26 Leadership and Advocacy for Pharmacy

However, each initiative should have clear objectives, even if it

3
is as simple as an effort to mobilize student pharmacists to send
e-mail or letters to the state legislature or board of pharmacy to
draw attention to a regulation that prevents pharmacists or stu-
dents from realizing their full potential. Certainly, a change in C H 1\ I' I I I{
the regulation is the outcome desired eventually, but mobilizing
dozens of communications clearly stating the case should be con-
sidered a positive intermediate outcome.
Margaret Mead has been quoted as saying, "Never doubt that
a small group of thoughtful, committed citizens can change the
LEADERSHIP THEORIES
world; indeed, it's the only thing that ever has." This is our call to FOR LEADING CHANGE
action and the promise that our efforts will, indeed, make a dif-
ference in the quality of health care our patients receive. David A. Holdford

References

I
1. American Pharmaceutical Association. The Role of the Pharmacist in Com-
prehensive Medication Use Management: The Delivery of Pharmaceutical Care f you thought you could make a change in the pharmacy
{position paper]. Washington, DC: American Pharmaceutical Associa- profession, would you be willing to try? If you had the lead-
tion; March 1992. ership skills and qualities to effectively promote the profes-
2. American Association of Colleges of Pharmacy. Pharmacists for the Future:
sional image of pharmacists and increase their influence within
The Report of the Study Commission on Pharmacy. Ann Arbor, Mich: Health
Administration Press; 1975. the health care system, would you use them? If you had the power
3. Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. to change things, would you do so? Most of us would probably
Boston: Back Bay Publishing; 2002. say yes to these questions, because we see things that need to
4. Joint Commission of Pharmacy Practitioners. JCPP Future Vision of Phar-
macy Practice. Available at: www.aacp.org/site/pdf.asp?TP=/Docs/Main
be improved in our profession. This chapter is designed to show
Navigation/Resources/6725_JCPPFutureVisionofPharmacyPractice you how to lead change.
FINAL.pd£. Accessed December 15, 2006. Across the country, pharmacists and students like you are
5. Johnson J, Bootman JL. Drug-related morbidity and mortality: a cost-of- making a difference in our profession. This book offers examples
illness model. Arch Intern Med. 1995;155:1949-56.
6. American Association of Colleges of Pharmacy. CAPE Educational Out- of leaders who are passionate about their chosen causes and are
comes 2004. Alexandria, Va: American Association of Colleges of Phar- using their leadership skills to advocate and infl11ence change.
macy; 2004. What sets them apart from nonleaders is that they care enough
7. Institute of Medicine. Health Professions Education: A Bridge to Quality.
Greiner AC, Knebel E, eds. Washington, DC: National Academies Press;
to work for change.
2003.

Phases of Leadership Growth

The typical pharmacist does not graduate with extensive lead-
ership capabilities. I consider myself a typical pharmacist-I'm
27
28 Leadership and Advocacy for Pharmacy
Leadership Theories for Leading Change 29
.
David A. Holdford solutions. For instance, it was very difficult for me to balance the
competing demands of my employer, boss, and co-workers with
Background my personal desires and family responsibilities. Someone always
David A. Holdford is Associate Professor, Phar- seemed to be unhappy, and it made me feel bad. My problems
macy Administration, at Virginia Commonwealth
were compounded by the fact that the skills and behaviors that
University (VCU; Medical College of Virginia
Campus) School of Pharmacy in Richmond. He made me a successful staff pharmacist did not necessarily make
completed his BS in Pharmacy at University of me a good manager. Sadly, I failed as a manager and leader more
Illinois, Chicago; MS in Pharmacy Administration often than I really want to admit-initially. But as my career pro-
at Ohio State University; and PhD in Pharmacy
Administration at University of South Carolina. gressed, I learned from my mistakes and began to succeed as a
Before joining the VCU faculty in 1995, Holdford leader.
