Theoretical approaches to leadership

There is no consensus about the most appropriate leadership theory or approach, either in general terms, or specifically in relation to dental surgeons. Well known theoretical approaches2 are summarised in Table 1.

Table 1 Well known theoretical approaches
Full size table

The above suggests that dental surgeons working in primary care have a choice of different approaches to leadership: either to focus on developing personal qualities, or on adopting a specific style, or on whether to take into account the practice setting, or to concentrate on how to bring about change or transformation in their practice. However, each theoretical perspective or approach has its strengths and weaknesses, and each has some relevance to the leadership role for dental surgeons. Therefore, the next section will review each of these theoretical approaches and assess the implications for the leadership potential and development of dental surgeons.

Leadership theory: implications for dental surgeons

Identifying personal traits

The implications for leadership partly depend on the approach taken. If one takes a personality-based approach, the emphasis is to a large extent on recruitment and selection, personality testing, and matching individuals against a list of personality traits. The problem with this approach is the lack of agreement about such lists, and the link with leadership effectiveness. The other issue is that this approach assumes that leadership qualities are part of an individual's genetic makeup. In other words it assumes nature not nurture, ie that leaders are to a large extent 'born not made'.

However, there are some general personal characteristics which may be said to be important in relation to leadership. These include, for example, confidence, stamina, intelligence, emotional competence, tolerance, sociability, drive and initiative. Some of these have been supported by research studies. For example, there is a correlation between leadership effectiveness and the following: intelligence, supervisory ability, initiative, self assurance and individuality.4

One needs to take the view that such characteristics can be developed through training and experience, although some of these characteristics will be present already in dental surgeons as they also underpin their clinical role. It can be argued that dental surgeons need to consider such lists as a way of informing their personal developmental needs, as part of clinical development / CPD.

Identifying a way of behaving / style

A second way forward is to focus on behaviour or style of leadership. The style of leadership is determined by the philosophical stance taken by the leader, ie an underpinning set of beliefs about human nature. Thus, one may believe that workers are in need of motivation and direction, or, alternatively, that workers are self-motivated and able to work with less overt direction.5 A further influence on style is the culture of dentistry. It has been suggested that dental surgeons 'have become accustomed to being the decision maker and taking a proactive role in both the business and clinical elements of their work'.6

This suggests that dental surgeons need to identify a preferred way of interacting within the dental team. This may be to emphasise the importance of individual and team contributions to the dental practice. In this case, the dental surgeon needs to display people-centred behaviours designed to motivate staff and build effective teamworking. Alternatively, one may adopt a task-centred style, a focus that to some extent lends itself to the current dental contract. However, it can be suggested that undue attention to this aspect can lead to problems with staff engagement, motivation, and sustainability of performance.

Adair has rightly suggested that both styles of leadership are important in terms of ensuring both individual and team wellbeing and goal achievement. This view suggests there are three inter-related sets of needs: (a) individual needs – the leader attends to individual needs, addresses problems and conflict, motivates and rewards, (b) team needs – the leader engages in team building, ensuring team cohesion, setting standards, communication, (c) task needs – the leader focuses on collective responsibility for achieving goals, tasks, planning, organising and controlling.7

Identifying and understanding the leadership situation

This approach builds on earlier perspectives on style / behaviour but suggests that the latter is determined largely by the situation. The contribution of this approach is summarised thus: 'situational and other contingency models of leadership have broadened out the scope of leadership theory and research to include not just leader traits and behaviours, but also situational and follower characteristics'.8

It focuses on identifying the key variables within the situation, such as culture, structure, individuals and teams. Culture, in particular, is important, because it represents a potential barrier to effective leadership. In dental practice there are subcultures, professional cultures and the remnants of 'tribalism', and there have been attempts to change this towards a more market-oriented, competitive culture.

Thus, the choice of a particular style of leadership will depend on the nature of the dental practice, for example, team members in the practice, both individuals and as a group. It might depend on the culture of the practice, on power relationships between team members or partners. It has been suggested that dental surgeons have a preference for professional autonomy, control and status.6 This has implications for their relationships with others and, by implication, their approach to leadership. The situation might also be influenced by the outer context of the dental practice, for example, the amount of competition, commissioning policy or contractual issues. The leader needs to be flexible in adopting a style appropriate to the situation.

Transformational leadership

The transformational approach is contrasted with traditional, transactional approaches;10 the latter are essentially about management, not leadership. Transformational leadership is associated with change; transactional approaches are associated with the status quo. Thus, leadership has been described as 'more to do with aligning people, setting direction, motivating, inspiring, employing credibility, adopting a visionary position, anticipating change and coping with change'.9 Given the context of dental practice, ie one of continuing change, the latter approach is likely to be more relevant, although both approaches are needed to ensure the long-term sustainability of the practice. It has been argued that business management has already been instilled into dentistry6 but there is now a need to extend this to leadership.

