.
It is part of the profession's responsibility to ensure that the next generation of leaders have the appropriate skills mix and are fully aware both of theoretical and practical aspects of leadership. Humility with wisdom must be the hallmark of a good leader, and we hope that this volume will contribute to obtaining these skills.
This volume brings together a team of international experts with clinical and non-clinical backgrounds to pull together the theories and practical skills required to be a successful leader. Inevitably, there is some overlap between chapters, but we have deliberately left this so that chapters can be read independently of each other. We are grateful to our contributors, who in spite of their busy schedules managed to deliver their chapters and have been a source of inspiration as well as support. Our thanks also go to Joan Marsh and her team at Wiley-Blackwell.
Andrea Livingstone brought sterling support and energy to the project. Without her steer and hard work, this volume would not be in the wonderful shape it is in now. We are grateful to her.
Dinesh Bhugra, Pedro Ruiz and Susham Gupta
Part A
The Role of the Leader
Chapter 1
What is Leadership?
Dinesh Bhugra, Susham Gupta and Pedro Ruiz
Introduction
Leadership is crucial in any sphere of life. The meaning and functions of leadership are influenced by a number of factors, including culture and the role of leadership. Leaders lead because their role is to act with vision related to an organization or an institution. The task of the leader is to provide a blueprint for members or people to follow. This may include political parties, business organizations, membership organizations and social organizations. Leaders exist because there are followers. Often individuals put themselves up for such roles, or are thrust into leadership positions.
There has to be some degree of self-awareness in the first instance, whereas in the second instance it is the status of the individual or the family/kinship or organization they come from which pushes them into leadership roles. The latter has been repeatedly shown in politics, for example, in the Indian subcontinent, where children, spouses or siblings of leaders who die in harness are encouraged to take on their leading responsibilities, or in the United States, where the family names can provide a platform for entry into local or national level politics. Furthermore, leaders may take on the task for a single specific objective, whatever it is, for practical ends, or to deliver a specific result. The leadership styles will differ in a number of ways and may be influenced by the specific purpose for which leadership is sought or offered.
In this chapter, we propose to set out some broad principles for the readers of this book. The focus of the book remains on leadership in the mental health profession.
What is leadership?
Leadership can be conceptualized in a large number of ways.1 Leadership is the focus of the group processes as described by Bass.2 But it is more than that. It is a concept and a process, both of which are embedded in a single person, but rarely in a body of individuals. Northouse3 illustrates leadership by the power relationship that exists between leaders and their followers. Leadership can be transformational, involving management of change, and carries with it a skills set to influence individuals, events and processes. The specific task(s) related to leadership roles can be carried out only with the implicit or explicit consent of followers.
Northouse3 asserts that while some are leaders, those towards whom the leadership is directed can be seen as followers. Both are needed in our understanding of the process of leadership. Neither the leader nor the followers can exist in a vacuum. However, who initiates this relationship is an interesting question. Embedded within the question is the purpose, function or goal of leadership. Leaders are not above their followers, but often, in politics especially, the power differential is so great that there may be a chasm between the leader and the followers.
Leadership is both a trait and a process. Development of leader and leadership skills and traits can be attributed to the family and early life.4 According to Zaleznik, 4 provision of adequate gratification in childhood can lead to a harmony between what individuals expect from life and what they achieve. On the other hand leadership skills can be developed within organizations due to the need for changes, or be honed through mentorship.
Skills needed in and for leadership roles
Leadership requires a certain set of skills. In an impressive explanation of skills approach, Northouse3 points out that the skills needed are technical, human and conceptual, although levels required in different roles will vary. In some settings and at some levels the skills mix will be different. A crucial element is the role of technical competence. Technical skills are about proficiency in a particular specialized area with analytical ability in that field and to use appropriate tools and techniques.5 Technical competence becomes incredibly significant in the field of mental health, where the leader has to be able not only to understand technical aspects but also be able to communicate these to the key stakeholders. Technical competence is critical in convincing the funders if services are to be developed in a certain framework. In the Northouse modified model of Katz, 5 it is argued that at higher levels (e.g. top management), technical aspects are not as critical; but in the field of clinical sciences as well as mental health, technical knowledge is helpful. In their model, technical skills are concerned with working with things. In clinical matters, it is useful to know about conditions and potential treatments, which also gives the leader a degree of credibility. Understanding of the complexities and nuances of mental health is crucial in understanding, advocating and garnering of accurate resource allocation. Interestingly, along with technical competence, clinicians also have to possess human and communication skills, which are concerned with dealing, negotiating and working with people. These skills enable the leader to work with followers, delegate tasks appropriately and mentor followers. With these skills, it is possible for the leader to trust others and create an environment of trust, where followers can express their views and feel listened to. A good leader is sensitive to the needs of others and will take them into account. These skills become increasingly relevant higher up the leadership ladder.
