Writer’s choice

The assessment is in two parts:

A 2000 word essay analysing a current educational leadership issue and applying at least three models and theories to the analysis.
2. A 1000 word reflective account of your leadership ‘journey’, discussing the learning from the course and lessons learned through practice.
Both parts should be fully grounded in and referenced by relevant literature.

I have attached 2 assignment samples, which can be used as a guideline for you. Also, I have attached the summary of the course which can help you to get all the resources that you might need and to have a better understanding of this course and its requirements.

My current position is acting head of the Basic Cardiac Sciences unit.
Please feel free to contact me at any time if you need more information.

Module Details

MED 507

Leadership and innovation in Medical Education


Section 1                     Outline and learning outcomes

Section 2                     Introduction to leadership

Section 3                     Followership

Section 4                     Personal skills and qualities

Section 5                     Resilience& Emotional Intelligence

Section 6                     Leadership styles and situations

Section 7                     Working in teams and managing change

Section 8                     Complexity thinking and adaptive leadership

Section 9                     Collaborative leadership theories

Section 10                   Quality improvement and Innovation

Section 11                   Summary, references and follow up activities/readings


Section 1

Outline and Learning Outcomes

“Leadership is a journey, not a destination. It is a marathon, not a sprint. It is a process, not an outcome”. (Bill George, quoting John Donahoe, 2010)

Learning outcomes

 After completing this course you should be able to:

  • Define core leadership theories;
  • Differentiate between educational leadership, management and followership activities and skills;
  • Recognise various types of leadership behaviour in practice;
  • Use the theory and examples to improve your leadership performance and set your own development goals.


Leadership is vitally important to organisational and team effectiveness and in all contexts, huge emphasis is now placed on developing and supporting leaders. Leadership can be learned and many development opportunities are now available. An understanding of theories and concepts helps develop a deeper insight into good and poor leadership. This session is designed to explain and explore various aspects of leadership, management and followership as applied to health professions’ education. This module aims to introduce students to educational and clinical leadership, management and innovation theories, approaches and practice.


The assessment is in two parts:

  1. A 2000 word essay analysing a current educational leadership issue and applying at least three models and theories to the analysis.
  2. A 1000 word reflective account of your leadership ‘journey’, discussing the learning from the course and lessons learned through practice.
  3. A summary of your key learning points from the course and how you will put these ibto practice (no word limit)

Both parts should be fully grounded in and referenced by relevant literature.

Section 2

 Introduction to leadership

 “A leader takes people where they want to go. A great leader takes people where they don’t necessarily want to go, but ought to be.” (Rosalynn Carter)

Although there is a broadly chronological aspect to how the leadership and management literature has evolved, many of the earlier concepts and models are still very relevant and widely used. We might think of leadership as about setting and communicating a vision, about working with people and managing relationships:

It involves a way of thinking and behaving so that people see you as a leader. Authentic leaders are those who stay true to themselves, to their vision and values, but who are also in tune with what other people and organisations want. More recently in education and health we have moved away from thinking that leadership is just about individual leaders (their qualities, attributes, personalities, styles and emotional intelligence) to looking at leadership as a process which involves networks, complexity, collaborations, power-sharing, social accountability and awareness. This has led to leadership development focussing as much on developing leadership capacity in organisations, professions or sectors as it does on providing courses for individuals. In healthcare, we are starting to talk about collaborative and collective leadership as a way of engaging doctors, health professionals, managers and patients in improving and sustaining health outcomes (Eckert et al, 2014).


Looking at the leadership approaches, features and assumptions listed in the table, find an example of each of the approached from your own experience, the medial, politics, literature, etc.


Leadership approach Key Feature Key Assumptions
Trait Theories Personality based, heroic leader, ‘great man’, resides in individual leaders’ qualities Leaders are born, not made
Task vs team, styles Managing is a balance between task, team and individual Leaders are managers, others’ behaviours can be modified
Contingency theories

Situational leadership

Leaders’ styles and behaviours are contingent on the situation Leaders’ behaviours can be modified
‘New paradigms’ – transformational, charismatic Leaders’ can transform people/organisations through a mix of personality and ‘people work’ The individual leader is essential to organisational success

Leaders can ‘learn leadership’

Followership Followers are as important as leaders Followers and leaders together co-create what leadership entails
Servant leadership The leader wants to serve first and make a difference That leaders’ values are aligned with the organisation
Authentic, value based, moral leadership Followers value leaders who are consistent and authentic Leaders own values are important
Adaptive leadership Leaders need to adapt to and be comfortable working in complex situations in order to drive organisational change Leaders work within complex, organic systems

Those in the system have ‘agency’

Distributed or dispersed leadership Leadership is at ‘all levels’ of an organization Leadership is a process, building social capital important
Collaborative, collective, shared leadership Leadership is about working together to achieve shared goals and outcomes The more power we share, the more power we have to use
Eco-leadership Leadership needs to be carried out in relation to the wider environment Sustainability and social accountability important


‘Leadership in threes’

The ‘Leadership in 3s’ model (McKimm et al, 2016) is a useful framework which synthesises and summarises key aspects of leadership. We will go on to discuss each of these aspects in this module.


The table summarises some of the predominant leadership approaches and development activities and we can cluster these as follows, first under three levels.


On the top left of the framework is a helpful conceptual framework that describes leadership theories and development in terms of three levels (Swanwick and McKimm 2014):

  • The intrapersonal – those which relate to you as an individual, your personality traits or charisma;
  • The interpersonal – working with others, for example in teams, relational leadership;
  • Organisational or system – this includes senior/strategic leadership, but also aspects of complexity theory and systems thinking.



Many formal opportunities exist for educators to ‘learn leadership’ through short course, workshops and longer award bearing programmes.  Such ‘horizontal leadership’ (Petrie 2014) provide an evidence base (in terms of theories, concept, models and tools) about what leadership is, how it works and ways of approaching situations or tasks.  However, it is only through practice, obtaining constructive feedback and reflection that you will learn for yourself how to lead, follow and manage effectively.


This involves ‘vertical leadership’; meeting challenges (‘heat experiences’); ‘sense-making’ of the experience (through reflection and conversation) and being open to ‘colliding perspectives’ about what is going on (Petrie 2014, 2015).


‘Heat Experiences’: opportunities that disrupt a leaders’ habitual thinking and should be designed, within their competency levels, to stretch the leader beyond their comfort zone and into new, more advanced models of thinking.


‘Colliding Perspective’: occur within ‘heat experiences’ to develop the leaders’ thinking further.  Ideally, exposure to professionals with different views, backgrounds and thinking should be incorporated.  This is vital within education and healthcare where leaders often interact with wide ranging multi-disciplinary teams across organisational boundaries.


‘Elevated Sense Making’: should incorporate time for reflection, coaching and mentoring.  This allows for greater development and integration of the learning from heat experiences and understanding gained from colliding perspectives.  Utilised effectively this develops a wider and more in depth view.


Learning leadership is therefore a lifelong endeavour: good leaders have learned from their experiences and gained a practical wisdom (phronesis) about how to behave and function in different situations.


All leaders (at whatever level or role) need to have credibility, which can be developed in three ways:

  1. By understanding your industry – for us this is medical or health professions’ education. As educationalists, leaders need to understand how education systems, structures, funding and programmes work and possess a theoretical educational knowledge.
  2. Understanding your strengths and weaknesses helps you to build effective teams and structure your leadership development.
  3. Understanding the wider sociocultural, political and economic context will help you keep abreast of trends and policies that might affect the education you provide and help you identify and seize opportunities.

Becoming an expert in your area, project or initiative, also helps to build your credibility, particularly when your power and influence is relatively low because of position in the organisation and professional hierarchies (Till et al., 2014)


‘Managers are people who do things right, leaders are people who do the right thing’ (Peter F. DruckerEssential Drucker: Management, the Individual and Society, 2001)


In the centre of the ‘Leadership in 3s’ model lie three core areas of activity: leadership, management and followership.


