The aim was to explore the tactical officers’ (TOs) main concerns when leading licensed medical personnel (LMP) in combat zones and how they resolved them.
A classic grounded theory was chosen in order to develop a theory, which explained and conceptualized the TOs behaviors. Ten individual interviews and five informal conversations were conducted with TOs with various ranks, experienced in leading LMPs on military operations in Afghanistan, Mali and/or Aden (outside the coast of Somalia).
The theory unifying loyalty explains how TOs handle the challenges when leading LMP. To create loyalty TOs use four strategies: executing orders, clearing out roles, marking limits and clarifying rules and laws. These strategies can be used by two leadership styles, hierarchical and democratic.
In order to fulfill the military duties it is essential to unify LMP in the unit, which is a challenge since LMP experience dual loyalty. The main goal for TOs is to ensure and maintain stability and do the military duties when being in combat zones and that requires using both leadership styles, depending on what the conditions in combat zones requires.
- leadership styles
- military medical personnel
- tactical officers
Sweden participates with military forces in United Nations-mandate operations in combat zones. The contexts of combat zone are blurred, sudden and characterised by high mobility, and the environment is often dangerous due to various threats (Dalenius 2000; Butler et al. 2007; Blaz et al. 2013; Andersson 2014). The threats could be hostile forces and fire, homemade bombs, i.e. improvised explosive devices, diseases and difficult climate, which in all make the context extreme (Swedish Armed Forces 2009, 2015; Andersson et al. 2017). In this context of combat zones, Swedish licensed medical personnel (LMP) are part of the military forces, and they are under the command of tactical officers (TOs) of different ranks, from non-commissioned officers to officers. The core duties of TOs in combat zones are to maintain stability, ensure security and protect their forces (Enemark 2008), and together with the troops the TOs are obliged to successfully execute the required combat operations.
Being leaders on a tactical level means that TOs have a responsibility for emergency care in the combat zone, and this responsibility encompasses ensuring secure caring areas where LMP can undertake their healthcare duties (Andersson et al. 2015). In addition to their leading roles, TOs are also instructors in first aid, accident first aid and cardiopulmonary resuscitation (CPR). The role as leader is complex (Larsson et al. 2015) and leadership in combat zones is sometimes put at stake, since military leadership involves from leading during secure conditions which soon may contrast into perilous situations of violence (Holenweger et al. 2017). It also means that TOs’ military duties sometimes can collide with the duties LMP have as healthcare personnel (Allhoff 2008). Healthcare personnel in the military navigate between contrasting goals such as working with preserving life and at the same time supporting soldiers who have a role where they are trained for taking lives (Enemark 2008).
The Swedish LMP are educated in medical science and trained in civilian universities. Their ordinary work is in civilian hospitals or in pre-hospital care. When recruited by the armed forces for employment in combat zones, LMP's experiences of military operations are often limited. However, before deployment, LMP receive a compulsory basic military training (Lundberg et al. 2009). When being employed, LMP become a part of a military unit. LMP are uniformed (Hague Regulations 1907) and the Swedish LMP are armed (Andersson 2014; Lundberg et al. 2014). The importance of undertaking military education and preparation before rotating to combat zones are always highlighted, since there are no opportunities to complete training in the actual context elsewhere (Andersson et al. 2017). A problem is that the provided preparation is not always enough and well adapted to the reality in combat zones (Kingdom 2012; Andersson 2014).
The duties for LMP in combat zones vary, such as crew at a health centre at the camp or in a forward surgical team (Andersson 2014; Andersson et al. 2015), but they also undertake duties that are not pure healthcare (Lundberg et al. 2014). In combat zones, LMP experience ethical problems and dual loyalty (Lundberg et al. 2014, 2017). Dual loyalty can be understood as having simultaneous obligations which come into conflict with each other, such as medical and military duties (Allhoff 2008; Physicians for Human Rights 2015). For LMP this could be concretised in situations wherein, for example, they are rendering healthcare services among the people in the host nation and simultaneously gathering intelligence. Accepted article: Gathering intelligence or providing care on military operations: an ethical problem for Swedish licensed medical personnel (LMP) in combat zones. Military Ethics (2018).
