eBook Download An Occupational Perspective on Leadership, 3e Sandra Dunbar-Smalley, Kristin Winston

SLACK Incorporated

6900 Grove Road

Thorofare, NJ 08086 USA

856-848-1000 Fax: 856-848-6091

www.slackbooks.com

ISBN: 978-1-63091-853-8

© 2022 by SLACK Incorporated

Senior Vice President: Stephanie Arasim Portnoy

Vice President, Editorial: Jennifer Kilpatrick

Vice President, Marketing: Mary Sasso

Acquisitions Editor: Brien Cummings

Director of Editorial Operations: Jennifer Cahill

Vice President/Creative Director: Thomas Cavallaro

Cover Artist: Katherine Christie

Cover photo taken by and reproduced with permission from Jaden Dunbar.

All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publisher, except for brief quotations embodied in critical articles and reviews.

The procedures and practices described in this publication should be implemented in a manner consistent with the professional standards set for the circumstances that apply in each specific situation. Every effort has been made to confirm the accuracy of the information presented and to correctly relate generally accepted practices. The authors, editors, and publisher cannot accept responsibility for errors or exclusions or for the outcome of the material presented herein. There is no expressed or implied warranty of this book or information imparted by it. Care has been taken to ensure that drug selection and dosages are in accordance with currently accepted/recommended practice. Off-label uses of drugs may be discussed. Due to continuing research, changes in government policy and regulations, and various effects of drug reactions and interactions, it is recommended that the reader carefully review all materials and literature provided for each drug, especially those that are new or not frequently used. Some drugs or devices in this publication have clearance for use in a restricted research setting by the Food and Drug and Administration or FDA. Each professional should determine the FDA status of any drug or device prior to use in their practice.

Any review or mention of specific companies or products is not intended as an endorsement by the author or publisher.

SLACK Incorporated uses a review process to evaluate submitted material. Prior to publication, educators or clinicians provide important feedback on the content that we publish. We welcome feedback on this work.

Library of Congress Control Number: 2022930721

For permission to reprint material in another publication, contact SLACK Incorporated. Authorization to photocopy items for internal, personal, or academic use is granted by SLACK Incorporated provided that the appropriate fee is paid directly to Copyright Clearance Center. Prior to photocopying items, please contact the Copyright Clearance Center at 222 Rosewood Drive, Danvers, MA 01923 USA; phone: 978-750-8400; website: www.copyright.com; email: info@copyright.com

De Dication

To leaders who ensure that justice, humility, and equality are embedded into their practices and their lives.

—Sandra and Kristin

about the eDitors

Sandra Dunbar-Smalley, DPA, OTR/L, FAOTA, completed her undergraduate degree at Loma Linda University in Loma Linda, California; her Master of Arts in Occupational Therapy from New York University in New York City; and her Doctor of Public Administration degree from Nova Southeastern University in Fort Lauderdale, Florida. The last degree exposed her to organizational behavior, leadership, management, and strategic planning content, all of which have influenced her work in occupational therapy.

Sandra is currently the provost at AdventHealth University. She was previously the assistant dean of professional development and education in the College of Health Care Sciences at Nova Southeastern University. Her responsibilities included the coordination of the Center for Academic and Professional Excellence, which incorporates a Leadership and Management Academy for faculty who desire to develop and improve their leadership skills. Sandra’s belief that everyday leadership provides numerous opportunities to encourage personal and professional growth has been reinforced by the process of compiling another edition of An Occupational Perspective on Leadership: Theoretical and Practical Dimensions.

Kristin Winston, PhD, OTR/L, FAOTA, completed her bachelor’s degree in occupational therapy at the University of New Hampshire in Durham, New Hampshire. She went on to complete a Master of Education degree at the University of Vermont in Burlington, Vermont, with a specialization in early childhood special education. Kristin’s PhD in occupational therapy was earned at Nova Southeastern University in Fort Lauderdale, Florida. It was while studying at Nova Southeastern University that Kristin first had an opportunity to explore the topic of leadership under the guidance of Sandra Dunbar-Smalley, who continues as a leadership mentor.

Kristin currently serves as program director and associate professor in the Master of Science in Occupational Therapy program at the University of New England where she continues to study and teach leadership concepts. She has held several formal leadership positions in clinical, academic, and community organizations and has also participated in informal leadership opportunities in those settings. Kristin is a graduate of the College of Health Care Sciences Leadership and Management Academy at Nova Southeastern University and the American Occupational Therapy Association Academic Leadership Institute.

contributing authors

Sue Baptiste, MHSc, OT(Reg), OT(C), FCAOT (Leadership Narrative) Professor Emerita

School of Rehabilitation Science

McMaster University

Hamilton, Ontario, Canada

Patricia Bowyer, EdD, MS, OTR, FAOTA, SFHEA (Chapter 3) Professor and Coordinator of Post Professional Programs

Texas Woman’s University

Institute of Health Sciences

Texas Medical Center

Houston, Texas

Marge E. Moffett Boyd, PhD, MPH, OT/L (Chapter 14)

Assistant Professor of Occupational Therapy (Retired) Coordinator of Graduate Academics and Community Outreach

Dominican College of Blauvelt

Orangeburg, New York

Tami Lawrence Buck, PhD, MSOT, OTR/L (Chapter 14)

Contributing Faculty

Post Professional Programs

University of Saint Augustine for Health Sciences

Saint Augustine, Florida

Lynelle F. Callender, DNP, RN, INS (Chapter 5)

Online Vice Chair of Nursing

AdventHealth University

Orlando, Florida

Charles Christiansen, EdD, OTR, FAOTA (Forewords)

Rochester, Minnesota Professor Emeritus

The University of Texas Medical Branch at Galveston

Galveston, Texas

Lisa L. Clark, MS, OTR/L, CLT (Chapter 7)

Manager, Cardio-Pulmonary Rehabilitation Program

Community Health & Wellness

Mid Coast–Parkview Health

Brunswick, Maine

Audrey Comeau, MS, OTR/L (Leadership Narrative)

