The shadows in healthcare leadership

Introduction

Many readers have likely crossed paths with people whose ethical compass points away from the espoused values of courage, integrity, compassion, and accountability. Such individuals may have particular neurobiological features with associated traits which drive their destructive behaviours, casting shadows around them. A vignette illustrating a prototypical scenario will be provided, followed by an overview of the pertinent traits. The potential impacts of such traits and mitigation efforts in the context of health leadership will be outlined.

Jane’s behaviours illustrate neurocognitive processes that may reveal differences in value systems, decision-making, and interpersonal strategies. Readers may be familiar with frameworks for individual differences, such as the Myers-Briggs Type Indicator, ¹ which is an evidence-based approach to various trait dimensions such as introversion-extroversion. Such traits can be thought of as enduring, although not necessarily immutable, tendencies “to feel, perceive, behave, and think in relatively consistent ways across time and across situations.” ²

Historically, consideration of personality traits in the context of leadership has focused upon the positive, such as the Big Five factor model of personality, which includes Extraversion, Emotional Stability, Agreeableness, Conscientiousness, and Openness to Experience. ³ Correlations between such personality traits and various neurobiological features have been identified, including variability in cerebral blood flow, ⁴ amygdala functions, ^5,6 neurochemistry, ⁷ and neuroanatomical structures. ^8,9

Increasingly, attention has been focusing upon less constructive traits and their influence upon leadership and organizations. ^2,10 This increasing focus may reflect growing public, academic, and professional awareness of the prevalence and impact of such personality traits across corporate, political, and public sectors. ⁹ Within the literature, a triad of toxic, or Shadow Traits (STs) has emerged (note 1) including narcissism, psychopathy, and Machiavellianism, ^2,11,12 which has been expanded to a tetrad with the addition of sadism. Understanding of these STs is setting a new direction in leadership research ¹³ and is foundational to a comprehensive understanding of leadership and organizational outcomes. ^2,14,15 While still an emerging area of inquiry, there is initial evidence of correlations between ST’s and neurobiological features. ^{5,16– 18}

Shadow traits: Psychopathy, narcissism, Machiavellianism and sadism

The STs have common features and tend to relate with each other while also having distinguishing aspects. Commonalities include limited empathy, conscious or unconscious motivation to cause harm, ⁶ and ego-centric and exploitive social strategies such as duplicity. ^8,19

Psychopathy has primary aspects of selfishness and uncaring manipulative approaches toward others and secondary aspects of impulsive and self-defeating behaviours (eg, contravening laws). ^7,9 The primary features are often explicit in the successful corporate arena; secondary features are relatively covert and sophisticated, such as fraud. Elevated psychopathic traits are associated with limited experience of fear, anxiety, guilt, and embarrassment compared to the general population. ^6,20 Such individuals have a propensity toward taking credit for others’ work and diverting accountability for failures. ²¹ Imaging studies have identified several neuroanatomical correlates with this trait, particularly in the prefrontal cortex and amygdala. ^22,23

Narcissistic traits are characterized by a sense of entitlement, grandiosity, disdain for others, and relentless pursuit of self-enhancement. ^9,24 Projecting confidence, even in uncertain circumstances, individuals high in narcissism are drawn to roles with dominant authority over others and pursue high-profile positions. Emerging initially as leaders, their impression management is typically time-limited, eventually being undermined by damaging interpersonal strategies and accumulating evidence of deceit. Preliminary research in the area identifies associations between narcissistic traits and the integrity of white matter in the frontostriatal pathway. ²⁵

Machiavellianism, named after the amoral leadership advice of Niccolo Machiavelli, ⁶ is characterized by cold and manipulative behaviour, in both laboratory and real-world studies, with an exclusive focus upon one’s own interests. ^9,10 Those high in Machiavellianism experience pleasure and accomplishment in successfully deceiving ²⁶ but do not necessarily have superior deceptive abilities. ²⁷ They are particularly effective at forming political alliances and cultivating a charismatic image.

Sadism is the desire and intention to cause harm to others, simply for the enjoyment of others’ distress and was recently suggested by Paulhus, ^5,28 expanding upon the concept of a triad of ST’s. This relatively new addition to the literature on STs has had limited investigation to date.

It is important to distinguish STs from other phenomena, such as incompetence or general ambition, which lack malevolence or deception but can also yield destructive outcomes. Further, STs refer to presentations found in the general population, ²⁹ rather than diagnosable psychological pathologies. Everyone has some degree of these STs, and even fairly high elevations may still be subclinical, rather than indicative of a clinical personality disorder. ^30,31

Shadow traits applied to LEADS

Shadow traits, which may manifest in complex and subtle ways, are relevant to leader performance and outcomes. ^32,33 Research shows robust relationships between narcissism and counter productive work behaviours; Machiavellianism with subordinates’ lower job satisfaction, well-being and career success, ⁹ experience of abusive supervision; ² and psychopathy with aggressive leadership behaviours. ³⁴ A review of how STs may impact key areas of healthcare leadership can be guided by the LEADS framework, ³⁵ comprising the five domains of lead self, engage others, achieve results, develop coalitions, and system transformation.

