Not the cry, but the flight of a wild duck, leads the flock to fly and follow.

(Chinese Proverb)

Introduction

When I was being interviewed for my current job, a very high-ranking senior academic on the interview panel asked:

How would you recognise a leader, if you saw one walking along the waterfront?

I did not expect that question, and had not prepared for it. The names and traits of some my favourite leaders chased each other through my mind. I glanced out the window at the waterfront. I could not see any leaders walking along it, but there was a scuttle of children laughing and playing

I almost said, The Pied Piper: I would know him anywhere by his music and the rats following him.

But this was a serious interview! I could not discuss the Pied Piper, King Arthur, Julius Caesar or Eleanor of Aquitaine—I was sure he meant a more modern leader. So I described some of the traits I admired in these leaders. Thankfully, he nodded thoughtfully then said:

Now describe your leadership style.

I found the question challenging, but later I reflected on my personal view and worldviews about leadership. Eventually, that academic’s question became the impetus for this chapter.

The purpose of Chapter 13 is to briefly explore leadership from a ­historical perspective, outline some of the definitions of leadership and the main leadership theories and styles, and the core and advanced ­competencies leaders require to lead effectively. However, the main focus of the chapter leadership is on leadership in diabetes education and care, given that leadership is a core component of the diabetes ­educator role.

Leadership: a brief historical perspective

Leadership is an intriguing concept. Many images of leaders have their roots in conflict where leadership was seen as outwitting opponents and taking control. There are five broad generations of leadership theories:

Leadership was a broad concept in the ancient world that suited the environment and context at the time. Most ancient leaders were men, but there were a few notable women who blazed their mark on history, for example Boudicca, Hatshepsut and Cleopatra, and more recently Florence Nightingale and Maggie Thatcher. Leadership became more complex as society and technology advanced.

In the 1900s, the focus was on the ‘Great Man’ theory. Leadership was regarded as the role of people from the privileged ranks of society or ­geniuses. ‘Group theories’ emerged in the 1930s during the Great Depression when psychologists in the United States were studying groups that had a democratic leadership style. They concluded, democratic leadership was possible and was more effective. Consequently, an egalitarian view of leadership evolved. Later research indicated that ­leadership behaviours in small groups is not necessarily transferable to large groups or organisations.

During World War II, people began to debate what traits leaders needed to win the war but no consensus was reached: and a comprehensive literature review indicated the evidence was contradictory (Stogdill 1948). Later, Stogdill and other researchers hypothesised about behavioural leadership styles, but were not able to determine which behaviours or behavioural patterns distinguished leaders.

Two distinct leadership behaviour categories were described: concern for tasks and concern for people (House and Aditya 1997). Some experts suggest ‘the ultimate test of [leadership] should be how the leader’s ­colleagues behave’ (Zenger et al. 2009). However, many confounding ­factors are likely to influence followers’ behaviour besides the leader. Therefore, making the leader totally accountable for followers’ behaviour may be too simplistic.

Behaviour leadership theories were followed by transformational leadership theories in the 1970s. Transformational leaders communicate with and engage and mentor followers. Many experts believe transformational ­leadership is the ideal. Skill at effecting change emerged as an essential leadership trait in the 1990s (Yuki et al. 2002). Change-oriented behaviours include utilising and undertaking research to guide practice (Gifford et al. 2007).

Traditional healthcare leadership models were consistent with organisational theory and focused on influencing other people to accomplish organisational goals. Modern healthcare services/organisations are expected to be effective, competitive, high performing, cost-effective and safe. To achieve these high pressure stretch goals, the leaders must find ways to engage with and motivate staff, as well as being mindful of their own well-being. The latter is important for ethical reasons, as well as to ensure the organisation meets its goals.

Alimo-Metcalfe (2008) developed a leadership model, Engaging Leadership, which enables organisations to develop leaders and create an environment where staff can remain motivated, perform optimally and have less stress. Robinson et al. (2004) defined ‘engagement’ as:

A positive attitude held by the employee towards the organisation and its ­values. An engaged employee is aware of business context, and works with ­colleagues to improve performance within the job for the benefit of the ­organization.

Alimo-Metcalfe’s (2008) Model of Engaging Leadership includes:

• Engaging with individuals
  
• Engaging the organisation
  
• Moving forward together by engaging stakeholders
  
• Personal qualities and values.

Research suggests organisations with a culture of engagement perform better than their competitors (Towers Perin 2005; Watson-Wyatt 2006). Leadership in high performing organisations:

• Engages key stakeholders
  
• Has a shared vision of ‘a quality, safe service’
  
• Functions in collaborative, non-hierarchical teams
  
• Fosters a supportive culture
  
• Is an effective change agent (Alimo-Metcalfe 2008).

