LEARNING OUTCOMES
After completing this module, the paramedic will be able to:
Leadership is an essential feature of the life of a paramedic. Paramedics will be expected to demonstrate leadership during incidents, while working with multi-agency colleagues and within employing organisations. Simply, leadership (however it is defined) is an expected quality of paramedics—be they in practitioner or management roles.
Leadership is said to be of pivotal importance to the future of health and social care organisations (Darzi, 2008; Ham, 2011). Many authors (e.g. Alimo-Metcalf and Alban-Metcalf, 2006; Vardiman et al, 2006; Anderson et al 2009; Amagoh, 2009; Hotho and Dowling, 2010) have identified that organisations considered to have good leadership are those that thrive, even when times are difficult. Conversely, poor leadership is an often cited reason for organisational failure. As a consequence, the need to develop leadership capacity has been identified as an important issue in organisations across the world. Leadership is, however, a complex multifaceted concept that has been subject to much debate.
In spite of this debate and the development of many models of leadership, disagreement still exists as to how it should be defined. The current article seeks to explore a new approach to leadership that might help paramedic practitioners, managers and leaders at all levels of an organisation begin to understand their unique approach to leadership roles, whatever their particular experience and schooling of leadership, and wherever they are placed within the hierarchy of the organisation.
The many approaches to leadership
In current times, there appears to be a constant cry for good leaders and for good leadership to lead us out of our difficulties. As an example, at the 2011 Conservative Party Conference, David Cameron (2011) had stated:
‘In these difficult times, it is leadership we need, to get our economy moving, to get our society working. Leadership works.’
It is relatively easy to speak eloquently about the merits of leadership; people have been studying it and attempting to do so for millennia. The difficulty is that while leadership is a concept that most people instinctively understand, it becomes difficult to closely define what good leadership actually is or means (Crainer, 1998). Who decides when, to use Cameron's comments, ‘leadership works’? Northouse (2007) suggests that people are captivated by the concept of leadership; but as they begin to explore this complex and multi-layered phenomenon, they develop their own understanding of what it is, and this understanding is often subjective.
In recent times, there has been an exponential increase in research activity into what effective leadership within organisations is. In 1991, Fleishman et al (1991) identified 65 different classifications of leadership. In 1995, Crainer (Mullins, 2007) suggested that 400 definitions of leadership existed. Eight years later, Bennis and Nanus (2003) concluded that 850 different classifications had been developed. In 2003, 14 000 books related to leadership were on sale via the online retailer Amazon.co.uk; by 2009, this had increased to 53 000 (Grint, 2010). A similar search in July 2013 revealed that this total had reached approximately 72 000 books. A literature search in July 2013 of the Sheffield Hallam University Library gateway using the word ‘Leadership’ indentified approximately 1 600 000 items. When filtered to only consider peer-reviewed publications, 415 000 journal articles were identified. Research into effective leadership appears to have experienced exponential growth.
Simkins (2005: 10) commented that even though defining effective leadership had proved elusive, ‘some still believe that this holy grail is within our grasp, or at the least the search for it is not in vain.’ Crainer (Mullins, 2007: 363) warns, however, that so many definitions of leadership can lead to ‘minefields of misunderstanding’, through which practitioners and researchers must tread carefully. Grint (2010) postulated that the field had become so complicated that even the concept of leadership was now contested.
A brief history of leadership
The majority of research studies in the first half of the 20th century were concerned with attempting to define and refine behaviours, qualities or characteristics of leaders (Avolio, 2007). This period of research, sometimes labelled trait theory, sometimes labelled ‘great man’ theory, is characterised by the belief that leaders are born and not made.
The search was to identify the characteristics or traits that made great leaders. Large numbers of traits were identified. The significant problem that Mann (1959) discovered after reviewing all of the studies conducted between 1900 and 1957, was that the correlation between leadership and the identified personality variables (or traits) was inconsistent and, significantly, overall quite low.
A series of models of leadership that fitted into an approach known as Contingency or Situational Leadership followed. The concept behind these approaches was first identified by Stodill in 1948. Stodill was engaged in a meta-analysis of leadership traits and could not identify any significant results. He did, however, identify for the first time that the situation played a large role in how the leader behaved. Research effort then focused on validating a number of contingency and situational models. The majority of models from this period (a number still have relevance today) consider that effective leadership is an artefact of the fit between the leader's characteristics and of the unique situation that they confront (Avolio, 2007; Haslam et al, 2011). Northouse (2007) suggests that leaders should adapt their style to meet the needs of the situation. Frontline practitioners may experience the reality of this model every day, as the demands of the situation and the needs of the patient cause them to adjust their approach. Additionally, managers might adopt a different style of working when talking to an experienced and trusted colleague compared with when they are dealing with an inexperienced and untested member of the team.
In 1978, MacGregor Burns developed a new concept of leadership that he called transformational leadership. A collection of similar transformational approaches emerged during this time and became known as new paradigm approaches (Alimo-Metcalf and Alban-Metcalf, 2005). The adaptation of the term transactional leadership also became common and is considered the antithesis of transformational leadership. McGregor Burns' concept gained momentum and, in the 1990s, was perhaps the most popular and the most researched of the new paradigm approaches to leadership (Judge and Bono, 2000; Alimo-Metcalf and Alban-Metcalf, 2006).
