Article Relational leadership, decision-making and the messiness of context in healthcare Leadership 9(2) 254–277 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1742715012468785 lea.sagepub.com Liz Fulop Griffith Business School, Australia Annabelle Mark Middlesex University Business School, UK Abstract Decision-making is a neglected area in the leadership literature and in healthcare in particular. This paper draws on the Cynefin framework, which is a practice-based approach to decision-making, to theorize about leadership in healthcare. The framework uses a multi-ontology cognitive-based sense-making perspective to identify five domains of decision-making that are linked to individual leadership styles and given contexts. It is markedly different from other complexity approaches by the inclusion of the central domain of Disorder. While this inclusion is vitally important, the leadership implications of the approach are under-theorized. Focusing on the idea of Disorder, we argue alternatively that a relational leadership approach is needed to understand decision-making as a multi-ontology sensemaking approach and this also necessitates accounting for professional sensemaking in healthcare settings. The relational approach adopted here is based on Dian Hosking’s work and views decision-making as a task that is undertaken through organizing processes that are cognitive but also social/cultural, political and emotional, and in which the social construction of leadership and context are inseparable individual and collective undertakings. When skilful relating is a part of leadership practice then multi-ontology sensemaking is a possibility in decision-making tasks. We support our arguments with illustrative examples to put forward a relational approach to leadership in healthcare. Keywords Healthcare, relational leadership, decision-making, sensemaking, multi-ontology Corresponding author: Liz Fulop, Griffith Business School, Griffith University, Gold Coast campus, Queensland 4222, Australia. Email: l.fulop@griffith.edu.au Fulop and Mark 255 Introduction Decision-making is a largely neglected area in the leadership literature and in healthcare in particular, though it is gaining prominence. This paper seeks to address this deficiency by drawing on a multi-ontological approach to explore how decision-making is critically linked to both the context, content and practice of leadership. By utilizing the Cynefin framework, which has been used as a practice-based approach, and then subsequently applied to leader decision-making, it is possible to enhance its multi-ontological explanatory power by retheorizing the domain of Disorder within Cynefin, through the lens of relational leadership as initially explored by Hosking (1988) and Hosking and Morley (1988). Relational leadership is approached differently by postmodernists and social constructionists depending on how sensemaking (without a hyphen) is used to explain reality construction as subjective or inter subjective, as contexts, relationships and connections between actors, actions, processes and practices, the nature of social ordering, and meaning making through language, narrative, conversation, discourse and dialogue (Cunliffe, 2008; Fairhurst, 2007; Hosking and Fineman, 2000; Izatt-White, 2011; Klenke, 2008; Peck and Dickinson, 2009; Raelin, 2011; Uhl-Bien, 2006). These differences lead to distinct orientations to the study and practice of relational leadership such that any categorization is a highly contested matter and hybrid or blended approaches are not uncommon (e.g. Fairhurst, 2007). There are studies on leadership and decision-making using social constructionist (Hosking, 1988; Hosking and Morley, 1988; Maitlis and Sonsenhein, 2010) or social constitutive approaches (Grint, 2005a; Grint and Holt, 2011) to describe leadership as complex decision-making but not specifically in healthcare contexts. The Cynefin approach to sense-making (with a hyphen) draws on a cognitive approach, and in practice sessions uses context to create collective sense-making through discourse so that language and narrative is emphasized (Browning and Boudès, 2005). That said, the contextual options are a given and reality construction is not central to understanding decision-making (Kurtz and Snowden, 2003; Snowden, 2002). The approach provides predetermined reductionist frameworks of context while relational leadership is intrinsically about co-constructing context through the processes of organizing. Nonetheless, such juxtaposition of ideas, we suggest, can also illuminate the differences between individual leader decision approaches, to what Raelin (2011) terms agentic collaboration that harnesses others to achieve outcomes and pays attention to the processes through which these outcomes emerge. The focus moves away from an initiating individual or leader as in the Cynefin approach to a host of possible co-contributions to leadership. The relational approach affords a more nuanced understanding of sensemaking and leadership practice that is important given the critical role of professionals in healthcare, who are mostly steeped in the single ontology of science and rational methods, and struggle to engage with other perspectives. The notion of professional sensemaking (Hall and White, 2005; White, 2002) is an important idea here because it helps to account for the representativeness of leadership situations (Izatt-White, 2011) in healthcare where clinicians are known to habitually story their work and make decisions based on a medical model to the exclusion of other ways of meaning making and social construction, that could lead to different ways of treating patients, families and others (Hall and White, 2005; Holstein and Gubrium, 2005; Reissman and Quinney, 2005; Rycroft-Malone et al., 2004; White, 2002). We use the idea of Disorder, the central and under-theorized space in the Cynefin framework explained later, as a discursive space and arena in which, through skilful relating, multi-ontology sensemaking 256 Leadership 9(2) can become part of the decision-making processes or enable one form of maneuvering ‘among multiple foci of decision-making’ (Denis et al., 2010: 83). It is only through skilful relating that contexts can be changed so that new ideas and innovations are brought forth (Hosking and Morley, 1991; Hosking, 2011a). Relational processes feature multiple reality construction and influence and skilful relating promotes the clever use of systematic methods to promote open-minded thinking and cultures of productivity (Morley and Hosking, 2003: 75). By tying relational leadership to task accomplishment, hence decision-making, the representativeness of healthcare settings are able to be taken into account. Fairhurst (2007) suggests that task accomplishment is always also task interaction and can help us to identify constraints within discursive practices at a micro-level, such as occurs in conversation analysis. The other more important benefit of a task orientation she says is, that it allows us to notice the task skills and expertise that actors draw on and this can reveal ‘influential acts of organizing’ (Hosking, 1988) that are important to account for in healthcare settings. In these settings there is often a ‘monopoly of meaning’ (Peck and Dickinson, 2009: 126) in clinical decision-making that spills into other areas of decision-making and delimits patterns of meanings consequent to social construction and sensemaking (Holstein and Gubrium, 2005), and hence, the context in which future discourses can emerge. However, discourses of themselves do not lead to actions and discursive practices (narratives, conversations, story-telling and dialogue, for example) produce locally distinct meaning systems in everyday life (Fairhust, 2007; Holstein and Gubrium, 2005). This suggests that interpreting leadership is, however, itself problematic as is its link to decision-making, but what we hope to demonstrate is that decision-making is a key relational practice of leadership that connects things together. But why a relational orientation? Things are changing in healthcare to support a relational orientation. In the UK for example, the NHS Institute commissioned a review of a number of leadership approaches to address the training needs of those who have to achieve extraordinary efficiency savings of between 15 and 20 billion in healthcare reforms (Teamwork Management Services, 2010). This review reflects a stronger focus on collective approaches to leadership, such as shared or distributed leadership (Buchanan and Bryman, 2007), and concludes that leadership is no longer about individual heroic leadership but about human and social capital development; expressed theoretically as blended and hybrid initiatives (Fulop, 2012). The report goes on to mention however, that innovation depends on effective communication and decision-making skills suggesting that, ‘[m]ore could be done to provide a theoretical base for leadership and management that would help practitioners make sense of their experience’ (Teamwork Management Services, 2010: 136). Many of these newer approaches are moving from more blunt forms of extracting human capital to cognitive, social and emotional capital forms of leadership development. Others have attempted, in a wider context (e.g. Burgoyne and Turnbull, 2006), to address these issues through sensemaking as a key element of this discourse (Bate et al., 2008; Conroy, 2010; Grint, 2000; Hosking, 1988; Maitlis and Sonsenhein, 2010; Peck and Dickinson, 2009; Pye, 2005), but the relationship between this and decision-making remains somewhat unexplored in healthcare. These simultaneous but contrasting approaches can also be seen within another contemporary review of leadership in the UK NHS (Kings Fund, 2011) suggesting that it requires Fulop and Mark 257 what they describe as complicated leadership and negotiated authority between clinicians and professional managers and between clinicians from different professional orientations, to promote innovation and change (Kings Fund, 2011), confirming Hosking’s view of this process as, in reality messy and untidy (Hosking, 1988). It also highlights the need to focus on leadership development that is embedded and driven by the contexts in which leadership is performed; reflecting wider concerns about understanding how organizations work (Rousseau and Fried, 2001), by emphasizing roles, relationships and practices that are made within contexts and through social interactions, while learning with people who share these contexts. The Kings Fund