General practitioners' views on leadership roles and challenges in primary health care: a qualitative study

Beyond the microscope: the importance of leadership skills in IVF laboratory management

In healthcare, leadership plays a crucial role in determining the quality of care and overall clinical performance. However, the pivotal role of leadership in the effective functioning and success of IVF laboratories is often overlooked. This commentary seeks to address this gap. It is necessary to explore the multifaceted nature of an IVF laboratory director's role, as well as the need for a new approach to IVF laboratory management that strongly emphasizes the cultivation of leadership skills in tandem with technical expertise. By enhancing leadership skills, IVF laboratories can improve their efficiency, team morale and patient outcomes.

Understanding of 'generalist medical practice' in South African medical schools

BACKGROUND

In South Africa, medical students are expected to have acquired a generalist competence in medical practice on completion of their training. However, what the students and their preceptors understand by 'generalist medical practice' has not been established in South African medical schools.

AIM

This study aimed to explore what the students and their preceptors understood by 'generalist medical practice'.

SETTING

Four South African medical schools: Sefako Makgatho Health Sciences University, University of KwaZulu-Natal, Walter Sisulu University and the University of the Witwatersrand.

METHODS

The exploratory descriptive qualitative design was used. Sixteen focus group discussions (FGDs) and 27 one-on-one interviews were conducted among students and their preceptors, respectively. Participants were recruited through purposive sampling. The inductive and deductive data analysis methods were used. The MAXQDA 2020 (Analytics Pro) software was used to arrange data, yielding 2179 data segments.

RESULTS

Ten themes were identified: (1) basic knowledge of medicine, (2) first point of contact with all patients regardless of their presenting problems, (3) broad field of common conditions prevalent in the community, (4) dealing with the undifferentiated patient without a diagnosis, (5) stabilising emergencies before referral, (6) continuity, (7) coordinated and (8) holistic patient care, necessitating nurturance of doctor-patient relationship, (9) health promotion and disease prevention, and (10) operating mainly in primary health care settings.

CONCLUSION

The understanding of 'generalist medical practice' in accordance with internationally accepted principles augurs well in training undergraduate medical students on the subject. However, interdepartmental collaboration on the subject needs further exploration.Contribution: The study's findings can be used as a guide upon which the students' preceptors and their students can reflect during the training in generalist medical practice.

Better with GPs as managers? - Variation in perceptions of feedback messages, goal-clarity and performance across manager´s in Swedish primary care

BACKGROUND

Primary care in several countries is developing towards team-based and multi-professional care, requiring leadership and management capabilities at the primary care practice level. This article reports findings from a study of primary care managers in Sweden, focusing variation in performance and perceptions of feedback messages and goal-clarity, depending on managers' professional background.

METHODS

The study was designed as a cross-sectional analysis of primary care practice managers' perceptions combined with registered data on patient-reported performance. Managers perceptions was collected through a survey to all 1 327 primary care practice managers in Sweden. Data about patient-reported performance was collected from the 2021 National Patient Survey in primary care. We used bivariate (Pearson correlation) and multivariate (ordinary least square regression analysis) statistical methods to describe and analyse the possible association between managers' background, responses to survey statements and patient-reported performance.

RESULTS

Both GP and non-GP managers had positive perceptions of the quality and support of feedback messages from professional committees focusing medical quality indicators, although managers perceived that the feedback facilitated improvement work to a lower degree. Feedback from the regions as payers scored consistently lower in all dimensions, especially among GP-managers. Results from regression analysis indicate that GP-managers correlate with better patient-reported performance when controlling for selected primary care practice and managerial characteristics. A significant positive relationship with patient-reported performance was also found for female managers, a smaller size of the primary care practice and a good staffing situation of GPs.

CONCLUSIONS

Both GP and non-GP managers rated the quality and support of feedback messages from professional committees higher than feedback from regions as payers. Differences in perceptions were especially striking among GP-managers. Patient-reported performance was significantly better in primary care practices managed by GPs and female managers. Variables reflecting structural and organizational, rather than managerial, characteristics contributed with additional explanations behind the variation in patient-reported performance across primary care practices. As we cannot exclude reversed causality, the findings may reflect that GPs are more likely to accept being a manager of a primary care practice with favourable characteristics.

Factors associated with selection of practice in primary care and rural health among medical and nursing students in China

BACKGROUND

China has a shortage of physicians and nurses in primary care and rural health. This study explores factors that influence the choices of medical and nursing students in China to select a career in primary care, or in rural health.

METHODS

A total of 3826 medical students and 1771 nursing students were surveyed in China. Data were analysed using descriptive statistics, Chi-squared tests, and logistic regression models.

RESULTS

The majority of medical and nursing students were willing to practice primary care (55% and 59%, respectively). Yet, only 16% and 5% of medical and nursing students, respectively, desired to work in a village or small city. The most common reasons cited to not practice primary care is the lack of opportunities for clinical skills improvement, academic and personal development, and networking. Medical students who were living in a rural residence between ages 1 and 15years were more likely to report a willingness to work in a rural location (OR: 2.18, 95% CI: 1.33-3.58) or in primary care (OR: 1.72, 95% CI: 1.31-2.25).

CONCLUSION

More efforts are needed to understand how preferences among medical and nursing students influence their career choices and change in choices over time. Understanding the concerns of students can help to tailor interventions in healthcare education and training to increase student satisfaction with their career choice and enrolment counts in medical and nursing fields.

[Potential improvements of psychosocial working conditions in general practices: Development of a discussion guide for medical assistants for staff appraisals]

BACKGROUND

Staff appraisals can provide employees and their supervisors with the opportunity to improve their communication and collaboration. However, one can assume that staff appraisals are not yet common instruments for human resources management in physician practices. The aim of this study was to develop a discussion guide for medical assistants (MAs) in general practices to support MAs in preparing, carrying out and documenting staff appraisals.