Occupational Therapist

Virginia Hospital Center

Arlington, Virginia

xii contributing authors

Thomas J. Decker, EdD, OTD, OTR/L (Leadership Narrative)

Associate Professor

Department of Occupational Therapy

Dr. Pallavi Patel College of Health Care Sciences

Nova Southeastern University

Clearwater, Florida

Steven Fowler, DNP, CRNA, APRN (Chapter 3)

Associate Professor

DNAP Program

AdventHealth University

Orlando, Florida

Elizabeth Francis-Connolly, PhD, OT/L, FAOTA (Leadership Narrative)

Dean, School of Interdisciplinary Health and Science

University of Saint Joseph

West Hartford, Connecticut

Jan G. Garbarini, PhD, OTR/L (Chapter 6)

Program Director (Retired)

Assistant Professor and Research Coordinator

Graduate Occupational Therapy Program

Dominican College of Blauvelt

Orangeburg, New York

Tara Griffiths, DrOT, OTR/L (Chapter 13)

Associate Professor and Associate Chair in Occupational Therapy

College of Health Professions

The University of Findlay

Findlay, Ohio

Yvette Hachtel, JD, MEd, FAOTA (Chapter 15) Professor Emerita

School of Occupational Therapy

Belmont University

Nashville, Tennessee

DeLana Honaker, PhD, CLT, OTR, FAOTA (Chapter 4)

CEO/President Well Versed, LLC & KidLife

Amarillo, Texas

Lesly Wilson James, PhD, MPA, PMP, OTR/L, FAOTA (Chapter 17)

Associate Professor

School of Occupational Therapy

Lenoir-Rhyne University

Columbia, South Carolina

Sonia F. Kay, PhD, OTR/L (Chapter 8)

Associate Professor of Occupational Therapy (Retired)

Adjunct Faculty

Department of Occupational Therapy

Dr. Pallavi Patel College of Health Care Sciences

Nova Southeastern University

Fort Lauderdale, Florida

Brianna Black Kent, PhD, RN (ret.) (Chapter 9)

Associate Professor

Assistant Dean of Professional Development and Education Director, Coalition for Research and Education Against Trafficking and Exploitation (CREATE)

Dr. Pallavi Patel College of Health Care Sciences

Nova Southeastern University

Fort Lauderdale, Florida

Carol Lambdin-Pattavina, OTD, MSOT, OTR/L, CTP (Chapter 16)

Assistant Professor

Occupational Therapy

University of New England

Portland, Maine

James Laub, EdD (Chapter 5)

Professor of Leadership

MacArthur School of Leadership

Palm Beach Atlantic University

West Palm Beach, Florida

Jason D. Mahilo, MOTR/L, TCR, LSVT-BIG (Chapter 17)

Regional Director of Sales

Accentcare HH Midwest Region

Chicago, Illinois

James Marc-Aurele, OT/L, MBA (Chapter 7)

Senior Program Manager

Point32Health

Canton, Massachusetts

Said Nafai, OTD, MS, OTR/L, CLT, CAPS (Leadership Narrative)

Associate Professor, Founder and President, Occupational Therapy Association of Morocco

School of Health Sciences, Occupational Therapy

American International College

Springfield, Massachusetts

Terry Morrow Nelson, PhD (Chapter 11)

Associate Dean of Student Affairs/Associate Professor

Dr. Pallavi Patel College of Health Care Sciences

Nova Southeastern University

Fort Lauderdale, Florida

xiv contributing authors

Teresa Plummer, PhD, MSOT, OTR/L, CAPS, CEAS, ATP (Chapter 15)

Associate Professor of Occupational Therapy

School of Occupational Therapy

Belmont University

Nashville, Tennessee

Nicole R. Quint, DrOT, OTR/L (Chapter 10)

Professor and Doctoral Capstone Coordinator, Occupational Therapy

Dr. Pallavi Patel College of Health Care Sciences

Nova Southeastern University

Fort Lauderdale, Florida

Gustavo Reinoso, PhD, OTR/L (Leadership Narrative)

Associate Professor

Department of Occupational Therapy

Dr. Pallavi Patel College of Health Care Sciences

Nova Southeastern University

Clearwater, Florida

Jacquelyn M. Sample, DrOT, MEd, OTR/L (Leadership Narrative)

Pediatric Occupational Therapist

Disability Advocate

Columbia, Missouri

Laura Schmelzer, PhD, MOT, OTR/L (Chapter 13)

Assistant Professor

School of Exercise and Rehabilitation Sciences

University of Toledo

Toledo, Ohio

Deena L. Slockett, EdD, MBA, RT(R)(M) (Chapter 12)

SVP Operational Strategy and Learning Professor

AdventHealth University

Orlando, Florida

Scott Truskowski, PhD, OTRL (Chapter 15)

Associate Professor and Department Chair

Occupational Science and Therapy Department

Grand Valley State University

Grand Rapids, Michigan

Jacqueline Reese Walter, PhD, OTR/L, CHT (Chapter 17)

Associate Professor

Occupational Therapy Department

Jacksonville University

Jacksonville, Florida

ForeworD to the thirD eDition

You gain strength, courage, and confidence by every experience in which you really stop to look fear in the face. You must do the thing you think you cannot do.

—Eleanor Roosevelt

This third edition of An Occupational Perspective on Leadership: Theoretical and Practical Dimensions is being published at a most extraordinary time. It emerges during a global pandemic that has already rapidly transformed the lives of the world’s population in ways that few could have imagined. As I sit here thinking about this historical event, and about this book and its aims, I realize a truly rare and remarkable social consequence of this viral invasion: Everyone, everywhere, is experiencing the same life-changing phenomenon simultaneously. This likely has never occurred before within the recorded history of the planet, and for many it arrives gift-wrapped with “spare time” to think about what it means for each of us and the world we will inhabit in the months and years ahead.