also notes the autonomy granted to clinicians, especially doctors, in their work and the powerful influence they have over decision-making around budgets, as a unique feature of professional service organizations. The need to link leadership and decision-making in healthcare is now paramount (Spurgeon et al., 2011: 137) as the decisions become more difficult in times of increasingly contested priorities and reorganizations which are also ‘revealed as imperfect, messy and highly political’ (Denis et al., 2010; McKee et al., 2008: xxvii). One avenue for pursuing this is to challenge the dominant discourse of science in healthcare in which, as Bauman and Haugaard (2008) suggest, drawing on Luke’s (2004), power is exercised by controlling and limiting possibilities through single ontologies and methodologies without accounting for context in its widest sense. Confounding these singular approaches in understanding behavior and differing perspectives, is however of increasing interest in both research (Frost et al., 2010) and through the multiple actors in healthcare where leadership can be associated with a voice that emerges (rhetorically) as the dominant voice for a particular clinical context (Mol, 2003). Multi-ontology sense-making and sensemaking We now turn towards our multi-ontology approach, drawing first on the Cynefin framework as used by Snowden and Boone (2007) in their Harvard Business Review (HBR) article on the relationship between leadership and managerial decision-making, while our second focus is on relational leadership as a process of social engagement and co-construction, explored mainly through the work of Hosking and her colleagues. The reason why we pursue the idea of relational leadership in the context of the Cynefin framework is: firstly, it is premised on action research or a practice orientation; secondly, it does not advocate a single hierarchy of knowledge and expertise (Hosking, 2011a). In fact one of the strengths of the Cynefin framework (as shown in Figure 1) is that through each reiteration or use in practice, it provides several simultaneous levels of explanation through its multi-ontology sensemaking approach, without privileging any one of them. Thirdly, by using complexity theory the Cynefin approach is framed in a discourse that has growing currency in healthcare contexts and provides an opportunity to challenge entrenched ways of talking about leadership. Fourthly, some of the ideas that informed Hosking’s (1988) and Hosking and Morley’s (1988) early writings on relational leadership were directly linked to decisionmaking and also drew insights from cognitive science as does the Cynefin approach. Lastly, by introducing the notion of Disorder within the Cynefin framework, but only in the vaguest of terms, the theoretical door was opened for a re-interpretation of leadership and decision-making practices through the lens of multi-ontology sensemaking. Sensemaking is itself subject to interpretation in different ways material to our discussion, so while most approaches to sensemaking draw on Weick’s work (e.g. 1995, 2001) as a collaborative process of creating shared awareness out of different interests and perspectives 258 Leadership 9(2) Figure 1. The Cynefin framework. Source: Reproduced and modified with permission from Kurtz and Snowden (2003). http://www. cognitive-edge.com/ in order to experience situations as meaningful; Snowden alternatively uses sense-making to develop an approach to decision-making that draws mainly from the work of Dervin (1998, cited in Snowden, 2005: 122–123). Unlike Weick, Dervin was not concerned with sensemaking in an organizational context, but rather on how individuals make sense of the world (an external reality) initially from an information systems perspective, fitting frames to data and data to frame, thereafter how actors make and unmake sense as they move through time and space and respond and adapt to different modes of communication (Peck and Dickinson, 2009). Snowden’s approach was therefore, initially predicated on ‘how individuals choose between multiple possible explanations of sensory and other input as they seek to confirm the phenomenological with the real in order to act in such a way as to determine and respond to the world around them’ (Snowden, 2005: 46). We would argue the individualism inherent in the earliest Snowden definitions, now somewhat revised through his practitioner work, made it difficult to think of it in relational leadership terms, as set out in the his 2007 HBR article because a relational constructionist approach is a way of ‘orienting to practice – to ongoing relational processes and the ways they (re)construct particular relational realities’ (Hosking, 2011b: 57). By their own admission, complexity leadership theorists, and this includes Boone and Snowden, do not explore relationships in the same way that social constructionists do who, according to Uhl-Bien and Marion (2011: 476), focus on ‘meaning-making, trust, power and Fulop and Mark 259 identity.’ Complexity theories focus on social mechanisms or dynamic non-linear processes of self-organizing and adaptative systems that are also a feature of the Cynefin framework. We focus on the domain of Disorder in name only because, we suggest, its real value lies in allowing us to better understand leadership through decision-making tasks in healthcare settings. As stated above, Hosking’s earlier approach to relational leadership dealt with the cognitive, social, political organizing processes through so called decision-making tasks. Later she added the emotional process (Hosking and Fineman, 1990) that is considered critical to any understanding of leadership (Denis et al., 2010). Relational constructionism goes further and does not admit cognitive assumptions because as speaking subjects, others are always implicated in relationally responsive interactions that are principally linguistic in nature. With this perspective also comes the moral and ethical responsibility for others (Cunliffe, 2008; Cunliffe and Eriksen, 2011; Hosking, 2011a, 2011b). It is our contention that a relational approach to leadership gives the Cynefin idea of Disorder practical relevance that is currently lacking, especially when applied to professional settings such as healthcare, as our examples will illustrate. Leadership and the Cynefin framework The Cynefin framework did not start as a leadership theory based on a decision-making perspective. Its practice orientation has driven this evolution as a sense-making framework for a range of contexts. The HBR article by Snowden and Boone places the Cynefin framework into the popular management domain or discourse, with increasing interest shown in it from the academic community (Mark, 2006; Marion and Uhl Bien, 2011). Our intention here however, is to explore the notion of Disorder, from which we argue all else flows both theoretically and practically, rather than critique the framework itself as an instrument. However, it is important to acknowledge the limitations of an approach that uses a reductive typology to make sense of a limited interpretation of differing domains as already shown in Figure 1. Snowden and Boone (2007) outline a scenario to make the point that traditional individual leaders often assume a certain level of order and predictability exists, and these are based on the laws of Newtonian science that have been transposed into the precepts behind developments such as scientific management. However, they argue, the world is more complex than this, and through working with complexity science it has been possible to devise the Cynefin framework. They say it can enhance leader communication about ways of understanding and acting in different contexts where positivist rationalities have only marginal utility, now argued more specifically in relation to the practice of clinical leadership (McKimm, 2011). The framework sorts the issues facing leaders into the four contexts or domains (see Figure 1) defined by the nature of the relationship between cause and effect, distinguishing two domains within an ordered world where cause and effect are discernible (simple and complicated) and two being in the unordered (complex and chaos) world, where cause and effect are not discernible and past patterns of action will not provide present or future solutions. A fifth domain of Disorder sits at the centre-point of the four others. The four domains of Simple, Complicated, Complex and Chaotic require leaders to diagnose situations and to act in contextually appropriate ways, which may also involve movement across from one domain to another. The fifth – Disorder – applies when it is unclear which of the other four contexts is predominant, presuming that leader communication is mutually understood and accepted in the other domains. The framework, which appeared in their 260 Leadership 9(2) article (Snowden and Boone, 2007) and has since been revised (2012), is meant to provide leaders with both ways of understanding and leading in contextually appropriate ways through a description of the four domains and the leader’s role within it (Table 1). Disorder was excluded from the HBR article. Through indicating the dangers signals within the domain, especially if wrongly interpreted, leaders are also shown ways to regain understanding of how to proceed. For example, in the Simple domain (the domain of best practice and already routinized knowledge), problems of complacency or a desire to generate quick outcomes can make this an attractive but perhaps inappropriate option, especially if a higher level of expertise is required as exists within the Complicated domain (the domain of new expertise); however, here the leader may become too reliant on expertise and will often need to challenge it. It is in the Complex domain (the domain of emergence) that we move into the unordered world where, if the leader tries to over control the organization, they will pre-empt the opportunity for informative patterns to emerge that are often counterintuitive; in this domain there is a need to allow for a variety of safe fail experiments with associated risks, that must replace the imposition of known fail safe solutions from the simple and complicated domains. In the Chaotic domain (the domain of rapid response) action precedes any analysis and must focus on the symptoms of the problem until it can be moved into an alternative domain, but this is also where the greatest opportunity exists to impose change. All four domains require leaders to diagnose situations and to act in contextually appropriate