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THEORETICAL PAPERS

Effective leadership within hospice and Specialist Palliative Care Units

The Yorkshire Hospice Peer Review Audit Project, NYCRIS, Cookridge Hospital, Leeds, UK
Keywords Leadership, Gender, Health care Abstract In this study the Repertory Grid interview technique was used to investigate constructs of leadership held by a group of male and female senior managers from within hospice and Specialist Palliative Care Units (SPCUs) in the UK. The themes that emerged were compared with those from existing research models of leadership. Results: men and women in these roles describe different constructs of effective leadership. The women's constructs that emerged were predominantly transformational, whilst the men's were predominantly transactional. Themes were also identified in this study, which differed from previous studies, i.e. those of political and environment awareness and the valuing of others' views regardless of their status. These themes do not feature highly in other research, and may be in response to the environment within which hospice and specialist palliative care functions.

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Liz Barker

Background Change is the key to innovation and to the future; as change is inevitable, we must learn to love change in order to succeed (Handy, 1985). Hospices, like other organisations, are facing constant change. A model of leadership concerned with ensuring organisational survival in times of turbulence and change has been found to be that of transformational leadership (e.g. Bass et al., 1996). Research into whether gender affects leadership style, and whether men and women perceive leadership differently, has concluded that in general women's constructs of leadership appear to be more transformational than are men's (Rosener, 1990; Alimo-Metcalfe, 1995; Franklin, 1997). Taking this factor into account together with the findings from research that transformational leadership is best suited to organisations in today's climate of constant change and that women demonstrate a predominantly more transformational approach to leadership, why then is there a paucity of women in senior management posts? It is within this context that this study investigates constructs of effective leadership, in a group of senior managers within hospice and SPCUs. Transformational and transactional leadership Leadership is considered by many as a positive phenomenon; however, there is much less agreement about what leadership actually is (Cronin, 1993).
Journal of Management in Medicine, Vol. 14 No. 5/6, 2000, pp. 291-309. # MCB University Press, 0268-9235

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Leadership is usually categorised in modern texts as either transformational or transactional; modern theorists refer to management also as leadership but call it transactional leadership. Leadership arises in response to a need and requires followers. A leader must therefore understand the needs and motivators of the followers to be effective. Leaders are in the people development business their own development, and that of their followers with a definite link between effective people management and strong business performance (West and Patterson, 1998), with satisfaction of the workforce linked to higher productivity and profitability. The effectiveness of leadership style Articles abound on leadership; however, few evaluate the impact of leadership and its effectiveness within the organisation. The estimated 50 per cent failure rate of senior executives in the USA has been suggested as being due to the use of invalid selection processes. Various methods of assessment, such as personality and cognitive ability tests, structured interviews, simulations and assessment centres, have varying degrees of predicting leadership success. The effectiveness of leadership can be judged from five groupings of evaluative criteria: the performance of the team; others' ratings of the leader, i.e. multi-rater (360 degree) feedback, assessment centres etc.; evaluating the leadership potential of strangers, through interviews, assessment centres etc.; self-ratings of leadership; and studies of derailment of people (Hogan et al., 1994). The effectiveness of leadership is perhaps best measured by those who are the consumers of leadership, e.g. subordinates, peers and superiors. Research has demonstrated that subordinate ratings through multi-rater feedback are better predictors of managerial effectiveness for two to four years into the future (and are less expensive) than assessment centre ratings (McEvoy and Beatty, 1989). Consistent findings are emerging from the research into 3608 multi-rater feedback that recognise the link between high levels of self-awareness, effectiveness, self-esteem and motivation of staff (Alimo-Metcalfe, 1998a, p. 14), with females generally showing greater self-awareness as defined by self-other rating agreement (Fletcher, 1998). Insight into one's own leader behaviour and the impact of one's behaviour on others may have value for predicting future leader success (Fletcher, 1998). Generally, leaders are people with high selfesteem and self-awareness, who are secure enough in themselves to create and share a future vision for others (Sofarelli and Brown, 1998). In some studies, a direct link has been demonstrated between the degree of agreement between how managers perceive themselves and how staff perceive them, with the level of agreement more likely to be stronger in transformational leadership. Bass (1998b, p. 27) found that organisations with transformational leaders have been found to be more effective, i.e. with higher performance than those managed by a leader with a predominantly transactional style. On the reverse side, incompetent managers cost organisations billions in lost productivity (Hogan et al., 1994). Effective people management is the key. The

