Leadership Development in Healthcare: A counter narrative to inform policy

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Leadership Development in Healthcare: A counter
narrative to inform policy
Hewison, Alistair; Morrell, Kevin
DOI:
10.1016/j.ijnurstu.2013.08.004
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Hewison, A & Morrell, K 2014, 'Leadership Development in Healthcare: A counter narrative to inform policy'
International Journal of Nursing Studies, vol. 51, no. 4, pp. 677-688. DOI: 10.1016/j.ijnurstu.2013.08.004
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Author's personal copy
InternationalJournalofNursingStudies51(2014)677–688

ContentslistsavailableatScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Leadership development in the English National Health

Service: A counter narrative to inform policy

Alistair Hewisona,*, Kevin Morrellb,1

aSchoolofHealth&PopulationSciences,UniversityofBirmingham,Edgbaston,BirminghamB152TT,UnitedKingdom
bWarwi ck Busines s School,Univ ersityof Warwick,C ov entryCV47A L,UnitedK ingdom

A R T I C L E I N F O A B S T R A C T

Articlehistory: Objectives: To examine the current approach to leadership development in the English
Receiv ed17April2012 NationalH eal thService (NH S)and consideri tsi mplications fornursing.

Receivedinrevisedform16August2013 Tostimulatedebateaboutthenatureofleadershipdevelopmentinarangeofhealth

Accepted16August2013 caresettings.

Background: Goodleadershipiscentraltotheprovisionofhighqualitynursingcare.This

Keywords: has focussed attention on the leadership development of nurses and other health care
Nursingleadership staf f.Ithasbe enakeyp olic yco ncerninth eEnglishNHS ofl ateand fost eredth egrow thof
Epistem e leade rs hip devel o pme ntpro gramme sf oun dedon comp et ency bas edappro ach es.
Leadershipdevelopment
Design: Thisisapolicyreviewinformedbytheconceptofepisteme.
Policy
Datasources: Relevantpolicydocumentsandrelatedliterature.

Reviewmethods: UsingFoucault’sconceptofepisteme,leadershipdevelopmentpolicyis

examined in context and a ‘counter narrative’ developed to demonstrate that current

approaches are rooted in competency based accounts which constitute a limited, yet

dominantnarrative.

Conclusion: Leadershiptakesmanyformsandvarieshugelyaccordingtotaskandcontext.

Acknowledging this in the form of a counter narrative offers a contribution to more

constructivepolicydevelopmentintheEnglishNHSandmorewidely.Amorenuanced

debate about leadership development and greater diversity in the provision of

development programmes and activities is required. Leadership development has been

advocatedasbeingcrucialtotheadvancementofnursing.Detailedanalysisofitsnature

andfunctionisessentialifitistomeettheneedsofnurseleaders.

(cid:2)2013ElsevierLtd.Allrightsreserved.

Whatis already knownaboutthe topic? (cid:2) Relationalandempoweringleadershiphasbeenfoundto

be effective in nursing.

(cid:2) Leadership development is necessary for effective (cid:2) Leadership developmentis largely competencybased.

nursing leadership.

Whatthis paperadds

* Correspondingauthor.Tel.:[phone].
(cid:2) Theuseoftheconceptofepistemerevealsthelimitations
E-mailaddresses:[email protected](A.Hewison),
of competency based approaches to leadership devel-
Ke1viTne.Ml.:[email protected] 9(K9.. Morrell). op ment.

0020-7489/$–seefrontmatter(cid:2)2013ElsevierLtd.Allrightsreserved.

http://dx.doi.org/10.1016/j.ijnurstu.2013.08.004
Author's personal copy
678 A.Hewison,K.Morrell/InternationalJournalofNursingStudies51(2014)677–688

(cid:2) Thereisanevidencebasedemonstratingthelimitations demonstratingtheeffectthatsuchassumptionscanhave.

of competency models that is overlooked for policy Epistemes have been used to describe organisation-level

purposes. settingstoo,forinstanceO’LearyandChia(2007)described

(cid:2) The development of a counter narrative is a useful how epistemes supported sense-making at a family-

corrective to current leadership development policy. owned newspaper.

Here we describe the effects of a policy episteme –

1. Introductionand background relating to ‘leadership’ in healthcare. This episteme

results in a narrative about leadership that is theoreti-

Theneedforleadershipin,andof,theNationalHealth cally thin and simplistic. It produces a certain view of

Service(NHS)hasbeenarecurringthemeinEnglishhealth leadership – as based on a dominant competency

policy in recent years (DH, 2000, 2008a,b, 2009a,b). This account – that neglects complexities such as the

canbeseenasthelatestinaseriesofinitiativesdesignedto interrelationship between the context for leadership

engagecliniciansmoredirectlyinthemanagementofthe and individual leaders. This in turn influences

NHS (Glennerster et al., 1994; Harrison et al., 1992; approaches to development. We suggest that the

HuxhamandBothams,1995;Packwoodetal.,1991).The complexity of NHS leadership cannot be adequately

latest example of policy development in this area is the conveyed unless alternative accounts are also accessed.

establishment of the NHS Leadership Academy with its To demonstrate this, and develop a counter-narrative of

mission to develop outstanding leadership, in order to NHSleadershipdevelopment,wedrawonGrint’s(2000)

improvepeople’shealthandtheirexperiencesoftheNHS fourfold typology of approaches to representing leader-