ways. The very nature of the fifth domain, – Disorder, – makes it particularly difficult to recognize when one is in it and who else might be there. Here, multiple perspectives jostle for prominence, factional leaders argue with one another, and cacophony rules. The way out of this realm offered by Snowden and Boone (2007), however, is one of breaking down the situation into constituent parts and assigning each to one of the other four realms. This is a reductionist approach which, we suggest, is completely inappropriate to the context, especially of so-called leader decision-making, because while it is argued that leaders can then make decisions and intervene in contextually appropriate ways, it also implies that they reemerge and remain uncontested in the role of leader. The heroic individualist assumptions mentioned earlier are well entrenched in these assumptions. Furthermore, the problem with the prescription by Snowden and Boone is that it assumes that decisions are easily manipulated and assigned by a single leader, but such models are widely challenged in the leadership literature including healthcare (Denis et al., 2010; Fulop and Day, 2010). However, Snowden and Boone (2007) suggest that leaders who understand that the world is often irrational and unpredictable can find the Cynefin framework particularly useful, as it helps them and those they work with, to sense which context they are in, so that they can not only make better decisions, but also avoid the problems that arise when their preferred management style causes them to make mistakes in interpretation, decisions and action. In essence, the leadership being advocated is one of style by Snowden and Boone, in which management operates as outlined in Table1. The framework is also meant to allow leaders to prepare their organizations to understand the different contexts and the conditions for transition between them. Many leaders, Snowden and Boone (2007) suggest, can lead effectively – though usually in only one or two domains but not in all of them, and few, if any, prepare their organizations for the co-existence of diverse and dynamic contexts appropriate for different parts or levels of an organization. The ‘Cynefin’ framework moves the concepts within it forward in a number of ways: the name itself distinguishes a way of understanding the relationships between how things are Source: Reproduced with permission from Snowden and Boone (2007). http://www.cognitive-edge.com/ Table 1. Decisions in multiple contexts: A leader’s guide. Fulop and Mark 261 262 Leadership 9(2) and how they are perceived because the reader needs to understand this obscure Welsh word that has multiple meanings: ‘habitat’ when used as a noun but as an adjective meaning acquainted or familiar. It describes both the relationship to your place of birth and your upbringing, and the environment in which you live and to which you are naturally acclimatized. However, it also conveys the sense that we all have multiple influences from our pasts of which we can only be partly aware: for example cultural, religious, geographic, or tribal. In healthcare these pasts also include professionalization that influences how doctors and nurses behave (Richard Scott, 2008) and how doctors from different specialities behave towards each other and patients (Norredam and Album, 2007). Snowden also uses it to create the platform for advancing individual/collective knowledge that links a community into a shared history that allows it to adapt to profound uncertainty (Mark and Snowden, 2006; Snowden, 2005), showing a retrospective if not prospective need for shared understanding. As a sense-making framework, it is an approach that seeks to foster a learning culture of understanding and action. Snowden, like so many practitioners, uses metaphor to describe what is going on, but unlike many, he explicitly does this simultaneously at a number of levels: in the name and meaning of his framework, then in the second layer where the metaphors provided by the Complex and Chaotic domains reference theory resting within complex adaptive systems. Snowden then uses processes and techniques that are co-developed through workshops with practitioners and clients (as a form of action research), and thus the framework is always emerging and changing depending on the context or contextualizing experiences involved (Browning and Boudès, 2005). The framework has emerged from projects originally in such fields as knowledge management, cultural change and community dynamics (Kurtz and Snowden, 2003), and in practice Snowden differs from Weick and Hosking in that his approach to sense-making is concerned with what he terms ‘multiontology sense-making’ to achieve a requisite level of diversity. The idea of multi-ontology sense-making is a critical contribution of the framework and has practical implications but the theorization of leadership so far, as summarized in the HBR article, sells it short. We are therefore concerned with how the Cynefin framework can inform collective multiontolgy sensemaking (in a relational sense), and how it can be used as a discourse-in-practice, to provide the contextualizing for discursive practices (Fairhurst, 2007; Holstein and Gubrium, 2005) to emerge about how decisions are known and understood (Dachler and Hosking, 1995), and how relational leadership helps us to better understand what this means in healthcare settings. These settings are often characterized as exemplifying the ontological dominance noted earlier or where ‘hot dialogues’ (Hoggett, 2009) are prevalent because participants usually have so much at stake in defending a certain ontological world view that decision-making becomes habitual and ritualistic. In this situation relational leadership and skilful relating becomes a question of how to change what is termed ‘an avoided sensemaking process’ and to overcome the muting of other possibilities (Dachler and Hosking, 1995: 6) that a Cynefin-type discourse, for example, might otherwise invite. Relational leadership becomes a special organizing process that can be more or less skilfully constructed (Hosking, 2011a) and the idea of Disorder is just another way of expressing the contested nature of the talk that surrounds deciding, deciding who decides and deciding what to do. The Cynefin framework, in providing a way of framing a new discourse in situations where a paradigm hierarchy generally provides the socio-cultural limits on meaning making (Dachler and Hosking, 1995: 7), allows for a way to talk about movement between ‘contexts’ which are themselves relational and emerging and changing all the time because context is Fulop and Mark 263 interactional, emergent and textual or has a feel to it (Denis et al., 2010). Disorder opens the possibility to consider complexity as being what actors make of it in decision-making performances and skilful relating involves a special kind of organizing to achieve acceptable influence (Hosking, 1988, 2007, 2011a; Hosking and Morley, 1988; Morley and Hosking, 2003) and buy-in to multi-ontology ways of framing problems. For us, the Cynefin framework, and its five domains, presents multiple ways in which to engage actors in talk about decision-making that will be shown in examples from healthcare settings. The very notion of Disorder suggests it is the discursive space where, through skilful relating, the monological, expert dominated leader-led discourse can be challenged rather than imposed (Hall and White, 2005; Hosking, 2011a), which is often the case in healthcare. This is confirmed by West and Poulton’s (1997) research on primary care teams where they observed the barriers to communication caused by hierarchy and professional boundaries; these continue to be a source of concern in healthcare teams from theatres (Edmondson, 2003) to clinical handovers (Iedema et al., 2009) where resistance can take many forms from ‘sly civility’ as identified by Bhabha (1994) to overt opposition, and may only be overcome through new approaches within the educational development of professionals (Bleakley, 2006a). A Cynefin discourse in healthcare When it comes to healthcare settings, each domain represents a particular dominant (big ‘D’) or competing (small ‘d’) discourse about decision-making (Fairhurst, 2007). Once they actually become part of a reflective discourse, where assumptions are suspended, tested and debated (Raelin, 2011), relational engagement becomes like a form of ‘professional artistry’ (Rycroft-Malone et al., 2004: 88) where multi-ontology strategies, methods and tools are deployed in decision-making (Denis et al., 2010). Our own take on the Cynefin framework is based on an already developed narrative account that was framed to encourage conversations between healthcare professionals about decision-making. Its original intent was not linked to concerns about leadership but in trying to find new language and concepts to challenge monological ways of framing problems in healthcare settings. The leadership implications came later through the struggle to make senses of the notion of Disorder and trying to understand why it was so hard for healthcare professionals we have worked with to adopt a multi-ontology sensemaking approach to problems and decision-making. The Simple domain Discourse (i.e. the so called known and ordered) is dominant and is talked about as where cause and effect relationships are generally linear, empirical in nature and not usually open to dispute. The decision-making talk this encourages is focused on recognizing the type of problem as belonging to this domain, sense incoming data, categorize the data and respond in accordance with predetermined practice. Structured and quantitative techniques, such as randomized control trials and statistical models are the methods that dominate the talk (Kurtz and Snowden, 2003; Mark, 2006; Mark and Snowden, 2005; Snowden, 2005). However, when the dominant logic and Discourse of the Simple domain is confused with other domain discourse then problems arise. A good way to illustrate this is with the application of Six Sigma in healthcare as a vehicle for hospital-wide change management that runs the risk of sub-optimal results, when applied to areas with higher levels of ambiguity, than the so-called ordered. The point of the Cynefin framework is to open up new and compelling talk about multi-faceted and diverse problem orientations; for example, Weiner’s (2000) work on re-engineering of hospitals in the US (cited in Miller et al., 2006: 328), as well as a UK example explored by McNulty and Ferlie (2002) demonstrating