Accepted article: Gathering intelligence or providing care on military operations: an ethical problem for Swedish licensed medical personnel (LMP) in combat zones. Military Ethics (2018).
To sum up, situations of TOs leading LMP in combat zones can involve complexities due to dual loyalty of military and medical duties, lack of preparations for LMP and collision of TOs’ and LMP's duties. However, there is paucity of research into how the TOs are handling this complex situation in combat zones.
The aim is to explore the TOs’ main concern when leading LMP in combat zones and how they resolved it.
Required inclusion criteria included the TOs needing to have experiences of leading LMP on military operations in a combat zone. Formal individual interviews with 10 TOs (seven male and three female), of various ranks from non-commissioned officers to officers (two sergeants, one captain, two majors, one lieutenant-colonel, two colonels and two lieutenant-commanders), ages from 38 to 60, were carried out by the first author (KL). The interviews lasted 45–90 min, and were conducted at the TOs’ offices and at cafes.
These interviews were followed up by five informal conversations with additional TOs (three males and two females; two majors and three lieutenant-colonels; ages 45–61), with the purpose of saturating the emerging concepts.
In order to encourage participants to talk about their experiences of leading LMP in combat zones, the questions were open-ended. Follow-up questions were asked, and the interview situations were conversational. Data collection and analysis occurred simultaneously, and the theoretical sampling functioned as a guide to decide which data to be subsequently sought, i.e. each interview was analysed before conducting the next interview. The analysis guided the questions needed to be asked in the following interview, in order to saturate the emerging concepts. During the interviews field notes were written. Memos, which are essential in GT, were written after each interview and during the analysis.
In the first open coding phase, the field notes were analysed thoroughly, and incidents were identified, compared and then coded. During the process of analysis, the data were constantly compared, and the following questions were asked: ‘What is the main concern?’ and ‘How do TOs solve the main concern?’. The open codes were compared, and new concepts were compared, in order to abstract the concepts. Memos about concepts were written. The TOs’ main concerns and core concepts emerged during this phase. The focus was on finding a core concept that related to as many concepts as possible and explained how the main concern was solved. Informal conversations were done during the selective coding, with the purpose of saturating the emerging concepts (Glaser 1978). In this phase, the coding was delimited into concepts, which had relationships with the core concept. Saturation in data was reached when the latest informal conversations did not contribute to the emerging theory. In the theoretical coding phase, more memos were written, explaining the relationships between the concepts and the core concept. The memos were sorted and the theory of
An informed consent process was provided ensuring voluntariness, withdrawal any time without being questioned and confidentiality (World Medical Association Declaration of Helsinki 2013). Since the process involved humans, according to Swedish privacy law and code of ethics (Ministry of Education and Research 2003; Ministry of Justice 1998), the Regional Ethics Review Board in Gothenburg approved the study (D Nr 816-14).
Leading LMP is challenging, and this aspect emerged as the main concern for TOs. LMP have sets of values that contrast with those of TOs, such as not being prepared to kill even though they are employed in the armed forces where that can be a necessary action. LMP sometimes question the orders, wanting to discuss reasons to why an order should be obeyed and arguing about issues concerning the orders. There are often shortages of LMP, they sometimes have requirements of almost no training before rotation to combat zones and the lack of training makes TOs frustrated. The military training is essential and therefore demanding less training is a challenging experience for TOs. Due to these differences in sets of values, constant questioning and lack of training, TOs find it challenging to incorporate LMP into the unit.
The theory of
Unifying loyalty is done through either a hierarchical or a democratic leadership style. The hierarchical leadership style is built on one-way communication and demanding subordination, e.g. doing as you are told. The democratic leadership is built on consensus through participation and communication, e.g. openness for reasons concerned with duties. Each TO can use either of these leadership styles depending on the actual conditions and situations.