worked as a pharmacist and manager at hospitals My leadership training progressed through four different
in Chicago and Columbia, South Carolina. At VCU,
he teaches professional and graduate students
phases of growth described by Maxwell.1 The first was "I don't
about pharmacist leadership, the marketing of pharmaceuticals and pharmacist know what I don't know." In this phase, I did not realize my
services, and other topics important to contemporary pharmacy practice. deficiencies as an effective leader. I had an inflated sense of my
Holdford's current research interests focus on pharmacoeconomics, health capabilities and contributions to the pharmacy. When problems
outcomes assessment, and the role of marketing in health care. He has published
more than SO articles and book chapters in health care and business publications occurred, I was more likely to blame my boss or co-workers than
and is the author of the textbook Marketing for Pharmacists, published by the to assume any responsibility for a problem. Over time, however,
American Pharmaceutical Association.
I moved to the second phase of leadership growth, "I now know
Holdford describes in this chapter his own road to leadership. what I don't know." At this point, it began to dawn on me that
my own inexperience and ignorance were the reason for many
of my failures as a manager. It became clear that I did not have
relatively intelligent, I work hard, and I care about others. My the answer to all problems and that my success hinged upon the
grades were good in pharmacy school, and I even completed a people with whom I worked. It was also apparent that many of
graduate degree, taking courses in organizational behavior, psy- the assumptions I made about leadership were incorrect and that
chology, and sociology to better understand people and their my behavior needed to change if I wanted to gain the respect and
behaviors. After graduation, I worked for 5 years as a hospital trust of those I managed. It was in this second phase that I dedi-
pharmacist. Observing others in ~eadership positions caused me cated myself to becoming a student of leadership and learning
to conclude, "I can do a lot better than that." I assumed that I was what it takes to become a leader. I observed leaders in my life and
ready for success as a pharmacist manager, but I was wrong. in the public arena and reflected on what caused them to succeed
I was unprepared for the demands of being a manager. My or fail. I read a lot of leadership books, too.
education and training really did not help me understand how Nevertheless, it was not until the third phase, "I now know
to manage and lead others. I naively thought that my managerial and it is starting to show," that I truly began to develop as a
title gave me power over the people I supervised, but they regu- leader. In this third phase, I applied what I'd learned about lead-
larly resisted my ideas and proposals. The resistance was rarely ership to my work and everyday personal life. I identified per-
overt. Instead, opposition usually took the form of a lack of com- sonal weaknesses and bad habits that were holding me back as
mitment to the things I felt were important. Although co-workers a leader and systematically worked to improve upon them. For
might go through the motions of accepting my initiatives, they example, I sometimes carelessly forgot about the promises I'd
usually exerted minimal effort toward making them succeed. made to others. This would lead them to conclude that I didn't
It was surprising to learn that many of the managerial dilem- care about them or their feelings, and it hurt my credibility with
mas I faced were not easily solved by common sense or textbook them. To correct this bad habit and repair my relationships with

j
30 Leadership and Advocacy for Pharmacy Leadership Theories for Leading Change 31_

~o-workers, I developed a habit of noting each of my promises Six approaches to leadership are discussed in the followi~g para-
m a pocket calendar, along with a deadline for responding graphs: coercive, affiliative, transformational, democratic, pace-
2
to the person to whom I'd made the promise. This helped me setting, and coaching (Table 3-1).
remember my promise and reminded me when I failed to keep
it. Then, if I forgot a promise, I was clearly aware of it, making Coercive. The coercive leadership style relies on the use of
me more determined to keep my word in the future. By system- rewards and punishments to motivate followers. It can be very
atically identifying and changing similar ineffective behaviors, effective in getting people to take action but can be seen
I developed better personal and professional relationships and manipulative and demeaning. A leader who dangles rewards m
increased my leadership effectiveness. Furthermore, I sought front of followers or threatens to punish them essentially sa~s,
out additional opportunities to develop my skills by choosing "Do this or else." This style might get people to act, but they will
likely do so with little enthusiasm. It emphasizes the leader's
different tasks that stretched my capabilities. Rather than see-
power over followers and generates an ad~ersar~al re~ationship
ing these tasks as additional work, I viewed them as leadership
of "us versus them." Coercion can hurt relationships with follow-
training. Over time, I grew as a leader and my effectiveness
ers, especially highly productive ones, because it does not treat
became noticeable to others. It was when others recognized me
them as mature,. contributing individuals. To the contrary, coer-
as a leader that I realized I truly was one.
