“Leadership means timely, appropriate actions that guide and support the group to set and achieve realistic goals. Effective leaders create an environment that both allows and inspires individuals within groups to achieve their full potential.”
In Plato’s “Republic,” the problems endemic to existing systems of governance were likened to a leaderless ship and her dysfunctional crew, an allegory that has since come to be known as the Ship of Fools. In the parable, a ship is without her captain but is crewed by a mob of unruly sailors who each yearn for the role. The equally unqualified sailors are without knowledge of captaincy nor have the experience of the sea-weathered mariner; regardless, they justify their deficits by both denying their relative importance and by misrepresenting the very nature of their learned ability. Rather, they consider them intrinsic qualities, unable to be taught and therefore beyond acquisition, in this way, the sailors justify their continued ignorance and forever ensure their unsuitability for the role of captain.
Related
One need not read Socratic teachings to recognize that parallels exist in the modern era surrounding the nature of contemporary leadership. Rarely does a word (leadership) so often spoken in the common tongue evade consistent description! Indeed, when queried as to the characteristics of a good leader, the answers often serve to be a greater indication of an individuals’ particular set of values and beliefs, their prejudices, and biases. As a natural consequence of this ambiguity, an ad hoc style of leadership is bred whereby individuals seek to unify their preconceived notions of leadership with extrinsic factors such as peer relationships, workplace or group culture and social expectation. This low-fidelity approach to leadership development retards adaptation, is overly dependent on individual experience, and produces an uncertainty of outcome.
In response, many organizations dependent on effective operational leadership have mitigated these shortcomings through structured, purposeful attempts at leadership training that is contiguous with career progression. For instance, the NFPA 10211 qualification is a requirement for advancement as an officer within a professional fire service, and the Canadian Armed Forces requires its Non-Commissioned Members (NCMs) to successfully complete its Platoon Leadership Qualification (PLQ) course in order to receive promotion into its leadership ranks.2 Such courses are conspicuously absent in healthcare; when emphasizing clinical acumen, leadership is often assumed – a product of position instead of purposeful recognition and progressive development within the profession.
To that end, the National Outdoor Leadership School (NOLS) offers a reproducible model of small group operational leadership which incorporates the delineation of four distinct roles, the development of seven core skillsets, and the adoption of a unique leadership style denoted as the “signature.”3 This model offers direction to practitioners of prehospital medicine as they develop their own leadership styles in the face of both traditional and consistently evolving job expectations and requirements.
The Four Leadership Roles
The NOLS leadership roles are categorized by Self-Leadership, Active Followership, Peer Leadership and the Designate Leader. The roles are distinct yet not exclusionary nor mutually exclusive; rather, students of the model are to see these (four roles) as being distinct pursuits within a shared objective.
Self-Leadership
Self-Leadership is, broadly defined, the development of the personal characteristics to which effective leaders personify; one could effectively summarize its goals as encouraging the individual to be the best version of themselves so as to model the group how to be the best version of itself. Within the prehospital realm, this encompasses the unity of professional and personal character; participating in gossip, neglecting dress and deportment, and eschewing responsibility all conspire to lessen one’s standing in the eyes of colleagues and patients. In its stead: pursing professional excellence, mentoring and developing subordinates, and holding oneself accountable to self and others.
Active Followers
Active Followers embrace the philosophy that to be a good leader, you must be a good follower. Professional fire services and their military counterparts hold freelancing, or the independent actioning of tasks without command or delegation, within the realm of the forbidden. In contrast, amidst the prehospital realm, such behavior and actions can often be regarded as “initiative” or “situationally dynamic” and are thus often fostered as admirable qualities in the face of task saturation, cognitive overload, and inaction. It is little wonder that each group fosters a distinct culture within its rank-and-file and leadership cadres; however, unlike their comrades in the fire service, prehospital care practitioners are often tasked in limited numbers to which command designation imparts a cognitive workload that competes with, and may compromise, care in the sickest of patients.