The theory of unifying loyalty includes four different strategies: executing orders, clarifying the rules and laws, clearing out roles and marking limits. Regardless of which leadership archetype is used, the strategy of clarifying the rules and laws must be done in order for TOs to use the strategies of clearing out roles and marking limits.
Executing orders refers to TOs, in a formal way, ordering what to do, when to do it and who is going to undertake each duty. These orders are often executed when the whole unit is lined-up and on parade.
Executing orders with no or scarce information is done when there is some secrecy about the order, when the reason for the order is unknown by TOs or when there is not enough time to explain why a particular order should be executed.
When using a hierarchical leadership archetype, TOs are showing ‘who is the boss’ and pointing the direction by leading with a firm hand and dictating orders. No time is given for discussions or questioning the decisions and LMP are not invited to co-determination and dialogues. The reason for not enabling dialogue is that this would create a precedent for every subsequent order. The urgency which combat zones engender will require any attempt at discussion of orders from LMP to be overridden by the TOs.
When using a democratic leadership style, TOs have a large amount of information and need to motivate the what, when and why aspects associated with LMP's following an order or undertaking required duties. When motivated to obey orders, LMP sometimes questioned why they should follow an order given by someone who does not even have a civil education. However, the TOs questioned the other way around, i.e. why listen to someone, like LMP, who has no military education.
Clarifying rules and laws is necessary since any organisation must follow specific rules and laws. LMP are expecting to do everything by the book and obey the regulations; otherwise, the consequences are severe. Therefore, the TOs need to make the LMP obey the rules and the laws in different ways.
When using a hierarchical leadership style, TOs are forcing obedience. If laws and rules are not followed, TOs are threatening LMP with consequences, which for LMP could lead to being sent home with a dishonourable discharge.
When using a democratic leadership style, TOs are explaining the rules and the laws and making them understandable for LMP. Through explaining what might happen in different scenarios, the TOs are trying to explain the importance of following the rules and the laws.
Clearing out roles means that the roles and positions in the organisation are cleared out, including what kind of duties LMP are expected to undertake, i.e. what, when and how to do, and which responsibilities LMP have.
When using a hierarchical leadership style, the TOs are telling the LMP in a determined way which duties they are undertaking, how they want them to undertake these duties and what else they are expecting from them during the operation.
When using a democratic leadership style, clearing out the roles is done in a softer way where possibilities are created for LMP, in order to accommodate their view of their role in combat zones. The TOs are open-minded, creating an atmosphere conducive for exchange of ideas, listening to how LMP view their role and making LMP feeling comfortable by remaining receptive for discussions. The goal of the TOs is to create a spirit of unity.
In an organisation, which deploys multiple professions, such as the military, it is essential to mark limits for responsibility, whether they be wide and unclear or narrow and clear. During emergencies, attacks on the unit, for example, limits can be crucial. This includes limits between areas, such as not allowing to pass certain frontiers, borders or restricted areas.
When using a hierarchical leadership style, the TOs are marking the limits by resolving with a firm hand the question of which duties the LMP are required or not required to undertake. When LMP transgress a limit, TOs will respond robustly since a misstep could put the whole unit in danger. Marking limits can even include not allowing LMP leave the camp until rotation.
When using a democratic leadership style, the TOs are explaining what happens if the limits are not properly understood. The TOs and the LMP are then debating why limits are important and averring that surpassing these limits could put the whole unit at risk.
Conditions that can impact the unifying and/or the leadership style are: shortage of LMP, LMP's training, TOs experience and knowledge, the kinds of duties and age.