This approach places emphasis on the individual leader inspiring and motivating the team, bringing about engagement, and support for transformation, and ensuring ownership. It can be argued, therefore, that dental surgeons will need to acquire transformational skills and attributes to enable them to be effective.

These transformational skills or characteristics include:

  • Charisma – providing vision, gaining respect and trust

  • Providing inspiration – communicating high expectations

  • Providing intellectual stimulation – promoting intelligence, rationality, problem solving

  • Providing individual consideration – providing attention, treating employees individually.10

Fundamentally, the leadership role may be conceptualised as change agent / change leader within dental practice.

The approach in the NHS? Competency approach

In addition to the above theoretical approaches, the competency approach remains popular. Competency is defined as 'a capability or ability'.11 It is linked to leadership skills in that the latter 'refer to learned competencies that leaders are able to demonstrate in performance'.5 The emphasis on 'learned' is important: it is not just ability but aptitude, 'the capacity to learn and develop abilities'.12 One general model of leadership skills is presented in terms of three inter-related clusters of skills (Table 2).

Table 2 Model of primary leadership skills5
Full size table

This model attempts to bring together a set of inter-related skills or competencies. It has been noted that the competency approach has already been utilised in healthcare, with examples such as the Key Skills Framework, the Leadership Qualities Framework and the Medical Leadership Competency Framework.13 The latter also attempts to provide a set of competencies, although aimed primarily at clinicians. It has been devised specifically for doctors at different stages in their development from medical school through to consultant grade or GP principal.

This competency framework identifies five domains, competence in which is said to be essential to any clinician: demonstrating personal qualities, working with others, managing services, improving services and setting direction. Within each domain there are four elements and these are divided into four competency outcomes.

Within the framework there is emphasis on shared decision making and leadership. Shared decision making is a key part of the new government's strategy outlined in Equity and Excellence: Liberating the NHS.14 Dental surgeons work in clinical teams alongside other professionals and it is prerequisite of such teams that the leadership role be shared. This is an important aspect of the leadership role, although a possible omission or perhaps underplayed aspect of these competencies is the requirement to situate such competencies in the specific context.

The competency framework could be applied to the leadership role for dental surgeons. It is important, however, to ensure that dental surgeons are able to adapt the competencies to the context of dental practice. It has been pointed out that there are several differences between doctors and dental surgeons in terms of motivation, values, work patterns, and so forth.6 This has to be taken into account. It is also important to note another important factor with regard to competency frameworks: it 'is not simply what you do [competencies] but how you do it'.15

Conclusion: leadership development?

The above theoretical approaches to leadership are all important in developing leadership effectiveness for dental surgeons. Indeed, they are essentially related to the core concepts underpinning an answer to the question: what is leadership? The core concepts are: leadership as a trait, leadership as an ability, leadership as a skill, leadership as a behaviour and leadership as a relationship.5 The key developmental issues are summarised in Table 3.

Table 3 Key developmental issues
Full size table

It can be argued, therefore, that the approach to the development of the leadership capacity / capability of dental surgeons should be necessarily eclectic. There is a need to ensure that leadership development includes a range of key factors: (a) individual factors – competence, ability, aptitude, traits, behaviour, (b) situational factors, and (c) transformational factors, the latter being particularly relevant in times of change. Perhaps an overarching requirement is to emphasise individual and organisational learning within dental practice, and the need to develop the latter as learning organisations, ensuring they are receptive to the development of leadership.

Competency frameworks are a starting point for this development but there is a need to be cautious in taking this forward. There are some doubts about the validity and the scope of competency frameworks: 'it is becoming more and more evident that while competency frameworks are necessary, they are not sufficient for assessing the full range of leadership behaviours required for effective leadership and organizational success'.15 It is suggested that an inclusive, as opposed to exclusive, theoretical approach is needed. A critical success factor will be ensuring ownership and clinical engagement. The latter has been a major weakness of earlier attempts to transform primary care and so will be a priority.

Dental surgeons will need to embrace a more collegial and shared style of leadership, at the same time ensuring that there is clarity and direction for the practice. Equally, there is a need to take account of contextual differences within and between dental practices. The latter points to the importance of understanding the specific setting or situation. It is important to ensure that leadership is seen as contributing to overall quality and performance in dental practice. It is not a separate unrelated activity. Indeed, it will be central to implementing a different way of working in the future:

'The change in emphasis from quantity to quality will be a considerable challenge for the [dental] profession: it will require a different mindset and a different approach to care.'1

Leadership is, to some extent, the glue that will hold dental practices together, making them coherent and purposeful and linking the clinical and non-clinical activities.