Fundamentals of clinical leadership
(By Dr (Mrs) B.A. Aina)
Clinical leadership refers to both a set of tasks to lead to improvements in the safety and quality of health care, and the attributes required to successfully carry them out (Victorian Quality Council, 2005).
According to the Centre for Innovation in Health Management (CIHM), University of Leeds, UK, clinical leadership is important because healthcare organisations are professional organisations where frontline clinical staff possesses a high degree of control over their work.
Professionals in health facilities e.g. ward sister, clinical pharmacists and medical laboratory technologists providing clinical services to patients, may have roles including a clinical leadership element; hence, according to clinical leadership in nursing, the essence of clinical leadership can be summed up in the vision provided by Florence Nightingale when she said “let whoever is in charge keep this simple question in her head…how can I provide for the right thing to be always done?”
The best clinical leaders strive to do the right thing; they ensure their staff and support services always do the right thing for patients. They go the extra mile to find better ways of getting the work done.
Clinical leaders are exceptional individuals with caring values, intelligence, physical and emotional resilience and dexterity. Their leadership results in excellent patient experience and outcomes.
When clinical leadership falls short, the result is low staff morale, leading to higher rates of incidents and a poor patient experience.
Analysis of a study by HPERU of the BMA 2012
According to the Health Policy & Economic Research Unit (HPERU), vision is important to clinical leadership. The ability to offer a vision to the widest audience within the health service was considered a quality that sets clinical leadership apart from management.
Thus, clinical leadership is defined to comprise skill-based leadership by example, innovative clinically-engaged demonstrated expertise and the provision of vision to colleagues.
Attributes and skills required for clinical leadership include communication skills, political skills and clinical credibility.
Separating leadership from management
Leadership is like the abominable snowman whose footprints are everywhere but who is nowhere to be seen (Benniset al., 1985). This quote neatly encapsulates one of the characteristics of leadership.
Leadership is different from management. Leadership is about setting a new direction or vision for a group, influencing others and managing change; while management is concerned with the marshalling and organisation of resources and maintaining stability or directing and controlling according to established principles.
This classification tends to make management seem boring and unsatisfying and hence the question ‘who would want to manage when they can lead’?
Leadership requires more of personal power
Clinical leadership has a strong focus on the patient and clinical specialty. According to the CIHM, it is largely based on a combination of ‘personal power’ (credibility, respect, trust, persuasion etc.) and ‘expert power’ (knowledge of clinical condition).
Managerial leadership, on the other hand, tends to take corporate or organisational view point and is largely based upon ‘positional power’ (CIHM).
Leadership and management are complementary
Current theorists see leading and managing as distinct but complementary activities. Both are important for success and the separation of the two functions – management without leadership and leadership without management – is seen as harmful.
In the first half of the twentieth century, leadership theory revolved around personal qualities that you either had – usually in conjunction with a Y chromosome – or didn’t have. From the 1950s onwards, however, attention shifted from the personal characteristics of leaders to their behaviours or styles. This relates to how leaders make decision and their primary focus of concern. A new paradigm emerged later which is that of transformational leadership
Decision-making style models include styles which range from autocratic to abdicatory (Tannenbaum and Schmidt). The focus of a leader’s attention should be distributed flexibly between the task, the team and the individual.
In transformational leadership, the leaders release human potential through the empowerment and development of followers. Vision and values are clearly stated and the organisation and the work of individuals within it are aligned to the achievement of longer-term goals. Transformational leadership has proved an enduring model, and therefore incorporated into many public sector frameworks such as the UK’s NHS leadership framework.
Leadership framework provides a consistent approach to leadership development for all staff in health care, irrespective of discipline, role, function or seniority and represents the standard for leadership behaviours that all staff should aspire to.
Fundamental to the development of the leadership framework is a desire to create a single overarching framework for all health care staff, building on best practice standards for leadership development such, as existing leadership frameworks used by different staff groups.
The leadership framework was developed by the National Leadership Council (NLC), UK, after extensive research and consultation with a wide cross-section of staff, patients, professional bodies and academics.
The leadership framework has five core domains and two additional domains
The five core domains are:
- Demonstrating personal qualities
- Working with others
- Managing services
- Improving services and
- Setting direction
The two additional domains comprise:
- Creating the vision
- Delivering the strategy,
Not everyone is necessarily a leader but everyone can contribute to the leadership process by using the behaviours described in the five core domains of the leadership framework. The final two domains recognise that a relatively small group of people do hold designated senior positional roles, and are required to act as leaders in formal hierarchical positions.
These two domains therefore focus more on the contribution of individual leaders rather than the general leadership process. They apply particularly but not exclusively to individuals in senior positional leadership roles.
The leadership context
The strategy and opportunity to demonstrate leadership will differ, and the context in which competence can be achieved will become more complex and demanding with career progression. The leadership context
Four stages are used to describe this and to help staff understand their progression and development as leaders.
4 Stages of the Leadership context
Stage 1: Own practice/immediate team
Here, leadership is about building personal relationships with patients and colleagues, often working as part of a multi disciplinary team. Staff will need to recognise problems and work with others to solve them. The impact of the decisions staff take at this level will be limited in terms of risk.
Stage 2: Whole service/across teams
This is about building relationships within and across teams, recognising problems and solving them. At this level, staff will need to be more conscious of the risks that their decisions may pose for self and others for a successful outcome.
Stage 3: Across services/wider organisation
The leader will be working across teams and departments within the wider organisation. He or she will challenge the appropriateness of solutions to complex problems. The potential risk associated with their decisions will have a wider impact on the service.
