Becoming an effective leader

The COVID-19 pandemic has called for leadership across the world – from governments, public health and health care systems, in clinical and other workplace settings, among local communities and within families. Leaders can emerge from anywhere. Are you one of them?

At the start of the current COVID-19 crisis many individuals were in ‘designated’ leadership roles, but many others have come to the fore and taken on roles that they may never have expected and, even more impressively, sometimes without even leaving the confines of their own homes. What can be learned about current leadership skills from this unexpected consequence of the global crisis in 2020? One clear observation is that leadership skills exist in most people and, that given the right time and the right circumstances, these skills can come to the fore. They may not be skills that have been formally learned and there could be room to develop them to a higher level but, nevertheless, the fundamentals exist.

In this article we will explore some of the key leadership theories to help frame your thinking. It will suggest how you might improve on your own personal leadership skills and help others to develop theirs. Individual leaders take a variety of pathways to develop their skills and an individual’s desire to lead – or not – will be driven by different personal circumstances. It is important to recognise that not everyone starts from the same place at the same time. However, wherever you are on your personal leadership journey as a clinical leader, the aim is to give you some tips and tools to help you along the way. Everyone will have a unique style and we aim to identify where you can capitalise on your strengths.

THE IMPORTANCE OF CLINICAL LEADERSHIP IN PRIMARY CARE

Primary care is the cornerstone of the NHS; 307 million appointments were estimated to have occurred in England in general practice in 2018.¹ Adoption of innovation in primary care has, historically, been a long and complex process. The recent pandemic has, however, shown that primary care, along with other parts of the health service, is able to adapt and innovate at pace when urgent need arises. For example, the need for social distancing led primary care to adopt digital triaging as its primary way of working in only three weeks.² The introduction of new clinical models and patient pathways at a time when there is a demand to improve efficiency means that all members of the primary care workforce will need to adapt and change the way they work, and build stronger collaborative relationships with other teams and organisations.³ Continuous and unprecedented changes such as these, in an uncertain and complex environment, will require adaptable and innovative leadership across the board in primary care. There are nurses who can champion team working, evidence-based care and new ways of caring. These individuals, and you may be one of them, need encouragement to know that they are where they are for a reason.

Leadership is not about titles or roles, status, or power, but behaviours. As an example, stress triggered by uncertainty and new ways of working, such as that caused by COVID-19, may be unavoidable, but how leaders behave can reduce or increase the levels of stress among their colleagues.⁴ Although there are several leadership theories and styles, the extent to which leaders provide both material and emotional support is known to affect stress levels of staff.⁵ What the best leaders have in common is self-awareness of the impact of their behaviours on others.

LEADERSHIP THEORIES

Since the early 20th century, researchers have been studying which leadership qualities and styles appear to be more successful than others and, additionally, which contextual factors have an impact. As a result, several leadership theories have evolved and more are still evolving. Full discussion is beyond the scope of this article, but here is some background to some of the most well-known.

Trait theories

Trait theories assumed that people inherit certain qualities and traits that make them better suited to leadership. They identify personality traits and characteristics, such as extroversion, self-confidence, charisma and courage, that were linked to successful leaders of the time. One trait theory, known as ‘the Great Man Theory’, supported the belief that ‘leaders are born and not made’. It assumed that the capacity for leadership is inherent and leaders are simply born with the necessary internal characteristics, intelligence, and social skills that make them natural-born leaders. This theory portrayed great leaders as heroic, mythic and destined to rise when required. Leadership was thought of primarily as a male quality, especially in terms of military leadership. Trait theorists suggested that people cannot really learn how to become strong leaders.

It is highly unlikely that individuals are born with a set of leadership skills bestowed upon them. However, trait leadership theory is inextricably linked to personality theory.