METHODS

MAs were recruited through their professional organization [Verband medizinischer Fachberufe e. V.] and social media (06/2020-10/2020). An early draft of the discussion guide was devised comprising an introduction, a checklist for logistic preparation, a documentation sheet and a section to prepare the content of the meeting. The discussion guide was revised based on interviews with MAs who also rated the instrument. Data collection, analyses and the revision of the guide were carried out in an iterative process to the point where no further significant suggestions for improvement were made.

RESULTS

In total, 20 interviews were conducted. Revisions were based on recommendations pertaining to a) how to interact with the supervisor (e. g., raising awareness of and responding to changes of the topic; anticipating counterarguments, scheduling of follow-up meetings), b) the choice of topics, c) additional measures to respond to MAs' needs (e. g., rotation to distribute tasks), and d) the preparation of the staff appraisal (e. g., rehearsals with an experienced colleague). Both the likelihood to use the guide in the future and its usefulness for staff appraisals were considered to be high.

DISCUSSION AND CONCLUSION

We developed a discussion guide for and with MAs in general practices which can be helpful in preparing, conducting and documenting staff appraisals. This serves the purpose of bringing one's psychosocial working conditions to the supervisor's attention and to possibly improve them. To further improve the tool, future research should explore the experiences of MAs and physicians who actually use the discussion guide.

A Feeling of Ambiguity: A Qualitative Content Analysis of Managers' Experiences of Evidence-Based Practice in Swedish Primary Care

Background

The Primary care manager plays a vital role in promoting a research culture in the healthcare center. The position involves both the implementation of organizational directives and patient care. The research culture and use of evidence influence each individual healthcare professional and ultimately the quality of patient care.

Purpose

To describe primary healthcare managers’ understanding of evidence-based practice in the Swedish primary healthcare context and their ability to influence its implementation.

Methodology

Qualitative content analysis of data collected in individual interviews.

Results

In general, managers expressed a positive view toward the use of evidence in daily practice. However, they were sometimes hesitant about fully implementing evidence-based results. This was mostly attributed to the struggle of balancing finances and allocating sufficient time for staff to keep up with and engage in evidence-based practice.

Conclusion

The organizational culture impacts the mind-set of all co-workers including managers. Those managers influenced by traditions and norms may fall into the trap of devaluing the benefit of research and evidence. The inherent feeling of being alone and without guidance in some matters related to evidence-based practice inevitably leads to inconsistency and ambiguity. The use of clinical pathways that constitute one form of evidence has become a substitute for proper, careful, individual investigation, implementation, and evaluation of each patient case. This means that managers experience moral and physical stress when trying to meet organizational, staff, and patient demands.

Practice Implication

Awareness of managers’ influence and experience of working according to evidence-based practice is valuable to gain an insight into how Swedish primary healthcare functions at local level. Illuminating and discussing evidence-based practice is an assurance of quality that contributes to many aspects of the overall safety of care.

Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations?

BACKGROUND

Hospital professionals are "dual agents" who may face dilemmas between their commitment to patients' clinical needs and hospitals' financial sustainability. This study examines whether and how hospital professionals balance or reconcile clinical and economic considerations in their decision-making in two countries with activity-based payment systems.

METHODS

We conducted 46 semi-structured interviews with hospital managers, chief physicians and practicing physicians in five German and five Israeli hospitals in 2018/2019. We used thematic analysis to identify common topics and patterns of meaning.

RESULTS

Hospital professionals report many situations in which activity-based payment incentivizes proper treatment, and clinical and economic considerations are aligned. This is the case when efficiency can be improved, eg, by curbing unnecessary expenditures or specializing in certain procedures. When considerations are misaligned, hospital professionals have developed a range of strategies that may contribute to balancing competing considerations. These include 'reshaping management,' such as better planning of the entire course of treatment and improvement of the coding; and 'reframing decision-making,' which involves working with averages and developing tool-kits for decision-making.

CONCLUSION

Misalignment of economic and clinical considerations does not necessarily have negative implications, if professionals manage to balance and reconcile them. Context is important in determining if considerations can be reconciled or not. Reconciling strategies are fragile and can be easily disrupted depending on context. Creating tool-kits for better decision-making, planning the treatment course in advance, working with averages, and having interdisciplinary teams to think together about ways to improve efficiency can help mitigate dilemmas of hospital professionals.

Optimising care coordination strategies for physical activity referral scheme patients by Australian health professionals

Physical activity (PA) has been identified as an essential tool for the prevention and management of multi-morbidity in patients. Coordination of patients’ care through interventions like physical activity referral schemes (PARS) could foster the utilization of PA. This study explored the views of General Practitioners (GPs) and Exercise Physiologists (EPs) as key stakeholders, for optimizing patient care and efficiency of PARS. Sequential explanatory mixed methods design was used to explore the perceptions of these health professionals on PA and coordination strategies for PARS patient care. Data analyses included descriptive and inferential statistics for questionnaires and theoretical framework analysis for the semi-structured interviews. Participants demonstrated a good knowledge of PA and valued PARS. However, the findings unravelled external factors, inter-organisational mechanisms, and relational coordination obstacles that hinder efficient coordination of PARS patient care and delay/limit beneficial health outcomes for patients. Incentivising the PARS initiative and empowering patients to seek referral into the programme, are strategies that could boost PARS efficiency. Improving inter-professional relationships between GPs and EPs could lead to enhanced PARS functionality and efficient coordination of care for patients with chronic diseases.