Early leadership theories often made a distinction between leadership, management, and administration (Zaleznik 2004). Leadership was seen as: strategic, articulating a vision, and setting direction, promoting change and movement, aligning people, motivating, and inspiring creating new paradigms and challenging systems whereas management was seen as operational, promoting order, stability, and structure (Kotter, 1998); concerned with planning, budgeting, setting rules and procedures, problem-solving and working within existing paradigms. Administration was seen as part of the bureaucracy that made things happen for clinicians or academics, similar to management. However, whilst management and leadership activities are different, in practice leaders do both.


Rich et al (2008) describe the qualities needed of medical school deans under the broad headings of management skills, leadership skills, knowledge, and attitudes. It is this broad approach that we take now because trying to distinguish between management and leadership can lead to problems between those deemed ‘managers’ and ‘leaders’. For example, we see tensions between academics or clinicians (who just want to get on and teach or practice clinically) and administrators who are seen as imposing (sometimes unnecessary) quality assurance processes.


In clinical contexts, ‘managers’ can be seen as ‘on the dark side’ imposing targets and forgetting the complexity of patients’ needs. Leaders, whatever their position, need to weave leadership and management activities together. In terms of management: to enable the organization or programme to be high quality and financially viable; to operate within legal and regulatory constraints and to meet multiple stakeholders’ demands. However, leadersalso promote innovation through change, motivation of people, communication, and enactment of a positive vision for the future.


It is now accepted that leadership and management are inseparable although one difference between them is their orientation to organizational change. Fulop and Day (2010) describehis as ‘hybridity’ where both individual and collective, or distributed, leadership exists, and the hybrid professional manager has a crucial role. Universities and healthcare organizations are structured hierarchically, even though some flattening of organizations has occurred with matrix management structures designed around functional units (e.g. marketing, admissions, or operating theatres). Leading and managing in education and health is challenging because much of the workforce comprises professionals who value and demand relative autonomy and power to make professional decisions.


Mintzberg (1992) suggests that professional organizations are managed by a small ‘strategic apex’ (e.g. senior management team), assisted by a ‘supporting technostructure (systems, procedures, processes) and staff (support, administrative staff)’ through a small middle line (directors, managers, heads of department) who themselves manage a large operating core of professionals. Effective leaders understand the purpose and methods of management (including budgeting, managing people, quality management, and service/programme delivery) and either learn these skills themselves or ensure that their team equips itself with these skills. Leading professionals is challenging, involving power relations and balancing allowing autonomy with control.

As leaders need to be managers too, or at least understand management concepts, a management tool such as the McKinsey’s 7S model (see can help a leader focus on the interrelated elements within an organizational system that need to be attended to when implementing the strategy (Waterman et al, 1980).

The 7S model categorizes elements as either hard or soft; all elements relate to one another—change in any one of them will influence the other elements directly or indirectly.


Taking a recent project or initiative at work, how do you think the 7S model could help explain its success or limitations?See the site where it discusses the 7S modeland how it might be used in practice.


Other useful management tools, particularly when thinking about change, include:

  • SWOT (where the organization’s internal strengths and weaknesses are mapped against the external opportunities and threats)
  • PESTLE (a tool used to consider external factors from political, economic, socio-demographic, technological, legal, and environmental perspectives)
  • Lewin’s Forcefield analysis
  • options appraisals
  • risk analyses
  • project management tools

See JISC-INFONET  which has a range of useful management tools including those above.

Key points

  • Leadership theories consider the intrapersonal, interpersonal, organisational and systems levels
  • Traditionally, leadership studies have been focussed around individual leaders, now there is consideration of leadership as a process, the importance of followers and relational aspects of leadership
  • In education and healthcare, there has been a shift towards collective and collaborative approaches to improving services and attending to the users’ needs


Drucker, P. F., & Wilson, G. (2001). The essential drucker (Vol. 81). Oxford: Butterworth-Heinemann.

Eckert R, West M, Altman D, Steward K, Pasmore B (2014) Delivering a Collective Leadership Strategy for Healthcare. The King’s Fund, London, UK

Fulop L, Day GE. (2010) From leader to leadership: clinician managers and where to next?  Australian Health Review.  Aug 25; 34 (3): 344-51.

Kotter JP (2014) Accelerate. Harvard Business Review Press: Boston, Massachusetts, USA

Kotter J (1995) Leading Change: Why transformation efforts fail. Harv Bus Rev.March-April: 1–20

Mintzberg H, Westley F(1992) Cycles of organizational change.  Strategic management journal, 13(s2), 39-59

Petrie N (2015) The how-to of vertical leadership development – part 2.  Centre for Creative Leadership, available from

Petrie N (2014) Vertical Leadership Development–Part 1 Developing Leaders for a Complex World. Center for Creative Leadership. Accessed at:

Petrie N (2014) Future trends in leadership development.  Centre for Creative Leadership available from

Rich EC, Magrane D, Kirch DG (2008) Qualities of the medical school dean: Insights from the literature. Academic Medicine, 83(5), 483-487

Swanwick, T and McKimm, J (2014). Faculty Development for Leadership and Management, in Steinert, Y (ed) Faculty Development in the Health Professions: A focus on research and practice. Dordrecht: Springer

Till A, Pettifer G, O’Sullivan H, McKimmJ  (2014) Developing and harnessing the leadership potential of doctors in training, British Journal of Hospital Medicine, 75 (9) 281-285

 Waterman RH, Peters TJ, Phillips JR (1980) Structure is not organization.  Business Horizons, 23(3), 14-26

Zaleznik A (2004) Managers and Leaders: Are they different? Harvard Business Review, January, 1-5

Section 3




He who cannot be a good follower cannot be a goodleader’.  Aristotle


Followership is gaining in momentum as a research topic. Just as now the study of leadership is distinguished from management, (when once it was considered a sub-set of management); now more attention is being paid, not just to leaders themselves, but on the relationship between leaders and followers.  Now leadership is seen as comprising a balance between management, leadership and followership activities.


It is suggested that followers actually shape leaders behaviours, even their very existence, because there would be no leaders without followers.  For decades, most of the literature on leadership and management has taken the role of the ‘follower’ to be at best fairly passive, or in many cases followers are absent from the literature and research studies. These are termed ‘leader-centric’ approaches. Although we know that leaders cannot exist without some sort of followers, the literature has been so focussed on leaders themselves that followers have not been researched into much at all.

Since the mid 2000’s, writers have looked at followership from various perspectives, from Kelley’s (2008) work looking at typologies of followers, Kellerman’s work on followers’ engagement with organisations and activities (2008) , through to more recent work on the leader-follower relationship and dual influence. Increasing attention is being paid to followers, not only to their activities and typologies in respect of how leaders can best ‘manage’ followers but more recently suggesting that followers are more highly influential on leaders’ behaviours and success than previously thought.  What is interesting and relevant in terms of healthcare educators and leaders is the very recent focus on leaders’ and followers’ social identity formation.



Take a look at this video on YouTube



Recent research has shifted from a focus on individuals to exploring followership behaviours as they help to co-construct leadership processes, these include the social identity and relational approaches (Hogg, 2001; Uhl-Bien, 2006) and complex adaptive leadership (DeRue, 2011). These theories see leadership and followership as socially constructed processes, mediated through relational interactions between people (Oc and Bashshur, 2013). The organisation is therefore best understood in terms of a complex, dynamic system. Hollander (2012) suggests that from this perspective, the leader is part of the collective leadership process (and may be highly influential) but is only one of possibly many individuals involved. From a systems perspective, leadership is the product of the interaction between leaders’ and followers’ self-schema, culture, and relational, information-processing and task systems. Understanding this complexity is essential if organisationsare able to support both leaders and followers to deliver required culture shifts. Followers may need to be prepared to follow non-traditional leaders as work patterns and roles change, leaders may need to be adaptive and change their ways of working to attract, motivate and retain a range of different followers and all may need to be able to shift rapidly between both leader and follower roles as leadership becomes more collective and dispersed.