(NHSLeadershipAcademy,2013).Howevertheleadership ship, (see below). Each typology generates different

challengefornursingisnotconfinedtotheEnglishNHS,for insights on the nature of leadership, and this raises

example the International Council for Nurses (ICN) has a questions about how leadership development is being

visionthatNursinginthe21stcenturywillhavenursesata pursuedinhealthcare.Theidentificationofthiscounter-

country and organisational level equipped with the narrative is important in order to counterbalance the

knowledge, strategies and strength to lead and manage prevailing competency-based, instrumental approaches

in health services and in nursing through change for a to leadership in contemporary policy (Bolden and

healthier future for all populations (ICN, 2013). This Gosling, 2006; Bolden et al., 2006). This approach could

indicates that leadership, and its impact on nursing and also be applied more widely to inform debates about

patient care, is of international concern (Bishop, 2009; howbesttoapproachnursingleadershipdevelopmentin

Freshwateret al., 2009). Furthermore detailed considera- othersettings.ForexampleinIrelandithasbeenargued

tionofarangeoftheoreticalinsightsisvitalifpolicyinthis that greater attention needs to be given to interdisci-

area is to be appropriate and result in approaches to plinarity(Fealyetal.,2011),andinTurkeydevelopment

leadership development that improve the quality of based on a model of transformational leadership has

leadershipand patientcare. been advocated (Duygulu and Kublay, 2010). Similarly,

The purpose of this paper is to examine this develop- in Canada, an empowerment framework for develop-

ment in the context of the instrumental logic which has ment has been recommended (MacPhee et al., 2011),

informedEnglishhealthpolicyoflate,andcontrastitwith which suggests that a variety of approaches need to be

the normative logic (Brown, 2008; Taylor-Gooby and considered and evaluated.

Wallace, 2009) evident in the literature that discusses The paper is divided into five main sections. First, we

leadership development in health care, and consider its offerabriefreviewofleadershipinhealthcareinEngland

implications for nursing. The intention is to make a to provide a context for the discussion. Second, we

contribution to the burgeoning literature which has summarise the principal approaches to the development

examined leadership in nursing (see for example Cum- of leadership capacity in health care, launched as part of

mingsetal.,2010;Laschingeretal.,2011;MacPheeetal., theNHSPlan(DH,2000)andgivenfurtherimpetusinthe

2011;Salmelaetal., 2012;StewartandUsher,2010)and Darzi Review of the English NHS (DH, 2008a,b, 2009a,b),

demonstratehowtheapplicationofanaspectoftheorycan andmostrecentlyculminatedintheestablishmentofthe

illuminateimportantissues withregard to leadership. NHSLeadershipAcademy.Thisillustrateshowtheleader-

To do this we use the concept of episteme (Foucault, shipdevelopmentchallengeisbeingaddressed.Third,we

2002). An episteme is a collectively internalised logic or presentasummaryofthemajortheoreticalstrandsinthe

‘codeofculture’(O’LearyandChia,2007,p.392);asetof leadership literature and argue that the current perspec-

interconnected,typicallyunspokenassumptionsthatboth tiveonleadershipdevelopmentinEnglishhealthcareisbut

describeandbringintobeingsocialphenomena.Epistemes oneepisteme,whichhasemergedasanattempttoimpose

makethesocialworldbecausetheycreateparticularkinds order on an inherently complex area of policy develop-

ofsubjectsandcategories,andindoingsotheyjustifythe ment.Finallyweargueforamorenuancedpictureofthe

use of power and, ultimately, support different kinds of realityofleadershipdevelopmentandgreaterdiversityin

violence.Mostinfluentially,Foucault(2001,2002)studied the provision of development programmes and activities

epistemesinrelationtotheinventionofmadnessandthe for nurses. Acknowledging that leadership takes many

label, ‘insane’; the nature of academic knowledge and forms and varies hugely according to task and context,

disciplines, and a range of other topics. Spivak (2009) offersamoreconstructiveplatformforpolicydevelopment

describes how an episteme of imperialism makes the in complex healthcare organisations (Fairhurst, 2009;

colonial subject into someone that is regarded as ‘other’, Grint, 2010).
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2. Leadership in the EnglishNational Health Service 2.2. General Management anda newperformance regime:

1984–1990
With an organisation as large and complex as the

National Health Service (NHS) there is always a risk in In the wake of the publication of the Griffiths Report

attempting to summarise aspects of its history. Indeed (DHSS, 1983), private sector management approaches

drawinganygeneralconclusionsaboutitsleadershipand wereintroducedprimarilyintheformofthenew‘General

managementisfraughtwithdifficultybecausethereareso Managers’,whowereintendedtobetheequivalentofthe

manyfactorstotakeintoaccountincludingtradition,the chief executives in commercial companies. There was

poweroftheprofessions,thelegacyofstructuralchanges, considerableoppositionfromtheRoyalCollegeofNursing

successive reforms, and different ideologies. Notwith- to the changes proposed by Griffiths, however the

standing these caveats, the shift in policy focus to recommendations were implemented in full (Klein,

‘leadership’ and ‘leadership development’ in the NHS 1995), and resulted in the removal of many nurses from

occurred comparatively recently (Edmonstone and Wes- the senior management positions created following the

tern, 2002), and gained momentum following the pub- Salmon Report, (see above) (Owens and Glennerster,

lication of the NHS Plan (DH, 2000) (Currie and Lockett, 1995), and signalled the importance of ‘management’ as