Assessing innovative approaches for global health capacity building in fragile settings in the MENA region: development of the evaluation of capacity building (eCAP) program

Background

Given the magnitude and frequency of conflicts in the MENA region along with their devastating impact on health responses and outcomes, there exists a strong need to invest in contextualized, innovative, and accessible capacity building approaches to enhance leadership and skills in global health. The MENA region suffers from limited (1) continued educational and career progression opportunities, (2) gender balance, and (3) skill-mix among its health workforce, which require significant attention.

Main text

The Global Health Institute at the American University of Beirut incepted the Academy division to develop and implement various global health capacity building (GHCB) initiatives to address those challenges in fragile settings across low-and middle-income countries in the MENA region. These initiatives play a strategic role in this context, especially given their focus on being accessible through employing innovative learning modalities. However, there exists a dearth of evidence-based knowledge on best practices and recommendations to optimize the design, implementation, and evaluation of GHCB in fragile settings in the MENA region. The present paper describes the development of the evaluation of capacity building program (eCAP), implemented under the Academy division, to assess the effectiveness of its initiatives. eCAP is composed of 3 phases: (1) a situational assessment, followed by (2) production of multiple case studies, and finally (3) a meta-assessment leading to model development. The goal of eCAP is not only to inform the Academy’s operations, but also to synthesize produced knowledge into the formation of an evidence-based, scalable, and replicable model for GHCB in fragile settings.

Conclusion

eCAP is an important initiative for researchers, educators, and practitioners interested in GHCB in fragile settings. Several lessons can be learned from the outcomes it has yielded so far in its first two phases of implementation, ranging from the situational assessment to the production of evaluation case studies, which are expanded on in the manuscript along with pertinent challenges.

Primary care physician leaders’ perspectives on opportunities and challenges in healthcare leadership: a qualitative study

Background

There is an increasing demand for physicians to assume leadership roles in hospitals, health systems, clinics and community settings, given the documented positive outcomes of physician leadership and the systemic shifts towards value-based care. The purpose of this study is to examine how primary care physicians (PCPs) perceive and experience leadership roles. Better understanding how PCPs perceive leadership affords the opportunity to influence changes in primary care training in order to more adequately prepare and support physicians for current and future leadership roles.

Methods

This study used qualitative interviews, conducted from January to May 2020. The participants included 27 PCPs, recruited via the Harvard Medical School Center for Primary Care newsletters and through snowball sampling techniques. Participants worked in 22 different organisations, including major urban health systems, corporate pharmacy, public health departments and academic medical centres.

Results

Using content analysis and qualitative comparative analysis methodologies, three major themes and seven subthemes emerged from the interviews. The primary themes included the advantage PCPs have in leadership positions, the lack of leadership training and development, and disincentives to leading.

Conclusions

While PCPs perceive primary care to hold a unique position that would incline them towards leadership, the lack of training and other noted disincentives are barriers to leadership. Therefore, health organisations should seek to invest in, better train and promote PCPs in leadership.

Work-Related Intervention Needs of Medical Assistants and How to Potentially Address Them according to Supervising General Practitioners: A Qualitative Study

Work stress is common among health care professionals and this observation also holds true for general practitioners (GPs) and their medical assistance staff in Germany. Therefore, prior studies have examined the work-related intervention needs of medical assistants (MAs). We sought to explore potential interventions that may help to address these needs according to GPs’ views. Between December 2018 and April 2019 GPs were recruited via physician networks and through personal visits in general practices. Information on the nature and prevalence of 20 work-related intervention needs of MAs was presented to GPs. GPs then participated in a qualitative interview to reflect on the MAs’ needs. Qualitative content analysis according to Mayring was carried out using MAXQDA. A total of 21 GPs participated and perceived many of the needs as justified. The least understanding was expressed for requests of MA related to occupational aspects that were already known prior to hiring. The responsibility to address needs was often assigned to the German health policy. GPs expressed though that they considered addressing the need for better leadership style as their own responsibility as supervisors. Furthermore, professional training was discussed as one opportunity to raise the recognition and remuneration of MAs. Measures to address the work-related intervention needs of MAs and to thereby improve the working conditions of MAs were discussed with GPs.

Psychosocial demands and resources for working time organization in GP practices. Results from a team-based ethnographic study in Germany

Background

General practitioners (GPs) are challenged, e.g. by long working hours, and as employers they are responsible for the creation of working conditions that prevent work-related psychosocial risks. Leadership behaviour plays an important role within the working conditions of employees, thus we focused on two research questions: To what extent and how do GPs fulfil their role as entrepreneurs and leaders responsible for occupational safety and health of the team members in the organization of working time of the employees? What psychosocial factors result from the way of organization of working time for the practice team?

Methods

Data was collected by participant observations, individual interviews with six GPs, and five focus group discussions with 19 members of the practice staff in total. We gained access to five general practices through a teaching network associated with the Institute for General Medicine, University Hospital Essen (Germany). The analysis was carried out according to the Grounded Theory approach.

Results

GPs have several roles and related tasks to fulfil in the organization of working time. This can lead to perceived psychological stress. With regard to the organization of predictable working hours, vacations and sickness absence, the GPs determined the scope of action of the practice assistants. The delegation of these tasks took place to varying degrees and resulted in different work-related resources and stressors.

Conclusion

We described transactional and transformational leadership behaviours which are all related to specific psychosocial demands and resources and may overlap on site. Leadership training seems recommendable as part of the training of GPs and other future leaders of micro-enterprises to promote self-reflection by the entrepreneurs and leaders and strengthen occupational health of leaders and staff.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12995-021-00336-w.

Development of an intervention to support the implementation of evidence-based strategies for optimising antibiotic prescribing in general practice

Background

Trials show that antimicrobial stewardship (AMS) strategies, including communication skills training, point-of-care C-reactive protein testing (POC-CRPT) and delayed prescriptions, help optimise antibiotic prescribing and use in primary care. However, the use of these strategies in general practice is limited and inconsistent. We aimed to develop an intervention to enhance uptake and implementation of these strategies in primary care.

