**2. Overview of the concept of leadership in the health care sector**

In the health care sector, the term 'leadership' is closely associated, and often used interchangeably, with 'management'. Thus, this section presents an overview of the concept of leadership in the health care sector, drawing upon both management and leadership as both terms are seen as being relevant to health care services.

In a general sense, management entails planning, organising, control, budgeting, implementation, and evaluation; it ensures efficient utilisation of resources to achieve organisational goals [24]. The concept of management has been described as 'unique' in the sense that it has no universal application but rather is dictated by context, that is the policies, structures, and cultural values in which it is practised [25]. There are different schools of thought in management; one such school is the 'traditional' or bureaucratic (scientific) approach to management which emphasises a clear management structure, based on hierarchical chains of command involving workers' control and accountability for performance [26]. A competing school is the human relations approach to management which focuses on involvement of workers in the design of their work (participation, self-governance), motivating workers, satisfying their needs, promoting quality of life at work and managing conflict [27]. Numerous other theories of general management have followed, including institutional theory, open system and resource dependence theories, strategic management perspective, and organisational ecology [27]. These theories are beyond the scope of this chapter. Leadership, on the other hand, revolves around vision, ideas, direction, and inspiration; it establishes direction [28, 29] and motivates others [30, 31] to achieve organisational goals rather than a focus on day-to-day implementation of those goals [24]. According to (Bennis and Nanus [32] p. 21), "managers are people who do things right and leaders are people who do the right thing. The difference may be summarised as activities of vision and judgment (effectiveness) versus activities of mastering routines (efficiency)". Regardless of the differences between management and leadership in terms of roles and functions, both are recognised as important to the attainment of organisational goals and objectives [24].

policies, and advancement in medical and information technologies, also exert profound influences on the health sector [7–9]. Thus, the health care sector undergoes constant reforms arising from the interplay of factors both within and outside its control. Such reforms are necessary to meet the expectations of the population and ensure the delivery of safe, effec-

Effective leadership has been recognised as crucial in shaping organisational culture and driving the implementation of reforms in health care sector. This is evident in the growing interests in the concepts of health management and leadership, especially since the turn of the century, as reflected in the prevalence of studies on health management and leadership across different countries. Countries include Australia [3, 10, 11], Canada [12, 13], Ireland [14], Latin America [15], New Zealand [16], South Africa [17–19], and the United States of America [20–23]. Current interests in health management and leadership are, however, geared towards identification and assessment of essential competencies (that is knowledge, skills, and attitudes) required by health managers and leaders for effective performance in roles. Identification of such competencies is central to initiating appropriate training or professional development to

The purpose of this chapter is to examine the concept of 'leadership' in relation to the health care sector. This is achieved through a review of key studies on health management and leadership to provide contextual understanding of the concept and identify key areas of focus by health care organisations and researchers related to leadership in the health care sector.

In the health care sector, the term 'leadership' is closely associated, and often used interchangeably, with 'management'. Thus, this section presents an overview of the concept of leadership in the health care sector, drawing upon both management and leadership as both

In a general sense, management entails planning, organising, control, budgeting, implementation, and evaluation; it ensures efficient utilisation of resources to achieve organisational goals [24]. The concept of management has been described as 'unique' in the sense that it has no universal application but rather is dictated by context, that is the policies, structures, and cultural values in which it is practised [25]. There are different schools of thought in management; one such school is the 'traditional' or bureaucratic (scientific) approach to management which emphasises a clear management structure, based on hierarchical chains of command involving workers' control and accountability for performance [26]. A competing school is the human relations approach to management which focuses on involvement of workers in the design of their work (participation, self-governance), motivating workers, satisfying their needs, promoting quality of life at work and managing conflict [27]. Numerous other theories of general management have followed, including institutional theory, open system and resource dependence theories, strategic management perspective, and organisational ecology [27]. These theories are beyond the scope of this chapter. Leadership, on the other hand, revolves

enhance individual competence and improve organisational performance [21].

**2. Overview of the concept of leadership in the health care sector**

terms are seen as being relevant to health care services.

tive, and high quality-health care.

84 Leadership

Although management and leadership may represent two distinct disciplinary and practice areas, distinguishing between the two concepts in practice may be difficult [24]. In certain instances, management functions can provide leadership while leadership activities can contribute to managing [24]. Additionally, managers and leaders are expected to function effectively in different situations, not limited by their traditional roles, reflecting the view that they (managers and leaders) are expected to be all things to all people [33]. This view is consistent with that of Bass and Avolio [34] who opined that effective leadership is a reflection of an optimal mix of different styles, including management and leadership practices. Furthermore, the concept of 'distributed leadership' [35], which suggests one does not need to have a formal position of managerial authority to be a 'leader', further renders the debates on management/ leadership dichotomy as less important. Thus, while the distinction between management and leadership arises from the differences in roles and functions, the reality is that a role is often unconsciously chosen and not outlined explicitly in the organisation [36]. A role appears and changes as a result of gaps that need to be filled in the managerial jobs.

