1. 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

2. 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.

3. 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)

4. (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)

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

6. 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

7. 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

8. 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

9. 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

10. 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)

11. -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.