Leadership is an intricate construct, with widely disparate qualities and definitions. According to Northhouse (2007) and Giltinane (2013), leadership refers to the focus of several group processes i.e. it is a process of influencing group processes in setting and achieving mutually negotiated goals. By implication, leadership is a contextual construct born out of interactions among leaders and their respective followers. Specifically, Rowe (2007) describes leadership as a process of influencing members of a group to agree on, and understand what needs to be, and how it should be done, as well as the process of mediating group and individual efforts to attain shared objectives. On the other hand, the trait view of leadership conceives it as one or more attributes (e.g. integrity, persuasiveness and personality) innate in some individuals, but that may be encouraged through learning and practice. Within healthcare contexts, leadership is conceived as the direct involvement in clinical care, while also continuously influencing others to enhance the care that they provide, by motivating, inspiring and encouraging desired values, empowering and creating a consistent focus on the patient needs. With the rapid and uncertain changes in healthcare, leadership is absolutely indispensable in shaping the development of shared values, expectations and vision to enhance the healthcare sector’s overall goals and effectiveness (Rolfe, 2011; Giltinane, 2013).
Leaders are visionary motivators, catalysts and goal-driven individuals who command respect, collective vision, and enhanced group culture. The manner and processes through which they achieve their (and their followers’) goals varies depending on the specific leadership styles that they use. Autocratic leadership is a classical style that is probably most employed, but often the least effective, because it relies on a power imbalance between the leader and the follower, which is markedly diminished in many environments characterized by individually powerful/independent experts such as healthcare. Autocratic leadership characteristics include the need for unquestioning obedience, centralized authority, leader-driven group processes, unidirectional communication and reliance on coercion to secure collective action. In modern healthcare contexts, autocratic leadership is limited to the relationship between nursing/medical students and their instructors and/or mentors while in college and on internships. Since instructors and mentors possess considerably more knowledge, experience and authority/power over their followers, including coercive instruments such as hiring, grading the performance or making recommendations on their followers’ which can be used to achieve absolute obedience (Gupta & Singh, 1999; Bolden & Gosling, 2006).
Democratic or participative and affiliate leadership styles draw on the followers skills and knowledge and seeks to create collective commitment to collective goals. Leaders and followers share in the decision-making process, by sharing ideas and alternatives in an environment where they enjoy mutual respect and recognition. Communication is multi-directional, and an emphasis is laid on the collaboration, teamwork, harmony. Affiliative and democratic leadership styles are encouraged in situations of utter uncertainty, in which the direction of the organization is unknown, and leaders need to tap into the followers’ collective wisdom. This leadership style is perhaps best applicable in highly specialized areas in the health care industry, involving highly qualified practitioners, in which leaders are merely “firsts among equals”, but the group takes decisions. For instance, specialists and consultants in different fields may work together on panels with functional leaders, but the judgment and expertise of every member of the group bears similar weight as that of the leader, in solving complex medical and organizational problems. In environments characterized by extreme uncertainty e.g. the introduction of the Patient Protection and Affordable Care Act (2010) in the US promises major disruptions in the market, which requires that care providers, insurers, and other specialists work together to navigate through the uncertainty introduce by the law.
The extreme manifestation of democratic leadership is laissez-faire leadership style, by which all members of the group are free and have the same powers as the leader. The leader is effectively just another group member, with little or no control over the group. Leaders are not in a position to offer any meaningful direction, coordination or cooperation of the followers in the achievement of collective goals. According to Herold, Fedor, Liu, & Caldwell (2008), mature leaders and professionals can thrive under laissez-faire leadership style and full autonomy to act according to their expert judgment. For instance, healthcare systems across the world include independent consultants, whose work and decisions are least influenced by the hospitals for which they consult, but still work towards the achievement of desired patient and organizational goals. However, Goleman (2004) against overly decentralized decision-making (characteristic of democratic, laissez faire and affiliative leadership) for its potential to cause undue delays and crises due to the need to build consesuses every time key decisions are to be taken.