The third set of skills are conceptual and deal with the ability to work with ideas and concepts.3 It can be argued that in some ways these are the most significant skills. These are at the core of strategic thinking and are central to creating a vision and plan for an organization or functionality of the organization. These are the central essential skills that allow a leader to express their vision and bring about changes.
Individual style and competencies in problem-solving, effective communication, passion and courage are important attributes of leadership. Clinicians are aware of and trained in developing hypotheses and then testing these to devise diagnostic and management strategies. Therefore, they are better placed at problem-solving and looking at problems ‘outside the box’. Creative abilities for solving complex management problems in the organization include good judgement in defining problems and formulating solutions, which is essential in the armoury of leadership skills.6 Identifying problems and solutions is one aspect, but communicating these effectively and gaining the support of others are equally important in achieving change. Along with problem-solving and social judgement skills, the capacity to understand people and social systems is helpful. Mental health professionals, by virtue of their training, must be able to utilize these skills in working with others, enthusing, supporting and mentoring them. Part of the conceptual ability is to take a perspective that is equivalent to social intelligence7 or emotional intelligence.
Northouse3 points out that, at an individual level, general cognitive ability, crystallized cognitive ability, motivation and personality all will play a role in leadership skills. Career experiences and environmental influences will also play a role in decision-making and leadership abilities.
A major challenge to this model is its breadth, which not every leader may be able to match. Although Northouse3 indicates that its predictive value is weak, it is not entirely clear whether this poor predictive value also applies to clinical settings. Furthermore, an added problem with any competencies model is the actual level of competencies obtained. The behaviour of the leader may not be related to skills. The style approach of leadership focuses both on tasks and relationships. Both the task and the relationship will also depend upon the context within which leadership works – and this is where the situational approach to leadership may work. The situational approach sees the leader as having directive and supportive dimensions. Northouse3 classifies leadership styles into:
high directive–low supportive;high directive–high supportive;high supportive–low directive;low supportive–low directive.These are self-explanatory.
Leaders: born or made?
As noted earlier, organizations help to identify and develop leaders. Peer review and training can be both productive and destructive, depending upon how it is carried out. Zaleznik4 notes that peer reviews may influence managerial skills more than leadership skills. There is no doubt that our individual personality traits allow us to develop certain skills. For example, extrovert individuals may find it easier to communicate than introverts. In addition, other personality traits, such as aggression, may be more inherent. This means that some skills needed for leadership are innate, whereas others can be learned. The abilities to manage conflict, to negotiate and to manage resources can be acquired through direct observation, training and mentoring. Learning to develop strategy and develop expertise in a field is possible through training. Leaders have to learn how to manage change and how to make the most of opportunities that can emerge from such change. Strategic direction for an organization can develop from extensive analysis of the functions of the organization and testing strategic scenarios in the context of complexity, technological advances, geographical factors and organizational structures.8
Some leaders, by virtue of their own personality traits, can manage change effectively, whereas others feel the need to maintain the status quo irrespective of what might be the needs of the organization at that particular time. Challenges related to change are strategic, technical, adaptive or rejecting. Individual personality traits will influence the type of approach used. Managing distress related to change and inherent ambiguity in change is important for any leader. Psychiatrists, by virtue of their training, should be more capable at sensitively dealing with ambiguity and uncertainty. It is also helpful that psychiatric training teaches individuals to deal with group dynamics and to explore not only what is being conveyed openly, but also what is not. These can help individuals and the organizations adapt to change. Heifetz and Laurie9 observe that, at first, a leader must be able to create a holding environment which is a temporary ‘place’ or an ongoing safe space where ideas can germinate and grow. These skills are both inherent and acquired.
Heifetz and Laurie9 propose that in adaptive work leaders have to take on the responsibilities for direction, protection, orientation, managing conflict and shaping norms requiring technical and adaptive skills. These authors suggest that good leaders encourage those below them to speak up, participate actively and contribute their skills. In addition, good leaders must also maintain disciplined attention to their views, and be able to give constructive feedback and justify their decision-making. Pilot training and working on a flight crew provide an excellent example of where any member of the team can point out problems without fear or ridicule, the primary aim of which is to reduce overall risk. In the healthcare services, certainly in the United Kingdom, whistle-blowing is still not widely encouraged. Technical orientations of the leadership role can be learned and this competence stands the leader in good stead.