cion undermines pride in mature adults and encourages passiv-
I now find myself in the final leadership growth phase, "I
now lead because it is what I am." In this phase, leadership is ity by teaching them to wait for incentives from the leader before
no longer a conscious act; it is just a part of my life. That is not to acting. Coercion is also ineffective when leaders have little abil-
say that I don't make mistakes or that I don't have a lot more to ity to reward or punish, such as when working with volunteers
learn about leading. It just means that I've reached a point where or when followers are more intrinsically motivated by th~ work
I am not consciously aware when I influence others. I just do it, in which they engage than by the extrinsic rewards received for
because it is a natural extension of what I am and what I want to completing that work.
achieve. I still consciously assess my leadership performance and Hence, coercive leadership is best used sparingly. It should
adjust my behavior accordingly. However, many of my leader- be reserved for crisis situations in which qu,ick and firm action
ship behaviors have been internalized and become a part of me. is required. It may also be used temporarily in support of other
leadership styles. For example, a co-worker who does not keep a
promise may be told, "I feel as though you let us down. You did
not do what you promised. We need to know that we can rely
The Need for Different Leadership Styles on you in the future. Your help is critical to our success." Within
this statement is an implied threat that behavior must improve
Some of the difficulties I faced in my first formal managerial posi- or something will happen. At the same time, the statement sup-
tion occurred because I used the wrong leadership approach for portively emphasizes the co-worker's importance. Nevertheless,
the circumstances. I tried to use a democratic leadership approach, coercion is not desirable over the long term in most leadership
as I had in my previous staff pharmacist position. However, I situations. It is better to use one of the other five styles of leader-
found that democratic .leadership is not effective in every situa- ship whenever possible.
tion. Indeed, I discovered that no single leadership style can be
effective in all situations because leadership conditions differ and Affiliative. The affiliative style of leadership revolves around
•constantly change. Effective leaders must recognize and adapt to meeting the emotional needs of followers. It focuses on people,
the changing circumstances. A leader's ability to adapt will grow whereas coercive leadership focuses on the task. Affiliative lead-
as he or she masters and effectively uses different approaches. ers seek happiness, harmony, and, ultimately, loyalty between
 cy
32 leadership and Advocacy for Pharma leadership Theories for Leading Cha
nge 33
.
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34 Leadership and Advocacy for Pharmacy
Leadership Theories for Leading Change 35.
Democr~tic. ~emoc_ratic leaders solicit input from followers in the leader's mind. Ambiguity Effective lcadel'sl1ip
and attam their buy-m for major decisions and initiatives. Par- about what is expected can cause is needed to help
tici?ative d~mocracy shows respect to followers and helps build anxiety and low mora~e in. fol- pharmacists organize
their commitme~t mor~ e~fectively than simply telling them what lowers. It is similar to being given
tests in college and never know- and coordinate their
to do. E~couragmg their mput can also provide a broader range
ing if the answers are correct or advocacy efforts.
of solutions and push followers to take greater responsibility for
their success. Morale increases, too, because followers feel valued what scores are needed to pass.
and part of the change process. Still, leading by example is a . . 1
ve useful style. It is most effective for managing team~ of high y
The primary drawback of democracy is that it can be frustrat- mlvated and self-directed individuals, su;h as medical teams
ingly inefficient. It typically results in too many meetings, debates, in a hospital or professional sports teams. It also works well
and negotiations. Reaching consensus also leads to compromises when used in combination with other styles that supplement th:
that produce less than optimal results, especially when deadlines pacesetter's actions with explicit written and spoken comm~-
are to be met. On the other hand, democracy can bring many cation. Actions may speak louder than words, but words clarify
minds to bear on a problem and lead to group commitment to a the meanings of those actions.
