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hierarchical leadership, contemporary theory posits leadership as a group process, which should be distributed across all levels of health care organisation.
leadership Dimensions, discourses and differences: trainees conceptualising health care leadership and followership Lisi J Gordon,1 Charlotte E Rees,2 Jean S Ker1 & Jennifer Cleland3

CONTEXT As doctors in all specialties are expected to undertake leadership within health care organisations, leadership development has become an inherent part of medical education. Whereas the leadership literature within medical education remains mostly focused on individual, hierarchical leadership, contemporary theory posits leadership as a group process, which should be distributed across all levels of health care organisation. This gap between theory and practice indicates that there is a need to understand what leadership and followership mean to medical trainees working in today’s interprofessional health care workplace. METHODS Epistemologically grounded in social constructionism, this research involved 19 individual and 11 group interviews with 65 UK medical trainees across all stages of training and a range of specialties. Semi-structured interviewing techniques were employed to capture medical trainees’ conceptualisations of leadership and followership. Interviews were audiotaped, transcribed verbatim and analysed using thematic framework analysis to identify leadership and followership dimensions which

were subsequently mapped onto leadership discourses found in the literature. RESULTS Although diversity existed in terms of medical trainees’ understandings of leadership and followership, unsophisticated conceptualisations focusing on individual behaviours, hierarchy and personality were commonplace in trainees’ understandings. This indicated the dominance of an individualist discourse. Patterns in understandings across all stages of training and specialties, and whether definitions were solicited or unsolicited, illustrated that context heavily influenced trainees’ conceptualisations of leadership and followership. CONCLUSIONS Our findings suggest that UK trainees typically hold traditional understandings of leadership and followership, which are clearly influenced by the organisational structures in which they work. Although education may change these understandings to some extent, changes in leadership practices to reflect contemporary theory are unlikely to be sustained if leadership experiences in the workplace continue to be based on individualist models.

Medical Education 2015: 49: 1248–1262 doi: 10.1111/medu.12832 Discuss ideas arising from the article at www.mededuc.com discuss.

1

Medical Education Institute, School of Medicine, University of Dundee, Dundee, UK 2 Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Australia 3 Division of Medical and Dental Education, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK

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Correspondence: Lisi J Gordon, Centre for Medical Education, University of Dundee, MacKenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK. Tel: 00 44 1382 381974; E-mail: [email protected]

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Conceptualising of leadership and followership INTRODUCTION Table 1

Contemporary health care leadership is seen as something that should be distributed across many levels of an organisation and undertaken by those most appropriate to the situation, regardless of position or profession.1–3 This is reported to improve the patient experience, reduce errors, infection and mortality, increase staff morale, and reduce staff absenteeism and stress.4,5 However, reports from different contexts worldwide have illustrated fundamental failures in leadership in health care, highlighting that issues are related to traditional leadership hierarchies (e.g. the 2013 Francis Report1 in the UK and the 2008 Garling Report3 in Australia). In other words, there is a gap between theory and practice in health care leadership. With this in mind, and with awareness of both the many different approaches to, and costs of, leadership development, better understanding of how leadership is experienced in the interprofessional health care workplace is essential to inform future leadership development practices. Before considering the most effective ways in which leadership can be developed, it is important to consider the health care literature on this topic. We were particularly interested in the broad discourses of leadership in the health care literature. The word ‘discourse’ is used here to describe discourse according to the Foucauldian view of discourse as a system of thought that is historically situated.6–8 Using discourse in this way characterises a way of thinking and talking about a concept (such as leadership) that appears in a range of contexts (e.g. in research literature or policy documents) at a given time.9 Although we did not conduct a formal discourse analysis of the literature, we identified four broad discourses of leadership in the grey and academic literature: individualist, contextual, relational and complexity discourses. Table 1 summarises these discourses.10–23

Discourses of leadership

Example Discourse

Definition

theories

Individualist

Focus is on leaders as

Trait theory10,11

individuals exerting

Skills theory12

‘power’ over others to

Styles theory13

meet leader-defined goals Contextual

Context determines how a

Situational

leader behaves: either the

leadership

leader ‘flexes’ to the

theory14

context or the context ‘flexes’ for the leader

Least preferred co-worker theory15,16

Early relational

Focus is on the leader–

Leader-member

follower relationship.

exchange

Relationship is either

theory17,18

based on exchanges

Transformational

between leaders and

leadership

followers (transactional) or

theory19

the leader’s ability to ‘inspire’ followers to act (transformational) Current relational

Leadership is a process generated through interactions between team members. Leaders are thus socially constructed through this interaction.

