Leading from the middle: Constrained realities of clinical leadership in healthcare

organizations
Author(s): Graham P Martin and Justin Waring
Source: Health , July 2013, Vol. 17, No. 4 (July 2013), pp. 358-374
Published by: Sage Publications, Ltd.

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Article health:
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Graham P Martin
University of Leicester, UK

Justin Waring
University of Nottingham, UK

Abstract
In many developed-world countries, there have been efforts to increase the 'leadership
capacity' of healthcare professionals, particularly lower-status staff without formal
managerial power. Creating frontline 'leaders' is seen as a means of improving the
quality of healthcare, but such efforts face considerable challenges in practice. This
article reports on a qualitative, interview-based study of 23 staff in two UK operating
theatre departments, mostly nurses by professional background, who were given
formal leadership responsibilities by their hospitals and redesignated as 'team leaders'
and 'theatre co-ordinators'. While participants were familiar with leadership theory
and could offer clear accounts of good leadership in practice, they were often limited
in their ability to enact their leadership roles. Professional and managerial hierarchies
constrained participants' leadership capacity, and consequently the exercise of
leadership rested on alignment with managerial relationships and mandates. The findings
highlight difficulties with accounts of leadership as something to be distributed across
organizations; in healthcare organizations, established institutional structures and norms
render this approach problematic. Rather, if fostering leadership capacity is to have the
transformational effect that policymakers desire, it may need to be accompanied by
other, wider changes that attend to institutional, organizational and professional context

Keywords
Health policy, organization of health services, profession and professionalization

Corresponding author:
Graham P Martin, SAPPHIRE Group, Department of Health Sciences, University of Leicester, Adrian
Building, University Road, Leicester LEI 7RH, UK.
Email: graham.martin@le.ac.uk

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Martin and Waring 359

Introduction

In many developed-world countries, efforts to improve the quality, effectiveness an

efficiency of healthcare provision have moved away from being driven by top-down
strategies, towards approaches that rely more on the engagement and empowerment o
frontline staff. Various clinician-led, network-based initiatives in Europe and elsewher
(Addicott et al., 2007; Van Wijngaarden et al., 2006) represent attempts to delega
responsibility for improving health-service provision to staff at the 'coal face', who, it
considered, are better placed than senior managers and policymakers to transform ser
vices in a sustainable way.
This trend has given rise to various debates in medical sociology and cognate
fields about the changing nature of healthcare work, including the reconfiguration
professional boundaries (Nancarrow and Borthwick, 2005), the management of p
fessional identities (Waring, 2011) and shifts in authority and accountability in
changing organizational forms (Martin, 2009a). Of particular note in this context are
efforts to empower frontline staff with the capacity, skills and legitimacy to drive
changes in the organization of healthcare. In particular, there have been concerted
efforts to increase the 'leadership capacity' of clinical staff (Koteyko and Carte
2008). In common with other public services, a panoply of initiatives to promote and
support leadership in healthcare have been introduced, in the USA, UK and interna
tionally. Leadership is increasingly seen as a skill that should not be confined t
senior managers at the apex of organizations, but something to be embraced by staf
at all levels (Hartley and Allison, 2000). British healthcare policy calls upon man
ers, clinicians and even patients to be 'leaders', exemplifying good practice an
influencing their peers in order to achieve change that is embraced by all (Martin a
Learmonth, 2012). However, practical problems face those charged with exercisi
leadership, particularly in public service contexts such as healthcare organization
where policy imperatives, professional divisions and bureaucratic structures ma
interfere with the ability of staff to lead across boundaries and up hierarchies (Coope
et al., 2012; Martin, 2009a). The notion of 'distributed leadership', as advocated i
the management literature and as operationalized by managers and policymaker
has thus come in for considerable criticism (Currie et al., 2011 ; Martin and Learmont
2012; O'Reilly and Reed, 2010).
This article considers such challenges in the enactment of leadership roles by a grou
of staff, operating department team leaders and co-ordinators, who are newly constructed
by national policymakers and local managers as 'leaders', responsible for directing care
taking charge of teams and influencing colleagues from diverse professional ba
grounds. We explore the dynamics of how these staff members put their leadership rol
into practice, highlighting the way these interact with existing professional identities and
disciplinary boundaries to give rise to a variegated realization of leadership, contingen
on wider aspects of the formal and informal organization of healthcare. In particular, w
demonstrate how the norms and structures of the healthcare context work to constra
the enactment of leadership - but also, in certain circumstances, to enable leaders to
challenge existing orders and change the way healthcare is delivered - though not in
quite the way envisaged by proponents of leadership theory.