the 264 Leadership 9(2) risks associated with such large-scale approaches, especially when implemented at high speed. The rigid application of evidence-based medicine and clinical guidelines are also a case in point where, given the diverse behavioral contexts involved, minimum standard specifications might work better than rigid, highly specified procedures and manuals (Bate et al., 2008; Minas, 2005; Rycroft-Malone et al., 2004). The result of such approaches, when those involved in decision-making tasks do not see things coming because of entrained patterns of thinking, can lead to what is technically described by Kurtz and Snowden (2003) as asymmetric collapse from the Simple into the Chaotic domain; responses to errors of interpretation in this domain are posited as almost always driven by emotion alone, because no alternative decision process is effective because no room for discussion then exists. The Complicated domain Discourse (i.e. the so called knowable and ordered) is also dominant and where stable cause and effect relationship can be talked about routinely as existing but may not be fully known, or may be known only by a limited group. Expert opinions are relied on and trusted. This is the discourse domain. Discourse where such things as system thinking and learning organization strategies are extolled and experiments, expert opinion, fact-finding and scenario planning are usually deemed appropriate. The decision model talked about here is said to be one where you need to sense incoming data then respond in accordance with expert advice or analysis. The doctor-patient relationship is such an example in this approach, where decisions depend on the level of confidence in the expert opinion of doctors, and hence a key dependency relationship exists, undermined more recently by patient access to on line information allowing for a challenge to expertise. This is the domain in which entrained patterns are said to be most dangerous because a simple error in assumptions can lead to false conclusions that are difficult to isolate and may not be seen at all (Kurtz and Snowden, 2003; Mark, 2006; Snowden, 2005). In healthcare it is said such errors are often accumulated on a large scale, such as took place in the UK in Bristol, where a high volume of inappropriate childhood deaths occurred before questions were asked of experts involved (Mark, 2006; Mark and Snowden, 2006); similar examples from Van Der Weyden (2005) chronicle events in Australian health jurisdictions as those that occurred in Bristol, and can be found in health systems worldwide. In the Complex domain discourse (so called patterns and interactions and un-ordered) the patterns that prevail can be talked about as not being controlled by a directing-intelligence, they are self-organizing systems because cause and effect relationships between agents, both in the number of agents and the number of relationships, defy categorization or analytic technique. The talk here will be about patterns emerging through the interaction of many agents that can be perceived but not predicted. This can be called ‘retrospective coherence’ and aligns with the notion of ‘post hoc rationality’ used by Weick (1995). A key shared understanding about this space is that structured methods that seize upon retrospectively coherent patterns and attempt to codify them into predictable and repeatable procedures will only confront new patterns that emerge. The decision-making approach needed is said to be that which creates probes to make patterns or potential patterns more visible before taking action, then stabilizing patterns that are most desirable, i.e., find what are described as attractors in the system in order to change behavior (Kurtz and Snowden, 2003; Mark, 2006; Minas, 2005; Snowden, 2005). It is claimed that understanding this space requires the following: multiple perspectives; unstructured and novel experiments; increased levels and variety of communication and interaction across stakeholders; use of open discussion to Fulop and Mark 265 stimulate attractors; encouragement of dissent and diversity; and the management of the starting conditions for change or conversations of change (Ford and Ford 1996; RycroftMalone et al., 2004). Narrative techniques, learning network strategies and sense-making software (Kurtz and Snowden, 2003, 2007) are also posited as being appropriate, most of which are also mentioned in theories using social constructionist approaches (Barge and Fairhurst, 2008) or relational constructionism (Hosking, 2011b). The development of cancer patient stories and patient journey improvement narratives as demonstrated in healthtalkonline.org belong in this domain. Martin and Sturmberg (2005) apply the approach to understanding primary healthcare reform in Australia in relation to general practice (GP), distinguishing between the different decision-making modes of generalists (Complex) versus specialists (Simple, Complicated) and the evolution of self-organizing networks amongst GPs as well as their potential collapse (Chaos). The Chaos domain discourse (patterns and interactions and un-ordered language) is where the talk is about having no specific perceived cause and effect relationships. The system is talked about as being turbulent and the time needed to investigate is not available. The decision model proffered in this domain is therefore, to act quickly and decisively to reduce turbulence, as in an Emergency Department when a major incident is notified outside and the patients begin to arrive, then to sense immediately the reaction recognizing that the trajectory of any future intervention varies according to the changing nature of the space. An authoritarian intervention might be used to make the space knowable or known and this is acceptable where the threat is deemed as symmetric and where parameters of behavior are known and intentions can be determined, such as when a hospital closure occurs. However, when there is an asymmetric threat, for example, such as an infection outbreak (Macias and Ponce-de-Leon, 2005), the dimensions of the threat are unknown or dispersed, and not necessarily perceptually linked, then the heuristics of relevant professional groups come into play rather than just the organizational ones. Movement out of this space is said to be either towards the Simple or Complex domains. Furthermore this interpretation may become the dominant discourse by continually precipitating major changes and reorganizations for political reasons (Hunter, 2008), giving rise to what Agamben (2005) describes as a state of exception within which democratic process can be permanently suspended. Disorder, the fifth and final domain, can be talked about as sitting between the domains (in some entitative or thing like way) but is described as being critical to understanding conflict among decision makers, looking at the same situation from different points of view, with individuals competing to interpret the central space on the basis of their preference for action. Understanding Disorder is critical to the explanatory power of the framework, drawing as it does on both the destructive and productive aspects of conflict. Re-thinking the domain of Disorder in terms of its leadership implications will demonstrate, as Houchin and MacLean (2005: 16) suggest, that ‘the rules for determining the interactions in social systems are socially constructed and are not fixed by laws of nature’, as later confirmed by Barge and Fairhurst, (2008). We go further because in relational terms, it also involves cognitive, social, political and emotional processes, as we have argued, and this is where the relational notion of leadership and decision-making belongs. Disorder is a domain in name only because what is important is to understand that ‘leaders enter into mutual construction processes (i.e. negotiation of a particular social order) because they have been assigned and/or earned the responsibility to encourage certain kinds of conversations’ (Morley and Hosking 2003: 70) as Bleakley’s (2006b) research into close calls in operating 266 Leadership 9(2) theatres demonstrates. In Morley and Hosking’s terms, they are those who most contribute to the co-onstruction of ‘cultures of productivity’ (Morley and Hosking, 2003: 43). Relational leadership and disorder The ability to entertain multi-ontology sensemaking becomes one of the real challenges of leadership in healthcare where many clinically oriented encounters are monological (authoritative) rather than dialogical or facilitative, and where conditions for sensemaking are routinely denied. The real problem with the framework is that, though it is open to a constructivist interpretation (Bradbury, Bergmann and Lichtenstein, 2000: 552–554) because ‘[It] is particularly useful in collective sense-making in that it is designed to allow shared understandings to emerge through the multiple discourses of the decision-making group’ (Kurtz and Snowden, 2003: 468) and hence, guide actions, most of the time the idea of multiple discourse and narratives is reserved for the Complex domain and least of all, Disorder (Grint, 2005b; Grint and Holt, 2011; Peck and Dickinson, 2009). Yet the framework provides a way of starting to bring in reflective discourses and different ways of talking about problems, and the pitfalls that come from blindly subscribing to one at all costs, as is often the case in evidencebased environments such as healthcare where the call for hard, scientific evidence is part of a disciplinary and professional culture (Middlehurst et al., 2009; Rycroft-Malone, 2004; White, 2002) that has to be contended with. The concept of professional artistry mentioned above is an attempt to address this single ontology bias in healthcare by referring to critical appreciation (negatives highlighted and positives appreciated); synchronicity (how things can be meaningfully related and not always causally); balance (in what evidence is used); and interplay (reciprocal action and interaction), as core to changing how clinical decisions are made (Rycroft-Malone et al., 2004). The framework also brings into the question the claim that everything in healthcare can be described as complex and that complexity theory should be elevated to the same ontology of control that positivism has had to date (Hoggett, 2009). In terms of healthcare, the central domain of Disorder (uncertainty about everything) is a convenient way to describe where much of the disagreement and conflict exists around decision-making tasks (see e.g. Ham, 2003; Mintzberg, 1997; Smith and