Methods

We drew on the Person-Based Approach to develop an implementation intervention in two stages. (1) Planning and design: We defined the problem in behavioural terms drawing on existing literature and conducting primary qualitative research (nine focus groups) in high-prescribing general practices. We identified ‘guiding principles’ with intervention objectives and key features and developed logic models representing intended mechanisms of action. (2) Developing the intervention: We created prototype intervention materials and discussed and refined these with input from 13 health professionals and 14 citizens in two sets of design workshops. We further refined the intervention materials following think-aloud interviews with 22 health professionals.

Results

Focus groups highlighted uncertainties about how strategies could be used. Health professionals in the workshops suggested having practice champions, brief summaries of each AMS strategy and evidence supporting the AMS strategies, and they and citizens gave examples of helpful communication strategies/phrases. Think-aloud interviews helped clarify and shorten the text and user journey of the intervention materials. The intervention comprised components to support practice-level implementation: antibiotic champions, practice meetings with slides provided, and an ‘implementation support’ website section, and components to support individual-level uptake: website sections on each AMS strategy (with evidence, instructions, links to electronic resources) and material resources (patient leaflets, POC-CRPT equipment, clinician handouts).

Conclusions

We used a systematic, user-focussed process of developing a behavioural intervention, illustrating how it can be used in an implementation context. This resulted in a multicomponent intervention to facilitate practice-wide implementation of evidence-based strategies which now requires implementing and evaluating. Focusing on supporting the uptake and implementation of evidence-based strategies to optimise antibiotic use in general practice is critical to further support appropriate antibiotic use and mitigate antimicrobial resistance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00209-7.

Exploring the challenges in leadership roles experienced by nurse managers in a mining primary healthcare setting in South Africa

Background

The challenges in leadership roles hinder the rendering of quality primary healthcare service in the mines. Mining, the heart of the South African economy, requires good health to its personnel to carry out operations. However, nurse managers, the leaders in a mining primary healthcare setting experience difficulties in their leadership roles.

Objectives

The aim of this study was to explore and describe the challenges in leadership roles experienced by nurse managers in a mining primary healthcare setting in South Africa.

Method

The study was conducted in a mining primary healthcare setting in West Rand, Gauteng province, South Africa. A qualitative, exploratory, descriptive design that is contextual in nature, using a phenomenological approach, was adopted. Data from nurse managers in the mine were collected and data saturation was reached by the seventh participant. The study followed Giorgi’s four stages of the phenomenological descriptive data analysis. An expert independent coder in qualitative research coded the data, and consensus on the findings was reached with the researcher.

Results

Three subthemes emerged from the study: mining management and unions interfere with nurse managers’ leadership roles, incongruent mining primary healthcare policies and communication gap between nurse managers and mining management.

Conclusion

The triangulation of nurse managers, mining management and unions requires a collective fusion to directly tackle the challenges in leadership roles in mining primary healthcare.

Improving drug prescription in general practice using a novel quality improvement model

INTRODUCTION

Quality improvement (QI) clusters have been established in many countries to improve healthcare using the Breakthrough Series' collaboration model. We investigated the effect of a novel QI approach based on this model of performed medication reviews and drug prescription in a Norwegian municipality.

METHODS

All 27 General Practitioners (GPs) in a mid-size Norwegian municipality were invited to join the intervention, consisting of three peer group meetings during a period of 7-8 months. Participants learned practical QI skills by planning and following up QI projects within drug prescription practice. Evaluation forms were used to assess participants' self-rated improvement, reported medication review reimbursement codes (MRRCs) were used as a process measure, and defined daily doses (DDDs) of potentially inappropriate drugs (PIDs) dispensed to patients aged 65 years or older were used as outcome measures.

RESULTS

Of the invited GPs, 25 completed the intervention. Of these, 76% self-reported improved QI skills and 67% reported improved drug prescription practices. Statistical process control revealed a non-random increase in the number of MRRCs lasting at least 7 months after intervention end. Compared with national average data, we found a significant reduction in dispensed DDDs in the intervention municipality for benzodiazepine derivates, benzodiazepine-related drugs, drugs for urinary frequency and incontinence and non-steroid anti-inflammatory and antirheumatic medications.

CONCLUSION

Intervention increased the frequency of medication reviews, resulting in fewer potentially inappropriate prescriptions. Moreover, there was self-reported improvement in QI skills in general, which may affect other practice areas as well. Intervention required relatively little absence from clinical practice compared with more traditional QI interventions and could, therefore, be easier to implement.KEY POINTThe current study investigated to what extent a novel model based on the Breakthrough Series' collaborative model affects GP improvement skills in general practice and changes their drug prescription.KEY FINDINGSMost participants reported better improvement skills and improved prescription practice.The number of dispensed potentially inappropriate drugs decreased significantly in the intervention municipality compared with the national average.The model seemed to lead to sustained changes after the end of the intervention.

Perceived facilitators and barriers to chronic disease management in primary care networks of Singapore: a qualitative study

OBJECTIVE

The increasing chronic disease burden has placed tremendous strain on tertiary healthcare resources in most countries, necessitating a shift in chronic disease management from tertiary to primary care providers. The Primary Care Network (PCN) policy was promulgated as a model of care to organise private general practitioners (GPs) into groups to provide GPs with resources to anchor patients with chronic conditions with them in the community. As PCN is still in its embryonic stages, there is a void in research regarding its ability to empower GPs to manage patients with chronic conditions effectively. This qualitative study aims to explore the facilitators and barriers for the management of patients with chronic conditions by GPs enrolled in PCN.

DESIGN

We conducted 30 semistructured interviews with GPs enrolled in a PCN followed by a thematic analysis of audio transcripts until data saturation was achieved.

SETTING

Singapore.

