Rehabilitation team leadership
At a recent meeting in Genoa of RIMS (Rehabilitation in Multiple Sclerosis), Dr Carlotte Kiekens discussed the leadership of the rehabilitation team, providing some challenging evidence and ideas to consider. In this blog post, I will review the whole question of leadership in rehabilitation. Traditionally doctors have considered themselves the leader, which is still the cultural norm in some countries and services; culturally, many professionals also expect the doctor to lead. The matter is complex. We easily conflate being the service lead with chairing a rehabilitation planning meeting or representing the service in committee meetings. We also conflate being clinically responsible for a patient’s clinical well-being, often legally expected of a doctor, with being a leader. I will disentangle these issues and review the limited evidence. I conclude that leadership must be earned, not expected with a role, it is collaborative, not dictatorial, and it should be specific to the situation, not a universal feature. A good leader should also be a productive team member when someone else leads. An overview of this blog post is below.
Table of Contents
I have already discussed the imprecise nature of a rehabilitation team because there is a hierarchy of units, as illustrated in this figure. The primary team, the group working with a particular patient at a specific time, will likely comprise primarily professionals in the lead rehabilitation service. However, the other people will be from other teams, often from entirely different organisations. Thus, a person with rehabilitation needs frequently draws upon a broad network of rehabilitation services.
When considering leadership in rehabilitation, one faces the same problem. Are we discussing the leadership of the group seeing a patient, the group that constitutes a rehabilitation service, or the group of rehabilitation services provided by a health service rehabilitation network? The knowledge and skills needed will differ between different types of leadership.
But, before discussing leaders and leadership in more depth, I should first consider what leadership is and how it relates to the leader.
Leadership, or being a leader?
The Oxford English Dictionary [OED] gives an illuminating description of the meaning attached to the word leader, “the person who leads or commands a group, organisation, or country”. I am struck by the two meanings implied – leading or commanding. In political discourse and management discussions, leaders are often referred to as people who control, and someone is considered a good leader if others accept their view or wish. Leadership is “the action of leading a group of people or an organisation.”.
McKinsey, a management consultancy, takes a different view, “leadership is about guiding and impacting outcomes, enabling groups of people to work together to accomplish what they couldn’t do working individually. In this sense, leadership is something you do, not something you are.” They follow this with a statement everyone will agree with, “ Some people in formal leadership positions are poor leaders, and many people exercising leadership have no formal authority. It is their actions, not their words, that inspire trust and energy.”
One can see a philosophical or linguistic conflict. One side is leaders who acquire the power of being a leader and then control and command others. This approach sees leaders as people who, by one means or another, mould the members of the team or group into an organisation doing what the leader deems proper. This is easily recognised in healthcare; it is the leader appointed by others to achieve a task using the team.
This is consistent with another definition taken from the book Executive Leadership: a practical guide to managing complexity; leadership is “a process by which one person sets the purpose or direction for one or more persons and helps them to proceed competently and with full commitment”. This definition has been used in healthcare research.
The alternative is leaders who behave in a way that encourages others to follow and collaborate and often engage in forming and revising the way the group does things. This approach sees leaders as people who emerge from the team or group and are effectively appointed by the group to lead them; the person has earned their role. This is seen in healthcare but rarely within the organisation’s management structure. That phrase, a management structure, shows why this type of leader is rare.
Leadership in complex adaptive systems.
Politicians and others frequently call for improved leadership in healthcare, hospitals spend a fortune on sending staff on leadership courses, and most senior professionals will have been on leadership training courses. Yet, after 40 years, the same calls are made. A mixed methods systematic review investigating the effectiveness of training on leadership competence found that it probably increased leadership behaviours, at least in the short term. Still, the effect of this on organisational performance could not be established.
One reason might be a failure in analysis and understanding. Healthcare is considered a predictable mechanism where, if everyone did the right thing, there would be no problems. A leader is viewed as a mechanic fixing a complicated machine, but ultimately a machine.
An alternative theoretical approach is to recognise healthcare as a complex adaptive system, as Paul Plsek and Trisha Greenhalgh described in 2001. The article needs to be read to gain a complete understanding but, in brief, it says:
- Modern healthcare is a complex network with many component subsystems, all inter-related and interdependent
- Each system is self-adjusting to maintain its central purpose
- This is a mathematically complex (not complicated) system characterised by being unpredictable, often showing paradoxical behaviours, and with many unknowable effects and interactions.
