The study of leaders and leadership has led to many competing theories which attempt to distill the essence of great leadership into its component parts, to allow others to acquire some of these attributes, and become more effective leaders.
The very earliest theories on leadership tended to assume that leaders were born, and that leadership was not a skill, or set of skills that could be acquired. The overall impression was that "Great Men" had inherited leadership qualities from their ancestors, which would make them effective leaders when placed in positions of authority (Kirkpatrick and Locke 1991). This is not a very helpful way to look at leadership, and does nothing to assist students of leadership in their efforts to become better leaders themselves. It is not, though a great leap from identifying "natural" leaders to identifying which parts of their character or personality mark them out from others. This underpins the Trait theories of leadership.
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Trait theory was studied extensively in the mid part of the 20th Century, and had a wide range of results. Kirkpatrick and Locke (1991) explain that trait theory made no assumptions as to the origins of the traits studied, but simply highlighted the differences between leaders and non-leaders. In 1974, Stodgill published the results of his studies of leadership theory, and identified 22 traits and skills which are present to varying degrees in the individuals studied. This did not show how individuals could become better leaders, but, the identification of leadership as a skill has been vital in the subsequent development of leadership training. He himself ultimately concluded that "A person does not become a leader by virtue of the possession of some combination of traits." (Stodgill 1948 cited in Levine 2008)
McGregor (2005) looked at leadership behaviours as relating to underlying traits or world views. They examined the ways in which managers and leaders approached a task, and tried to understand the motivating factors. McGregror (1960) felt there were two major theories of human motivation which lay behind the actions of the leaders he studied. His theories were labelled X and Y. Theory X assumes that the average human being inherently dislikes work, and therefore must be coerced to perform at the required level. The motivating factors here are extrinsic. Theory Y assumes that work is a natural part of life, as much as is play or rest, and intrinsic motivation is key. This intrinsic motivation can be viewed as an expression of the Hierarchy of Needs (Maslow 1943) The work of McGregor informed the production of methods to map leadership behaviours. Blake and Mouton (1964) plotted concern for production against concern for people. This produces a helpful framework for mapping behaviours, but it is rather passive in form, and seems mainly useful for reflection or critique, to inform future endeavours. It does not necessarily inform leaders of what behaviour is best suited to the group they are working with at a particular time.
Action centred leadership was proposed as a leadership model by Adair (1973). His time in the Army and work as a trainer at the Royal Military Academy at Sandhurst led him to develop a model that considers three domains; Task, Team and Individual. He argues that each domain requires the attention of a leader, but the relative importance of each will vary. The relationship of these domains is represented by a venn diagram:
This model then details the areas a leader should address in each domain:
Task: Practical managerial concerns, for example creating a plan, monitoring performance
Team: Facilitating group working by agreeing standards of behaviour, resolving group conflicts etc.
Individual: Ensuring individuals are performing as well as possible by supporting through challenges, allocating work according to strengths etc.
There is considerable overlap and interaction between each of these domains, and it is argued that attention to each domain is required for a balanced team.
The key feature of this model which made such an impact was providing a practical framework which allowed leaders to combine some of the softer skills of leadership with more managerial traits of time management and task focus.
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Situational / Contingency Theories of Leadership
The studies of leadership discussed above have all looked at leaders and leadership behaviour and described them, allowing leaders to analyse their behaviour. The theories above, over time have been developed to include a degree of dynamism, but were initially descriptive exercises. It was the recognition that there was not necessarily on "right" way of leading that prompted thinking about the possibility of adaptive styles of leadership (Schermerhorn 1997). The study of leadership in different situations and settings, and the observation that the most effective style of leadership changed with respect to situational variables led to situational leadership models.
The earliest described was the Contingency Model (Fiedler 1964). This model relies on a self-rated scale to determine a preferred leadership style. Fiedler then studied working conditions, and described them through three variables:
Leader-member relations - how willing team members trust and will follow a leader
Task structure: how well defined a task is, or if it follows a standard procedure
Position Power: the extent of the rewards and punishments a leader has available.
Through his studies, Fiedler constructed a visual guide to represent his findings about which type of leader was most effective given the situational variables.
The model states that leaders with high LPC scores should work with teams where the situation is moderately favourable. The more task focused leaders will be more effective in situations which are either very favourable or unfavourable to the the leader. This model has been studied extensively and has received both criticism (Ashour 1973) support (Strube and Garcia 1981). A major source of controversy in this model is the LPC. One important point to note is that Fiedler felt leaders would find their behaviour difficult to alter, and organisations should therefore pick the correct leader for a given team. This is in contrast to other models which suggest leaders should be adaptable.