2007; Ford, 2005). opposed to administration in the NHS. The need for

The organisation of the NHS can be characterised as management and organisation was identified, however

movingthroughfourmajorphases(Mannionetal.,2010) leadershipdidnotfeatureprominentlyinanyformalway,

whichsummarisetheformalstructuresinplaceatspecific although as noted earlier, leadership was being enacted,

periods of time, which in turn determined in part the eventhoughitwasnotexplicitlyacknowledgedinpolicy.

emphasis given to leadership. These phases provide a

broadframeworkforchartingtheemergenceofleadership 2.3. The QuasiMarket 1991–1997

development as an organisational concern, and as we

argueinthesecondsection,canbeunderstoodintermsof This period saw the establishment of the Internal

theFoucauldianconceptofepisteme–implicitlogicsthat Market model of purchasers and providersto impose the

govern what constitutes legitimate knowledge, and that discipline of the market on health care organisation, and

structureinferenceandactioninsocialsettings(Foucault, clinicalgovernancetoraisequality(DH,1989,1997).This

1973, 2002). wasallinthecontextofwhatbecameknownastheNew

Public Management (Ferlie et al., 1996; Hood, 1991) and

2.1. From thebeginning: 1948–1983 attentionwasonthetechnicalitiesofthemarketandthe

contracting process (Appleby, 2004; Dixon, 1998). In

Although relatively little academic social scientific addition the development needs of purchasers, and

research into NHS organisation occurred until the mid subsequently commissioners were of concern (Ham,

1960s(Mannionetal.,2010),extensivehistorieshavebeen 1994; Mohan, 1996). Although some leadership develop-

written about this period (see Webster, 1988, 1998 for ment was taking place it was not the major project it

example) which indicate that the service was run on the becamein later years.

basisofsupportingthehealthprofessionalstodelivercare

and treatment, thus the emphasis was on administration 2.4. Investmentand reform:1997–2008

rather than leadership. The managers were ‘diplomats’

(Harrison,1988)whoensuredtheprofessionalswereable More recently, drawing heavily on the philosophical

to treat and care for patients in the way they saw fit. preceptsofthe‘ThirdWay’(Giddens,1996),theNHSPlan

Nursing was focused on professional care and aside from (DH, 2000) signalled further investment in, and develop-

the Matron role had little involvement in leadership in a mentof healthcare organisation focussed on modernisa-

formal sense (Clarke, 1995). This is not to suggest that tion (DH, 2001). This was accompanied by the

nurses were not engaged in departmental and team establishment of the National Institute for Health and

leadership in delivering clinical care, rather to indicate Clinical Excellence (NICE, 2005), formalising a system of

thatatapolicylevelorganisationalleadershipwasnotan evaluating services based on evidence. The Darzi Review

overridingconcern.Twoofthemajorpolicyreformsofthis (DH, 2008a,b, 2009a), with its distinct, if not always

period, the Salmon Report (MOH, 1966) and the 1974 consistent,emphasisonleadership,referringtoitatleast

reorganisation (DHSS, 1974), reflected this emphasis on 50 times (OT, 2009), and in different ways (Morrell and

management structures and organisational control. For Hewison,2013),wasamajorpolicypronouncementonthe

example both of these reports drew on ‘systems theory’ organisation and management of the English NHS. This

(Scott, 1961) to an extent in recommending that the document accords great importance to leadership and

differentelementsoftheserviceandthelevelsofnursing exhorts all those who work in health care to become

organisation needed to be sub-divided, and managed as leaders. The outcome of this is examined in more detail

separateunitsiftheyweretobeeffective.Innursingthis below.

resulted in a hierarchical structure being developed in Imposingdistinctstartandendpointsfortheseperiods

whichsenioritywasdesignatednumerically.Soanumber can never be entirely accurate, because proposals pre-

7 was a ‘nursing officer’, senior to a ward sister, and a sentedaspartofapolicypackageinoneyearmaynotbe

number 8 was at the next level in the nursing organisa- implementeduntilsometimelater,andtheeffectscantake

tional pyramid. manyyearstobecomeapparent.Inaddition,withgeneral
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trends in public sector change, such as the New Public 3.1. TheLeadership Qualities Framework

Management, it is not always possible to identify the

precise origins, trajectory and effect of their component The NHS Leadership Qualities Framework (LQF) was

parts (Clarke et al., 1994; Ferlie et al., 1996). Nor is the developed by the Modernisation Agency as a set of

presentationofthisfourphaseaccountintendedtosuggest standards for ‘outstanding leadership’ in the service. It

there was no concern with, or activity in relation to describesthequalitiesandbehavioursexpectedofexisting

leadershipdevelopmentintheearlieryearsoftheNHS.For andaspiringleaders.Itwasdesignedtobeusedacrossthe

example the Leading Empowered Organisations pro- NHStounderpinleadershipdevelopment,forindividuals,

gramme was accessed by more than 32,000 nurses and teams and organisations. The NHS Leadership Centre

was positively received by many of its participants conducted an early implementation programme in 37

(Faugier and Woolnough, 2003; Garland, 2003), although health and social care organisations to pilot the frame-

itwasacknowledgedthattheinitialempowermentofstaff work, which informed the production of a Good Practice

would be undone if organisations did not recognise the Guide to assist other organisations in adopting the LQF

value of the principles the attendees had explored (NHS Leadership Centre, 2004). However as Bolden and

