Abstract
Introduction
The Special Issue has sought to foreground context in theories and research on leadership and leading in healthcare organizations. We hope this focus will encourage greater relevance of healthcare research to those who are tasked with ‘doing’ leadership in research and/or practice. Context has been a topic of interest in many articles in Leadership addressing different analytical constructions, approaches and settings (e.g. Denis et al., 2010; Iszatt-White, 2011; Jepson, 2009; Middlehurst et al., 2009; Peck et al., 2009) as well as in other disciplinary areas (e.g. Chouliaraki and Fairclough, 2010; Leitch and Palmer, 2010). Context can encapsulate everything from dyadic interactions, through teams and professional settings to the wider organizational and institutional domains as well as national culture. A fairly recent Special Issue of Human Relations (Linden and Antonakis, 2009) also drew attention to the need to further theorize the contextual dynamics of leadership and this need we suggest is perhaps the greatest in healthcare. It is possibly the most complex and challenging of all contexts in terms of the actors involved, starting with the patient clinician relationship and going all the way through to government levels as well as the politicized nature of professional organizations that have particularly challenging authority relations and systems of influence (e.g. Denis et al., 2010). It is also a context in which party politics, elections cycles, and policy regimes pervade (Grint and Holt, 2011), orchestrating anything from minor to major upheavals and ruptures. Various interpretations and constructions of leadership have to be locally negotiated and enacted so that actors shape and are shaped by their contexts in mutual, dialectic or other ways of relating (Grint and Holt, 2011; Izatt-White, 2011; Pye, 2005).
When it comes to healthcare, leadership theorists have challenged the dominance of individualistic and heroic approaches, especially those that singularly focus on developing skills and capabilities of health professionals, dubbed the ‘competency movement’ (Bolden et al., 2006) and epitomized by programmes such as the Leadership Quality Framework (LQF) of the National Health Service in the UK (NHS, 2002). Critics rightly complain that these approaches are devoid of context, treat leadership as a product and are misused as universal panaceas for promoting healthcare reforms; or alternatively they act as a re-badging of the activities of management to make them more acceptable, especially to encourage clinical or professional engagement. To this end there is now a call for medical clinicians or doctors to have their own version of leadership in healthcare called ‘medical leadership’ to capture management and leadership aspects that to date have been largely resisted by this highly professionalized group (Spurgeon et al., 2011).
What remains a problem then is finding a set of sufficiently understood theory to underpin the activity of health leadership that also has current and future credibility. The development of health leadership that takes as its focus how leadership was done in the past, or in other places, may not be sufficient to develop such understanding. Any interpretation of leadership can be contested, but perhaps none more so than in healthcare settings, to the extent that those in these setting tasked with leadership are often characterized as having a poor shared understanding of both the theoretical bases and practical enactment of leading. To this end, the Special Issue has sought to attract papers that will encourage shared understandings of different interpretations of both leadership and the contextual conditions that give rise to it. We were keen to see papers that examined leadership in post-heroic terms (e.g. distributed, shared and followership) in which the conceptualization of leadership practice is contextualized taking into account how, for example, the personal, political, social, structural, spacial and temporal aspects shape perceptions and experiences of leadership (Bolden et al., 2008: 362; Grint and Holt, 2011; Izatt-White, 2011) and were not disappointed. We also invited papers that were critical of the re-emergence or re-cycling of ‘less acceptable’ forms of leadership, such as charismatic and narcissistic forms that may find new contexts in healthcare and what we have in the papers in this volume is a general critique of any such move. An exploration of the constitutive approach, such as posited by Grint (2000, 2005) that uses the notion of problem orientated contexts to explain how leaders and followers co-create the contexts to which they must respond, was also thought to be of particular significance to healthcare systems that are often depicted as complex, in crisis or chaotic. Several papers do in fact address these concerns and there is a noticeable social constructionist epistemology underpinning most of them. Not surprisingly, and in keeping with the trend noted by Bryman (2011), all the research papers in the Special Issue are qualitative in nature.
