Distributed leadership, team working and service improvement in healthcare

Leadership in intellectual disability practice: design, development, and evaluation of a programme to support practice

BACKGROUND

Intellectual disability services have and continue to experience changes in service provision. This has an implication for leadership in practice as the quality of leadership has a direct influence on staff practice and care provided.

AIM

To design, deliver, and evaluate a leadership programme for nurse and social care managers in Ireland.

DESIGN

An accredited programme was designed based on evidence from literature, practice, and national expertise. A cross-sectional survey was used to collect information on the attitudes and behaviour of participants before commencing and after completing the programme. Data from the questionnaires were analysed using SPSS and open-ended questions were analysed using content analysis.

SETTING

Intellectual disability services.

PARTICIPANTS

102 participants completed the programme and survey.

METHODS

Pre-post survey and reported using the CROSS guidelines.

RESULTS

Participants' expectations were rated highly, and all items scored higher in the post-survey. Qualitative data was overall positive regarding opportunities for more time to work through each aspect of the programme. The key learning was through the forum day where participants shared their group projects.

CONCLUSIONS

Overall, the programme was positively evaluated and through engaging with the programme participants' perceptions moved from seeing leadership as mostly task-oriented to realising that qualities such as good communication, person-centredness, advocacy, supporting, role modelling, and empowering are key to leadership.

Distributed leadership in health quality improvement collaboratives

BACKGROUND AND PURPOSE

Distributed leadership has been suggested for describing patterns of influence in collaborative settings where public services are performed across professions and organizations. This study explores how leadership in health quality improvement collaboratives (QICs) is characterized by aligned distributed leadership practices, and how these practices relate with experienced progress and achievements in the quality improvement (QI) work.

METHODS

The analysis relied on a qualitative, multicase study of two nationwide Danish QICs. Data consisted of 12 single-person and 21 group interviews with local QI teams and local and regional QIC coordinators (85 informants in total), participant observations of 34 meetings within the QICs, and a collection of documentary material. The collected data were analyzed thematically with NVivo.

RESULTS

Leadership practices in local QI teams are characterized by aligned distributed leadership, with leadership activities being widely distributed based on negotiated, emergent practices regarding the aims, roles, and scope of the QI work. However, local quality coordinators play a pivotal role in driving the QI activities, and hierarchical support from hospital/municipal management is a precondition for the contribution of aligned distributed leadership to experienced progress and QIs.

PRACTICE IMPLICATIONS

Emergent distributed leadership should be balanced by thorough consolidation of the practices to provide the best circumstances for robust QI. The active participation of formal managers and local coordinators plays a pivotal role in this consolidation and is decisive for the increased potential for long-term success and sustainability of the QI work, particularly within complex QICs.

The Use of Quality Improvement in the Physical Therapy Literature: A Scoping Review

INTRODUCTION

Quality improvement (QI) is a useful methodology for improving healthcare, often through iterative changes. There is no prior review on the application of QI in physical therapy (PT).

PURPOSE AND RELEVANCE

To characterize and evaluate the quality of the QI literature in PT.

METHODS

We searched four electronic databases from inception through September 1, 2022. Included publications focused on QI and included the practice of PT. Quality was assessed using the 16-point QI Minimum Quality Criteria Set (QI-MQCS) appraisal tool.

RESULTS

Seventy studies were included in the review, 60 of which were published since 2014 with most ( n = 47) from the United States. Acute care ( n = 41) was the most prevalent practice setting. Twenty-two studies (31%) did not use QI models or approaches and only nine studies referenced Revised Standards for QI Reporting Excellence guidelines. The median QI-MQCS score was 12 (range 7-15).

CONCLUSIONS/IMPLICATIONS

Quality improvement publications in the PT literature are increasing, yet there is a paucity of QI studies pertaining to most practice settings and a lack of rigor in project design and reporting. Many studies were of low-to-moderate quality and did not meet minimum reporting standards. We recommend use of models, frameworks, and reporting guidelines to improve methodologic rigor and reporting.