RESULTS

Our results suggest that PCNs facilitated GPs to more effectively manage patients through (1) provision of ancillary services such as diabetic foot screening, diabetic retinal photography and nurse counselling to permit a 'one-stop-shop', (2) systematic monitoring of process and clinical outcome indicators through a chronic disease registry (CDR) to promote accountability for patients' health outcomes and (3) funding streams for PCNs to hire additional manpower to oversee operations and to reimburse GPs for extended consultations. Barriers include high administrative load in maintaining the CDR due to the lack of a smart electronic clinic management system and financial gradient faced by patients seeking services from private GPs which incur higher out-of-pocket expenses than public primary healthcare institutions.

CONCLUSION

PCNs demonstrate great promise in empowering enrolled GPs to manage patients with chronic conditions. However, barriers will need to be addressed to ensure the viability of PCNs in managing more patients in the face of an ageing population.

Modifiable determinants for the success or failure of inter-physician collaboration in group practices in Germany - a qualitative study

Background

A growing demand for physicians exists worldwide. Due to political changes, economic incentives and new workplace expectations a trend from single-handed practices to group practices has been noticed in many countries over the last years. In view of this background, our study aimed to identify determinants for success or failure of inter-physician collaboration in order to positively influence future collaboration in anticipation of the important role group practices may play in future health care delivery.

Methods

We chose a qualitative study design, using semi-structured phone interviews to collect data from physicians and non-physician consultants with experience in inter-physician collaboration that were analysed using content analysis. Eleven physicians with experience in collaborative working and fourteen non-physician consultants specializing in advice to health care professionals participated.

Results

Education in entrepreneurial skills as well as implementation of good practice management in preparation for collaboration are crucial modifiable facilitators for successful inter-physician collaboration. Furthermore, open communication and realistic insight into the mode of acquaintance, moral concept and degree of specialisation of the colleagues involved play major roles for the success of inter-physician collaboration in group practices.

Conclusions

There are several underlying themes beyond clinical expertise concerning success or failure of group practices. To influence future collaboration positively, it is important to focus on management and communication skills as well as to address basic understanding of economics.

Leadership training in family medicine residency: a scoping review

Background

Graduate medical education, including family medicine residency, has historically focused on building clinical competencies with little attention paid to leadership skills, leaving residents feeling ill-prepared for leadership roles after training.

Objective

To analyse the format, content and outcomes of leadership training programmes offered to family medicine residents.

Methods

A MEDLINE (OvidSP) literature search from 1976 to October 2018 for articles on Family Medicine AND Residency AND Leadership Programs retrieved 184 articles. After reviewing inclusion and exclusion criteria, 12 articles were chosen for full review and synthesis.

Results

Three articles described leadership training available to Family Medicine all residents while nine focused on a select group. Programme format and content varied, ranging from a 1-day programme on emotional intelligence to a 5-year integrated leadership track. The most comprehensive curricula were longitudinal and offered to a small group of residents. Inclusive programmes often taught leadership through the lens of a specific competency. Mixed teaching methods were valued including online learning, simulations, small group discussions, mentorship, reflection, placements and projects. Conceptual frameworks were inconsistently used and programme evaluation seldom addressed high-level or long-term outcomes.

Conclusions

Leadership skills are important for all family physicians; however, there is limited literature on comprehensive leadership development during training. Existing curricula were described in this review and we suggest a longitudinal mixed-methods programme integrated throughout residency, covering basic comprehensive skills for all residents. However, evaluative data were limited, and a considerable gap remains in how to effectively approach leadership development in family medicine residency, warranting ongoing research.

Social and Contextual Influences on Antibiotic Prescribing and Antimicrobial Stewardship: A Qualitative Study with Clinical Commissioning Group and General Practice Professionals

Antibiotic prescribing in England varies considerably between Clinical Commissioning Groups (CCGs) and general practices. We aimed to assess social and contextual factors affecting antibiotic prescribing and engagement with antimicrobial stewardship (AMS) initiatives. Semi-structured telephone interviews were conducted with 22 CCG professionals and 19 general practice professionals. Interviews were audio-recorded, transcribed, and analyzed thematically. Social/contextual influences were grouped into the following four categories: (1) Immediate context, i.e., patients' social characteristics (e.g., deprivation and culture), clinical factors, and practice and clinician characteristics (e.g., "struggling" with staff shortage/turnover) were linked to higher prescribing. (2) Wider context, i.e., pressures on the healthcare system, limited resources, and competing priorities were seen to reduce engagement with AMS. (3) Collaborative and whole system approaches, i.e., communication, multidisciplinary networks, leadership, and teamwork facilitated prioritizing AMS, learning, and consistency. (4) Relativity of appropriate prescribing, i.e., "high" or "appropriate" prescribing was perceived as relative, depending on comparators, and disregarding different contexts, but social norms around antibiotic use among professionals and patients seemed to be changing. Further optimization of antibiotic prescribing would benefit from addressing social/contextual factors and addressing wider health inequalities, not only targeting individual clinicians. Tailoring and adapting to local contexts and constraints, ensuring adequate time and resources for AMS, and collaborative, whole system approaches to promote consistency may help promote AMS.

The Management Experiences, Priorities, and Challenges of Medical Directors in the Subspecialty of Consultation-Liaison Psychiatry: Results of a Needs Assessment

BACKGROUND

Medical directors need management skills, yet few studies describe the specific tasks that directors consider most important, their confidence for these tasks, and how their confidence develops. We studied these questions among directors in the subspecialty of Consultation-Liaison Psychiatry.

METHODS

A needs survey was sent to 48 registrants of a new forum for Consultation-Liaison Psychiatry directors. The survey asked about 6 professional experiences, the relative importance of 14 management tasks, and the directors' confidence in managing these tasks, using 7-point Likert scales. Correlations between experiences, task importance, and task confidence were performed.