Team leadership and managing teams
Different styles and competencies are needed work in teams. The structure and function of the team and the personalities of team members will play key roles in determining how the leader is allowed to lead. In this context, we identify a single leader for the team rather than the (entire) team in a leadership role. The latter model may work in some executive committees but a leader is still required to play a central role in allowing decision-making by the group and to liaise and negotiate with outside agencies and stakeholders, and to communicate outcomes back to the group. In mental healthcare delivery teams the leader is the driver in ensuring that the team is effective. Hill10 points out that leaders must have a ‘model’ of a situation wherein the model reflects not only the components of the problems faced by the team but also the environmental and organizational contingencies affecting the smooth functioning of the team. Flexibility, vision and a broad range of skills are required for this. As mentioned earlier, mental health professionals are trained to understand group dynamics; so, theoretically, they should be able to run teams effectively by managing them. However, this observation does not take into account individual personalities as well as their roles and functions within the team. A range of options is available to leaders. They will have to assess internal and external factors and monitor the situation and reach decisions. Mentoring team members and enabling them is part of the responsibility of the leader to ensure that the team works as an effective functional unit.
Manager or leader?
Mintzberg11 notes that if managers are asked what they do, they are most likely to say that they plan, organize, coordinate and control; but when observed in their role, what they actually do often does not correspond to what they say they do. Managerial activities are said to be characterized by brevity, variety and discontinuity. Mintzberg11 goes on to highlight that managers have formal authority and status and their interpersonal role as figurehead has associated informational roles as monitor and decisional roles as negotiator, allocator of resources and entrepreneur.
Leadership complements management and does not replace it
Kotter12 argues that management is about coping with complexity, and its practices and procedures are in general a response to the development of large and complex organizations, whereas leadership is about coping with change. Both leadership and management require decisions, especially as to what needs to be done, thus creating networks of people and relationships that can accomplish an agenda and ensure that these tasks are carried out effectively. However, the manager and the leader do these differently: a manager will identify resources, whereas a leader will set the direction. Zaleznik4 observes that the managerial culture emphasizes nationality and control and may adapt passive attitudes towards goals. The role of the manager and the leader may be entirely separate, embedded in each other, or may have slight overlap.
Psychodynamic understanding of leadership
Leadership as a process itself can be understood by looking at psychodynamic aspects. Similarly, the dynamic aspects of the personality of the leader are also of interest in explaining decision-making and leading. There have been various studies of leaders using psychoanalysis as a process by which the leader's actions can be understood.4,13,14 There have also been studies of illnesses (physical and psychiatric) that various leaders have suffered and how these may have influenced their decisions in leadership roles.15,16
There is no doubt that childhood experiences and child rearing patterns will influence how an individual develops. In early life children start by idolizing their parents and older siblings and then, as they grow older and attempt to find an individual identity, they tend to identify external figures as role models, for example pop stars, teachers, leaders, film stars or other celebrities. Hero worshipping can influence their subsequent behaviour, thinking, values and development. There is always a risk of attributing leadership roles to these role models, even if they are not true leaders. Stech17 points out that the psychodynamic approach starts with the analyses of human personality, and these are then related to leadership levels and types. These personality traits are deeply ingrained. The psychodynamic approach also explores unconscious motives both of leaders and their followers. Stech17 provides further details of transactional analysis and Freudian theories, which readers will find extremely helpful. Jungian personality types also provide an insight into the way a leader behaves.
Krueger and Theusen18 remark that leadership involves the use of power, comprising both the personal and organizational. This is especially relevant when looking at the leadership roles of clinicians, particularly psychiatrists, as the latter have the legal power to deprive patients of their liberty and have the organizational power to medicate them against their will. The personality traits of the leader – whether they are an extrovert, introvert, thinker, intuitor, etc. – dictate the way they may respond to crises and how they reach decisions.