Thus, leadership styles slowly evolved from leader-follower-dyads to more collaborative leadership styles that include modern contingency models that focus on the context in which leaders operate (Reicher et al. 2007).

What is leadership and what/who is a leader?

There are many definitions of leadership. Many people still believe a leader is being the person out in front; an entrenched hangover from the Great Man theory. Some diabetes educator’s experiences indicate Great Man leadership styles still exist and are a challenge or barrier to diabetes educators in some countries undertaking leadership roles. For example, one educator said:

Hierarchical [leadership] models still exist, usually male medical dominated. They do not want to be challenged, to discuss things, they think their knowledge is greater and their position superior.

Dunning and Manias (2008, pp. 392–398)

One could ask whether these male medical leaders’ thinking is outdated. The Great Man leadership style is not fit for purpose in modern diabetes care where the ‘gold standard’ is held out to be interdisciplinary team care. Effective leaders set the direction and influence people to follow the direction. The way the leader sets the direction and influences people depends on a range of factors, most particularly their concept of leadership and leadership style. One definition of leadership states:

Leadership means the ability to shape what followers actually want to do, not the act of enforcing compliance using rewards and punishments.

Reicher et al. (2007)

Encouraging followers to ‘want to do’ is an art. It is impossible without the cooperation of and support from followers. The term ‘follower’ is interesting, and could be a hangover from the Great Man theory. I have used it in this chapter for expediency, but it does not accord with group or transformational leadership theories, or with consumer engagement and person-centred holistic care.

Encouraging followers is a multidimensional process that includes behaviours, attitudes and skills applied to the context, in this case diabetes education and care, including educating individuals and self. Thus, although leadership traits are important, leaders must position themselves within the group and be clearly representative of the group to be credible. Some leadership styles and the key leader traits of the styles are shown in Table 13.1.

Table 13.1 Common leadership styles (Bielby Consulting 2012).

However, different researchers and authors use many different terms to describe leadership styles, for example, autocratic, democratic, servant, laissez-fair, adaptive, appreciative, authentic, charismatic, dynamic, heroic and situational, but most are encompassed in the styles described. The second part of the table outlines the various styles followers adopt.

Leader functions

Leading is different from managing but there are many similarities, and both encompass four major functions:

Leaders need to maintain a balance between leading and managing and be able to use different skills and styles at different times to suit the circumstance or situation.

Leadership philosophies, theories and models

The terms ‘philosophy’, ‘theory’ and ‘model’ are often used interchangeably. Generally, a philosophy is a broad set of beliefs derived from long observation and/or research. A theory refers to an idea or hunch about why ‘something’ happens, based on observations, research and philosophies. Theories are used to explain the traits needed to be effective leaders (Table 13.2). In contrast, a model describes a theory of leadership that includes the core and extended role components and leadership attribute. A key component of leadership philosophies, theories and models is ­leadership styles.

Table 13.2 Some key traits effective leaders need: although common desirable traits are described in the literature, the most desirable trait depends on the group being led and the context leadership occurs in.

In order to competently lead others, the individual must be able to lead themselves.

Leadership styles

Leadership style refers to how an individual acts in their leadership capacity. Researchers/theorists have identified several main styles, but they use various terms to describe each style. Table 13.1 outlines commonly used descriptors applied to leadership styles as well as follower styles (Beilby Consulting 2012). Importantly, there is no right style, but adaptability and flexibility are important personal leader attributes.

The leadership style most likely to be effective depends on:

• The prevailing situation and context
  
• The people the leader works with
  
• The leader’s personal characteristics.

A leadership qualities checklist and a leadership questionnaire that can help people identify their personal leadership characteristics can be accessed on http://www.teamtechnology.co.uk/leadership-qualities.html

Leadership competencies and attributes

Diabetes health professionals (HPs) are very familiar with competencies and some diabetes education associations describe core leadership and management competencies (Australian Diabetes Educators Association (ADEA) 2008). However, most apply to management. The competencies needed to lead in successively more complex situations, from individuals to groups, to organisations and beyond, become successively more ­complex. These ADEA core competencies describe the minimum needed to lead others rather than the extended domain competencies needed in some leadership roles. The latter include managing ‘power and influence’, political awareness and managing organisational change.

Table 13.3 Competencies a leader requires to function effectively.

Competencies are usually acquired in a cumulative fashion through opportunity, ­mentoring, role modelling and experience. Core competencies refer to the minimum competencies needed to lead others. It is essential competence is maintained in all domains.