two human resource practices closest related to profitability and productivity are the acquisition and development of skills through effective selection and appraisal (West and Patterson, 1998). However, is the current system of selection and assessment effective and equitable? Historical perspective of gender on leadership research Morrison (1992) suggests that the lack of female representation at the top of organisations is explained as providing evidence of a ``glass ceiling'' which presents an invisible but nonetheless impenetrable barrier to women's advancement to positions of senior management. Despite 20 years of equal opportunity legislation in th UK, there is still a paucity of women in senior management positions. In 1974, 0.6 per cent of managers at director level were women, while in 1998 this has increased to 3.6 per cent (MIC, 1999). Yet, the percentage of women in the general workforce has increased from 41 per cent in 1979 to 47 per cent in 1997 (Donnellan, 1996; MIC, 1999). Women make up three-quarters of the National Health Service (NHS) workforce, which is the third largest employer of women in the world (Alimo-Metcalfe, 1994b). Despite this, women are still under-represented in management. In 1989, only 4 per cent of women were district or regional general managers, and only 17 per cent unit general managers. In 1995, women held a quarter of the jobs in medicine, but just 1 per cent were consultant surgeons (Davies, 1995, p. 46). Generally the more senior a post is in the NHS, the less likely is it to find a woman in it (Davies, 1995). In hospices 14 per cent of the chief executives/general managers were women (Barker, 1999). The Glass Ceiling Commission (1995, p. 12) believes that every member of society should have the opportunity to strive for positions of responsibility and leadership, regardless of their race, ethnic background or gender. Why then is there still under-utilisation of women in senior management? Jacobson and Jacques (1990, p. 4) and Fagenson (1993, p. 6) both propose frameworks to assist in our understanding of the historical under-utilisation of women in management. The historical perspective of gender on leadership research Knowledge production and all social interaction is gendered in its nature (Jacobson and Jacques, 1990). Feminine and masculine identities are deemed to be constructed, i.e. not natural or given in biology, and therefore understood as cultural achievements (Moore, 1994). Mackie, cited in Harding (1997), expands this by determining that male and female identities are shaped differently. Females are deemed to exist as feeling creatures in their roles as wives and mothers, men to be ``doing'' doing demonstrates strength and toughness. Therefore, it is through the ``doing'' of gender that it is reproduced, becoming something we continually do and think (Mills and Murgatroyd, 1991). This creates role confusion, as men see women and managers differently, and do not perceive women as possessing

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the characteristics they associate with effective managers (Alimo-Metcalfe, 1998b). When women become managers, this creates dissonance for men (Schein, 1990). Most pre-1980s research concluded that there was no real evidence of sex differences in preferred leadership style (e.g. Bartol et al. cited in AlimoMetcalfe, 1994a; Dobbins and Platz, 1986). By the mid-1980s the following studies: Jago and Vroom (1982); Vinnicombe (1987); Ferrario (1994) had demonstrated some differences of style of leadership in relation to sex differences. Research had also identified that the instruments used in the past were developed in the main from studies of men (Alimo-Metcalfe, 1993b). Equally these had been conducted within the corporate and military arenas, i.e. Mintzberg's study, which reflected only male norms (based on males and how they rank their needs), so that those equated with ``female'' are at the lower end of the scale. The language of management is the language of masculinity. Leaders are often referred to as ``he,'' and chairs of committees often remain ``men'' (Hearn, 1994). Harding (1997) and Alimo-Metcalfe (1994b) believe that organisational theory reflects dominant male values, and that this has been the ethos of organisations. Androcentric bias (male as norm), in management theory and literature, assumes that the experience of all managers will be similar, whether male or female. It purports that the concept of ``hegemonic masculinity,'' i.e. dominance within society of certain forms and practices of masculinity, excludes not only women, but also black men and those openly gay (Harding, 1997). Even for men within organisations there is a requirement to conform to male dominance and a certain type of masculinity is dictated and expected, requiring the mirroring of this behaviour in line with the dominant model (Harding, 1997). Masculinity is equally about relations between men and men and relations between men and women (Hearn, 1994). Schein in the 1970s investigated male and female middle managers' perceptions of men and women and found that both sexes perceived that the qualities required of a successful manager were more commonly held by men in general than women in general. She replicated the study in 1989 to gauge the effect of equal opportunities programmes and found women perceived the qualities of effective managers, and those of women and men, to be equally strongly correlated but, in men's perceptions of the qualities of effective managers and women, nothing had changed. In over 15 years men still held a masculine stereotypical view of successful managers (Schein, 1990). This creates gender bias which has consequences at all levels, and starts at the entry level (Alimo-Metcalfe, 1994a). Men set the criteria of assessment for entry into an organisation (which are subsequently based on male norms), creating gender bias throughout the process. Gender bias in selection and assessment has been purported to be one possible reason for the paucity of women in management (Alimo-Metcalfe, 1993a). There are three major stages to the assessment process; the job analysis, i.e. the skills, knowledge, abilities and qualities for the job, the