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 360 Health 17(4)

First, however, we take a step back from our empirical work to consider the rise of
leadership as a means of achieving change in healthcare and other public services, aca
demic approaches to the concept and the place of leadership in recent healthcare policy.
I

Leadership, leaders and healthcare: academic

developments and policy rhetoric
Traditionally, theories of leadership have tended to equate it with the work of those in
charge of organizations, often casting leaders as inspirational individuals who command
from the top (Bryman, 1999). This heroic vision of organizational leadership has its roots
in Max Weber's accounts of hierarchical bureaucracies under the control of powerful
men (see Davies, 1995). Recent developments in organizational theory have given rise to
a more pluralistic view of what constitutes leadership. There is increasing recognition
that leadership need not necessarily be confined to those with formal power in organiza
tions, but rather includes various activities that involve 'a process of social influence in
which one person can enlist the aid and support of others in the accomplishment of a
common task' (Chemers, 2000: 27). In this understanding, leadership is less about formal
position or role, and more a situated activity where a diversity of actors can 'do leader
ship'. Leadership responsibilities thus shift between individuals depending on the nature
of the situation faced and the capacities of the actors involved.
Correspondingly, scholars of leadership have begun to delineate a variety of forms in
which leadership is enacted, 'from apex to front line' (Hartley and Allison, 2000: 39; cf.
Van Wart, 2005). In particular, recent studies have identified the importance of 'distrib
uted' leadership for achieving organizational change (e.g. Martin, 2009a), especial y in
complex contexts that involve multiple agencies and professions (Denis et al., 1996). In
such situations,

potential for effective leadership lies alike with those who do and do not have formal positions
of power and authority. Indeed, this view of leadership may be most useful in reminding those
with little authority how powerful they can be through collaboration . . and in reminding those
in a supposedly powerful position just how much they rely on numerous stakeholders for any
real power they have. (Crosby and Bryson, 2005: 29)

Current mainstream theorists of leadership, especial y those writing in relation to public

services, thus emphasize the potential, and indeed the necessity, of drawing on the lead
ership of those who are, in formal-hierarchical terms, relatively subservient, but who
nevertheless can 'lead up and out rather than down' (Crosby and Bryson, 2005: 32).
Distributing capacity and responsibility for leadership to the frontline is seen as a means
of ensuring that changes are led by those best placed to ensure their appropriateness,
legitimacy among colleagues and chance of lasting success in the face of challenge. As
we shall consider shortly, however, other scholars are more critical of the notion of dis
tributed leadership, suggesting that in both formulation and realization it is less challeng
ing of traditional organizational hierarchy than its advocates suggest.
In line with these developments in theory and practice, policymakers too have given
attention to the role of leadership in the delivery of healthcare. Faced with 'wicked'

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Martin and Waring 361

social issues that are not amenable to improvement through the actions of a single profes
sion, organization or even sector, policymakers are increasingly emphasizing the need
for leaders at every level of service delivery, driving change across organizational and
professional boundaries. In the British context, Martin and Learmonth (2012) have
tracked the development of leadership discourse in major government policy documents,
highlighting both a growing emphasis on leadership in general, and also a shift in focus
towards the importance of frontline, clinical leaders across the health professions. The
culmination of this shift is visible in recent policy documents such as the NHS Next
Stage Review (Secretary of State for Health, 2008), which calls on all clinicians (explic
itly including non-medical as well as medical staff) to be 'practitioners, partners and
leaders' (2008: 14; see also ch. 5 passim). Though the product of a different government
and heralding significant changes in NHS organization (in England), the recent white
paper Equity and Excellence maintains this emphasis on the leadership role of clinicians
on the front line, promising to 'liberate professionals and providers from top-down con
trol' (Secretary of State for Health, 2010: 27): 'clinicians will be in the driving seat and
this must be reflected in the education and training system so that current and future
clinicians are equipped to be professionals, partners and leaders' (2010: 51).

Leadership, leaders and healthcare: tensions and

critiques
There is, then, an increasing expectation that - with the right support and with some
structural changes - frontline clinicians (doctors, nurses and others) will exercise leader
ship roles. On the one hand, this might be understood as a reassertion of the values of
professionalism in the face of an increasing managerialisation of clinical work (Kitchener,
2000; Waring, 2010). The Next Stage Review speaks of a 'new professionalism, acknowl
edging clinicians' roles as partners and leaders, [and giving] them the opportunity to
focus on improving not just the quality of care they provide as individuals but within
their organisation and the whole NHS' (Secretary of State for Health, 2008: 60). This
resonates with recent sociological writing on the place of healthcare professionals as a
countervailing force against the power of managerialism and marketization, empowered
to advance quality of care and the patient interest in the face of bureaucratization, ration
ing and deprofessionalization (Freidson, 2001; Timmermans and Oh, 2010).
On the other hand, though, some academics have suggested that the discourse of lead
ership is deployed by policymakers to achieve precisely those managerial aims, rework
ing the identities of professionals to encourage them to accept and even promote the
managerialization of clinical work (Martin and Learmonth, 2012; O'Reilly and Reed,
2010; cf. Traynor et al., 2008 on the similar case of 'entrepreneurship'). Such critical
accounts suggest that 'distributed leadership' - as conceived or as enacted - should not
be understood as fundamental reconfigurations of the distribution of power and influence
within organizations. Rather, they represent a more sophisticated means of governing
clinical behaviour at a distance, achieving 'control primarily through the "internalized
compliance" of employees rather than "external constraint'" (Delbridge and Ezzamel,
2005: 606), recognizing the limitations of top-down direction of clinical work without
relinquishing control over it. In this conception, the discourse of'leadership', and indeed