(Woolnough and Faugier, 2002). Rather, it is a way of Gosling(2006)pointout,thishasaquestionableempirical

summarisingacomplexmixofcircumstanceswhichhave foundationastheinitialresearchitwasbasedonconsisted

culminated in the current preoccupation with leadership solely of self-report data from a small number of chief

in the English NHS. Setting these cautionary comments executives and directors. The LQF is made up of 15

aside, ordering the approaches to the organisation of the leadership behaviours which are meant to provide NHS

NHS in this way serves to locate the origin of the major staffwithameansofanalyzingtheirleadershiprolesand

thrust for leadership in health policy in the late 1990s. responsibilities (NHS Leadership Centre, 2004). These

Since then it has been an area of continuing concern. In qualities are arranged in three clusters which are: Self-

viewofthisthenextsectionwillreviewtheapproachesto Belief, Setting Direction, and Delivering the Service. The

leadership development that have been pursued in the Good Practice Guide (NHS Leadership Centre, 2004)

NHS,taking 2000 as thestarting point. includes a brief report of a one year evaluation project

The review takes the form of a discursive narrative commissioned to review the different applications of the

analysis. It is based on the approach developed by LQF in the implementationsites. Presented as short ‘case

McSherry et al. (2012) and informed by Smith (2007) studies’,thelongestbeingonefullpageoftext,withmost

which draws on a wide and sometimes disparate range constituting between 6 and 19 lines, they are purely

of theoretical, empirical and policy literature to ensure descriptiveandthereisnoindicationthattheyhavebeen

the diverse sources that have influenced, and reflect the subjecttotheanalysisrequiredwhencasestudiesareused

approaches taken to leadership development are asaresearchapproach(Yin,1993,1994).Consequentlythe

addressed. results of this review are somewhatbrief and again raise

concerns about methodological rigour. The case studies

nonethelessrevealarangeofapplicationsoftheLQFfrom

3. Leadershippolicy simplyraisingawareness,throughtoprovidingastructure

for leadership development activity, and use in recruit-

In stating that ‘delivering the plan’s radical change ment andselection processes.

programme will require first class leaders at all levels of Althoughtheframeworkwaspresentedasallowingfor

the service’ (DH, 2000, p. 86) and suggesting that these ‘...flexibilityandcreativityinitsapplication’(NHSLeader-

leaders will need to be both clinical and managerial, the ship Centre, 2004: 4), it has been characterised by Ford

NHSPlan(DH,2000)servesasasuitablepointofdeparture (2005)asanattempttooffera‘holygrail’solutiontothe

for examining the representation of leadership in health definitional difficulties associated with leadership. Even

carepolicy.IndeedtheNHSPlancandidlystates:‘Leader- so,ithasbecometheassumedidentitythatNHSManagers

shipdevelopmentintheNHShasalwaysbeenadhocand and professionals should adopt if they are to become

incoherentwithtoofewcliniciansinleadershiprolesand successfulleadersintheNHS(Ford,2005).Thispointwill

too little opportunity for board members to develop be explored further when reviewing the literature (see

leadershipskills.Thatwillnowchange’(DH,2000,p.87). below), however itis includedhere to illustratehow one

This changewas tobe broughtabout by a‘Leadership particular perspective on leadership has been very

Centre’, established in 2001 as part of the newly formed influential in the policy approach taken to leadership

ModernisationAgency(DH,2007).Asummaryreportofits development in the NHS.

workfrom2004(DH,2004),indicatesthescopeandscale The expansion in leadership development activity has

ofitsactivity.Deliveringandcoordinatingatotalofsome continued in the wake of the Darzi Review (DH, 2008a,b,

47leadershipdevelopmentprogrammesorinitiatives,the 2009a), which was produced following a year-long

Leadership Centre was central to the realisation of the consultation process involving more than 62,000 NHS

leadershipaspirationsoutlinedintheNHSPlan(DH,2000). staff,patients,stakeholdersandmembersofthepublic.It

These programmes were accessed by more than 68,000 contained plans including: ‘Placing a new emphasis on

nurses,AlliedHealthProfessionals(AHPs)andHealthcare enablingNHSstafftoleadandmanagetheorganisationsin

Scientists (DH, 2004, 2007). This extensive leadership which they work’ (DH, 2008a, p. 13), based on a ‘need to

development activity was organised within a broad further develop clinical and managerial leadership’ (DH,

frameworkknown as The Leadership QualitiesFramework. 2008a,p.61).Withregardtoleadershipdevelopment,the
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recommendationwasthatanewstandardbeintroduced. GiventhewidespreadchangeunderwayintheEnglish

This is the Leadership for Quality Certificate, which will NHS (Ham, 2010), it is timely to examine the relevant

operate at three levels. Level 1 will be for members of literature to contribute to the important policy debate

clinical and non-clinical teams with an interest in concerninghowbesttoapproachleadershipdevelopment

becoming future leaders. Level 2 will be for leaders of intheNHSandnursing,whichalsohasrelevanceforother

team and service lines, and level 3 will be for senior healthsystems.Theapproachtakeninthisdiscussionisto

directors(DH,2008a,p.66).Thisistobecoordinatedbythe drawon theconcept ofepistemeto informthe analysis.

