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Perspectives |
Key words: leadership, change, dental education
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Abstract |
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 TopAuthor information Abstract Current status of leadership...Competencies for the exercise...Developing leadership expertise...Closing commentsReferences |
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Most recently, two national projects, both highly visible, have provided a breadth and depth of guidance for needed change in dental education. Pyle et al., members of the American Dental Education Association’s Commission on Change and Innovation in Dental Education (ADEA CCI), argued that "there is a compelling need for rethinking the approach to dental education in the United States."5 In a series of twenty-one articles published in the Journal of Dental Education from 2006 to 2008, the ADEA CCI has called attention to problems that on their face continue to vex dental educators at every level. Pyle et al. state that these problems are "1) the challenging financial environment of higher education, making dental schools very expensive and tuition-intensive for universities to operate and producing high debt levels for students that limit access to education and restrict career choices; 2) the profession’s apparent loss of vision for taking care of the oral health needs of all components of society and the resultant potential for marginalization of dentistry as a specialized health care service available only to the affluent; and 3) the nature of dental school education itself, which has been described as convoluted, expensive, and often deeply dissatisfying to its students."5
The Macy Study,6 the other national project, has shown through compelling examination of historical trend data, review of archival narratives and records, and policy analyses that new models of dental education are needed to address the financial and educational challenges of dental education. Dental schools have increasing difficulty meeting their education, research, clinical care, and service missions. The cost of clinical education is out of balance with the other segments of dental education’s mission, threatening the institutional vitality of dental schools. Resources continue to decline for research, curriculum innovation, faculty recruitment and retention, and faculty development because of the high cost of school-based clinical education. Contributors to the Macy Study National Convocation observed that the current responses of schools to these economic challenges have not been adequate and that the most promising solutions require new models of clinical dental education—models that are organizationally and systemically sensitive to "financial viability and institutional vitality" through attention to patient-centered care, cost, and efficiency, as called for in the 1995 Institute of Medicine report on dental education.2
With all this in mind, how must we exercise leadership for needed change? We write this article to provide a view of change in dental education that places leadership in the context of adaptation.
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Current Status of Leadership in Dental Education |
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TopAuthor informationAbstractCurrent status of leadership...Competencies for the exercise...Developing leadership expertise...Closing commentsReferences |
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To be sure, our goal in this article is not to focus on the challenges facing dental schools per se. Rather, it is our intention to link these ongoing, persistent issues to misconceptions of leadership and a new understanding of what it will take to move us forward to productive solutions.
First, we must ask several questions: How do we shape our understanding of the problems? Are our current practices of leadership providing us with an understanding of what is hanging in the balance? How are we working to understand whether the cultures for education, pedagogy, and clinical care are changing? How must we proceed to ensure that the right degree of attention and persistence is applied to the questions of change? Is change mindful and adaptive or more or less accidental and technical? More importantly, how is the responsibility for leadership diffused throughout the dental school and its stakeholders? Our read of the past and current conditions within and around dental education suggests that leadership is more accidental and technically understood and less adaptive to address sustainable change and innovation.
The Challenges Facing Dental Education Are Adaptive in Nature
The challenges and questions described above cannot be met by applying our current thinking and leadership approaches. We have been oriented to view leadership through a technical lens: here is the problem; this is what we need to do about it. Technical problems can be solved through the knowledge of experts and senior authorities. We are accustomed, indeed well trained, to define or diagnose a case that solves the problem presented. We also would like to be able to "fix" the challenges/problems facing dental education through the application of our existing knowledge and expertise. But for many of the systemic challenges facing dental education, no clear solutions exist; they do not lend themselves to technical, "quick-fix" answers. These are problems we can’t solve through application of our traditional conceptions of leadership; instead, contemporary challenges facing dental education are adaptive in nature. The parameters and magnitude of these challenges are ill defined and evolving, and they involve our willingness and ability to confront existing values, beliefs, and ways of being. We must develop new competencies to effectively exercise leadership in this adaptive environment. The challenges we face cannot be addressed solely by applying the knowledge of experts or through the repetition of previous responses to emerging challenges.