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362 Health 17(4)

the wider revalorization of professional values in policy rhetoric, might be understood

less as an appeal to professionalism as traditionally constructed, and more as a recon
structed 'organizational' professionalism, in which a professional discourse is deployed
as a means of securing practitioners' acquiescence to policy and managerial aims (Evetts,
2009).
Moreover, on a practical level, despite the policy rhetoric, significant challenges face
those seeking to enact leadership in practice, especially those in lower-status professions,
or in subordinate roles where the ability to lead is significantly constrained by formal
hierarchy. Studies in healthcare and other fields have demonstrated the difficulties of
reconfiguring roles in ways that run 'against the grain' of established rules and norms of
service provision. These include not just formal hierarchies but also the less formal - but
equally entrenched -divisions between professions and disciplines that are especially pro
nounced in healthcare. Finn (2008), for example, demonstrates how policy efforts to pro
mote better team work among clinicians operating theatre to improve quality and safety
of care were stymied by institutionalized divisions between professional groups. Charles
Jones et al. (2003) describe the ways in which, faced by policy efforts to redistribute clini
cal work in primary care, general practitioners mobilized to ensure that reforms reinforced
rather than challenging their hierarchical position and status. The social-scientific litera
ture is replete with examples of policy efforts to redistribute responsibility and influence
that have run up against existing powerful institutional forces, such as established hierar
chies and professional jurisdictions (Martin, 2009b).
Even if they represent more than a means of imposing managerial identities, then,
policy-led efforts to distribute leadership across professional groups face a deeply chal
lenging context. This is especially so for lower-status groups, who are expected to
become leaders and achieve influence in an institutional environment which, on the face
of it, may be hostile. Yet to date - and perhaps in part due to the novelty of labelling such
individuals 'leaders' - there has been little study of the enactment of leadership among
such groups in healthcare and other public-service settings. This article addresses this
research gap. Drawing on an interview-based study of a group of practitioners who found
themselves in newly designated 'leadership roles' in a multi-disciplinary healthcare set
ting, we ask: what form is taken by the leadership enacted by these new leaders (whom
do they lead, how and based on what experience and training?); how does this differ from
their prior work; and how does the clinical context in which they work mediate this reali
zation of leadership?

Setting and methods

This article draws upon an interview-based study undertaken in the operating depart
ments of two NHS hospitals located in the English Midlands. Like other NHS service
providers, these hospitals were seeking to implement the NHS Leadership Qualities
Framework (NHS Institute, 2005). This comprises a broad template for defining and
shaping leadership practice as prescribed competencies and activities in the areas of
'personal qualities', 'setting direction' and 'delivering the service'. As a part of this
emphasis on enhanced, distributed leadership, within each hospital explicit efforts had
been made to create new leadership roles - or (as we later discovered in interviews) to

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Martin and Waring 363

redesignate established nursing positions and bands with leadership titles. For exam
ple, matrons (Band 8a) and sisters (Band 7) were rebranded as departmental and team
leaders respectively. This also assigned a variety of 'leadership responsibilities' to
other (Band 6) staff, previously known as theatre nurses and operating department
practitioners (ODPs) and now redesignated as theatre co-ordinators, in areas such as
productivity improvement, infection control and, notably, leading the implementation
of the World Health Organization's peri-operative surgical safety checklist.1 To sup
port the acquisition of these new roles, responsibilities and identities, both organiza
tions made available a number of training opportunities. For more senior staff this
involved regional training based upon on the NHS Leadership Qualities Framework
delivered by specialist training agencies. For lower-level leaders, training was pro
vided through the 'Leading an Empowered Organization' programme, comprising a
three-day course of situated learning.
This study focused on the experiences of newly designated team leaders (Band 7) and
theatre co-ordinators (Band 6) with leadership responsibilities. Across the two hospitals,
38 clinicians were identified as being designated as either team leaders or theatre co
ordinators, and all were invited in writing to participate in the research. In total, 23 clini
cians agreed to participate (12 team leaders and 11 theatre co-ordinators). These included
both nurses and ODPs. Data collection involved in-depth one-to-one interviews. The
interviews followed a thematic template that reflected wider theoretical and conceptual
debates, national and local policies, and descriptive accounts of day-to-day practice. This
included career background, description of leadership role and philosophy, training and
support for leadership, constraints and facilitators to leadership, and leading change
within the workplace. All interviews were undertaken on site at each hospital in a private
room, and lasted 40-90 minutes. In accordance with our research ethics and governance
approval, all participants gave written consent prior to participation. Interviews were
recorded and transcribed verbatim.
Data analysis combined inductive and deductive approaches. Before formally com
mencing analysis, the authors met to discuss the data and the issues of interest arising
from them. The first author then read each transcript several times, noting recurrent
themes, including those which were covered by the topic guide and others which were
brought to the fore by participants. These themes were then developed into a coding
frame, which thus comprised codes derived both from the topic guide (and thus the aca
demic and policy literature on leadership) and from the talk of participants themselves.
Excerpts from the transcripts were allocated to these codes using NVivo software. We
then discussed, developed and refined these themes, returning to the transcripts to con
sider how these themes related to individual participants' presentations of themselves
and their work, considering how the themes related to each other, further refining the
coding frame and reallocating data as necessary. To clarify and validate our interpreta
tion of the findings, we convened a one-day regional workshop for all those involved in
the study, together with clinicians with similar roles from other hospitals in the area. At
this event we provided summary feedback of our analysis and, through focused group
work, asked participating clinicians to explore the relevance of our findings to their own
experiences. The confidentiality of our cohort of research participants was maintained
during this engagement. This feedback helped further develop and hone our analysis.