The Hersey-Blanchard (1969) model of situational leadership looks at a different variable in the team context; the maturity of followers. The underlying assumption is that a leader should adopt a style of leadership which reflects the needs of the team. This is in direct contrast to Fiedler's (1964) assertion that organisations should pick leaders given the favourability of the situation. In this model, a two by two grid which is very similar to the Blake Mouton (1964) Managerial Grid, is used to describe four leadership styles:
S1: Telling (low relationship, high task)
S2: Selling (high relationship, high task)
S3: Participating (high relationship, low task)
S4: Delegating (low relationship, low task)
There is an accompanying scale which rates the team a leader is concerned with:
M1: Low competence, and low commitment
M2: Low competence, and high commitment
M3: High competence with low/variable commitment
M4: High competence and high commitment
The M score for maturity of the team members was developed over time, and was later divided to reflect job and psychological maturity (Hersey and Blanchard 1982). Job maturity is the ability or capacity to perform the task in hand. Psychological maturity indicates motivation.
The model has received criticism from a theoretical standpoint, and from empirical research. Graeff (1983) claims that the maturity scale is invalid, as it classifies workers who have skill and are unmotivated (M3) as more mature than those who lack skill but are dedicated to a task(M2). He also argues that the additive nature of job and psychological maturity in the model is invalid. He supports this view by suggesting that in tasks where skill requirements are low, motivation has a much greater importance. One study into the model concluded that, because high follower maturity did not obviate the need for supervision, their results lent very little support to the model (Cairns et al 1998). This study though had methodological flaws, a skewed population, and did describe some support for aspect of the SLT model.
The practical application of this model relies on the ability of the leader to determine the maturity of their followers, and reflect this in their leadership style. Perhaps the most important aspect of the model is the recognition that leadership styles are not fixed, and leaders can change their approach to suit a given team or individual.
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In modern healthcare settings, there has been a change in the nature of teams. There is no longer a stable, small, hierarchical team. Instead, teams form and disperse on an almost shift-by-shift basis. To lead effectively in this environment, it is necessary to be adaptable, and be able to support team members to realise their potential. The models described above illustrate that there is no one "best" way to lead a team. Instead, by appreciating the different situations, individuals and tasks involved, leaders stand a better chance of forming teams which can cope with the varying demands of the modern NHS. Perhaps Goleman (2000, p.4) has argued this most eloquently through his work which revealed that the most effective leaders "do not rely on only one leadership style; they use them ... seamlessly and in different measure - depending on the business situation."
Service Improvement Methods:
The literature describes a large number of service improvement methods which have been applied in some form to healthcare settings. Most service improvement methodologies that have been implemented in healthcare have been adopted from industry, where the driving force is to maximise profits for shareholders. The adoption of industrial techniques for service and quality improvement has often met with a degree of resistance from the medical profession (Moss and Garside 1995) and from the health sector as a whole. This has been attributed to the professional nature of healthcare, which involves large numbers of autonomous, independent practitioners who often place independence of clinical decision making at the heart of their operating values. (Degeling et al 2003)
Recently though, there has been a recognition within the medical profession of the need to drive up standards in healthcare, and to focus on overall quality of care, rather than just direct clinical activity. Included in most definitions of quality is efficiency of healthcare delivery. This focus on efficiency is built on the growing recognition that publicly funded healthcare systems need to be accountable for the expenditure they make. (Donabedian 1988)
It is in the context of increased demands for efficiency, increasing burden of chronic disease, and ever increasing expectations from the users of the health services that service improvement tools have started to be implemented on a wider scale than ever before.