Shared leadership20 Distributed leadership21 The romance of leadership22

Leadership is available to all. Included in this are follower-centric theories Complexity

Leadership is an emergent

Complexity

process occurring within

leadership

complex adaptive systems.

theory23

The leadership process is affected by relationships,

In medical education, leadership is often defined as a skill to be learned or a set of behaviours to be developed. Training programmes often focus on the development of personal and interpersonal leadership competencies through the use of competency frameworks.24–26 For example, within the UK context, a ‘Medical Leadership Competency Framework’ was developed in 2010 and more recently a ‘Healthcare Leadership Model’ has been created.24,27 In addition, the UK General Medical Council (GMC) document Leadership and Management for all Doctors pinpoints ways in which

context, systems (local and organisational) and time. Leadership is distributed across an organisation at all levels

leadership ‘competencies’ can be met.28 Perhaps related to this competency focus, a recent systematic review of leadership education programmes described only a ‘modest’ impact of training on knowledge, skills, attitudes and behaviours.29

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L J Gordon et al Traditionally, followers are understood to be the ‘recipients’ of leadership who act on and ‘moderate’ the leader’s vision or goals.30 Within the wider leadership literature there is an acknowledged lack of specific discussion about followership, which is reflected in health care education research.31,32 For example, an interview study with community nurses concluded that ‘following’ was a complex process that contributed to the social construction of leadership, suggesting that any future research should consider both leadership and followership as interdependent concepts.30 The health care grey literature commonly argues for shared and distributed leadership, mapping to a relational discourse.33,34 However, empirical studies in health care have focused on establishing leader traits, behaviours and styles, aligned with an individualist discourse (e.g.35,36). Other research perpetuates this individualism by focusing on defining what makes a good leader or what attributes belong to whom (e.g.37–39). However, Fairhurst and Uhl-Bein argue for leadership research approaches that ‘go beyond individual based theorising and survey approaches to the interactional processes at the heart of leadership’.40 Others have called for more distinct articulation of the definitions of leadership, recognising the important roles of context and organisational systems.41,42 Often, participants of interview studies have already attained leadership roles within health care or academic medicine.43–45 For example, in interviews of 16 medical education leaders, Leiff and Albert45 found four key areas of leadership practice (intrapersonal, interpersonal, organisational and systemic) and reported that leaders preferred to link leadership development to the workplace. Representing a departure from the perpetuity of individualist approaches, this research takes into account wider contexts, relationships and systems that are inherent parts of leadership processes.44,45

professional roles, professional bodies and organisational expectations (see also50). By contrast with the single-specialty focus of much research,51,52 such findings suggest there is a need to explore variations in conceptualisations of leadership across different groups and, indeed, contexts. Souba53 argues that the way in which leadership is conceptualised in a context affects how it is talked about and, indeed, enacted. To date, no study has explored how medical trainees conceptualise leadership and followership and how these conceptualisations map to the differing leadership discourses common to the grey and academic literature. In addition, there is a need to explore how different contexts might influence trainees’ understandings of leadership and followership. Therefore, this paper aims to answer the following research questions: what do medical trainees most commonly understand by the terms ‘leadership’ and ‘followership’? What leadership discourses do trainees’ definitions of leadership and followership map to? Thinking about the importance of context, how do conceptualisations of leadership and followership vary according to stage of training and specialty?

METHODS

In line with the premise that meaning is constructed through social interaction, this research is epistemologically grounded in social constructionism.54 This epistemological stance aligns with our theoretical viewpoint that leadership is a socially constructed process that is both relational and contextual.40 In order to answer research questions aimed at understanding multiple perspectives and interpretations of reality, an interpretive approach using thematic framework analysis of group and individual interviews was employed.54,55 Sampling and recruitment

There is, however, limited evidence on those who could be seen to be ‘developing’ as leaders (i.e. medical trainees or residents) and how they conceptualise leadership and followership. This is true although the importance of leadership development at all stages of medical careers has been endorsed by medical regulators worldwide.46–49 One of the few published studies exploring early-career doctors’ and nurses’ understandings of leadership found that each group conceptualised leadership differently.39 These conceptualisations were influenced by a range of sources, including educational background,

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Upon receiving ethical approval and appropriate institutional consents, medical trainees from two UK deaneries (covering both urban and rural locations) were invited to participate in either group or individual interviews. In order to elicit as broad a range of understandings as possible, maximum variation sampling was used to ensure diversity in terms of gender, ethnicity, training stage, specialty and location. Recruitment was initially conducted by e-mail through relevant gatekeepers within the deaneries. Following this, further recruitment was achieved by