‘NHS Leadership Council’ (NLC) a sub-committee of the

NHS Management Board with a remit to champion the 4. Epistemes ofleadership development

transformation of leadership across the NHS, however at

the time it was not clear how the council would operate Epistemes are implicit rules of formation that govern

(Dawson et al., 2009). Subsequently the Medical Leader- what constitutes legitimate knowledge (Foucault, 1973,

ship Competencies Framework (NHS III, 2009) was 2002). They are underlying codes that control language,

developed,buildingontheNHSLeadershipCompetencies logic, schemas of perception, values and techniques

Framework.Themostrecentsignificantdevelopmenthas (O’Leary and Chia, 2007). These internalised rules of

beentheestablishmentoftheNHSLeadershipAcademyin formation and preconscious processes of inclusion or

July2012whichseekstointegrateallthenationalactivity exclusion give structure to social relations. They are

supporting leadership development in health and NHS systematicallyinternalisedassocialconventions(O’Leary

funded services with the principal purpose of developing andChia,2007).Epistemesresultinthecreationofobjects

outstanding leadership in health, focussed on improving of attention, the fixing of key reference points, and are

patients’ experiences and health outcomes (NHS Leader- sense-givingsincetheyembedproceduresforinterpreting

ship Academy, 2013a). In pursuit if its mission it has the social world (Foucault, 1973). Although concerned

launched what it claims to be the largest and most withtherulesandconventionsforsense-makingthattake

comprehensiveapproachtoleadershipdevelopmentinthe place within broad sociocultural contexts, the focus on

world(NHSLeadershipAcademy,2013).Thiswillinvolve epistemes can also direct attention to the policy process

workingwithanumberofinternationalacademicinstitu- andthegovernanceoflargecomplexinstitutionsincluding

tionsandhigh-performingfirmstodeliverfoundation,mid the NHS. Our account of the four phases of NHS

andseniorlevelleadershipprogrammes(seebelow)forup development, drawing on the work of Mannion et al.

to 25,000 NHS staff, including doctors, nurses, Allied (2010) presented earlier, is one chronological account of

Health Professionals, healthcare scientists, and Human epistemes,butwithmorespecificreferencetoleadership,

Resourcesandfinancepersonnel,startingSeptember2013 several other such epistemes can be described and

(NHSLeadershipAcademy, 2013). examined. This supplements a purely historical analysis

of the empirical context for healthcare policy, with a

(cid:2) ThefoundationlevelprogrammeisforNHSstaffaspiring diachronousaccountofthetheoreticalcontextforstudy-

to a rolethat involvesleading others. ing leadership.

(cid:2) Themid-levelprogrammeisforstaffwhomanageteams

and services. 4.1. Rationalityas the dominantepisteme ofleadership

(cid:2) The senior level programme is for experienced indivi- development

duals whoaspire toexecutive level roles.

Leadership and leadership development are complex

Partoftheinvestmentintheacademywillbedevoted phenomena and a ‘one size fits all’ policy approach to

totwoprogrammesspecificallyfornursesandmidwives, improving leadership in the NHS seems unrealistic.

bothscheduledtostartin2013(NHSLeadershipAcademy, However, the overall framework for leadership develop-

2013). mentintheNHSismainlyqualitiesorcompetencebased.

This summary of leadership development activity in Thissuggeststhereisaneedforanalternativeaccountto

Englishhealthcaresince2000demonstrateshowleader- inform policy. The emphasis on competencies as the

ship has come to be seen as a policy priority. This is foundation for leadership development in the NHS is the

reflected in statements such as ‘Leadership is vital to dominantnarrative.Wehavetracedthisintermsof(small

realising our ambitions in the plans for the NHS’ (DH, e)epistemesofpolicydevelopment,butperhapsitcanbe

2008c,p.17)andtheorganisingvisionoftheNLC:‘World- explainedintermsofanoverarching(bigE)Episteme,or

class leadership talent and leadership development will collective myth: the assumption of rationality in the

exist at every level in the health system to ensure high administration of work and organisations. We draw a

qualitycareforall’(Dawsonetal.,2009,p.2).Againthisis distinction between E/episteme in an analogous way to

not to suggest that leadership development activity for howsomedifferentiateD/discourseorN/narrative.So,the

nursing was non-existent before this period, indeed the Episteme of rationality is a grand, overarching set of

RoyalCollegeofNursingLeadershipProgrammehasbeen related ideas reflected in the prevailing culture and

runningsince1995andparticipantshavereportedthatit developedovertime.Wesuggestthatsmaller,morelocal

results in positive change in their leadership capability epistemes(suchasattitudestoleadershipdevelopmentin

(CunninghamandKitson,2000;Largeetal.,2005).Rather the NHS) can be seen as nested within this overarching

itistoindicatethatitbecameasignificantpolicyconcern Episteme (though they are not necessarily contained in

at this time. their entirety or coterminous). Both kinds of episteme
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shapeexpectationsaboutwhatispossibleandimaginable safety(Botwinicketal.,2006;WHO,2008),thecorefunction

butsincewediscussaspecificcontext,itishelpfultosignal ofanyhealthsystem.

the difference between a context specific sense and the Yet in the context of representing leadership, and in

traditional, Foucauldian sense. Foucault used the term devisingpolicytodevelopleaders,instrumentalrationality

slightly differently over the course of his work, but maynotbeuniversallybeneficial,becauseitclosesdown

generally his usage is closer to the grander sense of representations of leadership as something dialectically

Episteme, as defining the sensibilities, assumptions and complex or (locally) socially constituted. In order to

fashionsof an age (Foucault,1973,2002). standardiseandsystematisetheprocessofpreparingstaff

There are many dimensions of rationality, (Albrow, to become leaders, competency based approaches, with

1990; Brubaker, 1984; Collins, 1994; Eisen, 1978; Ritzer, their assumptions of predictability, calculability and

2004),andmostrelevanthereistheworkofWeberandhis measurability, seem a ready fit with pre-existing norms

concernwiththeprominenceofinstrumentalrationality. associatedwiththerationalityEpisteme.Thisisreflected

