Developing Medical Leader Identity
through Reflection and Narrative
Professor Judy McKimm
International Reflective Practice Conference
9 September 2013
Swansea
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Policy rhetoric
Medical leadership development
Identity formation
Theoretical underpinnings
Reflection and narratives
A shifting narrative
• Learning from Bristol (2002)- clinical
governance, audit, children’s health/care
• Laming reports (2003, 2009) – Victoria Climbié
– led to Children Act 2004, reform of child
protection services and more integrated care
• Shipman Inquiry (2005) – strengthened GMC’s
powers, oversight of prescribing, mortality
figures, revalidation
Francis Report
“Patients must be the first priority in all of
what the NHS does by ensuring that, within
available resources, they receive effective
care from caring, compassionate and
committed staff, working within a common
culture, and protected from avoidable harm
and any deprivation of their basic rights”
Francis, 2013, p67, para 1.122
Francis Report
“ The common culture and values of the
NHS must be applied at all levels of the
organization, but of particular
importance is the example set by
leaders”
Francis Report: Executive summary, 2013, p78, para 1.196
Keogh Review (2013)
• Review into 14 NHS trusts with high mortality figures
• Leadership, quality management and governance key
factors
• Disconnect between senior medical and nursing leaders
and what was happening in wards and departments
• Lack of strong clinical leadership, changes and capability
gaps
• Junior doctors seen as the clinical leaders of today and
the most powerful agents for change
Keogh Review (2013)
• Not sharing or learning, unconnected
and isolated – ‘Nut Island’ effect
• Vacancies, hard to recruit, lack of good
training, supervision and mentoring
• Culture of ‘blame and fear’
• Patient experience not at the heart of
organisations
• 11 hospitals placed on ‘special measures’ for
‘fundamental breaches of care’
Berwick Review of
Patient Safety in NHS (2013)
• Compassionate patient care should be top
priority – clinicians as leaders and managers
• Recommends a new criminal offence of ‘wilful
neglect’ at individual and corporate levels
• NHS needs to become a learning organisation
• Staff supported and put first, safe staffing
levels
• Culture rooted in continual improvement
“Making change actually happen takes
leadership. It is central to our
expectations of the healthcare
professionals of tomorrow “
Darzi, ‘Next Stage Review’,DoH, 2008
Regulatory and professional bodies
• Medical leadership competency framework (DH, 2008, 2011)
• National Foundation School – Academic competencies in
teaching, research, leadership and management (2009)
• Faculty of Medical Leadership and Management (established
2011)
• General Medical Council (Leadership and management for
doctors, 2012)
• NHS Leadership Academy (established 2012)
• Higher Education England (April 2013), similar bodies in the
devolved countries, Leadership Foundation for HE
General Medical Council
“being a good doctor means more than simply
being a good clinician. In their day-to-day role
doctors can provide leadership to their
colleagues and vision for the organisations in
which they work and for the profession as a
whole. However, unless doctors are willing to
contribute to improving the quality of services
and to speak up when things are wrong,
patient care is likely to suffer.”
General Medical Council 2012
“Leadership is not an esoteric topic
relevant to a select few, but a
ubiquitous feature of daily life for
every physician”
Gunderman, R, Leadership in healthcare, London:
Springer-Verlag, 2009
Policy to practice
• Number of national and international
initiatives:
– Darzi Fellows (senior trainees)
– Clinical leadership fellows (post Foundation
trainees)
– LeAD (web based learning resources for clinicians)
– Masters programmes, workshops
The Medical Leadership Competency Framework
• built on concept of shared
leadership
• leadership not restricted to those
who hold designated leadership
roles
• shared sense of responsibility for
the success of the organisation and
its services
• acts of leadership can come from
anyone in the organisation, as
appropriate at different times,
focused on the achievement of the
group rather than of an individual
• … shared leadership actively
supports effective teamwork.
www.institute.nhs.uk
The trouble with competencies …
• Reductionist, ‘tick box approach’
• Assumes people, behaviours and situations are the same
• Looks at current or past performance not future needs or
potential
• Focuses on a measurable set of traits, abilities and
behaviours that make up a ‘great leader’
When actually leadership is about engagement,
relationships, process, power, understanding rules and
negotiation within complex systems
(Bolden and Gosling, 2006; Hollenbeck et al, 2006; AlimoMetcalfe, 2007)
Competing leadership paradigms?
The doctor's frequent role as head of
the healthcare team and commander
of considerable clinical resource
requires that greater attention is paid
to management and leadership skills
regardless of specialism. An
acknowledgement of the leadership
role of medicine is increasingly
evident
Aspiring to Excellence, Prof John Tooke, 2008
“From the dark side to centre stage”
“doctors have ‘their
own all pervading
culture’ which
centres on their
occupational
identity, its
exclusiveness and a
tendency towards
traditional values”
(p15, 2011)
Changing leadership is needed for changing
healthcare contexts
Management, leadership and
followership
Management/transactional leadership – activity that
provides predictability and order (Kotter, 1990).