In writing this article, we were strongly influenced by the leadership model developed by Ron Heifetz and Marty Linsky of Harvard University’s John F. Kennedy School of Government and Cambridge Leadership Associates (www.cambridge-leadership.com/index.php4),9 especially in regard to their work with Ed O’Malley, president and CEO of the Kansas Leadership Center (www.kansasleadershipcenter.org/index.html).10 We strongly believe that their model of adaptive leadership provides the best guidance and hope for dental education.
Adaptive challenges bring to light the gap between our aspirations and current reality. The seven principles underlying educational reform articulated by the Macy Study6 describe our collective aspirations for dental education (Figure 1
).
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Leadership Is an Activity, Not a Position
We see leadership in dental education as mobilizing others to make progress on difficult (adaptive) issues9 and, therefore, take the position expressed by the Kansas Leadership Center that "individuals do not become leaders, but that individuals choose to exercise leadership."10 Because leadership is an activity not a position, it can be achieved by anyone, but no one does it all the time. Leadership can be fleeting, in-the-moment interventions that bridge competing factions and serve to mobilize others to move forward an adaptive challenge.
In the exercise of leadership, then, it becomes important to clarify the role of authority and distinguish authority from leadership. From the perspective of Heifetz and Linsky, authority is viewed as a delivery of services in exchange for power. People in positions of authority (for example, deans and department chairs) are rewarded for meeting others’ expectations and acting within their scope of authority. We want those in authority to be consistent and predictable. However, adaptive challenges often require improvisational thinking and action. Consistency and predictability may actually work against the exercise of leadership in real time. Some people who are comfortable in the role of authority are not good at exercising leadership beyond this role. Through this view, deans and department chairs are authorized to deliver specific services for their constituents, but not authorized to exercise leadership. Otherwise, we might actually be tackling these tough, adaptive issues.
Adaptive leadership requires going beyond a title-bound authorization no matter what one’s position. Thus, anyone (administrator, faculty, staff, student) can choose to exercise leadership beyond his or her authority. But what are the consequences of doing this? It is dangerous to question values, beliefs, and ingrained ways of operating. Leading beyond one’s authority typically results in resistance. One person’s ideas for progress are often viewed by others as loss. That is why adaptive leadership is so difficult, and so rare, in dental education.
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Competencies for the Exercise of Leadership |
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TopAuthor informationAbstractCurrent status of leadership...Competencies for the exercise...Developing leadership expertise...Closing commentsReferences |
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The Kansas Leadership Center, in its work to promote civic leadership throughout the state of Kansas and in consultation with Cambridge Leadership Associates, has articulated four competencies for the exercise of leadership: diagnosing the situation, managing self, facilitating interventions, and energizing others. To us, this framework for understanding and exercising leadership makes sense for dental education. Let’s take a look at each of these competencies.
Diagnosing the Situation
The key to this competency is determining what is going on in the moment, in the current situation, or in the larger organizational context, so we can figure out how to intervene within the system to mobilize others to make progress. Fundamentally, this competency requires us to be able to observe and interpret what is going on within a group, an organization, or a system. Heifetz and Linsky apply the metaphor of getting on the balcony to observe what is happening on the dance floor. Adaptive leadership requires us to move fluidly between being in the midst of the action (the dance floor) and stepping back to observe what is actually happening in the moment as well as to interpret what it means (the balcony). Interpretation can be a contentious and tricky activity. Heifetz and Linsky argue that we tend to interpret events as technical problems rather than recognizing the adaptive elements of these challenges, or to reduce problems to tangible, technical aspects so they can be addressed with technical solutions; we tend to focus on what is happening among individuals rather than viewing what is happening at the system level; and we tend to accept comfortable explanations rather than acknowledging that competing values are embedded in the situation and in potential responses to the situation.
