Abstract
The past two decades have seen changes in the policies guiding delivery of mental health services [1–4].
To position itself appropriately within this changed health environment, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) commenced a formal strategic planning process in May 1996. As an integral part of this process, the college identified training and continuing professional development as critical components in preparing psychiatrists for their changing role. One aspect of their training and development is the acquisition and enhancement of leadership and management skills.
An increased focus on working within multidisciplinary teams and in partnership with consumers, carers and general practitioners has increased the demand for psychiatrists to demonstrate leadership as part of their clinical role – advocating for mental health within the broad health arena, influencing the multidisciplinary team, and facilitating appropriate coordination of clinical care. Even in private practice such skills are required as new models of collaboration with general practitioners are promoted and new funding models are explored.
The project described in this article was commissioned and funded by the RANZCP strategic planning group in 1999. It aimed to explore views about leadership and management issues among psychiatrists in Australia and New Zealand, create an agenda for discussion, and identify skills-acquisition processes. One of the first tasks of the project steering committee was to discuss the terms which are commonly used in this context. Some acceptable definitions derived from the literature were agreed upon for use in the project. These are:
1. Management: The process of achieving organizational goals by engaging in the four major functions of planning, organizing, leading, and controlling [5].
2. Leadership: The process of influencing others to engage in the work behaviours necessary to reach organizational goals [6]. Leadership comprises two distinct aspects: one is the interaction between leader and follower that in effect induces followership; the other is the context which concerns the destination towards which the leader points [7]. Burns described these two components as transactional leadership (pertaining to interpersonal influence and persuasiveness) and transformational leadership (pertaining to new directions, contexts and destinations) [8].
3. Administration: An approach that focuses on principles that can be used by managers to coordinate the internal activities of organizations [9].
The steering committee then proceeded to differentiate the various roles for psychiatrists at different levels of position and influence. Broad agreement was reached that there are three levels. These comprise: level one positions (such as team leader, unit director, clinical director) where psychiatrists would usually be combining clinical work with some management functions; level two positions (for example, service director, area director, regional director) where the psychiatrist would have overall responsibility for the service including financial resources, clinical governance and staff (it might include maintenance of clinical practice but that would usually be less than half time); and level three positions (for example, regional directors, and corporate, state and national directors) where the psychiatrist would influence funding and other policy decisions and interact with various levels of government. This third level usually concerns leading large departments.
In each of these roles, regardless of level, the psychiatrist would be required to demonstrate leadership. The degree of management and administration required will vary across services and with seniority and experience.
An initial paper [10] discussed terminology of management and leadership concepts, articulated a range of roles for psychiatrists and provided examples of good and bad management practice. Following feedback received about this paper, a broader survey of fellowship attitudes to the issues raised was undertaken.
Method
A survey of fellows was conducted via a semistructured telephone interview which canvassed interest in and knowledge about the issues.
A sample of 150 key informants nominated by branch committees in
Australian states and New Zealand received a written questionnaire prior to being contacted by telephone for interview.
The questionnaire was developed by the project team from issues identified in the clinician management literature. There were 50 semistructured questions in total, across three sub-topics. These sub-topics were: (i) the impact on psychiatrists of changes in the health care system, (ii) the psychiatrists’ views about leadership and management of the system and the transition from clinician to manager, and (iii) education and skills acquisition for psychiatrists undertaking management roles. Each question required a short answer of one to three sentences. Respondents could elect to answer questions in only one or two sections. Only six people completed the entire questionnaire. The answers were transcribed by the interviewer onto the questionnaire, and analysed in de-identified format. Analysis involved listing key themes which emerged and grouping these according to the frequency with which they were mentioned.
Results
Key informant characteristics
The response rate for the telephone survey was 55%, with 83 of the 150 fellows nominated agreeing to be interviewed. Respondents were predominantly male (69% male, 31% female); urban (72.6 urban, 10.4 rural); and working in the public sector (60.5 mostly public sector, 21.5 mostly private sector, 1 academic only). The majority of respondents had more than 10 years’ experience since fellowship (1 trainee, 7 with less than 5 years’, 15 with 5 to 10 years’, and 60 with 10 or more years’). They represented the following categories of practice: clinicians, 41 (public and private); service directors, 26; clinician managers, 8; and 8 academics. Only three respondents identified themselves as clinicians working predominantly in the private sector.
Impact on psychiatrists of changes in health systems
Twenty-five respondents answered questions relating to the impact of the previous decade of health system change on their clinical practice. Only one indicated no impact. Loss of power was reported by 18 and decreased autonomy by eight. Three-quarters of respondents expressed positive views about these changes, citing benefits of working with multidisciplinary teams, a more analytical approach to service delivery, involving patients in service re-structuring, greater consistency across services, enhancement of clinical standards, and more innovative policy. Two respondents felt it was highly appropriate to make psychiatrists more accountable for mental health resources.
