Beyond Western Leadership: The Potential of Ubuntu and Confucian Leadership in NHS Echocardiography Services

Abstract

Transthoracic echocardiography services are overwhelmed by long waiting lists, limited career progression, high attrition rates, and a shortage of future trainees. Unfortunately, leaders focus on throughput and performance targets while neglecting human factors, which drives healthcare scientists into the independent sector to perform similar roles for considerably higher salaries. Leadership theory in general, and NHS leadership efforts, are Western-centric. This perspective paper aims to broaden the leader-follower paradigm to include non-Western leadership styles – Ubuntu and Confucianism - to redirect leadership values towards changes necessary to improve service provision. Ubuntu is an ancient Indigenous African concept that emphasises “humanness” and interconnectedness, while Confucianism is an ancient Chinese philosophy that emphasises benevolence and social harmony through hierarchical structures. Such principles could fuel transparent, involving and creative decision-making processes that will likely engage staff and cultivate commitment and shared responsibility. Moreover, by establishing a clear career structure from band three to nine and dedicating resources to training, departments would combat the low “career ceiling”, create career development opportunities and improve trainee success and quality. This paper advocates for a decolonised, pluralistic leadership model that combines Western principles with Ubuntu and Confucian philosophies in the leadership of echocardiography services within the NHS. Such leadership could enhance staff morale and well-being, promote upskilling, improve training regimes and help reduce high attrition rates. These improvements are vital to prevent workforce shortages, address waiting list issues, and ensure patient safety.

Introduction

Transthoracic echocardiography (TTE) is the most widely used non-invasive cardiac imaging modality.^1,2 Unfortunately, in cardiac science, there is no career pathway allowing healthcare scientists (HCS) to progress from healthcare science associates to healthcare science practitioners, clinical scientists, and finally, to consultant clinical scientists.^3,4 Across the United Kingdom (UK), healthcare science practitioners and clinical scientists involved in TTE are recognised as “physiologists”. In reality, healthcare science practitioners utilise scientific knowledge to safely perform and report diagnostic tests, where clinical scientists should engage in more complex decision-making as well as education, research, quality improvement, and service development.⁵

The coalescence of these roles leads to a lack of motivation to become a clinical scientist, as those who do see minimal change in roles and responsibilities. Consequently, a low “career ceiling” exists, creating the previously described impenetrable bottleneck from band seven to band eight,³ meaning the height of career achievement can be acquired with a single training programme (eg the echocardiographer training programme).

Shortages of skilled professionals and inadequate training numbers are leading to recruitment problems; additionally, attrition rates are high as experienced HCS continue to leave the National Health Service (NHS).^3,6,7 This creates a staffing crisis with a 10% locum occupancy rate and dramatic patient waiting times.^3,8 Currently, 30% of patients referred for TTE wait longer than the NHS pledge of six weeks,^9,10 significantly higher than the operational standard of 1% and the pre-pandemic level of 4%.¹¹ Such waiting times delay diagnosis and therapy, compromising patient safety.¹²

Leaders aim to maximise throughput to meet key performance indicators, elevating clinical output to the most valuable asset a HCS can possess, thereby fostering a culture where HCS are neither encouraged nor valued for engaging in work beyond performing TTE. This can be manifested by exclusively allocating HCS to TTE clinics, adding extra appointments to the start or end of clinics, and/or reducing appointment times. Additional work, such as training, service improvement and quality assurance, is performed outside of paid hours, if at all.⁶ This exemplifies the extensification and intensification of labour in a workplace offering little/no opportunity for progression and therefore “no way out”. There is no doubt that throughput must be a priority, however, the primary issue is the current neglect of human factors causing distress (eg “We are broken”⁶), demoralisation, and frustration, which result in staff seeking comparable roles in the independent sector for considerably higher salaries, further deepening the staffing crisis. The status quo cannot continue, otherwise, demand will keep rising until capacity is completely overwhelmed and struggling departments become reliant on the independent sector to guarantee staffing levels, creating a financially unsustainable situation before complete “privatisation” of the TTE sector.

Leadership is recognised as the most influential factor in organisational culture,¹³ and therefore, leadership is where change must begin. The NHS’s “Healthcare Leadership Model” and “Our Leadership Way” are evidence-based, eclectic leadership frameworks that enable leaders to adapt their style to various situations.^14,15 Nevertheless, leadership literature is generally Western-centric, and these frameworks are no exception, primarily drawing from transformational, compassionate, and transactional leadership styles.^16–19 Although these styles are valuable, they emphasise efficiency, extrinsic rewards, and performance over collective well-being and relational factors.²⁰ It is possible that HCS are too exhausted to respond to the transformational leader’s motivational calls, or the transactional leader in an environment where extra effort goes unrecognised, or a compassionate leader able to mitigate but not eliminate the high mental and physical toll exerted on the workforce through pressurised, intense and repetitive work.

