Leadership programs in health care for managers and physicians

Size: px

Start display at page:

Download "Leadership programs in health care for managers and physicians"

Madeline Mills
5 years ago
Views:

1 Institutionen för Lärande, Informatik, Management och Etik (LIME) Frontiers in leadership research 5 poäng Examensarbete Vårterminen 2007 Leadership programs in health care for managers and physicians Author: David Bergman, MD, PhD candidate Medical Management Centre Karolinska Institutet 1

2 Leadership is a complex concept and leadership in health care is an even more complex concept. Stodgill (Stogdill 1974) concluded that there are almost as many definitions of leadership as there are persons who have attempted to define the concept. Leadership has been defined in terms of individual traits, leader behavior, interaction patterns, role relationships, follower perceptions, influence over followers, influence on task goals and influence on organizational culture. Most definitions of leadership involve an influence process (YUKL 1989). Theorists have argued whether leadership is a distinct phenomenon or if it is no different from the social influence processes occurring among all members of a group. One view is that all groups have role specialization; including a specialized leadership role and that the leader in a group has more influence than other members in the group. Another controversy in this area is the differences between leadership and management. Bennis and Nanus (Bennis and Nanus 1985) propose that mangers are people that do things right and leaders are people who do the right thing. Zalenik (Zalenik 1977) proposed that managers are concerned about how things get done and leaders are concerned with what things mean to people. Yukl (1989) concludes that it appears to be that leaders influence commitment, whereas managers merely carry out position responsibilities and exercise authority. What types of managerial behavior are related to effectiveness? Several studies have shown evidence that task-oriented and relationship-oriented behaviors are both required for leadership effectiveness (Misumi 1985). Descriptive case studies of effective managers have shown that participation and empowerment of subordinates is an integral part of the leadership style found to be characteristic of effective managers (Kouzes 1987). The effectiveness of power sharing and delegation tends to be supported by research on selfmanaged groups (Sims 1987). Traits that relate to managerial effectiveness or advancement 2

3 include high self-confidence, energy, initiative, emotional maturity, stress tolerance, and belief in internal locus of control. Successful managers tend to be pragmatic and results oriented, and they enjoy persuasive activities requiring initiative and challenge (Bass 1981) (Yukl 1989). Physicians are due to their leading position in the patient care process key persons for the development of the health care organisation and since they influence the other professionals they can be considered as leaders in the health care system. My preliminary findings in a study of physicians conceptions of their role in a health organisation show that the there is a prominent hierarchy among the physicians (Bergman 2007) as senior physicians have more power and dominance than junior physicians. Boyatzis and other researchers found evidence that effective leaders in large, hierarchical organizations tend to have a strong need for power, a fairly strong need for achievement, and a relatively weaker need for affiliation. Effective managers have a socialized power orientation due to high emotional maturity. They are more interested in building up organizations and empowering others than in domination of others (Boyatzis 1982) (Stahl 1983). Effective leaders balance their traits, such as tempering a high need for power with the emotional maturity required to ensure that subordinates are empowered rather than dominated. Sometimes balance must be achieved between competing values (QUINN and ROHRBAUGH 1983). Concern for the task must be balanced against concern for people (Mouton 1982). Concern for the needs of subordinates must be balanced against concern for the needs of peers, superiors and clients. Desire for change and innovation must be balanced against need for continuity and predictability. In some cases balance involves different leaders in a management team who have complementary attributes that compensate for each other s weaknesses and enhance each other s strengths (Bradford and Cohen 1984). 3

4 The role of the physician as a leader in health care is complex and demanding and the competencies involved is obviously not only about medical knowledge and do not only encompass empathy in relation to patients, but also such things as an understanding of relations to colleagues and other professionals, understanding of the organisation one is part of and the larger system from which external resources are drawn. Physicians also need to find ways to balance their traits as leaders in a working team with colleagues and other health personnel. To learn these competencies requires learning together with colleagues in the context. One way of doing this is to use dialogue groups as described by (De Maré, Thompson et al. 1991; Olausson 1996; Isaacs 1999; Bohm 2004). Dialogue in groups is not only a technique to improve organizations, enhance communication, engender consensus or to solve problems. During the dialogue process people are given the opportunity to think together not only to analyse common problems or to create new parts of shared experiences but also to learn from others and to create a collective sensitivity in which thoughts, feelings and acts do not belong to a specific person but to all in the group (Senge 1994). I have studied a project of dialogue groups for physicians at Sachs Children s Hospital at one of the main hospitals in Stockholm, Södersjukhuset. Two dialogue groups with ten physicians per group started in late 2001, in all 20 resident doctors. Thereafter, six new dialogue groups started in March 2003 with ten physicians per group, in all 60 physicians (Bergman 2007). Five focus group interviews were performed after termination of the groups (Bergman 2007, manuscript in preparation). The dialogue groups for physicians and the supervision groups for managers used in my studies have many similarities with Focused Group Therapy as described by Sandahl and Lindgren (2006). Focused Group Therapy was in this study developed for treatment of 4