Personality theory

Personality theorists, such as Eysenck (1947) and Allport (1937), suggested we are born with certain characteristics and traits, and that our personalities embed from a very early age. The psychoanalyst Sigmund Freud suggested that personality was largely set in stone by the age of five.⁶ The personality theorists suggest that these characteristics, traits and personalities follow us into adulthood. Research is underway looking at how genes affect personality, and several large-scale twin studies suggest a strong genetic component.⁷

Trait theory has lost its general popularity and the attributes it suggests no longer fit with leadership in many cultures today. One ongoing critique is that trait theory does not explain how people with these leadership traits do not always become leaders and, conversely, how some who lack some key traits sometimes excel.⁸ It is widely believed that it is a mix of nature and the surrounding environment that shapes who we are and how we behave in certain situations. Although an individual’s behaviour in a given situation can generally be predicted from their personality traits, when confronted with stressful work situations they may exhibit entirely different behaviours. This may apply both to the leader or those around them and is described in the literature as the ‘plasticity principle’.⁹

Behaviourist Leadership Theory

This theory is based on the principles of behavioural psychologists, such as Watson (1878-1958) and Skinner (1904-1990), who take the opposite view from that held by trait theorists. Rooted in behaviourism, this leadership theory focuses on the actions of leaders, not on mental qualities or internal states. According to this theory, anyone can learn to become a leader through teaching and observation.

Participative Leadership Theories

These suggest that the ‘ideal’ leadership style is one that considers the input of others. These leaders encourage participation and contributions from group members, and help them feel relevant and committed to the decision-making process. Opponents to this approach believe it can lead to indecisiveness.

Transactional Leadership

This is grounded in managerial theory, so focuses on supervision, organisation, group performance and targets. The leadership characteristics are based on a system of rewards and punitive actions and has most frequently been used in business. This approach to leadership does not fit well in cultures such as health care and is not the best approach for developing multi-disciplinary teams.

Contingency and Situational Leadership

These theories believe that both context and culture are vital. They suggest that no one style is right for all situations. Leadership should focus on variables related to the environment and that these variables determine which style of leadership is best suited for the situation. Research has suggested that truly effective leadership is not just about the qualities of the leader; it is about striking the right balance between behaviours, needs, and context.¹⁰

Transformational Leadership

This is based on relationship theories and focuses on the connections formed between leaders and followers. It is the leadership model which is known to have the most positive influence on employee well-being by increasing staff morale and motivation.¹¹ Humans respond to those who treat them well and make them feel good, so emotional intelligence is key. Transformational leaders motivate and inspire people by sharing a vision and help others to see the importance and higher good in what they are doing. These leaders focus on encouraging people to fulfil their potential by embracing positivity and supportive behaviours. There are four components to Transformational Leadership (Box 1) and leaders with this style often have high ethical and moral standards.

What can you do to become a more transformational leader? Leadership experts suggest that having a strong, positive vision of the future plays a critical role. Not only is it important to believe in this vision yourself, but you also have to inspire others to buy into your vision. Being genuine, passionate, supportive, and trustworthy will help motivate others to support your goals for the group. Emotional intelligence requires a broad range of skills related to emotional awareness, emotional knowledge and understanding. It is the ability to think and act prudently in social situations and to understand and manage people.

In summary, leadership theories vary, as do their basis and psychological grounding, but all have some plausibility and are helpful in understanding where certain leadership styles and characteristics may have come from. In the complex environments in which we work, and with the challenges of interprofessional working, there is a need to adapt leadership for the situation in which you might find yourself. Most of the theories lead us to believe that it is possible to learn and finesse leadership skills. However, how comfortable you are, and the circumstances in which you find yourself, make a huge difference as to whether you choose to exert these skills. So, if it is true, that everyone can become a leader if they wish to, then how do we make it easier to weight their chances of being a success in the right direction and what does good leadership look like?

WHAT DOES A GOOD LEADER LOOK LIKE?