This perspective article seeks to culturally broaden the leader-follower paradigm by examining how two ancient non-Western leadership frameworks – Ubuntu and Confucianism – could address the serious issues identified within the unique and desperate context of echocardiography services in the NHS.

What is Meant by Non-Western Leadership Styles?

Non-Western leadership styles have existed as long as Western styles, but current scholarship does not reflect this. To seek an alternative perspective, Ubuntu and Confucianism were chosen as complementary, well-theorised leadership styles that significantly contrast with Western philosophies. Other prominent, non-Western styles like Islamic and Indigenous leadership were considered less suitable due to religious focus or limited evidence.

Ubuntu

Ubuntu is an ancient Indigenous African concept that encompasses many variations in definition, primarily because it reflects a broader worldview and belief system rather than a fixed set of characteristics.^21–23 The most common themes of Ubuntu include “humanness”, interconnectedness, valuing others, community contribution, forgiveness, and compassion (Table 1).^21,24–26 Ubuntu draws attention to horizontal relationships through the key phrase “I am because we are”, highlighting the focus on community and the contrast with Western styles that are typically geared towards individuality and competition.²⁷

Table 1.

Key Philosophies of Ubuntu and Confucian Leadership

Ubuntu25	Confucianism28,29
Believe in collective responsibility	Benevolence
Exercise collective decision making	Structured hierarchy to generate social harmony
Serve the community	Morality and righteousness
Compassion and respect	Being an example
Value people	Trustworthiness
Display loyalty	Wisdom
Conflict management through reconciliation	Learning by reading, listening, and seeing; being cautious and prudent
Demonstrate enthusiasm and optimism	Follow the Doctrine of the Mean
Support interconnectedness	Being perseverant, ambitious, and optimistic
Encourage employee development	Self-examination and correcting mistakes
Be transparent and open

Confucianism

Confucianism is an ancient Chinese philosophy that is over 2500 years old.³⁰ It is founded on the belief that practising key virtues can create social harmony and foster positive employee attitudes and behaviours (Table 1).^30–32 In Confucianism, vertical relationships are emphasised, stating that social hierarchy and dyadic relationships are unavoidable; however, authoritarian regimes of power are rejected, instead prioritising benevolence, ethics, moral education, self-examination, relationships, accountability, humility, and social harmony.^28,33–35

Ubuntu Leadership in Echocardiography

Ubuntu leadership emphasises relationships and collectivism over material aspects such as ownership of opportunities.³⁶ Nzimakwe³⁶ argues that such a focus can enhance team performance and improve organisational effectiveness through solidarity. Additionally, Ubuntu promotes group work, shared accountability and cooperation over individual competitiveness, favouring solidarity instead of solitary activities.³⁷ Critical components of Ubuntu and potential benefits revolve around creating a sense of belonging and shared responsibility for challenges, furthermore, the key principle is that of consensus decision making.^38,39 For example, in the complex, high-stakes issue of long waiting lists and exhausted workforce there are competing interests that must be considered. Ubuntu would require all members of the “community” to express their opinions and concerns before decisions are made. That does not mean every opinion must be followed, as this level of hierarchical flattening would have little practical utility.⁴⁰ However, all members could openly share motivations, concerns, and rebuttals, potentially fostering a highly creative decision-making process where staff feel involved and are therefore more likely to engage.⁴¹ Thus, through collective communication and decision-making, the perspective can shift from “I can” (or even “you can”) to “we can”, encouraging strong collegiality and unity within the workforce while promoting high diagnostic standards through shared accountability and responsibility.⁴²

Such transparency in a team would cultivate trust, a vital component of any team trying to tackle objectives that cannot be achieved alone.⁴³ Without trust, no meaningful advances can be made for the echocardiography services as the UK echocardiographer workforce is diverse, comprising over 20 different medical and scientific backgrounds.³ Emphasising the shared values, as opposed to what separates us, may improve inter-disciplinary and inter-organisational relationships, increase recognition, and perhaps produce the psychological safety needed to highlight concerns.^21,44

Unfortunately, difficult working conditions, such as those described in TTE departments, can breed workplace conflict,⁴⁵ which can harm staff relations, recruitment and retention, staff engagement, and patient safety.¹³ Ubuntu encourages recognising one’s connection to others, aiming to foster a sense of responsibility for any wrongs committed.⁴⁶ Ubuntu perceives punishment and retribution as means of destruction, emphasising the rehabilitation and reintegration into the community.²⁶ If applied effectively, this approach could cultivate healthy relationships and assist in conflict resolution through reconciliation.