Weber used the term to explain the development of intheformalisedandcentralisedleadershipdevelopment

Westernsocietyinwhichactionswerequantifiedinorder systemsintroducedintheeducation,government,defence

toinformtheorganisationofworkandtheadministration and health sectors (Currie and Lockett, 2007). The

of large-scale organisations, which in turn was necessary Episteme of rationality seems to be at the root of policy

to underpin the specialised division of labour character- in leadership development. Ford (2005) contends that

istic ofbureaucracy (Jary andJary, 1991;Weber, 1978). leadershipresearchreflectsfunctionalistrootsintheoris-

Instrumentalrationalityshapessocialstructuresinways ingonleadersandleadership,assumingthatleadershipis

thatmeanindividualsarenotlefttotheirowninitiativein anindispensiblecomponentofallorganisations.Through

thesearchforthebestmeansofattainingagivenobjective. this process of reification the concept of leadership takes

Theinfluenceofthecontinuingprocessofrationalisationis onanobjectiveexistence,whichseemstoplaceitbeyond

most evident in the organisational form of bureaucracies, challenge (Ford, 2005). A similar process seems to have

and a marker of this is a reliance on, and reification of, occurred in relation to leadership development. Even

measurable competencies. Rationalisation emphasises the though the limitations of competency based approaches

quantification of as many things as possible and leads to arewidelyacknowledged(Bolden,2004;Burgoyne,1989;

modes of exerting control over people through the Conger and Ready, 2004), there appears to have been an

replacementofhumanjudgementwithdisciplinaryregimes uncritical acceptance of them as the basis for leadership

of rules, regulations and structures (Ritzer, 2004). Ritzer’s development in the NHS. This has occurred despite the

relatedaccountofformalrationalitydescribestheadvance existence of extensive theoretical accounts which reflect

of McDonaldization, where society is becoming progres- the diversity of leadership.

sivelyrationalisedandcharacterisedbythepredominance

ofefficiency,calculability,predictabilityandcontrol(Ritzer, 4.2. Leadershipas contestedterrain

1998). Although there has been a drive to dismantle

bureaucracies in order to create flexible responsive orga- Grint(2000, pp. 2–3)identifiesfourbroad approaches

nisations, Hales (2002) found that there has not been a to representing leadership in the academic literature. He

wholesale de-construction of hierarchies and regulations. categorisesarangeofstudiesintermsoftheirtreatmentof

Whereattemptshavebeenmadetodothiswhatisleft,are the individual and/or the context as ‘essentialist’. These

notpost-bureaucratic,internalnetworkorganisations,but levelsofcategorisationaresummarisedbrieflybelow.Trait

‘bureaucracy-lite’ organisations, with all the strength of approaches place the emphasis on the qualities the

bureaucraticcontrolaccompaniedbyadepletedhierarchy individual has and what the leader does as a result of

(Hales, 2002). In the case of health care it is evident that this, and take little account of the importance of the

rationalisation and bureaucracies are alive and well. For contextinwhichleadershiptakesplace(VeraandCrossan,

exampleinaninterviewbasedstudyinvestigatingcapital 2004).SituationalaccountssuggestNHSleaders(including

investmentappraisalintheNHS,contrarytotherhetoricof nurses) can diagnose situations and determine an appro-

debureaucratisationthataccompaniedtheintroductionof priate course of action (Hersey and Blanchard, 1988;

this process, bureaucracy remained dominant and it was VroomandYetton,1973),arisingfromarationalperspec-

concludedthatfarfrombeingdead‘KingBureaucracy’was tive, which assumes leaders possess the necessary

alive and well (Schofield, 2001). This was also found by information and insight, and have the ability to modify

Ackroyd et al. (2007) who reviewed public management their styles. The dominant situationalist approaches also

reforminhousing,healthandsocialservicesandconcluded assume a limited number of ways of describing the

thatacrossallthreesectorstherewasevidenceofincreasing context. Whereas contingency approaches combine ele-

bureaucracy and managerial supervision. Some would ments of trait and situational accounts, suggesting

regard this as a positive thing, bureaucratic rationality effectiveness is a matter of fit – the right person for the

may seem inefficient viewed through the lens of the new job (Fiedler, 1967). Finally a constitutive approach rejects

publicmanagement,yetitmightalsobeseenascrucialto theobjectiveandstaticsensesof‘an’individualleaderand

the securing of effective parliamentary democracy and ‘a’contextasactsofreificationandsimplification.Instead,

satisfyingethicalnorms(suchasadutyofcareforall)(Du itinvolvesacknowledgingthatthesetermsareinterrelated