Implicit leadership theories

A set of theories that help explain the phenomenon of the personality based theories and the way in followers see leaders are the implicit leadership theories (ILTs). ILTs suggest that followers have preconceived beliefs and schemata for leadership behaviour that influence their perception of ‘good’ and ‘bad’ leaders. These schemata or prototypes are developed through experiences, the media and socialisation and are used to match leaders’ behaviour or attributes against. These ‘folk theories of leadership’ (Sivasubramaniam et al, 2002) are highly influential in shaping followers’ acceptance and tolerance of different types of leader (Uhl-Bien et al, 2014).

ILTs help to explain some of the struggles faced by leaders who do not ‘fit’ into their followers’ schemata, based not on leadership skills but on general attributes such as gender, profession, sexuality, disability, age or race. In practical terms, this means that some leaders may have to work much harder to overcome deeply held (but not always articulated) beliefs about what leaders should look like and behave. Over time as education and health professionals (and their leaders) are drawn from a more diverse pool and leadership is dispersed at all levels of organisations, these attitudes should change.



How does your thinking about leadership shift if you consider management and followership activities as well?

If you consider your day-to-day work, what proportions of each do you think comprises your activities?


Key points

  • Being able to work in and lead teams is a key leadership skill
  • Understanding more about what makes teams work and how you work in teams can help a team be more productive
  • The relationship between leaders and their followers is more than a simple one way, it is relational and followers help co-create leaders
  • The Implicit Leadership theories help explain why some leaders become leaders and others struggle and why leaders usually become time-expired





DeRue, D. S., Nahrgang, J. D., Wellman, N. E. D., & Humphrey, S. E. (2011). Trait and behavioral theories of leadership: An integration and meta‐analytic test of their relative validity. Personnel Psychology64(1), 7-52.

Hogg, M. A. (2001). A social identity theory of leadership. Personality and social psychology review5(3), 184-200.

Hollander, E. (2012). Inclusive leadership: The essential leader-follower relationship. Routledge.

Kellerman B (2008) Followership.  How followers are creating change and changing leaders.  Harvard Business School Press, Boston.

Kelley RE (2008) Rethinking followership.  The art of followership: How great followers create great leaders and organizations, 5-16.

Oc, B., &Bashshur, M. R. (2013). Followership, leadership and social influence.The Leadership Quarterly24(6), 919-934.

Sivasubramaniam, N., Murry, W. D., Avolio, B. J., & Jung, D. I. (2002). A longitudinal model of the effects of team leadership and group potency on group performance. Group & Organization Management27(1), 66-96.

Uhl-Bien, M., Riggio, R. E., Lowe, K. B., & Carsten, M. K. (2014). Followership theory: A review and research agenda. The Leadership Quarterly25(1), 83-104.

Uhl-Bien, M. (2006). Relational leadership theory: Exploring the social processes of leadership and organizing. The Leadership Quarterly17(6), 654-676.

Further reading

Gibbons A, Bryant D (2013) Followership: the forgotten part of leadership.  Casebook, Vol 21, Issue 2

Section 4


Personal skills and qualities

“It is a curious thing, Harry, but perhaps those who are best suited to power are those who have never sought it. Those who, like you, have leadership thrust upon them, and take up the mantle because they must, and find to their own surprise that they wear it well.” 

  1. K. Rowling, 2009.


Nothing has been more discussed and debated than leader’s personal qualities, whether these are innate or can be learned and what the ‘core’ personal qualities are, both of effective leaders and those who are more destructive or ‘toxic’. In the Leadership in threes model, we define three key qualities distilled from the literature, but it is also useful to consider some elements of the debate first before we discuss those.


Are leaders born or made?

Much of the early work on leadership focussed on the way the leader looked and behaved, based on a combination of their position in society and/or their personal qualities. It was considered at one time that people were born with such leadership qualities, that they were somehow innate. However, whilst individuals might have certain personality traits or preferences, many leadership skills and behaviours can be learned and developed. Some leaders are ‘born’ into positions of power and authority (such as in some tribal societies, religions or the monarchy) whereas others become leaders through virtue of their profession or position (e.g. military, religious or organisational leaders). ‘Great leaders’ are those who combine a number of the positive traits associated with leadership and who come to represent a certain time in history or set of circumstances (Mandela, Clinton, Ghandi for example). Because many of these great leaders have been men, and are often seen as having heroic traits, these theories are sometimes referred to as the ‘Great man’ or ‘heroic’ theories of leadership.


Trait theories

Although trait theory has been criticized, there is increasing evidence that certain personal qualities in leaders can have an impact on personal effectiveness and leadership success. For example, Zaccaro (2007) identifies studies that showed a link between such attributes as optimism, proactivity, adaptability and nurturance. The paper also identifies a meta-analysis of 78 studies that linked one or more of the ‘big five’ personality factors (extroversion, conscientiousness, neuroticism, openness and agreeableness) to leadership. Although extroversion showed the strongest correlation, openness was also positively correlated and being open to different experiences and people. Zaccaro (2007) lists several personal qualities where there is some form of evidence linking that quality and effective leadership:


  1. Cognitive capacities: general intelligence, creative thinking capacities;
  2. Personality: extroversion, conscientiousness, emotional stability, openness, agreeableness, Myers–Briggs type indicator preferences for extroversion, intuition, thinking and judging;
  3. Motives and needs: need for power, need for achievement, motivation to lead;
  4. Social capacities: self-monitoring, social intelligence, emotional intelligence;
  5. Problem-solving skills: problem construction, solution generation, metacognition;
  6. Tacit knowledge

(Zaccaro, 2007).


Charismatic and transformational leadership

Charismatic leadership combines personality traits with an additional ‘something’ that draws followers to a leader. These leaders are typically charming, attentive to people and have many of the traits of transformational leaders: visionary, articulate, good communicators, motivating, inspiring and sensitive to others’ needs (Conger and Kanungo, 1998). Some of these skills can be learned and acquired, particularly if you can obtain honest, constructive feedback on your performance. However charismatic leaders can be more concerned with themselves than in transforming organisations and this can lead to their downfall. Leaders who fail to be authentic or value-led, or who lose touch with what their followers want or need, can also fall out of favour.



Take a look at for advantages and disadvantages of charismatic leadership.


The idea of transformational leadership is highly pervasive throughout the world, summarised by Bass as the ‘4I’s’:

  • Idealised influence – being a positive, value-led role model to others, Walking the walk and leading from the front when needed;
  • Inspirational motivation – motivating and inspiring others to work hard for the betterment of the cause or the organisation;
  • Intellectual stimulation – providing challenge and an ‘edge’ to people so that they perform to the very best of their ability;
  • Individualised consideration – paying attention to individuals as well as the team.



Take a look at this presentation about transformational leadership


The concept of transformational leadership starts to combine personal qualities and behaviours with charismatic leadership and a high degree of emotional intelligence. Critics point out that there is little evidence of transformational leadership working, because leadership is a process that is much more complex than simply resting on one leader’s activities and personality (however wonderful they may be). This brings into play the idea that leaders are fallible, they are ‘of their time’ (and thus can become time expired) and that their leadership identity and presence is created and maintained by their followers as we discussed earlier.



Read the article ‘How to be a Transformational Leader: Additional Theories and ideas to get you there’



Toxic or destructive leadership

Most leadership theories focus on the positive aspects of leadership and on how we develop the positive leadership characteristics that will transform education and health services.  However, we need to keep in mind the impact of dark personality and toxic leadership and find ways to mitigate its effects when we find it.  Some attention has been paid to destructive or toxic leadership; Lipman-Blumen(2006) even suggests that it can be ‘alluring’. However when these traits and behaviours get out of hand, perhaps due to the leader’s underlying personality, then there is real risk to the leader themselves (they may be sacked or disciplined), to the followers (who become stressed, scared and submissive) and to the organisation, which suffers because of the leader’s reputation and actions. Leaders can also be destructive when they don’t have the skills or competence to carry out their job properly, yet won’t admit it.