By creating a collective culture that recognises the equal and shared “humanness” in all members of the community (leaders and followers) one can see how all demeaning behaviours of leadership become incompatible as to dehumanise others is a direct dehumanisation of oneself.²⁵ Nussbaum⁴⁷ further expands on this, suggesting that Ubuntu philosophies could free Western organisations from a culture of soulless professionalism and emotional denial. Finally, a leader who embodies the key principles of Ubuntu has the potential to foster a positive work environment where staff feel supported and recognised, directly addressing recruitment and retention challenges, while aligning with the NHS’s “Our People Promise”.⁴⁸

Confucian Leadership in Echocardiography

Confucian principles assert that leaders are not inherently exceptional but extensions of followers, the key difference being that the leader persistently acts on virtuous qualities.⁴⁹ This humility could yield numerous benefits for leaders within echocardiography. For example, being open to regularly discussing and learning from followers may help leaders stay informed about team morale and the possible solutions to complex problems. Equally, leaders are encouraged to self-examine in the face of failure, courageously reflect on their own limitations, and practice self-criticism.²⁸ Emphasising this may help eliminate the “blame culture” and foster genuine root cause analysis and improvement following failure.

HCS in cardiac science are encouraged to discover new, innovative methods to provide care and enhance patient outcomes.⁸ In Confucianism, it is both a moral and organisational obligation of leaders to assist followers in developing their personal character through continuous learning. Consequently, a leader would offer education and training to all employees, thus creating opportunities for service innovation, growth, and development.²⁸

Currently, mentorship, training, and education are being neglected in favour of a demand-driven approach. Many echocardiography departments hold key training and educational meetings during lunch rather than within paid hours, meaning staff are not mandated to attend. This also creates a mentality that training is an additional task rather than a key role. However, without investing in training and education, workforce shortages will persist, worsen, or resurface.³ Confucianism regards the training of others as a central obligation of leaders rather than an “add-on” requirement. This significant shift from the Westernised economistic paradigm could lead to long-overdue recognition of substantive training roles to support sustained and meaningful investment in the future TTE workforce.^3,7

This recognition of advanced roles resonates with the critical principle of social harmony achieved through structured hierarchy and respectful dyadic relationships.²⁹ Confucian leadership would endorse the recognition of advanced roles (eg transoesophageal and stress echocardiography operator, research, quality improvement and assurance roles etc) to create a community where individuals specialise in their area and collaborate to improve the service. Similar to an orchestra, where each person plays a unique instrument to produce a single, harmonious symphony. A potential professional structure has already been proposed by Leary and Punshon and would support a Confucian leader’s task of actively recognising their followers’ strengths and working to enhance their talents and abilities.²⁹

By dedicating resources to training and promoting a clear and complete career structure, staff retention could be improved by alleviating the “low ceiling”, allowing staff to progress instead of stagnate. This would enhance trainee success rates, retention, and quality, thereby likely reducing the risk of future workforce shortages.

Considerations

Since the 2000’s there has been an increase in literature appreciating leadership as a collective process.⁵⁰ Although national leaders in the NHS are trying to shift leadership from heroic to collective, the reality is that pressures entice leaders to focus on personal performance without collective consideration.⁵⁰ Nevertheless, there is consensus that shared leadership can be more sustainable and creative than individual leadership⁴¹ but central leaders are still required to impact on practice.⁴⁰ Compared to individualistic leadership styles collective leadership ensures dialogue and encourages and enables all staff to lead meaning they are more likely to take responsibility in delivering efficient and safe care. Furthermore, responsibility and accountability are shared at both individual and collective levels meaning they encourage regular reflection focussed on failure and exploratory learning resulting in continuous improvement in organisational habit.⁴¹

However, despite the proposed benefits of Ubuntu and Confucianism, we must appreciate the pitfalls in order to sustainably implement such philosophies in Western organisations. For example, some argue that Ubuntu and Confucianism are fundamentally no different from servant and transformational leadership, respectively.²¹ This would be incorrect as Ubuntu focuses on serving the community as a whole, while servant leadership serves individual followers.⁵¹ Transformational and Confucian leadership both aim to transform followers, with the former emphasising motivating individuals towards a shared goal, and the latter seeking to create a harmonious environment through self-cultivation.^29,30