Leaders also have different ways of dealing with followers. In some cases, especially with extreme right-wing political ideology, the use of uniforms may be used to give a definite message, 19 as will wearing a white coat. The primary aim of the psychodynamic approach is to make both the leader and the follower aware of personality types and of underlying motives. In working with others, there may be unconscious motives that need to be identified, understood and explained if pragmatic decisions are to be reached. Stech17 highlights the strength of the psychodynamic approach in analysing the relationship between the leader and the follower. Stech also recognizes weakness of the psychoanalytic approach due to its focus on personality traits. The approach remains attractive as it explores both the personality and the unconscious motives.
Key qualities of successful leaders
Communication
Even if the leader has an excellent vision of the development and direction of the organization, they may not be able to communicate their decisions effectively for the followers to realize and accomplish the vision. Charismatic leaders are good at listening and communicating with others. Effective and successful leaders convey their message in a straightforward way that allows followers to understand their roles and tasks clearly. Communication style may be intuitive but can also be learned. The basic communication model as described by Weightman20 is about encoding the message, transmitting it in the context of the environment on the one hand, and decoding information and providing feedback on the other. The communication feedback loop is helpful in conveying even the most complex messages.21 Communication networks can be of different varieties, such as chain, circle, wheel, all-channel, Y or inverted Y.22 In order to succeed, good leaders follow both upward and downward methods of communicating with their followers. Effective communication within an organization means giving the same clear message to everyone, changing behaviour, improving motivation or sharing information.23 Active listening and paraphrasing are important aspects in the stages of learning.24 Leadership carries with it ethical and confidential responsibilities. Informed decision-making is discussed in Chapter 8.
Managing conflict
In professional settings in clinical practice, it is inevitable that conflicts may arise within teams. Clinical leaders need to be aware of potential areas that may lead to conflict and have strategies in mind to deal with these situations.
Barr and Dowding24 point out that conflict may be seen as negative and confrontational, but also can be a positive way of bringing growth to the team. Obviously it depends on the type of conflict, the reasons for it, and how the conflict is managed and resolved. These authors go on to describe various levels of conflict, which are: intrapersonal (i.e. within the individual); interpersonal (between two or more people perhaps related to their beliefs, values, roles and rules); and intergroup conflict, which may be across professional groups or organizations. The responses as a result of conflict also vary both at individual and group levels. Conflict can result from overt and covert objectives and motives, differences in perceptions at various levels of organizations, resource management, and poor clarity of roles and responsibilities. The ‘symptoms’ as a result of conflict can be poor communication, frustration, rivalry, jealousy, friction at individual and professional levels, and loss of control or increased control as a response to conflict. If not tackled appropriately, the conflict can adversely affect the organization as well as the individual.
A leader can manage conflict using a number of strategies. These include: creating a friendly atmosphere; helping everyone to feel valued and part of the team; supporting and looking after colleagues; showing public acknowledgement and appreciation; and demonstrating respect and consideration towards others.24
Conflict can be avoided but in some settings it may be worthwhile building this up constructively to reach a satisfactory conclusion. Various options available to the leader include avoidance, accommodation, compromise, creative management and collaboration. Conflict management style may be active or passive. Thus leaders have to choose a way of dealing with the conflict according to their personality style.
Clinical leaders may need to use both personal and organizational strategies to manage conflict. Within such management, skills related to negotiation, ethics, confidentiality and objectivity are critical. Furthermore, cultural conflicts may become more relevant if team members are not aware of cultural nuances and differences. Hofstede25 described cultural context in five dimensions while studying culture within IBM. These five dimensions are: distance from the centre of power, uncertainty avoidance, individualism-collectivism, femininity-masculinity and long-term orientation. They are vital in the understanding of cultural values and managing conflict that may be related to cultural variations.
Most professional organizations and regulatory bodies have policies on working in teams and collaborating. A competent clinical leader will thus be fully aware of potentials for tensions and negative conflicts, how these can be avoided, and if they happen how best these can be managed. Teams will have their own stages, whether they are new or old, mature and experienced. The type and degree of conflict therefore may be related to this setting as well, and the clinical leader may have to take this into account in managing conflict.
Gender and leadership
It is well known that gender plays a key role in leadership styles (also see Chapter 17). Rosener26 argued that men were more transactional leaders and women had transformational styles. However, as Barr and Dowding24 point out, in the last two decades this approach may well have become less evident. Certainly gender plays a key role in communication, collaboration and conflict management styles. Men and women socialize differently, 27 and their roles, how they relate to colleagues, and their perceived and real power in teams will also vary. These differences are important in our understanding of leadership styles.