technique or method for selection, and the assessors' judgement of performance of the individual. Assessing potential and measuring effectiveness is a complex area. The process usually begins with a job or person analysis. Many methods are available for producing a job analysis, but all stem from one question: What is the view of an effective manager? Hospice and Specialist Palliative Care Units The modern hospice movement has its origins in the work of Dame Cicely Saunders, who in 1967 created St Christopher's Hospice in London. The concept of hospice care grew out of the failure of the State to provide a cradleto-grave service of the right quality (Clark, 1993, p. 172). Since that time there has been a proliferation of some 236 hospices in the UK (HIS, 1999), ranging from a few years old to 31 years. Their level of maturity, i.e. diversity of service provision, also varies and may bear no resemblance to their age. In 1993, 43 independent hospices were in the top 500 fund-raising charities, and it was estimated that 100 of the 500 charities with the highest annual income in the UK were hospices (Johnson, 1998, ch. 2, p. 17). Each hospice has a different structure some are part of larger organisations, and some are independent. Currently in the UK 66 per cent of the voluntary adult in-patient hospices have a chief executive and 34 per cent a tripartite structure (Barker, 1999). The external environment for hospice and specialist palliative care A charity operates within the political context of the day. In the late 1980s and early 1990s the radical reforms contained within the government paper Working for Patients (DoH, 1989) and the NHS and Community Care Act (DoH, 1990) caused the creation of a market in Health care, which challenged the attitudes and values of professionals and questioned the position and standing of hospice care within the commissioning process. A change in government, and the issues of major policy documents, The New NHS: Modern and Dependable (DoH, 1997) and A First Class Service (DoH, 1998) have added to the speed of change facing hospices. For an organisation to be effective and therefore survive and prosper there must be an understanding of the external environment in which the organisation operates to anticipate and respond to change (Ginter et al., 1992, p. 254). Sofarelli and Brown (1998) note the importance in health service leadership of the awareness of both the internal and external environment, and utilising this information to develop the vision for the organisation. A transformational leader will ensure that followers are aware of the impact of the environmental factors on the ability to achieve a shared vision. Method A qualitative approach, that of The Repertory Grid Technique (Kelly, 1955), was used to gain insight into the participants' constructs of leadership. This technique is an effective way to elicit personal constructs (Robson, 1995).

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Sample Hospices' chief executives and general managers were selected using the Hospice Directory (HIS, 1999). Repertory grid George Kelly (1955), a clinical psychologist, proposed a theory of personality based on the notion of personal constructs, dimensions which are used to make sense of and extend our experience of the world. Data or elements are used to form constructs, which then provide a framework of meaning. He suggests that these constructs are bipolar on a dimension from ``good'' to ``bad.'' The Repertory Grid Technique is a way of eliciting these constructs (Robson, 1995), and qualifying people's attitudes, feelings and perceptions (Easterby-Smith, 1980). Interviews The participants were asked to select six individuals in a position of leadership with whom they had worked or are currently working; two with excellent leadership skills, two with poor skills, two average, and themselves. Letters of the alphabet were used to depict the individuals to retain anonymity. These seven letters were written on seven separate pieces of paper. The seven papers were shuffled and the respondent was asked to select three elements at random from the seven. This group of three (a triad) was used as the basis for identifying the constructs. The participant was asked to consider the three elements (individuals) corresponding to the pieces of paper and to describe in what ways two of them differ from a third in terms of leadership; they were then asked to explain the difference. This process was continued and further triads selected and the process of construct elicitation continued. The process of ``laddering'' up or down the construct system was used to allow for further clarification by generating ``lower order'' constructs from existing ones. The participant was also asked to give an opposite to the construct being elicited, thus helping to clarify meaning and reducing ambiguity. The participant was then asked if there were any other aspects that were important and had not been described on the grid. After eliciting all the constructs the participant was asked to rate each construct against each element using a five-point scale. The interviewer reflected back to the participant the constructs elicited, enabling further checking for accuracy of documentation and reliability. At the end of the interview, the respondent was asked to identify which elements were male and which female, and which had been described as excellent, average and poor. The only identification left on the grid was the participant's sex, the sex of the elements, and whether they were rated as excellent, poor, or average. The process of triangulation was not incorporated into this study (Campbell and Fiske, cited in Nolan and Behi, 1995, p. 829). One method of achieving this

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would have been to use the Transformational Leadership Questionnaire (AlimoMetcalfe, 1998a) as part of this study. However, it was felt that this would be making an assumption that the constructs of leadership used within the Transformational Leadership Questionnaire in the NHS and local government would be equally applicable to this study, which is conducted in a different area. Analysis Grids were photocopied and each construct was cut up into a separate card. The cards were sorted by the researcher into groups of constructs that related together. These categories were labelled. The labelling of the categories and the assigning to groups was completed by the author and then independently by another individual to enhance reliability (Mays and Pope, 1995). Where differences emerged, these were discussed and re-examined, using the opposite pole of the construct to clarify any differences. The categories of constructs were then further grouped into ten themes. By relating the themes of constructs identified in this study with those elicited in other studies, similarities were identified, although differences did emerge. Results and links to the literature From the 16 interviews conducted, 304 constructs were elicited. Of these, 148 were elicited from the male participants and 156 from the female participants. The female participants had a mean of 19.5 constructs per interview with a range of 18-23, whilst the men had a mean of 18.5 with a range of 14-23. The 304 constructs were grouped (without knowledge of the sex of the participants) into 44 groupings. These groupings were then further summarised into ten themes to establish whether there were any patterns emerging. The ten themes of constructs are listed below: (1) Dynamic, entrepreneurial, proactively embraces change. (2) Political/environmental awareness, networking, strategic thinker, visionary, charismatic. (3) Good communication skills. (4) Develops, values and supports other. (5) Consultative, shares, information, knowledge. (6) Integrity, fairness, honesty, respect, humility, responsive. (7) Professional, self-motivated, develops self, confident. (8) Self-awareness, openness. (9) Organisational skills, performance management. (10) Inspirational, takes the team with them. Once the constructs had been distilled into themes, the gender of the participant was identified and noted, and women's and men's frequencies of constructs of effective leadership totalled within each theme, (see Figure 1).