During these high-acuity “all hands on deck” scenarios, independent action may be warranted; however, when the number of responders allows for effective task delegation and traditional command and control to be established, it is incumbent that the effective follower eschews independent action in favour of allowing the designated leader to substitute direct patient contact for a greater degree of scene management and operational control.
Peer Leadership
Peer Leadership involves one leading by example in the quagmire of cultural/social uncertainty. Exampled daily, shift to shift, moment to moment by how one conducts themselves in the front cab of the ambulance; the conversations and comments, applying dispatch bias or “crystal balling” of prospective patient acuity and the peril this entails. The delineation of roles in emergency health services lends itself to accomplishing the mission with each member of the team knowing their defined tasks and roles so as to achieve the overarching purpose (the mission); however, too often this rigidity allows members to forget the nature of their shared burden and to pass on a necessary task as being “not my job.” Proactively replacing equipment such as oxygen cannisters, assisting in de-servicing, unit preparation for the next call, and participating in station duties all embrace the ethos of never passing a fault.
Designate Leadership
Finally, the Designate Leader role encompasses the expectations and responsibilities that traditionally define leadership. This designated leader is mindful of the objectives and utilizes the team to achieve them; the architect of success – or failure. The Designate Leader informs subordinates, coaches, and mentors them, seeks professional excellence, and is a master of orientation and observation. In the field of prehospital medicine, this role is designated by the attendant, and often assigned seemingly at whim. In the setting of the paired paramedic crew configuration, individuals with equal level of licensure employ a variety of arcane methods to designate the role for the shift; knowledge and experience compete with calendar days, mood, and personal preference. However, regardless of pre-assigned roles, the mantle of leadership must be readily modified and assumed by colleagues not previously assigned the role.
At times when the attendant must leave the patient’s side – perhaps to triage others, attend to allied agencies, perform a specialized procedure, or to seek out relevant information from bystanders or family – the paramedic operating within this Active Following role (aka “the driver”) must be ready to assume command and direct other responders in a way in which the aims of the greater mission may thusly be achieved. In keeping with the non-mutually exclusive NOLS model, upon the return of the attendant, the role of the Active Follower requires reversion to pre-assigned roles and responsibilities so as to maintain an intact command structure.
The Seven Leadership Skills
The seven, core skill sets of this model are Self-Awareness, Expedition Behavior, Competence, Communication, Judgement and Decision-Making, Tolerance for Adversity and Uncertainty, and Vision and Action.4
Self-Awareness
Of these, Self-Awareness requires a profound degree of personal reflection; it may be summarized as encompassing the need of a leader to seek professional competence, be accountable to self, and ensure their continuing suitability for the role. In the prehospital field, such actions may include, but are not limited to, reviewing clinical practice guidelines, ensuring patient oriented documentation is completed and factually correct, and maintaining mental adaptability prior and post-call all. Self-Awareness plays into the core skillset of Competence, the pursuit of which is essential to both the demonstration and perception of effective leadership. From a patient-care perspective, leadership without clinical acumen degrades the ability to lead during all aspects of the call; this directly and adversely impacts suitability as the Designate Leader.
Expedition Behavior
Expedition Behavior (aka professionalism) encompasses the operational mindset and actions which serve to set the tone that will either contribute to, or stymie, the building of relationships with peers and public. The NOLS leadership model,4 while respecting the distinct roles demanded of leaders and followers, embraces an ethos whereby the group environment is a shared responsibility. In the realm of emergency health services, the actions, words, and mindsets of individual paramedics reflect upon the profession itself and contribute to the prosocial behaviors that are essential for concordance of action.5
When practitioners take actions to expand their knowledge, build on their education, and encourage the highest standards in themselves and their others, the profession is enriched in the eyes of the public and in those others that don the uniform. This focus on the broader group environment recognizes its importance in determining outcome and provides an opportunity for the designated leader to shape it. The NOLS leadership model recognizes this subset within its framework as Vision and Action; in this, the opportunity for the leader to influence their environment to motivate, inspire, and materialize their plans. Paramedics working within their field exhibit principles of NOLS oriented leadership within their teams by celebrating the work culture, participating in the development of a distinct job identity, and fostering the continuing evolution of the profession.