The measurement of compassionate leadership: Adaptation and Spanish validation of the compassionate leadership self-reported scale

BACKGROUND

A culture of shared leadership is widespread among palliative care teams based on a commitment to valuing and including all people equally. As compassion is a core value for end-of-life care work, compassionate leadership may be the best way to lead in palliative care.

AIMS

The aims of this study were twofold: (1) to adapt and validate the Compassionate Leadership Self-reported Scale in a sample of palliative care professionals; and (2) to study the relation between compassionate leadership and associated concepts of self-compassion, awareness and self-care.

METHODS

A cross-sectional survey of 296 Spanish end-of-life care professionals was conducted. Analyses included descriptive statistics, a confirmatory factor analysis (CFA) with four-correlated factors, reliability estimates and a structural model.

RESULTS

Results suggested there were medium to high levels of compassionate leadership in the sample. The CFA showed an adequate overall fit: χ² (98) = 277.595 (p < 0.001); CFI = 0.986; SRMR = 0.047; RMSEA = 0.088 [0.076, 0.100]. Reliability estimates for four subscales of compassionate leadership (attending, understanding, empathising and helping) were also adequate, ranging from 0.72 to 0.96. Finally, the structural model predicting compassionate leadership suggested that the dimensions of attending and understanding were most highly related to positive self-compassion and awareness; empathising, to self-care and awareness; and helping, to positive self-compassion and self-care.

CONCLUSION

The Compassionate Leadership Scale has adequate psychometric properties when used to assess compassionate leadership in the context of end-of-life care. Our results indicate that self-compassion, awareness and self-care are important correlates of such compassionate leadership.

What makes a socially skilled leader? Findings from the implementation and operation of New Care Models (Vanguards) in England

PURPOSE

The article aims to argue that the concept of "distributed leadership" lacks the specificity required to allow a full understanding of how change happens. The authors therefore utilise the "Strategic Action Field Framework" (SAF) (Moulton and Sandfort, 2017) as a more sensitive framework for understanding leadership in complex systems. The authors use the New Care Models (Vanguard) Programme as an exemplar.

DESIGN/METHODOLOGY/APPROACH

Using the SAF framework, the authors explored factors affecting whether and how local Vanguard initiatives were implemented in response to national policy, using a qualitative case study approach. The authors apply this to data from the focus groups and interviews with a variety of respondents in six case study sites, covering different Vanguard types between October 2018 and July 2019.

FINDINGS

While literature already acknowledges that leadership is not simply about individual leaders, but about leading together, this paper emphasises that a further interdependence exists between leaders and their organisational/system context. This requires actors to use their skills and knowledge within the fixed and changing attributes of their local context, to perform the roles (boundary spanning, interpretation and mobilisation) necessary to allow the practical implementation of complex change across a healthcare setting.

ORIGINALITY/VALUE

The SAF framework was a useful framework within which to interrogate the data, but the authors found that the category of "social skills" required further elucidation. By recognising the importance of an intersection between position, personal characteristics/behaviours, fixed personal attributes and local context, the work is novel.

Shared accountability in distributed leadership for improved healthcare access: a study of a US dental institution

PURPOSE

Accountability within distributed leadership (DL) is critical for DL to drive positive outcomes in health services organizations. Despite this, how accountability emerges in DL is less clear. This study aims to understand how accountability emerges in DL so that distributed leaders can drive improvements in healthcare access - an increasingly important outcome in today's health services environment.

DESIGN/METHODOLOGY/APPROACH

The authors use an instrumental case study of a dental institution in the USA, "Environ," as it underwent a strategic change to improve healthcare access to rural populations. The authors focused on DL occurring within the strategic change and collected interview, observation and archival data.

FINDINGS

The findings demonstrate accountability in DL emerged as shared accountability and has three elements: personal ownership, agentic actions and a shared belief system. Each of these was necessary for DL to advance the strategic change for improved healthcare access.

PRACTICAL IMPLICATIONS

Top managers should be cognizant of the emergence processes driven by DL. This includes enabling pockets of employees to connect, align and link up so that ideas, processes and practices can emerge and allow for shared accountability in DL.