As we reflect on this crisis, each of us may likely agree that our reactions include amazement at the scope and speed of the changes to our lives; grief at the deaths, illnesses, and economic losses that have resulted; fear about the ubiquitous threat of infection and the safety of those we love; and anxiety about the future. The uncertainty of what the world will be like when the pandemic is over is distracting. We yearn for reassurance and hope, but we also need factual information to prepare for the conditions that may result. We seek trustworthy and competent leaders to inform us, to guide us through this uncertainty, and to foster that important sense of community that provides reassurance, strength, courage, and hope. In fact, the word encourage derives from the Latin word for heart, so to encourage is to “make strong or hearten.” Good leaders strive to encourage those they serve.

It is no coincidence that history has shown that leadership reveals itself best during times of crisis and transition. Often, this is exemplified by the leaders of nations. Abraham Lincoln, Winston Churchill, Franklin Roosevelt, and Nelson Mandela are examples of legendary leaders who rose to the challenges of their time and earned the respect and support of followers in their respective nations and beyond. Historians make it clear that these leaders were not without personal flaws, and that they also experienced fear and uncertainty. Yet, they found within themselves the wisdom to remain humble and listen appreciatively to their knowledgeable advisors, the conviction to trust their values, the integrity to accept their responsibilities, and the courage to live outside themselves and think creatively and act boldly in the service of others. Such characteristics and behaviors can predictably enlist and inspire others to become helpful participants in finding ways through the darkness and chaos of crisis.

In the COVID pandemic, many leaders demonstrated these virtues. When histories of this period are written, it is possible, even likely, that the leaders who stood out will not be national figures or elected officials, but local volunteers and professionals working on the front lines and risking their own well-being in the service of others. There have been countless stories of such individuals inspiring others and reaffirming the truth that authentic leadership arises from the heart.

These leaders also stand out because they are seen against the backdrop of an infrastructure made grossly inadequate by longstanding neglect. The social and economic catastrophe that resulted makes it seem inevitable that the pandemic will lead to structural changes in societal and health programs that can better contend with pandemics and other global crises in the future.

Such structural changes will undoubtedly affect occupational therapy, too, in ways that are now unknowable. What should be apparent, though, is that the manner in which the profession embraces opportunities for creating better practices and structures that are durable and adaptable will be important. This will require that leaders within the profession seize the moment, apply the lessons of history, and demonstrate the principles elaborated in this important and timely book. They will be most successful if they remember that the values that inspired the field’s founding can serve as a powerful motivator for both providers and their clients. Those values honor and connect the life stories of clients with the increasingly scientific, economic-driven, and impersonal world of health care. If this return to core values occurs, good things will happen. Let it be so.

Charles Christiansen, EdD, OTR, FAOTA February 2022

ForeworD to the seconD eDition

In the earliest years of civilization, leaders evolved informally based on family ties, strength, age, or popularity. While some leaders were generous and wise, others were ruthless and ignorant. Power was based on position or earned by conquest, and leadership training was typically learned by experience. In the 21st century, we know that leading people effectively requires more than titles, power, popularity, or armies. In fact, like competency in any art or science, leadership requires study, experience, and genuine commitment to the point that being effective seems deceptively easy (but, of course, isn’t).

Throughout my career, I have been an avid student of leadership, attempting to apply its principles in various positions of influence and advocating for the importance of succession planning and leadership development. I have learned that knowledge of people and groups provides a key beginning for becoming an effective leader, but truly effective leadership requires a keen knowledge of self, character (the right values), mentorship by competent leaders, an honest appraisal of failures, and good communication skills. Invariably, it helps if one has experience being a good follower, has a passion for learning, and understands that leadership is a privilege to serve others that must be unselfishly honored.

In thinking about leadership, I am always reminded of these lines in the Tao Te Ching by the Chinese sage Lao-Tzu (translation by Stephen Mitchell):

When the Master governs, the people are hardly aware that s/he exists.

Next best is a leader who is loved.

Next, one who is feared.

The worst is one who is despised.

If you don’t trust the people, you make them untrustworthy.

The Master doesn’t talk, s/he acts.

When her/his work is done, the people say, “Amazing: we did it, all by ourselves!”

To me, these lines communicate key messages about leadership, such as the importance of humility and patience, trust, being approachable, and leading quietly and effectively to empower by example. Many of these lessons are features of servant leadership.

Sandra Dunbar and Kristin Winston have assembled a talented group of authors to prepare the second edition of this well-regarded leadership text. Their use of buildings and structures as metaphors for understanding leadership principles is quite effective, and in this edition they have worked hard to integrate occupational therapy theory with lessons of leadership. As occupational therapy celebrates its centennial year, effective leaders will continue to be vital to ensure that the profession and its members are providing vital, client-centered, life-relevant services throughout the next 100 years.

Charles Christiansen, EdD, OTR, OT(C), FAOTA June 2014

We are what we build.

introDuction

—Lois Farfel Stark

There have been significant social, health, and political shifts, both on a national and global level, since the 2015 publication of An Occupational Perspective of Leadership: Theoretical and Practical Dimensions. Now, more than ever, it is necessary for occupational therapists and occupational therapy assistants to equip themselves with leadership knowledge and application skills. This is our imperative to adequately meet societal demands and engage in efforts for a more just and equitable global community.

Continuing the building metaphor for leadership, new bricks are part of the architectural plans in our ever-evolving landscape of leadership opportunities. This third edition of the textbook incorporates updates on the intersection of leadership and occupational therapy theories, as well as posits perspectives not included in previous editions, such as the construct of followership. In order for leadership to be effective, it is important to include followership considerations to enhance our understanding of the essential intertwining between group members with different roles. Another new aspect in this edition is the introduction to appreciative inquiry. This positive approach to understanding group perspectives and forging a way forward to establish a vision is a resource that can help leaders develop blueprints to manage the most challenging of situations within organizations. In addition, shared leadership is introduced, as we flatten the hierarchy in groups and invite others to lead along with us while recognizing the essential power of diversity. These additional building blocks are intended to further fortify the foundation for optimal leadership.

