Critical leadership

The Journal of Emergency Medfone, Vol 4, pp 335-340, 1986

CRITICAL Kenneth SectIon of Emergency

Printed m the USA

Copyrfght

??

1986 Pergamon Jarna~s l.td

LEADERSHIP

V. Iserson,

MD, FACEP

Medlclne, Arizona Health Sciences Center, Tucson. Awona

? ?Abstract - Leadership is the process of motivating others to think or act in a specific manner. In critical clinical situations leadership is often lacking. This results from a failure both to understand the leadership role and the elements necessary to carry out this role. The basic elements and models of leadership are described. Eleven basic principles needed to understand and teach medical crisis management are developed. 0 Keywords-leadership: administration; management; crisis; resuscitation; emergency: teaching

When a major trauma patient rolls in or a “code blue” is called for a cardiac arrest, why does chaos and confusion reign? Why does no one assume leadership and restore order? Physicians are well trained in the basic sciences, diagnostic and therapeutic maneuvers, and physician-patient interactions. But these same physicians are never taught clinical leadership. This is a serious deficiency in medical training. Most people are not born leaders: they must be taught leadership techniques.

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power, authority, and force of personality. Any time two or more persons are involved in a situation, power and authority results. The persons involved will either be arranged or arrange themselves into a hierarchy. If both recognize the dominance by one-that person is a leader.’ Power and authority can be either organizationally or individually derived.2.3 Organizational authority and power are held by persons who, because of their position within the organization, are able to reward or coerce subordinates. These persons are seen as formal leaders with legitimate influences. However, the authority inherent in a formal position does not necessarily result in leadership. It all too often leads only to administrative bureaucracy.” Individual authority and power are found in the informal emergent or peer leaders. Their influence originates from unique qualities of the individual, such as professional knowledge or other special abilities. The position they hold within an organization is of minimal importance.

What Is Leadership? What Makes a Leader? Leadership is the process of motivating others to think or act in a specific manner. It connotes a certain type and degree of power by the leader and is an attempt to gain interpersonal influence by the use of

Three leadership models have been studied in an attempt to determine what characteristics make a leader. In the 1940s and 195Os, the trait theories of leadership were intro-

=IIZX=Y Administration of Emergency Medicine is coordinated by Ellen Taliaferro, ‘MD, of =IIXX=Z Bakersfield, California. RECEIVED:6 December 1985; ACCEPTED:7 May 1986 0736-4679/86 $3.00 + .OO

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duced.s Multiple individual characteristics or personal traits were analyzed in an attempt to identify future leaders. However, the results were inconsistent and only showed that different leadership traits predominated in different situations. Trait theory was able, finally, to only identify, by their individual traits, those persons who already were recognized by their peers and subordinates as being leaders. During the 1950s and 196Os, the behavioral theories of leadership were investigated.6.7 This was an attempt to measure the effect of a leader’s style on group behavior. Leaders were evaluated on different scales, with the extreme criteria being task-oriented and employee-oriented styles of leadership. Task-oriented styles placed emphasis on assigning and organizing work and on making decisions necessary to get the job accomplished. Employee-oriented styles stressed openness and friendliness by the leader toward subordinates. The conclusions that could be drawn from these investigations were limited, as they were based on an arbitrary division of the leader’s behavior into two extremes. Neither extreme was usually applicable to the leadership situation. It was also determined that viewing leadership in this way was too simplistic, as leadership style was much more complicated. Since the 1970s the contingency or situational model of leadership has been developed. 3.8Based on the work of F. E. Fielder, this model looks at the impact of situational factors (such as managerial characteristics), subordinate factors, group factors, and organizational factors to determine how leaders optimally function in different situations.9 The model suggests (Table 1) that in a critical or stressful situation, such as exists in a medical emergency, the authoritarian style of task-oriented leadership would be optimal. At the other extreme, substitutes could be utilized in place of leadership (Table 2). l”.ll However, they will not be effective in the crisis of a nonroutine medical emergency.* The “individual leadership substitutes” are adequate for developing a leader

Kenneth V. lserson

for the situation plus active, participating team members. The “organizational factors,” if they exist, may lead to a more supportive team. But, taken together, the three groups of factors that may substitute for leadership on an individual basis or in routine situations will not be effective where critical leadership is required.