Systematic approaches to service improvement have been in existence for a long time. Taylor published his Principles of Scientific Management in 1911 after many years of employing what are now known as time and motion studies to various industrial processes. His approach was much criticised for giving too much power to managers, and its use was even banned by the American Senate in defence establishments for relying too heavily on command and control leadership (Mullins 2005a). However, his methods produced great improvements in efficiency, and he made an argument about systems which is still valid today: "The remedy for this inefficiency lies in systematic management rather than in searching for some unusual or extraordinary man."(Taylor 1911)
Total Quality Management
This approach to systematic improvement was developed by Deming during his work with Japanese manufacturers in the aftermath of World War II. He was initially concerned with teaching statistical control methods to Japanese manufacturers to improve efficiency. However, he adjusted his teaching to focus on the process, rather than individual performance, and emphasised the need for good management and a collective push for optimisation. He published his recommendations for industry, government and education, which set out his 14 points for management in the seminal work Out of the Crisis (Deming 1986). TQM is more than a technique or set of tools for improvement, and can be described as
"a way of life for an organisation as a whole, committed to total customer satisfaction through a continuous process of improvement and involvement of people." (Mullins 2005b)
TQM has been utilised in healthcare since the early 1990s, and aspects of it are increasingly being employed today. It is often the tools associated with the approach which are used, rather than the wholesale systems change originally described, and this lack of clarity regarding the true nature of what is called TQM has contributed to a lack of clear evidence of benefit. (Øvretveit and Gustafson 2002) Where the whole "package" of TQM has been implemented, results have been mixed, but there are numerous examples of where certain elements have shown benefit. The most commonly employed techniques derived from TQM are statistical control methods, and the PDSA cycle.
Plan Do Study Act (PDSA)
Alongside his work on TQM, Deming is credited as being one of the key proponents of the PDSA (or PDCA) cycle. This cycle of learning, implemented as a quality improvement tool had been taught by Shehwart (1939) whilst Deming was working with him. Deming took this knowledge to Japan and it formed part of his work on TQM (Hossain 2008).
The cycle reflects Kolb's learning cycle (1973), and is a tool for testing changes, and reacting to the results. It can be seen as either a standalone tool for change, as part of a larger system of change, or as a key part of a philosophy for wide-scale change across an organisation.(Cleghorn and Headrick 1996)
The PDSA cycle consists of four parts:
Plan: The objective of the test must be defined, and a method of data collection must be incorporated.
Do: The planned change to a process is carried out, with concurrent data collection
Study: The data is analysed, compared with predicted outcomes, and a summary of learning is produced.
Act: The conclusions from the data are utilised, and used to inform the next plan.
The underlying rationale for the PDSA cycle lies in systems theory. Systems theory implies that small scale changes within a system can create large results. The PDSA cycle is useful for testing small changes, and reflecting on the effects before either applying them across a whole system, or making further changes (Berwick 1998). When linked together, PDSA cycles can be used to drive up quality.
This approach of multiple linked cycles and this approach of multiple linked PDSA cycles is used in the Model for Improvement, the rapid cycle model of change, and the collaborative approach (Langley et al 2009, 1992; Institute for Healthcare Improvement 2003).
In contrast with small PDSA schemes within a team or organisation, the collaborative approach uses multiple PDSA cycles within separate organisations, whilst aiming for improvement in a shared area of care:
The PDSA model, when used within the model for improvement, or as a chain of cycles within a single team is a clear, simply understood, but powerful tool for implementing change, and improving quality. Its strength lies in its ability to be applied to small scale changes, but achieve significant results. From an organisational point of view, the relatively small amount of resource which is required to test each hypothesis makes this model very attractive. Processes can be studied with little disruption of everyday activity, and if the results are not favourable, learning can continue without significant loss to the organisation. In clinical processes, the PDSA cycle is an excellent tool for testing hypotheses, especially where evidence may be lacking and "inaction seems inappropriate, but action without reflection sees un-wise" (Berwick 1998)
The smaller, more local focus of PDSA cycles, and small resource requirements make this model particularly accessible to staff of all levels, and as the engagement of frontline staff, and in particular doctors has been shown to be a key factor in the success of change in the healthcare setting, this is a major strength. (Greenhalgh et al 2004 and Øvretveit 2005)
The incorporation of the PDSA cycle into wider schemes of change management brings additional complexity, and also invites additional problems. There have been varied results in the implementation of the collaborative approach within healthcare as a service improvement tool. Some studies report great success (Monteleoni and Clark 2004; Schonlau et al 2005) while others (Newton et al 2007) found that there were difficulties using the same model. The major difficulties identified were lack of adequate resources, the conceptual difficulties associated with the model, and poor leadership. A recent review concluded that there is currently no evidence about the long term results or cost effectiveness of collaboratives compared with other models. (Øvretveit 2002).