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Conceptualising of leadership and followership presenting flyers at trainee teaching sessions and snowball sampling.56 Data collection A series of group and individual interviews were carried out at times and places convenient for participants. Individual interviews were offered when group interviews were not possible (e.g. as a result of work schedules). After they had provided written consent, participants were asked to complete an individual written data sheet, which included demographic questions, plus space to provide free-text answers to the questions: ‘What is leadership?’ and ‘What is followership?’ An interview schedule was designed to provide guidance to the interviewers as to the structure of the interview for consistency in approach. Relevant to this paper, participants were asked about how they defined leadership and followership, and to explore their experiences of health care leadership and followership (at this point narrative interview techniques were used and are reported elsewhere [L.J. Gordon, C.E. Rees, J.S. Ker, J. Cleland. Exploring medical trainees’ experiences of leadership and followership through narratives of the health care workplace; unpublished paper 2015]). All interviews were audio-recorded (with permission) and along with the written answers to the free-text items, transcribed. Data analysis Thematic framework analysis was undertaken.55,57 Familiarisation with the data was achieved by listening to audio-recordings while reading transcripts. At this point, all transcripts were checked for accuracy, and paralinguistic features (e.g. pauses, laughter) were added and data were anonymised. The research team then developed a thematic framework through discussion and negotiation of key themes. An initial coding framework was drafted which included both what participants said and how they said it (this was done by listening to the interviews whilst reading transcripts). All data pertaining to trainees’ definitions of leadership and followership were coded as dimensions of leadership and followership (‘dimensions’ being akin to the ‘themes’ of the definitions) using ATLAS.ti Version 7.0 (Scientific Software Development GmbH, Berlin, Germany). New dimensions were added as and when identified (and agreed through further discussion within the research team). In addition, we coded these definitions as either solicited (when participants were specifically asked to

define leadership or followership) or unsolicited (when participants volunteered a definition of leadership or followership as part of the general discussion or within narratives). Differentiating between solicited and unsolicited definitions allowed us to make comparisons between structured and unstructured parts of the interviews and perhaps identify differences in explicit/conscious and tacit/unconscious understandings of leadership and followership.58 These definitions were then mapped to the discourses of leadership common in the literature: individualist, contextual, relational and complexity discourses (Table 1). ATLAS.ti software allowed us to explore patterns in the data in terms of differences between trainee groups. It is increasingly common within qualitative research to numerically explore such patterns through the use of computer-assisted qualitative data analysis software (CAQDAS).59 We interrogated the data according to four specialty groupings: (i) surgical (including trauma and orthopaedics, general surgery, ear, nose and throat [ENT], obstetrics and gynaecology); (ii) medical (including general medicine, emergency medicine, psychiatry, cardiology, renal medicine, acute medicine, paediatrics and core medical training); (iii) general practice (GP), and (iv) service specialties (including anaesthesiology, radiology and pathology). We also explored patterns in the data according to training stage: (i) early-stage (Foundation Programme [FP] trainees, core trainees and specialty trainees at or prior to the half-way point of specialty training), and (ii) higher-stage (trainees beyond the half-way point of specialty training up to certificate of completion of training).

RESULTS

We conducted 11 group and 19 individual interviews with 65 medical trainees (25 male, 40 female; 51 White, 14 non-White) in early-stage (n = 34) and higher-stage (n = 31) postgraduate medical training. Participants included 23 GP trainees, 13 medical trainees, 11 surgical trainees, 10 service trainees and eight FP doctors (who had not yet entered specialty training). Individual interviews lasted between 29 and 52 minutes (average: 37.9 minutes) and group interviews lasted between 37 and 80 minutes (average: 52.5 minutes), and provided a total of nearly 22.5 hours of audio data for transcription.

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L J Gordon et al and therefore may not be the ‘right person’ to undertake leadership.

Definitions Discussion about leadership and followership focused on patient care or how the clinical environment in which trainees worked was led and managed. Leadership of the wider National Health Service (NHS) was only occasionally mentioned. Across the dataset, we identified 347 explanations of leadership and 131 explanations of followership (‘explanations’ refer to sections of talk that were specifically linked to defining leadership and followership). Within these broad explanations, we identified multiple, distinct definitions of leadership and followership. In total, we coded 757 definitions of leadership (414 solicited and 343 unsolicited) and 317 definitions of followership (302 solicited and 15 unsolicited). Dimensions of leadership Through our analysis of what trainees said, we identified 15 dimensions of leadership. These included leadership as: behaviour; role; hierarchy; group process; personality; principles and values; responsibility; skills; emergent; management; knowledge; gender; exclusive; not management, and followership. Table 2 presents the eight most commonly used (and therefore arguably the most robust) leadership dimensions, with associated illustrative quotes. Within solicited definitions, leadership behaviours were seen to be conducive to good leadership. Behavioural descriptors included coordinating, delegating, supporting, facilitating, making clear decisions, directing, setting an example, and optimising performance and efficiency (Table 2, Quote 1). Leadership as behaviours was often coded alongside leadership as a group process (Table 2, Quote 4). Leadership was also seen to come through designated interprofessional roles: the role of ‘doctor’ was identified with automatic ‘leader’ status. Within their own profession, trainees saw ‘role’ and ‘hierarchy’ as linked. ‘Clinical leader’ was associated with the most senior person present, which could be a trainee, particularly during out-of-hours care (Table 2, Quote 3). Effective leadership was related to good team performance and a sense of belonging. Also popular was ‘leadership as personality’, with trainees talking about certain individuals being ‘naturally’ drawn to leadership and being charismatic or dominant (Table 2, Quote 5). Some expressed anxiety that they may not possess these qualities

