LEADERSHIP

People are led and resources are managed. Knowing this critical and sometimes subtle difference is the beginning of leadership wisdom. Leadership wisdom is an essential component to being successful in a fast-paced, ever-changing, and highly complex health environment. 1 Today, evidence-based leadership is a common phrase, as are evidence-based management and evidence-based medicine. Evidence-based means that the practice of leadership, management, and medicine is informed by empirical evidence from the structure, process, and—especially—outcomes of practice. This text provides foundations, principles, and strategies for leadership that are also informed by quantitative and qualitative evidence. Performance initiatives such as value-based purchasing, pay for performance, and accountability requirements, coupled with electronic medical records “meaningful use” criteria, and community assessment and integration, all require strong leadership.

This chapter presents some of the basic definitions and distinctions of leadership. Specific emphasis is placed on defining the importance of leadership study in the healthcare environment and its appropriate place in the field of both academics and professional practice. Leadership is differentiated from management; although there are certainly differences between these two skills, health organizations need leaders and managers who are consistently focused on the direction of the enterprise. Emphasis is placed on both descriptive (tells about leadership) and prescriptive (gives direction and guidance) notions of leadership. In summary, this chapter provides an overview of the complex and exciting topic of leadership.

Within the realms of graduate education, business practice, and organizational analysis, there is no topic more important than the study of leadership. The contemporary study of leadership is a century-old, enormously complex discipline; however, fewer topics inspire more interest and have more stakeholder consequences than leadership in any organization in any industry. In the highly complex health industry, the role of leadership is further pronounced, and adept leadership is clearly necessary for success. Furthermore, no great leaders of our time have become successful and prosperous without first understanding the principles of leadership.

As scholars, future practitioners, and current practitioners, we need to perform at least two roles—that is, to wear two hats. One of these hats is that of the practitioner, who is directly in touch with the delivery of human services in health systems and leadership change for process improvement. In this role, you work closely with individuals, families, and other groups, organizations, and communities as a helping professional; from this perspective, you are positioned to observe the issues and emerging trends that most challenge those persons you serve in living healthy and fulfilling lives. The other hat you wear is that of scholar. In other words, early careerists must be capable of becoming a critical consumer of leadership research by personal study. Leaders must be aware of both the practices and habits of successful leaders, as well as the recognized traits and skills that are commensurate with leadership success as documented in the literature over the years. 2 ,3 For example, as a working health executive, suppose you encounter an issue with outside stakeholders that you are not familiar with. It is to your benefit to turn to the archived literature and search out articles and research that can help you gain deeper understanding of the problem facing you. Because of your training in leadership gained from this text, as well as from your mentors and educators, you can approach this literature with a basic understanding of the foundations of leadership and select the most appropriate course of action based on both your burgeoning experience and the successful practices documented in the literature of best practices.

Leadership is holistic. This means that leadership requires leading laterally or collaboratively, and not just from the upper echelons in a top-down approach. Leadership entails leading the people, the structure, and the processes of the organization. In addition to the many definitions of this concept, there is an abundance of literature on leadership in general, leadership principles, and topics related to leadership. As a topic, leadership is of immense interest to international militaries, governments, businesses, and health organizations. Leadership and attributed outcomes in schools are commonly taught, but likewise encompass varying approaches and lines of thought. 4

WHY STUDY LEADERSHIP?

Simply stated, leadership is complex. To become a leader, an individual must possess a strong didactic educational background, be focused on taking care of people and resources simultaneously, and also be confident in his or her own abilities. Furthermore, a successful leader must have extraordinary critical thinking skills, be a life-long learner, and be willing to (graciously) accept information that may be counterintuitive to his or her sensibilities or current understanding. Additionally, leadership further requires—but is not limited to—having the ability to profoundly understand the big picture and the minutiae, the possibilities and the potential roadblocks, and to do so coupled with the ability to motivate sustainable enthusiasm and focus amongst key stakeholders, staff, and the community. Finally, leadership may ultimately be about having foresight, hindsight, and vision; the personal presence to garner trust; and the art of knowing not just how to delegate, but also how to elicit others’ desire to always do their best—including knowing when to seek help and not feeling badly about doing so. At the end of the day, leadership is about having that special “something” that makes others feel they are contributing in a meaningful way to the greater good. This is why we study leadership.