Solving problems as leader
Problem-solving is part of the clinical role of the clinical leader. This allows a degree of conflation between decision-making and problem-solving, which is not entirely accurate. As problem-solving focuses on the root cause of the problem so that it can be understood and dealt with, this process is different from decision-making, which itself may be a part of the problem-solving activity. However, the organizational approaches of problem management are four-fold.24 These include classical management, human relations, systems and contingency. Recognition of the nature of the problem is the first step, followed by assessment of the impact and the implication of the problem with an understanding of identifying outcome success criteria, actual decision-making and communicating solutions. The type of problem will obviously dictate how it is identified and solved. Problems have been described as simple (also called difficulties) or hard (complex) problems.28 Complex problems may have more than one component and may be interrelated or even interdependent.
The steps in problem-solving are related to correct identification of the problem and gathering the right information and data, which will lead to the exploration of a range of alternative solutions, selecting the right option, implementing it, evaluating the success and communicating it effectively. Some of the solutions may have to be found by delegating matters to other members of the team.
Delegation of responsibilities
No leader can manage all the activities expected of them. It is inevitable that some matters will have to be delegated. This process is key in managing time as well as in managing teams, where the ultimate responsibility continues to rest with the leader but the person to whom the task has been delegated becomes responsible to the superior for carrying this out. Leaders may retain authority and responsibility as well as a degree of accountability. Accountability within the healthcare delivery system is within the regulatory structures of the individual's profession as well as civil, employment and criminal law. The culture of any organization and type of leadership will determine what type of delegation is allowed to occur. The act of delegation is also part of the process by which individuals within the team are supported and, indeed, encouraged to develop skills to take on additional responsibilities. Leaders influence the culture of the organization and the organization itself will allow the development of leadership skills and strategies.
Conclusions
Leadership means different things to different individuals in different settings. The art of leadership can be both acquired and influenced by a number of factors. Theories of leadership provide an overview of tasks that a leader may face. The culture of the organization on the one hand, and gender, personality traits, education and experience of the leader on the other, will produce an interaction that will affect the growth and the strategy of the organization. Leaders need followers, and leadership styles will be determined by the type of task that needs to be completed. Skills related to problem-solving and conceptual and strategic skills are all key in any leadership role. Clinical leadership can mean both leadership by clinicians as well as by those leading on clinical matters in clinical settings and healthcare structures. Clinicians are generally aware of decision-making and problem-solving, which makes it relatively easier for them to take on leadership roles. Various models of leadership provide an insight into our understanding of clinical leadership.
References
1. Fleischman E, Mumford M, Zaccaro S, Levin K, Korothis A, Heim M. Taxonomic efforts in the description of leader behaviour: a synthesis and functional interpretation. Leadership Quart 1991; 2:245–87.
2. Bass BM. Bass and Stogdill's Handbook of Leadership. New York: Free Press, 1990.
3. Northouse P. Leadership: Theory and Practice. Thousand Oaks, CA: Sage, 2007.
4. Zaleznik A. Managers and leaders: are they different? In: Harvard Business Review on Leadership. Boston, MA: HSB Press, 1977; reprinted 1998; pp. 61–88.
5. Katz RL. Skills of an effective administrator. Harvard Bus Rev 1955: 33:33–42.
6. Mumford MD, Zaccaro S, Harding F, Jacobs T, Fleischman EA. Leadership skills for a changing world: solving complex social problems. Leadership Quart 2000; 11:11035.
7. Zaccaro S, Gilbert J, Thor K, Mumford M. Leadership and social intelligence: linking social perspectiveness and behavioural flexibility to leader effectiveness. Leadership Quart 1991; 2:317–31.
8. Farkas CM, Wetlaufer S. The way chief executive officers lead. In: Harvard Business Review on Leadership. Boston, MA: HBS Press, 1998; pp. 115–46.
9. Heifetz RA, Laurie DL. The work of leadership. In: Harvard Business Review on Leadership. Boston, MA: HBS Press, 1998; pp. 171–98.
10. Hill SEK. Team leadership. In Northouse P (ed.), Leadership: Theory and Practice. Thousand Oaks, CA: Sage, 2007; pp. 207–36.
11. Mintzberg H. The manager's job: folklore and fact. In: Harvard Business Review on Leadership. Boston, MA: HBS Press, 1998; pp. 1–36.
12. Kotter JP. What leaders really do. In: Harvard Business Review on Leadership. Boston, MA: HBS Press, 1998; pp. 37–60.
13. Berens L, Cooper S, Ernst L et al. Quick Guide to the 16 Personality Types in Organisations. Huntingdon Beach, CA: Telos, 2001.
