Primary research

Comparing the content of leadership theories and managers’ shared perceptions of effective leadership: A Q-method study of trainee managers in the English NHS

Health Services Management Research 26(2–3) 43–53 ! The Author(s) 2013 Reprints and permissions: DOI: 10.1177/0951484813513245

Tim Freeman1

Abstract Health service managers face potential conflicts between corporate and professional agendas, a tension sharpened for trainees by their junior status and relative inexperience. While academic leadership theory forms an integral part of contemporary management development programmes, relatively little is known of trainees’ patterned subjectivities in relation to leadership theories. The objective of this study was to explore such subjectivities within a cohort of trainees on the National Health Service Graduate Management Training Scheme (NHS GMTS), a ‘fast-track’ programme which prepares graduate entrants for director-level health service management posts. A Q-method design was used and four shared subjectivities were identified: leadership as collaborative social process (‘relational’); leadership as integrity (‘moral’); leadership as effective support of subordinates (‘team’); and leadership as construction of a credible leadership persona (‘identity’). While the factors broadly map onto competencies indicated within the NHS Leadership Qualities Framework which underpin assessments of performance for this student group, it is important not to overstate the governance effect of the assessment regime. Rather, factors reflect tensions between required competencies, namely the mobilisation of diverse interest groups, the ethical base of decisions and the identity work required to convince others of leadership status. Indeed, factor 2 (‘moral’) effectively defines leadership as the embodiment of public service ethos.

Keywords leadership, management education, managers, trainees, UK

Introduction In an era of governance, public management reforms in Australia, Canada, New Zealand and the UK have reframed management as the leadership of service change.1 Reflected in the modernisation agenda of successive New Labour governments from 1997 onwards, the UK variant has informed policy developments within central and local government, police, defence, education and health.2 The importance accorded to leadership is ongoing and evident in policy documents from the Conservative and Liberal coalition government, such as the structural reorganisation of NHS commissioning and public health functions.3 It is perhaps unsurprising that leadership has become a core component of public management development programmes such as the NHS Graduate Management Training Scheme (NHS GMTS),

a programme which explicitly promises to equip its students to lead complex service transformations. However, the exercise of leadership is problematic within complex professional bureaucracies such as the NHS, a distinctive setting characterised by potentially conflicting systems of collegiate (medical) and corporate (managerial) governance in which managers must aspire to lead clinical colleagues who are often primarily oriented towards their respective professional bodies rather than their employing organisations. 1

Middlesex University, UK

Corresponding author: Tim Freeman, Middlesex University Business School, The Burroughs, Hendon, London NW4 4BT, UK. Email: [email protected]

Downloaded from at UNSW Library on July 11, 2015


Health Services Management Research 26(2–3)

Figure 1. Main findings and implications.

This difficulty is sharpened for GMTS trainees given their relative inexperience and lack of seniority within corporate management structures. While leadership programmes aim to provide development opportunities, little is known of the shared subjectivities of trainees’ in relation to conflicting normative claims of academic leadership theories. This paper addresses the gap, exploring the patterned subjectivities expressed by a cohort of NHS GMTS trainees through an application of Q-methodology. The following sections provide an overview of the NHS GMTS leadership development programme and its leadership content, introduce Q-methodology as the approach best suited to explore patterned subjectivities in relation to complex and contested phenomena, compare and contrast four trainee subjectivities found in relation to leadership theories and considers their implications (Figure 1).