Cartesian paradigms, dominant in the West, might contend that the strong communalism under Ubuntu could foster negative perceptions towards “outsiders” and may compel individuals to abandon their personal needs for the benefit of the collective, thereby festering resentment and dysfunctional behaviours.^21,37,52 Conversely, Confucianism favours the individual over the institution, suggesting that restrictive rules can create mistrust and are often overly complicated, allowing the knowledgeable to manipulate for personal gain.^32,49 However, this does raise the question of potential damage from an unrestrained leader compared to organisational loopholes.³⁵

Unfortunately, much of the supporting literature for Ubuntu and Confucian leadership styles is derived from non-Western research, raising questions about the cultural applicability of such philosophies. Because of the sharp contrast with Western values, where instrumentalism and greed are mainstream cultural tropes, a leader genuinely embodying Ubuntu or Confucian virtues may find themselves neither respected nor financially competitive.⁴⁹

Although, to my knowledge, there is no available literature evidencing the implementation of Ubuntu or Confucian leadership styles in the NHS, there are examples of non-Western philosophies such as “lean” being adopted with great success in the UK.^53–55 This demonstrates that with the correct approach, vastly different cultural changes can take place.

Clearly, there are fundamental differences between Ubuntu, Confucianism, and dominant Western leadership theory. Ubuntu aims to flatten the hierarchy and share responsibility, while Confucianism emphasises structured, interconnected roles and dyadic relationships. Consequently, implementing either style or both in totality cannot work. Equally, uprooting the NHS leadership frameworks entirely cannot be to the benefit of the wider NHS community. Therefore, this paper aims to explore the implementation of a decolonised, pluralistic leadership style that incorporates the shared decision-making and collective “humanness” of Ubuntu, as well as the clear career structure and training-focus of Confucianism, within current leadership approaches (Figure 1).

Figure 1.

Infographic illustrating the current leadership challenges and the spectrum of potential benefits between Ubuntu and Confucian leadership styles.

Implications

Leadership Development Programmes and Policy

Emerging leader programmes (such as those offered by the British Society of Echocardiography and the British Cardiovascular Society) and the NHS’s leadership academy should seek to educate trainees about the Western bias in leadership theory and literature. Case studies can illustrate how non-Western leadership approaches, like Ubuntu and Confucianism, might provide alternative perspectives and solutions to leadership challenges.

Career Structure

With a low “career ceiling” and no signs of a clear career structure developing it is hard for echocardiography to appear attractive to the future workforce. Therefore, echocardiography leaders across the country should aim to create clear, interconnected hierarchical roles from band three to nine (as in other healthcare science disciplines). This approach would remove the “career ceiling” creating a more appealing profession and enable willing and capable individuals to take on more advanced roles.

Training

Leaders must regard training as a fundamental moral responsibility. Associated with the previous implication, one should create dedicated training and educational roles with protected time to focus on delivering the best possible training, contributing to higher success rates, improved workforce quality, and a reduced risk of future workforce crises. Such roles should be carefully audited to ensure value.

Shared Decision-Making

Leaders should spend time truly understanding the complex and difficult reality that TTE services in the NHS face. Attempting to reach consensus agreements by openly involving all members of the echocardiography community will lead to challenging but valuable conversations that should enhance creativity in decision-making and foster a greater sense of belonging and willingness to engage among staff.

Conclusion

Echocardiography services are essential to contemporary cardiology diagnostics and treatment, yet they face significant challenges. Leadership knowledge and practice are typically Western-centric, emphasising efficiency, throughput, and performance targets. While valuable, these approaches can overlook the relational, ethical, and “human” aspects of leading teams through difficult periods. This paper has demonstrated that Ubuntu and Confucian leadership provide valuable complements to existing frameworks. Ubuntu is particularly significant in promoting cohesion and resilience through solidarity, shared decision-making, and collective responsibilities. Confucian leadership addresses training, mentorship, and career structure, emphasising benevolence, and the duty to train. These philosophies underline that it is not only leadership but also “followership” that is crucial in building relationships and enhancing staff and patient experiences. For NHS echocardiography services, adopting the proposed leadership approach could lead to culturally diverse leadership within the NHS. By incorporating Ubuntu’s communal ethos and Confucianism’s dedication to mentorship, echocardiography departments can foster cultures that are inclusive, resilient, and patient-centred.

This paper urges leaders in echocardiography, professional societies, and NHS training organisations to actively explore Ubuntu and Confucian leadership, incorporating key principles into leadership and leadership development related to echocardiography services. In doing so, services can develop in ways previously unconsidered, leading to multiple changes in core philosophies and resulting in a redesign of echocardiography services to enhance service delivery and patient outcomes.

Disclosure

The author reports no conflicts of interest in this work.