14. Maccoby M. The Leader: A New Face for American Management. New York: Ballantine, 1981.
15. L'Etang H. Fit to Lead. London: William Heinemann Medical Books, 1980.
16. L'Etang H. The Pathology of Leadership. London: William Heinemann Medical Books, 1969.
17. Stech EL. Psychodynamic approach. In: Northouse P (ed.), Leadership: Theory and Practice. Thousand Oaks, CA: Sage, 2007; pp. 237–64.
18. Kreuger O, Theusen JW. Type Talk at Work. New York: Dell, 2002.
19. Bhugra D, de Silva P. Uniforms: fact, fashion, fantasy or fetish. Sexual and Marital Therapy 1996; 11: 393–406.
20. Weightman J. Introducing Organisational Behaviour. Harlow: Addison Wesley Longman, 1999.
21. Shannon C, Weaver W. The Mathematical Theory of Communication. University of Illinois Press, 1954.
22. Leavitt HJ. Some effects of certain communication patterns on group performance. J Abnorm Soc Psychol 1951; 46:38–41.
23. Greenbaum HW. The audit of organisational communication. In: Weightman J (ed.), Introducing Organisational Behaviour. Harlow: Addison Wesley Longman, 1999; p. 70.
24. Barr J, Dowding L. Leadership in Health Care. London: Sage, 2008.
25. Hofstede G. Culture's Consequences. Thousand Oaks, CA: Sage, 2001.
26. Rosener J. (1990) Ways women lead Harvard Business Review. In Markham G. Gender in leadership. Nursing Management 1996; 3:18–19.
27. Grohar-Murray ME, Di Croce H. Leadership and Management in Nursing. London: Prentice-Hall, 2002.
28. Ackoff A. The art and science of mass management. In: Mabey C, Mayon-White B (eds), Managing Change. London: Paul Chapman, 1981; pp. 47–54.
Chapter 2
What Makes a Leader? Skills and Competencies
Juan J. López-Ibor, Blanca Reneses and María-Inés López-Ibor
None of the different ways to approach the study of leadership cover all the diverse characteristics of a subject that is key in management. The traditional perspective emphasizes the personal characteristics of the leader, that is, the personality traits that facilitate or hinder his or her function. A second approach focuses on the behaviour that ‘makes’ the leader effective. The third perspective considers the situation in which the leadership process takes place, and therefore the group the leader runs and the context in which the process happens.
In this chapter we will consider the more personal aspects of leadership in its broadest sense, and how to put them into practice, while considering the crucial role of the context in which leader and workforce function. Of course we will highlight the specific requirements for leadership in the field of psychiatry and mental health.
Leader and leadership
The English words leader and leadership have been incorporated exactly so in most of the languages of the world. The reason is that putative translations may convey a very negative meaning. Caudillo in Spanish, führer in German or duce in Italian are good examples. Etymologically caudillo comes from the Latin caput ‘head’, from where also derives captain. The German führer, derived from fahren ‘to drive’, and the Italian duce from ducere, also ‘to drive’, denote persons who guide unchallenged. Instead, in the managerial jargon, leader and leadership have a positive meaning as they are fundamental elements of good quality management. Leadership is put into practice taking into account the best interests of the organization, basically because the organization's roles serve the best interests of the individuals in the organization, the clients and society at large. Therefore we have to keep in mind this distinction between a ‘leader’ and a caudillo, to say the least.
Leader
In its purest sense a leader is somebody whom people follow, someone who drives or directs other people. However, the term ‘leader’ is used in many different senses and has been abused to include anyone having any responsibility involving people in an organization. Yet there is far more involved in the fact of being a leader than simply holding a role.
A leader1 is a person who holds a dominant or superior position within their field, and is able to exercise a high degree of control or influence over others. The leader may or may not have any formal authority, and more often than not they surpass the institutional role that they hold.
A pragmatic point of view considers an effective leader ‘as an individual with the capacity to consistently succeed in a given condition and be viewed as meeting the expectations of an organization or society’.2 A leader comes to the forefront in case of crisis, and is able to think and act in creative ways in difficult situations. Unlike management, leadership flows from the core of a personality and cannot be taught, although it may be developed and enhanced through coaching or mentoring.