With constant change around us, the leadership imperative today also includes agility, foreshadowing, effective communication, and innovative thinking. For anyone who gets comfortable with the familiar and resists sensible change, they will find it difficult to use new tools and engage in the stimulating work of the “smart” organization. Authentic occupational therapy has always been adaptive and creative. The best of leadership is as well.

Sandra Dunbar-Smalley, DPA, OTR/L, FAOTA

—Eraldo Banovac

If you want to have a strong structure, build the foundations the right way.

I

Introduction to Theoretical Perspectives

Leadership Theories

Sandra Dunbar-Smalley, DPA, OTR/L, FAOTA

Learning Objectives

1. Recognize the essential need for leadership knowledge and skill development.

2. Describe leadership from multiple perspectives.

3. Identify key leadership theories.

4. Identify essential leadership competencies.

5. Understand the relevance of leadership theories to occupational therapy.

A great leader’s courage to fulfill their vision comes from passion, not position.

—John Maxwell

Occupational therapists and occupational therapy assistants serve in leadership roles within a variety of work environments. These unique opportunities are often experienced without a formal understanding of leadership theory or a methodical way of gaining leadership competencies.1 As the occupational therapy profession continues to progress, it is essential that occupational therapy students and practitioners enhance their ability to learn key leadership principles to gain and sustain leadership roles in health care and community arenas.

In addition to advancing to leadership roles, it’s imperative that each practitioner envision themselves as a change agent, capable of influencing others and making a difference for clients and communities. In an ever-changing leadership landscape, the ability to adapt, be open to varying perspectives, stay abreast of current evidence, and promote innovation are critical for professional survival.2 Recent global public health events and a heightened awareness for social justice certainly heighten the need for effective leadership for managing not only the work environment challenges but significant health crises that impact every occupational aspect of life.

Leadership defined and described

Leadership has been defined in various ways throughout business and organizational behavior literature. Fleishman et al indicate as many as 65 different classifications in a review of 50 years of literature. 3 Bass, a well-recognized author on the subject of leadership, also suggests many ways to classify leadership perspectives.4

The trait theory, or personality perspective, is focused on particular traits that an individual possesses related to leadership skills. Early theorists believed that people were born with characteristics that enabled them to be effective in getting others to accomplish a designated goal. Individuals with qualities such as strong social skills, empathy, and a charismatic presence were considered born leaders.4

The style approach to leadership was an enhancement to trait theory, with the inclusion of consideration of the actions of leaders. Blake and McCanse revised previously developed descriptions of leadership styles based on the degree of concern for production and concern for people. 5,6 They concluded that there are 5 leadership styles, which they formerly related to management styles: authority-compliance management, country club management, impoverished management, middle-of-the-road management, and team management. Table 1-1 provides an adaptation of the brief descriptions, which parallel well-recognized categories of leadership styles, such as democratic (team management) and authoritarian (authority-compliance).

An opposing view to the trait theorists’ perspectives is the situational approach. Situational theories indicate an emergence of leadership based on various factors that arise within an environment. Emergent leadership occurs when situational demands create a leader among a group that will address the needs within a particular environment.6 With these 2 perspectives alone, it may be easily understood how the controversy between the born leader versus developed leader viewpoints has remained a continuous discussion in leadership scholarship. Some early authors agreed that a combination of these 2 ways of thinking was needed for effective leadership to occur. One may recognize a need to rise to the occasion in a leadership situation, but unless an individual has some inherent qualities that will allow them to successfully lead, they will not be as effective.7,8

Power is often discussed in relation to leadership. There are various types of power, including power based on a position of authority and power based on personal characteristics. People in positions of power, such as CEOs, teachers, and ministers, may use their status to influence the thoughts and behaviors of others.6 Personal power refers to the type of authority that is granted to someone based on their ability to meet the needs of followers. If a leader is viewed as productive, compassionate, and competent, they are more likely to establish personal power than a person who is unresponsive to team members and lacks the necessary skills to get the job done. Individuals can use power in negative and positive ways, but if a leader can use power to benefit the common good and move toward the collective vision of a particular group, this is the optimal use.

Table 1-1 Leadership styLe descriptions

LEADERSHIP STYLE DESCRIPTION

Authority-compliance management

Social club management

Heavy emphasis on task, low emphasis on people

Results driven

Lack of emphasis on communication

Low concern for task

High concern for people

Low emphasis on production

Emphasis on social needs

Helpful and comforting climate

Deprived management

Lack of concern with people and tasks

Uninvolved leadership

Indifferent and apathetic

Fence management

Compromising

Some emphasis on task, some emphasis on people

Avoidance of conflict

Team managementStrong emphasis on tasks and on interactions

Participatory and engaged

Clear about priorities

Open-minded

Enjoyable work environment

Leadership in the 21st century is perceived quite differently from the way it was in earlier eras, when a sage or other individual might be thought to have all the answers to organizational difficulties. Modern definitions and descriptions vary greatly, but some common themes arise from the most recent literature, including the attainment of a common goal, the recognition of leadership complexity, influencing the behaviors of others, and the need to create a vision.9,10 For the purposes of this book, and to allow the reader to grasp a foundational perspective for subsequent chapters, the following definition will be used for leadership:

Leadership is a process that involves a significant degree of complexity through interactive and relational operations in order to meet the goals of individuals or groups.

This definition acknowledges the multiple aspects of leadership by describing leadership as “complex.” This descriptor was selected to exemplify the fact that being an effective leader takes intentionality and hard work. The process of leadership preparation, engaging in action, reflecting, adapting, and engaging again, creates a cycle that is well worth the journey. This cycle is illustrated in Figure 1-1. Leadership requires not only interactions with team members and/or followers, but it also incorporates a degree of relationship building, with efforts to meet the goals of individuals or groups. This relationship building is part of the essential preparation for key action that will help drive change or influence others’ behaviors. The action taken can relate to the theoretical perspectives

that are described in this chapter. Theory enables the occupational therapist to consider best steps for dealing with challenging and even everyday circumstances involving leadership. Theoretical perspectives are not the only way a leader may decide an action. Experience, evidence-based literature, and mentoring all serve as resources for engaging in leadership best practices.