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The data revealed differences in dimensions between solicited and unsolicited talk (Table 2). In solicited talk, trainees spoke more about leadership as a group process. In unsolicited talk, however, trainees focused on leadership as an inherent personality trait. Also central to unsolicited discussion were hierarchical leadership relationships (Table 2, Quotes 3 and 5). Dimensions of followership Trainees found it more challenging to define followership, often explicitly stating that they had not heard the term before. Paralinguistic features such as pauses, hesitations and laughter were indicative of this challenge to articulate their understandings. Through discussion, trainees began to define the term and we identified 13 dimensions of followership, including followership as: behaviour; active participation; group process; an unknown term; passive; hierarchy; personality; role; non-leadership; negative; emergent; responsibility, and responsibility-free. Table 3 depicts the eight most commonly identified followership dimensions, again chosen as the most robust. Across the dataset, trainees commonly referred to followers as a group of people rather than as individuals. Unlike the definitions of leadership behaviours, which had positive connotations, trainees described followership behaviours in both positive and negative ways. Definitions of positive follower behaviour included working constructively and actively engaging with leadership (Table 3, Quote 9). More negative descriptions of follower behaviour included following instructions ‘blindly’ and alluded to the perception of followership as representing more ‘cult-like’ behaviour than team working. Followers were seen to be able to facilitate or inhibit the move toward a goal according to whether they agreed or disagreed with the leader’s vision. Unlike their definitions of leadership, which trainees related to the context of the health care workplace, talk about followership was more hypothetical in nature. In fact, as discussion moved on and trainees did not respond to direct questioning about followership, explanations of followership became scarce. In total, we identified only eight specific explanations of followership within

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Conceptualising of leadership and followership

Table 2

Dimensions of leadership (n = 8 of 15)*

Instances, n Total

Solicited

Unsolicited

Definition

Illustrative quote (Quotes 1–8)

Leadership dimension: leadership as behaviour 176

114

62

Leadership is defined as behaviour including:

Quote 1: P33 (female/surgical/higher-stage):

effective communication; effective delegation;

‘I think communication probably is a huge

confidence; coordination; setting example;

part, erm, in being able to ask or tell

decision making, etc.

people to do things, erm, but also maybe just sort of show by example or, erm, gently sort of move people or, you know, cajole them to give information or do things, erm, that kind of thing. . .’ [Solicited conceptualisation]

Leadership dimension: leadership as role 106

54

52

Trainees describe the expectation by

Quote 2: P4 (male/GP/higher-stage):

themselves and others in the interprofessional

‘General practice is. . . a funny beast

workplace that as doctors, they are the

compared to. . . the hospital you can see

leader. Trainees also talk about leader as a

where the leadership comes, they [the

named role or described as stage-specific

consultants]. . . go on the ward rounds,

(e.g. GP or consultant equals leader)

they have a the lead, their junior doctors with them. . . In general practice it’s a team of one so I’ll, I’ll see 20-odd people in here during the course of a day, and I’m I am the, the single lead for recognising and investigating, and passing out to other individuals for further information. . .’ [Unsolicited conceptualisation]

Leadership dimension: leadership as hierarchy 94

42

52

Leadership is talked about as something that is

Quote 3: P5 (female/surgical/higher-stage):

part of the medical or interprofessional

‘When I do on-call out-of-hours, I am the

hierarchy. This includes when a junior trainee,

leader, I guess, of the medical team

as the most senior person within a context,

running [specialty name] ward. So I have a

will automatically be the leader

junior trainee who might be looking to me for advice and guidance’ [Unsolicited conceptualisation]

Leadership dimension: leadership as group process 82

66

16

This dimension is focused around team

Quote 4: P56 (female/service/higher-stage):

working that is both uni- and

‘. . .if you’re working within a group, then, I

interprofessional. Trainees talk about

think, you have to, to make the right

leadership as a process that is part of team

decisions, you have to be aware of what

working and closely related to team

the overall opinion of the group is. . .you’ve

performance through a sense of belonging

got to be very attuned to people’s feelings

and with a focus on group goals

within it. . .’ [Solicited conceptualisation]

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L J Gordon et al

Table 2

(Continued)

Instances, n Total

Solicited

Unsolicited

Definition

Illustrative quote (Quotes 1–8)

Leadership dimension: leadership as personality 80

28

52

Examples of this include trainees’ talk about

Quote 5: P53 (female/medical/higher-stage):

dominant personalities or individuals being

‘. . .it [a leadership course] makes you

‘natural’ leaders. Other data talks about

understand the theory. . .but even a day’s

people who prefer to be in leadership

course they say, “You know, you realise

positions. Often within this dimension there

that you need to be more assertive.” That’s

was discussion about whether leaders were ‘born’ or ‘made’

all very well’ P55 (female/medical/higher-stage): ‘Uh-huh, yeah’ P53: ‘. . .but if you’re not that by nature, how do you go and put that into practice?’ P55: ‘Yeah’ R53: ‘You can’t suddenly stand up to somebody’ P51 (female/medical/early-stage): ‘Um, you can’t change your personality’ [Unsolicited conceptualisation]