When diagnosing the situation, the following types of questions may help:
Managing Self
The key to this competency is how we manage ourselves when played or pressed to do what people want us to do rather than what people need us to do. When in positions of authority, we are faced with a huge range of expectations, and we are under tremendous pressure to satisfy as many of these expectations as possible. Heifetz and Linsky are fond of saying, "Leadership is disappointing your own people at a rate they can absorb." To accomplish this, we must be cognizant of our true values to ensure that these values align with the leadership work we promote. More important than formal authority, our degree of informal authority (our ability to influence change) will be based largely on what we do rather than what we say. We must consider how our typical ways of problem-solving, what Heifetz and Linsky refer to as "default settings," inhibit progress on difficult issues. For example, when things get heated, do we work to make the group more comfortable, or do we prefer to stir things up? We need to recognize when our default settings are helpful and when they are not helpful. If these default settings cover a relatively small range of behaviors, can we expand our operational range of behaviors so that we are more effective in a greater variety of situations? Going back to the previous example, if our default setting is to make a situation more comfortable, can we get ourselves to "turn up the heat" when that is what would be required for progress to be made?
Another critical aspect of managing self is to separate the role we play in an organization or system from our true selves. Most of us have experienced being attacked because of our stance on an issue, so this can serve as a live example of the need to separate role from self. If we take the attack personally, then we, in effect, displace the focus from the adaptive issue and, instead, we become the issue. By making the issue personal (about our self), we remove ourselves from the role of effectively exercising leadership. Keeping a steadfast focus on the issue at hand and not "avoiding the work" are primary acts of exercising leadership. Avoiding the work in the context of leadership includes avoiding uncomfortable discussions of conflicting values and priorities among individuals and groups with a vested interest in the direction of the decision or a proposed policy that may alter the "way things are done."
When managing self, the following types of questions may help:
Facilitating Interventions
How effectively can we take action within the group, organization, or system to mobilize others to make progress on difficult issues? At its core, leadership is an activity—an intervention into the system intended to move an issue or adaptive challenge forward. An intervention can be a planned, constructed proposal or an in-the-moment improvisation. Regardless of its style, an effective intervention has several attributes. First, it is critical to gain attention for the adaptive issue at hand; typically, this is accomplished through the degree of informal authority we hold. For an intervention to "take," we must be influential within the group, organization, or system. Our degree of informal authority has little to do with our formal positional authority. Another attribute of an effective intervention is identifying the adaptive work to be done. The most common "leadership error" is in not distinguishing technical from adaptive work.9 Thus, making this distinction becomes an important criterion of an effective intervention. Because adaptive challenges invariably involve competing values, which most often go unacknowledged, an effective intervention will identify potential losses to stakeholders and, in fact, orchestrate meaningful conflict across factions. Conflict, of course, raises the degree of disequilibrium ("raising the heat"); an effective intervention discerns the appropriate degree of disequilibrium, either raising or lowering the heat, necessary to make progress. Finally, an effective intervention places the responsibility for the work with the people who have the stake in the problem.
When facilitating interventions, the following types of questions may help:
Energizing Others
What does it take to get others engaged in adaptive work where the outcome is not predetermined? It becomes important to focus the work at a purposeful and meaningful level. We tend to define problems at such a high level of abstraction that no one can disagree; problems defined in this manner will generate little meaningful conflict and people can exist without having to do anything differently. In other words, no one is forced to give up anything they care about. For example, consider the Macy Study Principle 3, "Dental schools must have the resources needed to . . . ."6 If viewed technically, this problem results in virtually no meaningful engagement. Defining this as a technical problem often results in a collective whining about why we aren’t receiving more resources (i.e., providing more resources represents a technical solution to an abstractly defined problem). But if the problem becomes less abstractly defined—for example, looking at reallocation of resources, inefficiencies in our current way of operation, different approaches to meeting educational goals—then stakeholders may appreciate that they have something to lose in the adaptive work. Competing values come to the surface, conflict emerges, loss becomes real, and individuals have to change what they are doing and how they are thinking. Clearly, making progress on identified adaptive issues lies at odds with our culture of individualism in dental schools and in higher education in general.