Reflection is becoming a lost art in our faster-paced societies. Careful considerations of how we do something, deep thought about how we could have done something differently, and additional processing for how we will strategize and be intentional about making personal change are leadership skills that may appear challenging to some. However, this reflective and reflexive practice can be transformative for individuals, as well as for your clients and teammates in any setting that you may lead. Acknowledging our mistakes and continuously making self-improvements are part of the adaptation stage in the leadership cycle. This will lead to different action in the next phase. Creating opportunities for feedback among your peers further enhances your ability to act even more effectively at this point in the cycle.

It is important to understand that the leadership process in each situation may not be linear or cyclical. An individual may have to make a quick decision, or they may have opportunities to do group discussions in the adaptation stage, or any number of variances, so it is important to expect changes and to be flexible. Overall, these expanded views of the definition of leadership will enable the occupational therapy practitioner to see themselves as an active participant in their leadership journey.

Leadership cOmpetencies

Although descriptions and definitions of leadership vary in the literature, there are specific skills identified for optimal leadership that are relatively consistent.11,12 The chapter “Exploring the Leader in You” (Chapter 6) in this text explores ways to assess your own leadership and further develop your skills for competent practice. However, it is first important to recognize what competent leadership practice entails.

Today’s leader is challenged with ongoing political and social changes, which have a significant impact on health care. In addition, the complexity and ambiguity of organizational structures and functions make it increasingly challenging to lead within a shifting context. It is essential that

Figure 1-1. Leadership cycle.

leaders develop specific competencies to address the complexity of current work environments. From the author’s own experience, these include cultural humility, interprofessional value, effective communication, and ethical decision making, among others.

Table 1-2 illustrates the levels of competency in essential aspects of contemporary leadership. Level 1 is the lowest level, progressing to the most advanced skills, at level 3. Leaders may be at various levels within the grid, but thoughtful reflection regarding where one is located in each of these basic areas is helpful for meeting the demands of complex leadership situations.

Multiple resources provide details about these and other leadership competencies; Table 1-2 provides an overview of the range of skills within the most basic areas for effective leadership.11,12 Each one of the areas is worthy of a thorough study, and the reader is encouraged to seek out additional readings through the chapter learning activities. The application of leadership theories is enhanced with the development of these specific competencies.

Leadership theOries

Throughout this text, various leadership theories will be described and applied to different health care contexts. Theories describe, explain, and predict behavior and relationships between phenomena.13 Some of the most common leadership theories include situational leadership, servant leadership, and transformational leadership. 14–17 Specific chapters are designated for the expansion and exploration of these particular theories and their potential relationship to occupational perspectives. However, current literature includes less common and newer approaches to leadership that are described in this chapter, including path-goal theory, Theory U, and attributional leadership theories. 18–20 The reader is invited to continue exploration and application of these theories in academic and clinical realms, following this introduction.

Path-Goal Theory

The path-goal theory emphasizes the accomplishment of follower goals through the motivational efforts of the leader. Georgopoulos et al, Evans, Dessler, and House and Mitchell are among the best known authors on this theory.21–24 Although this theory dates back a few decades, its application to the occupational therapy profession is a timely effort, based on the significant needs of employees in the changing economic health care policy context. The path-goal theory is based on the premise that employees need to be motivated in order to perform well and experience job satisfaction. In addition, considerations need to be made regarding the specific work task, the structure of the task, and how this influences an employee’s overall motivation.6

With situational approaches to leadership, the leader takes an adaptive approach and shifts their style based on the readiness aspects of the follower. Path-goal theory recognizes the style of the leader and the follower as well as environmental factors, but it focuses the attention on what motivates the employee. The leader’s role is to provide the incentives or means for the employee’s path to be clear to reach their goal.18 The leader offers something, and, in exchange, the follower produces something.21 Barriers that limit an individual’s goal attainment are analyzed and removed so that the employee can more easily move forward to accomplish tasks in the work environment.

There are 4 main types of leadership behaviors offered by path-goal theory: directive, supportive, participative, and achievement oriented. 24 Each of these is stated to have a particular impact on the motivation of an employee or follower, but the degree of influence will depend on the characteristics of that follower. The directive approach is, as its name suggests and entails, just telling team members, with specific parameters, what they need to do. Supportive leadership, in this theory, is characterized by a friendly and respectful approach to employees, even to the point of considering followers equal to management. Participative leadership goes another step and invites

PERSPECTIVE THINKING

ETHICAL DECISION MAKING

EFFECTIVE COMMUNICATION

CULTURAL HUMILITY INTERPROFESSIONAL VALUE

Recognition of various viewpoints when discussing health-related aspects of client care, as well as healthoriented policies.

Understanding of formal and informal organizational rules and policies, as well as professional codes of ethics. Recognition of institutional and personal values.

Listening skills that provide enough time for individuals to express themselves. An ability to accurately assess verbal and nonverbal communication while responding in a tactful and clear manner.

Recognition that various professionals work together on behalf of the client.

Consistent literature exposure to gain varying perspectives on issues, intentional dialogue to understand other viewpoints.

Understanding of ethical theories and decisionmaking models and their significance to health care practice.

Knowledge of conflictresolution strategies, motivational strategies, and leadership theories that enhance interpersonal skills.

Intentional effort to understand the roles and responsibilities of other team members in the health care arena.

Positive engagement with others who have different opinions and thoughts, pursuit of alternative ways to see health care dilemmas and actively participate in solution finding, high degree of comfort with ambiguity, and flexibility of thought.

Ability to apply ethical theories and decisionmaking models, discuss alternative solutions with key players, and support effective and efficient solutions while considering all pertinent information.

Ability to engage in successful dialogues and formulate solutions beyond self-interest in a collaborative manner, applying conflict resolution, leadership, and other pertinent theoretical perspectives.

Ability to explain various health care team member roles and optimal collaboration with team members with positive client outcomes.