The ‘Dark Personality’ in leadership is defined as the subclinical level of the personality characteristics of the ‘Dark Triad’: Narcissism, Machiavellianism, and Psychopathy (Paulhus and Williams, 2002).  Narcissism is derived from Narcissistic Personality disorder which is diagnosed on criteria such as a sense of entitlement, requiring excessive admiration and a belief that the person is special (American Psychiatric Association, 2013).  According to Babiak and Hare (2006)  “Narcissists think that everything that happens around them, in fact, everything that others say and do, is or should be about them” (p. 40). Interestingly, there appears to be a relationship between narcissism and leadership emergence but not leadership effectiveness (Grijalva et al 2015) and this illustrates one of the dilemmas of the dark triad – that at first there may be positive outcomes with these personalities –narcissists may seem charismatic, dynamic and confident until the ‘dark side’ emerges.


Maccoby (and others) discuss the leader who has a narcissistic personality type: ‘productive narcissists’ are larger than life, good orators, visionary, creative strategists, motivating and inspiring. However, there is a dark side to narcissistic leaders, they can be prone to grandiosity, ‘emotionally isolated and highly distrustful. They’re usually poor listeners and lack empathy. Perceived threats can trigger rage. The challenge today—as Maccoby understood it to be four years ago—is to take advantage of their strengths while tempering their weaknesses’.

For more, read this 2004 online article from the Harvard Business Review


Jones and Paulhus (2011) describe Machiavellianists as being motivated by “cold selfishness and pure instrumentality” (p. 93) While Machiavellianism does not seem to be related particularly to the emergence or effectiveness of leadership,  the main issue is that  Machiavellianism is related to unethical behaviour (such as cheating, lying and betrayal)as well as persuasion, making it problematic in the workplace. There seems to be less of an ‘upside’ to Machiavellianism and less clear evidence of its impact on leadership.  Babiak and Hare (2006) describe the psychopath as being “without conscience and incapable of empathy, guilt, or loyalty to anyone but themselves” (p. 19). Psychopaths (being clear that we are referring to sub-clinical levels of psychopathy) are likely to be attracted to positions of influence and thus might be slightly over-represented in leadership, however, the potential damage done by psychopaths in positions of power are huge.  As with narcissism, it has been argued that some characteristic of psychopaths are linked to positive outcomes such as communication skills, but psychopathy is seen as mainly toxic (Smith and Lilienfeld, 2013).


Padilla et al (2007) developed the toxic triangle to show how it is not just the characteristics of individual leaders that should be considered but also focus on the confluence of leaders, followers and circumstances.

Key points

  • Whilst leaders can develop themselves and modify behaviours, their personality also influences how they behave and interact with others;
  • Transformational and charismatic leadership are positive approaches, although both still emphasise the leader’s personal qualities;
  • Toxic or destructive leadership can be personality based or related to a lack of skills or competence;
  • The ‘dark side’ of leadership is also typically personality based, usually at the sub-clinical level of psychopathy, narcissism and Machiavellianism (the dark triad).



Babiak, P., & Hare, R. D. (2006). Snakes in suits: When psychopaths go to work. New York, NY: Regan Books.

Conger JA, Kanungo RN (1998) (eds) Charismatic leadership in organisations. Sage Publications: Thousand Oaks, CA

Grijalva, E., & Newman, D. A. (2015). Narcissism and Counterproductive Work Behavior (CWB): Meta‐Analysis and Consideration of Collectivist Culture, Big Five Personality, and Narcissism’s Facet Structure. Applied Psychology64(1), 93-126.

Jones, D. N., &Paulhus, D. L. (2011). The role of impulsivity in the Dark Triad of personality. Personality and Individual Differences51(5), 679-682.

Lipman-Blumen, J. (2006). The allure of toxic leaders: Why we follow destructive bosses and corrupt politicians-and how we can survive them. Oxford University Press

Maccoby M (2004) Narcissistic leaders: The incredible pros, the inevitable cons.  Harvard Business Review, 82(1) 92-101.

Paulhus, D. L., & Williams, K. M. (2002). The dark triad of personality: Narcissism, Machiavellianism, and psychopathy. Journal of research in personality36(6), 556-563.

Rowling JK (2009) Harry Potter and the Deathly Hallows, Arthur A Levine Books

Smith, S. F., & Lilienfeld, S. O. (2013). Psychopathy in the workplace: The knowns and unknowns. Aggression and violent behavior18(2), 204-218.

Zaccaro, S. J. (2007). Trait-based perspectives of leadership. American Psychologist62(1), 6.

Section 5


Resilience& Emotional Intelligence


‘Knowing yourself is the beginning of all wisdom’ Aristotle


Resilience is fundamental to physiological and psychological survival and is closely linked to the way we cope with and manage stress and how we see and address risk.  Resilience is a key component of leadership – being able to ‘bounce back’ is central to be able to recover from setbacks, from failures and from uncomfortable situations.  Rutter (2010) also suggests that self-esteem, having confidants and being aware of and being able to deal positively with negative ‘chains of events’ is important but also to remember that an individual might deal with adversity very well in once aspect of their life or at one time, but not others.  Cooper et al (2013) suggest that resilience comprises four interlinked components, each of which can be developed:

  1. Confidence
  2. Social support
  3. Adaptability
  4. Purposefulness


People vary as to their tolerance of adverse events affected by their developmental stage (this might be at stage of career as well as biological development), their previous experiences and the way they and others construct the event and responses to it.  Social identity, work and cultural management are central processes to coping.  It can be difficult for new or ‘junior’ leaders to take on leadership when they are not seen necessarily as having a leadership role or position.  So, staying positive and resilient is key to achieving longer-term success (McKimm et al, 2016).  The adaptive leader who can work with ambiguity, messy complexities and uncertainty is key to resilient leadership.

To stay resilient it is important to have a safe place for reflection, restoration and reconstruction (e.g. through supervision, mentors, support people) especially when leaders are under (or feel under) threat.  In work, you need to be able to identify and attribute stressors – this may involve organisational critique.  Resilience is a means of reducing organisational exposure to risk – so be alert to concerns and monitor stress levels, such as through the annual NHS survey.


From a personal point of view, being able to identify the personal impact events is important and in particular, separating ‘what is me’ and ‘what isn’t’, instead of taking total responsibility for everything.  This is where a good friend or colleague who know you can help to give some perspective.  Finally, be aware that a positive adaption to adversity can in itself be risky behaviour and you can end up like the ‘boiling frog’, see here for more about the parable:


Emotional intelligence

Daniel Goleman (and others) suggests that effective communication is predicated on a high emotional intelligence (EI) (2000, 2007).  EI is basically the way that we utilise our emotions to adapt and respond to situations, particularly those which in earlier times would have stimulated a ‘flight or fight’ response.  So, for example if we encounter a situation or person who scares us or makes us angry, in modern society we cannot simply run away, fight them or ‘freeze’, we need to modify and control our emotions.


Goleman’s 5-point framework (2007) sets out five main components of EI:

  • Self-awareness– understanding yourself, your strengths and weaknesses and how you appear to others
  • Self-regulation – the ability to control yourself and think before you act
  • Motivation – the drive to work and succeed
  • Empathy – understanding other people’s viewpoints
  • Social skills– communicating and relating to others

We need a combination of all five of these to function with a high emotional intelligence. Getting feedback and learning more about our strengths and areas for improvement can help develop better EI. The more we understand ourselves and what drives and motivates us, the better we can lead, support and help others.



Here is an instrument which helps you identify strengths and areas for development in relation to Emotional Intelligence. Take the quiz and then develop some action points to develop your EI. If you can, get some feedback on your results from a trusted colleague or friend.  This quiz is from the Hay Group which works with organisations on professional development and with Daniel Goleman



In many professions, there is an increasing emphasis on acknowledging the impact of ‘emotional labour’ – ‘a requirement to produce emotional states in others or exercise a degree of control over the emotional activities of others’ (Crawford, 2009). The more congruent and authentic leaders’ emotional displays are, and the more skilfully they can use affect (expressed emotion), the more at ease they are with their actions and have more impact on those around them. ‘Leaders and followers constantly balance the tensions between rational thought, emotion and intuition’ (Held and McKimm, 2011).