Can Leaders Be Trained? People are not born to lead, they are taught to lead. However, to begin to teach the leadership skills needed for the management of clinical medical crises, the following basic principles must be recognized.‘2

The Individual Who Takes Charge Is in Charge The person who is willing to step from the crowd and assume the role becomes the leader. If one person is willing to emerge from the crowd and be identified as the leader, the remainder of the personnel, including peers, are usually willing to follow. Many persons who are uncomfortable with the prospect of leadership perform capably, even admirably, once they have made the decision to assume this role. This action will preempt a destructive situation seen commonly in many emergencies when multiple individuals, concentrating on only part of a situation, and always controlling overlapping resources of personnel and material, issue uncoordinated, unplanned, and usually contradictory orders. This is best described by the corollary, “If there is more than one leader there is no leader.”

Leadership Means Responsibiiity In accepting the leadership role, the individual assumes the mantle of the group’s possible failure. Any individual’s faltering can be laid at the leader’s feet. This is the law of total responsibility. If a person of

Recommended leadership style

Situational certainty

Situational favorableness

Situational Factors

Table 1. Fiedler’s

Task

Strong

Leader Position Power

Good

Good

Task

Good

3

Task

Strong

) Unstructured

Very certain situation

Favorable

Weak

Structured

2

1

Structured

Model9

Task Structure

Cell Leader/Member Relations

Contingency

Employee

Poor

Poor

favorable

Weak

Employee

Employee

certain situation

Moderately

Strong

1 Structured

6

5

) Structured

Moderately

Weak

Unstructured

Good

4

Very uncertain

Task

Poor

8

Task

situation

Weak

Unstructured

Unfavorable

Strong

Unstructured

Poor

7

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Kenneth

Table 2. Substitutes

V. lserson

for Leadership Will Decrease Need for

Leadership

Substitute

Task Orientation

Individual: Experience/expertise/training Professional education Self-confidence Task and Group Factors: Intrinsically satisfying task Routine task Self- or job feedback rather than supervisory feedback Established group norms Highly cohesive group Organizational Factors: Formalized rules and policies Extensive support staff Low leader reward/coercive power Spatial distance between leader and subordinate Adapted from Howell and Dorfman”

X X X

Employee

Orientation

X

X X X X X

X

X X X

X

X

X

and Kerr and Jermier.”

lesser authority doesn’t perform, responsibility for the failure reverts upward.13 The more obsessive we are, the more the fear of failure is with us. It is easy to be part of a team that may bask in the glory of success. It is easier still to be only a small part of the team’s potential failure. An individual’s confidence in his ability counts little when faced with the overwhelming burden of an entire team’s potential failure. Willingness to take the responsibility of leadership, then, can be seen as a form of maturity, needing careful development and nurturing. If a person is unwilling to accept this responsibility, he is voluntarily removing himself from the leadership position and then cannot deal with the problem.*3

ranking implies, and in some cases explicitly dictates, authority. However, in many situations the authority figure may not be up to the task of leadership. This may be because of inadequate knowledge of the patient, the process, or the situation. Or, he may not have the capacity to lead. In many situations the authority figure may feel he must attempt to lead despite these inadequacies. Poor leadership or no leadership is the result. However, if this individual has the self-confidence to specifically delegate leadership to a competent individual, the situation can be saved. Authority, like leadership, denotes responsibility. The authority figure can, at best, share this responsibility.