Because of resistance to loss, creating an environment in which others begin to engage becomes essential. Heifetz and Linsky refer to this as the "holding environment," where tough issues can be discussed in a safer, organized way. It takes intentionality to create such an environment, where conversations have a different feel from elsewhere in the dental school. We strengthen the holding environment by pacing the work of the group and enlisting others in making interventions. Creating a holding environment is extremely difficult, which is why external consultants are often used to facilitate these discussions. To exercise leadership, we must communicate an optimistic and shared vision centered on an orienting purpose. Heifetz and Linsky state, "Purpose is an orienting force in the exercise of leadership."9
When energizing others, the following types of questions may help:
One of the more intractable changes in dental education that would do well to be addressed with the competencies above is curriculum and its relationship to the delivery of contemporary, quality health care. How much do educational settings fail to resemble the care delivery systems in which graduates will practice? Nothing can be more pressing to the leadership of the dental school than the challenge of the curriculum, the clinical education setting, and the school’s system (i.e., budget model) for financing dental education. Work on this problem is work done each and every day the doors of the school and its clinics are open. Yet, how well is the funding challenge understood by all stakeholders?
Disentangling stakeholders from beliefs and values that tie the outcomes for either survival or innovation (depending on your local situation) to limited, technical solutions may well require a different daily routine for those in charge of change. Imagine, for example, an effort to introduce a comprehensive curriculum and clinical change to reflect the growing need for the integration of oral health with systemic health. The vision is to not only change what is taught, but how it is taught and how it is practiced in the clinics. Imagine that changes include infrastructure related to patient records and how the faculty is organized. You are not only one of the deans or chairs in charge, but a faculty member with relationships to departments. Colleagues who stand to be affected by the change were your teachers a decade ago, or they may have been your classmates in dental school. Understanding where you are in relation to the change is key to self-management. If the curriculum were redesigned to integrate, in part, diagnosis and primary care, would organizational structures change and thereby change your formal role—as dean, say, or chair? How does structural change influence how you see yourself and how you manage yourself through the change process?
On the face of things, facilitating interventions and energizing others may seem like the competencies needed to "work a plan" once a plan has been established and accepted. The plans, however, rarely specify the daily expression of values and beliefs that camouflage as "but we’ve tried that" and "the regulations won’t permit it." There have been numbers of plans that have yielded some change. The changes we are being called upon to make now are inextricably tied to financial viability and institutional vitality. Changing how we teach and in which venues or settings, such as school-based or community-based clinics, may present unique opportunities to examine long-standing institutional, locally derived beliefs and values. Taking these two competencies to their fullest meaning must be done with a mindfulness and acceptance of adaptive change for dental education and research to sustain and advance its leadership role in the health professions.
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Developing Leadership Expertise (Eminence) |
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TopAuthor informationAbstractCurrent status of leadership...Competencies for the exercise...Developing leadership expertise...Closing commentsReferences |
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What will it take to create a critical mass of leadership expertise within our dental schools, a cadre of individuals, not necessarily in positions of authority, who can mobilize people to make progress on dental education’s adaptive challenges? Let’s consider where, along the beginner-to-expert continuum, our current leadership practice falls. Thomas distinguishes three levels along this continuum: novice, adept, and eminent leadership performers.14 Novice performers in any field are beginners who need a lot of guidance. Although there are some novices in positions of authority in our dental schools, the important leadership distinction we want to make here is between adept and eminent performers. Adept performers repeat the same patterns of behavior over their entire careers. They are rarely successful when forced to develop new skill sets beyond their current capacity.13 Most current leadership in dental schools resides in individuals who hold positions of authority and, according to this framework, are adept performers. Eminent performers, on the other hand, excel in times of turbulence and change. They refresh and renew themselves and their organizations. Eminent performers are prepared, and prepare others, to address adaptive challenges. Thomas lists four distinguishing aspects of eminent performers,14 which we believe apply to dental education:
We must commit to developing a cadre of adaptive leaders within our dental schools. Many health professions organizations at the national level have embraced this critical need for leadership development, but have focused primarily on preparing educators for positions of authority in academic settings. For example, the American Association of Colleges of Nursing offers an executive leadership fellowship tailored for new and aspiring deans. The Association of American Medical Colleges offers an Executive Development Seminar designed for associate deans and department chairs, and the Executive Leadership in Academic Medicine (ELAM) Program has trained over 500 mid-career women for senior leadership positions in medicine, dentistry, and, recently, public health. Through its Leadership Institute, ADEA has provided year-long training to 150 dental educators since 2000, and many Leadership Institute fellows have assumed roles of senior leadership within their institutions. These programs have raised awareness regarding the importance of leadership and, indeed, helped many individuals build their own leadership toolkits. However, without greater emphasis on and support for addressing adaptive challenges, will these trained individuals have the needed impact?