Leadership dimension: leadership as principles and values 59

31

28

Trainees talked about a leader being fair,

Quote 6: P37 (female/GP/early-stage): ‘You

approachable, coaching and supportive, and

have to be seen to be fair, the leader as

allowing followers to develop and learn

well, I think. . . You can’t be seen to be putting your friends and yourself above the other people’ [Unsolicited conceptualisation]

Leadership dimension: leadership as responsibility 56

29

27

Trainees describe how leadership equates to

Quote 7: P50 (male/service/higher-stage):

clinical responsibility. The person who has

‘. . .because it’s as in medicine leadership is

ultimate clinical responsibility within a given

a, or superiority is with responsibilities so if

situation was perceived to be the leader

somebody is responsible then there the buck stops. It’s buck stops at the leader so whoever is the, so I’ve had a consultant who just jokingly saying, he said, “Why I get more paid because if this patient dies I’m the one who gets to go to coroner, not you so why I’m a consultant and you are a trainee”’ [Unsolicited conceptualisation]

Leadership dimension: leadership as skills 35

15

20

Trainees describe leadership as skills such as

Quote 8: P3 (male/surgical/higher-stage): ‘On

negotiation skills, delegation skills. This differs

a surgical point of view is, is your operating

from behaviours in that there is specific

skill and the things that you do that are

mention of skills. Trainees also describe specific clinical skills that identify a person as

different from others that you think are better’ [Solicited conceptualisation]

the clinical leader GP = general practice. * Please note that although these quotes are used to illustrate a particular dimension of leadership, many were multi-coded and it is therefore possible for the reader to associate the quotes with additional dimensions.

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Conceptualising of leadership and followership

Table 3

Dimensions of followership (n = 8 of 13)

Instances, n Total

Solicited

Unsolicited

Definition

Illustrative quote (Quotes 9–16)

Followership dimension: followership as behaviours 76

73

3

This dimension focuses on followership being a

Quote 9: P51 (female/medical/early-stage):

set of individual behaviours which trainees

‘Working constructively under somebody but

perceive to be typical within the health care

if you’re something that you were completely

workplace

thought was wrong then you don’t necessarily have to do it even though you’re not the leader of the team. Like, as long as you’ve you gone about it appropriately’ [Solicited conceptualisation]

Followership dimension: followership as active participant 44

43

1

Trainees described followers choosing who the

Quote 10: P57 (male/service/early-stage):

leaders are in a given situation or through

‘. . .you [as a follower] can have a huge

actively supporting (or not supporting) the

influence and come up with lots of ideas

leader

and, you know, by providing quality control, you actually have a lot of influence on the leader. . . in a group setting, you’re contributing to the overall vision. . . ensuring that that [in] particular all the goals, or aims are are achieved’ [Solicited conceptualisation]

Followership dimension: followership as group process 43

42

1

This dimension describes trainees’

Quote 11: P48 (male/service/higher-stage):

understandings of the role that followers have

‘. . .forming part of a team are, have bought

to play within a team. Within this, followers

into whatever the vision is that the leader

are seen to be team members and team

has set, and, er, are going to work as a team

players. Some trainees used the terms

with the same end goal in mind as to how

‘follower’ and ‘team member’ interchangeably

they get there. They may be taking on different roles, but the goal is the same’ [Solicited conceptualisation]

Followership dimension: followership as unknown term 35

35

0

Here, trainees explicitly state that ‘followership’

Quote 12: P42 (female/FP doctor): ‘I don’t

is an unknown or new term. Some trainees

know, I was filling that [the form] out and it

questioned whether the term had been made

is like “what does that mean?” I’m like I

up for the purpose of this study

don’t really know like’ [Solicited conceptualisation]

Followership dimension: followership as passive 24

24

0

Here, trainees see followership as passive.

Quote 13: P65 (male/surgical/early-stage):

Trainees describe following instructions ‘blindly’

‘. . .it’s the implicit assumption that you

and with no participation in decision making

would, I suppose, well, so if my boss in

about group goals

theatre says, “Do this” and he has a certain tone in his voice, I know it needs to be done immediately and I’m not to discuss that. This is not, this is not an open invitation, it’s “You

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L J Gordon et al

Table 3

(Continued)

Instances, n Total

Solicited

Unsolicited

Definition

Illustrative quote (Quotes 9–16) must do this now” and, you know, that’s the message given. So is that followership that in certain situations I am going to just do what I’m told basically’ [Solicited conceptualisation]

Followership dimension: followership as hierarchy 22

19

3

Trainees link followership talk about the clear-

Quote 14: P2 (male/medical/early-stage):

cut assumption that if there is someone more

‘. . .the nature of our job is that there’s

senior present, trainees will defer to them and

always an F – a junior who’s just qualified,

are therefore followers

and there’s always someone that’s about to retire, and you’re somewhere in the middle of that and the further on you go, the more, sort of, people there are below you to ask you to look to you for advice’ [Unsolicited conceptualisation]