The aesthetic concept of leadership was also an area in which we hoped we could attract papers, as this aspect relates to a form of emotional flow by those charged with leadership through constructed events which facilitate boundary crossing and insights through forms of ‘sensory knowledge and felt meaning’ (Hansen et al., 2007: 545). In healthcare emotional events are common place within professional practice and the leadership implications of this needs to be explored and we are delighted to note that several papers deal with this aspect of leadership in healthcare.
Contextualizing approaches (e.g. social constructionist and discursive leadership theories) emphasize an inherent contextualizing that problematizes the boundary between the external and internal environment, because contextualizing is searched for in organizational actions and within relationships (Cooper and Fox, 1990); other theorists, drawing on a critical perspective, use the idea of ‘formative contexts’ (Unger, 1987) to capture how actions are shaped by, but not necessarily determined by, wider socio-cultural influences. The policy domain of healthcare, we suggested, could be explored from this perspective given that it is a powerful force in framing leadership interventions, but these may give rise to significant problems relating to leadership engagement in healthcare at other levels of the organization. A number of papers address these concerns and creatively link the policy domain with local constructions of leadership.
None of the above excluded other relevant explorations around theories that draw on social constructionism, critical theory, reflexivity, discursive approaches, gender studies, poststructuralist, philosophical, narratives and storytelling and performativity, to explain how context and contextualizing are integral to the theory and practice of leading in healthcare. We are happy to say the Special Issue contains papers that address most of these understandings of context though as our conclusion suggests, there are aspects of context that require further elaboration and exploration.
We are also pleased to be able to reflect on the diversity of approaches to context and leadership in the papers selected for inclusion here, with contributions from the UK, Switzerland, Australia, the USA and Canada; in addition the papers reflecting the different institutional contexts from practice teams to national policy, and across a number of locations such as acute care to mental health. We were unable to attract papers from regions such as Latin America, Eastern Europe, Asia or the Middle East that could be included in the Special Issue. This perhaps suggests that a different Call for Papers might be needed to attract these contributors.
The papers show a concern about contextualizing (as a verb rather than a noun) that exists for leadership on a number of levels: from the value base of leading for the public interest, addressed by Brian Howieson, Roger Sugden and Mike Walsh; the organizational and team contexts and the role of professional identity in influencing boundaries and decisions considered separately by Linley Lord, Therese Jefferson, Des Klass, Margaret Nowak and Gail Thomas and then Samia Chreim, Ann Langley, Mariline Comeau-Vallee, Jo-Louise Huq and Trish Reay; to how change can be negotiated through Positive Deviance (PD) as part of a complex adaptive interpretation of the context suggested in the paper by Curt Lindberg and Marguerite Schneider; the role of relational leadership in decision-making within multiple and often simultaneous but differing interpretations of context as set out by Liz Fulop and Annabelle Mark; and finally Nada Endrissat and Widar von Arx’s exploration of leadership as context making, which also returns us to the link between leadership and values.
Thinking through the papers, thinking through contextualizing
The first paper by Howieson et al. looks at a form of ethical distance that is developing between the rapid move towards a neo-liberal agenda in England, as compared to the separate policy agenda now developing in Scotland, based as it is around the notion of mutuality, with the inherent notion of all stakeholders as co-producers of healthcare. Developing from this is their concept of leading for the public good, drawing particularly on the work of Dewey (1927), which can incorporate communities and self-help as well as statutory and even private sector providers. The challenge, they point out for all the UK health leaders, is to create higher trust for some of the very difficult decisions and actions in times of severe budget cuts, but this as they say can ‘be ameliorated through partnerships that are expressive not oppressive’. They explore notions of public interest and empowerment, social power and community drawing from these explorations ‘leadership as a process – contextually situated within the relationships between people’. A number of policy initiatives are examined within the wider UK context that exemplify this approach – what is apparent in this discussion, we suggest, is the close link between the values and ethics and the practice of health reform, rather than just the distribution of leadership for the purpose of engagement in policy change and implementation alone.