ORIGINALITY/VALUE

The overarching contribution of this research is identifying shared accountability in DL and its three elements: personal ownership, agentic actions and a shared belief system. These elements serve as a platform to demonstrate "how DL works" in a healthcare organization.

Strategies to reduce waiting times in outpatient rehabilitation services for adults with physical disabilities: A systematic literature review

Objective

Identifying effective strategies to reduce waiting times is a crucial issue in many areas of health services. Long waiting times for rehabilitation services have been associated with numerous adverse effects in people with disabilities. The main objective of this study was to conduct a systematic literature review to assess the effectiveness of service redesign strategies to reduce waiting times in outpatient rehabilitation services for adults with physical disabilities.

Methods

We conducted a systematic review, searching three databases (MEDLINE, CINAHL and EMBASE) from their inception until May 2021. We identified studies with comparative data evaluating the effect of rehabilitation services redesign strategies on reducing waiting times. The Mixed Methods Appraisal Tool was used to assess the methodological quality of the studies. A narrative synthesis was conducted.

Results

Nineteen articles including various settings and populations met the selection criteria. They covered physiotherapy ( n = 11), occupational therapy ( n = 2), prosthetics ( n = 1), exercise physiology ( n = 1) and multidisciplinary ( n = 4) services. The methodological quality varied ( n = 10 high quality, n = 6 medium, n = 3 low); common flaws being missing information on the pre-redesign setting and characteristics of the populations. Seven articles assessed access processes or referral management strategies (e.g. self-referral), four focused on extending/modifying the roles of service providers (e.g. to triage) and eight changed the model of care delivery (e.g. mode of intervention). The different redesign strategies had positive effects on waiting times in outpatient rehabilitation services.

Conclusions

This review highlights the positive effects of many service redesign strategies. These findings suggest that there are several effective strategies to choose from to reduce waiting times and help better respond to the needs of persons experiencing physical disabilities.

Learning from Lean: a quality improvement project using a Lean-based improvement approach to improve discharge for patients with frailty in an acute care hospital

A Lean-based improvement approach was used to complete a quality improvement project (QIP) focused on improving speed and quality of discharge of frail patients on two wards at a large teaching hospital in the UK. This was part of a national initiative to embed continuous improvement within the trust. The aim of the QIP was to improve the proportion of prenoon discharges to 33% of total patients discharged from the ward each day. An 'improvement practice process' followed, which included seven discrete workshops that took the QIP through four distinct phases-understand, design, deliver and sustain. Several improvement methods and tools were used, including value stream mapping and plan-do-study-act (PDSA) cycles. Ten PDSA cycles were implemented across the clinical areas, including improved planning and data collection of discharge, improved communication between nursing and medical staff, and earlier referrals to community hospitals for discharge. Improved performance was identified through the outcome metric prenoon discharges on both wards, with the average increasing from 8% to 24% on ward X and from 9% to 19% on ward Y, with no other significant change seen in other measures. Pettigrew et al's context-content-process change model was used to structure the learning from the QIP, which included the impact of varying ward contexts, the format of conducting improvement with staff, the importance of organisational support, the need for qualitative measures, agreeing to an apposite aim and the power of involving service users. The original aim of 33% prenoon discharges was not achieved, yet there was clear learning from completing the QIP which could contribute to ongoing improvement work. This identified that the Lean-based improvement approach used was effective to some degree for improving discharge processes. Further focus is required on collecting qualitative data to identify the impact on staff, especially related to behaviour and culture change.

A Realist Evaluation of Team Interventions in Acute Hospital Contexts-Use of Two Case Studies to Test Initial Programme Theories

BACKGROUND

Designing and implementing team interventions to improve quality and safety of care in acute hospital contexts is challenging. There is little emphasis in the literature on how contextual conditions impact interventions or how specific active ingredients of interventions impact on team members' reasoning and enact change. This realist evaluation helps to deepen the understanding of the enablers and barriers for effective team interventions in these contexts.

