Introduction
Leadership in healthcare is one of the most important issues which helps medical staff to ensure effective and high quality services delivered to patients. Task forces consistently identified significant and interdependent elements of leadership that are in dangerously low supply in their organization. An ineffective leadership process and the lack of skills to enact it prevented the healthcare setting, they reported to top management, from implementing and reformulating the new strategy top management had said was essential for success.
Problem Identification
I am working as a senior nurse and in one morning shift, a group of university student nurses were having appointment in my surgical unit and they heard from the doctor’s verbal order to remove one yeast drain of the abdominal wound. And they showed enthusiastic that go and ask their clinical tutor whether they can try to remove the drain or not. Finally, I discovered they removed the drain by one of the student and their Clinical instructor has not supervised, also no one notified me about the beginning of the procedure. I reported the case to my ward manager, but he only listened to me and did not take any action to prevent such situations in future. To my surprise, he blamed me in the situation occurred this morning. He has not showed up any guidelines or instructions to meet the ward policy in such clinical situations.
Analysis of the Problem
The case shows that the main problems occurred in the surgical unit were caused by poor leadership skills and inadequate communication between medical staff and the ward manager, the students and the supervisor (Barker 2001). Task forces identified the following barriers:
Unclear strategy and conflicting priorities: Employees had not heard the strategy articulated previously, it did not make sense to them, or the priorities of various functional departments were inconsistent with each other and the articulated strategy (Schien, 1996).
An ineffective top team: Employees perceived lack of cooperation and agreement at the top. Members of the top team met infrequently; when they met the agenda was filled with administrative rather then strategic issues. Consequently decisions were made one-on-one between the general manager and subordinates. They did not come out of group deliberations. General managers perceived that top team members approached problems with a functional rather then general management perspective.
A top-down or laissez-faire leadership style by the general manager: The leader dominated the top team or went around them to gather information and give direction. Or the leader did not engage the top team sufficiently to confront and resolve conflicts between them and their departments (Schien, 1996).
Poor coordination and teamwork across key interfaces: Functions, business units, or geographically dispersed entities whose close coordination was needed to implement the strategy efficiently and effectively were making decisions without consulting each other.
Inadequate management and leadership skills and development throughout the surgical setting: Key supervisors below the top team were perceived by employees to lack management and leadership skills. They were perceived as narrow, parochial, and insufficiently motivated by the objectives of the organization as a whole. This was often attributed to an inadequate career development system. Managers felt stuck and undervalued (Schien, 1996).
Communication Problems
Poor leadership was caused by inadequate communication inside the surgical unit. Low quality and frequency of communication between the top team and key managers, one or two levels below them, caused two problems. Lower levels often did not know, understand, and sometimes agree with the strategy. And they found it virtually impossible to communicate with the general manager and the top team about how behavior at the top was causal to the difficulties the organization was experiencing. It was the supervisor’s singlehanded and dominant role in the strategic management process as well as ineffective teamwork between domestic divisions, R&D, corporate marketing, corporate supply chain management, and the International Division that made it difficult to implement the corporate strategy (Segriovanni and Glickman 2006). Employee task force members in almost all organizations were both eager to participate and anxious about their assignment. They were energized by the opportunity to help straighten out the organization, but they were concerned about having a candid communication with the top about the real problems they knew existed. The last barrier, inadequate leadership and management skills and development throughout the organization, seems to be both a result and a cause of the organization’s inability to change. In all the companies, the new management paradigm that they were attempting to adopt was a lateral team organization. A team-based organization demanded more leaders with far better skills (Reed 2001). These skills did not exist because ineffective top teams did not typically have open and frank conversations about the capabilities and potential of managers in their respective organizations; talking candidly about managers reporting to peers might damage relationships with them. Moreover, ineffective top teams did not possesses leadership skills to assess and develop leadership in lower-level managers. (Vargas, n.d.). Nor were members of ineffective top teams ready to transfer their best managers to other parts of the organization for development. And they did not delegate responsibility. Lower-level managers, in turn, did not take leadership responsibility for changes they thought necessary. Anxiety about upward feedback by managers on task forces helps explain why lower-level managers are reluctant to risk leading change. The picture that emerges from this analysis is far from the ideal of heroic leadership. Indeed, the barriers cannot be overcome by strong heroic leaders; in many cases they are the ones who create the barriers. Instead, effective leadership of change requires a process that embodies inquiry, decision making, and action within the top team, between functions, and between the top team and lower levels. For this to occur, constructive conflict and mutual influence must dominate these relationships. Empowerment, the new paradigm many companies want to enact, is impossible without it. And without empowered managers, the general manager is left no alternative but heroic leadership. Open dialogue about substantive business and organizational design issues is not enough, however. We found that without this dialogue the organization and its managers could not learn about the pattern of organizing and leading that was blocking their effectiveness (Wofford and Whittington 2001).