During the preparation before rotation, the TOs are using a democratic leadership style in order to unify the LMP in the unit. Sometimes there is a shortage of LMP and they are recruited almost through persuasion, or coaxed into the military. LMP can have demands, such as rotating to combat zones on ‘own rotation’, meaning that they have limited amount of training before rotation. When being employed in the military, LMP expect that the fuss continues but then they are brought down to earth. When TOs become aware of LMP's lack of sufficient training, and consequently encounter difficulties in uniting LMP into the unit, they resort to using the hierarchical leadership style.
When LMP are lacking previous military experiences and have not undertaken training before their first rotation to combat zones, it is harder to unify them in the unit. For the military the training is essential in order to function in the environment of combat zones. Since the LMP are needed in combat zones the TOs know they must unify the LMP in the unit, ideally before rotation. LMP's participation in military training before rotation to combat zones is a pre-requisite for them to be fully unified into the unit.
Having previous experiences of leading LMP make TOs comfortable and facilitate them to unify LMP into the unit. When lacking experiences of leading LMP, it is difficult, and they feel unsecure and therefore the hierarchical leadership style is used as a protection of these feelings.
TOs sometimes have special knowledge in healthcare arising from their training in basic healthcare (mostly from a military setting), and then they are telling LMP when, where and how to undertake healthcare, which can lead to their being questioned by LMP. However, sometimes TOs have a background as registered nurses, which makes it easier for them to receive mandate in leading LMP. To obtain mandate, a democratic leadership style is often used. TOs have to show they are aware that LMP professionally undertake care in a better way than TOs. TOs also have to explicitly make an impression of understanding the importance of healthcare professionals.
Urgent duties may arise quite suddenly in combat zones, without warning. Reasons for these could be shootings and killings around the corner, and the units have to be prepared for transfers and advances very quickly. Therefore, it is necessary that everyone act quickly and efficiently. In these situations, TOs almost always use hierarchical leadership style.
The age of both LMP and TOs is crucial. Age sometimes coincides with rank; it is easier for a higher ranked officer to obtain mandate from LMP than for a low-ranking or non-commissioned officer. The TOs who work closest to the LMP may often have lower ranks. For TOs, it is hard to unify LMP into the unit if they are young, have low rank and are newly recruited as TOs, and consequently not having much experience of leadership. For LMP, when being young or new in the profession they are more questioning, and they do not take orders that easily. On average the LMP are older than the soldiers and therefore already formed, which makes it more challenging for the TOs to lead the LMP.
The theory of
In a Swedish civilian setting, the LMP are acclimatised either to a democratic- or discussion-oriented leadership style, the latter of these sometimes being referred to as transformational leadership (Halkias et al. 2017). The transformational leadership deals with issues that matter to the emotions and attitudes of the leaders when leading a unit, and it is in line with a democratic leadership archetype (Bass and Riggio 2006). A transformational leadership style can be both appropriate and a pre-requisite for leading LMP since the goal is to unify LMP and foster a ‘spirit within the unit’. When TOs are using a democratic leadership style they are negotiating, explaining, clearing out and receiving mandate, which is of importance for unifying the unit. In order to create ‘a spirit in unity’ a democratic leadership style is preferable, i.e. a leadership built on trust which strengthens LMP's self-esteem (Larsson et al. 2015). It is a pre-requisite for unifying LMP into the unit.
However, an important precondition for creating ‘a spirit in unity’ is that LMP are trained before rotating to combat zones. TOs are frustrated due to LMP's lack of training before rotation to combat zones, which causes the use of the hierarchical leadership style, which in turn makes LMP confused, since LMP are not always familiar with military leadership. It is, therefore, important that LMP are trained, unified and prepared for combat zones, before rotation (Andersson 2014).
A hierarchical leadership style has sometimes been expected within the military context (Cowper 2000; Wong 2006). Usage of a hierarchical leadership can be understandable, since in combat zones the leadership must maintain the security of the unit in life-or-death situations. The hierarchical leadership style is referred to as an action-oriented, or transactional leadership, in earlier leadership research, which is an approach where decisions are made quickly and eventual mistakes and problems are corrected along the way (Halkias et al. 2017). The hierarchical leadership style is used on several occasions by TOs where they are leading with firm hands, such as executing orders while fighting enemies in combat zones.