METHODS

Five previously developed initial programme theories were tested using case studies from two diverse hospital contexts. Data were collected from theory driven interviews (n = 19) in an Irish context and from previously conducted evaluative interviews (n = 16) in a US context. Data were explored to unpack the underlying social and psychological drivers that drove both intended and unintended outcomes. Patterns of regularity were identified and synthesised to develop middle-range theories (MRTs).

RESULTS

Eleven MRTs demonstrate how and why intervention resources introduced in specific contextual conditions enact reasoning mechanisms and generate intended and unintended outcomes for patients, team members, the team and organisational leaders. The triggered mechanisms relate to shared mental models; openness, inclusivity and connectedness; leadership and engagement; social identity and intrinsic motivational factors.

CONCLUSIONS

The findings provide valuable information for architects and facilitators of team interventions in acute hospital contexts, as well as help identify avenues for future research. Dataset: The data presented in this study are available on request from the corresponding author. The data are not publicly available due to their sensitive nature and potential identification of participants.

Distributive Leadership Within an Emerging Network of Integrated Youth Health Centres: A Case Study of Foundry

Background

Distributive leadership has been proposed as an effective means towards achieving integrated health services. This study draws from the case of Foundry, a network of integrated youth health centres in British Columbia, Canada, and explores the function and impact of distributive leadership in the context of a large-scale effort towards integrated service delivery for youth experiencing mental health and substance use challenges.

Methods

Qualitative data was obtained from a developmental evaluation of Foundry using a longitudinal, ethnographic approach. Over 150 participants involved in the development of six Foundry centres were interviewed individually or in focus groups. Purposive and theoretical sampling strategies were used to maximize the diversity of perspectives represented in the data set.

Results and Discussion

Distributive leadership was observed to be a facilitator for achieving service and system-level integration. Distributive leadership was effective in promoting streamlined service provision, and coordinating efforts towards optimized access to care. A new culture of leadership emerged through collaboration and relationship-building based on a common value system to prioritize youth needs.

Conclusion

As Foundry, and other integrated youth services, continues to expand, distributive leadership shows promise in assuring diverse and coordinated input for integrating services.

Sharing leadership: current attitudes, barriers and needs of clinical and non-clinical managers in UK’s integrated care system

Background

As systems become more complex, shared leadership (SL) has been suggested to have a dominant role in improving cross-functional working tailored to organisational needs. Little, however, is known about the benefits of SL in healthcare management, especially for UK’s recently formed integrated care system (ICS). The aim of this study was to understand current attitudes, barriers and needs of clinical and non-clinical managers sharing leadership responsibilities in the ICS.

Method

Twenty clinical and non-clinical leaders in 15 organisations were interviewed to understand current cross-functional leadership collaborations, and the potential SL may have on the recently established ICS in the National Health Service (NHS). The data were transcribed and analysed thematically.

Results

Findings showed perceptions and experiences of clinical and non-clinical healthcare management in relation to: (1) motivation to execute a leadership position, including the need to step up and a sense of duty; (2) attitudes towards interdisciplinary working, which is reflected in conflicts due to different values and expertise; (3) SL skills and behaviours, including the need for mutual understanding and cooperative attitudes by means of effective communication and collaboration; and (4) barriers to achieve SL in the ICS, such as bureaucracy, and a lack of time and support.

Conclusions

SL may help improve current leadership cultures within the NHS; however, for SL to have a tangible impact, it needs to be delivered as part of leadership development for doctors in postgraduate training, and development programmes for aspiring, emerging and established leaders, with clear lines of communication.

Identifying the context, mechanisms and outcomes underlying collective leadership in teams: building a realist programme theory

BACKGROUND

There is accumulating evidence for the value of collective and shared approaches to leadership. However, relatively little research has explored collective leadership in healthcare and thus, there is a lack understanding of the mechanisms that promote or inhibit the practice of collective leadership in healthcare teams. This study describes the development of an initial programme theory (IPT) to provide insight into the mechanisms underpinning the enactment of collective leadership.