People Feel Better if There Is a Leader Authority Is Not Equivalenf to Leadership

A hierarchial ranking system, equivalent to authority, is common to the police, fire department, and paramedic organizations. There is also a definite hierarchy within the hospital. Aides and orderlies report to nurses, who are often responsible to the intern, who in turn is responsible to the chief resident and attending physicians. This

The question must come up-why leadership? Leadership connotes effectiveness, direction, and lowered stress. A most obvious difference in a crisis team with a leader is the sense of direction and cohesion of the participants in the group. Individual and group anxieties are lowered, and there is planning and overall organization, rather than a moment-by-moment reaction to the situation. This, however, presumes a de-

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Crltlcal Leadership

cisive leader. Admiral Arleigh Burke, a noted naval commander in World War II, believed that “the difference between a good leader and a poor one was ‘about ten seconds.““4 This ten seconds is where the team feels abandoned in the company of an indecisive leader. It is all well and good that there must be a leader. But how to lead? There are some general principles that every potential crisis leader can use to effectively take charge.

People Perform Better in a Familiar Situation

One benefit of repetition, as well as the often maligned clinical algorithms, is the confidence the clinician gathers in dealing with specific situations. The old surgical training axiom, “The problem with every other night call is that you miss half of the pathology,” demonstrates an understanding that potential leaders may do better if they have had multiple similar clinical experiences. However, this is also true of leadership experiences themselves. The more often an individual leads a crisis team, the better they will perform. Leadership’s task is to help others become “doers” through delegation. I3 This is best learned by practice. Past behavior affects both the perception and reality of power and authority by an individual.‘,”

The Emergency

Exists for the Patient

That means that it is not your emergency. This is a principle that not only must be understood by those who will lead, but must be transmitted in word and deed to members of the team. In fact, in a medical crisis, even with limited time and resources, sparse information, rushed and somewhat stressed personnel, the patient should be the only one with an emergency. During this period it is necessary for the team to perform at their most professional and capable level. A calm leadership attitude is the method to convey this feeling.”

Screaming and Leadership Are Not Synonomous

True leadership in critical situations is most clearly identified by teams that are working with a hum rather than a roar. Loud noises punctuated by yelled orders is the hallmark of disorientation and disorganization. Respect and cooperation is gained by the calm, strong leader. The leader is the person who sets the tone for the team. This tone is “calm’‘-and its color “quiet.”

“Someone” Doing “Something” Is Identical to No One Doing Anything

Frequently heard during an emergency is the request for “someone” to hand over a piece of equipment, run to the lab, or draw a blood sample. Unfortunately, it is not usually noticed until after the fact that no one rises to this request by, again, taking responsibility to do the activity. The leader’s ultimate responsibility is to get the job done. Parts of that job need to be delegated. But specific rather than general delegation of the responsibility is needed, eg, “Dr Carter! Hand me the syringe.”

Individuals Given Responsibility in a Critical Situation Perform It (or Get Someone E/se to Perform It) Until Relieved

People like to be part of the excitement and like to help others whenever they can. Thus individuals can be asked to help with the expectation that they will perform conscientiously within their capabilities. Frequently a leader may not know specific names, or sometimes capabilities, of individuals. This is true in both hospital and prehospital care situations. However, pointing to an individual and giving them a specific job to do will almost invariably achieve the required response. When utilized in a prehospital care situation, this technique can allow a leader to make use of the invariable crowd of people even

Kenneth

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though trained medical personnel are not available in adequate numbers.

The Leader Must Protect His Team Especially important in the prehospital care setting is that the leader must discourage members of the team from taking risks with their own life. A leader’s primary concern is the safety of the team members.

A Leader Can Delegate To be an effective leader it is imperative that tasks be delegated to members of the team. However, effective leaders recognize

V. lserson

that there are often multiple ways of doing an individual task. The final task of leadership, then, is to have tolerance for team members in their individual method of fulfilling the specific required activities, provided that the method is compatible with the desired outcome. Leadership in critical situations is sorely lacking. Our educational system both on the undergraduate and the postgraduate levels does not recognize that clinical leadership is the ultimate synthesis of medical knowledge and one of the most important aspects of critical medical care. The concept that leaders cannot be developed must be put to rest. Especially in emergency care, development of clinical leadership is vital and must be integrated into our education system at all levels.

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Bureau of Business Research, Columbus, Ohio

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