Arising from changes in the social context of health care, the dichotomy between management and leadership in the sector is increasingly narrowing [37]. Thus, managers (generalist trained managers, professional health service managers) fill management roles, perform management functions and provide leadership. On the other hand, clinicians (including doctors and nurses) and other professionals with no background in management may move into management roles and provide leadership. One change which has significantly affected the social context of health care is the increasing involvement of clinicians in the planning, management, and organisation of care in line with the concept of clinical leadership. Clinical leadership is provided by clinicians in clinical settings to ensure safe, effective, and high-quality care [38, 39]. Such roles are usually performed in collaboration with non-clinical management or leadership roles and functions. Thus, in the health care sector, a 'managerialism' model, dominated by generalist trained managers, is being replaced by a unified (collective) leadership structure for the effective running of health care services. Such an approach to management is somewhat similar to the concept of 'distributed' or 'shared' leadership (see below), where different actors engage in tasks that are 'stretched' or distributed across the organisation [40].

There are many leadership theories which underlie management and leadership practices; prominent among them is contingency theory. Contingency (or situational) theory emerged in the early 1960s due to inability of previous theories to explain different aspects of leader behaviour [36]. Contingency theory is based on the premise that the behaviour exhibited by a leader varies, depending on the prevailing circumstance or situation [41–44]. According to Smirich and Morgan [45], leadership is a product of interaction between the situation, the leader, and the followers. Other theories which have their roots in contingency theory include transactional and transformational leadership theories, which were introduced by Burns in 1978 [36]. Transactional leaders are associated with contingency rewards (exchange of rewards for compliance) and management by exception (either actively or passively) [27, 36]; they emphasise legitimate power and respect for rules and tradition [46]. In view of the practices associated with transactional leadership, some authors have connected this leadership style with management functions [42, 43, 47, 48]. In contrast, transformational leadership motivates and inspires followers to rise above their personal interest for the sake of the organisation; it empowers employees to participate in the process of transforming the organisation and initiate major changes and reforms [27, 34]. One important outcome of transformational leadership is 'empowerment', which entails sharing of leadership process between the leader and the followers [34, 42]. This feature is consistent with the original idea of Burns that leadership may be exhibited by anyone in the organisation in any type of position [42].

specific needs of each manager in line with his or her dominant management or leadership role [5]. Thus, in addition to identifying core competencies, it may also be useful to identify specific competencies required by certain individuals or members of a professional body for

The Concept of Leadership in the Health Care Sector http://dx.doi.org/10.5772/intechopen.76133 87

Competence is the ability to consistently produce the outcomes (of behaviour) required for effective achievement of organisational goals [57]. In other words, a competent health manager or leader possesses the requisite knowledge, skills and attitudes that enable him or her to manage or lead effectively. The term 'proficiency', or 'competence level', refers to the level of expertise for a particular competency. A 'competency model' is a framework which contains competency statements in which essential knowledge, skills and attitudes desirable for specific roles are described [57], or a collection of competencies required for successful performance [58]. A 'competence model', on the other hand, refers to a framework which describes

Other terms commonly associated with competency are 'capability' and 'capacity'. Capability refers to the process which allows individuals to demonstrate or express the required competencies on their jobs; it is the ease with which the required competencies can be accessed, deployed, or applied by individuals [59]. Capacity, on the other hand, refers to the power or ability of individuals to hold or possess the required competencies at a level considered suf-

As pointed out earlier, several studies have been conducted on health management and leadership. The majority of these focused on identification and/or assessment of essential competencies required by health managers and leaders for effective performance in management and leadership roles. The focus on competencies has been informed by the need to develop strong and competent health management and leadership workforces, given the pivotal roles of leaders from health management and clinical backgrounds in driving changes and leading development in health care organisations. This much has also been recognised by the World Health Organisation, which has advocated the need to strengthen management and leadership capabilities at all levels of the health system [60, 61]. Different approaches are being used to identify and assess essential competencies required by health management and leadership workforces. These approaches include literature review, position description analysis, the Delphi technique, surveys, interview of job incumbents and focus groups. The optimal approach recommended for identification and assessment of competencies involves the use

A major point of contention in health management and leadership is whether competencies are similar across countries and organisational contexts, or are contextually sensitive. While some authors have argued that certain 'core' competencies are applicable to most health contexts [5, 11], others have advocated for more contextually compatible competencies based on the premise that competencies may be influenced by contextual factors such as demographic characteristics of personnel, as well as the size, culture and needs of organisations [12, 22, 63, 64]. Notwithstanding the argument, certain domains of competencies have been identified across several studies as important for health management and leadership roles, regardless of the contexts in which those roles are performed. These domains include communication, interpersonal

of multiple methods to improve the credibility of findings [54, 62].

the process and work outputs required to achieve the set goals of specific roles [57].

effective performance [5].

ficient for a role [59].

Closely related to the notion of 'shared leadership' is a concept known as 'distributed leadership'. As stated earlier, distributed leadership focuses on how actors engage in tasks that are 'stretched' or distributed across the organisation [35]; it sees leadership activities as a situated and social process at the intersection of leaders, followers, and the situation [49]. In practice, leaders from both health management and clinical backgrounds are expected to demonstrate leadership theories as they (the theories) underlie the basis of the knowledge, skills, and attitudes (that is competencies, see below) required by the health management and leadership workforces for successful performance in roles.