METHODS

This IPT was informed by a multiple-method data collection process. The first stage involved a realist synthesis of the literature on collective leadership interventions in healthcare settings (n = 21 studies). Next, we presented initial findings to receive feedback from a realist research peer support group. Interviews with members of teams identified as working collectively (n = 23) were then conducted and finally, we consulted with an expert panel (n = 5). Context-mechanism-outcome configurations (CMOCs) were extrapolated to build and iteratively refine the programme theory and finalise it for testing.

RESULTS

Twelve CMOCs were extrapolated from these data to form the initial programme theory and seven were prioritised by the expert panel for focused testing. Contextual conditions that emerged included team training on-site, use of collaborative/co-design strategies, dedicated time for team reflection on performance, organisational and senior management support, inclusive communication and decision-making processes and strong supportive interpersonal relationships within teams. Mechanisms reported include motivation, empowerment, role clarity, feeling supported and valued and psychological safety which led to outcomes including improvements in quality and safety, staff and patient satisfaction, enhanced team working, and greater willingness to share and adopt leadership roles and responsibilities.

CONCLUSIONS

This study has identified preliminary support for the contexts, mechanisms and outcomes underpinning the practice of collective leadership. However, it must be noted that while they may appear linear in presentation, in reality they are independent and interlinked and generative of additional configurations. This paper contributes to the nascent literature through addressing an identified gap in knowledge by penetrating below the surface level inputs and outputs of an intervention to understand why it works or doesn't work, and for whom it may work.

Interventions to develop collectivistic leadership in healthcare settings: a systematic review

Background

Collective or shared leadership approaches have been associated with team performance outcomes in several sectors. Based on this evidence, there have been calls for more inclusive approaches to leadership in healthcare settings, but guidance on how to achieve collective leadership is lacking. This study synthesised knowledge of interventions to introduce collectivistic leadership in healthcare settings.

Methods

The databases of PubMed, PsychInfo, ABI Inform, Cochrane and CINAHL and three grey literature databases were searched. Studies from any country were included if they reported on the development and evaluation and/or implementation of training/interventions to develop collectivistic leadership and reported individual and/or team-level outcomes. Results were synthesised using a narrative approach.

Results

The searches yielded 4448 records of which 21 met the eligibility criteria and were reviewed. Studies used a variety of interventions; eleven employed a team training approach, four described co-leadership, three explored service improvement, two detailed co-design approaches and one described an individual team development intervention. Most demonstrated moderate to good success in enabling collectivistic leadership, with benefits reported in staff engagement, satisfaction, and team performance.

Conclusions

Whilst collectivistic leadership interventions have demonstrated positive outcomes, there is a need for more rigor and consistency in the evaluation of interventions aimed at developing collectivistic leadership approaches in health settings.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3883-x) contains supplementary material, which is available to authorized users.

Leading on the edge: The nature of paramedic leadership at the front line of care

BACKGROUND

Health care organizations are considered complex systems that represent both formal leadership as well as more informal and shared leadership models. Implementing these models is essential for optimizing care and patient outcomes. The paramedic profession specifically, although considered informally, leads out of hospital patient care.

PURPOSE

To date, few empirical studies investigate shared leadership in health care settings. In paramedicine specifically, studies of leadership are scarce, despite paramedics' essential role in leading on the front lines of care. Using an exemplar of paramedics, we examine what it means to informally lead on the front lines of patient care with the emphasis on paramedics responding out of hospital.

METHODOLOGY

We employed a qualitative, semistructured interview methodology with 29 paramedics from a group of companies in central/eastern Canada to explore the conditions and practices surrounding shared leadership.

FINDINGS

Paramedics argue that, despite their job title, they classify themselves as informal leaders who share the leadership role. More specifically, the paramedics discuss the precursors, practices, and structural conditions surrounding shared leadership within the realm of emergency medical services. They note that they often face out-of-hospital care without a formal manager, requiring them to collectively lead. The leader will shift in times of urgency, and this is contingent on their skills and competence. Furthermore, managers routinely called upon paramedics to lead in their absence.