Lord et al. turn to a specific professional group, that of nurses in Western Australia, to consider, through their research, the current conceptualization of leadership in that context; drawing attention it appears to the contextual significance of the role of professions both within the institutions, but also separate from them, in terms of policy process and its implementation. They draw more specifically on Jepson’s (2009) dynamic interaction model that describes the immediate social, institutional and cultural factors to view contextual dimensions and how they interact. They discover leadership to be perceived negatively when representing individual rather than team interest, with a credibility gap between clinical and strategic roles and an informal training preference for ‘Acting’ in a role. Not surprisingly, given the location of the research, the Jepson model is found lacking in its consideration of geographical context, because, for example, greater delegation is a feature of rural health environments in Australia. The need to develop understanding of the relationship between the New Public Management (NPM) and nurse leadership it is suggested is also under explored but there is an ideological dissonance in relation to this as already identified by Nowak and Bickley (2005: 422). Problems of intergenerational acceptance of leadership roles, given the cultural shift in professional training in Australia that happened between the 1970s and 1990s, are also noted, indicating a changing context within the professional group itself. The presence of other professionals is, they say, still a significant contextual issue for nurse leadership citing Fagin and Garelick (2004: 282): ‘Nurses have to prove their competence in every interaction with physicians, whereas doctors’ competencies are assumed and it is their fallibility and shortcomings that have to be proved’.
Chreim et al. then move the leadership issues to the practice front line through an examination of inter-professional healthcare teams operating in Canadian mental health services. Context here is seen to be shaped through both formal and informal role identity, and how this is managed at different levels across the boundaries that exist between different leadership roles: leadership and clinical roles, leaders and followers in the team, different professions, personal experience and professional work and lastly, the team and its environment. This moves the issues from boundaries within individuals themselves to those between co-professionals, other team members and the wider environment. The study draws together the multiple roles and boundaries and shows them to be relational and social in nature. Indeed as Lamont and Molnár (2002) are cited as suggesting, if boundaries are distinctions that social actors make to categorize objects, people or practices, it seems they are also part of the interpretive context for leaders that must be understood before decisions can be made. Taking turns as leaders and contesting those who occupy the role is considered increasingly helpful within inter-professional working, symbolized in one example by the use of first names rather than professional titles such as Doctor. However, as Chreim et al. say ‘team leaders tended to close the boundaries when they felt that scope of practice – which is institutionally determined, and unique expertise had to be maintained and protected, and sought to open the boundaries and reduce professional demarcations when inter-professional participation might enhance client care.’ This in summary highlights the leadership practices of boundary work in opening, closing and contesting/negotiating through a process of what Weick and Roberts (1993) call heedful interrelating, this merits further exploration in the context of other specialist teams. On a more general note the suggestion from the research that clinical leaders are usually those whose leadership and boundary work practices contribute most strongly to the empowerment of other professional groups, further confirms their view of it as a social construction that occurs in interactions as Chreim et al. highlight in the conclusion and has much to do with social influence (Grint, 2005; Pye, 2005). The navigation of these multiple boundaries in health do however, Chreim et al. suggest, support the need for further understanding of the nature and levers of influence in complex settings.
Lindberg and Schneider develop the idea of health as a complex context, taking us again to front line health environments, this time in acute care where the need to tackle health associated infection is chosen as the locus in which to explore how the social aspect of leadership plays out. This is done in what is described at the outset to be a complex adaptive system, that is one in which as Lindberg and Schneider point out, adaptation and self-organization are inherent attributes. They then go on to propose the use of the change approach known as positive deviance (PD) to facilitate the research and change process to contribute to an understanding of the interplay between leadership and power and the shaping of the process of self-organization. While the intervention can have positive outcomes, reminiscent perhaps of the Hawthorne Studies (Mayo, 1933, 1960), perhaps the most important impact was that, as one participant said: ‘Leaders changed their view of how to lead’ through this disruptive technique. Despite issues such as tension created by power distribution between the professions, ‘Doctors write orders, they don’t write ‘suggestions’’, and value conflicts between the public and private providers, they conclude shifts in power related to change and the emergence of new patterns of interaction from which leaders emerge, suggesting context of itself both influences and predicates leadership. This paper is the only one to bring in a practitioner contributor to the study and highlights the need for reflection and reflexivity in navigating the complex challenges of dealing with the researcher’s own ‘knowledge constraining and constituting beliefs’ (Johnson and Duberley, 2000: 178) that are implicated in contextualizing, especially when studying a familiar setting.