Leaders of any organization encounter issues and decision-making challenges in everyday life. Some decisions are easily solved, whereas others may call for a critical analysis of the situation, a split-second judgment, an assessment made by one individual, or decisions made by a group. Whatever the circumstances, the decisions that are made will have consequences for human resources and the organization itself. It is, therefore, necessary for individuals to be trained in leadership and to become well equipped to make the right decision at the right time. 5

The concept and discussion of leadership is ancient; the discipline of leadership study can be consistently traced back to Machiavelli in 1530, but the first documentation of leadership dates back to 2300 B.C. However, leadership theory and research is a relatively modern discipline. Indeed, the first relevant theories were not proposed until the mid-1800s. From approximately 1840 to 1880, “great man” theorists Carlyle, Galton, and James studied great men from history who exhibited certain traits, and suggested those traits led to successful leadership. 6 This theory was later abandoned for more valid and reliable theories of leadership based on best practices and sound discovery. For nearly 125 years some of the greatest minds have attempted to catalogue and archive best practices in leadership for the benefit of the next generation of leaders and the current chief executives in the field. Although this area is a relatively modern topic of study, numerous qualitative and quantitative experiments continue to fill the stacks of journal articles each year. Clearly, the study of leadership is complex and ongoing, and the current and newer theories of leadership vary with its definitions as defined by the authors. 7 The authors of this text welcome you to the world of the study of leadership research and practice, and encourage you to join the many generations who came before in search of continuing education and new tools for your leadership toolkit.

Leadership is one of the few academic disciplines that is difficult for early careerists to embrace without both didactic training and real-world experience. Although some leaders may possess natural predispositions allowing them to become successful in small circles in colloquial events, successful leader practitioners will agree that as their ever-increasing circles of influence grow, it becomes necessary to develop and hone natural predispositions while simultaneously cultivating new skills necessary to bring them to the next level of leadership. Leadership skills and traits that enable a person to become successful within one circle with one group of individuals with particular skill sets and academic disciplines may not allow the same person to become successful in the increasingly more complex concentric circles. 8 – 10 All leaders along the continuum of care must engage in lifelong learning to be successful.

Many early careerists find that the transition from being a follower and an employee to one who leads others and takes responsibility can be difficult. Mistakes must be made and experience accumulated at lower supervisory levels to gain a perspective on which kind of leader each individual can become. However, without knowing the best practices of leaders, the strategies leaders employ for success, and the natural predispositions emulated by leaders, it will be difficult for early careerists to become successful. 11 Also, the health environment is continually changing. For example, recent literature suggests the need for new models of nurse leadership to deal with dynamic change but also to serve as the bridge between clinical and administrative practice in health organizations. 12

Early careerists will become engaged with many facets of leadership over their career. For example, you may have a natural predisposition toward introversion or extroversion. Although these traits may already be well known to you, formally diagnosing them provides a road map to developing those skills lacking in many persons who are determined to be leaders while also identifying current strengths to build upon. If an early careerist is already leaning toward extroversion, he or she may already be comfortable in delivering clear goals and sharing vision statements with future groups of employees. For those on the other side of the spectrum, developmental opportunities are suggested such as joining professional organizations and speaking groups where it may be possible to practice developing extrovert tendencies.

Leadership is a “universal phenomenon.” 13 ,14 As long as people are part of the equation of health systems as workforce members and patients, leadership will be a critical component of successful organizations. “Since the effectiveness of the leader has frequently determined the survival or demise of a group, organization, or an entire nation, it has been of concern to some of the foremost thinkers in history, like Plato, Machiavelli, and von Clausewitz. If leadership were easy to understand, we would have had all the answers long before now.” 15 Today, leadership far too often focuses more on coping strategies than on leading strategies. As scholars and experienced leadership practitioners in the health industry, the authors believe that leadership needs to be dramatically improved to enhance today’s systems and deal with the challenges our society faces. It is not acceptable to merely perpetuate the status quo.