PRACTICE IMPLICATIONS

It is shown here that, although informally enacted, paramedics view leadership as a necessary competency for clinical practice. We argue that leadership development of paramedics must begin during their formal education and training as part of the core curriculum. As well, direct managers can promote an environment of shared leadership and encourage paramedics to practice leadership with quality of patient service in mind.

Nursing leadership in Ireland: experiences and obstacles

PURPOSE

This paper aims to investigate nurses' experiences of leadership within health care in the Republic of Ireland.

DESIGN/METHODOLOGY/APPROACH

This mainly qualitative study made use of a mail survey sent to a random national selection of registered nurses. Participants were asked to provide narrative descriptors of good nursing leadership and identify obstacles to such leadership.

FINDINGS

Participants mainly provided examples of nursing leadership within a hierarchical context (concentrated leadership), such as meeting organisational goals and decision-making. While elements of distributed leadership were mentioned (good communication, providing help and support), they were mainly described as part of formal management roles, rather than leadership. Observed obstacles to developing nursing leadership included high workload, lack of support from management and peers, limited opportunities to gain experience, lack of education/training and poor work environments.

RESEARCH LIMITATIONS/IMPLICATIONS

The small sample (n = 72) limits generalisation. A wider interdisciplinary effort to address experiences with nursing leadership in Ireland may be needed to inform health services of the issues from a broader perspective.

PRACTICAL IMPLICATIONS

The findings suggest that development of nursing leadership in Ireland may still be in its infancy, and that several obstacles need to be overcome.

ORIGINALITY/VALUE

Very few studies have addressed narratives from nurses regarding personal experiences with nursing leadership. The examples provided by participants have yielded significant insight into the issues they encounter, which are reflective of health care elsewhere.

Quality improvement in physiotherapy services

Purpose The purpose of this paper is to evaluate a process change in physiotherapy services and to explore factors that may have influenced the outcomes. Design/methodology/approach This is a multiple case study and information was gathered from eight physiotherapy teams over 24 months. Findings The process change was successfully implemented in six teams. It had a clear, positive effect on service quality provided to patients in three teams. Whilst quality also improved in three other teams, other issues make changes difficult to assess. Factors that enabled process change to be effective are suggested. Research limitations/implications The findings are based on results achieved by only eight English teams. Practical implications This process change may be appropriate for other teams providing therapy services if attention is paid to potential enabling factors, and a learning approach is adopted to designing and introducing the change. Originality/value To the best of the authors' knowledge, no other longitudinal process change study in therapy services has been published.

Making sense of effective partnerships among senior leaders in the National Health Service

BACKGROUND

Changing health care systems depend on strong organizational leadership that realizes the collaborative potential of both physician and nonphysician leaders.

PURPOSE

The aim of this study was to seek insight into the everyday health care leader experience by examining 24 physician and nonphysician leaders working in the U.K. National Health Service. We explored (a) how they make sense of and act with respect to specific collaborative tensions in their interactions and (b) which aspects of their everyday leadership contexts heighten the probability for producing and resolving such tensions.

METHODOLOGY

We conducted 24 in-depth interviews with physician and nonphysician leaders in job titles including Chief Operating Officer, Managing Director, Medical Director, and Clinical Director. Ideas from the social psychological perspectives of sensemaking, organizational role theory, and organizational citizenship behavior helped frame the study.

RESULTS

We identified four areas of ongoing tension between senior leaders. Each of these was linked to a set of underlying drivers, with the strongest support for drivers with interpersonal roots. Effective strategies for resolving tensions involved significant effort by leaders at improving the interpersonal dynamics associated with everyday interaction and forging relational connections through enhanced trust within the leadership team.

CONCLUSION

This study outlines the organizational and individual characteristics that lend to effective collaboration among senior health care leadership and the types of collaborative tensions likely to be experienced by senior health care leaders.

PRACTICE IMPLICATIONS

Organizations should provide greater role clarity for senior leadership roles, promote "soft" interpersonal competencies within them, and better assess potential leaders for success in senior roles. Organizational support in the form of facilitation, time, and spaces to learn together can provide a better context for collaborative decision-making.