Toyota Production System (TPS) / Lean
One approach to service improvement which is being applied with growing enthusiasm within the NHS is Lean. Lean thinking and theory emerged from studies of the manufacturing processes at Toyota. The term was first used in the late 1980's and the approach grew in stature after the publication of "The Machine that Changed the World" (Womack et al 1990). Lean was not originally a single tool or approach, but instead was a philosophy to which all members of an organisation aligned themselves. This whole systems approach is probably now better recognised at the Toyota Production System (Liker 2003). The success of Lean/TPS has led to a proliferation of schemes which fall under the umbrella of "Lean thinking" but do not necessarily hold to the original principles.
The TPS was developed in the 1950's in Japan, and was first published in English in 1977 by Sugimori et al. The system has been studied extensively, but many organisations, despite implementing the principles behind the TPS, have not achieved the efficiencies and quality that Toyota exhibit. (Spear and Bowen 1999). There have been many attempts to reduce the TPS to a method which can be applied in many settings, but as Sutherland and Bennett (2007) state, such a complex process cannot be adequately documented. They suggest that instead, to understand the system, one must learn from mentors, much like a child learns and forms habits from their parents. Liker (2003) sets out 14 principles of the TPS, but for the purposes of this assignment, three will be examined:
1. The thorough elimination of waste (muda)
2. Jidoka - or the primacy of quality
3. Kaizen - continuous incremental improvement
Ohno (1988) identifies 7 wastes (muda) which should be eliminated from any system.
Overproduction - production of more than is required for immediate use
Delay / Waiting - any delay between the end of one process, and the start of another.
Unnecessary transportation of materials
Overprocessing - using more energy than required for a given process, or exceeding the agreed specification
Excess inventory - any raw materials or work in progress in excess of customer requirements.
Motion - any unnecessary movement of workers, eg. reaching / stretching.
Defects - any process or work that results in unacceptable goods
These wastes have immediate equivalents in most healthcare settings, and underpin a lot of the efforts in healthcare which are labelled as Lean. From these definitions many techniques for identifying waste have been developed. The NHS Institute for Innovation and Improvement (NHSIII) has developed a series of products known as the "Productive Series" which use the elimination of waste to improve healthcare. The tools used in the productive series are often taken directly from industry (NHSIII 2007), and include some elements which date back as far as the Scientific Methods described by Taylor (1911).
Jidoka is defined by Toyota (2010) as "automation with a human touch." When applied to a manufacturing context, this emerges as the principle that a process should continue unless a defect is noted. Once that defect has been detected, work should stop until the problem is solved. This principle ensures in manufacturing that if a machine or worker detects a problem, or a process issue, the line is stopped, a solution introduced and, vitally, incorporated into the standard workflow. In this way, the defect should not arise again. The early detection of defects on a production line, and the empowerment of workers to raise the alarm if defects occur also reduces waste. It is unfortunate that, although many principles of the TPS/Lean system are implemented in healthcare, it is often this concern for detecting problems and creating solutions which are incorporated into standard work which fails to be introduced. One reason cited for this area failing to be implemented is that clinical care cannot stop, in in this respect, clinicians feel methods for producing "widgets" cannot be applied to the art of healing (Wilson et al 2001). There are examples of where this concept has been introduced, into the healthcare environment, with clear evidence of improvements (Ballé and Régnier 2007), but a recent paper argues that more could be done (Grout and Toussaint 2010)
Kaizen is the culture of continuous, incremental improvements to a system (Imai 1986). This cultural philosophy of scientific experimentation, conducted at the lowest possible level in the organisation, is held up by Spear and Bowen (1999) as one of the key elements of the success of the TPS, and as a key stumbling block for others who seem unable to replicate Toyota's success. This philosophy, combined with other unwritten rules combine to create a "community of scientists," who engage in experimentation to solve problems. These problems are often on a small scale, and the process closely follows the PDSA cycle. When this principle of widespread, incremental change is adopted across an organisation, with recognition of the value of tacit knowledge, it is possible for a "learning organisation" to emerge (Howells 1996).
In conclusion, there are many approaches to leadership and service improvement which are being used in the healthcare setting today. Use of an adaptive model, which allows a leader to change management style depending on the team they are leading, and the task in hand, is most appropriate for leaders of modern medical teams, in a large part due to the very flexible nature of the teams involved. The application of industrial quality improvement techniques to healthcare has great potential, and successful trials have been conducted. However, a common feature discussed in analyses of obstacles to implementation is the engagement of medical professionals. Through the use of effective leadership, and engagement of these key stakeholders, it is possible to lay the foundations for a learning organisation. A learning culture which is open to the possibilities of change through quality improvement strategies will ultimately be the most fertile environment in which to implement change for a better quality of care.