Transformational leadership was felt to be a leadership style that fitted the needs of the workforce (Northouse, 2007). Burns wanted to develop a concept that positively linked leaders and their followers. The aim of his model was to transform people, to help them become the best that they could be, so that together, the organisation and the people in it could achieve so much more than had been originally expected.
The model included concern for ethics, standards and satisfying the needs of followers (Alimo-Metcalf and Alban-Metcalf, 2005). An example from practice might be the role of the clinical team mentor, who is able to provide on-the-job support and clinical supervision that promotes the best, evidence-based practice. The clinical team mentor might be the role model for front-line practitioners, helping colleagues to reach the peak of their transformation potential. Additionally, people may have experienced a time when they felt that there was a genuine mutual trust between the leader and themselves; they might have perceived that the leader believed in them, wanted them to do well in their job and provided support to enable their growth.
Burns also distinguished transformational leadership from transactional leadership. Transactional leaders rely on what is called the exchange or transaction that occurs between the leader and the follower. So, at a simple level, if the follower working in an organisation does what the leader requires of them, they will receive a salary that recognises their contribution to common goals. This is the transaction or exchange. Burns believed that most leadership models are transactional in nature. This approach is evident at all levels throughout all types of organisations. Transactional leadership is often associated with the term management. A traditional transactional leader might be a first-line manager who allocates tasks, with a clear expectation that they will be completed.
There is research focused on assessing the effectiveness of transformational models. For example, Alimo-Metcalf and Alban-Metcalf (2005) discovered, following a large study of organisations in the UK, that transformational leadership leads to higher levels of satisfaction, motivation and productivity, and lower levels of sickness, absence and employee turnover. In ambulance service organisations, this approach may equate to activities that engage practitioners in working within guidelines that empower them rather than enforcing protocols and pursuing performance indicators that are not perceived to benefit patients.
While the popularity of transformational leadership continues, a model of leadership called distributed or shared leadership has been gathering attention. This, again, is an area of contested definitions (Currie and Locket, 2011). The underlying concept is a recognition that it is becoming increasingly difficult in complicated multi-skilled environments (like ambulance service organisations) for a single person to be able to lead on all aspects of the organisation.
The leadership task is distributed or shared with others. To be effective, distributed leadership is intended to be a whole-organisation concept and culture, with all members of the organisation able to take a lead when required (Hartley et al, 2008). In some ambulance service organisations, this distributed leadership concept may manifest itself at first-line leadership level, with team leaders taking responsibility for the day-to-day management of resources and clinical team mentors leading clinical performance.
The leadership space has become increasingly complex, contested and noisy. With so many models of leadership, often supported by a strong evidence base, it is difficult for practitioners, managers and leaders to understand how and why they should behave. What is, perhaps, the latest leadership cloak that they should put on in an attempt to follow the latest leadership fad? Should they become transactional, transformational, or distributed in their approach? There is perhaps a need to attempt to cut through this noise, look for commonalities and develop a theory that paramedics find useful, whatever their leadership training or approach.
Leaders of the future
Grint (2010) discusses tame and wicked problems in organisations. Tame problems may be incredibly complex but solutions do exist. Wicked problems tend to have no known answers. He suggests that leaders of the future will have to face many wicked problems. Nearly 30 years ago, Handy (1989) suggested we were entering a new era, where the only thing that we could be certain of is that things will change. We can't anticipate how or when changes will occur, only that they will. He asserted that future leaders need the skills to be ready to adapt to this unknown world.
Drucker reports: ‘We are in one of these great historical periods that occur every 200 or 300 hundred years when people do not understand the world anymore and the past is not sufficient to explain the future’ (Cameron and Quinn, 2011: 1). Watkins et al (2011: 9) suggest that leaders will need to find new ways of working with people as they cope with the ‘reality that change is continuous relentless and accelerating.’ Grint, Handy, Watkins and Drucker do not refer to any particular sector; however, their words seem to have a particular resonance when considering the many complex issues that those who work within ambulance services face, as we continually move through uncertain and challenging times.
The paramedic leaders of the present and future will be dealing with many problems that require solutions that do not yet exist. How will we cope with an ageing population with ever more complex healthcare needs, who are better informed, and have high expectations? How will we continue to deliver our high quality service when faced with what Hawkins and Smith (Chard et al, 2013: 23) call ‘the unholy trinity of: greater demand for services, higher quality expectations and less resources,’ compounded by increasing unpredictability regarding capacity and demand? As such, the traditional models that may have been considered the maps for leadership within ambulance services might no longer provide the direction needed.