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Figure 1. Number of constructs for men and women within each theme

Comparing male and female constructs Differences emerge in the constructs identified predominantly by the men and those predominantly identified by the women. These differences resemble the distinctions in the literature that in general women's constructs of effective leadership appear to be predominantly more transformational than men's (Rosener, 1990; Alimo-Metcalfe, 1995; Franklin, 1997). The men's themes were: . dynamic, entrepreneurial, embraces change; . professional, self-motivated and self-confident; . organisational skills; . communication skills, show some transformational characteristics, i.e. good communication skills, negotiation skills, and intuitive, but are predominantly transactional. The men describe a single-minded dynamic individual who is entrepreneurial and enjoys success, has certainty of vision and is very persistent and action orientated. They are willing to take risks, have charisma and influence, and enjoy a high profile outside the organisation, working with external agencies. They use logic and put systems in place to solve problems. As individuals they are self-motivated, and develop themselves personally, they appear confident and competent and have a good generalist knowledge base, they are solid and unemotional. They have good organisational and administrative skills, and set targets and time-scales and stick within time constraints. In seeking to achieve their goal they do not need to be liked by others. They have clear communication skills, both written and verbal, and are good at delegating and motivating staff.

The themes that were identified predominantly by the women were: . political, environmental awareness, networking, strategic, visionary and charismatic; . develops, values and supports others; . integrity, fairness, honesty, respect, humility, responsiveness; . inspirational, takes the team with them; . consultative, shares information and knowledge. The women describe someone who networks well both internally and externally and consequently has a deep understanding of the environment and political arena, both locally and nationally. They have a clear vision, which they communicate well to others and a positive passion and enthusiasm for progress to achieve the vision. Their ability to remain consistent, fair and honest engenders a respect from those around them. They have the highest integrity and humility, they are not afraid to ask advice and utilise the skills and knowledge of others, actively encouraging positive participation; consulting, sharing and cascading information, ideas and enthusiasm. They value the opinions of others regardless of their status or position within the organisation. They support staff, seeking to develop their skills, even if this means that their staff's skill level will be greater than theirs. Within the themes identified the area that men and women felt to be equally important was the theme of self-awareness and openness. Described as the ability to be ``self-critical, and willing to admit that they are not always right'', a ``willingness to adapt to differing circumstances'', ``doesn't feel that they know it all'', ``recognises their own weaknesses'', ``not afraid to be seen as uninformed, willing to ask for help''. Comparing constructs of leadership from this study with those from other UK studies The findings are equivocal with respect to gender differences in preferred leadership styles (e.g. Ferrario, 1994). However, Alimo-Metcalfe (1998a) maintains that the type of instrument used in previous studies has been based on a predominantly male managerial population and is therefore gender biased. Recent UK research using the Repertory Grid (Kelly, 1955) has demonstrated differences in what men and women perceive as effective leadership (AlimoMetcalfe, 1995; Sparrow and Rigg, 1993; Franklin, 1997). If the constructs from the above studies and the current study are compared, it is clear that there are similarities in the themes identified, and the way the constructs are expressed. As with other studies the women identified predominantly transformational constructs, those of participative working and being people orientated, etc., whereas the men identified predominantly more transactional characteristics: ``organisational skills'', and ``performance management''. Sparrow and Rigg (1993) conducted their study on two groups of housing managers to identify skills and attributes believed to be required for the job of

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housing manager. They found that women were seen to emphasise ``teamworking'', ``working through others'', a ``participative approach'' and a ``broad understanding of others' needs'', whereas men were seen as being either ``entrepreneurial and visionary'' or ``transactional'', i.e. a structured, regimented approach, managing rather than leading. Alimo-Metcalfe (1995) conducted a pilot study looking at two groups of senior NHS managers, to identify constructs of effective leadership. Very different qualities and skills emerged from the male and female groups, although these findings were similar to both Sparrow and Rigg (1993) and a US study conducted by Rosener (1990). Franklin (1997) looked at male and female senior managers in a health authority, to identify characteristics of effective leadership. Her findings were similar to those of Alimo-Metcalfe (1995) and Sparrow and Rigg (1993). However, in addition she found that women describe their own style of leadership as more transformational than men, as well as being perceived to be predominantly more transformational by others. All the above studies and the author's current findings suggest that women describe predominantly more transformational characteristics than men. However, it is only fairly recently that the study of leadership has included inquiry into transformational leadership, and most of the studies looking at transformational leadership have been conducted in the USA. A recent UK study, that of Alimo-Metcalfe (1998a), looked at whether the nature of transformational leadership in the UK is distinct from that in the USA. This study of senior and upper middle managers in the public sector and the NHS used the Repertory Grid technique (Kelly, 1955) to elicit constructs with the aim of developing a questionnaire to measure transformational leadership (TFLQ). The findings of this study demonstrated that the US model of transformational leadership is sufficiently different from the UK model to warrant acknowledgement. Comparing the constructs in this study, those of other UK studies and studies in the USA Transformational leadership is the most meaningful in today's diverse and complex world (Sashkin and Rosenbach, 1993), yet differences have been found between the UK and US model of transformational leadership, as well as gender differences in relation to perceptions of effective leadership. Rosener's (1990) study identifies characteristics in women's leadership styles, which are similar to the constructs elicited by the women in this study. Rosener found that women have an ``interactive'' style, which encourages participation, sharing information and power, and enhancing others' self-worth. The characteristics described by the women in this study, such as ``seeks advice and utilises others' skills and knowledge'', ``open'', ``shares information, ideas and enthusiasm'', mirror those of Rosener (1990). They reflect a participative, inspirational approach that centres on engaging and encouraging followers' involvement, with the emphasis on credibility,