Whether the leader is leading a team or group, or working with an individual they need a core set of knowledge and competence to function effectively. In addition, they have other attributes that enhance their effectiveness. Importantly, a leader cannot effectively lead other people if they cannot lead themselves. Significantly, the competencies and attributes needed to lead in one situation might not automatically apply in other situations or contexts. The core leadership competencies are shown in Table 13.3 and can be surmised from the following:

The play The Admirable Crichton Barrie (1902) illustrates the particular leadership competencies required in two quite different situations, very clearly. Briefly, Lord Loam and his butler Crichton live by and believe in the class system. In fact Crichton says: ‘it is a natural outcome of civilised society’. Lord Loam, his family, friends and Crichton become shipwrecked on a deserted tropical island. Crichton is the only person in the group with the skills needed to survive in this very different environment. Crichton reluctantly assumes the leadership role and becomes more competent as a leader as he becomes more experienced and is finally accepted as the leader by his social superiors, and referred to as ‘Guv’.

The film Twelve O’clock High Bartlett et al. (1949) is set during the World War II when a squadron begins to suffer heavy losses and morale declines. The Squadron Leader, who has a people-oriented leadership style, is replaced by a dictatorial leader who restores the squadron’s pride and reduces losses. Twelve O’clock High shows dictatorial leadership styles might be appropriate in some situations. Interestingly, Hitler, one of history’s most despised dictators, was only able to rise to power because of the situation in Germany after World War I and the demoralising conditions the Germans found themselves in after the Treaty of Versailles, as well as the apathy of other world leaders.

von Goethe (1751–1858) wrote a very insightful description of leadership that involved self-reflection. He said:

I have come to the frightening conclusion that I am the decisive element.
                 It is my personal approach that creates the climate.
                      It is my daily mood that makes the weather.
        I possess tremendous power to make life miserable or joyous.
          I can be a tool of torture or an instrument of inspiration.
                                I can humiliate humor or heal.

One could assume from von Goethe’s self-observation that the ultimate test of an effective leader might be how their followers behave, as Zenger et al. (2009 p. 9) suggested. However, there are many confounding variables that would need to be accounted for. Thus, followers’ behaviour may only be a surrogate marker of the leader’s effectiveness. We can apply the same thinking to diabetes education and management outcomes where we base the effectiveness of HPs’ recommendation on the person with diabetes’ metabolic and other self-care outcomes. People with diabetes’ outcomes are also subject to many confounders and some are probably also only surrogate markers of diabetes educator/­education effectiveness.

There is a variety of valid tools to measure these parameters, but how often do HPs measure their own performance and its effect on the people with diabetes’ outcomes? Diabetes educators need to consider measuring their own performance as rigorously as they measure that of people with diabetes using more useful tools than ‘patient satisfaction surveys’ and quality of teaching scores, both of which are flawed. We could consider measuring the educator’s ability to establish and maintain a therapeutic relationship (Dunning 2011). Self-reflection is essential to leadership and is part of continuing professional development (CPD). Reflection could be a good starting point: in fact it is a required component of the recently revised ADEA CPD process.

As indicated, von Goethe’s comment highlights the importance and power of self-reflection. Self-reflection is not easy, but it is critical to self-improvement in any role. Reflection does not refer to ‘self-talk’ that goes on in most people’s head a lot of the time. Self-reflection is a constructive, purposeful introspective process undertaken to learn more about one’s nature, purpose and performance. It is essential to an individual’s ­personal and professional development. It also demonstrates a leader’s security and authenticity. von Goethe’s words show leaders create an atmosphere (climate) that can inspire or motivate or wound and demotivate. Building follower’s self-efficacy and reflective ability is more likely to motivate. Importantly, building other people’s self-efficacy builds the leader’s self-efficacy.

Leadership education and care of people with diabetes

Leadership is essential in all aspects of diabetes education and care: service planning and development, clinical care, including individual consultations, and research. Mullins (2009) described leadership as a relationship where one person influences and changes another. The type of influence the leader exerts depends on their leadership style and the quality of the relationship (see Chapter 3). Ideally, leaders and followers (educators and people with diabetes) influence each other and cogenerate information. Both parties must adapt to accommodate each other’s points of view. If mutual adaptation does not occur, the encounter may not be as effective as it could have been.

The core components of the diabetes educator role are clinical care, education, research and leadership: leadership is inherent in all components. Some ways diabetes educators demonstrate leadership is through:

• Developing local, national and international policies, guidelines and service models.
  
• Advocating for people with diabetes, the profession and the way of working, e.g. empowerment models and chronic disease models.
  
• Providing clinical governance.
  
• Providing expert clinical care and education.
  
• Mentoring colleagues.
  
• Working on committees.
  
• Undertaking and promulgating research to generate and support the evidence base of the profession. Opinion leaders such as diabetes educators can promote changes (Flodgren et al. 2011), but the effectiveness varies among studies. Many factors could account for the variability including methodological differences but leadership style could also play a role.