The papers so far have considered contextualizing issues of leadership theoretically and in practical, empirical terms from values through policy to practice; the paper by Fulop and Mark uses decision-making, a key though less well explored element of leadership in healthcare, to consider how leaders deal with multiple or simultaneous contexts, using as a discursive tool, the Cynefin framework, a multi-ontology sensemaking ‘tool’ (Denis et al. 2010) that considers contexts as Simple, Complicated, Complex or Chaotic, leading to a variety of interpretive and decision-making tools and practices. Their paper is specifically concerned with the leadership challenges posed by the prevalence of single ontology approaches to problem solving and decision-making in healthcare and specifically, in clinical settings where professional sensemaking is prevalent. They suggest that the framework’s unique central domain of Disorder is where relational leadership practices, as set out in Hosking’s work (e.g. Hosking, 1988; Hosking and Morely, 1988; Morley and Hosking, 2003), has relevance because context or contexts are co-created and leadership arises in part from the types of contributions actors make to solving problems and dilemmas. The domain of Disorder draws attention to the messy processes that surround what are often retrospectively made to appear as logical and orderly decision-making tasks, when interpretations influence which decisions and interventions may be deemed as appropriate. In demonstrating deciding how to decide within the domain of Disorder, they draw on the idea of skilful relating, which encompasses the social, emotional, political and cognitive processes, needed to achieve ‘the clever use of systematic methods, to promote open-minded thinking and cultures of productivity’ (Morley and Hosking, 2003: 43). In understanding the content and process of Disorder and its relational implications, they describe a different approach to the context making role of leadership in healthcare.
The final paper by Endrissat and von Arx continues this exploration of the context making role of leadership within research undertaken in a Swiss healthcare setting exploring the evolving dynamics and recursive leadership practice that demonstrate leadership and context as social constructions. Drawing on Grint’s (2000) constitutive approach of leadership and context as interdependent social constructions, they focus on practice and the linguistic turn (Fairhurst, 2009), as well as the how of leadership; which they suggest must also include the teleoaffective structures, such as acceptable emotional responses that are implicitly held. So the context is made up of institutionalized meanings that limit the possibilities to think and act, but the leader they suggest needs to influence both the vision, day to day standard activities and personal interactions including para-linguistic aspects; and these three aspects of context exist simultaneously. Their research was based on a longitudinal case study of a change process within a Swiss public hospital from 2004 to 2006. Leadership practice was defined as a re-occurring pattern of influence, tactic or decision-making behavior and so, for example, in order to move people into a different context to allow contentious issues to be discussed, the project lead created neologisms to separate the new from the old, marginalized or excluded negative influences, and delayed decisions until a crisis was reached precipitating a shift; however, such tactics were understood by others and also employed in this situated, dynamic, dialectic and collective process. This evidence leads to the assertion that an emphasis on everyday interactions was perhaps the most important level within the research context at which change might be achieved; although different levels produce different advantages for leaders, and the most neglected of these are the symbolic and paralinguistic aspects within research and possibly practice as well. As a recursive context producing practice it seems that leadership and context imbue the values and ethics through this process.
Drawing lessons
In setting out to understand the role of context and its relationship with leadership we were aware of the diversity of context and practice in healthcare. It has been interesting to discern the story that has emerged and indeed, storytelling itself is shown within health to be a powerful aspect of leadership, especially as a transmitter of values and ethics (Conroy, 2010). The importance of values and ethics arise because of the ‘sacred’ (Grint, 2010) nature of the leadership space in health, where we conclude as Grint does more generally, that it is not so much the elephant in the room as the room itself, perhaps because of the unique nature of the tasks. The diversity of the community involved in healthcare, although broadly separated into providers and patients, is now developing into a more mutual concept (Howieson’s paper) with the wider community, if policy change in Scotland comes to fruition. What is emerging across all relationships is a new context in which the boundaries between the knowledge between providers and between providers and patients is moving and redefining the leadership space as a new context. To understand these changes insights from the front line are instructive, as the work of Lord et al., Chreim et al. and Linberg and Schneider show, particularly in relation to change as an aspect of the leadership role. The omission of key recipients (e.g. clients, users, consumers) of care in any theorization or practice of leadership is short changing how we look at contextualizing and is a common problem in many approaches to leadership, as noted by Bolden et al. (2009) in relation to the Higher Education sector.