Leadership – activity that produces change and movement,
aligning people, motivating and inspiring (Northouse,
2004)
Followership interacts with leadership and provides an
analytical tool that assists in the explanation of teamwork.
Leaders need followers.
“Leadership is a relationship between those who
aspire to lead and those who choose to follow”
(Kouzes and Posner, 2002)
Medical identity formation
– Process of socialisation, enculturation
– Reinforcing rites and rituals
– Role models important (positive and negative)
– Media influential (even before entering medical
school)
– Encounters with patients
– Positive clinical placements and experiences
– Good mentoring and support
Narrative and medicine
Importance of the patient’s narrative
Launer’s ‘Narrative Consultation’ (2002)
– Circular and open questioning
– Focus on listening
– Exploring the whole context
– Using models to help understand the context
– Developing a shared story
– Shifting balance of power to the patient
A new narrative, a new identity?
Doctors as leaders and managers
Leadership for Foundation Doctors
• Foundation training in UK - first two years post
graduation
• ‘Academic’ foundation programme including
clinical leadership and management training
established in 2007
• Collaboration between medical schools, NHS
hospital Trusts and postgraduate deaneries
Developing understandings of junior
doctors as leaders
• Research study aligned with the academic
programme
• Involves students as co-researchers
• Exploring lived experience of developing
leadership role, knowledge, skills and
behaviours
• Methods include: survey (based on MLCF);
interviews; focus groups; reflective narratives
Becoming and being a medical
leader
World view
Responses to
experiences,
insights
‘Openness to
experience’
Experiences
Becoming and being a medical leader
World view
Scientific paradigm, hierarchical,
managers ‘dark side’, little experience of
leadership, ‘naive’ sense of leadership
‘Openness to experience’
Responses to experiences, insights
Action learning sets, group and paired
discussions, co-coaching, writing and
feedback, linking theory to practice
Reflection
on, in and
for action
Actively want to learn, engage in
activities/projects, willing to make
mistakes and learn from them
Experiences
Contact days and activities, workplace
based learning, project champions and
‘little l’ leaders, applying models in
practice
Participants – 4 cohorts
• 46 F2 doctors
• Competitive selection via application and interview
• Four had previous experience/study in management (one
had BSc)
• None had studied leadership
World view
“before the start of the programme, I was very naive to the
idea of clinical leadership. The idea had never been
discussed in medical school. Once I had graduated and
started working, the idea was rarely discussed. When it
was discussed, it was not for my benefit” (C1)
Developing reflective practice
Action
learning
sets
Reflective
writing
Reflection
Theories
and
models
Group
exercises
Leadership theories
Adaptive leadership
Engaging leadership
Affective leadership
Followership
Authentic leadership
Leader-member-exchange (LMX) theory
Charismatic leadership, narcissistic
Ontological leadership
Phenomenological leadership
Complex adaptive leadership
Relational leadership
Collaborative leadership
Servant leadership
Contingency theories
Situational leadership
Dialogic leadership
Trait theory, ‘Great man’ theory
Distributed, dispersed (shared) leadership
Transactional leadership
Eco leadership
Transformational leadership
Emotional intelligence (EI)
Value led, Moral leadership
Using theory to underpin reflection
Three domains:
1. Theories that focus on the personal
qualities or personality of the leader as
an individual
2. Theories relating to the interaction of the
leader with others
3. Theories which seek to explain
leadership behaviours in relation
to the environment or system
(1) Personal qualities/personality
• ‘Great man’ theories
- position, heredity, religion
- ‘Heroic leader’
• Trait theory – qualities of a leader
• Servant leadership –to serve first
• Authentic, fallible, value led,
affective (emotional labour)
• Ontological leadership – being a leader
• Wise leader
The servant-leader is servant first. It begins with the
natural feeling that one wants to serve, to serve first.