integrity, fairness and concern for their individual needs. Bass and Avolio (1997, p. 208) talk of women's moral reasoning and the highlighting of responsibility and care. Rosener (1990) talks of ``energising others''; the women in this study describe someone who ``inspires others to go with them and rise to a challenge'', the ability to ``enthuse others'' and ``engender unity amongst the team''. One who ``sees relationships with people as getting the best for the organisation''. This links well with Rosener's (1990, p. 120) view of transformational leadership, that of getting followers to ``transform their own self-interests into the interest of the group'' to achieve a greater goal. The differences identified in women's and men's perceptions of effective leadership in this and other studies could be due to differences in the way women and men perceive the world and communicate. The theme of communication has been identified in the literature as one with different gender dimensions. Currently the scientific debate is intensifying with regard to whether the proposed ``brain based distinctions'' in relation to gender represent a reflection of how men and women think, feel and behave differently (Schrage, 1999, p. 1; Moir and Moir 1998). Rosener (1997, p. 217) describes how women's style of communication differs from men's. Women use communication as a means of interacting with others, exchanging thoughts and feelings and building relationships, described in this study as ``makes time for staff, makes them feel special'', ``values and respects people regardless of their status'', whereas men ``speak and hear a language of status and independence'', communicating to obtain information and with that establish power and independence (Tannen, 1996 p. 42). Women are more able to view things holistically, sometimes referred to as intuition, whereas men view things in a linear way (Rosener, 1997; Rigg and Sparrow, 1994). Rosener (1997) found women more sensitive to body language, verbal nuances, and emotional cues than men (Schrage, 1999, p. 2). In this study one participant described how a woman was aware of her body language and actively used this as a means to break down barriers with others. Perrault and Irwin (1996, p. 7) found that women were more likely to see things through, were stronger on commitment, and more likely to share information than men. Women were also more responsive to others' needs, giving support and direction to others. This was echoed by Bass et al. (1996), who found that women were more individually considerate, more empathic and able to move followers to go beyond their selfinterests to concerns for their group or organisation. Bass and Avolio (1997) also identified that women generally rated higher on the 4 Is of transformational leadership than men, with more ``idealised influence'', being more ``inspirational'' and ``individually considerate''. Women in this study describe a leader who develops, values and supports others, is charismatic, and has a strong public image, well respected by others, described by Bass and Avolio (1994a) as `` idealised influence''. The men and to some extent the women talk of a leader who is self-motivated, ``good at motivating others'', ``promotes personal development of others''. The women, however, appear to motivate

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more through their relationships with others. Valuing others and their individuality, ``able to spot potential in others''; ``makes people feel responsive to them''; ``engenders feelings of security, motivation and rising to a challenge'', ``inspires others to go with them''. These characteristics are described by Bass and Avolio as ``inspirational motivation''. There is clearly some overlap between this category and the category of ``individualised consideration'', which the women in this study described as someone who feels that ``personal relationships with others are important in getting the best for the organisation'', ``takes the team with them''. ``Values others' contributions regardless of status'', ``treats people as individuals'', and ``people feel supported, extend themselves to new tasks, and are open to change''. The men described someone who ``gets people to work with them'', ``identifies the unperceived value in others'', and ``understands the needs of others''. In Bass and Avolio's final category of ``intellectual stimulation'', the women described a leader who ``is a positive force'', ``has challenges rather than problems'', who ``enables others to feel competent and confident to challenge''. The men describe fewer and much less descriptive constructs, i.e. ``instils confidence in others''. Although there is evidence that the men do describe some transformational characteristics, theirs are predominantly transactional, e.g. ``able to make decisions that may adversely affect others'', being ``entrepreneurial, visionary, concentrating on administrative, figure type work, flamboyant, forceful, operating close to policies and tradition'' (Rigg and Sparrow, 1994). It is evident that some of the constructs that have emerged in this study, described by men and women, but predominantly by women, do not fit clearly into Bass and Avolio's 4 Is of transformational leadership. This phenomenon has arisen in a number of other UK studies (Franklin, 1997; Alimo-Metcalfe, 1998a), suggesting that the UK model of leadership is more complex than the US model (AlimoMetcalfe, 1998a). This study appears to endorse this finding. In this study additional constructs relating to networking at all levels, both internally and externally, being able to ``integrate at all levels of society'', ``being politically and environmentally aware'' were identified, which all the women felt important, but only one man. The other distinction, which was mentioned by all women, was the importance of ``valuing others' views regardless of their status'' and ``inspiring others to go with them, and rise to a challenge'', ``engendering unity amongst the team'', the latter referred to by Bass (1998a) as ``inspirational motivation''. Alimo-Metcalfe (1998a, p. 37) comments that the emphasis within the UK model of transformational leadership seems to be on what the ``leader directly does for the follower'' as opposed to inspiring the followers by acting as a role model; humility and the acceptance that ``popularity and rewards don't matter'', but ``getting it right'' is what matters; doing things through participation, ``sees relationship with others as getting the best for the organisation'' are characteristics described in this study, which reflect a transformational leader who places heavy emphasis on differentiating the varying developmental needs of their followers and then developing them to a higher level (Bass, 1998a, p. 77).