The coping strategy nature of leadership has been a concern for at least the past two decades, if not longer. In 1989, Warren Bennis talked about this issue in Why Leaders Can’t Lead: The Unconscious Conspiracy Continues, in which he discussed the restrictions leaders place on themselves. More recently, Jo Manion, in 1998’s From Management to Leadership: Interpersonal Skills for Success in Health Care, discussed the critical decline of skills and the overall lack of leadership in the healthcare industry. Hints of self-protection and self-promotion have begun to taint the noble profession of health leadership. It seems there is a significant lack of morality, knowledge, skills, and abilities at the individual leader level.

In the last decade, nurse managers have learned that they must rely on more “leadership” capabilities than on “nurse” capabilities to be successful. 16 In 2000, Ian Morrison posited several leadership challenges for different sectors of the health industry. He called on political organizations to create consensus, reduce party indifference, and reform Medicare. In the realm of managed care, he noted the need for innovation, a sustainable business strategy, and the establishment of a positive public image. In his estimation, the pharmaceutical and medical technology industry needed to take care of rising costs while keeping its primary focus on developing new drugs. As for hospitals and health systems, he called on them to reconcile the differences between improving general health and delivering sick care. Morrison then turned his attention to individual players within the healthcare field. Physicians must advocate for physician leadership, move beyond nostalgic views of the medical profession in years past, and take a more active role in developing organizational models. He then targeted leaders and their support teams:

· Public health leaders and workers must: 1) decide to participate in the mainstream of medical care …; 2) decide how to incorporate the ideas of public health into the mainstream political agenda without sounding too much like socialism for the average American (socialism and fiscally irresponsible social justice ideology will not “play well” in mainstream America); and 3) [recognize that] the public health community can be incredibly self-righteous about having a monopoly on compassion for the poor… 17 , 18

To tackle these challenges, leadership is required. Those who wish to lead must be competent; competence starts with knowing what you know and what you do not know.

There are four states of knowing:

· • Unconscious incompetence, where “we do not know that we do not know”

· • Conscious incompetence, where “we know that we do not know”

· • Conscious competence, where “we know how to perform a skill but must consciously think about it”

· • Unconscious competence, where performance of a skill is second nature 19

Moving from one state of knowing to another takes considerable effort. Becoming a “conscious leader” takes study, effort, trial, error, and evaluation. Clearly, the most successful health leaders are not lucky, but rather are competent at leading people to do important and tremendous tasks and achieve great success. Successful leaders have discipline, persistence, and humility while continuously working to improve their capabilities.

Studying, learning, and applying leadership knowledge, skills, and abilities are crucial to being a successful leader in the health industry. Regardless of where and at what level you lead—as a laboratory chief, physical therapy director, clinical office administrator, or health system chief executive officer—leadership knowledge, skills, and abilities are important to you, your organization, and the communities you serve. The health industry in the United States is destined for renewal; leadership will be essential to the health industry throughout this period of change. 20

Regardless of cultural identity, all leaders of health organizations lead people and manage resources. Their work involves focusing the collective energy of both leading people and managing resources toward meeting the needs of the external environment in the most efficient, effective, and—most importantly—efficacious approach possible (that is, focusing on the mission of the organization). It is important for leaders to understand that the individuals who make up the health workforce are people with vastly different education, training, and experience. These same individuals also have vastly different roles within the organization—and no leader can ever hope to understand the complexity of all aspects of jobs within the system. As a result, the good leader’s job is to successfully motivate individuals within the organization toward goal-directed behavior that supports the leader’s vision and organization’s mission. As Presidential Medal of Freedom recipient Eric Hoffer has suggested, “The leader has to be practical and a realist yet must talk the language of the visionary and the idealist.” 21

The last important job of leaders is the management of nonhuman resources in the system. The role of a healthcare administrator, healthcare executive, public health leader, or healthcare manager is to merge the complexity of leading people and the complexity of managing resources into a culture that serves communities by maintaining and improving the health of individuals in those communities. This is done by influencing the people and distributing the resources under their stewardship to serve those individuals who come to health organizations for assistance, to build strong and effective relationships with their communities, and, especially, to build working relationships with the public health infrastructure in their communities.