Level 1

Acknowledgment and awareness of differences among ethnic groups and individuals with varying abilities, religious and/or spiritual beliefs, and sexual orientations.

Level 2

Understanding and appreciation of cultural differences and pursuit of information to further understanding.

Level 3

Active engagement and participation in cultural aspects, with intentional efforts to immerse oneself in continuously learning about other cultures within and external to the work environment.

the followers to actually be a part of key decisions within the work environment. Achievementoriented leadership is described as a style that promotes optimal performance of followers through appropriate high-level challenges and high expectations.24

In path-goal theory, any of these leadership styles can be used with a variety of individuals. A leader needs to assess what is preventing an employee from achieving their goals and then implement strategies using the most appropriate style to remove the barriers to optimal job performance.

Similar to situational theory, which is discussed further in Chapter 2, path-goal theory suggests a need to understand team member characteristics and consider styles that match the team member’s needs. For instance, if a worker is unsure of their tasks and when to do them, a more directive approach will be successful. They need to know the structure of the tasks and expectations to have their path unblocked. Again, however, the focus in path-goal theory is to provide an environment that will increase an employee’s motivation, job satisfaction, and performance. In path-goal approaches, the leader will only provide what is needed by the team member, including motivational level, environmental factors, and the specifics regarding the tasks.

Occupational therapy application of path- goal theory

Occupational therapists are able to relate to the specific aspects of path-goal theory, given our familiarity with the Person-Environment-Occupation (PEO) perspective.25 The PEO Model describes the transactional relationships among person, occupation, and environment; outlines major concepts and assumptions; and applies these ideas to an occupational therapy practice situation. The model recognizes and celebrates the complexity of performance of occupations within different environmental contexts. Occupational performance is a result of an optimal fit between the person, their occupation, and their environment.25

In path-goal theory, the “path” may be parallel to occupational performance. Barriers to performance in everyday functions are analyzed by an occupational therapist in the same way that a leader might try to decipher what prevents satisfaction and motivation in an employee. The “tasks” in path-goal theory may be related to the specific occupations one must engage in for fulfillment and productivity. An analysis of these parts will lead to a plan that will enable a person to be more successful. This “plan” in path-goal theory may be likened to a treatment plan that requires a variety of therapist styles to reach certain goals. At times, the occupational therapist will have to incorporate incentives, remove barriers, or even provide clearer instructions in order for the client to reach success. This comparison to our familiar theoretical roots may assist us in recognizing key points in leadership that are feasible for application in various environments.

Currently, there is limited research on leadership theory in direct application to occupational therapy practice. Leadership theory and leadership behaviors can be effectively utilized to guide therapeutic intervention and facilitate successful outcomes for our clients. Table 1-3 provides an example of path-goal theory when working with clients in a clinical setting.

Theory U

Theory U emerged a few years ago, when Scharmer19 published a text that provided significant detail about a new perspective on leading. This contemporary literature creates a way of viewing leadership with an eye to the future, to enable leaders to create a vision that is able to adapt to the ever-changing contexts in which we live and work. The recognition of economic and political strife, as well as failures in education, business, and government, provides an opportunity for the development of a new view on how to lead in changing times. Traditional ways of leading cannot continue to be effective, with varying social and political shifts that continuously challenge us to develop more effective ways to function within our communities and organizations.

Table 1-3

Four types oF Leadership Behaviors

BEHAVIOR APPLICATION

Directive behavior: Set guidelines, clarify expectations, and give specific guidance on the tasks to be accomplished.

Supportive behavior: Show concern and respect for the followers’ needs and preferences and create a friendly, supportive environment.

Participative behavior: Collaborate with clients to make decisions.

Achievement-oriented behavior: Set challenging but realistic goals to push clients to excel and have confidence that they can attain goals.

Education on precautions to adhere to following surgery, energy conservation techniques, or home exercise programs that are new to the client and are important for safety or increasing participation.

Establishing a therapeutic relationship by creating an occupational profile and getting to know the values and goals of the client, practicing from a perspective of client-centered and occupation-centered care.

Encourage and facilitate a collaborative process in which the client guides the treatment sessions and is an active partner in problem solving and setting goals for therapy.

Creating the “just-right challenge” in intervention to motivate the client to achieve their greatest potential; being intentional in terms of choosing or guiding interventions that help move the client forward toward their goals.

Reproduced with permission from Cleveland K, Winston K. Bridging theory and practice through leadership. Poster presented at 93rd Annual Conference of the American Occupational Therapy Association; April 24–28, 2013; San Diego, CA.

Scharmer proposes that we take the initiative to facilitate and support the needed changes within our society and organizations, which will make us more accountable to each other for the good of everyone. When we make intentional efforts to identify issues and improve conditions, positive things can take place. Attending to needed change requires a concerted effort and determination that anyone can develop. This is done through the 3 main features of Theory U: an open mind, an open heart, and an open will.19

The open mind experience relates to the identification that one’s assumptions may be taken for granted and new knowledge may help to enlighten a perspective. For example, the occupational therapist who is working with someone from another country with which they are unfamiliar will have assumptions about that culture. The therapist may approach the client with stereotypes in mind and not really take the time to ask the client about their culture and understand its relationship to occupational performance. An open mind will allow for new learning and new perspectives. A leader with an open mind will seek out new information in order to stay current and competent, as well as to meet the demands of the changing environment. This is helpful when planning for a department’s future with decreased reimbursement and a changing demographic, or when helping employees reach their professional goals.

An open mind can also be thought of in a broader sense, in regard to occupational therapy becoming widely recognized. In order to lead in this century, occupational therapists must develop an open mind to listen to our global communities, strive to eradicate occupational injustice, and focus on authentic occupational therapy for meeting society’s needs.

Developing an open mind is an important aspect for leading into the future, but without the reflective activity of an open heart, action for change may be minimal. An open heart requires a process of deep attention to understand our part of a particular issue and take personal responsibility for our feelings and thoughts related to it. An open heart is related to observing the status quo and assessing whether change is actually needed. In addition, recognizing our part in inhibiting needed change is another perspective of an open heart that is critical to pay attention to in developing optimal leadership skills.