Followership dimension: followership as personality 17

14

3

Trainees talk about followership as something

Quote 15: P59 (female/FP doctor): ‘. . .if you’ve

relating to someone’s personality. They were

not had any training in leadership then it’s

often seen to be lacking leadership traits and

easier just to be a follower if that’s your

therefore by default they become a follower

personality’ [Unsolicited conceptualisation]

Followership dimension: followership as role 16

14

2

Trainees expect junior doctors to be the

Quote 16: P46: (male/service/higher-stage):

followers within the interprofessional health

‘Well there are situations where you just

care workplace. This dimension is also relevant

don’t have the, you know, ability or expertise

when trainees are talking about

to actually take on a leadership role at, you

interprofessional roles and expectations of who

think surgery, for example, you know, the

should lead and who should follow (e.g.

scrub nurse to the surgeon, you know, he

doctors as leaders and nurses as followers)

knows what he’s doing, they are all working for his one goal, so she’s going to follow his instruction. . .’ [Unsolicited conceptualisation] Note: This quote was also coded as followership as gender

FP = Foundation Programme.

unsolicited discussion, coding a total of 15 definitions across all data (Table 3). The focus of these unsolicited definitions revolved around how an individual’s personality or the medical hierarchy could define a person as a follower (Table 3, Quote 14).

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Discourses of leadership and followership Trainees’ talk mapped to all four discourses of leadership identified within the literature (Table 4). Differences in discourses were noted between solicited and unsolicited talk.

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Conceptualising of leadership and followership

Table 4

Distributions of the broad discourses of leadership and followership as they align with trainees’ dimensions*,†

Talk solicited/unsolicited, % Specialty Discourse

Training stage

Total

GP

Surgical

Medical

Service

Early

Higher

Individualist discourse

42/57

46/49

53/66

29/62

28/53

49/53

37/64

Contextual discourse

10/15

6/11

3/20

14/10

25/23

8/15

12/14

Relational discourse

41/21

40/32

37/10

51/23

38/15

37/24

43/16

7/7

8/8

7/3

6/5

9/8

6/8

7/6

41/50

35/100

55/67

45/0

40/0

42/40

43/67

Discourses of leadership

Complexity discourse Discourses of followership Individualist discourse Contextual discourse

4/0

3/0

9/0

0/0

8/0

2/0

6/0

Relational discourse

48/25

55/0

32/33

55/0

44/0

47/20

46/33

7/25

7/0

4/0

0/0

11/40

5/0

Complexity discourse

8/100

GP = general practice. * Discourses were coded to each broad explanation rather than each distinct dimension; thus the numbers within this table are lower than in Tables 2 and 3. In addition, the percentages within this table are rounded to the nearest whole number and are depicted as the percentage of talk across the four discourses. † It is useful to note that the numbers within the columns do not add up to the totals presented in the first column. This is because: (i) according to the nature of the group interviews, an explanation of leadership might be attributed to more than one participant (e.g. an explanation resulting from discussion between an early- and a late-stage trainee would be coded to both groups), and (ii) within the specialty groups, Foundation Programme trainees are excluded.

Individualist discourse As the most commonly identified discourse mapped to talk across the dataset (Table 4), trainees would single out ‘the leader’ within their workplace. Individualist ideas about defining leadership were articulated through descriptions of individual behaviours, personality and leadership style. Trainees also described leaders individualistically with relation to designation and role, defining individuals as leaders as a result of their knowledge and expertise (Table 3, Quote 16). Contextual discourse Trainees explained that they might approach certain leaders for certain things (e.g. to resolve conflict) and others for different issues (e.g. career planning). Trainees also described how in certain contexts (e.g. surgical theatre), different individuals would take on leadership as it was appropriate to their position and responsibilities within that context (Table 2, Quote 7). Leaders were also seen to

adapt their leadership style according to the situation, for example, as they moved from routine clinical care to an acute cardiac arrest. Relational discourse Effective team working and how leaders coordinated and facilitated this represented the focus of much discussion, particularly within solicited definitions. Trainees saw team members (or followers) as key to influencing a leader’s decisions; who the leaders and followers were in their workplaces were thought to remain static (Table 3, Quote 11). Trainees also aligned with a relational discourse when discussing the medical hierarchy, in particular from the perspective of defining their own position within that hierarchy (Table 3, Quote 14). Complexity discourse Trainees talked about leadership and followership as representing a process rather than as characteristics attributed to an individual. Leadership was seen as a dynamic entity that moved around the health care

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L J Gordon et al team and was negotiated according to the situation. Trainees talked about the complex interplay among individuals, relationships and context, and described ‘stepping forward’ or ‘stepping back’ into leadership or followership roles according to the needs of the immediate situation. Complexity was the discourse least mapped to talk across the dataset.

come from a different (and perceived as non-traditional) professional, such as a nurse. Some saw this as a dilemma, stating that in their role as ‘doctor’ they should be taking the lead. Early-stage trainees were also more likely to state that they had not previously heard the term ‘followership’. Differences by specialty group