plan of action. In truth, group commitment to a mediocre plan
is usually preferred to weak backing of the best plan. The key to Coaching. The coaching style encourages followers to develop
successful democratic leadership is to establish and enforce an their skills and capabilities, with the goal of improving perfor-
explicit and accepted process for the conduct of all individuals mance and increasing their ability to take on greater responsi-
(e.g., bylaws, policies, and procedures). Accepted rules for behav- 1{
bilities. The goal of coaching is to develop followers so that they
f,'
ior help ensure an orderly democratic process. no longer need assistance from leaders. Followers are encour-
aged to identify personal goals that match those of the leader
Pacesetting. Pacesetting occurs when leaders demonstrate and organization. Subsequently, the coach and follower collab-
expected behaviors through their own personal actions. Com- oratively establish long-term plans to meet their mutual needs.
monly called leading by example, this is considered an admirable
For instance, the president of a student organization may direct a
form of leadership. In essence, the leader says, "Do as I do." This
member to volunteer for an open position as chair of a subcom-
is the type of leadership seen in military officers who lead the
mittee, if that member aspires to run for future office. When the
charge or star athletes who lead the team. Pacesetters often gain
new subcommittee chair succeeds, everyone benefits.
credibility with followers by setting a good example.
Coaching's biggest drawback is the time and patience it
A major problem with pacesetting can be that it sends unclear
messages about desired performance.2 The meanings of a leader's requires. It is often easier in the short run to do something your-
actions can be ambiguous. For instance, a pacesetter may want to self or just tell someone what to do. It also takes substantial
communicate through his actions the message, "If we all work patience and self-control for leaders to share responsibility and
hard, we will succeed." But the follower may interpret the lead- be tolerant of mistakes as followers learn new tasks and skills.
er's message as, "If you do not work as hard as I do, you aren't In the long run, however, well-coached individuals rarely need
good enough." Or, the actions of pacesetters may be misinter- to be told what to do, and they share the workload with leaders.
preted as an expectation of conformity by followers, devaluing Coaching leadership benefits organizations by growing future
their individuality. With pacesetting as the primary style, no one leaders. It also builds commitment by telling followers, "I believe
can ever be as good as the leader, who is the "gold standard." in you and your potential enough to invest my time with you. I
Furthermore, followers often have to guess the leader's intentions know that you will succeed." This powerful message is typically
because expectations of performance are typically locked away met by the best efforts of followers.
36 Leadership and Advocacy for Pharmacy Leadership Theories for Leading Change 37
.
Using Multiple Leadership Styles your goals. Theories can only inform your behaviors. It takes
application and experience to identify a blend of styles that works •
Effective leaders use a broad range of leadership styles to encour- best for you.
age others to advocate change. At Virginia Commonwealth
University, pharmacy students have been active in school gov-
ernance, holding various leadership roles in student, school, You Can Lead and Not Be in Charge
and local organizations. One student leader (DK) succeeded
in seamlessly switching from one style to another depending Some people think they must possess a formal leadership posi~on
on the specific situation. DK was transformational because he in order to lead change. On the contrary, anyone can lead. In my first
identified and articulated a clear, persuasive vision for what he job as a hospital pharmacist in Chicago during the 1980s, I worked
wanted to achieve at the school. One element of his vision was with a pharmacy technician who was nicknamed "IR:' IR was a
that students who adopt professional behaviors in pharmacy pharmacist from India who took a job at the hospital as a technician
school will be more professional as pharmacists. DK argued that until he could meet the requirements for the Illinois pharmacist
a code of student behavior and dress should be adopted for all licensing exam. Officially, I was his superior and responsible for
students. Although this viewpoint was not universally accepted supervising his work, but in reality, his influence on the day-to-day
by his classmates, his vision was moved forward by students work in the pharmacy was much greater than mine. Although a
who did share his viewpoint. Another element of OK's vision technician, IR never let his official role limit his influence on how
was that good leaders prepare others for leadership. Thus, he pharmacy was practiced at the hospital. He developed credibility
helped coach other students to be better leaders. His credibility as someone who could be relied upon in any situation, and he used
was such that he could provide feedback in a manner that was !1'at credibility to s~g~est ways to_ improve our patient care. He typ-
appreciated and valued by others. It helped that DK never let his ically took the lead m implementing new ideas.