Eades, 2003). Decision-making tasks are, however, construed by us as what goes on when actors are engaging in ‘decision readiness’ (Brown, 1990: 632) where reviewing solutions, tactics and making and remaking decisions that might connect to a problems and future actions are the name of the game. As Mark (2006) notes, those most comfortable with the notions of stable order (Simple domain Discourse), will subscribe to a discourse that enforce rules through control which can result only in an emotional rejection, and there are recognized patterns to this. Those who draw their knowledge from the discourse associated with notions of the knowable (Complicated domain Discourse), will look to experts and will seek to conduct research to find the ‘right’ evidence-based answer, especially common amongst clinical professionals and managers (Rycroft-Malone et al., 2004). But more importantly, relational leadership starts from the premise that complexity depends on what actors make of their contexts as they engage in decision readiness and it cannot be seen as a pre-given rationality that pervades all contexts because in this approach context has to allow for local realities to emerge (Hosking, 2011a; Hosking and Fineman, 1990). Fulop and Mark 267 Skilful relating and decision-making As mentioned above, Hosking and colleagues have eschewed the link between relational leadership and decision-making in more recent writings on leadership as they pursue the dialogic or linguistic turn in relational constructionism (Hosking, 2011a, 2011b). However, the core relational processes - the cognitive, social, political and emotional/affective – remain central to arguments about leadership as a special kind of organizing process (Hosking and Fineman, 1990). Each is a key factor in skilful relating and none is less or more important than the other. It is a package of skills, knowledge and understanding that depends on relational awareness as the orientation to leadership practice through decision-making. The cognitive process was initially framed around the notion of ‘intelligent social action’, which describes how participants construct a social order that helps them add meaning and value to their lives. It was argued that it is through ‘projects’, such as a decision-making task, that a particular social order emerges because it is through their social interactions and actions that participants establish relationships with their contexts (Hosking and Fineman, 1990). Projects are performed in ways that add value to the lives of actors but are ‘intelligent’ only to the extent that they promote their values and interests. While for Hosking and Fineman ‘[P]rojects are decision-making tasks ‘set’, so to speak, both by the person and their context’ (1990: 588), for us they are about decision readiness and the to-ing and fro-ing that leads to the identification of an issue or a problem. All decision-making processes occur in value referenced contexts where core values are always in play and places limits on the possibilities of organizing and social ordering (Brown, 1990; Denis et al., 2010). Making valuations and valuing are critical to intelligent social actions and identity formation, and plays a large part in influencing the terms under which actors are willing to ‘do business’ and go along with decisions (Hosking, 1988: 154). Disorder gives salience to decision readiness and intelligent social actions. The concept of intelligent social actions draws on two forms of expertise (Hosking and Fineman, 1990) that are in fact noted in the Cynefin framework under the concept of entrained patterns of thinking. The first is of a general kind that enables actors to recognize the kind of problem or issue they are dealing with and is often associated with expertise, an example of which is the use of triage to classify patients on admission to emergency departments in hospitals (Fitzgerald et al., 2010). This form of knowledge is transferrable and knowable to the extent that even if the content of the issue changes, if the ‘type’ is understood, then intelligent social action is possible. Hosking and Fineman state, ‘actors act intelligently when they show an understanding of the relationship between their values and interests and their context’ (1990: 590, their emphasis). The other form of expertise is ‘issue specific knowledge’ that relates to things that are familiar and have been experienced in the past and thus serve as guides to how best to handle a situation or issue. Creating or shaping a particular context (over others) often hinges on actors trying to mobilize issue-specific knowledge (Hosking and Fineman, 1990) that in healthcare may remain within medical specialty silos as Gilmore (2010) suggests they do, undermining multi-ontology sensemaking. Subsequently, Morley and Hosking further elaborated on intelligent social action suggesting that research on leadership failed to fully appreciate ‘the cognitive processes whereby people make sense of issues, amplify their interpretations, and mobilize them in the ongoing construction of ‘intelligent social action’’ (2003: 73). They argued that cognitive processes function to extend evidence and fill gaps in evidence, to make it acceptable to particular reference groups, and that ‘different kinds of conversations or narratives work to instantiate 268 Leadership 9(2) different kinds of cognitive tuning’ (2003: 74). Furthermore, they suggested that different kinds of thinking are guided by different conversations and norms (values). By combining these two insights, they are able to explain why people engage in limited conversations and become overly confident that they understand the world. In healthcare this confidence is often seen as a prerequisite for clinical intervention to take place. For Morley and Hosking, intelligent social action consists of rules of good thinking so that bias and ambiguities become a fundamental part of conversations and it is through skilful relating that these conversations take place; in other words, for us that means multi-ontology sensemaking is accepted as a part of dealing with dilemmas and decision-making tasks. As they say, relational processes feature multiple reality construction and influence and as stated before, skilful relating promotes the clever use of systematic methods, perhaps we suggest as is afforded by the Cynefin framework, to promote open-minded thinking and cultures of productivity (Morley and Hosking, 2003). In terms of the social process, Hosking (1988: 160) originally asserted that ‘organizing processes are processes in which order is negotiated, within and between groups’. Subsequently, Hosking and Morley (1991) defined these same processes as ‘those in which participants (in organizing) construct a sense of who they are (identity) in relation to a context which importantly consists of other people and their constructions’ (cited in Hosking, 2011a: 457). However, it was also proposed that the most fundamental dilemma endemic to complex decision-making is the achievement of a ‘flexible social order’ so that core problems, such as some threat to the status quo (e.g. change it, uphold it, allow things to decline) can be solved, yet does not create a rigid and inflexible way of relating to others (Hosking and Fineman, 1990). Where values and interests are particularly strong and entrenched, the dangers are the greatest in allowing a rigid social order to prevail. Having a knowledge base to draw on (such as that which underscores intelligent social action) is seen as essential to organizing and dealing with expertise but preserving a vital and viable knowledge base to address core problems is a leadership challenge in itself, and that without a flexible social order, serious forms of atrophy and identity crises can emerge (Hosking, 1988; Hosking and Morley, 1988; Hosking and Fineman, 1990). In terms of professional sensemaking, this could means that instead of relying on trusted frameworks and interpretations, new frameworks can be tested that will encourage mistrusting the trusted frameworks through allowing knowledge and ignorance to co-exist (Fairhurst, 2007). Later Hosking stressed that leadership is essentially about creating the scripts and schemas that have acceptable influence (Hosking, 2011a) and maintains a flexible social order in which, for us multi-ontology sensemaking and decision-making are shaping the context. Skilful relating mean providing the discursive space for exploring different ways of seeing and interpreting issues and situations and thus creating possibilities for change (Cunliffe, 2008). It is hard to maintain a flexible social order and to do so at the very least requires encouraging such things as dialogue, which is a special kind of conversation, that in the case of the Cynefin framework, would invite the suspension of assumptions and certainties and letting go of monological constructions (Hall and White 2005; Hosking, 2011a). Leadership plays an important part in revising interpretations and having shared meanings and collective knowledge that avoids the problems of extreme confidence and extreme caution (Maitlis and Sonsenhein, 2010). Maitlis and Sonsenhein suggest that both constant updating of information and actively doubting by revising and testing assumptions, prevent arriving prematurely at an answer and is critical to how issues and problems need to be Fulop and Mark 269 tackled if we take the notion of Disorder seriously. Disorder describes sensemaking as provisional and fragile (Maitlis and Sonsenhein, 2010: 565–566). Hosking’s third aspect is the political processes that she originally framed around the idea of networking as a collaborative skill needed to promote or protect interests especially with those upon who the social order most depends (Hosking, 1988: 158). The need to move around the decision-making environment was initially a key part of skilful relating and was the basis of building knowledge and understanding that comes from what she terms ‘ordinary seeing’. By this she means that ‘participants are less likely to distort, deny or remain unaware of contradictions’, but also reduce the likelihood of inflexible and categorical judgments (Hosking 1988:159) that are necessary for multi-ontology sensemaking and for allowing new scripts and schemas to emerge (Hosking and Fineman, 1990: 591). Hosking and Fineman (1990) say that to influence change and new ways of framing problems requires an ‘interactional bargain’ that allows participants to act in relation to one another. Hosking and Morley (1991, cited in Hosking, 2011a; 457) state that relational processes ‘are ‘political’ to the extent that they support particular local-cultural constructions or valuations – and not others-constructions that are more or less open to otherness.’ For Maitlis and Sonsenhein (2010) this equates with what they term the ‘politics of sensemaking’ in which narratives reveal how dominant interpretations come to stick and which ones evaporate. Drawing on Weick, they say a key challenge in sensemaking is the presence of too many, not too few, interpretations but they do not realize that this ‘too many’ might be single ontology in nature. They say it is always the political process that shapes the way this sticking pans out, contrasting markedly with the constrained domains of sense-making found in the Cynefin framework. Morley and Hosking (2003) reach a similar conclusion and what emerges are a set of rules that define the terms of doing business. Thus, we would argue that skilful relating is premised on knowing when and how to broaden or narrow interpretations. It also means that when new conversations are being considered, and this is something we hear a lot about in healthcare, the narrative skills of participants is critical in being able to engage in a multi-ontology conversation as Mol (2003) demonstrates through her exploration of the multiple and simultaneous narratives of the treatment of atherosclerosis. This echoes the view that leadership is about the management of meaning by providing ‘intelligible formulations’ from what might be a ‘chaotic welter of impressions’ (Fairhurst, 2007: 57) that is part and parcel of multi-ontology sensemaking and Disorder. The last aspect of relational leadership is the emotional process. One of the most important findings from Hosking and Fineman, also found elsewhere (e.g. Denis et al., 2010) and applied more recently to doctors (Larson and Yao, 2005) as part of the emotional labour process, is that doctors in particular learn to protect themselves from negative emotions associated with dealing with patients, by practicing ‘through a tighter rational framework – the medical model’ (Hosking and Fineman, 1990: 601), often as a part of their identity construction (Rowe, 2005). Mintzberg (1997) noted how this approach spilt over to many areas of decision-making and the dominance of a particular ontological view. The key message from Hosking and Fineman was that doctors in particular had power and discretion to emotionally re-code their work organization, but not always perhaps in the interests of patients and co-workers (Obholzer, 2005). Maitlis and Sonsenhein (2010) note the prevalence of negative emotions in work places, particularly in healthcare, and their impact on how crisis and change are interpreted and hence, their effect on sensemaking. Panic and fear, for example, is the most common form and can lead to a narrowing of attention to new cues and engaging in systematic and less expansive forms of sensemaking, thus falling into 270 Leadership 9(2) dominant action repertories. In healthcare, the medical model is a strong anti-dote to these emotions but by the same token, a probable source of positive emotions of pride and even arrogance, that Maitlis and Sonsenhein (2010) also associate with exaggerated consensus and a belief that others see a situation the same way. The narratives that are central to identity construction of this kind are referred to by Hoggett (2009) as ‘mobilizing fictions’. In such contextual spaces multi-ontology sensemaking is difficult to nurture and skilful relating can be equated with what Hosking terms being ‘relationally responsive’ or having a special kind of conversation. She says one way of doing this is to practice collective dialoguing which means developing rules of engagement such as: ‘not interrupting, not allowing anyone to persuade others, using respectful language, asking questions only for clarification and listening to your listening’ (Hosking, 2011a: 462). Developments within healthcare to facilitate this kind of approach can be found in work on reducing professional and disciplinary boundaries for example in operating theatre teams (Edmondson, 2003) and clinical handover (Iedema et al., 2009). Discussion and conclusion Presenting the Cynefin framework through the lenses of relational leadership and skilful relating in decision-making, depicts processes that need to be understood. This is important if a multi-ontology sensemaking is to be negotiated though interactional bargains, beginning with the narratives and conversations upon which relational leadership is premised. Skilful relating occurs when decision-making is dealt with in terms of the four relational processes as applied by our paper and theorized through the realm of Disorder. All four relational processes are in play as part of decision readiness and this brings sensemaking and leadership into all facets of decision-making (Peck and Dickinson, 2009), and not only in the realm of the complex, as originally presented by Boone and Snowden. Figure 2 represents how we conceptualize this approach drawing on a Cynefin-type framework. A key aspect of the figure is the prominence given to the processes of leadership that shape contexts and frustrate or facilitate the emergence of flexible social orders in which multiontology sensemaking can become a possibility. It recognizes that domains are artifacts of the talk and ultimately conversations that, if conducted in a single ontology way, can never optimize decision-making and thus becomes a failure of leadership. Skilful relating is not a given, and the Cynefin framework does not necessarily make sense on its own for those who make decisions every day. It takes skilful relating to invoke special kinds of conversations or dialogue about each of the four ontologies, and to understand Disorder as a space that is critical to embrace in order to prevent fore-closing options and possibilities that otherwise would never be considered. Those interested in relational leadership are able to use the new framework to appreciate that it is much harder than the Cynefin framework suggests to change how people see the world and that any such change has to start with an array of storytelling, narratives, conversation, discourse and dialogue that are relationally tuned. Furthermore, we suggest that our framework is not neat or tidy and that each time there is a challenge to the status-quo, which can be a simple act of posting something on the web, the framework will change in terms of the contextualized reality that is emerging, and in terms of which of the four processes is most problematic and needs paying attention to. In this sense it adds to the view of leadership as dynamic and emergent (Denis et al., 2010). There are three key ways in which this new relational leadership framework can have significant leadership potential in healthcare: First, the domain of Disorder, in which we Fulop and Mark 271 Figure 2. Relational leadership as decision-making. suggest any type of problem identification has to take place, allows us to broaden our understanding about the political and emotional dimensions of decision-making. We can then better appreciate the resistance to ideas that are framed in multi-ontology ways in settings that are dominated by single ontology sensemaking and paradigms such as is prevalent in healthcare. Second, those who have engaged with the contextualized Cynefin framework, especially through the various exercises that accompany the approach, have generally been able to identify entrained patterns of thinking about problems and their own and others approaches to them. It provides a useful handle or tool for engaging with leadership and decisionmaking in a way that frames it as socially (Denis et al., 2010) and relationally constructed. This helps to reveal the way intelligent social actions are legitimated, as well as those that become, especially in the public-eye, unintelligent social actions. Intelligent social action can come into play when the context is perceived to be such that existing rules and procedures are not working; the intelligent social action is to ignore the existing context and work to create a new one in which values will be more relevant and meaningful (Hosking, 1988). The challenge to build productive cultures through relational leadership is pressing if decisionmaking is to be more than just ritualistic and provide a way out of the ‘stuckedness’ that characterizes single ontology approaches. Contexts that signal cultures of productivity (Morley and Hosking, 2003: 79) are ones in which things appear legible (i.e. where ‘equivocality is reduced in a recognizable and agreeable way’: are coherent so that participants experience an integrated structure throughout the process of decision-making; and is open-ended so that relationships are flexible so that they can accommodate change. Those 272 Leadership 9(2) who influence these three processes are usually the ones called effective leaders by virtue of their contribution to flexible social ordering. Lastly, it is a powerful way of developing a new shared language for members of decisionmaking groups to confront their own preferences for action and hence biases, be they intellectual or intuitive; and to use it as an artifact for negotiating and creating common meanings to create a flexible social order in healthcare settings to ensure that problems can be solved, yet not create a rigid and inflexible way of doing things. While the development of understanding around complexity in healthcare (Plsek and Wilson, 2001) and leadership is ongoing, the problems of defensive response to it (Peterson and Flanders, 2002) that we have highlighted, shows the need for an understanding of different perspectives and the leadership challenges these pose. Where these new perspectives are seen as contentious the power of the Cynefin framework is that it provides an explanatory framework with which to start to work with the idea of multi-onotology sensemaking, through rethinking the domain of Disorder. Snowden’s work originally focused on identifying patterns within whole communities rather than just organizations, but contemplating decision-making within the context of Chaos, for example, will be of increasing importance to those affected by, for example, the global economic downturn, and its impact on health provision. But such contemplation will be useless unless relational leadership is understood in terms of the four processes that cannot be ignored. In the Cynefin framework, the domain of Disorder grows or shrinks depending on how politicized processes