Leadership is less of an object more of a process from which leading rather than leaders emerge. Indeed as Chreim et al. show, effective leaders are usually those whose leadership and boundary work practices contribute most strongly to the empowerment of other professional groups, and whose identity, as Lord et al. point out, is bounded and renegotiated by the context bestowed by others. These shifts in power relate to such changes, and the emergence of new patterns of interaction from which leading is co-constructed (see Lindberg and Schneider) often through both external and internal shocks, show how context of itself both influences and predicates leadership.
The hierarchies of power now contested in health by both providers and patients’ role within their shared spaces influences both the perception of relationships and their boundaries. However, where leadership is invested in the individual alone there are contextual dangers as described by Collinson (2012) for example in his exploration of ‘Prozac leadership’ and the limits to positive thinking; in times of radical change they will appear especially inauthentic not least because it is as much about power over the self for the individual leaders, as it is about power over others. The role of power lies between people within contexts that they share and recognize together, as the Cynefin framework central space of Disorder described by Fulop and Mark seeks to demonstrate. Indeed the collective understanding of Disorder, in which leading roles may emerge according to the context that is deemed appropriate through negotiation and skilful relating, be it Simple, Complicated, Complex, or Chaotic, allows also for the emergence of a collective leadership that can distribute those leaders most expert for the given context. This echoes Middlehurst et al.’s (2009: 83) argument that perhaps we should be exploring the notion that ‘leadership needs to be ‘fit-for-context’’ to signal the inexorable way in which leadership and contextualizing are connected. This relationship between knowledge and expertise within collective leadership, we have recently been reminded, is not new but goes back to the earliest forms of leadership as practiced by Aboriginal tribes (Sveiby, 2011).
Context is an evolving space as leadership itself is and as Endrissat and von Arx shows is not always positive in effect, this may be because of failures to engage in an interpretive analysis with others or because the possibilities of multiple contextual ‘environments’ being present, and requiring mixed approaches, are not recognized; but as a recursive context producing practice they will imbue the individuals and the collective, at whatever level, with values and ethics for good or ill.
What of the future?
A casual browse of a general book on leadership theory (e.g. Bryman et al., 2011) or qualitative research in leadership (e.g. Klenke, 2008) very quickly reveals that there are many more ways to look at leadership and context in healthcare settings than is contained in the Special Issue. While understandable, it also alerts us to noticeable gaps and omissions. For example, we did not have any papers that draw on action research or participatory action research, yet these approaches provide the opportunity for researchers to work in partnership with the healthcare practitioners, consultants, patients and consumers and provide a rich understanding of how leadership is a contextualizing and contextualized practice or performance (e.g. Koch and Kralik, 2006). These approaches align with Howieson’s concerns with the co-creation and integration of new community orientated healthcare contexts that need to entail different and novel forms of leadership and partnerships with diverse stakeholders. We had no papers that presented cases or research on community-based healthcare organizations and their leadership practices or for that matter in aged care, a rapidly growing and important sector.