Some organizations follow a traditional model of profitability, based on figures (i.e. the bottom line, number of visits, length of stay) while others adopt a more innovative approach, with leaders that strive to bring out the best in their teams, in order to enable people to contribute to the goals of the organization more creatively. This approach is essential in the healthcare sectors, where one of the functions of (clinical) leaders is to confront the economic demands of their superiors, namely the administrators of a Managed Care Organization or of a National Health Care System approach.
Leadership
Leadership is the ability to organize a group of people to achieve a common goal. Leadership is also the process of social influence whereby one person can enlist the collaboration and support of others in the achievement of a common task.3
Leadership has also been defined as:1
The so-called ontological–phenomenological model for leadership4 (see below) considers leadership as ‘an exercise in language that results in the realization of a future that wasn't going to happen anyway, which future fulfils (or contributes to fulfilling) the concerns of the relevant parties’. Therefore, leadership is about the future and includes the fundamental concerns of all the relevant parties instead of considering the dualism of a leader and their followers.
Every organization needs leaders at every level. The corroboration of leadership is in the following of the followers. Leadership is all about the influence to change wills, not just about dominance.5 Leadership is a service, not a right nor a position in a hierarchy. A leader should never forget President Kennedy's chiasmus: ‘Ask not what your country can do for you, ask what you can do for your country’. A leader should also convey this attitude to their team.
Management versus leadership6
A manager and a leader function in very different ways, 7,8 although they may share common responsibilities. The fact is that not all managers are leaders, but all leaders are, or should be, managers.
To manage is a designated and structural competence, which must comply with rules and regulations, is hierarchical and tries to control and influence people. In management as such, decisions are routines and are taken within the framework of a strategy already established, based on retrospective analysis, aiming to solve problems and to reduce uncertainty.9,10
To lead, on the other hand, is to manage wills, to provide the framework, values, resources and motivation to members of an organization to enable them to achieve previously agreed goals. Decisions are made from a strategic perspective with a prospective analysis method and tuning the culture of the organization.
Very often a manager is considered a replica of the leader, responsible for communicating the rules and philosophies of the organization to individual employees, and ensuring that they abide by them. A manager is a component in a hierarchical decision-making system. Managers are responsible for maintaining the day-to-day operations of the organization. The functions of a manager are to plan, organize and coordinate. A manager asks ‘how’ and ‘when’ in a passive way and expects to get answers about ‘what’ and ‘why’.
In contrast, the main objective of leadership is to generate changes.11 Leadership is emergent and personal, and has a modus operandi that has moral and ethical components.9,10 A leader has to inspire and motivate and their agenda concerns interpersonal relationships. As implied above, a genuine leader should also be willing to surpass or confront hierarchies and ‘bottom-line’ short-range demands, keeping in mind and encouraging a long-range perspective. Leaders are considered ‘fearless innovators’ in that they challenge the status quo and are unafraid to take big risks in search of excellence.
In other words, management is a kind of a ‘transactional’ leadership (characterized by emphasis on procedures, contingent reward, management by exception) while true leadership is ‘transformational’ leadership (characterized by, e.g., charisma, personal relationships, creativity).12Table 2.1 summarizes the differences between management and leadership, although we have to insist that a leader is also a manager, whereas the opposite should not be sustained.
Table 2.1 Management versus leadership. Modified from Lease77
View of managerView of leaderGoalsTo maintain and exploit business advantages78To plan and budgetTo organize and staff79To keep the current system functioning80Goals arise out of necessity8To successfully achieve organizational transformation78To manage wills, to provide the framework, values, resources and motivationTo generate useful changes11Goals arise out of vision8Kind of competenceA designated, hierarchical and structural competence, which must comply with rules and regulations10,11To solve problems81Decisions are made from a strategic perspectiveTo manage dilemmas81Methods of workTo control and influence peopleTo create stability82Surrenders to the context, focus on the bottom line, on systems and structure, on tactics, accepting the status quo83Controlling and problem-solving79Prospective analysis method, tuning the culture of the organization9,10Masters the context, focus on the horizon, on people. Challenging the status quo83Motivating and inspiring peopleTo explore opportunities84Attributes of workFacilitator84Emphasis on rationality and control82Innovator, risk-taking, flexible, active83Emphasis on inspirationRequired personal characteristicsIntelligence, analytical ability, persistence, tolerance, goodwill8Tolerance of chaos, passion, intensity, empathetic8Expected outcomesPredictability, order, consistent production of key results85Dramatic and useful changes (new products, new approaches, new processes)85The Managerial Grid, 13,14 which we would prefer to call a ‘Leadership Grid’, is a graphical tool for evaluating leader behaviour along two basic attributes: concern for production (straightforward management) and concern for people (authentic leadership). The managerial grid model13 distinguishes five leadership styles with varying concerns for people and production (Figure 2.1):