are and the extent to which the cognitive, social and emotional process are understood and entrained patterns of speaking and talking about problems are able to be turned into reflective discourses. The new ideas presented in this paper provide a way for those tasked with leadership to interpret and negotiate an understanding of what is happening and how to appreciate that in relational terms, leadership is made in context and relational processes are much more than any individual leader could ever hope to tackle. It also offers the sobering insight that being designated a leader does not make one a leader, but only to the extent that one (and this can be single or many) is significantly implicated in developing a productive culture and achieves acceptable influence that is deemed by others as meriting being called leadership. The immediacy it offers to those tasked with time limited decisions is both important to their role and purpose, because it does not negate the stabilizing effect of, for example, expert knowledge creation of outcomes. That is so long as there is a culture of productivity and multi-onotolgy sensemaking as the norm, ensuring that decision-making is guided by and encourages skilful relating. Widening the understanding of the domain of Disorder, as the primary discursive space where decisions are made about how social order works, as well as the politics of decisionmaking, adds a critical element to the multi-ontology approach, and its link to leadership as a contextual and contextualizing process. It also allows us to incorporate the Cynefin framework with that of Hosking’s work, referencing other aspects of leadership. We chose to focus on the relational leadership approach to highlight that leadership is, as Hosking says, very much about individuals, groups or teams producing the schemas, scripts and stories that affect a social ordering and we argue that, it matters very much from where they start this process and the conversations that are had. There will always be disaffected, resistant, compliant or indifferent actants. Hence, what we term relational leadership practice, means recognizing that intelligent social action is the perennial challenge for multi-ontology sensemaking that is always dependent upon the extent to which a flexible social order can emerge. Fulop and Mark 273 From our own experiences with the Cynefin framework, we have been able to develop a shared language for looking at problems in different ways and have a better understanding of the failures in healthcare interventions and some more ideas about what to do about them. The relational approach advocated here is also being used in research, for example, to identify how skilful relating (or the absence of it) shapes decision-making in cancer networks and seriously limits the possibilities for innovative interventions of care (Harden and Locke, 2011; Harden, 2012). Relational leadership in healthcare is critical to instantiating multiontology sensemaking using a Cynefin-type framing as an example, recognizing that other similar frameworks exist or can be developed. References Agamben G (2005) State of Exception. Chicago: University of Chicago Press. Barge JK and Fairhurst GT (2008) Living leadership: a systemic constructionist approach. Leadership 4(3): 227–251. Bate P, Mendel P and Robert G (2008) Organizing for Quality: The Improvement Journeys of Leading Hospitals in Europe and the United States. Oxford: The Nuffield Trust. Bauman Z and Haugaard M (2008) Liquid modernity and power: A dialogue with Zygmunt Bauman. Journal of Power 1(2): 111–130. Bhabha HK (1994) The Location of Culture. London: Routledge. Bleakley A (2006a) Broadening conceptions of learning in medical education: The message from teamworking. Medical Education 40(2): 150–157. Bleakley A (2006b) You are who I say you are: The rhetorical construction of identity in the operating theatre. Journal of Workplace Learning 18(7/8): 414–425. Bradbury H and Lichtenstein B (2000) Relationality in organizational research: Exploring the space between. Organization Science 11(9): 551–564. Brown HM (1990) Women’s centres: Relationships between values and action. Journal of Management Studies 27(6): 619–635. Browning L and Boudès T (2005) The use of narrative to understand and respond to complexity: A comparative analysis of the Cynefin and Weickian models. E:CO 7(3-4): 32–39. Buchanan DA and Bryman A (2007) Contextualizing methods choice in organizational research. Organizational Research Methods 10(3): 483–501. Burgoyne J and Turnbull JK (2006) Towards best or better practice in corporate leadership development: Operational issues in mode 2 and design science research. British Journal of Management 17(4): 303–316. Conroy M (2010) An Ethical Approach To Leading Change: An Alternative and Sustainable Application. Houndsmill, Basingstoke, Hampshire: Palgrave/MacMillan. Cunliffe AL (2008) Orientation to social constructionism: Relational responsive social constructionism and its implications for knowledge and learning. Management Learning 39(2): 123–139. Cunliffe AL and Eriksen M (2011) Relational leadership. Human Relations 64(11): 1425–1449. Dachler HP and Hosking DM (1995) The primacy of relations in socially constructing organizational realities. In: Hosking DM, Dachler HP and Gergen KJ (eds) Management and Organization: Relational Alternatives to Individualism. Aldershot: Avenbury, pp.1–29. Denis J-L, Langley A and Rouleau L (2010) The practice of leadership in the messy world of organizations. Leadership 6(1): 67–88. Dervin B (1998) Sense making theory and practice: An overview of user interests in knowledge seeking and use. Journal of Knowledge Management 2(2): 36–46. Edmondson AC (2003) Speaking up in the operating room: How team leaders promote learning in interdisciplinary action teams. Journal of Management Studies 40(6): 1419–1452. 274 Leadership 9(2) Fairhurst GT (2007) Discursive Leadership: In Conversation with Leadership Pyschology. London: Sage. Fitzgerald G, Jelinek GA, Scott D and Gerdtz MF (2010) Emergency department triage revisited. Emergency Medicine Journal 27(7): 86–92. Ford JD and Ford LW (1995) The role of conversations in producing change in organizations. Academy of Management Review 20(3): 541–570. Frost N, Nolas SM, Brooks-Gordon B, Esin C, Holt A, Mehdizadeh L and Shinebourne P (2010) Pluralism in qualitative research: The impact of different researchers and qualitative approaches on the analysis of qualitative data. Qualitative Research 10(4): 441–460. Fulop L (2012) Leadership, clinician managers and a thing called ‘‘hybritiy’’. Journal of Health Organization and Management 26(5): 578–604. Fulop L and Day G (2010) From leader to leadership: Clinician managers and where to next? Australian Health Review 34(3): 344–351. Gilmore T (2010) Challenges for physicians in formal leadership roles: Silos in the mind. Organisational and Social Dynamics: An International Journal of Psychoanalytic, Systemic and Group Relations Perspectives 10(2): 279–296. Grint K (2000) The Arts of Leadership. Oxford: Oxford University Press. Grint K (2005a) Leadership: Limits and Possibilities. Houndsmill, Basingstoke Hampshire: Palgrave/ Macmillan. Grint K (2005b) Problems, problems, problems: The social construction of ‘leadership’. Human Relations 58(11): 1467–1494. Grint K and Holt C (2011) Leading questions: If ‘Total Place’, ‘Big Society’ and local leadership are the answers: What’s the question? Leadership 7(2): 85–98. Hall C and White S (2005) Looking inside professional practice; Discourse, narrative and ethnographic approaches to social work and counselling. Qualitative Social Work 4(4): 379–390. Ham C (2003) Improving the performance of health services: The role of clinical leadership. Lancet 361(9373): 1978–1980. Harden H and Locke S (2011) Methods for investigating decision making in healthcare network meetings. The Medical Journal of Australia 194(4): s42–s45. Harden H (2012) Skilful relating: a critical skill for healthcare leaders. In: Presentation at the ACHSM 2012 International Annual Congress, Inspiring Concepts in Health Management- Surfing the Crest of the Waves. August, Gold Coast, Australia. Hoggett P (2009) Politics, Identity, and Emotion. Boulder: Paradigm Publishers. Holstein JA and Gubrium JF (2005) Interpretive practice in social action. In: Denzin NK and Lincoln YS (eds) The Sage Handbook of Qualitative Research, 3rd ed. Thousand Oaks: Sage Publications, pp.483–505. Hosking D (1988) Organizing, leadership and skilful process. Journal of Management Studies 25(2): 147–166. Hosking DM and Morley IE (1988) The skills of leading. In: Hunt JG, Baliga BR, Dachler HP and Schriesheim CA (eds) Emerging Vistas of Leadership. Massachusetts: Lexington Books, pp.89–106. Hosking D and Fineman S (1990) Organizing processes. Journal of Management Studies 27(6): 583–604. Hosking DM and Morley EI (1991) A Social Psychology of Organising. London: Harvester Wheatsheaf. Hosking DM (2007) Not leaders, not followers. In: Shamir B, Pillai R, Bligh MC and Uhl-Bien M (eds) Follwer-Centred Perspectives on Leadership: A Tribute to the Memory of James R. Meindl. Greenwich: Information Age Publishing, pp.243–264. Hosking DM (2011a) Moving relationality: meditations on a relational approach to leadership. In: Bryman A, Collinson D, Grint K, Jackson B and Uhl-Bien M (eds) Sage Handbook of Leadership. London: Sage Publications, pp.455–482. Fulop and Mark 275 Hosking DM (2011b) Telling tales of relations; appreciating relational constructionism. Organization Studies 32(1): 47–65. Houchin K and MacLean D (2005) Complexity theory and strategic change: An empirically informed Critique. British Journal of Management 16(2): 149–166. Hunter DJ (2008) Speaking truth to power; on the discomforts of researching the contemporary policy process. In: McKee L, Ferlie E and Hyde P (eds) Organizing and Reorganizing – Power and Change in Healthcare Organizations. Houndsmill Basingstoke Hampshire: Palgrave/Mcmillan, pp.87–98. Iedema R, Merrick ET, Rajbhandari D, Gardo A, Sterling A and Herkes R (2009) Viewing the takenfor-granted from under a different aspect: A video-based method in pursuit of patient safety. International Journal of Multiple Research Approaches 3(3): 290–301. Izatt-White M (2011) Methodological crises and contextual solutions: An ethnomethodologically informed approach to understanding leadership. Leadership 7(2): 119–135. Kings Fund. (2011) The Future of leadership in the NHS – No More Heroes. Report from The Kings Fund Commission on Leadership and Management in the NHS. London: Kings Fund. Klenke