Solicited and unsolicited discourses Differences between solicited and unsolicited discussion were noted. As interviews progressed to talk about workplace experiences of leadership, trainees’ dimensions typically turned to personality, role and hierarchy. Thus, in unsolicited discussion, there was an increase in participants’ talk aligning with an individualist discourse, with a simultaneous reduction in the extent to which it aligned with a relational discourse (Table 4). Differences in dimensions of leadership and followership Finally, we present differences and similarities by training stage and specialty group. Differences by training stage In solicited discussion, early-stage trainees described leadership as behaviours, personality, role and hierarchy, and their interpretations were more likely to align with an individualist discourse (Table 4). By contrast, the interpretations of higher-stage trainees were more likely to align with a relational discourse (Table 4). However, in unsolicited talk, similarly to early-stage trainees, higher-stage trainees’ definitions turned to personality and an individual’s ‘ability’ to lead or his or her position within the medical hierarchy, aligning more prominently with the individualist discourse (Table 4). For higher-stage trainees, leadership was seen to come with increasing clinical responsibility, experience and time served. Some higher-stage trainees expressed concern about preparation for the transition to consultant. Despite feeling ready clinically to take on the ‘leadership role’, they expressed feelings of unpreparedness for the non-clinical responsibilities of the trained doctor role. Early-stage trainees defined leadership as something one could ‘step into’ or ‘step down’ from according to what was right for patient care at the time. Often this definition was based in the context of interprofessional working and leadership was seen as able to

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Differences were noted in the types of behaviours typically described by different specialty trainees. For example, GP, medical and service trainees linked leader behaviours with group processes, principles and values, and most commonly aligned with a relational discourse to define leadership behaviours, describing coordination, and supporting and listening to group members as important leader behaviours (Table 2, Quotes 4 and 6). By contrast, surgical trainees saw decision making, providing direction, setting an example, optimising performance and efficiency as important leader behaviours. The surgical specialty group talked about the leader–follower relationship in the context of ‘providing support and guidance’, but this talk was focused on an individual’s influence on another with the aim of persuading that person to do something (Table 2, Quote 1). Surgical trainees also stated that there was a clear-cut hierarchy within theatre which placed the consultant at the top as ‘ultimate leader’. In terms of followership, GP, medical and service trainees, in particular, described a follower as an active member of the group who contributes to team goals and the group’s direction. These trainee groups saw that although decision making would often come from the leader, it was up to a follower to participate in the process and often to decide how to ‘implement’ those decisions. A follower was seen as being responsible for his or her own actions, but ultimately needed to undertake the leader’s instructions. Similar to their definitions of leadership, service trainees understood skill, job role and experience as dependent on how active a follower could be (Table 3, Quote 16). It was common for these trainee groups to align with a relational discourse when defining followership (Table 4). Surgical trainees used the medical hierarchy and roles within it to define who the followers were; very few saw the leader–follower relationship as a two-way process. Types of behaviours attributed to followers by surgical trainees included deference, compliance, taking instruction and asking for help (Table 3, Quote 13). For some surgical trainees, the word ‘follower’ indicated inaction rather than active team membership.

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Conceptualising of leadership and followership

DISCUSSION

This research focused on how medical trainees conceptualise leadership and followership. At the outset, trainees concentrated on the clinical environment and clinical leadership, which is perhaps unsurprising given the point at which participants were in their careers.60 We framed our questions differently from those used in previous leadership research. Rather than focusing on an individual’s behaviour, traits and skills,40 we asked participants to discuss ‘what is leadership’ and ‘what is followership’ rather than ‘what’ or ‘who’ makes a good leader. Through this approach, we explored the multiple ways in which leadership and followership can be defined. Despite the breadth of dimensions identified, the preference was for more unsophisticated ways of understanding leadership (such as behaviours, hierarchy and personality), particularly in unsolicited talk, highlighting that an individualist focus dominates medical trainees’ understandings. This suggests that educational approaches, which emphasise leader–follower relationships and distributed leadership processes, are required to narrow the theory–practice gap.5,33,34 Initial difficulties in getting trainees to define followership gave way to descriptions echoing contemporary definitions of leader–follower relationships in the literature; for example, followers were sometimes constructed as active participants in the leadership process.61 However, much of this talk was hypothetical in nature and as discussion moved on to unsolicited talk, explanations of followership became scarce. This may be related to our observation that the terms ‘follower’ and ‘followership’, although commonplace within the contemporary leadership literature, are not widely utilised within health care spheres. Arguably, the terms ‘follower’ and ‘followership’ in health care are replaced by terms referring to ‘teams’.4,24,26 For example, within the UK, the Healthcare Leadership Model uses ‘team’ and the promotion of ‘teamwork’ when talking about leader–follower relationships.24 Interestingly, trainees commonly recognised that leadership was a group process, thus indicating an awareness of the importance of relationships. Medical educators should therefore ensure that consideration of followers and followership is an integral part of any educational intervention. We found that trainees’ articulations of their conceptualisations aligned with all four discourses