Consider a top management team that instituted cross-functional teams to develop new products. A year after teams had been put in place, top management had failed to learn from them that their own behavior violated their espoused theory of organization and management. According to team members, top managers were still making decisions. Teams were simply executing; as team members put it, “we are go-fors.” Team members had not found a way to tell top managers that their behavior was not consistent with the change they claimed to champion (Zaccaro and Klimoski 2001). Virtually all change initiatives—attempts to change strategy, structure, systems, staff (through better selection and training), culture, and leadership itself—are blocked by the inability to surface, diagnose, and act on an ineffective leadership process represented by the six barriers. In other words, the hard or soft aspects of the organization cannot be realigned in any fundamental way with a new strategic direction without engaging and overcoming the six leadership barriers. Avoiding the barriers through a series of change initiatives that disconnect hard from soft and rational from emotional does not work either (LaFasto and Larsen 2001).
Proposed Improvements
The case under analysis shows that the barriers are interdependent and mutually reinforcing. Good coordination, the organizational behavior needed to implement or change virtually anything in the organization, is clearly dependent on an effective leadership context (Mccormick, 2001). There has to be agreement on strategy and priorities. To have agreement at the top, the leadership team must be effective—its members must be capable of debating with each other and the leader and be capable of coming to a unified view of strategy and organization To have an effective top team and effective coordination, the general manager had to engage the organization through his top team as opposed to going around them and driving change personally. Forcefulness in pushing process, not content, was important, however; laissez-faire leaders who did not engage their team in constructive debate were equally ineffective. The three barriers that emanate from the top are themselves interconnected and mutually reinforcing. Teams may be ineffective because of the leader’s behavior. Conflicting priorities are a function of an ineffective team. Leaders go around their top team if they lack the will or skill to engage their team in the constructive conflict needed to shape a team and a vision (Lazaridou, 2002).
Personal Leadership
In order to develop leadership skills, it is important to take a special attention to motivation and charisma. Intervention theory and method has not focused sufficiently on the possibility that strategic change can be motivated by a carefully designed action learning process that confronts the fit between strategy, organization, and leadership behavior. Such a process could guide surgical setting in leading framebreaking changes in their respective settings, at the same time developing their leadership skills and transforming the organization’ (Baruch, 1998). Although this appears inevitable given present leadership skills and social technology, the economic and human cost of waiting until a crisis creates a revolution are sufficiently high to warrant a search for an alternative to the heroic leadership model we argue dominates the landscape of change. An action learning approach to change such as Organizational Profiling is also more consistent with reality that only a very limited number of leaders possess the will and skill needed to transform their everyday operations (Katzenbach and Smith, 2003). To avoid the cost of ever-increasing turnover of ward managers and their teams, a need exists for an institutionalized process for change that can guide leaders and from which they can learn. That process would have to foster a valid dialogue between leaders and followers about how leader behavior and the instruments of their leadership—organizational design and management process—shape organizational effectiveness. If that process were the norm, defensive routines could not and would not prevent the transparency organizations require for ongoing learning. The results would be both organizational change and leadership development (Kalleberg, 2003).
SMART
The key to success of the feedback process lies in management’s selection of its best people, in the fact that task force members are reporters of others’ views, and in the fishbowl method itself. The fishbowl enables task force members to speak to each other and as a group—much less threatening than making an individual presentation and speaking for yourself. Because the issues are raised in the context of business strategy, personal feedback is not taken personally, so to speak. Indeed, the report of the task force covers all facets of the system—leadership and organizational behavior as well as harder issues of strategy, structure, and systems. The feedback also has a very powerful effect on leaders, particularly when the leader has been in the organization for some time and the data reflects his or her leadership (Mccormick, 2001). The data is received by general managers as an appraisal of their leadership and stewardship and it motivates them to act. Because feedback comes from their own employees, it has face validity and obligates general managers to act. And task force members are powerfully motivated and affected by the experience. Institutionalizing a specific organizational learning process provides a company with a core strategic management process. It constitutes an integrated systems approach to change; it connects hard and soft strategy with style, structure, and staffing. Most importantly, it is the vehicle for changing the cultural context that blocks mediocre medical units from becoming high-performance organizations capable of continuous adaptation (Katzenbach and Smith, 2003).