The combat zone contexts require from the LMP, together with the units, the achievements of extraordinary goals such as contributing to peace enforcement (Andersson 2014). Altogether this puts pressure on TOs since they have to relate to two different kinds of leadership styles, and could be experienced as dissonant by LMP. The democratic and hierarchical leadership styles are contradictory to each other, which is experienced by the LMP, but in light of the military's core duties that the TOs are having a responsibility for, in pursuing combat effectiveness while maintaining security of the unit, both ends of tension spectrum must be sustained (Kark et al. 2016). This is not simply a binary choice, an either/or decision whether to deploy democratic or hierarchical style of engagement; rather, both might be necessitated as dictated by the requirements of each particular situation.
TOs’ primary duties in combat zones are to maintain security and to prosecute combat objectives. These duties require discipline and rigidity as well as flexibility and the ability to be open-minded; so, the question of which leadership style needs to be used rather depends on the operational or organisational situation (Kark et al. 2016). Being an extreme context, which is characterised by threats and puts stress on people, the context of combat zones forms the leadership and sometimes there is no time for discussions or motivating decisions (Kark et al. 2016; Uhr 2017). These are the reasons why TOs need to use different leadership strategies in different situations.
When unifying the LMP into the unit, the TOs need to create loyalty. Loyalty is a value commonly regarded as a military virtue, and it is especially related to the role of the officer (Nilsson et al. 2010). Loyalty is expressed as showing loyalty towards the military unit when becoming a unified team (Coleman 2009; Robinson 2008). But loyalty is also referring sometimes to LMP's experience of a fundamental dual loyalty between healthcare norms and military norms (Lundberg et al. 2017). Dual loyalty occurs when LMP contribute with undertaking duties that are not pure healthcare (Lundberg et al. 2014) and is seen in earlier research within a military context (Physicians for Human Rights 2002; London et al. 2006; Olsthoorn et al. 2013). Therefore, when LMP are experiencing dual loyalty, unifying loyalty becomes particularly difficult for TOs when leading LMP. But TOs’ strategies concerning unifying loyalty may also make LMP feel pressurised to compromise with their healthcare norms. If the TOs are focused on unifying the LMP fully into the unit and the LMP experience dual loyalty, then there is a conflict between TOs and LMP as to how they view loyalty and how they can unify the LMP into the team.
A classic GT study should be judged by its fit, modifiability, relevance and workability (Glaser 1998). The theory of unifying loyalty fits into the concepts that are derivable from the data. The theory's conceptual groundings in the data indicated relevance. The concepts both addressed and were relevant to the main concern, and they solved the main concern. The theory works since it explained the behaviour of TOs, and why it is challenging for TOs to lead LMP. However, the theory can always be modified if new data emerge. Given the limited amount of research in this area, a classic GT was considered as a suitable method (Grbich 2013).
The characteristic extreme conditions of combat zones put pressure on TOs. The pressure is increased when LMP experience dual loyalty. Unifying LMP into the unit and creating ‘a spirit within the unity’ facilitating functioning as a coherent whole is essential, and a pre-requisite for unification is that LMP have undertaken training. Therefore, TOs are most effective if LMP have undergone training, which prepares TOs to inspire loyalty in these extreme situations. When unifying loyalty, TOs’ leadership style can deploy either democratic or hierarchical leadership style, depending on what the conditions of the particular combat zone dictate.
There is a lack of previous research concerning leading the Swedish LMP in extreme environments, such as combat zones. Since Sweden participates in military operations abroad and the role of military leadership is of importance in these extreme environments, and given the fact that the TOs are challenged when leading the LMP, it would be of importance to evaluate the Swedish TOs’ leadership and the styles they are using, and more research in this regard is required.