Finally, an open will refers to the determination to make the actual change necessary for a better organization, country, and even a better world. Political uprisings in so many countries within the past few years are a testament of an open will at work in a collective sense. People have weighed within their own minds, through reflection, what is needed to make necessary change for the greater good and then have made widespread efforts to foster or ensure societal changes, even in the face of great challenges.19

Occupational therapy practitioners have numerous opportunities to do reflective work and take action to improve the lives of clients and the organizations in which they work. There are many occupational therapy leaders who take this to the next step of an open will by ensuring the necessary change on community, national, and international levels, to bring attention to widespread issues that impact more than a few clients. This type of exemplary leadership relates to the aforementioned concepts in Theory U.

Developing these core features enables occupational therapy practitioners to sense the future and lead in a more visionary manner than ever imagined. Scharmer19 refers to presencing as the ability to sense one’s future potential in the highest sense, making essential things happen. This combination of “presence” and “sensing” allows an individual to see themself as they will become, thus creating the path to goal attainment, based on the possibilities of the future. As occupational therapy practitioners, we are actually expecting this type of presencing from our clients on a daily basis. Imagining this process for ourselves could lead to far more powerful leadership within the profession.

Scharmer’s Theory U19 is illustrated by an actual U shape that incorporates 5 movement processes along the path of the U. At the top left of the U is co-initiating, which is the ability to listen to others and follow one’s own life passions. Just below this movement is co-sensing, which is the ability to understand one’s own fullest potential, using an open mind and open heart in the process. At the bottom of the U shape is co-presencing, which is providing oneself the opportunity to reflect and allow one’s new knowledge and understanding to emerge. On the right side of the U shape are co-creating and co-evolving movement processes. Co-creating is exploration of the potential action one could take in the future. A trial-and-error process will allow a person to see if there is a particular avenue they want to explore. The last movement process, co-evolving, is the actual participation in growth experiences that include the sensing, understanding, and realization of optimal plans that support and enhance leader contexts.

Occupational therapy application of theory U

An occupational therapist in an academic setting was asked to consider a newly created administration position. This position entailed the formulation of continuing education for area clinicians and professional development initiatives for the faculty in the college, which included multiple disciplines in the health professions.

The open mind of this process included the envisioning of a new way for occupational therapy to make a significant difference in an academic setting. The opportunity of helping to create the role was an unexpected challenge, but the occupational therapist sought out information from other universities and developed knowledge about similar roles as a way to feel more comfortable.

The open heart approach to this work-role transition included a mindfulness of past mistakes in administrative roles and a deep reflection on what leadership strengths could add to the position and what skills needed improvement. Adjustment to different support staff and administrators

within the same college posed new challenges. Different personality styles and work expectations resulted in difficult interactions. Further reflection revealed that former patterns of interacting primarily with occupational therapists in a work setting would not be as effective with the varying roles present in the new position.

The open will aspects of this work-role transition included a vision of a successful department with the development and implementation of creative professional development activities (co-sensing). With that in mind, different strategies were integrated for action to achieve this goal. Discussions were held with key people to clarify roles and expectations (co-initiating). Goals were set for the professional development initiatives (co-creating). Now, after 1 year in the role, the growth between work partners is evident, and outcomes are positive (co-evolving).

This brief overview of Theory U is just a window into a thought-provoking and detailed perspective. The reader is encouraged to continue to explore this contemporary approach to leadership and be intentional about their leadership exploration and growth, using the principles of this theory as a guide.

Attributional Theory of Leadership

Attributional theory actually dates back to Fritz Heider, 26 who described attributions as the cognitive processes individuals use to understand cause and effect in problem-solving situations. This allows for more effective interactions in the contexts in which we work. Attributional theory has gained more attention in recent years, with notable applications to leadership.27,28 These contributions to the literature have included the identification of strategies used to make attributions, such as consensus and consistency of team member behaviors, as well as explanations and descriptions of attributional processes.20,27,28

Occupational therapy application of attributional theory

To illustrate how attributions play a role in everyday leadership, consider potential employee behaviors, such as failing to document notes on clients in a timely manner. The leader uses observation to understand the failure to follow through on tasks. The leader may ascertain a lack of effort on the part of the team member, rather than an inability to perform, and therefore provide a more severe response to the team member. This lack of understanding the multiple factors involved in apparent poor performance presents a need to more fully understand the complex nature of performance.

The cognitive process of assessing cause and effect is an ongoing mental exercise in leadership contexts. There is difficulty in assessing thought processes, motivational levels, and the rationale for certain behaviors. This example provides a view of the many challenges of attribution research. Measuring thoughts, feelings, and their relationship to actions is a difficult task researchers clearly identify.28 In addition, there are numerous factors that impact a leader’s decision making in managing employees that may be unrelated to attributions, such as departmental policies, costs, and administrative expectations. Gender, experience level, culture, age, and personality traits also influence attribution and must be considered in evaluative processes.

Regardless of the challenges to researching this aspect of leadership, there continues to be a consistent effort to use attributional theory to understand and explain leader decision making and actions. Martinko et al 28 even argue that attributions are a significant reason for the observed variance in leadership behaviors, and they clearly identify this area of study as critical for understanding the dynamics of leadership. A distinction is made between perceiving attributions as related to personal characteristics versus the more in-depth causal approach that uses information sources to lead to conclusions. Both approaches have been linked to attribution theory, but it is the latter that provides the leader with a more substantive approach to analyzing their everyday leadership by considering the impact of gender, context, race, and experience, among many other factors.