ego get in the way; he shared credit with others, and he always IR realized that his ability to influence was not limited by h 1•s
listened to and respected others' viewpoints. He democratically formal position. He understood that the power to influence can
let- the majority rule even when he did not agree with the deci- come from different sources:
sion. And once a decision was made, he did not second-guess
it or complain. His inclusive and nonjudgmental manner made • Formal power is awarded to individuals when they accept
everyone around him feel good. He worked hard and set a good some position of formal authority, such as an office in a stu-
example for others, but he never used pacesetting as a vehicle dent organization or a position as a pharmacy manager. As
for self-aggrandizement or sympathy. He never mentioned his a technician, IR had little formal authority because he had
own efforts, preferring to highlight the efforts of others. His use no official authorization to reward or punish, make budget-
of pacesetting was effective because it was done quietly, without ary decisions, or set policy. Instead, he wielded other, non-
strong expectations of others. Indeed, his efforts were inspira- formal powers.
tional because they emphasized his commitment to his vision. • Reward power refers to one's ability to reward others who
There were few students or faculty members who did not know act in a desired manner. Although this is often associated
and respect him. with formal positions of authority, anyone can reward oth-
Although the management literature provides some guid- ers. IR rewarded people by helping out whenever needed,
ance on appropriate leadership styles in changing situations, the providing encouraging words, showing that he cared for
ultimate determinant of good leadership is the ability to achieve them, and making work more fun.
I'.1 38 Leadership and Advocacy for Pharmacy
Leadership Theories for Leading Change 39
.
li originally thought. As you exert your power, you will progress
·,1
• ~unishment power, the converse of reward power, exists
m a person's ability to punish. This, too, is not restricted to as a leader.
f; formal positions of authority. IR rarely used this form of
1i power, although he could easily have punished co-workers
1 with an unkind word or a dirty look. He avoided the use of How to Develop Leadership Capabilities
J
puni_shme~ts, because he believed they damaged personal
relationships and were thus counterproductive as a means Seek to better understand yourself. When learning to lead, you
of influencing change. must assess your current capabilities and identify the skills you
• E~pert power is derived from a person's special knowledge, need to develop. The more you know about what motivates you,
skills, and experience. Influence comes when others rely on how your emotions affect your reactions to circumstances, what
that person's expertise. IR developed expertise through his your personal strengths and weaknesses are, and what you want
knowledge of policies and technical aspects of running the to achieve as a leader, the better. Self-assessment can be con-
pharmacy. Consequently, he was regularly consulted about ducted through formal tests (e.g., Myers-Briggs Type Indicator)
issues of importance to running the pharmacy. and through the feedback of friends, family, employers, and co-
• Information power derives from the possession of critical workers. This self-knowledge is useful in developing skills as a
information needed by others. Beyond his expertise, IR often leader and learning to adapt to leadership demands.
possessed unique information because he developed strong
relationships with technicians, pharmacists, and managers. Learn about leadership from others. Leadership training can be
His professionalism, pleasant demeanor, and competence facilitated through observation . Students of leadership identify
gave others the confidence to share information with him. leaders and observe how they influence others. They examine
• Referent power is an individual's ability to influence another leaders in their personal lives, and by reading about them in the
by force of character or charisma. IR's referent power came news and reading their books, and then reflect on what works and
from the goodwill and mutual respect he built over time does not work for them. Students of leadership observe which
with others in the pharmacy. leadership styles are best employed in different situations, how
followers respon~ to the different styles, and how things might
I learned from IR that anyone can be a leader if he or she so have be_en done differently. Identifying and working with a men-
desires. Although IR was a technician, he developed consider- to~ during your early stages of leadership growth can facilitate
able power in the pharmacy to influence practice. IR would prob- this process.
