The medical leadership challenge in healthcare is an identity challenge

Untangling the perception of value in value-based healthcare - an interview study

PURPOSE

Value-based health care (VBHC) argues that health-care needs to re-focus to maximise value creation, defining value as the quota when dividing the outcomes important for the patient, by the cost for health care to deliver such outcomes. This study aims to explore the perception of value among different stakeholders involved in the process of implementing VBHC at a Swedish hospital to support leaders to be more efficient and effective when developing health care.

DESIGN/METHODOLOGY/APPROACH

Participants comprised 19 clinicians and non-clinicians involved in the implementation of VBHC. Semi-structured interviews were conducted and content analysis was performed.

FINDINGS

The clinicians described value as a dynamic concept, dependent on the patient and the clinical setting, stating that improving outcomes was more important than containing costs. The value for non-clinicians appeared more driven by the interplay between the outcome and the cost. Non-clinicians related VBHC to a strategic framework for governance or for monitoring different continuous improvement processes, while clinicians appreciated VBHC, as they perceived its introduction as an opportunity to focus more on outcomes for patients and less on cost containment.

ORIGINALITY/VALUE

There is variation in how clinicians and non-clinicians perceive the key concept of value when implementing VBHC. Clinicians focus on increasing treatment efficacy and improving medical outcomes but have a limited focus on cost and what patients consider most valuable. If the concept of value is defined primarily by clinicians' own assumptions, there is a clear risk that the foundational premise of VBHC, to understand what outcomes patients value in their specific situation in relation to the cost to produce such outcome, will fail. Health-care leaders need to ensure that patients and the non-clinicians' perception of value, is integrated with the clinical perception, if VBHC is to deliver on its promise.

Evidence behind the exhortation? A rapid review of servant leadership's influence and claims in healthcare over the last decade

Servant leadership is an other-oriented approach to leadership with multiple positive outcomes. However, its influence in the context of medicine, particularly on healthcare leaders, is less clear. We conducted a rapid review to examine the impact of servant leadership in healthcare over the last decade. We included a total of 28 articles, 26 of which described beneficial organisational, relational and personal outcomes of servant leadership. However, most of these were either conceptual or opinion-based articles. Moreover, most quantitative studies were cross-sectional, precluding causal inferences. Our review demonstrates that the purported positive association between servant leadership and healthcare outcomes lacks a strong evidence base. We conclude by calling for more rigorous empirical research to examine the effects and potential challenges of implementing servant leadership in healthcare contexts.

Physicians as leaders: a systematic review through the lens of expert leadership

PURPOSE

The purpose of this paper is to provide a systematic review of the current state of physician leadership. Theory of expert leadership (TEL) was applied to explore the effects of physician inherent knowledge, industry experience and leadership capabilities on leader behaviors and outcomes.

DESIGN/METHODOLOGY/APPROACH

This review (August 2011-February 2022) applied the preferred reporting items for systematic review and meta-analysis strategy. Our search began with 3,537 studies and a final sample of 12 articles.

FINDINGS

The findings offer a number of studies that note the relationship between physician leadership and the three dimensions of TEL. How influential these are on leadership behaviors and health-related outcomes varies. We also found a number of studies that described general physician leadership behaviors that were not directly linked to factors of TEL, as well as two additional themes: leader identity and trust.

ORIGINALITY/VALUE

To the best of the authors' knowledge, this is the first systematic review that has applied a highly cited theory (i.e. TEL) to the data and the first that has focused solely on a U.S. population. These findings offer healthcare organizations insight into the potential strengths and challenges of physician leadership.

Features that hindered the capacity development of a national prostate cancer service

Introduction

In Scotland, prostate cancer services have struggled to meet demand, and urological cancer services have missed Scottish Government waiting time targets to a greater extent than other cancer services. This study provides understanding of the capacity development needs of a national prostate cancer service including why the service had been unable to adapt to meet demand and how capacity could be developed.