Then conscious choice brings one to aspire to lead
(Greenleaf, 1970)
Listening
Awareness and sensitivity
Stewardship
Building a community
Conceptualisation
Healing
Facilitation
Foresight
Persuasion not coercion
Commitment to the growth of people
Empathy
Four pillars of leadership
Souba (2011)
1. Awareness – being a perceptive observer, with a
knowledge of own biases and weaknesses, able to perceive,
feel and be conscious of events, object and sensations
2. Commitment – to a purpose larger than ourselves, not
focused only on ourselves or self-fulfilment
3. Integrity – sticking to one’s word and honouring promises
– being transparent
4. Authenticity – acting consistently with own beliefs –
avoiding lure of desire for approval or status
The wise leader (Nonaka and
Takeuchi, 2011)
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Needs more than knowledge alone
Can practise moral discernment
Creates the context for organisational learning
Communicates effectively
Fosters development of practical wisdom in
others
“Reflective practice within this context has
helped me to identify strengths that I can
build on, and areas that I can improve in
order to evolve further as a leader” (C4)
(2) Interaction of leader with others
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Transactional leadership
Emotional intelligence
Leadership styles
Situational leadership
Team working
Relational, dialogical
Power relations, authority and control
Followership
“Innovation distinguishes between a leader and a follower”
(Steve Jobs)
Transformational leadership
The 4 ‘Is’
• Idealized influence
• Inspirational motivation
• Intellectual stimulation
• Individualized consideration
(Bass, 1985)
Learning from role models
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Speak out
Share experiences and learning
Be open, honest and use candour
Act when things aren’t right
Use the barometer of your family to judge
the care you see
• Utilise quality improvement tools and data
routinely and expect the same from others
Emotional intelligence
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Self-awareness
Self-regulation
Motivation
Empathy
Social skills
Back to trait theory?
Fullan (2001)
• Moral purpose
• Understanding
change
• Coherence making
• Building relationships
• Knowledge creation
and sharing
“The second driver ‘being strong’ meant that I
am strong in times of crisis, an asset for
leadership in the context of my clinical setting.
However, I have to guard against the tendency
to ‘bottle up’ and may appear to others
unwilling to admit to weakness. Richard
Branson stated ‘in business there is one thing
certain, you and everyone around you will
make mistakes’ (Crush, 2010). Admitting
mistakes and weaknesses where appropriate,
and being able to learn from them and move
on is a sign of integrity and strength, and a
reflection of a true authentic leader”. (C3)
(3) Leading systems and organisations
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Adaptive leadership
Complexity and systems theories
Metaphors or ‘frames’
Leaders as change agents
Transformational leadership
Shared, distributed, dispersed, collaborative
Eco-leadership, sustainability, connectivity
Management essential
Bolman & Deal (1997)
Leading and managing are distinct, but both are
important ….
The challenge of modern organisations requires
the objective perspective of the manager as well
as the brilliant flashes of vision and commitment
wise leadership provides.
Distributed leadership
Leadership
as a process
Importance of social
capital
Emergent, Open boundaries, Expertise dispersed
Collaborative leadership
• "a purposeful relationship in which all parties
strategically choose to cooperate in order to
accomplish a shared outcome."
Rubin, 2002, p17
• Requires a new notion of power... the more
power we share, the more power we have to use
www.collaborativeleadership.org
“as leaders, we seem to have grasped where
we fit in the system; we analyse situations
and understand the environment in which
we work ... I think this places us in a better
position to take on leadership roles in the
future. In our current role, our leadership
opportunities are limited, mostly due to
perceived lack of power. However the
knowledge we have now has given us
insight into our future roles and how we
can create momentum to drive change in
the future” (C1)
Written assignments linked to
workplace/service
• Essay on contemporary issues for
healthcare leaders
• Management report on individual projects
– Change management in clinical service
• Portfolio assessment
– Reflective commentary, significant event
analyses, critical literature reviews, PDP, self
analysis
The ‘learning leaders’’
narrative (after Launer)
– Focus on listening – respect, ground rules, attention
– Circular and open questioning – learn techniques
– Exploring the whole context – PDPs, whole life,
career
– Using models to help understand the context –
leadership ‘lens’
– Developing a shared story – developing the narrative,
leadership journey
– Shifting balance of power to the learner – it’s their
journey and story
Developing reflective practice
Tools and techniques
Structured narratives
Action
learning
sets
Learn from one another
using guided reflection
Reflection
Reflective
writing
Story telling
Group
exercises
Reframing
Reflective models, practice
and feedback
Tools/lenses for viewing the
world
Role modelling, creative thinking
Self insight, TA, EI
Theories
and
models
“I have found this leadership program
enriching on both a personal and
professional level. Reflective practice
within this context has helped me to
identify strengths that I can build on,
and areas that I can improve in order to
evolve further as a leader. My leadership
journey has just begun”. (C4)
“Leadership is a journey, not a destination. It is a
marathon, not a sprint. It is a process, not an
outcome.”
Joe Donahoe, CEO of EBay, used by Bill George in his
book, ‘True North: Discover Your Authentic
Leadership’
Thank you!
Any questions?
j.mckimm@swansea.ac.uk
References
Berwick, Don (2013)
www.gov.uk/government/publications/berwick-review-intopatient-safety
Francis Report (2013)
www.midstaffsinquiry.com/pressrelease.html
General Medical Council (2012) Leadership and Management for
doctors, London: GMC
www.gmc-uk.org
Keogh Review (2013)
www.nhs.uk/NHSEngland/bruce-keoghreview/Documents/outcomes/keogh-review-final-report.pdf