The leads self domain focuses on the character and integrity of the leader, ^36,37 reflecting leaders’ capacity for awareness of one’s own ethical framework and sensitivity to one’s impact upon others. ^5,38 Leaders with elevated STs are likely to exhibit several challenges in this domain, given their selt-interest, limited empathy, and propensity for deception. Convincing portrayals of altruism or compassion are belied by inconsistencies between their words and deeds. Such individuals will not hesitate to lie, take credit for others’ work, redirect accountability for failures, or sacrifice other’s well-being in their own self-interest.

The engage others domain of leadership involves fostering development of others, contributing to healthy organizations, and team building. Regrettably, STs salt the earth of the organizational environment, team function, and collaborative relationships through aggression, deception, and mercenary self-interest. ³⁹ Teams reporting to leaders with elevated STs will manifest low trust and high turnover, ^40,41 with subordinates learning to emulate dysfunctional behaviour, particularly when there are perceived benefits and little (or no) organization censure. ⁸ The effects spread in the form of increased interpersonal aggression, as well as attrition of those who experience moral distress. Various types of interpersonal workplace aggression are consistent with elevated STs ⁴² such as maligning the professional status of others; intimidating through criticism and abusive or belittling comments; isolation through exclusion from communications/events; setting unrealistic or inconsistent expectations; misattribution of responsibility (blame or credit) for outcomes; and assignment of lower status tasks, reassignments, and excessive monitoring. ^7,11,15,43 Notably, the negative impact to the psychological well-being of team members is rated as more significant in public than private sectors. ⁴

Achieving results involves setting and enacting direction in alignment with strategic priorities and reflects the extent to which organizations mobilize the full effort of its people. ⁴⁴ In the presence of a shadowed leader, strategic initiatives may be derailed by competing self-interest or destructive interpersonal strategies. For example, as the shadowed leader pursues opportunities for self-enhancement, efforts will be directed toward aligning organizational support resources toward initiatives which serve their interests, but not necessarily the best interest of the healthcare service. The shadowed leader’s tactics to align support and resources will be based upon their propensities for deception and manipulation. In the context of larger organization, deception will occur through managing information streams for decision-making (stakeholder engagement, environmental scans), communications (governance bodies, public), planning (costing forecasts, human resources impacts), and evaluations (information collection, analyses). “Inconvenient information” will be suppressed and analyses will be limited or misleading.

The quality of outcomes may also be negatively effected by the presence of STs though impaired group decision-making phenomenon such as Groupthink, ^45,46 where participant dissention is suppressed, or Escalation of Commitment ⁴⁶ as in the case of “too big to fail.” Eventually, a pattern of unfulfilled commitments will present itself, although blame typically falls upon others.

Developing coalitions entails purposeful development of connections within the socio-political environment in service to the health organization’s core mission. ²⁴ Shadowed leader’s connections will serve their own core mission and may involve unethical tactics including subtle threats, covert manipulation, and duplicitous charm. ⁹ Others (individuals or groups) are perceived as pawns, patrons, or patsies ⁴⁷ according to their utility for the shadowed leader in terms of support, advancement, or deflecting blame, respectively. As circumstances change, so may roles, with a pawn sacrificed as a patsy, a patron displaced through betrayal, or even patsies recycled into pawns.

Systems transformation represents enacting large-scale innovations based upon identified strategic priorities. Such high-profile change initiatives with their potential for self-enhancement may be actively pursued by those elevated STs. Superficial charm and positive first impressions can inspire confidence in the shadowed leaders’ capacity for such initiatives. However, initiatives within the shadow of misinformation, team dysfunction, and exploitive relationships will struggle. Compounded by faulty decision-making, there is increased potential for negative sequelae beyond an organization’s ability to course correct.

While the negative impacts of the STs are emphasized in the literature and above, the situation is complex and nuanced. The double-edged attributes such as extreme risk-taking, negotiation skill, and low anxiety may incidentally cut in favour of organizational success, with associated reinforcement. ⁴⁸ Incidental benefits may also accrue for subordinates through career advancement and organizational influence. Unsurprisingly, the degree of success of such leaders tends to be enhanced by higher levels of intelligence.

Damage limitation

Based upon related literature and evidence-based theory, measures to minimizing damage from shadowed leaders can be deduced and categorized as primary, secondary, and tertiary approaches.