Lakshman 27 provides a critical analysis of previous literature on attributional theory, indicating the negative influences, such as the view of a poorly performing team member, on attribution processes. He proposes a more positive approach by identifying desirable leader behaviors and perceptions, based on a positive attributional model of leadership. When leaders use “attributional accuracy,” it leads to high-quality performance from team members. This is the more correct assessment of attributes based on multiple factors that may impact an individual’s job performance. Expert attributional processes, including the use of more complex cognitive processes, involve a more in-depth evaluation of the potential reasons and influences on decision making and actions. Rather than concentrating on an individual’s weaknesses and how to fix them, this newer approach involves the identification of the team member’s strongest qualities and the causal factors that create high-performing individuals.

A leader who is able to assess environmental influences on performance, understand the multiple reasons for performance variations, and appreciate the complexities of organizational challenges, and who has a high level of interest in effective resolution, will be more likely to engage in attributional accuracy. In the previous example of a poorly performing team member, an effective leader will gather more data in the assessment process, including observations and discussions with the employee as well as evaluating contextual supports and barriers for performance. Occupational therapists routinely use these types of cognitive processes in serving clients but need to recognize the effectiveness of applying evaluative processes in leadership contexts as well.

Leadership theories are essential tools for application in the many health care work arenas. Informal and formal leadership roles are enhanced with the integration of theoretical perspectives.29 Just as the use of occupational therapy theories, frames of reference, and models serve as essential foundations for client evaluation and treatment planning, leadership theories serve occupational therapy practitioners well in the development and implementation of leadership initiatives. As the profession seeks to be widely recognized and globally connected, even addressing widespread public health issues, it is essential that its leadership standards are high and highly effective.

Learning activities Tier 1

1. Explore 2 other resources or references related to either Theory U or attributional leadership theory. Identify at least 2 main points that were not included in this chapter summary.

2. Describe specifically how you think understanding leadership theory can assist the occupational therapy profession to become better recognized and/or stay true to its authentic occupation roots in practice.

3. Review Table 1-2 and find at least 3 additional resources on conflict resolution, ethical decision making, and/or cultural competence or cultural humility. Discuss your findings and their relationship to effective leadership with at least one peer and/or the class.

Tier 2

1. Compare one other contemporary leadership theory to a theory in this chapter. Use at least 3 book, journal, and/or reputable web references to support your verbal or written statements.

2. Explain the application of one of the theories in a current school or work situation.

3. Describe how you would apply a leadership theory for using occupation to make a societal difference.

1. Braveman B. Leading and Managing Occupational Therapy Services: An Evidence-Based Approach. F.A. Davis; 2006.

2. Maxwell JC. Leadershift. HarperCollins; 2019.

3. Fleishman EA, Mumford MD, Zaccaro SJ, Levin KY, Korotkin AL, Hein MB. Taxonomic efforts in the description of leader behavior: a synthesis and functional interpretation. Leadership Q. 1991;2:245–287.

4. Bass BM. Bass and Stogdill’s Handbook of Leadership: Theory, Research, and Managerial Applications. 4th ed. The Free Press; 2008.

5. Blake RR, McCanse AA. Leadership Dilemmas: Grid Solutions. Gulf Publishing Company; 1991.

6. Northouse P. Leadership: Theory and Practice. 6th ed. SAGE; 2013.

7. Westburgh EM. A point of view: studies in leadership. J Abnorm Soc Psychol. 1931;25:418–423.

8. Case CM. Leadership and conjuncture. Sociol Soc Res. 1933;17:510–513.

9. Kouzes JM, Posner BZ. A Leader’s Legacy. Wiley; 2007.

10. Stanford-Blair N, Dickmann MH. Leading Coherently: Reflections From Leaders Around the World. SAGE; 2005.

11. Ledlow GR, Coppola MN. Leadership for Health Professionals: Theory, Skills, and Applications. Jones & Bartlett Learning; 2011.

12. Johansen B. Leaders Make the Future. Berrett-Koehler Publishers; 2012.

13. Cole MB, Tufano R. Applied Theories in Occupational Therapy. SLACK Incorporated; 2008.

14. Hersey P, Blanchard K, Johnson D. Management of Organizational Behavior: Utilizing Human Resources. 7th ed. Prentice Hall; 1996.

15. Greenleaf RK. Servant Leadership: A Journey Into the Nature of Legitimate Power and Greatness. Paulist Press; 1977.

16. Burns JM. Leadership. Harper and Row; 1978.

17. Bass BM, Avolio BJ. Transformational Leadership Development: Manual for the Multifactor Leadership Questionnaire. Consulting Psychologists Press; 1996.

18. House RJ. A path-goal theory of leader effectiveness. Adm Sci Q. 1971;16:321–328.

19. Scharmer CO. Theory U: Leading From the Future as It Emerges. Berrett-Koehler Publishers; 2009.

20. Green SG, Mitchell TR. Attributional processes of leader in leader-member interactions. Organ Behav Hum Perform. 1979;23:429–458.

21. Georgopoulos BS, Mahoney GM, Jones NW. A path-goal approach to productivity. J Appl Psychol. 1957;41:345–353.

22. Evans MG. The effects of supervisory behavior on the path-goal relationship. Organ Behav Hum Perform. 1970;5:277–298.

23. Dessler G. An Investigation of the Path-Goal Theory of Leadership [dissertation]. Baruch College, City University of New York; 1973.

24. House RJ, Mitchell RR. Path-goal theory of leadership. J Contemp Bus. 1974;3:81–97.

25. Law M, Cooper B, Strong S, Stewart D, Rigby P, Letts L. The person-environment-occupation model: a transactive approach to occupational performance. Can J Occup Ther. 1996;63:9–23.

26. Heider F. The Psychology of Interpersonal Relations. Wiley; 1958.

27. Lakshman C. Attributional theory of leadership: a model of functional attributions and behaviors. Leadersh Organ Dev J. 2008;29:317–339.

28. Martinko MJ, Harvey P, Douglas SC. The role, function, and contribution of attribution theory to leadership: a review. Leadersh Q. 2007;18:561–585.

29. Dunbar SD. Leadership, professionalism and teaching and learning. In: Stern D, Rosenthal R, eds. Clinical Education in Physical Therapy: The Evolution From Student to Clinical Instructor and Beyond. Jones and Bartlett; 2020:103–130.