RESULTS

Twenty-seven directors responded (56% response). The experiences that correlated most with management confidence were years in practice and health care leadership training, yet approximately half of responders were directors for ≤5 years and had received minimal training. Management tasks with the highest importance included demonstrating value of their service and roles for nonphysician clinical staff on their teams. Significant associations were identified between years in practice and confidence for leading faculty scholarship, trainee staffing ratios and roles, fee coding, measurement of faculty clinical productivity, and faculty recruitment. Leadership training correlated with confidence in demonstrating service value, measuring faculty clinical productivity, novel models of care, and growing a new service.

CONCLUSION

Consultation-Liaison directors with fewer years of experience and minimal health care management training need time and support to grow into their roles. They should be pointed toward training opportunities to improve their confidence to lead the wide range of management tasks that are important to their roles.

Quality improvement and antimicrobial stewardship in general practice - the role of the municipality chief medical officer. A qualitative study

AIMS

This study aimed to explore the conditions for the Municipal Chief Medical Officers' (MCMOs) involvement in quality improvement in general practice, specifically concerning antibiotic prescribing practices.

METHODS

This qualitative study consisted of semi-structured in-depth telephone interviews and group interviews with MCMOs (n = 12). The interview guide aimed to explore the MCMOs' views on their role and responsibilities regarding the quality of care in general practice. The data were analysed using systematic text condensation.

RESULTS

Three main themes were identified: 1) the relationship between the municipality and the general practitioner (GP), with the MCMO acting as an intermediary, 2) influencing the GPs' work and 3) antibiotic use and infection control. The MCMOs perceived themselves as liaisons between the municipalities and the GPs. They emphasized building trust, showing respect and sharing common values in their interactions with the GPs, upholding the GPs' professional autonomy. Working for quality improvement was considered a priority; however, MCMOs expressed a need for external support to establish a permanent quality improvement framework. The informants were positive about engaging in improving antibiotic prescribing practices because this combined the municipality's responsibilities for quality improvement and communicable disease control.

CONCLUSIONS

The MCMOs considered themselves as well-suited agents for quality improvement in general practice, as liaisons between the municipalities and the GPs. Quality improvement in general practice would benefit from a clearer structure in terms of the MCMOs' roles and responsibilities. Within communicable diseases control, the MCMOs have a clear mandate, which places antimicrobial stewardship initiatives in a favourable position amongst other areas of quality improvement.

Nurse managers experiences of their leadership roles in a specific mining primary healthcare service in the West Rand

BACKGROUND

Nurse managers are leaders in mining primary healthcare. Their leadership roles include inspiring and empowering operational managers and nursing personnel, by leading with competence developing them to become followers with insight and direction. However, these leadership roles are not clearly defined, and are negatively influenced by the traditional mining leadership style.

OBJECTIVES

The aim of this study was to explore and describe the nurse managers' experiences of their leadership roles in a specific mining primary healthcare service on the West Rand, to develop recommendations to enhance these roles.

METHOD

A qualitative, exploratory, descriptive and contextual research design was used in this study, following a phenomenological approach as a research method. A non-probability purposive sampling method was used. Nurse managers described experiences of their leadership roles during individual phenomenological interviews. Data saturation was reached on participant number 7. To analyse data, four stages of Giorgi's descriptive phenomenological data analysis was used. An independent coder coded the data and a consensus meeting was held. The study was guided by the theoretical framework of Winkler's role theory.

RESULTS

The following subthemes emanated from data analysis: (1) leadership role ambiguity, (2) leadership roles experienced and (3) challenges experienced in leadership roles.

CONCLUSION

This study revealed that the leadership roles for nurse managers in a specific mining primary healthcare service are not clearly defined. Hence enhancements and expansions of these leadership roles remained stagnant. A clearly defined policy on leadership roles for nurse managers should be developed.

Medical leadership: boon or barrier to organisational performance? A thematic synthesis of the literature

OBJECTIVE

The influx of management ideas into healthcare has triggered considerable debate about if and how managerial and medical logics can coexist. Recent reviews suggest that clinician involvement in hospital management can lead to superior performance. We, therefore, sought to systematically explore conditions that can either facilitate or impede the influence of medical leadership on organisational performance.

DESIGN

Systematic review using thematic synthesis guided by the Enhancing Transparency in Reporting the synthesis of Qualitative research statement.

DATA SOURCES

We searched PubMed, Web of Science and PsycINFO from 1 January 2006 to 21 January 2020.

ELIGIBILITY CRITERIA

We included peer-reviewed, empirical, English language articles and literature reviews that focused on physicians in the leadership and management of healthcare.

DATA EXTRACTION AND SYNTHESIS

Data extraction and thematic synthesis followed an inductive approach. The results sections of the included studies were subjected to line-by-line coding to identify relevant meaning units. These were organised into descriptive themes and further synthesised into analytic themes presented as a model.

RESULTS

The search yielded 2176 publications, of which 73 were included. The descriptive themes illustrated a movement from 1. medical protectionism to management through medicine; 2. command and control to participatory leadership practices; and 3. organisational practices that form either incidental or willing leaders. Based on the synthesis, the authors propose a model that describes a virtuous cycle of management through medicine or a vicious cycle of medical protectionism.

CONCLUSIONS

This review helps individuals, organisations, educators and trainers better understand how medical leadership can be both a boon and a barrier to organisational performance. In contrast to the conventional view of conflicting logics, medical leadership would benefit from a more integrative model of management and medicine. Nurturing medical engagement requires participatory leadership enabled through long-term investments at the individual, organisational and system levels.

Investing in Queensland's rural medical leaders: Lessons from the Queensland Rural Generalist Program

OBJECTIVE

To improve the leadership capacity of existing Queensland Rural Generalists and support the emerging leaders needed to assume future leadership roles.

