Image: Lane Erickson / Adobe Stock
One of the difficulties with understanding leadership is it is poorly defined and no universally accepted definition exists.
Gary Yukl (2013) probably gives the closest to a widely accepted definition in his description of leadership as a process of influencing and supporting others to accomplish agreed objectives.
Leadership can influence followers by modelling desired behaviours. It can also be described as a social construct that is constantly adapting to the environment and social interactions in the workplace; it has a political dimension.
Clinical leadership is a reflection of these broader definitions and has been contextualised to the health care setting. Jonas et al (2011) described clinical leadership as one of clinicians setting values, vision and purpose, ensuring the needs of patients are at the centre of service delivery and enhancing clinical service quality.
This captures additional important considerations – namely the patient and the quality of the clinical work.
General theories of leadership have evolved through the 20th and early 21st centuries.
An interesting development in our understanding of leadership is the concept of transformational leadership.
Transformational leadership is, in some respects, aspirational – it looks to what is possible to achieve and relies on the charisma of the leader to motivate followers to imagine a new future and work collectively to achieve that new future, so called idealised influence and inspirational leadership of this leadership model.
It also relies on trust and shared values – particularly followers identifying with shared organisational behaviours (for example, respect towards colleagues and conscientiousness).
“Transformational leaders motivate others to do more than they originally intended, and often even more than they thought possible” (Bass and Riggio, 2006).
The other two components of transformational leadership are intellectual stimulation and individualised consideration. Deployed well, these should enable team members to achieve mastery of tasks and autonomy, which are key motivators for employee engagement and job satisfaction (Pink, 2009).
Another leadership style that is described is transactional leadership, which may be thought of as “traditional management” – a leadership style partly based on what will satisfy me now (leader and/or follower). Transactional leadership focuses on supervision, hierarchy, management by exception, performance against targets and contingent reward for performance. It is related to concepts of management and views the leader as manager.
Transformational and transactional models of leadership are often seen as an either/or argument at the expense of both models and others. Nothing is this simple – and often elements of both leadership styles may be necessary and relevant.
Shared leadership is a more recent evolution of leadership theory, and is based on the idea that organisations are complex social entities and leadership is a social construct.
Shared leadership is a distributed form of leadership that recognises that, in an increasingly complex and complicated work environment, many people within a team (for example, a clinical team) may display leadership behaviours and “take leadership” at different points in delivering a service based on their experience and subject expertise.
Understanding the collective objective and being socially committed to the group are implicit in this model of leadership. Shared mental models, support and psychological safety are important factors identified in shared leadership scenarios.
A general criticism of almost all of the models and theories of leadership is they often focus on the leaders’ perspective, leader-follower relationship or specific traits and behaviours of leaders, and fail to recognise leadership in practice is dynamic and complex, and leadership practice can display aspects of many leadership models at once.
It is also difficult to attribute organisational outcomes to specific leadership styles or interventions due to a lack of high-quality longitudinal studies. Panel 1 summaries the main leadership models.
Clinical leadership places the clinical professional in the role of professional leader-manager – it is a dual role.
Clinical leadership exists, in part, due to the increasingly complex nature of health care, which requires financial and organisational management to be aligned with clinical service delivery, and not in competition with them (Jonas et al, 2011).
Vets and VNs are increasingly seen as gatekeepers to veterinary practice resource management, and increased competency in areas of team leadership and business management will enable veterinary organisations – whether independent, corporate or charity – to thrive and achieve their clinical, welfare and business objectives.
Berghout et al (2017), in their systematic review of medical leadership, identified two types of medical leadership:
- Type one – medical doctors in formal leadership roles either at management level or executive level. These roles could be full-time (with no clinical duties) or part-time with time split between the formal leadership role and clinical role.
- Type two – informal leadership roles – those clinicians who were leaders in their daily clinical duties.
The general leadership models deployed in clinical leadership are mostly related to transformational and collaborative styles.
The evolution of leadership theory towards shared and distributed leadership are commonly found in the clinical leadership literature (Boak et al, 2015; Aufegger et al, 2018; Spurgeon and Clark, 2018).
One reason for this is these models of leadership are amenable to patient-centred delivery of care. It is important to remember that our veterinary patient is a hybrid; an owner-animal patient. This is true for almost all scenarios – whether it’s a dog and its owner, a broodmare and its owner or a farmer and his or her flock of sheep.
These models of leadership have also been shown to improve patient outcomes, quality of health care, treatment safety and employee engagement (Dickinson et al, 2013).