5 burnout patients, defined as work-induced depression and exhaustion, on long-term sick leave. Central aspects of the methods used in the group therapy sessions as well as in the dialogue groups are support factors, learning factors and action factors. Support factors can be described as cohesion, alliance and goal-corrected empathic attunement (McClusky 2005). Learning in focus group therapy, in dialogue groups as well as group analytic, systems centered and interpersonal psychotherapy rests on the assumption that the most important learning takes place in the groups. It is assumed that being part of a group that develops from simple to complex is a healing experience. By internalizing interactions in the group, it is argued that the structure of each person s psyche gradually becomes more complex. The hypothesis is that a more complex psyche corresponds better to the outside world and will result in a better capacity to adjust to difficult circumstances and to deal with interpersonal challenges (Sandahl 2006). This hypothesis corresponds to my preliminary findings in a study of dialogue groups for physicians (Bergman 2007, manuscript in preparation). After participation in dialogue groups, the physicians described in group interviews that they had learned about different aspects of the organization and their view of their colleagues and their own role had become more complex. Since complexity is a sign of maturity (Agazarian and Gantt 2000) the results can be interpreted as a development of the physicians views of their role during the dialogue group sessions. The natural tendency in human groups is to deny differences or to scapegoat (Agazarian and Gantt 2000). Based on systems theory (Agazarian 1997) has developed a method to deal with this problem in groups. She calls this functional sub-grouping, which is a way to avoid and undo the negative influence of stereotype subgroups such as young and old, men and women, black and white. The basic idea is to accept human beings tendency to bond around similarities. As each subgroup explores similarities it will discover and integrate small differences among its members. The capacity to discover differences as well as the capacity to discover similarities between the subgroups will also increase and an integration of the group as whole will occur. 5

6 This theory seems to correspond to the physicians descriptions of the processes that occurred in the dialogue groups (Bergman 2007, manuscript in preparation) as the physicians discovered similarities between the subgroups of physicians at the clinic during the dialogue sessions. The action factors in focus group therapy as well as in dialogue groups are considered to consist of challenging interpersonal situations corresponding to an individual focus, which are mastered in the here-and-now of the group. An example of a focus from a therapy group for burnout patients was not being able to protect ones own boundary in relation to managers or work mates, or being unable to say: No! when somebody in authority expects to hear: Yes, of course!. The patients expressed satisfaction with the treatment of their exhaustion syndrome (burn-out) (Sandahl, 2006). The study of the dialogue groups for physicians showed that the psychosocial work environment among all physicians at the work place had improved significantly after the dialogue group sessions compared to the period before the intervention (Bergman, 2007). Another finding in this previous study was that the physicians scored higher on their ratings of leadership and feedback from supervisor. Since all physicians at the clinic participated in the dialogue groups but the head of the clinic, the findings may be interpreted as a greater understanding among the physicians of the complexities of the leadership issues at the clinic. This interpretation was confirmed by the interviews of the physicians after the dialogue sessions. Reviews of studies of group development have produced similar results. Susan Wheelan describes an integrated model that has been confirmed by later studies (Wheelan 2005). Stage 1, dependency and inclusion, is characterized by members dependency on the designed leader, concerns about safety, and concerns about feeling included in the group. At stage 2, 6

7 counter dependency and fight, the group seeks to free itself from its dependence on the leader, and members fight among themselves about group goals and procedures. The group s task at this stage is to develop a unified set of goals, values and operational procedures and this task usually generates conflicts. Only through conflict resolution and development of a unified view of the group s purpose and procedures can true collaboration be achieved. In stage 3, trust and structure, communication becomes more open and task oriented. Group development is at this stage characterized by more mature negotiations about roles, organisation and procedures. In stage 4, work, group development is a time of intense team productivity and effectiveness. The group becomes a high performance team that can focus more of its energy on goal achievement and task accomplishment. During the first project year in my study of dialogue groups, the resident doctors seem to have developed as a group at the clinic from stage one to stage three during the first project year (Wheelan 2005) as they increased their goal clarity and became more satisfied as a group (Bergman, 2007) and were described in the focus groups as more task oriented than before the project. An interview with the head of the clinic confirmed that the initial hierarchical changes and increasing influence on the organisation from the younger doctors were one reason for the decision to split the original groups of younger resident doctors into new groups mixed by physicians from all hierarchical levels. It seems as the development of the group of physicians as a whole returned to stage one and developed to stage two during the second project year (Wheelan, 2005) as the physicians expressed a need for dependable and directive leadership from the supervisors when they started in the groups and that conflicts were hidden but that conflicts emerged during the process and the participants began to challenge the supervisors and each other and subgroups of physicians emerged. These emerging conflicts and changes in the group climate is a 7