The concept of ‘grit’ has been described by Angela Duckworth in her psychological research (2016).  Although it is similar to resilience, it is described more like a personality trait that EI and resilience are, and seems to be fairly stable in individuals over time.  Gritty individuals do not require immediate feedback on their work as their internal drivers keep them focussed and determined over the long periods, even when they experience failure and adversity.

Along with resilience and hard work, the key components of ‘grit’ are:

  • Purpose: a clear sense of purpose and direction about your life and how your work contributes towards achieving long term goals
  • Passion: a passion for your work which excites and motivates you and is the driving force for ‘doing what you do’
  • Perseverance and determination: the ability and strength of mind to persevere when things get difficult


Key points

  • It is important to have a safe place for reflection, restoration and reconstruction especially when leaders are under (or feel under) threat.
  • Staying positive and resilient is key to achieving longer-term success


Crawford, M. (2009). Getting to the heart of leadership: Emotion and educational leadership. Sage.

Cooper C, Flint-Taylor J, Pearn M (2013) Building resilience for success: A resource for managers and organisations, Palgrave Macmillan

Duckworth A (2016) Grit: The power of passion and perseverance.  Simon and Schuster

Goleman D (2007) Social Intelligence.  Random house

Held, S and McKimm, J. ‘Emotional Intelligence, Emotional Labour and Affective Leadership’ in Preedy, M, Bennett, N and Wise, C (eds) Educational leadership: Context, strategy and collaboration, Sage/Open University Press, ISBN: 978-1-44620-1640, 2011

McKimm J, Forrest K, Thistlethwaite J (2016) Medical Education at a Glance.  Wiley Blackwell, Chichester (in press)

Rutter M (2010, 1987) Psychosocial Resilience and Protective Mechanisms.  American Journal of Orthopsychiatry, 57: 316-331. Doi: 10.1111/j.1939-0025.1987.tb03541.x

Section 6

Leadership styles and situations

“The challenge of leadership is to be strong, but not rude; be kind, but not weak; be bold, but not bully; be thoughtful, but not lazy; be humble, but not timid; be proud, but not arrogant; have humor, but without folly.” – Jim Rohn, entrepreneur, author and motivational speaker

Situational leadership, the emergence of the contingency theories and a focus on behaviours and styles developments from the 1930s onwards emerging from the realisation that trait theories did not really help leaders who didn’t have the requisite personal qualities. This shift started the thinking that leadership might in some way be able to be learned rather than based purely on position, heredity or personality traits.


One set of these theories were the behavioural theories which focus on how leaders behave. For instance, some leaders dictate what needs to be done and expect cooperation whereas others are more involving of their teams in decision-making to encourage acceptance and support. In the 1930s, Kurt Lewin developed a framework based on a leader’s behaviour and identified three main types of leader:

  1. Autocratic leadersmake decisions without consulting their teams. This style of leadership is considered appropriate when decisions need to be made quickly, when there’s no need for input, and when team agreement isn’t necessary for a successful outcome.
  2. Democratic leadersallow the team to provide input before making a decision, although the degree of input can vary from leader to leader. This style is important when team agreement matters, but it can be difficult to manage when there are lots of different perspectives and ideas.
  3. Laissez-faire leadersdon’t interfere; they allow people within the team to make many of the decisions. This works well when the team is highly capable, is motivated, and doesn’t need close supervision. However, this behaviour can arise because the leader is lazy or distracted; and this is where this style of leadership can fail.


How leaders behave affects their performance and their impact on others. Researchers have realized, though, that many of these leadership behaviours are appropriate at different times. The best leaders are those who can use many different behavioural styles, and choose the right style for each situation. Goleman (2000) identified that some styles and approaches were more effective than others in improving organisational performance and what he called ‘climate’ (we would probably call this the culture).



Read the discussion that looks at different types of leadership style that Goleman identified.



As you can see, Goleman develops Lewin’s styles further and looks at what leaders need to do, suggesting that effective leaders select the right style to suit different situations and people. It is not right just to stick with one and be always consultative for example, that would not work if the ship was sinking.


The realization that there is no one correct type of leader led to theories that the best leadership style depends on the situation. The contingency theories try to predict which style is best in which circumstance, e.g. for making quick decisions or when you need the full support of your team.


Hersey and Blanchard (1999) suggest that Situational leadershipis very useful when leaders are working with different types of follower. They identify four types of behaviour which can be selected depending on the situation and person. Leaders can move stylefrom ‘telling/directing’, ‘selling/coaching’, ‘participating/supporting’ to ‘delegating/observing’ depending on the development and competence levels of the follower.


See the Changing Minds site for a brief explanation, the diagram and some additional helpful links that expand situational leadership further

Although quite old, this is still a useful model.  It is always helpful to keep in mind that you might need to adapt your approach in different situations and seeking constructive, honest feedback from trusted colleagues will help you develop a wider repertoire of approaches.



What do you think your leadership style is?  From the cartoon above can you match each box to a leadership style identified by Goleman?


Key points

  • How leaders behave affects their performance and their impact on others.
  • You might need to adapt your approach in different situations and seeking constructive, honest feedback from trusted colleagues will help you develop a wider repertoire of approaches



Goleman (2000) Leadership that gets results.  Harvard Business Review, March-April 2000, 2-17

Hersey P, Blanchard KH (1999) Leadership and the one minute manager.  New York: William Morrow

Section 7


Working in teams and managing change


Leading and working in teams

“To lead people, walk beside them. As for the best leaders, the people do not notice their existence … When the best leader’s work is done, the people say, ‘We did it ourselves!'” – Lao Tsu, Chinese philosopher 

It is often considered that the team is the ‘cornerstone’ of the health system, e.g WHO, and research indicates that health professionals typically work in around five different teams, although most people have what they would call their ‘home’ team, the one with which they work most often or most closely identify themselves. In educational settings, people work in many teams and groups, some short life working groups, others (such as a programme team) which may last many years.  It is important for leaders to think about their strengths and areas for development in building, leading and working in teams. One of the best ways is to get feedback from team members on your performance. There are a range of tools for gaining feedback on your team working (such as the Aston team performance inventory, see and other 360 or multi-source feedback assessment of your leadership style and effectiveness (e.g.


Take a look at which looks at best practices for leading an ‘A Team’.


Various aspects of teams have been studied, including the importance of building and maintaining trust and how teams and groups can become so inward looking that they become disengaged from their leaders or managers which can lead to ‘groupthink’ or, in the case of Nut Island– disaster(Levy, 2001). More recently, West and Lyubovnikova (2012) have considered the reality of teams and what makes an effective team. Reflecting others’ findings, they suggest that leadership, setting and regularly reviewing shared goals and clearly defining tasks and roles are all essential for effective team-working.


Being able to work in and lead teams is a key leadership skill and therefore understanding more about what makes teams work and how you work in teams can help a team be more productive.



One long-standing way of considering how you work in teams is Belbin’s team roles test. Here is a similar free team role test Read here for how the Belbin test in practice and you can see how your results map onto the similar roles.

Leading and managing change


‘If you don’t change direction, you may end up where you are heading’ (Lao Tzu)


Change is an integral part of leadership, so much so that leaders who aren’t comfortable with managing and leading change are often viewed as ineffective.  Because change ‘is the only constant’ – effective leaders are comfortable with working in changing environments. Lao Tzu’s quote reminds us that change is necessary both for individuals and for organisations and systems, unless ‘where you are heading’ is where you actually want or need to be. It is helpful to consider your own role as a leader and change agent as well as how organizations are (and might be better) led and managed in terms of their responses to internal (e.g. financial, staff population) and external (e.g. government or regional policies or patient expectations) change drivers. Organizations should regularly be checking their progress against targets and goals as well as what the competition or external environment requires from them.