NHS GMTS programme The NHS GMTS is the national post-graduate ‘fasttrack’ training programme for NHS general managers, designed to prepare students for director level posts and recruiting approximately 90 students each year onto an intensive 2-year programme. While continually updated, at the time of the study it comprised four week-long academic blocks (organising, planning, delivery and evaluation of health and social care; healthcare policy in the international context;

management, leadership and organisational theory; and healthcare improvement science); a related programme of managerial skills training in topics such as project management, performance assessment and Professional Development Planning; eight days of locality-based action learning sets, providing supportive and challenging opportunities for personal development and reflective learning; and two extended work placements as health service managers with service responsibilities, in which trainees must demonstrate successful completion of a wide range of financial, service re-design and personnel management competencies as outlined within the NHS Leadership Qualities Framework (LQF), reproduced in Figure 2.4 Weeklong academic blocks were delivered three times – on consecutive weeks, to a third of the year intake on each occasion. The combination of intensive academic study and work-based placements provides trainees with the opportunity to apply academic theory, reflect upon experiences and develop their understanding of health services management within a supportive environment. During the course of their studies, GMTS students are exposed to a wide range of leadership theory (Table 1). Theories place varying emphasis on the attributes of leaders, relationships between leaders and followers, and the requirements of cultural transformation. While providing a rich resource to inform practice, their normative claims and prescriptions for action are often in tension, requiring trainees to make sense of conflicting claims. The empirical research reported

Downloaded from at UNSW Library on July 11, 2015



Broad scanning

Setting Direction Political astuteness

Intellectual flexibility

Personal Qualities

Seizing the future

Leading change through people

Drive for results

Self belief Self awareness Self management Drive for improvement Personal integrity

Holding to account

Collaborative working

Effective and strategic influencing

Empowering others

Delivering the Service Figure 2. The NHS Leadership Qualities Framework. The diagram represents elements in the Leadership Qualities Framework to which students in the research cohort were exposed and which forms part of the competency framework used in their assessment.

below explores common trainee subjectivities in relation to the normative claims of leadership theories to which they were exposed, and considers their implications.

Research design Q-method (‘Q-methodology’) is an ideal method for exploring shared subjectivities in relation to complex and contested phenomena, such as leadership, and does so by drawing on quantitative and qualitative data provided by participants in response to a set of structured questions.24,25 The process requires respondents (the ‘P’ sample) to order a set of statements which summarise a wide range of views in relation to the topic of interest (the ‘Q-sample’) to reflect their preferences (the ‘Q-sort’), from which common patterns of response (‘Q-factors’) are derived and interpreted by the analyst. Essentially, Q-method uses Q-factor analysis to derive patterns of shared (i.e. social) understandings, expressed through the Q-sort. It has been extensively used in health and health management research to consider shared subjectivities in relation to employee satisfaction,26 hospital strategy planning,27 the development of therapeutic relationships28 and case-management

allocations.29 Within the field of leadership it has been used to explore perceptions of clinical and collaborative leadership and the role of clinical directors.30–32 It is an ideal method for the aim of the present study to explore shared patterns of junior general managers’ response to the normative claims of leadership theories within a management development programme.

Stages in Q-methodology Basic procedures for conducting Q-sorts include deriving the statements to be sorted (the ‘Q-sample’); selecting participants (the ‘P-sample’); rules for ordering the statements (‘specification of conditions of instruction’) in the Q-sort and analysis. Ethical approval for the study was granted by the University Ethics Committee. Deriving the Q-sample. Also known as a Q-set or concourse, the Q-sample consists of a set of stimuli (‘items’). The content of the items is derived from literature reviews or other sources of information on the topic in question, and it is important that they cover the phenomenon of interest broadly.33 In practice, this consideration is held in tension by the need to keep the number of items within manageable bounds for

Downloaded from at UNSW Library on July 11, 2015


Health Services Management Research 26(2–3)

participants and typically they contain between 30 and 80 items.34 Given the focus on patterns of trainees’ responses to conflicting prescriptions within academic leadership theories, it was important to develop the Qsample from the existing literature rather than from interviews with trainees on a naturalistic basis. Programme content was reviewed to identify the leadership theories to which trainees had been exposed, and academic literature related to these theories retrieved. Salient features and prescriptions for each school of leadership theory taught were extracted from retrieved sources in narrative form, the important contours of which are briefly reported in Table 1. It is important to note that while these theories themselves are often

not mutually exclusive and there is much overlap and commonality between them, there are also distinctive elements and some sharp differences between specific schools (Table 1). Indeed, it is precisely this complex set of interrelationships within the literature which makes differentiated patterns of response possible and from which the research aim of exploring such patterns was developed. A close reading of texts associated with each specific leadership theory identified prescriptions associated with each, distilled into a series of statements (‘items’). . The total number of statements was limited to 60 to facilitate respondents’ comparisons,34 statements compiled to form the draft Q-sample. Given the overlap and commonality