This study has also identified a group of constructs relating to responsiveness, not only in relation to the needs of followers, but in responding quickly to issues which arise and require attention. This group of constructs has not previously been mentioned in the literature in any detail. Although Bass and Avolio (1994b, p. 557) note that women tend to be more proactive in addressing problems, this grouping is wider than this, described as the ability to ``follow through'' on issues and ``seeing things through, whilst maintaining others' interests''. Conclusions and recommendations A number of conclusions can be drawn from this study, although it is acknowledged that the study was conducted on a very small sample and within a fairly specialist area and therefore the results are not generalisable. Conclusions . The qualitative nature of the study using the Repertory Grid interviews (Kelly, 1955) enabled exploration of a complex phenomenon and elicited rich and varied constructs of leadership within a necessarily small sample of managers. . The study identified that men and women describe different constructs of effective leadership. These differences, although broader, mirror those found in other studies, such as those of Sparrow and Rigg (1993); AlimoMetcalfe (1995); and Franklin (1997). . The findings of this study also appear to endorse the conclusions of Alimo-Metcalfe (1995) and Franklin (1997), namely that the UK model of leadership appears to be more complex than the US model, proposed by Bass and Avolio (1990). . The study identified additional constructs to those in previous UK studies, relating to ``responsiveness'' and ``environmental and political awareness, networking and the ability to integrate at all levels of society''. These additional constructs may reflect the complexity of leading a charity, specifically a hospice. This supports the author's initial concerns regarding the content validity of the Transformational Leadership Questionnaire (TLQ) (Alimo-Metcalfe, 1998a) within the environment of hospice and specialist palliative care. . The study identified an area of commonality in relation to the perceptions and qualities of leadership held by a sample of men and women, that of self-awareness. Relevance of findings to hospice and Specialist Palliative Care Units Hospices function in an ever-changing dynamic environment with many challenges yet to be faced. The hospice world is changing from the visionary, charismatic style of the early days to a maturing, established entity, offering a

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career structure and, with this, staff who are perhaps not as committed as, and more career oriented than, the original pioneers. The challenges of managing growth and effectiveness attracts increased funding and expansion, which creates tensions as the disparate values of fund-raising and caring staff come into conflict. The fears of medicalisation and an associated less holistic approach to care, combined with diversification into education, research and audit, mean that hospices must remain proactive in facing change and influencing mainstream health-care policy, whilst retaining their founding values. People management is critical to organisational success and therefore organisations must fully utilise their most precious resource. However, a large percentage of this precious resource is currently being denied access to demonstrate its full potential. This represents a potentially huge loss to organisations, as management is still stereotyped to equate to male. This incestuous model of management passed unrecognised for many years, until the belief that male = manager (Schein, 1990) was questioned. The issue is one not only one of equity, but also of the right person with the appropriate skills and qualities to ensure the success of the organisation, regardless of gender (Bass and Avolio, 1994b). With the increasing numbers of women and minorities in the workplace and the decreasing number of white males, organisations cannot afford to deny women access to leadership roles (Klenke, 1996). If the perception of women as managers remains that because of their differences they are perceived less qualified than men for management (Eagly and Johnson, 1990), then organisations may be under-utilising the full potential of women within their organisations. Gender bias must be acknowledged and redressed in every aspect of management from the selection and assessment through to development of potential of individuals. The recruitment of chief executives in voluntary organisations is usually conducted by the Board of Trustees. Knowing that much of the research conducted on leadership is based on a male norm, and is therefore gender biased, in that men do not identify women as effective managers (Schein, 1990), then the recruitment and selection of chief executives/general managers has to be considered a vitally important component in ensuring equity for women in senior management in the voluntary sector. Hospice managers and Boards of Trustees must become familiar with the concept of the transformational leadership and the need to develop transformational qualities in individuals. Recent research is demonstrating that the positive impact of transformational leadership can be extended to teams. The extension of these skills has been linked to higher group effectiveness and an increased willingness to rise to challenges (Bass et al., 1996, p. 16). The concept of teamwork in palliative care is vital (Prouse, 1994), from the clinical perspective not only of the multi-professional team, but also of the wider hospice team. The use of volunteers, and maintaining their motivation without incentives such as those offered in the commercial sector relies strongly on effective interpersonal, organisational and team-building skills (Forde-Johnston and Allan, 1999). Effective leadership is about sharing,