There are many outstanding diabetes educator leaders, and many more are emerging. However, the profession rarely proactively identifies and mentors future leaders to develop a critical mass of positive educator ­leaders, although clinical mentoring does occur within teams. Once a leader emerges that individual often seeks informal and formal mentors, but leader identification, succession planning and sustainability, rarely, if ever, occurs nationally or internationally. Yet diabetes educators are able to identify their leaders and the attributes they value (Dunning and Manias 2008; Dunning 2012).

Leadership in diabetes clinical care

Diabetes clinical care is difficult to separate from education. Educators (and people with diabetes) expect their leaders (and leaders expect themselves) to be clinically competent (Dunning and Manias 2008). Leadership ‘status’ is often accorded by colleagues rather than conferred as a formal position title, unlike the titles diabetes education manager, diabetes nurse consultant, diabetes specialist, although leadership is inherent in these roles.

Transformational and group leadership theories appear to accord with diabetes clinical care and the philosophy of holistic person-centred care that actively involves people with diabetes in their care. In western countries, diabetes educators work in interdisciplinary teams, but many are also autonomous.

Leadership in diabetes education

Katzenmeyer and Moller (2009 p. 2) suggested the only way teacher ­quality will improve is if the teachers learn to teach better. The statement was made about school teachers in light of criticism about the quality of the teaching and poor student outcomes. Diabetes educators also need to consider the hard reality that many people with diabetes do not achieve ‘optimal outcomes’: ‘targets’ and ‘good control’. Educators need to reflect, like von Goethe did, about whether some of the reason people with diabetes do not achieve optimal outcomes is due to ineffective teaching and clinical care. Granted, educators are expected to cope with increasing numbers of people with diabetes with fewer resources and personnel and fulfil other administrative requirements that compromise education time.

Significantly, diabetes educators regard clinical and education expertise as key leadership competencies (Dunning and Manias 2008; Dunning 2012), which is consistent with the literature (Table 13.4).

Leadership in diabetes research

As stated, research engagement in its broadest meaning (Dunning 2011) is the responsibility of all HPs including diabetes educators, yet many ­diabetes educators feel research should not be an essential CPD category. This belief is mostly predicated on a narrow view of what research engagement means, but it is a major concern, given that all diabetes educators practise in a climate of evidence-based care and could be regarded as opinion leaders. Diabetes educator’s research behaviours comprise two main categories: facilitative and regulatory.

Table 13.4 Key leadership attributes and competencies that emerged from a survey of 60 Australian diabetes educators their colleagues regard as leaders and those that emerged in a survey of 10 international diabetes education leaders.

These are not in any priority order or category.

Facilitative

• Engaging in and encouraging research and research utilisation
  
• Sharing research information through publications, journal clubs and conference presentations
  
• Integrating relevant research findings into guidelines and policies and in their own clinical care and education
  
• Explaining research findings to people with diabetes, their carers and colleagues (Dunning 2011).

Regulatory

• Complying with relevant regulatory requirements, codes of ethics, professional conduct and other practice standards.
  
• Monitoring their own performance, for example through reflection, and the annual CPD process
  
• Undertaking practice audits/evaluations and using the findings to improve care.

What do diabetes educators think about leadership?

Dunning and Manias (2008) explored the leadership perceptions of 60 Australian diabetes educators their peers regarded as diabetes education leaders. The responses of nominated educators indicated they also regarded themselves as leaders, primarily because they:

• Had worked as a diabetes educator for a long time
  
• Mentored colleagues
  
• Worked in a range of practice settings and thus acquired a range of skills and knowledge that broadened their experience, outlook and clinical skills
  
• Attended conferences and professional development forums
  
• Had a high profile.

These views reflected the views of the educators who nominated them. They were nominated because they had worked in the role a long time, mentored and supervised colleagues, had a high profile, worked in niche areas such as wound management and were clinically competent.

A thematic analysis of a range of books and papers on leadership revealed a long list of skills and attributes leaders need to be effective. These are not all used at the same time or in every situation, but need to be available when the situation/context arises. Sometimes, people are not aware they are leaders until a situation arises and they have to cope or survive—for example, leaders who emerge during disasters and conflicts: as Lao Tzu said ‘When the time is right the master [leader] will appear’ (1999 translated by Mitchell).

Some key leadership attributes are shown in Table 13.4, which also shows the attributes and skills that emerged in Dunning and Manias’ (2008) survey and in a survey of international diabetes educator leaders I conducted in 2011 to inform the content of this chapter cited as Dunning 2012. I randomly selected and invited 16 outstanding diabetes educator leaders from around the world to complete an anonymous questionnaire that asked 12 open questions about leaders and leadership (see Box 13.1). I am very grateful to the ten who responded and who wrote so much.

Related posts:

The Teacher: Moving from Good to Exceptional Role and Use of Creative Arts in Diabetes Care Brief Overview of Diabetes, the Disease Sharing Stories of the Journey: Peer Education Turning Points and Transitions: Crises and Opportunities Making Choices, Setting Goals

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