A literature review used an approach called Critical Interpretive Synthesis to look for commonalities across leadership models. Mays et al (2005) argue that management and leadership research has many complexities. The real world research environment of leadership research has been described as messy and inefficient (Edmondson and McManus, 2007: 1155). Practitioners within the leadership and management community have myriad backgrounds and derived knowledge from an eclectic and pragmatic array of perspectives that might range from sociology and anthropology, to economics and statistical analysis (Easterby-Smith et al, 1991; Gray 2009). As a consequence, there is not a consistently agreed-upon approach to research within this field, and many sources of legitimate evidence exist that might include quantitative, qualitative and grey literature findings. It is argued that an effective leadership literature review would need to derive and synthesise often complex information from multiple sources. Critical Interpretive Synthesis (Dixon-Woods et al, 2006) is ideally suited to complex situations with multiple sources of evidence.
Dixon-Woods et al (2006) state that although a number of approaches to enable synthesis of qualitative data have been developed in recent years, very few methods allow for the synthesis of evidence, regardless of the study type. They believe the Critical Interpretive Synthesis approach allows for this. The review concluded with a number of what are described as ‘synthesising arguments’.
Leadership as a social construct
Bass and Bass (2008) argue that we are subjected to leadership influences from birth and throughout our lives. Our mothers, fathers, extended family, and schools, among others, all provide early influences into how we perceive leadership. Our friends, work environment, profession, colleagues and leaders all continue with this influence as we journey through life.
Social constructivists believe that truth does not exist independently of human interpretation; instead, meaning is attributed to an object as a consequence of its integration with the human world. Crotty (1998: 42) suggested that constructivists believe ‘meaning is not discovered but constructed.’ A constructivist world is not a static place—it has fluidity to it. As we engage with the world, we make sense of the concepts and objects that we encounter. That sense-making is influenced by our experiences. It may be our culture, values, or social class; it may be our profession, organisation, or our experience of leaders. Whatever it is, the sense we make of an object like leadership will be shaped by our experiences up until that time. This sense-making may continually evolve as our exposure and experience to the object increases.
There are many models and ways in which leadership can be described. Researchers, academics and philosophers have sought an answer to this difficult, complex and multifaceted phenomenon and, despite over 3000 years of questioning and research, it still appears to defy definition (Crainer, 1998; Grint, 2010). Northouse (2007: 2) suggests that although we ‘intuitively know what leadership is,’ when attempts are made to truly define it, many different meanings emerge. Hernandez et al (2011) describe how although many of the models that have been developed have helped our understanding, we are still striving to identify new and disparate approaches.
It is perhaps time to call off the search for Simpkin's ‘Holy grail’ (2005: 10). There is no one right answer or approach; leadership is a social construct and effective leadership is constructed by our understanding of ourselves, the world that we live in, and the values and experiences that we have had that have led us to become unique individuals. This will evolve as our experiences change our perception of leadership in organisations. As Grint (2005: 1471) suggests: ‘the book is never closed but always open to contestation.’
The leadership equation
Turnbull-James (2011: 7) questions the popular view that leadership is beyond definition. She reports that the field has unified behind a basic assumption for some time, and ‘in its simplest form leadership is a tripod’ made up of the leader, the follower and the goal that is to be attained. Others have recognised this position, as examples, Clark and Clark (1996: 25) did not agree with what they describe as the ‘common perception of the elusive nature of leadership.’ Their definition suggested that leadership is an activity, in which ‘leaders and followers willingly subscribe to common purposes and work together to achieve them.’ Northouse (2007) defines leadership as ‘a process whereby an individual influences a group of individuals to achieve a common goal.’
Avolio (2007) suggests that the context in which the leader operates is an important consideration to their approach to leadership.
The four common elements that contribute to the majority of leadership models are considered to be the leader, the follower, the operating context and common goals. These could be considered as a unique equation. Whatever model or approach to leadership that holds sway at any particular time, it appears it is always a balance or a rebalance of the four elements of the leadership equation.
The menu of leadership styles has become rich and diverse. Practitioners may choose from an eclectic array of approaches, many of which have a supporting evidence base. If there is no clearly defined right approach, how can effective choices be made? The leadership equation allows for multiple realities of leadership. It asks leaders to consider the best way for them to lead, regardless of the current fashion of leadership thinking.
Leaders, at any level in an organisation, should pay attention to the factors that contribute to the elements that form the leadership equation. It is suggested that if all of the elements have been scrutinised, analysed and uniquely considered by the individual leader, and a balanced view arrived at, the leader will have the best chance of success.
Conclusion
Leadership is a complex subject that has been studied extensively over a long period of time. Its importance to effective and efficient organisations has been considered and restated many times. This has led to a wealth of research seeking to identify the right approach to successful leadership. Despite much energy and activity, no single approach has been indentified that provides an answer to this question; instead, a wide and eclectic array of approaches is proposed. Through a critical interpretive synthesis of literature, a synthesising argument that suggests that leadership is a social construct has been propagated.
There will be no single right approach that is appropriate for all (Allio, 2009). The literature, however, does suggest that, fundamentally, each leadership model contains a balance of four elements: the leader, the follower, common goals and the situation. In order for individual paramedic leaders to be successful, consideration has to be given to how each of the elements relate to each other. If the paramedic leader is able to do this, regardless of the style that they adopt, it is suggested that they will be successful.