Stage 4: Whole organisation/health care system
Leadership here is about building broader partnerships across and outside traditional organisational boundaries that are sustainable and replicable. At this level, leaders will be dealing with multi faceted problems and coming up with innovative solutions to such They may lead at national/international level and will be required to participate in whole systems thinking, finding new ways of working and leading transformational change.
Their decisions may have significant impact on the reputation of the organisation/system and outcomes and would be critical to the future.
More on leadership framework
As earlier noted, the leadership framework comprises seven domains. Within each domain are four categories called elements and each of these elements is further divided into four descriptors. Descriptors describe the leadership behaviours, knowledge, skills or attitudes expected for each element. Also for each element there are contextual indicators.
An exhaustive review of the Leadership framework can be seen at http://www.leadershipacademy.nhs.uk/wp-content/uploads/2012/11/NHSLeadership-Leadership-Framework-LF-Quick-Reference-Guide-Summary-of-Domains-Elements-and-Descriptors.pdf
Below are the elements of each domain:
First core domain: Demonstrating personal qualities
Effective leadership requires individuals to draw upon their values, strengths and abilities to deliver high standards of service. This requires them to demonstrate effectiveness in:
- Developing self-awareness
- Managing themselves
- Continuing personal development
- Acting with integrity
Second core domain: Working with others
Effective leadership requires individuals to work with others in teams and networks to deliver and improve services. This requires them to demonstrate effectiveness in:
- Developing networks
- Building and maintaining relationships
- Encouraging contribution, and
- Working within teams
Third core domain: Managing services
Effective leadership requires individuals to focus on the success of the organisation(s) in which they work. This requires them to be effective in:
- Managing resources
- Managing people
- Managing performance
Fourth core domain: Improving services
Effective leadership requires individuals to make a real difference to people’s health by delivering high quality services and by developing improvements to services.This requires them to demonstrate effectiveness in:
- Ensuring patient safety
- Critical evaluation
- Encouraging improvement and innovation
- Facilitating transformation
Fifth core domain: Setting direction
Effective leadership requires individuals to contribute to the strategy and aspirations of the organisation and act in a manner consistent with its values. This requires them to demonstrate effectiveness in:
- Identifying the contexts for change
- Applying knowledge and evidence
- Making decisions
- Evaluating impact
Sixth domain: Creating the vision
Those in senior positional leadership roles create a compelling vision for the future, and communicate this vision within and across organisations. This requires them to demonstrate effectiveness in:
- Developing the vision for the organisation
- Influencing the vision of the wider healthcare system
- Communicating the vision
- Embodying the vision
Seventh domain: Delivering the strategy
Those in senior positional leadership roles deliver the strategic vision by developing and agreeing on strategic plans and ensuring that these are translated into achievable operational plans. This requires them to demonstrate effectiveness in:
- Framing the strategy
- Developing the strategy
- Implementing the strategy
- Embedding the strategy
The Leadership framework finds application in so many different settings, which include:
* As a tool to raise awareness that effective leadership is needed across the whole organisation.
* To underpin a talent management strategy.
* As part of an existing leadership development programme.
* To inform the design and commissioning of training and development programmes.
* To develop individual leadership skills.
* As part of team development.
* To enhance existing appraisal systems.
* To decide an organisation’s recruitment and retention processes.
There are behaviours observed when an individual is not yet demonstrating any of the listed domains.
First domain – demonstrating personal qualities
* Does not understand own emotions or recognise the impact of own behaviour on others.
* Approaches tasks in a disorganised way and plans are not realistic.
* Unable to discuss own strengths and development needs and spends little time on development.
* Demonstrates behaviours that are counter to core values of openness, inclusiveness, honesty and equality.
* Lacks confidence in own abilities to deliver results.
Second domain – working with others
* Fails to network with others and/or allows relationships to deteriorate.
* Fails to win the support and respect of others.
* Does not encourage others to contribute ideas.
* Does not adopt a collaborative approach.
Third domain – managing services
* Disorganised or unstructured approach to planning.
* Wastes resources or fails to monitor them effectively.
* Does not effectively manage and develop people.
* Fails to identify and address performance issues.
Fourth domain – improving services
* Overlooks the need to put patients at the forefront of their thinking
*Does not question/evaluate current processes and practices
* Maintains the status quo and sticks with traditional outdated ways of doing things
* Fails to implement change or implements change for change’s sake
Fifth domain – setting direction
* Unaware of political, social, technical, economic, organisational factors that impact on the future of the service /organisation.
* Does not use an evidence-base for decision-making.
* Makes poor decisions about the future.
* Fails to evaluate the impact of previous decisions and actions.
Sixth domain – creating the vision
* Does not involve others in creating and defining the vision.
* Does not align their vision with the wider health and care agenda.
*Misses opportunities to communicate and share understanding of the vision with others.
* Lacks enthusiasm and commitment for driving the vision.
Seventh domain – delivering the strategy
* Does not align the strategy with local, national and/or wider health care system requirements.
* Works to develop the strategy in isolation without input or feedback from others.
* Absolves oneself of responsibility for holding others to account.
* Fails to enable an organisational culture that embraces the strategy.
The leadership framework sets out the standard for leadership to which all staff in health care should aspire. The needs of the people who use services have always been central to healthcare. Delivering services to patients, service users, carers and the public is therefore at the heart of the leadership framework. All staff have to work hard to improve services for people and every staff in health is a potential leader.
The question is “which stage of leadership context are you and which stage of leadership context are you aiming at?”
By Dr (Mrs) B.A. Aina lectures at the Department of Clinical Pharmacy and Biopharmacy Faculty of Pharmacy, University of Lagos.