of leadership. Although participants’ talk most commonly aligned with an individualist discourse across the data, it was more likely to align with the more sophisticated relational discourse within solicited talk. Similarly to current definitions of leadership in the literature, many trainees identified the aim of leadership as being to coordinate or influence a team to move in a particular direction.20,21 In unsolicited talk, however, we identified a clear focus on individual leaders. As discussions progressed within the interviews to cover workplace experiences of leadership, trainees’ definitions aligned even more closely with traditional, historical conceptualisations in which personality, roles and hierarchies defined who a leader was (or was not) perceived to be.62 The differences between solicited and unsolicited talk may be indicative of the overarching discourses within the health care literature of a ‘shared’ approach to leadership, which may have influenced trainees’ solicited definitions.4,5,34,35,46 This contrasts with their unsolicited talk, which instead may reflect trainees’ actual workplace experiences of leadership and followership, which would seem to reinforce individualism. Similar influences have been found in medical students’ understandings of professionalism and thus highlight the importance of workplace experiences in learning about leadership.57 Exploring differences in conceptualisations between training stages revealed that early-stage trainees held less sophisticated conceptualisations of leadership than higher-stage trainees. This may reflect their limited workplace experiences of leadership and their inability to yet draw on any formal leadership development programmes (these being typically reserved for higher-stage trainees in the UK).63 Our research also highlighted the influence of context (in terms of specialty grouping) on trainees’ conceptualisations of leadership. Willcocks identified six factors that influence cultural context within different medical specialties, including historical background, the nature of the work and use of technology, internal and external relationships, individualism and motivation, inter-specialty interaction and communication, and values and socialisation, and argued that different specialty cultures experience ‘management’ (and thus possibly leadership) in different ways.50 For example, surgery is well known for its traditional hierarchical practices. The use of various tools to rate surgeons’ leadership behaviours, including example setting and individual

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L J Gordon et al performance indicators, might, for example, perpetuate an individualist discourse with respect to surgical leadership.51,52,64 Educational practices within specialties may also influence conceptualisations of leadership and followership; for example, within anaesthesia, leadership is seen as a non-technical skill to be learned.65 Given these factors, it is perhaps unsurprising that differences in conceptualisations were identified across specialties.50 Again, the differences among specialty groups highlight the important roles that context and educational influence can play in how leadership and followership are conceptualised. Methodological strengths and challenges To our knowledge, this is the first study that has sought to explore medical trainees’ understandings of leadership and followership, what discourses of leadership and followership dimensions align with, and what similarities and differences exist between trainees from different stages of training and specialties. Our study was multi-site and drew participants from a wide range of specialties. Therefore, we suggest that our study has a degree of transferability.66 Although our team-based approach to data analysis encouraged rigour, we acknowledge the lower proportion of male doctors and non-White trainees in our sample. Although this sample is demographically reflective of trainees within this UK country, it may mean that our findings are less transferable to these groups.67 In addition, our findings are likely to be specific to UK training programmes and therefore may not be transferable outside the UK to places with different health care practices, systems and education. We interviewed only medical professionals and thus future research should consider broadening our approach to include the wider interprofessional team. In addition, although our data suggest differences between early- and late-stage trainees, our study was cross-sectional rather than longitudinal. Hence there is a gap in the literature in terms of exploring how conceptualisations of leadership change as doctors move through their different training experiences and as they become socialised into specialty-specific cultures and practices.

for complex health care systems,24,26 and should instead consider how best to introduce and embed more contemporary leadership practices which have the potential to improve practice.4,5 However, given that we found UK trainees’ outdated understandings of leadership and followership to be clearly influenced by the contexts and organisational structures in which they work, formal education itself is unlikely to lead to change. Rather, change, in terms of the enactment of leadership playing out differently in health care environments, is required before more sophisticated understandings of leadership and followership can evolve. There is therefore a need for workplace-based learning whereby trainees can develop their understandings of leadership and followership and better align those with modern theoretical thinking, underpinned by the complexities of workplace context, relationships and organisational structures.

Contributors: all authors contributed to the study conception and design. LJG contributed to data collection and analysis, wrote the first draft of the paper and edited various iterations. All but one interview were undertaken by LJG. CER undertook one of the group interviews and listened to the audio-recordings of several initial interviews in order to provide feedback on interview technique to LJG. CER also contributed to the data analysis and edited each iteration of the article. JSK and JC contributed to data analysis and commented on various iterations of the paper. All authors approved the final manuscript for submission. Acknowledgements: the authors wish to thank all participants in this study, the Scottish Medical Education Research Consortium (SMERC), NHS Education for Scotland (Scottish Deanery) and Tim Dornan, Queens University Belfast, who contributed to the initial stages of data analysis in his role as visiting professor for SMERC. Funding: this research was part of LJG’s PhD research at the Centre for Medical Education, Dundee, which was generously funded by NHS Education for Scotland through SMERC. Conflicts of interest: none. Ethical approval: this study was approved by the University of Dundee Human Research Ethics Committee.

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