and leadership cannot be viewed separately from the effect it has on followers. An effective transformational leader increases job satisfaction, decreases stress, and increases the performance and profitability of the organisation by effective people management. West and Patterson (1998) assert that a holistic leadership approach is required, managing the whole person, developing skills and ownership, managing the organisation as a community, fostering creativity, and embracing change. The skills of collaboration and consultation, both internally and externally, increased political awareness and networking are required to work in the environment of hospice and specialist palliative care. Transformational leadership has been suggested as the most meaningful for today's climate, and research is suggesting that women's style of management is predominantly more transformational in general than men's, and consequently a woman will be judged more effective as a leader (Bass, 1998a, p. 78). Although it must be stated that feminine leadership is not the sole possession of women, some men exhibit those same characteristics (e.g. Klenke, 1996). This study is not about identifying one sex or the other as being a better leader, but is about identifying the key characteristics of leadership style for successful organisations. It is about acknowledging and celebrating the difference and diversity, to enable organisations to be more effective and creating opportunities for competitive advantage (Schrage, 1999). Limitations and future research Although this is not an extensive study, i.e. based on a small sample, it did represent 50 per cent of the female senior managers within the population in hospices in the UK. Expanding the sample to include all female chief executives/general managers in voluntary hospices would provide further information. The sample for this study was based on chief executive/general managers only and did not include tripartite management structures, i.e. medical director, matron and administrator, or other levels of management within hospices. The role of chief executive was selected to try to reduce the variables and the difficulty in identifying a lead individual. It would, however, be useful to identify whether professional background affects perceptions of leadership. Robinson (1998, p. 72) found that it did, in that male doctors were more transactional than male managers, and doctors in general did not recognise the concept of a ``teamplayer'' as an important characteristic in leadership. This may be an area for further study. Equally this study was selective, i.e. conducted in voluntary hospices. Further research would be useful to compare constructs of effective leadership in NHS hospices and those hospices which are part of a larger organisation, i.e. Sue Ryder, Marie Curie homes, which would identify whether the setting has any impact on individuals' constructs of effective leadership elicited. Further research into trustees' perceived characteristics of effective leadership would be very valuable, as frequently the appointment of senior managers within hospices is conducted by the Board of Trustees.

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It would be useful to profile each hospice Board of Trustees to identify the percentages of men and women in this role. Further work is required to measure transformational leadership within the voluntary sector, perhaps using the TLQ (Alimo-Metcalfe, 1998a). However, this current study has demonstrated differences in the constructs that emerge in the voluntary sector, specifically hospices, from those which emerged in the NHS and local government. The future The metaphor of the glass ceiling still persists, and organisations need to respond and utilise diversity in the workforce, as competition for talent, innovation and creativity increases. The current estimate of incompetence in 60 per cent of managers within organisations will no longer be tolerable. This, combined with the changes in the workforce and the predicted shift from manufacturing to service industries (Hogan et al., 1994), will require a change in skills and behaviours to lead organisations into the millennium. A transformational style of leadership has been suggested as the best suited to today's organisations and this style is predominantly held in general more by women than men. However, research acknowledges numerous barriers preventing women's access to senior management, but before these barriers can be addressed there must be acknowledgement that they exist from more than just researchers. To succeed women should not need to conform to a male norm and play men's games but should feel confident to use their differences to create opportunities. As Peters so eloquently comments:
It is perfectly obvious that women should be better managers in today's topsy-turvy business environment. As we rush into the 1990s, there is little disagreement about what business must become: less hierarchical, more flexible, and team oriented, faster and more fluid. In my opinion, one group of people has an enormous advantage in realising this new vision: women (Peters cited in Klenke, 1996, p. 130). References and further reading Alimo-Metcalfe, B. (1993a), ``All snakes and no ladders'', Nursing Times, Vol. 89 No. 38, pp. 29-31. Alimo-Metcalfe, B. (1993b), ``A woman's ceiling: a man's floor'', Health Service Journal, 14 October, pp. 25-7. Alimo-Metcalfe, B. (1994a), ``Gender bias in the selection and assessment of women in management'', in Davidson, M.J. and Burke, R.J. (Eds), Women in Management Current Research Issues, Paul Chapman, London, pp. 93-109. Alimo-Metcalfe, B. (1994b), ``Waiting for fish to grow feet: removing organisational barriers to women's entry into leadership positions'', in Tanton, M. (Ed.), Women in Management, a Developing Presence, Routledge, London, pp. 27-45. Alimo-Metcalfe, B. (1995), ``An investigation of female and male constructs of leadership and empowerment'', Women in Management Review, Vol. 10 No. 2, pp. 3-8. Alimo-Metcalfe, B. (1998a), Effective Leadership, Local Government Management Board, London. Alimo-Metcalfe, B. (1998b), ``360 degree feedback and leadership development'', International Journal of Selection and Assessment, Vol. 6 No. 1.