But although collaborative behavior, particularly the creation and sharing of knowledge, occurs all around us, it is not viewed as a legitimate process in the business world. On the surface, collaboration is questioned because, like delegation and participation before it, the process appears to conflict with hierarchical authority and control. Within the surgical unit, collaborative processes frequently occur across lines and ranks and may not hold to any set boundaries. Across organizations, collaboration may be recognized as having many potential benefits, but here again neither the process nor its returns are fully controllable by any of the partners. Beneath the surface, collaborative processes, even those that are successful, create unease because they seem to be at odds with basic concepts of business behavior. In these societies, basic life philosophies tend to cluster around two polar positions, libertarian or collectivist (Jameson, 2001). Libertarian views, as we know, emphasize the virtues and importance of individual freedom—the freedom to choose one’s occupation and lifestyle—and individual responsibility—the requirement to meet one’s own needs without the demand for social support. This philosophical position is expressed in neoclassical economics, which argues that aggregate social welfare will be maximized if individuals are allowed to pursue the maximization of their own utility functions through free-market interactions ( Imperato, 2000). Collectivist views, however, endorse the concerns expressed by the critics of libertarianism and argue, as we know, that distributions of societal goods and services should reflect effort and need rather than initial resources or capabilities (Bass, 2000). Social ownership and control of capital is advocated as essential if all members are to be protected from exploitation and assured appropriate returns and equal access to societal resources. Social control of capital is exercised through state-run hierarchical organizations utilizing a flow of resources guided through centralized planning. The theory promotes the search for incentives that meet both agent utilities and owner objectives. It recognizes the necessity of allowing some agent discretion, but is concerned that the outcome of that discretion will be adverse. Thus, although effective positive reward systems are crucial to collaboration, agency theory has to date focused primarily on the control of opportunism and the negatives that it might bring (Belbin, 2004). Unfortunately, leaders attempting to create and operate the newer organizational forms still run into theoretical and ideological constraints that may interfere with the success of their ventures. Effective leadership skills are expected to increase the value of resources by combining the efforts, knowledge, and capabilities of two or more units, but much of the literature related to them focuses on issues such as how to avoid opportunism, how to capture knowledge and skills from partners without giving any away, the dangers of “spillovers” of know-how, and the like (Hoyle and Wilmore 2009). These concerns are clearly more in line with a philosophy focused on cost minimization and individual profit gains than they are on collaboration as the means of maximizing resource and capability utilization. Surrounded by these views, it is not surprising that many collaborative ventures either fail or achieve only a fraction of their potential resource utilization gains. Although the theoretical underpinnings of collaboration remain incomplete, the notion of collaboration is slowly gaining ground both in practice and in theory (Boehnke and Bontis 2003).
Human relations, quality of work life, and cognitive volition would, however, ultimately not be denied. Workers have minds too. Reinforcement theory lacks utility and foundation until it can explain why a particular kind of reinforcement works with one individual and not another. As long as it is a matter of hungry pigeons pecking vigorously away at miniature piano keyboards, food release levers or missile guidance consoles, behaviorism enjoys great predictive simplicity (Belbin 1993). When it comes to explaining why one worker volunteers eagerly for overtime pay, another demands the boss’ personal assurance as to the importance of the task before working extra hours and yet another insists on the day off to go fishing, radical behaviorism offers little help. Vague reference to yet poorly understood complex contingencies of reinforcement offers little satisfaction (Buchholz and Roth1987). External reinforcers certainly do have influence. It would be foolhardy to deny the effectiveness of money and threat as reinforcers of desired work performance. But choice is dear to the free, independent human being (Borrill et al 2002). Future high performance systems will almost certainly not tolerate any signficant abridgment of individual choice the way those of the past have. Management must be prepared to go beyond radical behaviorism and actively consider how workers think about how to respond, even to those undeniably powerful external inputs and events like money and fear. Exclusive focus on reinforcement as motivator of behavior ignores the cognitive richness and complexity of motivation. An understanding of motivation requires appreciation that it operates in two distinct psychological dimensions: direction and purpose of action, and energy and intensity with which the action is carried (Charan et al 2001). Reinforcement that is sufficiently dramatic can focus behavior. And, while punishment or physical need like hunger may consistently evoke high intensity of response, much variation in intensity of response to reinforcement, even that which avoids physical discomfort, seems cognitive. A comprehensive grasp of human motivation must explain differences in choice of motivational direction and in level of intensity. Motivation to action starts with awareness of the situation’s existence and an understanding of its structure. It moves on to interpret and analyze the situation’s implications for personally desired or undesired outcomes, then proceeds to determination of preference for a suitable behavioral response and ends with assessment of what response to choose and the appropriate level of energy with which to apply that response (Dickson and Hargie, 2003).