Communication
Communication underlies the effectiveness of a leader; in its absence, all else is lost. To effectively communicate a plan is to plant the seeds of its execution, to bridge the known to the unknown is to effectively mentor and develop subordinates. NOLS emphasizes communication strategies which avoid inflammatory or aggravating language, clarify expectations, and encourage accountability. In prehospital care, these principles may be employed to apply effective and targeted communication methods to explain such things as the condition of a loved one to a family member, the effects of a medication to a colleague, and the rationalization for procedures and conveyance to a patient.
Judgement and Decision-Making
Judgement and Decision-Making is the skill that incorporates the traditional view of leadership. The NOLS model recognizes the importance of establishing, and communicating to team, the boundaries around which decisions are made; this informs the judgement that is developed from prior experience, mistakes, knowledge of task, and which underlies informed risk appreciation and continuous assessment. Clinically, prehospital care providers are often restricted through patient privacy legislation from learning of the downstream consequences of their actions and interventions; this imparts an impediment to learning and retards the consolidation of action through decision alignment and thus judgment. Practitioners must overcome this deficiency through curiosity, education, communication with peers, and adherence to the professional norms and conditions of their licensure.
Seeking strategies to overcome challenges such as these reflect the principles outlined in Tolerance for Adversity and Uncertainty. Prehospital practitioners face a multitude of challenges; among them, variations in knowledge and ability between practitioners, unpredictable patient populations, and consistently evolving clinical guidelines. Emphasizing patience, humor, and embracing the opportunities implicit to challenge form cornerstones of the NOLS approach and offers a blueprint for providers within the prehospital realm.
Conclusion
The NOLS roles and skills are comprehensive and non-exclusionary; however, they are merely the template to which an individual leader must apply their own One Signature Style. This principle unifies the skills and roles in the NOLS 4-7-1 model within the broader individual experience; it is what permits the wide diversity in leadership styles and techniques that are seen among leaders. The signature style is likened to a mathematical function – it is what results from an individuals’ application and understanding of its composite roles and skills.
The fools of Plato’s allegorical ship led solely with their style, and contested ideas to the contrary; the model presented here within aspires to address this through its teachings and approach to small group operational leadership. Paramedicine offers a dynamic model to apply the principles of the NOLS model in real-world situations that demand effective leadership, and in doing so offers an opportunity for practitioners to develop and hone their own signature style throughout their careers. It is therefore reasonable to expect that as an individual grows in maturity and experience, their change in individual leadership style will be commensurate.
Rather than resist change and the resolute staying of the course, leaders should expect that their experiences will continue to shape the lens through which they will apply their learned teaching and view this evolution as evidence of continued movement in their personal voyage. One need not remain a fool.
References
1. National Fire Protection Association. (2022). Codes and Standards. https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards/detail?code=1021
2. Canadian Armed Forces (2016). Primary Leadership Qualification. https://dln-rad.forces.gc.ca/production/cninv000000000148178/story_content/external_files/04_Guide_st udent.pdf
3. LaMouria, E., & Blazzard, K. (2009). Leadership at NOLS. The Leader in Wilderness Education. Retrieved October 25, 2021, from http://www.nols.edu/
4. Sibthorp, J., Paisley, K., & Gookin, J. (2007). Exploring participant development through adventure-based programming: A model from the National Outdoor Leadership School. Leisure Sciences, 29(1), 1- 18.
5. Furman, N., & Sibthorp, J. (2014). The Development of Prosocial Behavior in Adolescents: A Mixed Methods Study From NOLS. Journal of Experiential Education, 37(2), 160–175. https://doi.org/10.1177/1053825913489105