Methods

Delphi technique was applied to a purposive sample of prostate cancer clinicians working across Scotland between 2015 and 2017. Interviews were conducted with healthcare professionals involved in delivery of care to people with prostate cancer including General Practitioners, followed by questionnaires which were distributed to Specialist Nurses, Oncologists and Urologists involved in delivering specialist prostate cancer services within NHS Scotland. Findings are reported from interviews analysed using a directed approach to content analysis, followed by three rounds of iterative online questionnaires analysed using descriptive statistics.

Results

Reform is needed to meet demand within prostate cancer services in Scotland. Barriers to capacity development included: lack of shared understanding of quality of care between policy makers and healthcare professionals; lack of leadership of service developments nationally and regionally; and difficulties in drawing on other capacities to support the service. Cohesive working and a need for efficient training for nurse specialists were needed to develop capacity. Consensus was reached for development of national working groups to set standards for quality care (100% agreement) and further development of existing regional working groups (100% agreement) to implement this care (91% agreement), which should include input from primary and community care practitioners (100% agreement) to meet demand.

Discussion

This work provides important understanding of barriers and facilitators to service development across a national service, including highlighting the importance of a shared vision for quality care between policy makers and healthcare professionals. Mechanisms to support service change are identified.

Examining the differences between physician and administrative leaders at Cleveland Clinic and the implications for leadership development programming

BACKGROUND

The healthcare industry is currently facing unprecedented challenges, and the need for effective leadership has never been higher. One way organisations might address the need for healthcare leadership is through tailored leadership development programmes, which are designed to maximise impact. This research sought to examine potential differences between physician and administrative leaders' unique needs and to use this information to inform the design of future leadership development programmes.

METHODS

Survey data from a sample of international leaders who participated in cohort-based leadership development programmes at the Mandel Global Leadership and Learning Institute at Cleveland Clinic were examined to explore potential differences between physician and administrative leaders in order to cultivate future training outcomes.

RESULTS

Findings demonstrate that there are significant differences in personality, motivation to lead and leadership self-efficacy between the two populations at Cleveland Clinic.

CONCLUSIONS

These results indicate how understanding specific traits, motivations and developmental needs of the target audience may guide the development of more effective leadership development programming. Future directions for addressing leadership development in the healthcare industry are also discussed.

A scoping review of co-creation practice in the development of non-pharmacological interventions for people with Chronic Obstructive Pulmonary Disease: A health CASCADE study

BACKGROUND

Incorporating co-creation processes may improve the quality of outcome interventions. However, there is a lack of synthesis of co-creation practices in the development of Non-Pharmacological Interventions (NPIs) for people with Chronic Obstructive Pulmonary Disease (COPD), that could inform future co-creation practice and research for rigorously improving the quality of care.

OBJECTIVE

This scoping review aimed to examine the co-creation practice used when developing NPIs for people with COPD.

METHODS

This review followed Arksey and O'Malley scoping review framework and was reported according to the PRISMA-ScR framework. The search included PubMed, Scopus, CINAHL, and Web of Science Core Collection. Studies reporting on the process and/or analysis of applying co-creation practice in developing NPIs for people with COPD were included.

RESULTS

13 articles complied with the inclusion criteria. Limited creative methods were reported in the studies. Facilitators described in the co-creation practices included administrative preparations, diversity of stakeholders, cultural considerations, employment of creative methods, creation of an appreciative environment, and digital assistance. Challenges around the physical limitations of patients, the absence of key stakeholder opinions, a prolonged process, recruitment, and digital illiteracy of co-creators were listed. Most of the studies did not report including implementation considerations as a discussion point in their co-creation workshops.

CONCLUSION

Evidence-based co-creation in COPD care is critical for guiding future practice and improving the quality of care delivered by NPIs. This review provides evidence for improving systematic and reproducible co-creation. Future research should focus on systematically planning, conducting, evaluating, and reporting co-creation practices in COPD care.

ASCO's Leadership Development Program: Focusing on the Next Generation of Leaders in Asia Pacific

PURPOSE

The demand for high-quality and more comprehensive oncology care will continue to rise globally. Effective leadership is particularly important.