Table 1. Schools of leadership theory taught on the MTS programme, and Q-sample statements derived from the literature associated with each. Key reference

Leadership theory 1. Leader focused Trait (e.g. intelligence; self-confidence) Charismatic (traits required to build transformational change) Psychodynamic (insights into personality of self and others) Skills (repertoire of capabilities / competencies) 2. Follower and context Situational (flexibility to subordinate needs) Contingency (selection of leader for a given situation) 3. Exchange – dynamic and reciprocal relations between leader and follower LMX (different leader behaviour towards ‘in-’ and ‘out-’ groups 4. ‘New paradigm’ – affective and cultural dimensions Visionary (envision possible future; garner support) Transformational (secure radical change) 5. Responsive – engage with an evolving external environment Adaptive (shape follower ability to creatively respond) Distributed (leadership as collective, collaborative and mutual) 6. Ethical Servant (leader’s interests subordinated to the needs of followers) Authentic (attends to the emotional register of ‘true’ leadership) Spiritual (‘calling’ towards organisational ends; moral vision and altruistic culture) 7. Post-transformational Performative (identity formation of leader to constrain / enable leader behaviour)


Q-sample statement(s)b

5, 6 7 8 9

1;2;3 1;2;3 1;2;3

1 15, 16, 17, 18, 21 3, 38, 44, 45 9, 10, 52



11, 12


11, 13, 19, 25, 26, 31, 32, 35, 40, 47, 54, 56 2, 14, 6




14 15

1;2;3 1;2;3

16, 18, 21, 17 22, 23, 27, 28, 34, 35, 49, 55, 57, 60

16 17

1;2;3 1;2;3

24, 33, 36, 37, 39 8, 12, 41, 42, 43, 50, 51, 52, 53

18 19 20

1;2 1;2 1;2

15, 19, 29, 30, 48 5, 8, 15, 30, 59 4, 15, 20, 21, 46, 49, 58



3, 45


Refers to the number in the list of Q-sample statements in Table 2. Place in programme: 1 ¼ formal curriculum; 2¼ learning sets; 3 ¼ Personal Development Plans.


Downloaded from at UNSW Library on July 11, 2015



between theories, the statements particularly associated with each theory are indicated in Table 1. In order to ensure that respondents’ made meaningful comparisons, draft statements were reviewed for intelligibility and clarity by trainees attending the first week of delivery of the final educational module of the year intake (n¼30), and their suggested changes were incorporated into the final Q-sample (Table 2). The remaining two-thirds of the year intake (n¼ 62) were invited to take part.

P-sample selection. Participants are sampled from the bounded population of interest, in this case a cohort of NHS GMTS trainees, and may be selected on a naturalistic, purposive or representative basis as appropriate for the specific aims of the study. In contrast to traditional quantitative approaches the emphasis is on the representativeness of the statements to be sorted (the Q-sample) rather than the participants (P-sample); consequently, sample sizes are comparable to qualitative designs with 40–60 considered optimal.35 Consistent

Table 2. Q-sample statements, factor arrays and distinguishing items for each Q-factor. Factor arrays