We believe that adaptive leadership capacity building will best be accomplished at a local level. Nearly thirty distinct executive education/leadership development programs are offered at U.S. medical schools.15 While some of these programs provide intensive skill-based training, nearly all of them target educators aspiring to positions of authority in medical education settings.
The College of Health Professions at Wichita State University has taken a different tack by creating the Leadership Academy to promote and enhance leadership growth among faculty and staff to advance the vision and mission of the college and university. The Leadership Academy seeks to provide faculty and staff with opportunities to transform their capacity to exercise leadership in a challenging adaptive environment, foster a culture of leadership within the college, and reward faculty and staff work for advancing the goals and strategic vision of the college. After serving a year-long fellowship, academy fellows become senior coaches and mentors for faculty and staff who are incoming fellows. Academy fellows meet as a peer consultation group, which allows practice in diagnosing cases of personal adaptive challenges written by the fellows themselves. Academy fellows experience a two-and-a-half-day orienting program in adaptive leadership and meet weekly throughout the year to reinforce and practice these concepts. Ultimately, though, academy fellows are expected to exercise leadership across existing factions within the college and university to address adaptive challenges. With five to six new fellows accepted into the academy each year, over time a significant portion of the college’s faculty and staff should be poised to promote adaptive leadership work.
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Closing Comments |
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TopAuthor informationAbstractCurrent status of leadership...Competencies for the exercise...Developing leadership expertise...Closing commentsReferences |
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We cannot leave our discussion of leadership without acknowledging that the most valuable asset our institutions hold is people—our faculties and staffs and their connection to leadership. We recall the guidance of Peter Drucker,16 who argued that our faculties and staffs are "knowledge workers," who should be treated as though they were volunteers. Drucker asks us to remember that volunteers are committed to what they do, and if they don’t see results, they usually leave the organization. Without adaptive leadership, we are squandering this very precious resource.
Clearly, the leadership competencies developed by the Kansas Leadership Center overlap and are interrelated with much of what is described in the work of Heifetz and Linsky. From this body of work on change, leadership, and organizational dynamics, we know that there are casualties: ideas, values, and people are left behind. Adaptive work requires that we be prepared for what may well be experienced as casualties. With adaptive work, we are asking people, at times, to see the gaps between values and behaviors, between training under one set of historical principles and the need for new training environments, because materials, technologies, and economies have changed. Being adept at "authority" does not equate to being or becoming eminent at "leadership." We should be aspiring to leadership, not to being the leader.
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Author Information |
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TopAuthor informationAbstractCurrent status of leadership...Competencies for the exercise...Developing leadership expertise...Closing commentsReferences |
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This article is one in a series of invited contributions by members of the dental education community that have been commissioned by the American Dental Education Association’s Commission on Change and Innovation in Dental Education (ADEA CCI) to address the environment surrounding dental education and affecting the need for, or process of, curricular change. This article was written at the request of the ADEA CCI but does not necessarily reflect the views of ADEA, the ADEA CCI, or individual members of the ADEA CCI. The perspectives communicated here are those of the authors.
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REFERENCES |
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TopAuthor informationAbstractCurrent status of leadership...Competencies for the exercise...Developing leadership expertise...Closing commentsReferences |
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This article has been cited by other articles:
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  D. G. Dunning, T. M. Durham, B. M. Lange, and M. N. Aksu Strategic Management and Organizational Behavior in Dental Education: Reflections on Key Issues in an Environment of Change J Dent Educ., June 1, 2009; 73(6): 689 - 695. [Abstract] [Full Text] [PDF]
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H. F. Thomas What the ADEA CCI Series of Articles Means to Me: Reflections of a Dental School Dean J Dent Educ., February 1, 2009; 73(2): 172 - 176. [Abstract] [Full Text] [PDF]
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