I was intrigued when I read in Beyond the Wall of Resistance by Rick Maurer about Douglas McGregor’s theories on leadership. (Apparently, McGregor wasn’t the first to put forth these theories, but was the first to name them, back in the 1950s.) McGregor was a social psychologist interested in how human factors affected organizational behavior and organizational outcomes.
In short, McGregor’s work described two approaches to leadership. Theory X maintained that workers need to be led. That without tight oversight, workers will become unmotivated, unambitious, and resistant to change. In contrast, Theory Y put forth that workers were not passive and under the right conditions, the average adult will accept responsibility and engage in work with creative energy.
McGregor described the difference between the two approaches this way, “Theory X places exclusive reliance upon external control of human behavior, whereas Theory Y relies heavily on self-control and self-direction. It is worth noting that this difference is the difference between treating people as children and treating them as mature adults.”
Theory X dictates the need for a dictatorial style of management. It’s the old “top-down, mandating” type of leadership that is about control. It fuels a lack of engagement and fails to extract the full potential of employees and of the collective whole. Theory Y treats workers with respect and engages them fully in their work.
From my observations, Theory X seems to be a lot more prevalent in health care. And there is evidence it contributes to clinician burnout. A 2015 Mayo Clinic study showed that certain behaviors of leaders predicted a lower risk of burnout among physicians. These behaviors, such as “Encourages employees to suggest ideas for improvement,” are consistent with Theory Y.
Where can we find theory Y? There are a number of leadership philosophies that embrace it. For example…
I love the idea of turning a negative approach to improvement in health care—looking for problems—on its head. Appreciative inquiry, a process of focusing on a group’s inherent strengths and fostering positive interactions among group members, is one way of fostering change with a positive approach. Positive deviance (PD) is another.
Basically, PD involves identifying what’s working and usual local solutions owned by the people involved to make improvements. According to Leading Change in Healthcare: Transforming Organizations Using Complexity, Positive Psychology, and Relationship-centered Care, a fascinating book I’m currently reading, PD was first developed as a way to address malnutrition in poor communities—by looking for children who were healthy despite the limited resources, learning what the mothers of these children were doing differently (the “deviance”), and creating opportunities for other mothers to practice these different behaviors.
What if we were to apply positive deviance to the problem of clinician burnout? What might that look like?
When I was in residency training, I felt struggled with a conflict between my perception of reality and a seemingly widespread fallacy. As a human being, and especially as a human new at the tasks I was undertaking, I knew I was imperfect, yet the clinical world seemed founded on the belief that it is possible for humans to never make mistakes. Only perfection was acceptable. The possibility of unintentional medical errors was usually just denied. If errors occurred, they were seen as the individual health professional’s fault. In other words, if a mistake happened, I’m to blame, even if I was doing my best in a broken system, one that required multiple error-prone workarounds to complete a task. That conflict ate away at me, and was one of the factors that precipitated burnout and my decision to leave clinical practice several years later.
It was in the course of writing about the health care system that I first learned about organizational culture, which can be loosely defined as “how we do things around here.” It governs how people act, how they respond, how they treat each other. It is shaped by top leaders. They set the tone, model ways of being, and choose which behaviors to reinforce and reward, which to call out, and which to overlook (a choice that usually speaks louder than words). Leaders’ actions and choices demonstrate the organization’s culture for everyone else. Of course, there are micro unit cultures that differ across the organization, but the trickle-down effects of leaders show up here too.