We did not receive any comparative papers that might have shed light on how cross-cultural influences shape leadership practices and how to theorize these so that context or contextualizing are brought to the fore. Bate et al.’s (2008) ethnographic study of seven leading or exemplary hospitals the UK, Europe and the US, is a seminal piece of research that sheds light on how different forms of leadership (based on the notion of hybridity) arose in response to pressing problems and challenges across various levels of these organizations as they went along their respective quality journeys. It was also found that a significant disconnect existed between how the middle and the upper echelons saw their contexts and hence, their leadership roles, responsibilities and identities. Bate et al. make it clear that they never had a theory of leadership to start with and they still do not. Rather what they say they have is a contextualized understanding of leadership as solution and problem orientated, though in a different manner to Grint’s approach, mentioned earlier, that focuses on decision-making. It is a practiced-based approach somewhat akin to Denis et al. (2010) as it did not pay much attention to the discursive aspects of leadership. Their work aligns with the dynamic, collective, situated and dialectic nature of this approach, capturing both the upside and downsides of leadership when studied over time.
Both these aforementioned studies also take a different tack to most others in healthcare because they eschew the negativity and the legendary resistance to change or reform of those tasked with leadership. In fact, leadership studies in healthcare generally display the extreme opposite to the positive-ism that Collinson (2102) noted in mainstream leadership studies (MLS) coming out of the US where so much hype surrounds the excessive potency of the leader and leadership. We think we could do with some of this hype in healthcare when it comes to leadership but perhaps not the positive-ism.
Despite the fact that we asked for contributions that examined how leadership studies in healthcare could benefit from insights and research in other sectors, particularly Higher Education (HE), none of the papers explored the possibility of making connections between leadership and context across domains. Gleeson and Knights (2008) make the same point when they describe how NPM has created new cultures of audits and budgetary constraints that have seen the leadership responses being one of creating innovative skills and practices; these involve brokerage and mediation skills that are likely to be also be present in healthcare settings; this has been subsequently confirmed by Fulop (2012) in her research on clinician managers in Australia. Some of these innovative skills and practices include such things as: ‘underground working’, ‘hidden-trade’. ‘restorying identity’, tacit knowledge’, principled infidelity’, ‘conscientious objection’ and ‘added value’ (Gleeson and Knights, 2008: 64). Similar practices are encapsulated by the notion of ‘gambits of compliance’ (Kelly et al., 2006) and are part of the staging of so-called authentic performances of leadership noted in HE settings in response to NPM.
We could go on and identify other gaps but this would be an arbitrary exercise. Or we could follow the example of Leitch and Palmer (2010) who sought to examine how context was being used in in Critical Discourse Analysis (CDA); a key element of this approach is that texts should be studied in context, much the same way we assert that leadership in healthcare needs to be studied as a contextualizing phenomenon, however extreme the context (Mark and Jones, 2012). Leitch and Palmer started from the premise that context is often taken for granted and is defined or described in many and varied ways. They noted that there were five main ways context was treated in CDA: ‘as space, time, practice, change or frame.’ (2010: 1194); we can certainly see parallels to this in the Special Issue. In these five areas they identified a further 16 sub-themes, for example, under ‘space’ they added: intra-textual, situational, organizational, institutional, national, virtual and multi-spacial. The aim of the paper was to propose an agenda for bringing rigor to the study of context and to this end, Leitch and Palmer developed nine methodological protocols for guiding future research on the topic. Their quest for rigor or prescription was subsequently critiqued by Chouliaraki and Fairclough, (2010) as counterproductive and unlikely to enrich the understanding of the dialectic and constructionist ways in which context and discourse are implicated. Nor were Chouliarkis and Fairclough convinced that studying context on its own was a productive way to advance the understanding of CDA and indeed, they said this would tear context from the very contextualizing processes, such as power, that are important to its understanding. However, for us the value of Leitch and Palmer’s endeavor lies in being able to identify the state of play in theorizing and researching of leadership and context and most importantly, being able to identify the blind spots and where there is dominance, in much the same way that Collinson (2012) sees positive-ism in MLS. Even when we take a cursory look at the areas Leitch and Palmer identified under ‘space’, it is clear that none of our papers explored the virtual nature of context and leadership in healthcare though this is a significant part of the revolution taking place in the delivery of healthcare.
Understanding leadership in healthcare will always be a process of becoming (Harding, 2007) and we hope the insights from this special edition adds to that discourse; we thank our contributors and more especially our group of anonymous but expert referees whose insights and comments contributed so much to the final outcome.