They suggest that the traditional but, unfortunately, still prevalent “reduce and resolve” approach is unsuited to the real world of complex adaptive systems. They recommend an approach to clinical care and the organisation of services that is “dynamic, creative, and intuitive.”
In the third (of four articles) in a series on complexity science, Paul Plsek and Tim Wilson consider leadership with complex adaptive systems, basing their analysis on complexity and chaos theory features. They remark, “The interactions within a complex adaptive system are often more important than the discrete actions of the individual parts.” For example, they emphasise that identifying an attractor within a complex system causes change, whereas any amount of altering inceptive rarely works.
Other studies have looked at evidence from studies in healthcare. Kjeld Aij and Sofia Rapsaniotis reviewed studies on leadership in healthcare, considering and contrasting two approaches (Lean (as in Lean, just-in-time processes) and servant (as in serving the group). They found that the two leadership groups shared many common features. The characteristics of Lean leaders include respect for people, openness, empowerment, trust and modesty. They have a coaching style.
The paper lists specific characteristics associated with each style. The notable feature is the absence of any command-and-control features. The main elements related to:
- Being holistic and far-sighted, looking to the longer term
- Leading by example and behaviours indicating respect for others
- Developing and supporting members of the group
- Encouraging and facilitating interpersonal relations across the group
Leadership in rehabilitation.
People working in rehabilitation should be better at leadership than people from many other branches of health because they are trained in being holistic using the biopsychosocial model of illness and in managing complexity and uncertainty. They also are trained to understand the many organisations associated with healthcare and rehabilitation.
In the context of a single patient, any reasonably experienced member of a person’s rehabilitation team should be able to provide leadership. In this situation, the crucial aspect of leadership is to be person-centred and holistic, especially looking to the long term and considering social participation. Sadly, these are the vital aspects that are often overlooked partly because they are challenging, and focusing on short-term practical matters is much less demanding.
In the context of the team, most experienced professionals who will likely remain with the service for some years will be capable of leading the team in projects such as auditing practice and quality improvement or expanding into a new but related clinical area.
The leadership of the service (i.e. representing the service in the broader forum) will be less attractive to most group members. Still, there is no reason why any senior group member could not lead this way.
Thus, a rehabilitation team may have many leaders. Even excluding the role of leading a patient’s team, there will be people leading on, for example, developing a collaboration with a Social Service day centre, redesigning the clinics for people with spasticity, or introducing ward-based activity programmes.
At a higher level, there is traditionally a single leader. However, that person must have someone to deputise, for example, during holidays. With job-sharing becoming more common, two people may share the role.
Leadership and teamwork.
Leaders lead groups of people, whether large (an army or a hospital) or small (a tennis club team or a community physiotherapy team). Some groups will self-identify as a team, while others and unlikely to do so. Here I wish to consider leadership in the context of a multi-professional rehabilitation team of the whole service, which might include around 100 people, with most people knowing most people.
One approach would be having collective leadership, which may be quite common. Jaqueline Silva and colleagues undertook a Cochrane systematic review entitled “Collective Leadership to improve professional practice, healthcare outcomes and staff well-being.”. They defined collective leadership thus, “Collective leadership is a way of characterising the engagement of multiple healthcare team members to come together to make decisions and strengthen health service and system performance, towards the quality of care enhancement.” When I started my career at the Rivermead Rehabilitation Centre, Oxford, we had a Heads of Therapy group that effectively used this approach.
The review concluded that collective leadership probably improved leadership outcomes but its effect on service and clinical outcomes was uncertain.
A second study by Thorsten Meyer and colleagues in Germany collected data from six rehabilitation services, comparing three with high scores in the comparative league or rehabilitation services with three with low scores. They used qualitative data to investigate teamwork and cooperation. With all services, they found “a dominant role of the physicians within the rehabilitation team when it came to the distribution and ascription of responsibilities.” Nonetheless, team members experienced an equal relationship in the better services, and their views were more likely to be sought and accepted.
Groups working together on complex problems must consider and develop a common understanding, ensure sharing of goals and activities, and facilitate collaboration. This requires someone to lead, taking responsibility for transforming a group into a team working towards a common goal. There are two approaches. Treat the team as a complicated machine, and appoint a leader to organise and give direction to the team’s work. Or find someone in the group who leads by example, can see the bigger picture, and respects and develops the team members. Rehabilitation training will equip professionals with good collaborative, transformational team leadership skills.