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364 Health 17(4)

Findings
We present our findings under three headings. Under 'The rhetoric of leadership', we
present our participants' views on the nature of leadership, and what it meant to be a 'good
leader'. Then, under '(Un)doing leadership', we move onto participants' descriptions of
their work to put leadership into practice. This highlights some important constraints,
which gave rise to a sharp contrast between their accounts of what leadership should
involve, and their accounts of what it did involve in practice. Finally, under 'Managing to
lead', we highlight exceptions to this pattern: points at which participants were able to
enact a version of leadership which accorded better with their normative accounts of what
it should involve. These exceptions, we suggest, offer particularly sharp insights into the
contours of leadership among this group, illuminating the ways in which the institutional
environment variously impeded and facilitated the ability of these leaders to lead.

The rhetoric of leadership

In general terms, all participants in the study were able to articulate a vision of what
leadership involved, and many of these visions accorded closely with academic, policy
and popular notions of organizational leadership. Typically, responses highlighted the
need to influence others, to be respected and to lead by example:

It's about empowering people. [...A good leader] will leave the desk and go and help if there is
an emergency in their area. They don't necessarily have to stay if they can see everything is
being coped with as long as people know they have made the effort to check on the situation
and make sure everyone is fine.... I think people just appreciate someone who is seen to muck
in and who will do their best. (Team leader 3)

You have got to have very good negotiation skills. You almost need to make staff feel they have
been a part of the decisions that you are making.... You are seen as driving something forward
and they see you as a person who is proactive and who can instigate change. (Co-ordinator 3)

Frequently, participants referred to the need to balance a strategic vision with the task
of keeping 'followers' happy. Empathy, understanding and listening skills needed to be
drawn on at the same time as ensuring that things happen. This mirrored many of the
'quieter' characteristics of leadership highlighted in recent literature, which views col
legiality and dialogue as much more effective than bombastic declarations, especially
when leadership is distributed across peers rather than concentrated at the tops of organi
zations (Martin, 2009a):

You have to show that you value your staff and you have to be supportive of them. They have
to think for themselves and they may not do it quite the way you would, but you have to
question whether it matters. You can say to them, 'That's fine, but next time maybe you could
try this' - it's like role play, isn't it? As a team leader, no job should be too big or too small.
(Team leader 10)

Several participants had undertaken formal leadership training as part of their con
tinuing professional development, and it was clear that this had contributed to their

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Martin and Waring 365

thinking about leadership theory. Many had been through the Leading an Empowered
Organization (LEO) course, for example, and had found it helpful in developing their
leadership capacity:

I did the LEO leadership course and that was probably the only formal leadership training.... It
really made me think about how you manage situations and it looked at our strengths and
weaknesses. There were some useful guides to leadership skills and managing conflicts and that
sort of thing. (Team leader 4)

However, though they saw formal training as a useful supplement to personal devel
opment, most felt that they had acquired the majority of their skills from their firsthand
experience of working in the NHS:

It has been on the job, doing it within your own speciality area, and then as promotion comes
along you gain that experience. I think sometimes people are natural leaders and some people
aren't, and I think it is actually knowing the people you are working with and their skills and
limitations. (Co-ordinator 1)

On the job mainly. I am doing a leadership course and that is very good as it identifies what type
of person you are and what your leadership qualities are, [and] I have found that very useful
over the last six months, but the best work really is through trial and error. (Team leader 6)

Through this combination of on-the-job training and formal leadership education,

participants felt that they had developed a range of skills that helped them in their day
to-day work. However, despite their formal designation as leaders, there was a notable
ambivalence towards the label. Some participants, perhaps unsurprisingly given the
theme of the interviews, self-identified as leaders and appeared happy to take on the
responsibilities, qualities and attributes associated with the mantle. Most, however, were
much less strident in their talk of leadership, and more reluctant to speak about them
selves as leaders - despite the framing of the interviews in these terms. Frequently they
used the 'old money' of professional designations, referring to themselves as 'sisters',
'charge nurses' or 'staff nurses'. As a label which could be applied generically to any
staff member - including non-professional staff - for some at least, 'leader' seemed more
threatening than appealing as a designation:

Our title now is meant to be team leader, but I still think of it as a team sister. ... It shows a
person's background which is why they want it to be anonymous and call it team leaders
because some of them aren't nurses.... They are often ODPs [operating department practitioners]
and I appreciate that they have worked hard to get to that level, but they still haven't had the
overall experience that nurses have. (Team leader 2)

Leadership, then, was something in which the participants were well versed. Many saw
it an important component of their jobs, and they were clear about what constituted a 'good
leader' in terms of personal qualities, inteipersonal relationships and authority. Yet 'leader'
was not always an identity to which they aspired. Indeed, for some, it was in competition
with their preferred, professionally derived, identifications. The job title 'leader' lost some
of its lustre because of its generic application in an environment still dominated by

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366 Health 17(4)

professional affiliations. Moreover, as we see in the next section, participants did not
always find that they could play out the part scripted for them as leaders - and in part, this
too was because of the obstinacy of professional divisions and hierarchies.

(Un)doing leadership

Most participants were able to relate stories about good leadership in practice, and many
offered examples of situations in which they themselves had led effectively. However,
there was also something of a contrast between these examples, along with their descrip
tions of leadership in theory recounted in the previous subsection, and the way in which
they described the bulk of their day-to-day work as (designated) leaders. A lot of the
work they did might be characterized as less about the nurturing, influencing, example
setting leadership described above, and more about the tenacious administrative and co
ordinating skills needed to get things done in busy operating theatre departments:

Sometimes there are issues with equipment if they are very busy elsewhere, and sometimes
equipment doesn't come down to theatre promptly which delays us a few minutes each time
during the course of the day, and that takes time. Paperwork doesn't always get signed, so
dotting the Is and crossing the Ts is a constant battle. ... Equipment goes missing constantly
[laughs], it disappears behind your back. (Team leader 1)

I think clinically it is sometimes difficult because you are trying to co-ordinate with insufficient
staff. Because of the way things work, you have electives but sometimes you get emergencies
into the second theatre.... You have lots of staff in every theatre and everything that goes wrong
is deemed to be your fault and they all come in and shout a lot. That shouldn't be accepted as
part of that role but you do, you accept it. (Team leader 3)

In such environments, the distinction between 'leading' and being one part of a larger
team responsible for getting things done, faded. Insofar as leadership remained an impor
tant role, it was in co-ordinating and 'filling in the gaps' that it arose in the frenetic oper
ating department setting:

I have spent all morning trying to find beds for patients to go into, which creates pressure for
us because we have to send for that patient anyway, but then after their surgery there may not
be a bed available for them and then recovery get backlogged and the patients have nowhere to
go so they end up stuck in recovery. You also have the day-to-day problems of running the
theatre. Today we had four trays for one operation and they were all contaminated and they
hadn't got any more, so we had to actually piece together the kits for the patient that was on the
table, anaesthetized! (Co-ordinator 9)

The daily roles of these leaders, then, seemed less about creating visions for others to
follow, and more about the practical concern of making sure that things got done. This
implied a considerable amount of 'wheeling and dealing': negotiation and compromise
was highlighted by several participants as essential to their role. However, this was less
a matter of the social influence connoted by the term 'leadership', and more a matter of
brokering between two or more other, more powerful, actors. For example:

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Martin and Waring 367

On a daily basis there are sometimes issues where staff are on cover on specialist cases or doing
trauma and operating the electives, and I think that is partly about leading it, but communicating
with surgeons and anaesthetists and perhaps liaising with them so they speak to each other to
come up with solutions, guiding them to speak to each other. (Team leader 4)

Indeed, apparent from much of participants' description of their roles was the way in
which their formal designation as 'leaders' was insufficient to garner the kind of influ
ence needed to make things happen. Professional hierarchy, and associated claims to
knowledge, legitimacy and power, trumped this new leadership. At best, leaders could
hold the ring between more powerful surgeons and anaesthetists who remained dominant
in the operating theatres; at worst, they found themselves impotent bystanders whose
putative responsibility for the quality of care meant little when set against professional
hierarchy:

Co-ordinator2: Theatre staff put pressures on you by telling you you're pushing things
through too fast. ... Surgeons pressurize you by insisting that their case
should take priority over another case and demanding that second theatres
are open when it is not safe.
Interviewer: And how do you deal with those pressures, so for example if a surgeon is
demanding that their case take priority?
Co-ordinator2: Generally I try and enlist the support of the senior anaesthetist and talk it
through with them along with the surgeon. Secondly, you try to get the sur
geon to speak to the opposite surgeon who is also claiming priority and hope
they do it through negotiation. And if all else fails you just have to stand there
and say, 'Well we can only do one patient and this is the patient we are going
to do', and you wait to see what the fallout from that will be.