ably deny his leadership role, but he was dearly recognized as
a leader among his peers. All of us can be leaders whenever we
Practice leadership yourself. Leadership is a performing art,
choose to take a stand and act to influence others. We must real-
mastered only through participation and practice. Reading about
ize that we should never be limited by our formal ti'tles.
leadership and observing others may help, but true mastery does
A major step in leading change is to understand the power
not happen until you are faced with the tough decisions of lead-
you possess and are ~illing to use. If you want to start leading,
ing. Look for opportuniti es to lead at work, school, home, and
you should identify a situation at work, school, or home where
almost anywhere people interact. Simply choose a cause about
you desire some change. Then, think about the different sources
which you are passionate and then take the leap. Your pas-
of power you have to influence the situation. You will probably
sion can be about something small (e.g., littering) or very large
be surprised to learn that you possess more power than you
40 Leadership and Advocacy for Pharmac 1
y Leadership Theories for Leading Change
(e.g., world peace). With experience and time
41 .
, you will move from
"I don't kno w wha t I don't know" to "I now Additional Resources
lead because it is
wha t I am."
Phi Lambda Sigma, The National Phar
macy Lead ershi p Society (www.
philambdasigma.org)
The American Society of Health-System Phar
maci sts has leade rship resou rces
Conclusion on its Web site (www.ashp.org/).
The Harvard Business Review has excellent
articles on leade rship and relat ed
topics (harvardbusinessonline.hbsp.harvard
No pharmacist, acting alone, can be an effec Abrashoff M. It's Your Ship: Management Techn .edu).
iques from the Best Damn Ship in
tive advocate for the Navy. New York: Warner Business Books;
2002. This book by a retir ed
the profession. Change can occur only whe U.S. Navy Capt ain illust rates how mult iple
n pharmacists act leade rship style s were used
together. Effective leadership is needed in comm and of the destroyer USS Benfold.
to help pharmacists Covey S. The 7 Habits of Highly Effective Peopl
organiz~ and coordinate their advocacy effo e. New York: Free Press; 2004. Hab-
rts. Pharmacists who
und erst and and apply basic leadership prin its for success.
ciples can multiply Maxwell JC. The 21 Irrefutable Laws of Leade
rship. Nashville: Nels on Business;
their ability to advocate for change in the
profession. Effective 1998. This is the best of a serie s of book s by
Max well on leade rship .
leaders strengthen advocacy efforts by ener Thomas KW. Intrinsic Motivation at Work-Buil
gizing others to work ding Energy and Commitment. San
with them and inspiring them to work tow Francisco: Berrett-Koehler; 2002. Goo d
discu ssion of how to moti vate
ard a shared vision of
the future. • yourself and others.
The need for leadership in the pharmacy
profession is well
recognized in the literature.4- 7 A concern ofte
n expressed is that
too few pharmacists have the training and
experience needed to
succeed in leading the profession. Our hop
e is that the stories
presented in this book will inspire you to
use your power for
positive change.

References
1. Maxwell JC. The 21 Irrefutable Laws of Leade
rship. 1st ed. Nashville, Tenn:
Thomas Nelson, Inc; 1998.
2. Goleman D. Leadership that gets resul
ts. Harvard Bus Rev. March-April
2000:78-90.
3. Kotter JP. What leaders really do. Harvard
Bus Rev. May-June 1990:103-11.
4. Engle JP. Leadership and professionalism
in pharmacy. Am JHealth Syst
Pharm. 1991;48:1559-62.
5. Maine LL. Leadership in pharmacy.
Am J Health Syst Pharm. 1988;
45:2537-41.
6. Manasse HR. The power of phar macy leade
rship. Am JHealth Syst Pharm.
2005;62:1700-2.
7. Holdford DA. Leadership theories and their
lessons for pharmacists. Am
JHealth Syst Pharm. 2003;60:1780-6.