METHODS

The evolving endeavor of ASCO to reach out globally has covered the development of the next-generation leaders from Asia Pacific. Through the Leadership Development Program, the untapped talent of the region and the future leaders in oncology will gain the knowledge and skill sets, which prepares them to navigate the complex dynamics of oncology health care.

RESULTS

The region is the largest and the most populous with more than 60% of the world's population. It has 50% of cancer cases and is estimated to account for 58% of cancer deaths worldwide. The demand for high-quality and more comprehensive oncology care will continue to rise in the years to come. This growth will intensify the need for capable leaders. Leadership styles and behaviors are different. These are shaped within the context of cultural and philosophical views and beliefs. The pan-Asian interdisciplinary group of young leaders are expected to gain knowledge and skillsets through the Leadership Development Program. They will learn to work on strategic projects within a team and gain knowledge about advocacy. Communication and presentation skills and conflict management are also important components of the program. Through learning culturally relevant skills, participants can effectively collaborate with others, build relationships, and lead within their own institutions and societies and within ASCO.

CONCLUSION

Institutions and organizations need to have a deeper and more sustained focus on leadership development. Successfully addressing the challenges on leadership development in Asia Pacific is important.

Nurturing innovative culture in a healthcare organisation - Lessons from a Swedish case study

PURPOSE

Healthcare organisations are often described as less innovative than other organisations, since organisational culture works against innovations. In this paper, the authors ask whether it has to be that way or whether is possible to nurture an innovative culture in a healthcare organisation. The aim of this paper is to describe and analyse nurturing an innovative culture within a healthcare organisation and how culture can support innovations in such a healthcare organisation.

DESIGN/METHODOLOGY/APPROACH

Based on a qualitative case study of a healthcare unit that changed, within a few years, from having no innovations to repeatedly generating innovations, the authors describe important aspects of how innovative culture can be nurtured in healthcare. Data were analysed using inductive and deductive analysis steps.

FINDINGS

The study shows that it is possible to nurture an innovative culture in a healthcare organisation. Relationships and competences beyond healthcare, empowering structures and signalling the importance of innovation work with resources all proved to be important. All are aspects that a manager can influence. In this case, the manager's role in nurturing innovative culture was very important.

PRACTICAL IMPLICATIONS

This study highlights that an innovative culture can be nurtured in healthcare organisations and that managers can play a key role in such a process.

ORIGINALITY/VALUE

The paper describes and analyses an innovative culture in a healthcare unit and identifies important conditions and strategies for nurturing innovative culture in healthcare organisations.

How hospital top managers reason about the central leadership task of balancing quality of patient care, economy and professionals' engagement: an interview study

PURPOSE

This study aims to deepen the understanding of how top managers reason about handling the relationships between quality of patient care, economy and professionals' engagement.

DESIGN/METHODOLOGY/APPROACH

Qualitative design. Individual in-depth interviews with all members of the executive management team at an emergency hospital in Norway were analysed using reflexive thematic method.

FINDINGS

The top managers had the intention to balance between quality of patient care, economy and professionals' engagement. This became increasingly difficult in times of high internal or external pressures. Then top management acted as if economy was the most important focus.

PRACTICAL IMPLICATIONS

For health-care top managers to lead the pursuit towards increased sustainability in health care, there is a need to balance between quality of patient care, economy and professionals' engagement. This study shows that this balancing act is not an anomaly top-managers can eradicate. Instead, they need to recognize, accept and deliberately act with that in mind, which can create virtuous development spirals where managers and health-professional communicate and collaborate, benefitting quality of patient care, economy and professionals' engagement. However, this study builds on a limited number of participants. More research is needed.

ORIGINALITY/VALUE

Sustainable health care needs to balance quality of patient care and economy while at the same time ensure professionals' engagement. Even though this is a central leadership task for managers at all levels, there is limited knowledge about how top managers reason about this.