DESIGN

A customised leadership program for medical Rural Generalists, embedded in professional standards, was developed and delivered during 2016-2018. Pre and post-program and individual module evaluations from two Program cohorts were analysed. Qualitative, semi-structured phone interviews (n = 30) discussing participant views on leadership in a rural context and their Program experience were also conducted.

SETTING

The Rural Generalist Leadership for Clinicians Training Program runs over twelve months and includes three residential modules as well as online learning sets.

PARTICIPANTS

Forty-four participants completed the Program and obtained Associate Fellowship of the Royal Australasian College of Medical Administrators.

INTERVENTIONS

Development and delivery of the Rural Generalist Leadership for Clinicians Training Program.

MAIN OUTCOME MEASURE(S)

Participant's ability to apply Program learning in a rural leadership context. Participant views on leadership in a rural context.

RESULTS

Participants indicated they benefited most from the 'understanding self' and management aspects of the Program such as finance, budgeting, and understanding and navigating broader health system governance. They greatly valued the opportunity to enhance their professional networks and relationships and have since developed a regular forum to assist in the transition from individual leadership development to the development of the broader workforce and organisation.

CONCLUSION

The results of this study suggest that further attention and investment in medical leadership is warranted to support and enable the Rural Generalist workforce to continue to meet the complex, context-specific needs of the communities within which they deliver vital health services.

Leading Innovative Practice: Leadership Attributes in LEAP Practices

Policy Points An onslaught of policies from the federal government, states, the insurance industry, and professional organizations continually requires primary care practices to make substantial changes; however, ineffective leadership at the practice level can impede the dissemination and scale-up of these policies. The inability of primary care practice leadership to respond to ongoing policy demands has resulted in moral distress and clinician burnout. Investments are needed to develop interventions and educational opportunities that target a broad array of leadership attributes.

CONTEXT

Over the past several decades, health care in the United States has undergone substantial and rapid change. At the heart of this change is an assumption that a more robust primary care infrastructure helps achieve the quadruple aim of improved care, better patient experience, reduced cost, and improved work life of health care providers. Practice-level leadership is essential to succeed in this rapidly changing environment. Complex adaptive systems theory offers a lens for understanding important leadership attributes.

METHODS

A review of the literature on leadership from a complex adaptive system perspective identified nine leadership attributes hypothesized to support practice change: motivating others to engage in change, managing abuse of power and social influence, assuring psychological safety, enhancing communication and information sharing, generating a learning organization, instilling a collective mind, cultivating teamwork, fostering emergent leaders, and encouraging boundary spanning. Through a secondary qualitative analysis, we applied these attributes to nine practices ranking high on both a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see if and how these attributes manifest in high-performing innovative practices.

FINDINGS

We found all nine attributes identified from the literature were evident and seemed important during a time of change and innovation. We identified two additional attributes-anticipating the future and developing formal processes-that we found to be important. Complexity science suggests a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others.

CONCLUSIONS

Successful primary care practices exhibit a diversity of strong local leadership attributes. To meet the realities of a rapidly changing health care environment, training of current and future primary care leaders needs to be more comprehensive and move beyond motivating others and developing effective teams.

Legitimacy of work tasks, psychosocial work environment, and time utilization among primary care staff in Sweden

Objective: Primary care staff faces a complex work environment including a heavy administrative work load and perceive some work tasks as illegitimate. This study aimed to elucidate associations between the perceived legitimacy of work tasks, the psychosocial work environment, and the utilization of work time among Swedish primary care staff.Design and setting: The study was designed as a multicenter study involving all staff categories, i.e. registered nurses, primary care physicians, care administrators, nurse assistants and allied professionals, at eleven primary care centers in Sweden.Subjects: Participants completed the Bern Illegitimate Tasks Scale and the Copenhagen Psychosocial Questionnaire. They also recorded time spent on all work tasks, day by day during two separate weeks.Main outcome measures and results: More than a quarter (27%) of primary care physicians perceived a high proportion of unnecessary work tasks. After adjusting for profession, age and gender, the perception of having to perform unreasonable work tasks was positively associated with experiencing role conflicts and with the proportion of organization-related administration and service work tasks.Conclusion: Across all staff groups, the perception of unreasonable work tasks was more pronounced among staff with a high proportion of non-patient related administration. Also, the perception of having to perform a large amount of illegitimate work tasks affected the psychosocial work environment negatively, which might influence staffs perception of their professional roles. These results illuminate the importance of decision makers to thoroughly consider the distribution and allocation of non-patient related work tasks among staff in primary care.Key pointsWe observed an interaction between perception of having a large proportion of illegitimate work tasks and impaired psychosocial work environment. • More than a quarter of the primary care physicians perceived a high proportion of unnecessary work tasks.• Across all staff groups, performing unreasonable work tasks was associated with an experience of having role conflicts.• Across all staff groups, a perception of performing unreasonable work tasks was associated with the proportion of non-patient related administrative work tasks.

General Practitioners' Attitudes toward Municipal Initiatives to Improve Antibiotic Prescribing-A Mixed-Methods Study

Antimicrobial stewardship (AMS) interventions directed at general practitioners (GPs) contribute to an improved antibiotic prescribing. However, it is challenging to implement and maintain such interventions at a national level. Involving the municipalities’ Chief Medical Officer (MCMO) in quality improvement activities may simplify the implementation and maintenance, but may also be perceived challenging for the GPs. In the ENORM (Educational intervention in NORwegian Municipalities for antibiotic treatment in line with guidelines) study, MCMOs acted as facilitators of an AMS intervention for GPs. We explored GPs’ views on their own antibiotic prescribing, and their views on MCMO involvement in improving antibiotic prescribing in general practice. This is a mixed-methods study combining quantitative and qualitative data from two data sources: e-mail interviews with 15 GPs prior to the ENORM intervention, and online-form answers to closed and open-ended questions from 132 GPs participating in the ENORM intervention. The interviews and open-ended responses were analyzed using systematic text condensation. Many GPs admitted to occasionally prescribing antibiotics without medical indication, mainly due to pressure from patients. Too liberal treatment guidelines were also seen as a reason for overtreatment. The MCMO was considered a suitable and acceptable facilitator of quality improvement activities in general practice, and their involvement was regarded as unproblematic (scale 0 (very problematic) to 10 (not problematic at all): mean 8.2, median 10). GPs acknowledge the need and possibility to improve their own antibiotic prescribing, and in doing so, they welcome engagement from the municipality. MCMOs should be involved in quality improvement and AMS in general practice.