The quarter of respondents who were negative about the changes were critical of two major groups of issues. The first related to low resources and included budget stringencies, reduced availability of subsidized drugs, more paperwork, changes to the Australian Medicare Benefits Schedule (MBS), juggling a higher workload and tailoring treatment to meet the requirements of insurers. The second group related to loss of autonomy and included comments such as ‘have to resist efforts to diminish clinical decision-making’ and ‘feeling a loss of prestige’. One person commented ‘all manner of non-doctors have control over budgets, resources and manpower’. Another felt ‘powerless to influence decisions’ and resented ‘being told rather than consulted’. One clinician in private sector practice felt the changes were appropriate within the public sector but created ‘enormous ethical dilemmas for the private practitioner’.
Clinicians and managers
Thirty-four respondents provided answers in this section of the questionnaire, which opened with a request to describe differences between the two groups and continued with questions about the transition between the roles.
Clinicians were described as people having a healing relationship with patients, their priority being relief of individual suffering. Managers were seen as being distanced from patients, and more concerned with resources.
Examples of tension between the two groups included clinicians being asked to consider drug costs and choose the cheapest, which was described by one respondent as ‘creating an ethical dilemma’. There was a commonly expressed view that non-clinician managers do not understand the issues. Three respondents felt that managers’ inability to explain the relevance of their role and function contributes to anger and frustration on the part of clinicians.
Managers with a clinical background, especially in psychiatry, were described by most respondents as having the ability to bridge the gap between the two roles; however, of the 27 respondents who were in clinician manager positions, only three admitted they had experienced no major difficulties making the transition.
Four respondents said they had been hindered by clinical colleagues who expressed surprise at their change in role, implying it was a reduction in status, or a transition to ‘becoming the enemy’. One clinician who responded in this section said that the transition required psychiatrists to ‘develop the skill of hypocrisy’. More commonly, subtle shifts in relationships with clinical colleagues which created a feeling of distance were described.
The most frequent difficulty reported was that of not being wellequipped with the skills necessary to undertake the role of manager. The additional competencies most frequently cited as being required were better decision-making skills; financial, human resource and industrial relations management expertise; and greater knowledge of how health systems and bureaucracies work.
The personal impact on many clinicians of undertaking management roles included developing new prioritizing skills to cope with additional workloads, and facing the challenge of having chosen a demanding role with less personal satisfaction than their formal clinical practice.
At a personal level several expressed insecurity about future self employment if they returned to clinical practice and a view that such a return would result in a reduced variety of workload.
Education and training
Fifty respondents answered the series of questions relating to how the skills and competencies required of clinicians in management roles could best be acquired.
One-third emphasized the need to have excellent clinical skills before undertaking leadership and direction of clinical services.
All the respondents argued that management skills are additional to and different from clinical competency and hence need to be specifically acquired. Of interest was that only five respondents saw formal postgraduate training in management as being of use. The majority expressed preference for two models of skills and knowledge acquisition. These were ‘in house’ or local short courses such as seminars and formal and informal mentoring by more senior colleagues.
Discussion
Among Australian and New Zealand psychiatrists there is generally thought to be support for psychiatrist leadership of mental health services; however, in this sample, most of the psychiatrists currently in leadership and management roles perceive they are inadequately prepared for the task and poorly supported by their colleagues who remain in clinical practice.
The current RANZCP Consultancy Viva purports to examine competence in areas of systems advocacy, influence of clinical teams, communication and negotiation, all of which may be considered as basic building blocks of effective leadership and management. The responses of psychiatrist managers to this project raises the question of how adequate is the current RANZCP training or examination process as preparation for these roles, and infers how different these roles are in practice from the examination setting.
In a management role, one is advocating, influencing, communicating and negotiating with people who are outside the clinical hierarchy where people may have their own values about knowledge, skill and expertise. They do not necessarily value the specialist clinican for his or her own sake. Psychiatrists who find themselves in these positions need to develop their skills for these different settings. The first author (MT) has observed from personal experience some psychiatrists using their clinical skills in ways which may be considered inappropriate in management roles. Examples include interpreting executive group behaviour in ‘group dynamics’ terms, reflecting senior managers’ comments back to them, and adopting a patronizing tone with administrators who are enforcing organization rules and regulations.
Several Australian authors in the past 10 years have commented in various ways on the disempowerment of psychiatrists in the public sector mental health system [11–15]. This attests to the fact that clinical skills do not automatically confer success.
Examples of more effective clinician management practice might include demonstrating capacity to use power and influence outside of executive meetings so that outcomes are more predictable, reframing management group conflict in win-win terms and negotiating necessary changes in rules in a constructive manner.
Apart from recognizing deficits in their own skills and knowledge, it appeared to be in this sample a relatively common experience that psychiatrists undertaking management roles felt unsupported by their clinical colleagues. Some of this is attributed to nonmanagers viewing administration and management as relatively easy tasks, which should be able to be accomplished with little change in clinical practice patterns. Some of the negative attitudes, however, may also come from clinicians who view their management colleagues as having ‘betrayed’ their clinical roots by using language such as ‘accountability’ and ‘systems’ instead of maintaining a focus on individual patient care.
