Leadership Evolution in Healthcare

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Prof. Ciaran O’Boyle

It is widely accepted that good leadership is important in ensuring that organisations are effective, efficient and humane, writes Prof. Ciaran O’Boyle.  The culture and climate of an organisation have profound effects on the well-being of the staff and the organisation’s leadership has a major role in defining and setting the culture. Exciting new research has demonstrated the impact on staff engagement, performance and well-being of creating positive organisations in which people not only survive but thrive.[1]

Historically, the predominant style of leadership in healthcare could be described as transactional, a type of hierarchical command-and-control approach in which leaders led and followers followed. In 2011, the King’s Fund produced a commissioned report on leadership in the NHS entitled The Future of Leadership and Management in the NHS: No More Heroes[2].The commission concluded that the NHS needed to “move beyond the outdated model of heroic leadership to recognise the value of leadership that is shared, distributed and adaptive. In the new model, leaders must focus on systems of care and not just institutions and on engaging staff in delivering results.”

As we look to the future of healthcare leadership, the leadership model that is underpinned by the best research evidence is called authentic leadership[3] and it poses four key personal challenges for leaders: (1) Knowing oneself; (2) Doing the right thing; (3) Being fair-minded; (4) Being genuine and compassionate. 

Knowing yourself

The starting point for effective leadership is self-awareness and understanding. This involves knowing one’s strengths and weaknesses and, importantly, one’s mindset – how one makes sense of the world. This type of knowledge can only be gained through reflection and self-analysis but finding the time or inclination to do this, when one is living a busy life, is very difficult. The German poet Rilke describes the challenge of self-awareness thus:

For if we think of this existence of the individual as a larger or smaller room, it becomes clear that most people get to know only one corner of their room, a window seat, a strip of floor which they pace up and down [4]

Many, but not all, leaders arrive at some degree of self-awareness through coping with adversity, through personal development training or, increasingly, by engaging in coaching. In addition to the challenges to their technical knowledge and skills, the widespread and unpredictable nature of the current COVID-19 crisis requires leaders to deploy emotional intelligence, to remain calm, to show humility about what they know and don’t know, and to maintain a sense of hope and optimism. It is also crucially important that leaders’ self-awareness includes monitoring their own physical and psychological health. Burnout is not conducive to good leadership. 

We often see a significant and disappointing gap between the aspirational values an organisation professes and its lived values as expressed in its culture and climate.

Doing the right thing

Authentic leaders strive to regulate their behaviour by behaving ethically. This is also important for organisations. We often see a significant and disappointing gap between the aspirational values an organisation professes and its lived values as expressed in its culture and climate. Ethical leaders do the right thing rather than what is most expedient, simple or cost effective.This requires moral courage and the capacity to rely on one’s own judgement especially in situations where the costs of a dissenting view or decision can be significant. The followers of ethical leaders, knowing that they have chosen to behave in this way, do not have to second guess the leader’s likely response to a situation. This, in turn, generates a high levels of trust and respect. 

Being fair-minded 

This involves objectively analysing all relevant data before making a decision rather than exclusively pursuing one’s own agenda. For example, in leading highly skilled professional staff, the challenge is often to release the collective wisdom of the team. This is likely to result not only in better decisions but is also critical in the development of well-being because followers become more confident and develop an enhanced sense of self-efficacy. The key needs of staff in the workplace are (i) autonomy and control, (ii) belonging and (iii) competence. The greatest contribution a leader can make to helping staff meet these needs it by demonstrating fair-minded compassionate leadership.[5]

Being genuine and compassionate

This involves presenting one’s authentic self through openly sharing information and feelings, as appropriate for situations. Effective leaders show their concern, not only for the tasks in hand but also for their followers’ development and physical and psychological safety. They do this by listening, caring, empathizing and being compassionate, especially during the most difficult times when their people need them most. Remarkable new research is demonstrating the significant impact of compassion on employee engagement, organisational effectiveness and even on the biological substrates of disease and suffering. [6] [7] The important model of compassion at work proposed by Monica Worline and Jane Dutton of (i) attending, (ii) understanding, (iii) empathising and (iv) helping, is very useful here. [8]

Leadership has always been more difficult in challenging times, but the unique stressors facing healthcare organisations at the present time call for a renewed focus on the most appropriate type of leadership. As we move into the future, we need compassionate leadership which, while realistic, is also focused on maintaining confidence, hope, and optimism. We need leaders who are self-aware, lead with integrity and purpose and understand that their most important assets are the people they lead. Most of all, we need leaders who are capable of balancing their technical skills and knowledge with a deep understanding of their people. As the American writer, Maya Angelou said: 

“I’ve learned that people will forget what you did, they will forget what you said, but they will never forget how you made them feel.”

Professor Ciaran O’Boyle, Director RCSI Centre for Positive Psychology and Health and, formerly, Founding Director of the RCSI Institute of Leadership.


[1] Quinn R (2015 ) The Positive Organisation. San Francisco, Berrett-Koehler

[2] The King’s Fund (2011). The Future of Leadership and Management in the NHS; No More Heores.https://www.kingsfund.org.uk/publications/future-leadership-and-management-nhs

[3] Avolio B. J., & Walumbwa, F. O. (2014). Authentic leadership theory, research and practice: Steps taken and steps that remain. In D. V. Day (Ed.), Oxford library of psychology. The Oxford handbook of leadership and organizations (p. 331–356). Oxford University Press.

[4] Rilke RM, 1875-1926. (1992). Letters To A Young Poet. San Rafael, Calif. New World Library.

[5] West M and Copia D. (2019). Caring for doctors caring for patients. London, GMC: gmc@gmc-uk.org

[6] West, M. S., & Chowla, R. (2017). Compassionate leadership for compassionate health care. In P. Gilbert (Ed.).Compassion: Concepts, Research and Applications. London: Routledge, 237-57. 

[7] Trzekiak S, Mazarelli A. (2019). Compassionomics: The Revolutionary Scientific Evidence That Caring Makes a Difference. Penscola, Studer Group.

[8] Worline MC, Dutton JE (2017). Awakening Compassion at Work: The Quiet Power That Elevates. San Francisco: Berrett-Koehler Publishers.