Is postgraduate leadership education a match for the wicked problems of health systems leadership? A critical systematic review

PURPOSE

There have been a growing number of leadership education programs for physicians. However, debates about the value and efficacy of leadership education in medicine persist, and there are calls for systematic and critical perspectives on medical leadership development. Here, we review evidence on postgraduate leadership education and discuss findings in relation to contemporary evidence on leadership education and practice.

METHOD

We searched multiple databases for papers on postgraduate leadership development programs, published in English between 2007 and 2017. We identified 4,691 papers; 31 papers met the full inclusion criteria. Data regarding curricular content and design, learner demographics, instructional methods, and learning outcomes were abstracted and synthesized.

RESULTS

There was modest evidence for effectiveness of programs in influencing knowledge and skills gains in select domains. However, the conceptual underpinnings of the 'leadership' training delivered were often unclear. Contemporary theory and evidence on leadership practice was not widely incorporated in program design. Programs were almost exclusively uni-professional, focused on discrete skill development, and did not address systems-level leadership issues. Broader leadership capacity building strategies were underutilized. A new wave of longitudinal, integrated clinical and leadership programming is observed.

CONCLUSIONS

Our findings raise questions about persistent preparation-practice gaps in leadership education in medicine. Leadership education needs to evolve to incorporate broader collective capacity building, as well as evidence-informed strategies for leadership development. Barriers to educational reform need to be identified and addressed as educators work to re-orientate education programs to better prepare budding physician leaders for the challenges of health system leadership.

General practitioners' perspectives on care coordination in primary health care: A qualitative study

Introduction

To explore Norwegian general practitioners' experiences with care coordination in primary health care.

Methods

Qualitative study using data from five focus groups with 32 general practitioners in Norway. We analysed the data using systematic text condensation, a descriptive and explorative method for thematic cross-case analysis of qualitative data.

Results

The general practitioners had different notions of care pathways. They expressed a wish and an obligation to be involved in planning and coordination of primary health-care services, but they experienced organisational and financial barriers that limited their involvement and contribution. General practitioners reported lack of information about and few opportunities for involvement in formal coordination initiatives, and they missed informal arenas for dialogue with other primary health-care professionals. They argued that the general practitioner's role as coordinator should be recognised by other parties and that they needed financial compensation for contributions and attendance in meetings with the municipality.

Discussion

General practitioners need informal arenas for dialogue with other primary health-care professionals and access to relevant information to promote coordinated care. There might be an untapped potential for improving patient care involving general practitioners more in planning and coordinating services at the system level. Financial compensation of general practitioners contribution may promote increased involvement by general practitioners.

The role of eLearning in health management and leadership capacity building in health system: a systematic review

BACKGROUND

Health leadership and management are essential for ensuring resilient health systems. Relevant training opportunities are often scarce, and the use of digital education could help address this gap. Our aim was to assess the effectiveness of eLearning for healthcare leadership and management capacity building.

METHODS

We performed a systematic review on the effectiveness of eLearning for health leadership and management training. We also reviewed literature on relevant competencies and training programmes. We conceptualise the role of health leadership and management capacity building in health system strengthening and explore the use of eLearning in this area.

RESULTS

No evidence was found on the effectiveness of eLearning for health leadership and management capacity guiding. Evidence on health leadership and management education effectiveness in general is scarce and descriptive and reports learning outcomes. We explore how various forms of eLearning can help meet specific requirements of health leadership and management training.

CONCLUSIONS

Literature on the effectiveness of health leadership and management education is scarce. The use of eLearning could support this type of training by making it more accessible and tailored. Future research should be carried out in diverse settings, assume experimental designs, evaluate the use of information technology and report health system outcomes.

Physician leadership development: towards multidisciplinary programs?

Background

The format and content of leadership development programmes for physicians is a theme for discussion in the literature.

Objectives

The aim of this study is to explore healthcare executives’ perspectives on physician leadership development, focusing on perceived benefits and negative effects associated with multidisciplinary programmes.

Methods

We did a qualitative study based on data from semistructured interviews with 16 healthcare executives in US healthcare systems.

Results

We found that one group perceived programmes targeting one profession as advantageous, promoting openness and professional relationships among peers. Other executives argued that multidisciplinary programmes could add value because they could bridge professional boundaries, strengthen networks and build leadership capacity throughout an organisation. Costs, timing, organisational culture and a lack of knowledge about how to run multidisciplinary programmes were challenges our informants associated with multidisciplinary leadership development programmes.

Conclusion

This study identifies topics and challenges that can inform organisational policies and decisions about leadership development activities.

What do doctors and nurses think about development of clinical leadership?

Leadership development for health-care professionals is a priority within the NHS. Training is generally targeted at individual staff groups in isolation, even though contemporary leadership thinking recognizes the benefits of collaborative leadership between different clinical disciplines. Focussing on the attitudes and perceived training needs of undergraduate and qualified medical and nursing professionals, this article highlights the similarities and differences and will help to inform the design of existing and future leadership programmes.