Whatever the reason, there is an essential dissonance between psychiatrists who want to see fellow psychiatrists in leadership and management roles, but at the same time want them to look and behave as much like clinical psychiatrists as possible.
An unpublished review of an earlier version of this paper stated ‘it would seem to be unusual in a profession encouraged to examine transference/countertransference issues and interpersonal relationships, that the managers’ own contribution to perceived lack of support by clinical colleagues was not mentioned’. We argue that this is an important issue. For clinicians and managers alike there is always a tension surrounding difference. As human beings we are frequently uncomfortable when people with whom we identify adopt different positions, values and attitudes. Psychiatrists may be more likely than other groups to interpret such discomfort as arising from transference/ countertransference issues or from unresolved child/parent relationships being replayed in adult life. Whether using such an interpretation contributes to improvement of the clinician/manager working relationship can only be resolved at the individual level.
What is clear from our key informants is that psychiatrists in clinical roles may advocate for psychiatrists to be promoted to management and leadership positions; however, when psychiatrists as managers or leaders are called upon to make tough management decisions – often ones which limit the perceived clinical autonomy of their colleagues – there is a heightening of tension. It is likely that both parties contribute to this tension. Inability to manage it productively will limit the psychiatrist manager's effectiveness in his or her role. Thus we argue that changes are required on both sides. Clinicians will have to accept that things will not always be to their liking, even if psychiatrists are their managers and psychiatrist managers will need to gain the skills to effectively manage their clinical colleagues.
Across Australia and New Zealand there are many psychiatrists who have attempted the transition from clinician to manager, some with more success than others (if success is defined as satisfaction with their new roles). Many in this sample believe they would have been more confident and competent earlier in their roles had they been supported to undertake formal skill development, especially in early transition phases.
It has been noted that many psychiatrists tend to adopt a particular management style which emphasizes interpersonal approaches to management and downplays the role of authority [16, 17]. Their strengths are in the qualitative aspects of management and helping their organizations to achieve a balance between quality and cost concerns. They are most satisfied with the role of advising senior management with regard to clinical issues, and least satisfied with budget and resource utilization tasks [16, 17]. There are grounds for debating the relative merits of clinicians either using their clinical expertise to influence systems vs. developing new skills to take responsibility for systems – including management of resources. These are two different levels of influence, and it can be argued that there is room in the system for psychiatrists who wish to focus on either or both roles.
According to Silver [18], the path to becoming a psychiatrist manager is based on the interplay of five distinct factors: a mentor relationship; formal training in administration; individual personality traits; clinical psychiatric training; and administrative experience. Thus, providing education programmes alone, without also addressing mentoring systems and supported practical experience, is likely to be ineffective. This affirms what was told to us by psychiatrists currently in the roles, and provides the framework for the recommendations which emerge from the project.
One of the outcomes of this project has been the development of a series of recommendations to assist more psychiatrists to consider acquiring and demonstrating leadership and management skills. These recommendations include: the introduction of compulsory leadership and management modules during fellowship training; encouraging more trainees to undertake service development projects during the elective year; and inclusion of some relevant nonclinical topics during the annual congress and other continuing medical education (CME) forums. Maintenance of Professional Standards (MOPS) programmes are being broadened to ensure the interests of this group of psychiatrists are addressed and the formation of an ‘interest group’ in leadership and management psychiatry is being explored.
It is argued that adoption of these recommendations will position the RANZCP to better identify significant leadership roles in both countries, and to have the realistic expectation that fellows of the college will fill these roles.
Conclusion
There is interest in the issues of leadership and management of mental health services among fellows of the
College, and recognition of a gap between clinical and other required skills. There are opportunities to commence addressing these gaps in a systematic way. One of the first steps is acknowledging negative perceptions about leadership and management roles among clinical psychiatrists and understanding and managing them. Another important step is encouraging psychiatrists to undertake training and skill development to enhance their confidence and competence. This encouragement should include facilitation of formal mentoring and greater attention to role modelling.
Such processes would encourage psychiatrists already in leadership and management roles to reflect on their attitudes and behaviours which may unnecessarily contribute to negative perceptions. Systems advocacy for psychiatrists to have improved access to short courses in specific skill and knowledge areas would complement these approaches.
Footnotes
Acknowledgements
This project would not have been possible without the work of the following: Steering Committee and Working Party: Jennifer Alexander, Bruce Dowton, Peter Ellis, Brett Emmerson, Paul Friend, Don Grant, Aaron Groves, Judy Hardy, Adrian Keller, Lyndy Mathews, Wayne Miles, Louise Newman, Rosemary Schneider, Jeff Snars, Allison Weeks.
Technical assistance in data collection and analysis: Dr Maureen Gleeson, Ms Jennifer Rushworth, and Ms Jayne Wells.