Gay,2000).Notionsofrationalityanditsinherentcompo- andmutuallyconstitutive(Fairhurst,2009).Onebenefitof

nents of predictability, calculability and standardisation a constitutiveapproach is it allows space to explore how

persist and are essential elements in maintaining patient leadership is socially constructed (Collinson, 2005; Grint,
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2000, 2005). In sum, when adopting trait approaches, In view of this it is interesting to note that the

theoristsareinterestedinidentifyingthecharacteristicsof Leadership Framework (NHS Leadership Academy,

leaders, which apply regardless of context. Contingency 2011), which incorporates the model of the Medical

approachesfocusontheanalysisoftheleader’scharacter- Leadership Competencies Framework (NHS III, 2009) and

istics and the extent to which they match or ‘fit’ a theLeadershipQualitiesFramework(NHSIII,2009a),relies

particularcontext.Situationalistaccountsarebuiltaround on an approach which has been subject to considerable

diagnostic analysis of the context, which then dictates critique. It is consistent with the dominant episteme

appropriate behaviour. Constitutive accounts reject the summarised earlier and has been questioned by Bolden

idea that the individual and context can be viewed as et al. (2006) who have identified the limitations of NHS

separateentitiesorbinaries,andinsteadseektoexamine Leadership Qualities Framework, as reductionist (frag-

the nature of their interrelationship (Fairhurst, 2001). It menting the role of leader rather than representing it as

could be regarded as surprising then that the current anintegratedwhole);basedongenericcompetencies(that

leadershipframework,albeitbroaderinscopethanmany assume a common set of capabilities irrespective of the

of its predecessors, continues to place great emphasis on leadership situation); and an approach that reinforces

personal qualities and competencies (NHS Leadership traditional ways of thinking about leadership (rather than

Academy, 2011), perhaps reflecting their dominance, challengingthem).Theframeworkfocusesonmeasurable

andsuggestingtheneedforfurtherdiscussionofdifferent behavioursandoutcomes,totheexclusionofmoresubtle,

perspectives. andperhapsmoreimportantqualitiessuchasinteractions

and situational factors, encouraging a mechanistic

4.3. The evidence approachtoeducationwhichresultsin‘training’ofleaders

to improve job performance, rather than education to

The need for a different perspective in the form of a developwider cognitiveabilities (Boldenetal., 2006).

counternarrativeisconfirmedbyworkthatwascommis- Boldenetal.(2006)arguethatleadershipframeworks

sioned by the NHS Leadership Centre. The 15 reports such as the NHS Leadership Qualities Framework are too

producedwerereviewedbytheOfficeforPublicManage- conceptually and methodologically flawed to be of much

ment in 2004 (OPM, 2004), and the findings included the benefitontheirown.Indeed,theygoontosuggestthatthe

conclusion that leadership development in the NHS was longer this model is used, the greater the likelihood of it

underpinned by a traditional view of leadership as an erodingtheverythingthattheNHSistryingtonurture–a

individual skill resulting in an emphasis on developing cultureofresponsiblesharedleadership.Thisreflectsthe

individualskillsandabilities(HartleyandHinksman,2003). unease in certain theoretical accounts of leadership, for

It was recommended that an approach incorporating a instanceCollinson(2005)observesthatleadershipcanbe

conceptofleadershipasacomplexinteractionbetweenthe thought of as a set of dialectical relations. These include

leader, the organisation, and the social context would be those existing between: leaders/followers; control/resis-

moresuitableasitreflectsthenatureofleadershipasasocial tance; dissent/consent; and men/women. For example in

process. Furthermore although their use is widespread, theleader–followerdynamicthereisalwaysthepotential

competencyapproacheswerefoundtobelimited,because forconflictanddissent.Yetthisisnotreflectedinwhathe

of their individualistic focus. It was concluded that the terms ‘orthodox’ studies which present an uncontested

problem of an overemphasis on competencies could be notionof leadership(Collinson, 2005). It could be argued

resolved if there was a shift to consideration of team that this has been carried through into the competency

competencies.Thoughthislendssupporttotheideathatan approacheswhichrestonapresumptionofleadershipasa

emphasis solely on individuals is simplistic, this could of ‘given’ and unquestionable as a force for good. Collinson

course simply displace or reformulate the problem, and alsohighlightsthegenderednatureoftheambiguousand

promoteasolutionbasedonamodificationofcompetency contradictory relations between leader–follower, power–

frameworks(HartleyandHinksman,2003).Thereissupport resistance, and consent–dissent. This is a line of analysis

forthisapproachthough,asWilliams(2004)foundleader- which is pursued by Ford (2005) as well who suggests

shipwasmoreeffectivewhenitfocusedontheteamrather leadership is achieved through a range of exclusionary

thantheindividualandaddressedtheconnectionbetween practices, with one being the failure to consider the

leadershipandchange. androcentric (male dominated) nature of organisational

More promisingly perhaps, in terms of signalling a life, a particularconcern fornursing.

breakfromcompetencyframeworksanotherstudyinthis It is unrealistic to expect competency approaches to

programme concluded that there is no ‘one best way’ to engage directly with such complex issues, and so there

lead,oroneidealsetofcompetenciesforaleader.Instead, remains a significant challenge to show how these

Buchanan suggested that leadership development in the multiple dialectics interrelate and are mutually constitu-

NHS may need to embrace the notion of dispersed tive (Collinson, 2005). The popular and officially sanc-

leadership (Buchanan, 2003). Buchanan argued that the tioned notion that leadership at all levels of the NHS is a

NHS should ‘exploit the full range of leadership perspec- politicallydesirableandlegitimategoalcouldusefullybe

tives,offeringatoolkitoftechniquesandideas,ratherthan subject to sustained critical scrutiny rather than merely

being wedded to a single, narrow and possibly outdated assumed (Learmonth, 2003). As Learmonth argues, the

view’ (Buchanan, 2003, p. 16). These studies identify the personality qualities that ‘good’ leaders are deemed to

limitationsofrelyingoncompetencybasedapproachesto posses, such as self-confidence, and enthusiasm are not

development. objective categorisations. Rather they are terms of moral
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and political approval that are meaningless when (1997) argue that across different genres, two things

abstractedfromaparticularcontext.Thisagainunderlines make a narrative effective. First, it must establish

theneed for a counternarrative. credibility. Second it must create a sense of the

unfamiliar or novel. These two conditions can inform

5. Acounter narrative the development of a counter narrative to widen the

debate about leadership development in the NHS. First

For the last decade, policy making in England has thereisaconsiderablebodyofliteraturewhichpresents

ostensiblybeenfoundedontheprincipleof‘Whatmatters a credible challenge to competency approaches; second

iswhatworks’(CabinetOffice,1999).Howeverinastudy escaping from the repetitive refrain of competencies

based on interviews with 42 policy makers in a range of through greater consideration of reflection, discussion

middle management and senior civil service positions and experience (Bolden et al., 2006), is reliant on the