Though participants saw themselves as having a key role in facilitating the smooth
and safe care of patients in the department, they lacked the power to do this by them
selves, and frequently also the legitimacy and influence to enlist the support of others.
Their roles as enacted, then, could not easily be categorized as leadership, at least in the
sense envisaged in mainstream academic accounts. Leadership in practice was shaped,
constrained and sometimes undone by the established norms and rules of the hospital,
and the professional institutions these reflected.

Managing to lead
There were exceptions to this pattern, however. In situations where established hierar
chies aligned with, rather than contradicting, the direction of influence required in their
leadership roles, participants were rather more able to enact the role effectively. So for
example, in relation to subordinate members of their teams - and even, to some extent,
others of the same grade and professional discipline - participants were able to perform
the leadership role with much less difficulty, and in a way that corresponded more closely
to the theories of leadership they alluded to above, influencing others and delegating
effectively:

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368 Health 17(4)

We do have Band Sixes and Band Fives who do lead on things that I don't need to be involved
in or things that I do need to be involved in but which they can take forward. It is a case of
looking at people's best skills to do that so something like patient dignity, that is something I
am really interested in and would like to take forward, but one of my Band Six staff is even
more interested than me and has been to study sessions and is really enthusiastic and keyed up
about it, so I have asked her to lead on the challenges of dignity in recovery. (Team leader 8)

In contrast to the difficulties involved in attempting to lead powerful and independently

minded surgical and medical staff, the challenge here was in encouraging peers and
subordinates to act autonomously rather than rely on participants to direct their every
action:

It is silly things sometimes, like when you are trying to sort out lunch relief and making sure
that everyone gets breaks, they won't go until you tell them and it's like, 'I am busy, I forgot. I
haven't been for a break yet, you are all grown adults, sort it out amongst yourselves', but no
they won't make that decision, you have got to. (Co-ordinator 9)

In leading subordinate team members, there was an overlap between managerial and
leadership responsibilities, but many participants found they were able to complement
their formal managerial role with a more nurturing, influencing leadership role.
Perhaps more surprisingly, though, there were also some notable times at which
participants felt that their influence as leaders extended beyond those for whom they
had managerial responsibility. Given certain circumstances, participants found they
could command legitimacy with groups such as surgeons and anaesthetists among
whom, usually, their 'leadership' role was limited to facilitation or brokerage. Team
leaders and co-ordinators sometimes found they had at their disposal a set of resources
that could shift the balance of power to the extent that they were able to exercise con
siderable influence. Guidelines, checklists and protocols for safe surgical practice
endorsed by external authorities such as the WHO, the Department of Health and the
Royal College of Surgeons were sometimes a cause of tension between participants
and their surgeon and anaesthetist colleagues. But whereas with other issues partici
pants found they had to defer to these colleagues, on these issues team leaders found
they had the upper hand:

We had a surgeon actually, one of the staff came to me and said 'Dr [Name] doesn't like the
Time Out,2 he said it's a waste of time, and what are we doing it for?'... We have a fortnightly
labour suite meeting where theatre staff and the doctors come together and me or the team
leader can bring up any issues, and it is minuted. We talked about Time Out, and how it has got
to happen because it is part of the WHO policy for safer surgery, so he accepted it and got on
with it then. (Co-ordinator 7)

Co-ordinator 10: We do have some surgeons who will say, 'Well I have marked it and I know
which [site] I am doing.' They will do it because they know they have to, but
they are not enthusiastic....
Interviewer: And how do you think you would deal with it if they were like, 'I can't do
that now'?

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Martin and Waring 369

Co-ordinator 10: I would just reiterate that we have no choice in this and that it is policy and
this needs to be done before, during and after and we have no option. ...
There are individuals that feel that something doesn't include them, particu
larly the older ones, but at the end of the day I say, 'We are all here for one
thing and that is patient safety, and this is what you need to do.'

In contrast to their usually futile experiences of trying to exercise a leadership role

over superordinate medical and surgical staff, participants found that on these matters,
leadership could be enacted much more effectively. To some extent, this was because
guidelines and directives such as the WHO's peri-operative surgical safety checklist (and
the 'Time Out' it required) had a legitimacy for surgeons and anaesthetists that was lack
ing in other matters. Participants could therefore couch their influence in terms that were
instinctively appealing to these groups, for example in terms of audited compliance to
these guidelines:

We have looked at the past results and it is in no doubt so it is a case of going to the staff and
saying, 'Have you seen this, this isn't very good is it?' Also it is about getting staff involved in
how we can make the audit forms accessible so we have nice little folders for them now so you
can see it ail. It is just trying to make them aware of what we have got to do and saying to them,
'This is our theatre, let's take ownership of it', and the team is excellent for that. (Co-ordinator 4)

Perhaps more important than their legitimacy for medical and surgical staff,
though, was the mandatory nature of many of these initiatives, and the threat of sanc
tion that went with them. NHS organizations were required by regulatory authorities
to implement the WHO surgical safety checklist,3 for example, and this added to the
strength of the influence wielded by the leaders in ensuring compliance:

Team leader 3: We have problems with a couple of surgeons [complying with the checklist].
I discussed it with one of the consultants and brought it up at a recent suite
meeting, and the next time I asked the surgeon they did it [laughs].
Interviewer: So was there any particular reason why they didn't like it?
Team leader 3 : He just said he didn 't have time for it. One of the doctors has got a law degree
as well and he appreciates that it is not me asking them and that it is coming
from above.