A good leader:

• Is motivational. They can get people behind a cause or get them to do a better job. And, most importantly, they can get people to feel good about themselves. They are ‘people focussed’
• Displays honesty and integrity. They demonstrate ‘authenticity’
• Is thoughtful and respectful towards others
• Is reflective
• Remains positive. A good leader sees opportunities, not problems and generally has a ‘can do’ attitude: ‘What can we change?’, not ‘What we cannot change.’
• Is visionary. They see the bigger picture and are inspirational. At the same time they keep focussed on the ‘goal’. They develop a common purpose which is shared, while keeping it simple and focussed on the ‘where, how and what’
• Is decisive. They take control and avoid procrastination
• Signs up to the values. They eat, drink and sleep them! They ‘walk the talk’, and do not attack the past
• Is adaptable
• Is fun! They demonstrate emotional connectedness. They are nurturing and inclusive, show imagination and inspiration, and demonstrate gratitude towards the people they lead.

In summary, a good leader demonstrates the four Ps.

They are:

• People focussed
• Professional
• Positive
• Performance. (This may not always be how you are remembered in leadership, but it is your personal impact.)

DEVELOPING YOUR SKILLS

Leadership is a combination of an art and a science. The evidence shows us there is no single way to ‘do it’. Whether you are currently in a leadership role or aspiring to move into one there are ways in which you can be more impactful. But that will require time spent on reflection and self-awareness. The reflective activities are designed to help you with this. And remember, leaders are not just the ‘boss’ in the work place. There are many ways in which you can lead; through writing, social media such as a blog, and by giving presentations. All routes are equally important and can be equally influential.

Tackle your fears: the imposter syndrome

Most people assume that leaders are brimming with self–confidence, but that is not necessarily the case. What is important is to know your own vulnerabilities and to work on addressing them. It is not uncommon for leaders to have moments when they have feelings of self-doubt:

• ‘I’m not good enough’
• ‘Others might find out that I don’t know everything’
• ‘I’m making it up as I go long’.

If this resonates, do not worry. You are not alone.

The ‘Imposter Syndrome’ was first described in 1978,13 and is now widely recognised as a psychological phenomenon. It is described as a situation in which someone fails to internalise their accomplishments and is unable to accept that they are deserving of the position or status they have achieved. It appears to be more often expressed by women, but studies suggest that more than 70% of people experience the impostor syndrome at some point in their career.

So, if this feeling is so common how can you develop the skills to overcome it? The first step is to recognise it.

Stay curious and ask questions

Brené Brown, a prolific author and researcher on leadership,14 believes that those who step up to lead, should never worry about having all the right answers, but should stay curious and ask the right questions. During the COVID pandemic, when leaders have not had all the answers and admit this to be the case, they have appeared to be more trustworthy and authentic. This highlights that one of the key roles of a leader is to steer people in the right direction.

Develop your emotional intelligence

Being a leader, in a culture that is defined by fear and uncertainty, requires courage, empathy and connection.¹⁴ Yet ironically, we do not invest enough time in developing the hearts and minds of leaders – their emotional intelligence.

Being aware of your imperfections, recognising and accepting your vulnerabilities is the way to develop courage, compassion and connectedness as an individual and as a leader. It also helps to relinquish those feelings of being an imposter.

Be self-aware and reflective

This is about your own personality traits. The most important things to do are:

• Focus on your strengths
• Identify your weaknesses, and
• Build around these.

If you can do this it is the first step to success.

The best and most effective leaders are self-aware of how they impact on others. Many leaders, but certainly not all, are extroverts, and if you are outgoing and gregarious you need to know how that makes others feel and how your style can impact on them. One of the most powerful tools for any leader is the ability to ‘walk in someone else’s shoes’. Try to understand why people behave and respond to you in certain ways. This does not mean changing who you are. If you do you will then lose your authenticity. Rather, it is having an understanding of how to get the most out of someone who may have very different characteristics from you. Using a tool, such as Myers Briggs Type Profile, can be a useful framework for understanding both yourself and those with whom you are working. A chart with descriptions of each Myers Briggs personality type and the four dichotomies central to the theory can be found at https://en.wikipedia.org/wiki/Myers%E2%80%93Briggs_Type_Indicator#/media/File:MyersBriggsTypes.png

Be courageous

Brown believes that courage is a collection of four sets of core skills, which are underpinned by an array of behaviours which can be learned.