No. Statement






1 Leaders are born not made 2 leaders generally have a preferred style of leadership 3 Good leaders know their inner selves 4 Leaders should stand up for their principles 5 Leaders should be honest about their feelings 6 Leaders need to be the same person in every environment 7 The relationship between leaders and followers is crucial to success 8 Leaders should build trust and respect with their subordinates 9 Leadership skills can be taught 10 Leaders can improve their abilities through experience and training 11 Leaders should be directive or supportive as required 12 Leaders need to value and develop teams of staff 13 Leaders must adapt their approach to fit the experience and training 14 A leader who is good in one context will not be good in another 15 Leaders need strong moral values 16 Leaders should act as role models 17 Leaders should confidently expect others to meet their goals 18 Leaders should inspire others 19 Leaders should develop others 20 Leaders should encourage others to act for the greater good 21 Leaders need to offer followers a clear vision 22 Leaders need to work with others to develop a shared vision 23 Leaders need to be sensitive to internal and external stakeholders 24 Leaders should trust staff to take decisions 25 Leaders should act a s mentors 26 Leaders should be approachable 27 Leaders should keep in touch with others 28 Leaders should encourage new ways of working 29 Leaders should put aside personal ambition 30 Leaders should be open to criticism 31 Leaders should be equitable in their dealings with staff

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

3 0 0 2 5 5 5 5 1 2 2 1 2 4 4 0 2 5 1 3 3 4 0 2 2 2 1 1 5 2 0

5 4 0 5 4 5 3 3 0 1 3 1 2 4 4 4 4 5 0 2 4 3 0 1 1 2 2 1 2 4 1

5 2 2 0 3 5 5 4 0 3 4 3 5 4 0 1 4 0 2 1 3 4 1 1 1 3 2 2 4 1 2

5 0 5 4 1 5 5 1 1 2 3 3 3 3 2 1 2 3 0 2 2 4 4 1 3 1 2 2 4 1 3

Distinguishing statements For Q-factor # 1 2* 3,4* 2,4

1 2,4* 4* 2*,3* 2*,3 2* 3 1*,3* 2*,3 2,3* 4*

1* 2* 2* (continued)

Downloaded from at UNSW Library on July 11, 2015


Health Services Management Research 26(2–3)

Table 2. Continued. Factor arrays

No. Statement






32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

4 1 3 4 0 1 2 1 4 1 1 3 3 3 4 3 4 4 0 1 2 0 1 3 1 4 1 3 2

5 0 0 1 1 2 4 2 1 0 2 1 2 1 3 4 3 2 3 1 0 3 2 1 3 5 1 2 3

1 0 0 0 1 4 3 1 1 3 2 5 2 3 1 2 3 2 0 4 1 1 1 2 3 5 4 2 4

5 1 0 0 4 2 4 2 0 1 3 0 2 3 5 1 4 1 1 0 4 4 2 4 1 1 2 3 0

Leaders need to be prepared to take difficult decisions Leaders need to respond creatively to problems Leaders need to influence external and internal stakeholders Leaders should clarify objectives Leaders need to balance change and continuity Leaders need to be sensitive to the impact of change Leaders need to know their strengths and weaknesses Leaders should encourage creative problem-solving Leaders should provide recognition / reward when goals are reached Good leaders network and form alliances with others Leaders need to negotiate upwards to secure resources Leadership is performed by many people, not just the boss Leaders need insight into the personalities of others Leaders need insight into their own personality Leaders have a responsibility to fight injustice Leaders should attend to the unique needs of followers The welfare of others is the leaders primary responsibility Leaders need to define priorities Leadership is a collective activity, embedded within a particular context Leadership occurs in and through multiple collaborative relationships Leadership entails reciprocal learning Leadership is build through networks of influence Leaders should create opportunities to stretch others Leaders should challenge existing organisational values Leaders should offer corrective feedback Leaders need to arouse followers need for power or status Leaders need to evoke in others a sense of calling Leaders should act with genuine care towards others Leaders should concentrate on outcomes

Distinguishing statements For Q-factor # 3* 1 1* 1,4*

1* 3* 1,3* 2* 2* 2*,3* 2* 3* 2 3* 4 4 1*,2* 4* 1,3* 4

Variance ¼ 7.700, SD ¼ 2.775, p

Comparing the content of leadership theories and managers' shared perceptions of effective leadership: a Q-method study of trainee managers in the English NHS.

Health service managers face potential conflicts between corporate and professional agendas, a tension sharpened for trainees by their junior status a...
666KB Sizes 0 Downloads 4 Views