Campbell et al. (2007) found that the reality of policy involvement of policy makers. If presented in the right

making was messy and unpredictable. Evidence was way our analysis may influence policy makers to look

regardedasjustonefactortobetakenintoaccountalong beyond seeking to control and regulate individuals’

with political imperatives, media coverage and world identities within organisations, and consider an alter-

events.SimilarlyLavisetal.(2005)foundthatsystematic native to wishing for conformity with specific compe-

reviews were never cited as the source when research tencies’ (Ford et al., 2008, p. 79).

evidence was used by health care managers and policy One simple way of relating this counter narrative is

makers. The difficulties experienced by policy makers in provided by Rodgers et al. (2003). In an extensive

usingevidenceincludeaccessibility,usabilityandcompet- international study they found that accompanying the

ingsourcesofinfluence(JewellandBero,2008).Inorderto competency movement is an attendant risk of reverting

address these problems Sanderson (2002) advocates that to a checklist approach to development. Although the

researchers should understand the context of policy checklistapproachmaybeanattractiveandsuperficially

making and do more to relate their work to this context, rational way of imposing order on the complex task of

andconsiderpressingpolicyconcernsandchallenges.The leadership,itoperatesfromanempiricallycontestedand

development of a counter narrative of leadership devel- largely unproven base. Over-reliance on such an

opmentis one means ofdoing this. approach constrains and undermines meaningful, perti-

The role stories and language play in representing nent, innovative and potentially more effective leader-

phenomena,notsimplyincommunicationbutasaresource, ship practice (Rodgers et al., 2003). In response to this

isofwideinterest inthe study oforganisations (Alvesson theydeveloped aframeworkmade upoffour quadrants

and Karreman, 2000; Alvesson and Sveningsson, 2003; identifying broad approaches to leadership develop-

Oswicketal.,2000).Itisalsorelevantinparticularareasof ment: Prescribed and individual; Emergent and Indivi-

practicesuchasinnovationanddiffusionofnewpractices dual; Prescribed and Collective; Emergent and

(Abrahamson and Fairchild, 1999; Clark, 2004; Giroux, Collective.

2006; Green et al., 2009; Green, 2004), in establishing Mostleadershipdevelopmentactivitiescanbelocated

legitimacy (Benjamin and Goclaw, 2005; Chreim, 2005; in the first quadrant, in that they are designed for

MuellerandCarter,2005),andasaframeofreferencefor individuals and tightly specified in terms of content and

interpreting complexity (Barry and Elmes, 1997; Boje, outcomes. And, almost all leadership development activ-

1991).Inthiscasewesuggestthataparticularorthodoxy ities are focused on individuals – placing them in either

has developedinrelation toleadershipdevelopment–an quadrant one or two. This suggests that to emphasise

epistemebasedon‘competency’approachesthatisnested collectiveapproachescouldadvancethedebateonpolicy

in a grander or broader episteme of rationality. The development. One of their recommendations was that

prevalenceofthisepistemeinpolicyisimportantbecause researchers should consider applying this framework

itclosesoffotheraccountsanddrivespolicyinaparticular when considering how leadership and leadership devel-

direction.Indevelopingacounternarrative,wetrytodirect opment are constructed and evaluated. We suggest it is

attentiontotherolethatthestorieswetellourselves,and possible to use this framework as a way of summarising

others,playinsense-making(Grint,2007;Weick,1995).In and organising the more complex suggestions we have

termsoftherelationshipbetweenpolicydevelopmentand madeinouranalysis.TheRodgersetal.(2003)framework

policyimplementation,narrativeiscriticalsincethewayin canbeastartingpointtoexplorehowassumptionsabout

whichpolicymakersrepresenteventssurroundingreform leadershipinpolicyreflectanepistemeofleadershipasan

and leadership also shapes the thinking and practice of individual, competency based phenomenon, located

leadersinhealthcareandnursing. withinanoverarchingEpistemeofrationality.Theframe-

Barry and Elmes define narratives as, ‘thematic, workverysimplyidentifiesthelimitationsofcompetency

sequenced accounts that convey meaning from implied accounts(andconsequentlycontingencyandsituationalist

authortoimpliedreader’(BarryandElmes,1997,p.431). accounts), and the absence of a constitutive approach. It

Inthissense,thecompetencyapproachcanbeunderstood can also be used to acknowledge the various dialectical

astheoutcomeofanarrativereflectingaspecificmodelof complexities that characterise leadership as an activity,

leadership.Thisiscentraltotheworkofbodiessuchasthe andconsiderleadershipdevelopmentassomethingthatis

NHS Leadership Council and the Modernisation Agency, sometimesirreducibly complexor alocal, context-bound

and has contributed to the emergence of a particular phenomenon (rather than one that is susceptible to

approach to leadership development. Barry and Elmes standardisation).