Influencing by Following

As part of the parent questionnaire included in Sara Pollard's 1934 application to Vassar College, her father described her as "more of a follower type than a leader." The school admitted Ms. Pollard, with the explanation that it had enough leaders. 1 This story may be apocryphal, but it describes a significant contrast to the norm in our society that values leading over following. Leadership is almost universally regarded as something to aspire to, with many resources available for the development of the requisite skills, while following can be viewed as an unpleasant necessity with little emphasis given to its development. The priority placed on leadership may originate from a negative perception that following involves being under the influence or control of a more powerful person. Positional leadership also involves exercising authority over others and following involves submission to that authority, unpopular concepts in a culture that most highly values self-determination and equality in interpersonal relationships. Dysfunctional leadership and followership in the workplace can result in decreased personal satisfaction and ineffective interpersonal relationships, which in turn can reduce individual and organizational performance. In a clinical setting, reduced effectiveness and poor outcomes result in reduced quality of care, so understanding how to follow effectively is central to accomplishing our professional responsibilities. Most of us will spend more of our lives and careers following than leading. The authors of a review that will be considered later in this article point out that "to understand an organization's likelihood of success or failure we need to understand its followers, not only its leaders." 2 Can we understand followership as a constructive and positive contribution toward the achievement of personal and organizational goals, rather than a stage to pass through on the way to positional leadership? John Maxwell, a leadership guru who has sold over 20 million copies of more than seventy books, offers this simple definition of leadership: Leadership is influence. The focus of much of his teaching is on helping everyone— regardless of whether or not they have a formal leadership role—develop the attitudes and behaviors that maximize their influence. This article examines the concept of following as a way of influencing without a specific, identified position of authority. Models of Following Not surprisingly, there are many ways of describing leadership and relatively few models of followership. In 1988, Robert Kelley, PhD, professor of management at Carnegie Mellon University, published an article in the Harvard Business Review (HBR) titled "In Praise of Followers." 3 In the article he noted the discrepancy between our experiences as followers and the emphasis on leadership: "[Followership] dominates our lives and organizations, but not our thinking, because our preoccupation with leadership keeps us from considering the nature and the importance of the follower." 3 To address this imbalance, he developed a followership model that describes five patterns defined by two behavioral dimensions: "One dimension measures to what degree followers exercise independent, critical thinking. The other ranks them on a passive/active scale." 3 (See Figure 1.) According to Kelley, effective following is an active process that requires independent, critical thinking. "The key to being an effective follower is the ability to think for oneself—to exercise control and independence and to work without close supervision. Good followers are people to whom a leader can safely delegate responsibility, people who anticipate needs at their own level of competence and authority." 3 Effective followers do not see themselves as inferior to leaders, but as equals who have different responsibilities than leaders. They also are not intimidated by hierarchy and structure and are confident in disagreeing with positional leaders. Effective followers recognize that those with positions of leadership are accountable to others, and that the needs of the team and the goals of the organization are the priority. "Ineffective followers, on the other hand, buy into the hierarchy and, seeing themselves as subservient, vacillate between despair over their seeming powerlessness and attempts to manipulate leaders for their own purposes." 3 Recognizing the difference between positional leadership and the traits and behaviors of effective influence can help those without a defined leadership role contribute more effectively to their own and the organization's success. Essentially, followers are leaders without a title or position. "The qualities that make effective followers are…pretty much the same qualities found in some effective leaders…. Followership is not a person but a role, and what distinguishes followers from leaders is not intelligence or character but the role they play. [Effective] followers and effective leaders are often the same people playing different parts at different hours of the day." 3 Executive coach and consultant Ira Chaleff has published books and leads workshops on followership. In a 2017 article titled "In Praise of Followership Style Assessments," Chaleff describes an assessment of followership styles that he developed to stimulate personal awareness and improvement. 4 Chaleff's model is based on two dimensions of followership behaviors, "the courage to serve or support and the courage to question or challenge." 4 (See Figure 2.) Considering these dimensions and labels can help us realize our natural tendencies and be purposeful about developing our followership skills. Not all leaders want to be challenged and doing so may have negative consequences. Chaleff reports that students in his classes often describe modifying their following style based on the style of the leader. Chaleff advises that, while some modification of our following style is necessary, followers should "not give away all your power to the positional leader. Positional leaders who do not welcome candor (even though they say they do) need it the most. How to give such leaders input and feedback is a skill that must be developed, but the precursor to using the skill is understanding that you determine your style of followership, not the leader." 4 Effective followers, like effective leaders, recognize that the primary responsibility for their attitudes and behavior rests with themselves. Accurate self-assessment and the development of specific skills are both required to match the particular demands of each workplace relationship and role. There is no doubt that challenging a positional leader involves risk. However, adopting the role of a passive, dependent follower also involves considerable risk, since that behavior pattern can contribute to serious personal, interpersonal, and performance problems. Job security and performance outcomes can both be improved by mature and courageous followership. Followership Research Researchers at the University of Manitoba reviewed literature to answer this question: "Does followership style affect job performance and/or job satisfaction in healthcare?" 