Change can be enacted at various levels from the psychological impact of change on individuals or groups through to major system change. Developmental or transitional change is often planned and can be considered ‘managed’. Different models help plan and explain change processes from various perspectives. These include linear models such as project management tools which are helpful for projects which have some chronological aspect to them (such as a new building, moving house or planning a curriculum).


Kurt Lewin was one of the early change theorists and described the three basic steps involved in any change: ‘unfreezing’, the ‘change’ itself (often referred to as the transition period) and ‘refreezing’.

Unfreezing: Involves breaking the status quo whereby driving forces for change are met by counteracting restraining forces. Removing resistors and understanding the human behaviour behind these are key to unfreezing and providing the motivation for change.

Change/Transition: Once unfrozen, these driving forces must be enacted, directed and controlled to bring about the required change. This often requires a transition period.

Refreezing: Once the desired new direction is reached, stabilisation must be sought to embed the change and prevent regression.

(Lewin, 1948)

Within this model, Lewin discusses ‘drivers’ and ‘resistors’ – drivers are factors that push for change (e.g. a new government policy) and resistors are factors, which fight against it (e.g. human factors whereby people don’t understand the policy or they cannot see how to implement it locally). Lewin suggests that effective change leaders, rather than persistently adding drivers, should focus on limiting and overcoming resistors.

One of the strengths of Lewin’s model is its application as a concept rather than a direct implementation strategy. By thinking about what needs to be done in each of the three steps and how to limit resistors, change leaders are better able to initiate, progress and sustain change and understand when to implement more direct strategies as necessary.

Other models (such as Kotter’s 8 Steps) have some linearity but also help us to make sure the right steps are taken to embed change and analyse where change initiatives might have failed or faltered. See here for more detail of the model and how to use it All change involves some element of loss, no matter how positive the change might be and leaders need to build in time

and processes for individuals to adapt. People also respond differently to change, so leaders need to understand that and work with people to adapt to change.


In situations of complex change, change management will be as much concerned with preventing things becoming chaotic or over complex. Here the leader’s task may well be to obtain agreement about what could and should be done and work towards certainty that certain external and internal factors will be in place. Organisational and major system change is related closely to cultural aspects of the organisation or system and this is where an understanding of complexity theory can help, by using models such as Ralph Stacey’s ‘certainty agreement matrix’ (1995). See for a good description of Stacey’s approach. This model can be used in two ways:


  • The leader’s task is to judge the level of agreement and/or certainty there is amongst followers in order to work out how to bring things into the easier zones to work in (the complicated or the simple) – this will be through consultation and consultation, or it may be through fact-finding or authoritative leadership. The approach taken will depend on the level of certainty or agreement and the time available for dealing with the situation;

and processes for individuals to adapt. People also respond differently to change, so leaders need to understand that and work with people to adapt to change.


In situations of complex change, change management will be as much concerned with preventing things becoming chaotic or over complex. Here the leader’s task may well be to obtain agreement about what could and should be done and work towards certainty that certain external and internal factors will be in place. Organisational and major system change is related closely to cultural aspects of the organisation or system and this is where an understanding of complexity theory can help, by using models such as Ralph Stacey’s ‘certainty agreement matrix’ (1995). See for a good description of Stacey’s approach. This model can be used in two ways:


  • The leader’s task is to judge the level of agreement and/or certainty there is amongst followers in order to work out how to bring things into the easier zones to work in (the complicated or the simple) – this will be through consultation and consultation, or it may be through fact-finding or authoritative leadership. The approach taken will depend on the level of certainty or agreement and the time available for dealing with the situation;

Section 8


Complexity thinking and adaptive leadership

“Abandon the urge to simplify everything, to look for formulas and easy answers, and to begin to think multidimensionally, to glory in the mystery and paradoxes of life, not to be dismayed by the multitude of causes and consequences that are inherent in each experience — to appreciate the fact that life is complex.”
― M. Scott Peck


When working in complex organisations or systems (which education and healthcare are) then leaders need to be able to see things from different perspectives, this is what Jacobs describes as cognitive complexity, a hallmark of an adaptive leader.“If managers and leaders are to scratch beneath the surface and delve into the substance of their organizations, what is needed is “cognitive complexity” which can be defined as “the intellectual ability of a manager or leader to envision the organization from multiple and competing perspectives so as to develop a depth of organizational understanding that is at least equal to the factors impacting its functioning.”(Richard Jacobs, Analysing Organisations through cognitive complexity, Villanova University)

Linda Fisher Thornton (2013) describes 5 features of cognitive (or thinking) complexity:

  • Think in multiple dimensions and in relationships;
  • Deal well with ambiguity and contradictory findings;
  • Use systems thinking;
  • Connect employees, processes and tools to meet goals;
  • Simplify complexity for those they lead


A consideration of complexity and systems thinking has resulted in various authors identifying complex adaptive leadership as an approach that works best in the networked global society in which we now live and work.

  • Adaptive leadership is about recognising that leaders work in systems which have inherent challenges and incorporate political dimensions (Heifetz et al, 2009).
  • Adaptive leaders therefore work out what is going on in order to create the conditions in which the organisation (and the people who work within it) can become adaptive and resilient to external change in order to ‘thrive’ (Heifetz et al, 2009). This concept of ‘thriving’ is drawn from evolutionary biology which suggests that successful adaptation preserves the essential DNA of a species, discards or regulates DNA which is non-essential or inhibiting, and creates DNA arrangements that enable responsive adaptation to new situations (Heifetz et al., 2009).
  • For education and healthcare leaders, this requires thinking purposefully about what ‘thriving’ actually means in terms of various stakeholders and the organisation itself. Depending on the organisation and circumstances, thriving may include: financial efficiency or making a profit, meeting the needs of students, patients, communities and populations, demonstrating core values or delivering excellent education or patient care.

Fullan (2004) suggests six key principles underpinning adaptive leadership:

  1. The goal is not to innovate the most: Consolidating fewer changes sustainably is preferable to implementing multiple innovations too quickly which are likely to be short lived;
  2. It is not enough to have the best ideas:Remaining insightful so as not push own ideas onto others and understanding the importance of providing ongoing motivational support for good ideas (no matter who generated them);
  3. Appreciate the implementation dip: Understanding and managing the loss of competence and dip in performance which occurs with any change;
  4. Redefine resistance: Listening to different perspectives, build good relationships and working with the creative side of conflict and resistance;
  5. Reculturing is the name of the game: Restructuring is powerful but without addressing the required cultural shifts, sustainable change is unlikely to be achieved. Reculturing challenges the way things are done;
  6. Never a checklist, always complexity: Even when linear, change often becomes complex and new patterns emerge due to environmental factors and the unpredictable interaction between ‘agents’ within it;

(Fullan 2004)

Obolensky (2010) suggests those working within such complexity should consider shifting from a more traditional oligarchical approach (in which leaders carry out a number of tasks or functions) to one which is polyarchic (in which leaders delegate functions to ‘followers’ and attend to the process of leadership). His ‘four by four’ model (below) sets out eight principles, which at first glance seem paradoxical, but when set in place, create a culture within which change can emerge.

Define an underlying purpose Set clear objectives at individual and group level
Give discretion and freedom to act Set boundaries to enclose actions
Ensure everyone has the skills and motivation to work Identify a few simple rules
Build in tolerance for uncertainty and ambiguity Provide continuous and unambiguous feedback

Leaders’ tasks, adapted from fromObolensky, 2010

Four frames

Bolman and Gallostalk about an academic leader needing to be ‘an analyst and social architect who can craft a high-functioning institution where all parts contribute to the whole, a political leader who can forge necessary alliances and partnerships in service of the mission, a prophet and artist who can envision a better college or university and inspire others to heed its call, and a servant, both to the institution and to the larger goals of higher education and society’ (2010, p220).   More recently (2013, 2015), Bolman, Deal and Gallos write further on academic leadership using their ‘four frames’ model, which looks through four ‘lenses’ to better understand and explain how higher education organisations work and what skills leaders need. These four frames are four ways of looking at the world or organisations:

  • Structural frame (where systems and structures are important)
  • Human resource frame (where people are important)
  • Political frame (where power is important)
  • Symbolic frame (which considers rituals, visual symbols and cultural stories).

