Alignment and variation in managerial and professional perceptions of purpose, leadership roles and outcomes in a healthcare organisations change programme Stiofán deBúrca, University of Limerick September, 2006

Research Objective Identify domain variation and agreement in perceptions of change purpose, leadership and their reported outcomes. Study Design A pluralist [multi-site/level/discipline/ method] ethnographic-type case study that generates six data groups(24 data sets) providing over-arching categories and properties to create an analytic text. A modified Grounded Theory Method is used(Partington,2002). Population Studied Selected Managerial and Professional staff at different levels I.e. corporate, mid-mgt, heads of discipline, and staff in service sites --- acute, general practitioner, elderly and childcare, mental health.

Literature (a)Leading and Managing in a Healthcare Organisation - Context (Osborn et al, 2002; Griffin 2002) - Control (Drucker, 1991; Berry, 1995) - Leading change (Pettigrew et al, 88, 92, Mintzberg, 1983) - Waves of Reforms (Flynn & Strehl, 1996) (b) Domain Conflict - Separate identities (Edmondstone, 1986) - Consequences of hierarchies (Johnson, 1985, Manning `97, Saltman & Figueras, 1997) - Locals and cosmopolitans (Gouldner, 1957/8) - Domains (Kouze & Mico, 1979)

(c) Professions in Management - Clinicians (time, negative peer pressure, poor leadership e.g. : Berwick, 1989) - Nursing (Managerialist discourse : Salvage, 1985) - Hybrids (Bureaucratised : Kitchener, 2000) (Performance : Shipper, 2000) (Creeping Managerialism : Ferlie et al, 1996)

Principal Findings - Domains ExpectationsIndicationsOutcomes Quality Quality/Service Leadership Leadership – Concepts - Attributes - Prototypes Leadership StyleStyle/ChangeStyle/Change Approach Relationships OwnershipOwnership - constraintsOwnership Management PracticePractice Structure

Principal Findings – Domains (a) Expectations Quality -Population (Corp) and Service dimensions (M+P) Leadership -Commitment to organisation vision & values (M+P) -Positive, transforming ideology (M) -Corp. exemplars and transmission of values (P) Indications Quality -Accountability standards/training (Cl) -Holistic -Protocols and Guidelines (HoD) Leadership - Concepts -not in common use -Corp/generic accountability (M) -Clinical responsibility (Cl) -Influence morale and practice (N) -Systemic (M) v Domain (P) Leadership - Attributes - Primary : confidence, trust and teamwork -Secondary : (M) energy, drive, enthusiasm, integrity, participative style (P) vision, respect, good interactive behaviour, awareness of people and communications

Principal Findings – Domains (a) Expectations Style -from autocratic to participative Relationships -Quality linkages (M) Ownership -Empower (M + DN) Management Practice -Improve (M + Staff) Structure -Adapt (M + DN) Indications Leadership Prototypes (i) Change Agent (M+Cl+DN+Ch) (ii) Attractor/Influencer (Snr M, Cl, Nse) Style -Different perspectives -Positive, empowering stakeholders (Corp) -Prescriptive (Mid-Mgt) -CEO hands on/off (C/M) -Situational (M+P) Relationships - Intra-domain tensions Ownership – Constraints - Levels of autonomy and limitations - Systemic, professional and intrinsic - Reluctance (P/M) - Workload, time, peer pressure, cautious, suspicious (P) Practice - Role change, participation and development Structure Acute…. too hierarchical, Comm. Care…. too fluid

Principal Findings – Domains (b) Expectations Quality -Population (Corp) and Service dimensions (M+P) Leadership -Commitment to organisation vision & values (M+P) -Positive, transforming ideology (M) -Corp. exemplars and transmission of values (P) Style - from autocratic to participative Outcomes (M + P) Quality -Initiatives, awards and patient participation -Organisations and Clinical Governance -Improved service provision and infrastructure Leadership -shared Style - participative, delegative, energising

Principal Findings – Domain (b) Expectations Relationships -Quality linkages (M) Ownership -Empower (M + DN) Management Practice -Improve (M + Staff) Structure -Adapt (M + DN) Outcomes Relationships - good stakeholder morale - improvement….intra-domain - differentiated roles/levels Ownership – - Partnership in management and decision processes - Enabled by corporate Style/Delegation - Empowered and enthused staff although constraints Practice - Strategies, plans, performance management involving M + P Structure - Management Levels - Decentralised line and functions - Service Executive Teams - Care Group Mgt… positive

Conclusions Domains -Integrative action starts with a shared vision and goals. -Intra v Inter domain tensions, distance and hierarchy (Kouze & Mico 1979) -Domain shift – clinicians in lybrid or quasi - managerial roles (Kitchener, 2000) Leadership-Prototypes as functions of perceived primary purposes -Concept not in common use -Responsibility defines Leadership - accountability (M) - clinical responsibility (Cl) - professional influence (N) as against social influence process (Yulk 1989)

-Different types and levels of leadership must be connected although varied re. focus, context and primary orientation (Jacobs & Jaques, 2002, Osborn et al, 2002) Constraints – systemic, professional and intrinsic Change-Paradox of empowerment in a bureaucracy -Communications, pace, process, ownership -Diversity, variety and the problem of programmatic change – the need for plurality -Organisational cohesion based on what is shared and connected v control and controllability.