The case under analysis shows that applying motivation as a practical management concept requires, at a minimum, that the stage of the motivational process to be managed be identified if the application is to be effective. Much prevailing theory fails in this identification, leading to misunderstanding and miscarriage in operational use of the concept (Boyce and Herd, 2003). Motivational theory may focus on the manner in which opportunity is grasped or dramatized, or deal with expected outcomes. It may try to explain the manner and choice of responsive action, or it can be concerned with source and intensity of activation. With most contemporary motivational theories, one dimension of motivation always seems prominent while others hide in the shadows. It is not until theories of motivation are refocused around goal-setting methods that significant progress is made at integrating and understanding the directive and energizing aspects of work motivation (Fulton and Maddock, 1998).
Even if top management could discern ineffective leaders and unaligned organizations, it could not quickly replace all the divisional presidents short of a crisis. Such an action would jettison vital business knowledge and relationships, be perceived as unfair, destroy trust, and unsettle the organization in a major way (Blanchard, 2004). The process that emerged, is an action learning process by which a leader and his or her top team can assess how well organizational behavior and design and their own behavior as leaders fit the strategy and values espoused by them. Decision-making processes like these depend heavily on judgment, intuition, and creativity, but that they can be enhanced through heuristic problem-solving techniques (Hanlan 2004). Leadership should provide the decision-making context, valid data, and a heuristic problem-solving technique that will enhance decisions typically blocked by defensive routines and normally made in an ad hoc, unsystemic, unsystematic manner Depending on his or her expertise, the profiler, as the consultant is called, may also act as a resource to the top team on questions of strategy, organizational design, and change. A detailed manual provides less expert managers and consultants with the underlying theory of the process, step-by-step guidelines for how they can move through various phases of the process, and a heuristic framework for making organizational design decisions (Hanlan, 2004). Although the objective of forming a partnership between the top team and lower levels is not served by excluding the task force, experience suggests that the top team must work on its own development before establishing a partnership with the task force, something that happens at a later step in the process. However, to establish some connection between the top team and lower levels at this early stage, task force members call the people they interviewed immediately after they leave. They describe the receptivity of the top team and the quality of communication, but do not reveal the substantive issues they raised. The organizational conversation about hidden issues and the contention and actions that follow can, we argue, serve as the force for change when the general manager has the will to lead change and learn from the process (Hayes and Kuseski, 2001).
Finally, and importantly, flexible perspectives on ownership and rent sharing remove barriers to rapid resource utilization. Increasingly, medical units are agreeing on resource and knowhow sharing first and then worrying about the particulars of rent sharing. Similarly, most cellular organizations appear to be moving toward broad member ownership, recognition that knowledge is widely generated and owned and that only a portion of total intellectual property is capturable by the medical unit or attributable to traditional investment processes (Harvey, 2001).
Conclusion
The orientation and skills of surgical unit managers, therefore, reflected top management’s own orientation and skill. In the fast-paced world of the innovation era—with the prime asset, knowledge, widely diffused within and across units and constantly multiplying—self-organizing, collaborative behavior increasingly offers the best mechanism for economic achievement. Groupings of autonomous units within medical units allow the continuous flexibility that mirrors expanding opportunities and accommodates continuous innovation. Diffusing responsibility to another person in a surgical unit and spreading the responsibility across internal units promotes a higher level of utilization than might occur within a more specialized, hierarchical structure. Therefore, it could not easily discern deficiencies in change leadership among the division managers. One has to possess leadership attitudes and skills to see them in others. Developing the leadership skills in medical setting aligned with new and emergent strategies would require leadership. A hero-centered model of change leadership would have required the overnight replacement of many of senior executives.
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