Some of the medical staff didn't take it on board straightaway and wouldn't get involved, but
the best way to do it is to say, 'Right, we are doing the Time Out.' I think quite often it is your
approach to people, and it is a policy that we have to follow so there is no getting away from it,
so you do it and you involve them. Everyone now is fine with it, it's just that some people don't
like change and you have to ease them into it. (Co-ordinator 1)

The influence team leaders enjoyed in relation to the surgical safety checklist and
other initiatives, then, seemed intimately related to the fact that these were backed by the
clout of policy endorsement and managerial compulsion. As Team leader 4 put it in
describing how she went about leading change in operating theatre practice to comply
with Time Out, 'I think you have to make people see that the request is not optional.'
Successful leadership on these matters relied on managerial direction. With their

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370 Health 17(4)

subordinates, team leaders could draw on their hierarchical position to exercise their
leadership responsibilities; with higher-status professional groups, leadership was con
fined to those situations in which other - managerial and policy - imperatives provided
team leaders with the necessary legitimacy and authority to achieve change.

Discussion

Evident from our findings is the gap between participants' accounts of leadership
theory and normative descriptions of good leadership, and their day-to-day practi
as 'leaders' in the NHS. Much of their everyday work involved reactive admini
tive duties, and a notable degree of frustration at the challenges of leading medica
and surgical staff in the operating theatre department. Exceptions to this mismat
however, did arise when participants were seeking to lead their immediate pe
group and their subordinates, and also when externally driven policy mandates bol
stered their ability to lead across professional boundaries and up profession
hierarchies.
The ability to 'do leadership' in this setting, then, rested to a large extent on alignment
with existing organizational structures, norms and imperatives. In practice, participants
frequently found that their efforts to lead were 'undone' by the existing norms and struc
tures of the hospital. Indeed, it was when leadership responsibilities were better aligned
with existing power relationships that participants could 'manage to lead'. Where man
agement accountabilities coincided with leadership duties, or where other managerial
'technologies', such as the peri-operative checklist, provided participants with legiti
macy, they could lead in a way more in keeping with the normative ideals of leadership
they espoused. Bureaucratic authority worked here to bolster the power of the subordi
nate group, by curbing the autonomy of relatively powerful professionals and strength
ening the hand of team leaders and co-ordinators with extra 'strategic counters to play'
(Silverman, 1987: 31).
The nature of this apparent modest shift in professional relationships is, however, out
of kilter with much policy, popular and academic rhetoric about leadership, and about the
relationships between leaders and others. As we have seen, policymakers subscribe
increasingly to a notion of 'distributed' leadership which sees it as something distinct
from management, less reliant on formal position in organizational hierarchy than on
personal attributes and the particularities of the situation (Van Wart, 2005). Recent policy
calls for all clinicians, medical and non-medical, to have the opportunity to be leaders as
well as practitioners (Secretary of State for Health, 2008, 2010). What our findings sug
gest, though, is that where these opportunities to lead contradict established managerial
relationships and bureaucratic and professional hierarchies, they are likely to be difficult
to enact. Some writers in the critical management studies tradition go as far as to suggest
that 'leadership' is a chimera, indistinguishable from 'management' except in the way it
seeks to reframe reality (Alvesson and Sveningsson, 2003; Learmonth, 2005; O'Reilly
and Reed, 2010). What is clear is that at least in effect, if not in intent, efforts to imbue
leadership capacity in lower-status actors cannot be understood as a simple break from
top-down directiveness. Rather, they seem to represent a form of responsibilization of a
wider range of staff, distributing responsibility for and reworking subjectivities in terms