K (2008) Qualitative Research in the Study of Leadership. Bingley: Emerald Group Publishing Ltd. Kurtz CF and Snowden DJ (2003) The new dynamics of strategy: Sense-making in a complex and complicated world. IBM Systems Journal 42(3): 462–483. Kurtz CF and Snowden DJ (2007) Bramble bushes in a thicket: Narrative and the intangible of learning networks. In: Gibbert M and Durand M (eds) Strategic Networks: Learning to Compete. Massachusetts: Blackwell Publishing, pp.121–150. Larson EB and Yao X (2005) Clinical empathy as emotional labor in the patient-physician relationship. Journal of the American Medical Association 293(9): 1100–1106. Lukes S (2004) Power A Radical View, 2nd ed. Houndsmill Basingstoke Hampshire: Palgrave/ Macmillan. Macias AC and Ponce-de-Leon S (2005) Infection control: Old problems and new challenges. Archives of Medical Research 36: 637–645. Maitlis S and Sonsenhein S (2010) Sensemaking in crisis and change: Inspiration and insights from Weick. Journal of Management Studies 47(3): 551–680. Marion R and Uhl Bien M (2011) Implications of complexity science for the study of leadership. In: Allen P, Maguire S and McKelvey B (eds) The Sage Handbook of Complexity and Management. London: Sage, pp.385–398. Mark AL (2006) Notes from a small island: Researching organizational behaviour in healthcare from a UK perspective. Journal of Organisational Behaviour 27(7): 1–17. Mark AL and Snowden D (2006) Researching practice or practicing research: Innovating methods in healthcare - the contribution of Cynefin. In: Casebeer AL, Harrison A and Mark AL (eds) Innovations in Health Care: A Reality Check. Houndsmill, Basingstoke, Hampshire: Palgrave/ Macmillan, pp.30–41. Martin CM and Sturmberg JP (2005) General practice: Chaos, complexity and innovation. Medical Journal of Australia 183(2): 106–109. McKee L, Ferlie E and Hyde P (2008) Organizing and Reorganizing: Power and Change in Healthcare Organizations. Houndsmill, Basingstoke, Hampshire: Palgrave/Macmillan. McKimm J (2011) Leading for collaboration and partnership working. In: Swanwick T and McKimm J (eds) ABC of Clinical Leadership. Chichester: Wiley Blackwell, pp.44–49. McNulty T and Ferlie E (2002) Re engineering Healthcare: The Complexities of Organisational Transformation. Oxford: Oxford University Press. Middlehurst R, Goreham H and Woodfield S (2009) Why research leadership in higher education? Exploring the contributions from the UK’s Leadership Foundation for Higher Education. Leadership 5(3): 311–329. Miller G, Dingwall D and Murphy E (2006) Using qualitative data and analysis. In: Silverman D (ed.) Qualitative Research, Theory, Method and Practice, 2nd ed. London: Sage, pp.325–341. 276 Leadership 9(2) Minas H (2005) Leadership for change in complex systems. Australian Psychiatry 1(3): 33–39. Mintzberg H (1997) Towards healthier hospitals. Health Care Management Review 22(4): 9–18. Mol A (2003) The Body Multiple: Ontology in Medical Practice (Science and Cultural Theory). Durham: Duke University Press. Morley I and Hosking DM (2003) Leadership, learning and negotiation in a social psychology of organizing. In: Bennett N and Anderson L (eds) Rethinking Educational Leadership: Challenging the Conventions. London: Sage Publications, pp.43–60. Norredam M and Album D (2007) Review article: Prestige and its significance for medical specialties and diseases. Scandinavian Journal of Public Health 35(6): 655–656. Obholzer A (2005) The impact of setting and agency. Journal of Health Organization and Management 19(4/5): 297–303. Peck E and Dickinson H (2009) Performing Leadership. Houndsmill, Basingstoke, Hampshire: Palgrave/Macmillan. Peterson JB and Flanders JL (2002) Complexity management theory: Motivation for ideological rigidity and social conflict. Cortex 38(3): 429–458. Plsek PE and Wilson T (2001) Complexity, leadership, and management in healthcare organizations. British Medical Journal 323(7315): 746–749. Pye A (2005) Leadership and organizing: Sensemaking in action. Leadership 1(1): 31–50. Raelin J (2011) From leadership-as-practice to leaderful practice. Leadership 7(2): 195–211. Reissman CK and Quinney L (2005) Narrative in social work: A critical review. Qualitative Social Work 4(4): 391–412. Rousseau DM and Fried Y (2001) Location, location, location: Contextualising organisational research. Journal of Organisational Behaviour 22(1): 1–13. Rowe D (2005) The meaning of emotion. Journal of Health Organization and Management 19 (4/5): 290–296. Richard Scott W (2008) Lords of the dance: Professionals as institutional agents. Organization Studies 29(2): 219–238. Rycroft-Malone J, Seers K, Titchen A, Harvey G, Kitson A and McCormack B (2004) What counts as evidence in evidence-based practice? Journal of Advanced Nursing 47(1): 81–90. Smith D and Eades E (2003) The competent medical manager: Issues in the management of healthcare professionals. Clinician in Management 12(1): 11–20. Snowden D (2002) Complex acts of knowing: Paradox and descriptive self awareness. Journal of Knowledge Management 6(2): 100–110. Snowden DJ (2005) Multi-ontology sense making: A new simplicity in decision making. Informatics in Primary Care 13(1): 45–54. Snowden DJ and Boone ME (2007) A leader’s framework for decision making. Harvard Business Review 85(11): 68–76. Spurgeon P, Clark J and Ham C (2011) Medical Leadership: From the Dark Side to Centre Stage. London: Radcliffe Publishing. Teamwork Management Services (2010) Literature Review: Leadership Frameworks. Warwick: NHS Institute for Innovation and Improvement. The King’s Fund (2011) The Future of Leadership and Management in the NHS: Report from the King’s Fund Commission on Leadership and Management in the NHS. London: The Kings Fund. Uhl-Bien M (2006) Relational leadership theory: Exploring the social processes of leadership and organizing. The Leadership Quarterly 17(6): 654–676. Uhl-Bien M and Marion R (2011) Complexity leadership theory. In: Bryman A, Collinson D, Grint K, Jackson B and Uhl-Bien M (eds) Sage Handbook of Leadership. London: Sage, pp.468–482. Van der Weyden MB (2005) The Bundaberg Hospital scandal: The need for reform in Queensland and beyond. Medical Journal of Australia 183(6): 284–285. Weick KE (1995) Sensemaking in Organizations. London: Sage. Weick KE (2001) Making Sense of the Organization. Oxford: Blackwell. Fulop and Mark 277 Weiner C (2000) The Elusive Quest: Accountability in Hospitals. Hawthorne: Aldine de Gruyter. West MA and Poulton PC (1997) A failure of function: teamwork in primary health care. Journal of Interprofessional Care 11(2): 205–216. White S (2002) Accomplishing the case in paediatrics and child health: Medicine and morality in interprofessional talk. Sociology of Health and Illness 24(4): 409–435. Author biographies Liz Fulop is a Professor of Health Management at Griffith University and Adjunct Professor of Health at University of New England in Australia. She is also Co-Lead of the Health Management Research Alliance (HMRA), which has been formed to promoted cross-institutional research into healthcare, and is sponsored by the Society for Health Administration Society of Health Administration Programs in Education (SHAPE). She is also co-lead of the Special Interest Group (SIG) in Health Management and Organization formed by the Australian and New Zealand Academy of Management (ANZAM) promoting health management and organization. Liz was Foundation Dean of Research in the Griffith Business School and has been involved in health research and education since 1990 having helped develop the first national program for clinician managers in Australia. Annabelle Mark is Professor of Healthcare Organization at Middlesex University, Visiting Professor at Griffith University in Australia. She is founding Director of the award winning NHS Human Resource Management Training Scheme – HR specialism 2004–2012 to develop leaders for the UK NHS. A Fellow of both the Institute of Healthcare Management, and the Royal Society of Medicine, she is a Trustee for, and was the first elected Chair of, the Society for Studies in Organizing Healthcare (SHOC). This Learned Society is affiliated to the UK Academy of Social Sciences, and it was as Chair of SHOC that she co-launched the Health Management and Organization SIG at ANZAM. She was the founding academic of the associated international biennial conference Organizational Behavior in Healthcare (OBHC) and acts as Series Editor for the conference books published by Palgrave. Being a leader takes skills, decision-making qualities, and having a good rapport with people. Effective leadership means one cannot be indecisive, demeaning, uncertain, and fearful. According to Fulop and Mark (2013), great leadership means being able to effectively communicate and that the newer forms of leadership are blunt in their approach. The article speaks of the usage of Cynefin framework which allows leaders to ability of learning how to make rational decisions. With Cynefin framework “it is possible to enhance its multi-ontological explanatory power by re-theorizing the domain of disorder within Cynefin through the lens of relational leadership. It helps them and those they work with, to sense which context they are in, so that they cannot only make better decisions, but also avoid the problems that arise when their preferred management style causes them to make mistakes in interpretation, decisions and action” (Fulop and Mark, 2013, p. 260). This study used a framework to build up a concept and convey how best leaders should be able to bluntly explore their power. The article did not truly articulate the best ideas for effective leaders who are effective decision makers. It is my opinion that this article provided elements of a framework that could build on problem solving for leaders but it has its own usefulness. The one thing that I did take from this article is that every leader must find their own decision-making tactics and develop a flexible manner in which he or she works with others. I can personally take into account that I cannot be biased and I must find my own way even whether it is through blunt type leadership or through a more comforting leadership style. The Cynefin framework does allow leaders to view things in a different perspective and much newer viewing platforms. It is supposed to lessen the chances of problems arising and it could help decrease the mistakes I as a manager can make. Reference Fulop, L. (2013). Relational leadership, decision-making and the messiness of context in healthcare. Leadership, 9(2), 254-277.
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