Looking through these frames can help leaders understand the world in which we live, which Bolman and Deal term VUCA – ‘volatile – uncertain –complex – ambiguous’ (2015).


Today’s leaders work in complex organisational and cultural environments and therefore need good understanding of and willingness to work in complexity, but adaptive leadership and complexity thinking can be learned.  Complexity thinking helps to generate emergent (rather than managed) change.

Key points

  • Today’s leaders work in complex organisational and cultural environments and therefore need a good understanding of and willingness to work in complexity.
  • Adaptive leadership and complexity thinking can be learned.
  • Leaders need to use complexity thinking to generate emergent rather than managed change.
  • Finally, it is useful to think about how leaders might make decisions in complex situations, Snowden and Boone’s 2007 article looks at ways in which leaders might make decisions, based on the level of complexity the situation requires. LINK TO PDF (saved in Saudi 507)



Bolman, L. G., & Deal, T. E. (2015). THINK—OR SINK. Leader to Leader,2015(76), 35-40.


Bolman, LG and Deal, TE (2013) Reframing organizations: Artistry, choice and leadership (5th edition). Wiley, Chichester


Bolman, L. G., &Gallos, J. V. (2010). Reframing academic leadership. John Wiley & Sons, Chichester


Fullan M (2004) Planning, doing and coping with change.  The RoutledgeFalmer Reader in Science Education, p.245.


Heifetz RA, Linsky M, Grashow A (2009) The practice of adaptive leadership: Tools and tactics for changing your organization and the world. Harvard Business Press: Cambridge,

Massachusetts, USA


Jacobs R.  Analysing organisations through cognitive complexity, Villanova University, available at


Obolensky, M. N. (2014). Complex adaptive leadership: Embracing paradox and uncertainty. Ashgate Publishing, Ltd


Snowden, D. J., & Boone, M. E. (2007). A leader’s framework for decision making. harvard business review85(11), 68.

Section 10


Quality improvement and Innovation


‘We cannot solve our problems with the same thinking we used when we created them’  Albert Einstein


In this section we will look at the concepts of quality improvement and patient safety as well as innovation and disruptive innovation.


Quality and service improvement tools applied to a healthcare setting can help organisations to improve the quality, efficiency and productivity of patient care they provide (NHS Institute for Innovation and Improvement).


To be able to improve services it is essential that existing services are mapped to analyse current processes, service data and the views of all stakeholders are taking into account. Often small and steady changes are the best way forward rather than whole system changes.


The First Steps Towards Quality Improvement (created by the NHS) suggests ‘There are many models which can support your improvement project; however we promote two such models: a five step approach to successfully manage the change project from initial concept to completion, and the Model for Improvement to provide a framework for developing, testing and implementing changes’ (NHS Improvement –


The five-step model involves:

  • Preparation
  • Launch
  • Diagnosis
  • Implementation
  • Evaluation

It is by using a systematic approach that service improvements are more likely to succeed.  This can ensure that all ideas for change and improvement are brought to the attention of the service providers and that implantation of any changes is completed in a systematic way to enhance the chances of success.


The Model for Improvement focuses on the Plan, Do, Study, Act (PDSA) cycle.  Three key questions are asked before embarking on any improvement programme:

  • What are we trying to accomplish?
  • How will we know that a change is an improvement?
  • What changes can we make that will result in the improvements that we seek?

Once these questions have been answered the PDSA cycle can be used to test out ideas on a small scale to assess the impact the changes could have if released on a wider scale.

The Institute for Healthcare Improvement has developed and adapted tools to help organisations accelerate improvement. In addition, many organisations have developed tools in the course of their improvement efforts and have made them available on ( for others to use or adapt in their own organisations.  Improvement teams often make some mistakes when it comes to successfully sharing and spreading improvement ideas in their organisations. IHI faculty Carol Haraden and Roger Resar developed the “Seven Spreadly Sins” to give teams practical tips for overcoming challenges that impede successful spread. Please take a look at the PDF which shows the ‘Seven Spreadly Sins’ (INSERT LINK TO PDF – SAVED in 507 folder).


There are some wider healthcare initiatives that are going on around the UK, increasingly looking at the experiences of other countries and settings as governments and policy-makers respond to economic constraints as well as the issues raised in the Francis Report, Keogh Review, Berwick Report and the Andrews’ Report in Wales.  We have put together some articles and policy papers as starting point.


The Welsh context is interesting as the Government strives to develop and implement the ‘Prudent healthcare’ initiative. Prudent healthcare aims to deliver high quality services in times of increasing demand and economic constraints.


Three papers by Professor Sir Mansel Aylward and colleagues from the Bevan Commission set out the approach and some international evidence of service innovations that attempt to meet the same challenges, culminating in a set of principles published in 2015.

  • Simply Prudent healthcare (2013) Bevan Commission Simply Prudent Healthcare v1 04122013.pdf (SAVED IN 507 folder)
  • International examples of Prudent approaches to healthcare (2014) International-examples-of-prudent-approaches-to-healthcare.pdf (Saved in 507 folder)
  • Principles of Prudent healthcare (2015) Prudent Health Principles_2015.pdf (Saved in 507 folder)


The 2015 paper sets out six provisional principles and four approaches enshrined in Prudent Healthcare:

The 6 principles:

  1. Equity based care, treating greatest need first
  2. Do no harm – do some measurable good
  3. Do the minimum appropriate, to achieve the desired outcomes
  4. Choose the Most Prudent Care, openly together with the patient
  5. Consistently apply evidence based medicine in practice
  6. Co create health with the public, patients and partners


The four approaches:

  • Invest only in what gives tangible benefits
  • Stop doing things where there’s evidence they don’t work
  • Investigate areas where evidence is not clear
  • Improve quality and clinical outcomes


Engaging and supporting clinicians


Another widespread international initiative is that of engaging doctors and other clinicians in leadership, management and change. In this paper (written in 2013 by Ruth Hussey, the Welsh CMO, alongside the Prudent healthcare agenda) Ruth sets out how the approach in Wales has been informed by the work of Jack Silversin from the US, the author of Leading Physicians through change: how to achieve and sustain results. Doctors leaders of change 14 Nov 2013.pdf (PDF saved in 507 folder)


You may have been involved with or read about two initiatives from the US and Canada – the Quality and Safety Walk-round and Schwartz Rounds.  The first is involves senior managers and clinicians actually regularly walking the floor in a structured way, meeting with staff, patients and other stakeholders to discuss performance, quality and safety issues, concerns and compliments – read more in this toolkit (PDFQuality and safety walk rounds PDF – saved in 507 folder)


Schwartz rounds are designed to help staff have a safe space to discuss their emotions and get support. They are becoming more widespread in the UK, read more here JRSM-Goodrich_Schwartz rounds.pdf(Saved in 507 folder).


Finally, here is an article based on Penelope Campling’s editorial on Intelligent Kindness (Campling_intelligent kindness_2014.pdf Saved in 507 folder) and brings together some of the issues raised in the papers in this section. It is all about establishing the right culture.


Occasionally a change for improvement can result in a different outcome to that originally expected.   The term disruptive innovation was first described by Harvard Business School Professor Clayton Christensen, describing changes that improve a product or service in ways that the market does not expect, typically by lowering price or designing for a different set of consumers. It contrasts with sustaining innovation, a process of incrementally improving existing processes in ways that only serve the interests of existing customers. An enabling innovation is a new product or service that supports the disruptive process. An example of an enabling innovation is an information technology platform that allows a healthcare delivery company to decrease overall cost of care.



Have a look at this site and the accompanying video which explains the key principles behind disruptive innovation



Some examples of disruptive innovation noted on the site include:

Disruptor Disruptee
Personal computers  Mainframe and mini computers
Mini mills  Integrated steel mills
Cellular phones  Fixed line telephony
Community colleges  Four-year colleges
Discount retailers  Full-service department stores
Retail medical clinics  Traditional doctor’s offices


Further details about disruptive innovations can also be found on this website at




What disruptors and disruptees can you identify from your own experience either at home or in work?