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Martin and Waring 371

of the implementation of managerial edicts (Delbridge and Ezzamel, 2005; Evetts, 2009;
Martin and Learmonth, 2012).
However, insofar as this reconfiguration of roles sought also to endow these new lead
ers with greater influence, our findings attest to the durability of prevailing organiza
tional norms and structures in the face of policy-driven efforts to change them. We noted,
for example, the preference of many of our participants for their traditional, profession
ally derived job titles despite their redesignation with the (apparently desirable) label of
'leader'. Participants did not deride leadership; they discussed many of the positive ways
in which leadership theory had affected their style and helped them to influence the
behaviour of their subordinates and peers. However, they also recognized that in the
professional and organizational context of the NHS, labelling themselves as 'leaders'
bought them considerably less credibility than the 'old money' of their professional affil
iations. Echoing the findings of other studies (Charles-Jones et al., 2003; Cooper et al.,
2012; Martin, 2009b; Waring, 2011), apparent is the resilience of embedded professional
and organizational institutions against novel efforts at reform. In a system that remains
strongly hierarchical (Harrison and McDonald, 2008), in which organizational culture is
resistant to change (Waring, 2010), and in which medical and surgical knowledge are
privileged over nursing and managerial knowledge (Finn, 2008), it is perhaps unsurpris
ing that efforts to distribute leadership without altering organizational structures have
only a limited effect.
This is not to argue that efforts to endow those who are subordinate in the current
system with leadership capacity are necessarily doomed to failure. However, if the aim
of such policy drives is to develop capacity for 'bottom-up' influence and not just to aid
the implementation of 'top-down' edict, they do need to attend to wider organizational
characteristics, especially if they run against the institutional grain. There are examples
of efforts to reconfigure the power relationships and norms of accountability between
professional groups that have succeeded in modifying organizational culture and chang
ing the way in which health services are provided (Dixon-Woods et al., 2011). It is clear,
however, that this is not achieved through piecemeal changes to job titles and responsi
bilities in isolation from the context in which these are to be enacted. There is an impor
tant irony here: these changes aimed at empowering frontline clinicians were imposed by
local managers implementing national policy. Yet instilling capacity to lead from the
bottom up is not a project that can be achieved from the top down! 'Leadership' cannot
be treated as a free-floating set of character traits and dispositions that can be allocated
unproblematically to any individual in an organization (Currie et al., 2011). If it is to
achieve change, it must be understood as one component of wider strategies to improve
the quality, safety and efficiency of health services, and implemented in a way that
acknowledges the importance other key actors, whose acceptance or resistance will be
crucial to prospects of new leaders.

Conclusion

Our findings attest to the durability of institutional and structural forces in limiting
extent to which leadership roles could be enacted in the way envisaged in theory and
icy. However, they also highlight the importance of understanding how such polic

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372 Health 17(4)

discourses are transformed and redeployed in practice settings. The newly redesignated
'leaders' of our study could not realize the more Utopian theoretical prescriptions for dis
tributed leadership. But neither did they dismiss leadership as a managerial fad. And nei
ther could leadership discourse be understood as a form of 'organizational professionalism'
that simply 'suckered' these practitioners into subservience to managerial aims, reconfigur
ing their professional identities in line with organizational and policy priorities (Evetts,
2009; Martin and Learmonth, 2012). Rather, we see in our findings the creative ways in
which the new 'leaders' drew on the discourse to gain occasional strategic advantage in
their work-based relationships - marginal, transient and limited by powerful structures and
institutions, but still real. While the grand claims of policy and theory around the transfor
mational potential of leadership should be treated with scepticism, we should not dismiss
the incremental ways in which it is used to renegotiate order in empirical settings.
In the UK and internationally, there has been a sustained focus on the importance of
'leadership', as one strand of policy that seeks to empower frontline professionals at
every level in improving healthcare quality. As one of the first studies to focus on the
realization of such policy among relatively low-status professionals, our findings high
light some of the challenges faced by such efforts. Leadership remains a key policy
emphasis in the UK even as wider NHS policy has changed substantially; further research
will be needed on how the considerable changes to the financing and organization of the
NHS and other healthcare systems affect the prospects for leadership and other efforts to
shift power to frontline staff.

Notes

1 For a full explanation of the NHS job banding and career structure for non-NHS staff, s
www.nhsemployers.org/PayAndContracts/AgendaForChange/Pages/Afc-Homepage.aspx.
2 'Time Out' refers to the use of the WHO checklist in the operating theatre, immediate
before the first incision, to ensure that all staff know each other, understand the procedur
to be undertaken, have taken necessary safety precautions and have anticipated any possibl
complications. See http://www.who.int/patientsafety/safesurgery/ss_checklist/en/.
3 See www.nrls.npsa.nhs.uk/EasySiteWeb/getresource. axd?AssetID=61388.

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Author biographies
Graham P Martin is Professor of Health Organisation and Policy in the Social Science Applied to
Healthcare Improvement Research (SAPPHIRE) Group, Department of Health Sciences,
University of Leicester. His research interests include healthcare reorganisation, professionalism
in changing organisational contexts, and service user involvement. His work has been published in
ajournais across the fields of medical sociology, health policy and public administration.

Justin Waring is Professor of Organisational Behaviour at Nottingham University Business School.

His research makes connections between medical sociology, organisational studies and the sociol
ogy of the professions to understand the continuing re-organisation of healthcare work, especially
the social practices used to reconfigure, maintain or advance professional boundaries, identities
and interests. His research has been supported by the ESRC, NIHR and DoH and includes over 40
publications.

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