2 They included "any qualitative or quantitative study looking at followership type as the independent variable and any measures of job performance and/or job satisfaction as the dependent variable." 2 Before screening citations for inclusion in their review, the authors also conducted a search for healthcare articles related to leadership, "to illustrate the relative lack of articles on followership in the medical literature." 2 They found "6,539 unscreened citations on leadership, compared to 104 unscreened citations on followership," meaning that for every article on followership there are 60 articles on leadership. 2 Only three eligible articles on followership were found using healthcare databases, so the search was expanded to include non-healthcare databases. A total of 14 studies were included in the review. Ten of the studies investigated "individual measures of job satisfaction" and four investigated "the correlation between followership style and organizational or team performance measures." 2 One study within healthcare found that more effective followership styles correlated with reduced burnout among nurses, and another found a connection between increased critical thinking and active participation and higher job satisfaction among nurses. A third reported that job satisfaction among nurses was related to higher levels of active engagement. One study "found an association between followership styles characterized by higher active engagement and critical thinking when compared against observance with hospital infection policies." 2 Another "demonstrated an association between exemplary and pragmatic followership styles and higher team coordination traits among hospitalists…." 2 Mixed results were found in several studies in non-healthcare settings, but the authors concluded that their review "supports the hypothesis that followership styles affect individual and organizational performance. Specifically, followership styles with higher levels of active engagement and critical thinking are more often associated with personal accomplishment, job satisfaction and organizational performance." 2 Influence in O&P Interdisciplinary care involves working collaboratively with a variety of professionals and support staff across a wide range of disciplines in multiple organizations. Most of those interactions occur between individuals who lack formal, positional leadership authority. Licensing laws provide some definition of scope of practice, but most clinical decisions are made through collaboration between practitioners who are followers within their organizations. For example, a prosthetist, physical therapist, and social worker will use a combination of leadership and followership skills when collaborating to provide post-operative prosthetic care. Each professional takes more of a lead in decisions related to his or her area of expertise and functions as a follower when other aspects of the patient's care are considered. Recognizing the distinct skill sets and responsibilities each provider brings to the encounter and applying the skills of effective followers can help us maximize our influence on the clinical decisions that the team makes. The same principles apply within an O&P practice. While a positional leader, an owner or manager, is clearly identified in most practices, many daily responsibilities and decisions involve interactions between team members without reliance on a clearly defined authority structure. Some decisions and behaviors are determined or guided by business policies and procedures, but many (including some of the most significant) fall outside of parameters outlined in those policies. Residents and junior clinicians work closely with administrative and technical staff who often have more practical experience and organizational knowledge than they do. Collaboration outside of clearly defined leadership roles is required to navigate these relationships and make the most appropriate decisions regarding patient care. "No member of the healthcare team is leader on day-one, and all spend time as a relative subordinate. In other words, everyone in healthcare works, or has worked, in the followership role, regardless of eventual seniority. How people view their roles affects both the quality of work and interpersonal interactions." 2 These early career experiences can lay the groundwork for developing influencing skills that will serve clinicians well, whether they ever occupy formal leadership positions or not. Closing Thoughts In his book To Change the World, James Hunter, PhD, describes the relationship between leading and following this way: "Everyone exercises leadership to varying degrees, for we all exercise relative influence in the wide variety of contexts in which we live. By the same logic, we are all also followers in a sense, for even when we exercise leadership, we are held to account—we follow the dictates, needs and standards of others…a simple dichotomous view that divides people into leaders and followers either with influence or without it is…mostly useless, for it does not describe the reality of the world or our lives in it." 5 We all influence others, and more often than not, we do so without positional authority. The question is whether we will be intentional and purposeful about developing the skills necessary to influence effectively. Like Vassar College in 1934, our profession needs effective followers—engaged contributors who recognize their power to influence and are willing to actively support and challenge those in leadership positions. Understanding how to influence more effectively, regardless of our role and the amount of authority it imbues us with, allows us to work more effectively with others and make more significant contributions. John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has over 30 years of experience in patient care and education. Author's note: This article is dedicated to John Michael, CPO, whose prioritization of those he served over personal promotion is an example for all leaders and followers to emulate. References https://www.nytimes.com/2017/03/24/opinion/sunday/not-leadership-material-good-the-world-needs-followers.html Leung, C., A. Lucas, and P. Brindley, et al. 2018. Followership: A review of the literature in healthcare and beyond. Journal of Critical Care 46:99-104. Kelley, R. E. 1988. In praise of followers. Harvard Business Review Case Services 66:142-8. Chaleff, I. 2016. In praise of followership style assessments. Journal of Leadership Studies 10(3):45-8. Hunter, J. D. 2010. To change the world: The irony, tragedy, and possibility of Christianity in the late modern world. Oxford University Press.

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