Have a look at this site now and in particular look at what he says about US healthcare at ,


Watch the 2 videosClayton Christensen on Health Care Innovators and Smart Ideas For Fixing Health Care


List your learning points from this exercise



Further resources


For more information on technology based disruptive innovations, have a look at the Forbes best disruptive innovations from 2014 here


Please find a link here to a workbook that talks about project management QI workbook (LINK to PDF saved in folder 507)


There are lots of resources available to use when embarking on service improvement some of which are listed below:

The Future is Now

10th February 2015

Chris Ham, Anna Brown

Change for the better is happening across the health service in various areas of the UK.  This report brings together examples of such change, offering a glimpse of a future that already exists, albeit unevenly distributed.  It looks at the broader picture; from the patients perspective; the staff, leaders, mindsets & cultures:  and systems.  The document includes case studies and innovations that have the potential to improve delivery of care.


A conventional model of process mapping

NHS Institute for Innovation and Improvement 2008

A tool to help map the patient journey/pathway and to look for ways of improvement by seeing how the whole journey works and looking for any inadequacies along the way.  The foundation of this guide originates from the Improvement Leaders’ Guides, NHS Institute for Innovation and Improvement.



Plan, Do, Study, Act (PDSA)

NHS Institute for Innovation and Improvement 2008

This model talks through a way in which you can test an idea by temporarily trialling a change and assessing its impact. This approach is unusual in a healthcare setting because traditionally, new ideas are often introduced without sufficient testing.



First steps towards quality improvement: a simple guide to improving services


NHS Improvement –

If you are involved at any level in improving health or social care, this resource will provide the information you need for your first steps towards making quality improvements, giving your improvement project the best possible chance of success. Whether you are experienced at running improvement projects or not, this blend of project management and improvement tools, combined with practical know-how and first-hand experience gained from working with NHS teams, should prove invaluable.


The AQuA Six Step Improvement Model


AQuA, 2013

A toolkit produced by the Advancing Quality Alliance (AQuA) to support teams and managers who are looking to improve the experiences of all who use the service as well as improving efficiency.


The Handbook of Quality and Service Improvement Tools

NHS III Handbook serviceimprove.pdf,com_quality_and_service_improvement_tools/Itemid,5015.html

NHS Institution for Innovation and Improvement

The Handbook of Quality and Service Improvement Tools from the NHS Institute brings together a collection of proven tools, theories and techniques to help NHS staff design and implement quality improvement projects that do not compromise on the quality and safety of patient care but rather enhance the patient experience.  More information from the NHS institute can be found on their website


A GUIDE TO SERVICE IMPROVEMENT: Measurement, Analysis, Techniques and Solutions

Service improvement_Scottish_NHS.pdf

NHS Scotland: Centre for Change and Innovation, 2005

This Guide to Service Improvement introduces tools and techniques for improvement in delivering improved patient access.  The principle message is the need for service leaders, clinical and managerial, to improve upon the use of data to measure and analyse services in order to manage and improve them.


Institute for Healthcare Improvement

Lots of tools, forms, guidelines etc. to use when implementing service improvement.


Project Management Guide

This provides a framework for service improvement and is a useful guide showing the different stages to go through when managing a project.






Section 11



If your actions inspire others to dream more, learn more, do more and become more, you are a leader”.

John Quincy Adams

This session has set out some of the underpinning concepts on some key aspects of leadership, management and followership. We have taken a broadly chronological perspective but, as you can see,these theories and approaches overlap and build on one another so that currently we have a multitude of theories and models to drawn from in our everyday practice. There will inevitably be things that have not been discussed or only mentioned briefly, but you should have a good understanding of the core principles of leadership and management, have gained some self-insight if you have carried out the activities and have gathered some ideas about how you might take this forward into your work.

Key points

  • A wide range of leadership theories exist, drawn primarily from the social, behavioural and management sciences;
  • The majority of theories are ‘leader-centric’ (focus on the role of the leader) but increasing attention is being paid to the relationship between leader and follower and that leadership is co-created;
  • A recent shift towards more collective and collaborative leadership approaches is being seen in education and healthcare;
  • Leadership (and management) can be learned;
  • Leadership and management are distinct and leaders need to use management skills as well as leadership approaches;
  • Leaders are essentially change agents and thus need to be comfortable with change;
  • Effective leaders use a range of various approaches and styles to suit different people and situations, they are aware of and can work within complexity;
  • Obtaining feedback on your leadership from many sources will help you develop and hone your leadership skills and gain self-insight into the impact of your behaviours;
  • Toxic or destructive leaders can be highly damaging to organisations and individuals.

Useful resources/ Further reading

Oxford handbook of leadership and organizations (2013) – this book is expensive but is a great one for covering all aspects of contemporary leadership written by thought leaders in leadership from an international perspective


Day, D. V., Fleenor, J. W., Atwater, L. E., Sturm, R. E., & McKee, R. A. (2014). Advances in leader and leadership development: A review of 25years of research and theory. The Leadership Quarterly25(1), 63-82.


Dinh, J. E., Lord, R. G., Gardner, W. L., Meuser, J. D., Liden, R. C., & Hu, J. (2014). Leadership theory and research in the new millennium: Current theoretical trends and changing perspectives. The Leadership Quarterly25(1), 36-62.


Dionne, S. D., Gupta, A., Sotak, K. L., Shirreffs, K. A., Serban, A., Hao, C., … &Yammarino, F. J. (2014). A 25-year perspective on levels of analysis in leadership research. The Leadership Quarterly25(1), 6-35.


Preedy, M, Bennett, N and Wise, C (eds) Educational leadership: Context, strategy and collaboration, Sage/Open University Press, ISBN: 978-1-44620-1640, 2011


Bar-Yam, Y. (2004). Making things work. Knowledge Industry – describes lots of practical examples from all sorts of contexts to explain how complexity theory works, it is very accessible


Hazy, J. K., &Uhl-Bien, M. (2013). Changing the rules: The implications of complexity science for leadership research and practice. Oxford handbook of leadership and organizations – this book is expensive but is a great one for covering all aspects of contemporary leadership written by thought leaders in leadership from an international perspective


Uhl-Bien, M., Marion, R., & McKelvey, B. (2007). Complexity leadership theory: Shifting leadership from the industrial age to the knowledge era. The leadership quarterly18(4), 298-318 – great article, quite academic


Some journals focus just on complexity (in all sorts of areas) such as Complexity ( or Journal of Complexity ( ) if you’re interested in reading more.

General leadership journals

The Leadership Quarterly – for academic articles, one of the best journals on leadership


Leadership  – again, good for academic articles


Educational management, administration and leadership



Open access sites with lots of useful tips, tests, techniques and explanations:

Business balls –

Changing Minds –

If you want to develop your understanding of change further, the JISC Infokits provides a document on Change Management with descriptions of a wide range of different models and approaches

JISC Info-NetInfokits –

Mind tools –


On clinical leadership

The King’s Fund –

The Faculty for Medical Leadership and Management (FMLM) –

Australasian College of Healthcare leadership and management –


On higher education leadership

The UK Leadership Foundation for Higher Education –



Further reading activity

Here are a number of quick and easy self-reporting tests that you can use to evaluate your leadership style and approach:

From MindTools about key leadership skills –

About leadership styles (from Lewin)

Personality and leadership

About your leadership legacy

About teamworking. One long-standing way of considering how you work in teams is Belbin’s team roles test. Here is a similar free team role test Read here for how the Belbin test works in practice and you can see how your results map onto the similar roles.


The Turning Point resources are designed for public health leadership development and have a range of different activities and materials. This test looks at your potential and attributes around collaborative leadership


When you have done a couple of tests, ask your friends and colleagues what they think about the results. You can then start to think about your own effectiveness and areas for development.

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