Ethical leadership in a clinical setting is characterised by creating a supportive environment that enables both leader and team members to provide high‑quality health care upholding clinical professionals’ societal conceptions of ethical behaviour.
In a study of ethical leadership outcomes, Barkhordari-Sharifabad et al (2018) found “inner satisfaction of the leader”, “employee’s job satisfaction”, “patient’s satisfaction”, “providing better services” and “inspiring ethical behaviours in the employees” as key themes of this leadership model.
This is in contrast to situations where poor clinical leadership exists and results in higher treatment complication rates, higher litigation rates, and decreased patient and employee satisfaction (Mianda and Voce, 2018).
Distributed leadership is related to expertise and experience within the team, is socially constructed and shifts “leadership” to the most capable or relevant individual in any given situation (Swanwick, 2017). Distributed leadership at its core is an enabler of teamwork, and can be used successfully in change management and health care quality improvement (Boak et al, 2015).
Shared leadership is suited to the complex and multidisciplinary nature of health care service delivery (Spurgeon and Clark, 2018). As a system of leadership, it is dynamic and interactive, with the influencing and decision-making role typically held by the team. Again, shared leadership is an enabler of improving team effectiveness. Aufegger et al (2018) also demonstrated that shared leadership in the clinical setting leads to improved clinical outcomes and team member job satisfaction.
While not perfect leadership models, Spurgeon and Clark (2018) suggested distributed and shared leadership models are likely to be best suited to the clinical and health care context.
Some context-specific problems and criticisms of clinical leadership exist, including:
- competing logics between self as clinician and self as leader-manager
- role ambiguity – often vets are in ill-defined roles or leadership roles without formal responsibilities or delegation of decision-making authority
- leading in the face of conflict between animal care delivery and limited resources (owner) or the business objectives not aligned with clinical outcomes, owner satisfaction and employee job satisfaction
Pearson et al (2018) conducted a small study of in-practice veterinary leaders to understand veterinary clinical leadership and found a struggle exists in transition from team member to leader, with unrealistic expectations regarding work-life balance (leadership duties were in addition to clinical work) being a particular issue.
Relationships were recognised by the leaders studied as a key aspect of their leadership role, but also the biggest challenge of leadership. Pearson et al (2018) also acknowledged the importance of studying followership in the veterinary context to improve the effectiveness of veterinary clinical leadership.
Much can be learned from human health care colleagues by the veterinary industry in facing up to the importance of developing and deploying a well-designed practical model of veterinary clinical leadership that includes all members of the veterinary practice team.
- Aufegger L et al (2018). Can shared leadership enhance clinical team management? A systematic review, Leadersh Health Serv 32(2): 309-335.
- Barkhordari-Sharifabad M et al (2018). Ethical leadership outcomes in nursing: a qualitative study, Nurs Ethics 25(8): 1,051-1,063.
- Bass B and Riggio R (2006). Transformational Leadership, Erlbaum, London.
- Berghout MA et al (2017). Medical leaders or masters? – a systematic review of medical leadership in hospital settings, PLOS One, https://bit.ly/2MKYH75
- Boak G et al (2015). Distributed leadership, team working and service improvement in health care, Leadersh Health Serv 28(4): 332-344.
- Dickinson H et al (2013). Are we there yet? Models of medical leadership and their effectiveness: an exploratory study, final report, National Institute for Health Research Service Delivery and Organisation Programme, https://bit.ly/2Yt3zmu
- Jonas S et al (2011). The importance of clinical leadership. In Swanwick T and McKimm J (eds), ABC of Clinical Leadership, Wiley-Blackwell, Oxford.
- Mianda S and Voce A (2018). Developing and evaluating clinical leadership interventions for frontline healthcare providers: a review of the literature, BMC Health Serv Res 18(1): 747.
- Pearson CE et al (2018). Understanding veterinary leadership in practice, Vet Rec 182: 460.
- Pink DH (2009). Drive, Penguin, New York.
- Spurgeon P and Clark J (2018). Medical Leadership: The Key to Medical Engagement and Effective Organisations (2nd edn), CRC Press, London.
- Swanwick T (2017). Leadership theories and concepts. In Swanwick T and McKimm J (eds), ABC of Clinical Leadership (2nd edn), Wiley Blackwell, Chichester.
- Yukl G (2013). Leadership in Organizations, Prentice Hall, New Jersey.
This article first appeared in Vet Times (Volume 50, Issue 25, Pages 12-14).