Barker, E.A. (1999), ``Constructs of effective leadership within hospice and specialist palliative care units in England'', unpublished dissertation, Nuffield Institute for Health, Leeds. Bass, B.M. (1998a), Transformational Leadership: Industrial, Military and Educational Impact, Erlbaum Press, Hillsdale, NJ. Bass, B.M. (1998b), Current Developments in Transformational Leadership Research and Applications, address to the American Psychological Association, San Francisco, CA, 14 August, Center for Leadership Studies, State University of New York at Binghamton. Bass, B.M. and Avolio, B.J. (1990), Multi-factor Leadership Questionnaire, Consulting Psychologists Press, Palo Alto, CA. Bass, B.M. and Avolio, B.J. (Eds) (1994a), Improving Organisational Effectiveness through Transformational Leadership, Sage Publications, Newbury Park, CA. Bass, B.M. and Avolio, B.J. (1994b), ``Shatter the glass ceiling: women may make better managers'', Human Resource Management, Vol. 33 No. 4, pp. 549-60. Bass, B.M. and Avolio, B.J. (1997), ``Shatter the glass ceiling: women may make better managers'', in Grint, K. (Ed.), Leadership, Classical, Contemporary and Critical Approaches, Oxford University Press, New York, NY, pp. 199-211. Bass, B.M., Avolio, B.J. and Atwater, L. (1996), ``The transformational and transactional leadership of men and women'', Applied Psychology: An International Review, Vol. 45 No. 1, pp. 5-34. Clark. D. (Ed.) (1993), The Future of Palliative Care: Issues of Policy and Practice, Open University Press, Buckingham. Cronin, T.E. (1993), ``Reflections on leadership'', in Rosenbach, W.E. and Taylor, R.L. (Eds), Contemporary Issues in Leadership, Westview Press, Oxford, pp. 7-25. Davies, S. (1995), Gender and the Professional Predicament in Nursing, Open University Press, Buckingham. Department of Health (DoH) (1989), Working for Patients, CM 555, HMSO, London. Department of Health (DoH) (1990), NHS and Community Care Act, HMSO, London. Department of Health (DoH) (1997), The New NHS: Modern and Dependable, CM 3807, HMSO, London. Department of Health (DoH) (1998), A First Class Service. Quality in the New NHS. http:// www.doh.gov.uk/newnhs/quality.html Accessed September 1999. Dobbins, G.H. and Platz, S.J. (1986), ``Sex differences in leadership: how real are they?'', Academy of Management Review, Vol. 11, pp. 118-27. Donnellan, C. (1996), ``Men, women and equality'', Issues for the Nineties, Vol. 18, Independence, Cambridge, p. 13. Eagly, A.H and Johnson, B.T. (1990), ``Gender and leadership style: a meta-analysis'', Psychological Bulletin, Vol. 108, No. 2, The American Psychological Association, pp. 233-56. Easterby-Smith, M. (1980), ``How to use the repertory grid'', Human Resource Management, Vol. 4 No. 2. Fagenson, E.A. (Ed.) (1993), ``Women in management: trends, issues and challenges in managerial diversity'', Women and Work, Vol. 4, Sage Publications, London. Ferrario, M. (1994), ``Women as managerial leaders'', in Davidson, M.J. and Burke, R.J. (Eds), Women in Management, Current Research Issues, Paul Chapman, London, pp. 110-25. Fletcher, C. (1998), ``Gender differences in self-assessment: a review of research findings and of their implications for assessment and development practices'', paper presented at the Equal Opportunities Commission/Open University Business School Seminar, London.

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Morrison, A. (1992), The New Leaders: Guidelines on Leadership Diversity in America, Jossey-Bass, San Francisco, CA. Nolan, M. and Behi, R. (1995), ``Triangulation: the best of both worlds'', The British Journal of Nursing, Vol. 4 No. 14, pp. 829-32. Perrault, R.M. and Irwin, J.K. (1996), Gender Differences at Work. Are Men and Women Really that Different? Analysis and Findings of a Study of Women and Men, Advanced Teamware, Agoura Hills, CA. Prouse, M. (1994), ``Organisational audit for palliative care services'', European Journal of Palliative Care, Vol. 1 No. 4, pp. 184-6. Rigg, C. and Sparrow, J. (1994), ``Gender, diversity and working styles'', Women in Management Review, Vol. 9 No. 4, pp. 9-16. Robinson, A. (1998), ``A project to investigate what a group of NHS senior managers and clinical directors, working in an NHS Trust, perceive to be characteristics of effective leadership'', dissertation, Nuffield Institute for Health, University of Leeds, Leeds. Robson, C. (1995), Real World Research, a Resource for Social Scientists and PractitionerResearchers, Blackwell, Oxford. Rosener, J.B. (1990), ``Ways women lead'', Harvard Business Review, Vol. 68 No. 6, pp. 119-25. Rosener, J.B. (1997), ``Sexual static'', in Grint, K. (Ed.), Leadership, Classical, Contemporary and Critical Approaches, Oxford University Press, New York, NY, pp. 211-23. Sashkin, M. and Rosenbach, W.E. (1993), ``A new leadership paradigm'', in Rosenbach, W.E. and Taylor, R.L. (Eds), Contemporary Issues in Leadership, 3rd ed., Westview Press, Oxford. Schein, V.E. (1990), ``Sex role stereotyping, and requisite management characteristics: a crosscultural look'', presented at 22nd International Congress of Applied Psychology, 22-27 July, Kyoto, Japan. Schrage, M. (1999), ``Brave new work; why can't a woman be more like a man? It's all in your brain'', Fortune Archives, http://library.northernlight.com/PN19990805050000082 Accessed September 1999. Sofarelli, D. and Brown, D. (1998), ``The need for nursing leadership in uncertain times'', Journal of Nursing Management, Vol. 6 No.. 4, pp. 201-07. Sparrow, J. and Rigg, C. (1993), ``Job analysis: selecting for the masculine approach to management'', Selection and Development Review, Vol. 9 No. 2, pp. 5-7. Tannen, D. (1996), You Just Don't Understand, Women and Men in Conversation, Virago Press. Vinnicombe, S. (1987), ``What exactly are differences in male and female working styles?'', Women in Management Review, Vol. 3 No. 1, pp. 13-21. West, M. and Patterson, M. (1998), ``Profitable personnel'', People Management, Vol. 4 No. 1, pp. 29-32.

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