Despite the many changes in healthcare and government systems across the world, the need for bureaucracies to facilitate collaboration among disparate players to attain shared goals remains important. This is not least because the healthcare system interacts with multiple other systems to be efficient and functional. Healthcare policy, for instance, is initiated by political leaderships (the legislature and the executive) and implemented by bureaucrats within and outside the system. Similarly, bureaucratic leadership style has survived the onslaught of novel approaches to leadership, because of its role in achieving basic functionalism in large and complex settings. This leadership style is impersonal and characterized by a defined set of duties and responsibilities, hierarchy, technical expertise and system of regulations that government the relationship (including communication channels) among different people in the bureaucracy. Modern healthcare systems have retained leadership structures, with political leadership being at the top of the chain. It includes the health secretary/minister/president to the matrons and team leaders. This leadership style has little to do with the leader, but the defined roles/responsibilities assigned to the position that they hold (Giltinane, 2013; Bolden & Gosling, 2006).
The bureaucratic leadership is closely related to the transactional leadership style, which involves rewarding followers to incentivize compliance. Transactional leaders focus on managerial functions as against the shared group goals or inspiration, etc. This style is task-oriented and can be effective in meeting set deadlines or in the case of emergencies. When dealing with heart emergency or routine medical tasks for example, different professionals focus on only the tasks assigned to them, as against the patient as a whole. For instance, a nurse may be tasked with securing informed consent, counseling and prepping the patient before an operation, but would not have any further role in the operation. According to Giltinane (2013), transactional leadership falls into three categories i.e. management by exception (where leaders intervene if the followers’ behaviours fall out of line); contingent reward (where incentives are offered when certain goals are reached); and management by exception-passive (characterized by non-intervention except when the followers’ behaviours are out of hand). Weak an unpredictable transactional leadership can foster poor performance, negative patient outcomes and the emergence of harmful subcultures, especially when leaders refrain from intervening until after followers behave unacceptably (Giltinane, 2013; Rolfe, 2011).
Health care systems and practice environments have undergone and continue to undergo considerable changes, characterized by deep uncertainty, resistance, technical and practical challenges. Other than the continuing integration of technology in every practice aspect, part of the changes have seen an increasing interaction of experts from fields as different as computer/software engineering, epidemiology, psychology/psychiatry, nutrition professionals and business management. To bridge the differences and achieve the consensus necessary to thrive in an uncertain environment, transformational and situational leadership styles are critical. Transformational leaders are visible and empowering models, who possess skills such as self-knowledge, emotional intelligence, charisma, honesty, trustworthiness, vision, inspiration and effective communication skills, which they use to achieve different goals (Rolfe, 2011; Rowe, 2007). They have skills necessary to develop healthy and functional relationships with followers, and they draw on these relationships to identify and rally followers to work towards the achievement of the identified individual, group or organizational goals. Even most importantly, transformational leadership involves the identification, support and development of the followers’ skills and abilities necessary to attain. For instance, transformational leaders can successfully oversee the introduction of electronic health records and other technology, because they understand, help their followers understand using the strong relationships cultivated over time, and most importantly, develop the human capital capacity to ensure the successful implementation.
According to Herold, Fedor, Liu, & Caldwell (2008), however, transformational leadership is dangerous if it is not combined with traditional autocratic or transactional managerial skills, including in the management of internal conflicts. Transformational leadership is weak in addressing relationship difficulties among group members, even though the effectiveness of this style is dependent on fostering and leveraging positive group dynamics to achieve desired ends. Situational leadership style makes up for some of these failings, by allowing top-tier leaderships to seize control and manage difficult situations. This style is advisable in cases where the leader possesses unique knowledge, vision, insight, and skills, etc. than the followers. It strikes a balance between the leader’s directive and supportive behavior, to ensure that leaders retain control over the group/problem. For instance, while a surgeon may allow interning medical students to perform minor operations under supervision, in the event of complications during an operation, they will be forced to step in ans manage the situation.
Changing societal, and health care system values have resulted in an ever-shifting focus on different aspects of care and outcomes. Leadership is important in the identification and exploitation of opportunities to ensure the best possible outcomes for practitioners, patients, other professionals, and society. However, the complex and diverse nature of leadership as a concept and practice has made it ever more difficult to develop definitive theories to guide leaders, nor is there definitive evidence on which theory may be most effective. Leadership is still about adapting to change and difficult situations, which is why the most central ingredient to succeeding lies in one’s ability to learn continually and apply learned lessons to the new circumstances. It also means drawing on, and matching different leadership styles to the problems at hand (Goleman, 2004; Northhouse, 2007).
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