• Overcoming vulnerability
• Living into our values
• Braving trust, and
• Learning to rise (meaning it does not matter what gets done – ‘I am enough’).

Brown states ‘Choosing courage over comfort is not easy. Worth it? Always. We want to be brave with our lives and work. It's why we're here.’

Formal and informal ways to develop your skills

Formal leadership programmes will be available both locally and nationally and will generally integrate some theory with practical, experiential learning. More importantly, they may give you an opportunity to develop a peer network. However, these are not always accessible and may not be what you wish to do. What is also important is to recognise that any ‘leadership programme’ is not an isolated event. Leadership development will be a journey throughout life and is about quality improvement. (See Resources and further reading) There are also many other informal ways to develop your skills. (Box 2)

SUMMARY

The acquisition of the skills required to become an effective leader is an incremental process, but as with many ‘life skills’ it is not a simple linear process. As you move along your chosen career pathway, you will find a need to adapt and maybe enhance the leaderships skills that you have, but you will be grounded in your own unique style and personality. As a successful leader, you may never reach the nirvana of mastery, but this is the joy of leadership development. It is a lifelong journey on which you have embarked.

REFERENCES

1. NHS Digital. Appointments in General Practice, October 2018 [PAS], 2019 https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice/oct-2018

2. Delloite. COVID-19: Accelerating digital transformation in healthcare. 2020 https://blogs.deloitte.co.uk/health/2020/04/covid-19-accelerating-digital-transformation-in-healthcare.html

3. Swanwick T, Varnam R. Leadership development in primary care. BMJ Leader 2019; 3 59-61 https://bmjleader.bmj.com/content/leader/3/2/59.full.pdf

4. Harms PD, Credé M, Tynan M, et al. Leadership and stress: meta-analytic review. The Leadership Quarterly 2017; 28(1): 178-194

5. Bass BM, Bass R. The Bass handbook of leadership: theory, research, and managerial applications. The Free Press, New York. 2008

6. Frank G. Freud's concept of the superego: review and assessment. Psychoanal Psychol 1999;16(3):448–463. doi:10.1037/0736-9735.16.3.448

7. Johnson W, Turkheimer E, Gottesman II, Bouchard TJ Jr. Beyond heritability: twin studies in behavioural research. Curr Dir Psychol Sci 2010;18(4):217–220. doi:10.1111/j.1467-8721.2009. 01639.x

8. Grant AM, Gino F, Hofmann DA. Reversing the extraverted leadership advantage: the role of employee proactivity. AMJ 2011;54(3):528-550. doi:10.5465/amj.2011.6196804

9. Roberts BW, Wood D, Caspi A. The development of personality traits in adulthood. In John OP, Robins RW, Pervin LA (Eds.), Handbook of personality: theory and research, pp. 375-399. New York. The Guilford Press. 2008.

10. Hodgson P, White R. Leadership, learning, ambiguity and uncertainty and their significance to dynamic organisations. In: Peterson R, Mannix E, (Eds) Leading and managing people in the dynamic organisation. Hillsdale, New Jersey. Lawrence Erlbaum. 2003.

11. Jacobs C, Pfaff H, Lehner B, et al. The influence of transformational leadership on employee well-being: results from a survey of companies in the information and communication technology sector in Germany. J Occup Environ Med. 2013;55(7):772-8. doi:10.1097/JOM.0b013e3182972ee5

12. Bass BM, Riggio RE. Transformational leadership. Mahwah. New Jersey. Lawrence Erlbaum Associates Inc. 2008

13. Clance PR, Imes SA. The impostor phenomenon in high achieving women: dynamics and therapeutic intervention. Psychotherapy: Theory, Research & Practice 1978;15(3): 241–247.

14. Brown B. Dare to Lead: brave work, tough conversations, whole hearts. London; Vermillion: 2018