8 necessary condition in order to develop a group from a work group into an effective team (Wheelan, 2005). References: Agazarian, Y. (1997). Systems-centered therapy for groups. New York, Guilford Press. Agazarian, Y. and S. P. Gantt (2000). Autobiography of a theory: developing the theory of living human systems and its systems-centered practice. London; Philadelphia, PA, Jessica Kingsley. Bass, B. M. (1981). Handbook of leadership: Revised and expanded edition. New York, Fredd Press. Bennis, W. G. and B. Nanus (1985). Leaders: the strategies for taking charge. New York, Harper & Row. Bergman, D. (2007). "Effects of dialogue groups on physicians work environment." Journal of Health Organization and Management 21(1): Bergman, D. (2007). "Learning from dialogue groups - physicians conceptions of roles and hierarchies." Journal of Health Organisation and Management Manuscript in preparation. Bohm, D. (2004). On dialogue. New York; London, Routledge. Boyatzis, R. E. (1982). The competent manager: a model for effective performance. New York, Wiley. Bradford, D. L. and A. R. Cohen (1984). Managing for excellence: the guide to developing high performance in contemporary organizations. New York, Wiley. De Maré, P. B., S. Thompson, et al. (1991). Koinonia: from hate through dialogue to culture in the large group. London, Karnac. Isaacs, W. (1999). Dialogue and the art of thinking together: a pioneering approach to communicating in business and in life. New York, Currency. Kouzes, J. M. P., B. Z. (1987). The leadership challenge: How to get extraordinary things done in organizations. San Francisco, CA, Jossey-Bass. McClusky, U. (2005). To be met as a person. The dynamics of attachment in professional encounters. London, Karnac. Misumi, J. (1985). "The behavioral science of leadership: An interdisciplinary Japanese research program." Ann Arbor, MI: The University of Michigan Press. Mouton, B. (1982). "Management by grid principles or situationalism: Which?" Group and organisational Studies 7: Olausson, I. (1996). Dialogue. Dialog. Stockholm, Svenska Dagbladets förlag. 8

9 QUINN, R. and J. ROHRBAUGH (1983). "A SPATIAL MODEL OF EFFECTIVENESS CRITERIA - TOWARDS A COMPETING VALUES APPROACH TO ORGANIZATIONAL ANALYSIS." MANAGEMENT SCIENCE 29(3): Sandahl, C. (2006). "Focused Grou Therapy: An Integrative Approach." Journal of Contemporary Psychotherapy 36: Senge, P. M. (1994). The fifth discipline fieldbook: strategies and tools for building a learning organization. New York, Currency. Sims, M. (1987). "Leading workers to lead themselves: The external leadership of selfmanaging work teams." Administrative Science Quarterly 32: Stahl, M. J. (1983). "Achievement, power and managerial motivation: Selecting managerial talent with the job choice exercise." Personnel Psychology 36. Stogdill, R. M. (1974). Handbook of leadership; a survey of theory and research. New York, Free Press. Wheelan, S. A. (2005). Creating effective teams: a guide for members and leaders. Thousand Oaks, Calif., Sage Publications. YUKL, G. (1989). "MANAGERIAL LEADERSHIP - A REVIEW OF THEORY AND RESEARCH." JOURNAL OF MANAGEMENT 15(2): Zalenik, A. (1977). "Managers and leaders: Are they different?" Harward Business Review:

The Art of Empowerment. Lynn E. Lawrence, CMSgt(ret), USAF CPOT, ABOC, COA, OSC Consultant

The Art of Empowerment. Lynn E. Lawrence, CMSgt(ret), USAF CPOT, ABOC, COA, OSC Consultant The Art of Empowerment Lynn E. Lawrence, CMSgt(ret), USAF CPOT, ABOC, COA, OSC Consultant Quote If your actions inspire others to dream more, learn more, do more and become more, you are a leader. John