The impoverished style (point 1, 1), is characterized by low concern for both people and production; its primary objective is for managers to stay out of trouble.The country club style (point 1, 9), is distinguished by high concern for people and low concern for production; its primary objective is to create a secure and comfortable atmosphere where managers trust that subordinates will respond positively.The authoritarian style (point 9, 1), is identified by high concern for production and low concern for people; its primary objective is to achieve the organization's goals, and employee needs are not relevant in this process.The middle-of-the-road style (point 5, 5) maintains a balance between workers' needs and the organization's productivity goals; its primary objective is to maintain employee morale at a level sufficient to get the organization's work done.The team style (point 9, 9), is characterized by high concern for people and production; its primary objective is to establish cohesion and foster a feeling of commitment among workers.Figure 2.1 The managerial grid1,13
The grid is a chiasmus (again) of theory X (management assumes employees are inherently lazy and will avoid work if they can and that they inherently dislike work. As a result, workers need to be closely supervised, and systems of controls implemented, and managers should rely heavily on threat and coercion to gain their employees' compliance)15 and theory Y (management assumes that employees are ambitious, self-motivated, able to exercise self-control, and that they possess the ability for creative problem-solving, but their talents are underused in most organizations). Managers believe that the satisfaction of doing a good job is a strong motivation. Many people interpret theory Y as a positive set of beliefs about workers.16
Effective leadership styles exhibit high levels of both attributes (Figure 2.2).
Figure 2.2 The McGregor XY theory86
Power, authority and leadership
Power is the ability to influence others in their behaviours, attitudes or beliefs. Effective leaders develop and use power. The traditional manager's power comes from their position within the organization. There are various forms of power used by managers to change employee behaviour.17,18
Legitimate power and reward power are most likely to generate compliance, where workers obey orders even though they may personally disagree with them. Coercive power most often generates resistance, which may lead workers to deliberately avoid carrying out instructions or to disobey orders.
Leaders also possess other kinds of power.19Personal power is the tool of a leader who is followed because of the respect, admiration or care that workers feel for this individual and his or her ideas. The following two types of personal power exist:
Expert power results from a leader's special knowledge or skills regarding the tasks performed by followers.Referent power results from leadership characteristics that command identification, respect and admiration from followers who then desire to emulate the leader. When workers admire a supervisor because of the way he or she deals with them, the influence is based on referent power. Referent power depends on a leader's personal characteristics rather than on his or her formal title or position, and is most visible in the area of charismatic leadership.The most common response to expert power and referent power is commitment. Commitment helps team members to overcome fear of change, and it is especially important in those instances.
Another way to describe power is making the distinction between formal and informal power. This dichotomy is closely linked to the concept of formal and informal leadership. Formal power is legitimate power conferred by the hierarchical position in the organization.18 Informal power is instead the result of personal characteristics and integrates ‘referential power’.20 Authentic leadership is associated with personal characteristics and therefore with informal leadership.21
In the healthcare world, and specifically in psychiatric services, the informal power and the expert power lie sometimes with physicians who are not at the highest hierarchical level; conversely, it is not always the professional with the ‘legitimate power’ who has the greatest expert power or referent power. The balanced combination of different types of power is important in a leadership position. Therefore, it is necessary that the leaders of the medical services in general, and psychiatric and mental health in particular, cultivate not only the expert power, but also the power of reference.22,23 The skills specific to reference power can be learned. Leaders with significant medical expert power can develop skills that increase their power of reference such as communication skills, to negotiate differences or for conflict management.
Leadership and charisma
Charisma is a leadership feature that is difficult to define. Charisma is all about personal traits and skills that are hard to acquire because they cannot be easily learned; rather, charisma is regarded as a personal gift that seduces or attracts others. The charismatic leader is able to influence how individuals or the group identify with the goals.21
Charisma can be defined by taking into account the personality of the leader or those powers conferred by the group. Charisma is an attribute that followers confer on the leader as a result of certain behaviours of the leader, such as the formulation of how a project differs from the status quo of the organization, the ability to take risks to achieve that vision, and the skill to articulate and convey the vision through good communication skills.24–26 Charisma would then depend on the leader's talent to get his or her ‘vision’ shared by the followers.