Primary approaches aim to prevent the presence of leaders with elevated STs through stringent and robust recruitment processes and succession planning. ²² Candidates with STs may excel at interviews ^49,50 and have curriculum vitae which are impressive, at least on the surface. Hence, emphasis should be placed upon candidates’ track records, demonstrated ethical leadership activities, and sustained constructive relationships. Familiarity with the nature and impacts of STs may inform recruitment analyses: What is the turnover and morale of their team? Do they demonstrate accountability for mistakes or redirect toward others? Has decision-making been ethically driven and based upon consideration of inclusive and diverse inputs? Obtaining information from knowledgeable others may be particularly valuable. ²

Secondary approaches focus on identifying and minimizing the impact of STs in existing leaders. Such approaches may be applied through organizations’ development/training programs, human resourcing, governance structures, and workplace culture initiatives.

Leadership development programs which address STs can build capacity across the organization for awareness of this phenomenon, the consequences, and related organizational supports. In particular, broad understanding of faulty decision-making phenomenon (eg, Groupthink) and vigilant decision-making processes may be helpful. ³⁹ Those emerging leaders with modestly elevated STs may self-identify and be sensitized to the potential downsides for themselves as well as opportunities for self-development.

Human resourcing measures for damage mitigation would be contingent upon organizational expertise in this subject area. Such expertise could be accessed for ad hoc performance consultations regarding those with repetitive and significant patterns consistent with STs. Where applicable, informed consultation would be available regarding approaches to address identified concerns such as behaviours that are disruptive, disrespectful, and/or harmful. Concurrently, performance evaluations (formal and informal) should include validation and reward for exemplary commitment to upholding ethical values in the workplace. ¹⁸ Additionally, standard performance review processes could be enhanced through 360° feedback sources beyond those selected by reviewees. For departments with high levels of turnover, exit interviews performed by third parties may be particularly informative. This will require a level of sophistication in analyses and interpretation in order to distinguish shadow influences from system pressures or competency issues.

Governance processes which promote transparency and accountability may also mitigate risk related to STs. A prime consideration should be meaningful and supported participation by individuals invested in the quality of the outcomes who are qualified to make informed input. ⁵¹ This may be particularly important at initial planning stages where foundational commitments are made regarding resourcing, timelines, and deliverables. Large healthcare organizations typically have financial monitoring infrastructures; analogous mechanisms for quality may be an option (eg, imbedded quality support or process consultants). While resource-intensive, this may be a “pay now” or “pay later” situation particularly with large-scale initiatives.

An ethical organizational culture can attenuate some impacts of STs (abusive supervision, advancement of shadow leaders). ^10,25 Supportive infrastructure to this end would include ombudsman offices or workplace culture departments with clear mandates and the requisite expertise. All levels of the organization would be in scope, with context-specific approaches (eg, executive, corporate services, operational leadership, direct service), which leverage existing mechanisms in the organization where possible. Such departments would be enabled by arms-length governance (eg, direct board reporting), expertise in the area of organizational psychology, and adequate operational resourcing. Capable leadership in this area would look to manage the risk of zealistic (McCarthyistic ⁵² ) attribution of STs to basic competency challenges or ambition.

Care should be taken to ensure these mechanisms are not subverted as instruments by leaders with STs, ⁵³ particularly those with high levels of authority, intelligence, and/or sophistication of thought. Governance bodies may be covertly orchestrated though favourable chair assignments or terms of reference, and critical analyses branded as obstructive. Subversion can also occur through cultivation of participants aligned with the shadowed leader or those lacking expertise (patsies). Additionally, organizational processes such as workplace culture or respectful workplace programs can be leveraged to enact what is effectively organizationally supported intimidation.

Tertiary approaches may be used when an individual identified with elevated STs is having profound negative impacts exceeding secondary approaches. There may be such harm to the organization that maintaining the status quo and continued trajectory is unacceptable. Transitioning from, or tactical reassignment with supervision within, the organization may be indicated. Organizations ultimately hold some accountability for recruiting, promoting, or retaining individuals with STs who may, in fact, have some positive impacts for the organization depending on their nature and guidance. The degree to which these traits can be identified and mitigated or directed toward constructive outcomes will be dependent upon the nature of the individual and external supports applied. There will be challenges with tertiary approaches as the shadowed leader enacts increasingly intense defensive strategies to protect their persona and self-interests. Maintaining the status quo, however, will also be associated with costs and a prudent decision to be made about the consequences to be borne by the organization and those it serves.

Conclusion

The widespread attention to values-based leadership signifies a collective awareness of the impact of leaders’ character. The espoused importance of values such as courage, integrity, compassion, and accountability implicitly reflects what many have learned through experience: Self-interested individuals with limited empathy and social conscience who regularly utilize deception and tactical manipulation have a negative impact on people and health systems across many domains. The degree of negative impact likely reflects many factors including the organizational environment as well as the individual’s intelligence, sophistication, and composite of STs. The multiple mechanisms reviewed (primary, secondary, and tertiary) can be utilized to mitigate such adverse impacts. Such mechanisms are akin to tools left sitting on the shelf without those with the initiative to begin and resolve to sustain the challenges of understanding and addressing their own STs, being sensitive and appropriately responding to potential STs in others, and enabling related organizational mitigation resourcing.