Catholic Ownership, Physician Leadership and Operational Strategies: Evidence from German Hospitals

Previous research has revealed that Catholic hospitals are more likely follow a strategy of horizontal diversification and maximization of the number of patients treated, whereas Protestant hospitals follow a strategy of horizontal specialization and focus on vertical differentiation. However, there is no empirical evidence pertaining to this mechanism. We conduct an empirical study in a German setting and argue that physician leadership mediates the relationship between ownership and operational strategies. The study includes the construction of a model combining data from a survey and publicly available information derived from the annual quality reports of German hospitals. Our results show that Catholic hospitals opt for leadership structures that ensure operational strategies in line with their general values, i.e., operational strategies of maximizing volume throughout the overall hospital. They prefer part-time positions for chief medical officers, as chief medical officers are identified to foster strategies of maximizing the overall number of patients treated. Hospital owners should be aware that the implementation of part-time and full-time leadership roles can help to support their strategies. Thus, our results provide insights into the relationship between leadership structures at the top of an organization, on the one hand, and strategic choices, on the other.

Clinicians' psychological empowerment to engage in management as part of their daily work

PURPOSE

The purpose of the article is to analyze how physicians and nurses, as the two major health care professions, experience psychological empowerment for managerial work.

DESIGN/METHODOLOGY/APPROACH

The study was designed as a qualitative interview study at four primary care centers (PCCs) in Sweden. In total, 47 interviews were conducted, mainly with physicians and nurses. The first inductive analysis led us to the concept of psychological empowerment, which was used in the next deductive step of the analysis.

FINDINGS

The study showed that both professions experienced self-determination for managerial work, but that nurses were more dependent on structural empowerment. Nurses experienced that they had competence for managerial work, whereas physicians were more ignorant of such competence. Nurses used managerial work to create impact on the conditions for their clinical work, whereas physicians experienced impact independently. Both nurses and physicians experienced managerial work as meaningful, but less meaningful than nurses and physicians' clinical work.

PRACTICAL IMPLICATIONS

For an effective health care system, structural changes in terms of positions, roles, and responsibilities can be an important route for especially nurses' psychological empowerment.

ORIGINALITY/VALUE

The qualitative method provided a complementary understanding of psychological empowerment on how psychological empowerment interacted with other factors. One such aspect was nurses' higher dependence on structural empowerment, but the most important aspect was that both physicians and nurses experienced that managerial work was less meaningful than clinical work. This implies that psychological empowerment for managerial work may only make a difference if psychological empowerment does not compete with physicians' and nurses' clinical work.

Exploration of the mediating role of physicians' managerial attitude in the relationship between their self-efficacy and workplace performance

PURPOSE

Self-efficacy, or a person's belief in his/her ability to perform specific tasks, has been correlated with workplace performance and role adjustments. Despite its relevance, and numerous studies of it in the management literature, evidence regarding its function in professionals employed in hybrid roles, such as doctor-managers, is lacking. The aim of this study was to fill this gap by exploring the mediating effect of physicians' managerial attitude on the relationship between their self-efficacy and workplace performance.

DESIGN/METHODOLOGY/APPROACH

Primary and secondary data from 126 doctor-managers were obtained from the Italian National Health Service. A structural equation modeling approach was used for analysis.

FINDINGS

This study's results provide for the first time empirical evidence about a surprisingly little-analyzed topic: how physicians' managerial attitude mediates the relationship between their self-efficacy and workplace performance. The study offers important evidence both for scholars and organizations.

PRACTICAL IMPLICATIONS

This study's results provide valuable input for the human resources management of hybrid roles in professional-based organizations, suggesting a systematic provision of feedback about doctor-managers' performance, the adoption of a competence approach for their recruitment, and a new design of doctor-managers' career paths.

ORIGINALITY/VALUE

The authors provide new evidence about the importance of managerial traits for accountable healthcare organizations, documenting that behavioral traits of physicians enrolled into managerial roles matter for healthcare organizations success.

Exploring developmental assignments shaping experience-driven acquisition of leadership competencies in young clinicians

BACKGROUND

Experiential leadership development is well documented in the corporate sector, but those models cannot be applied as is, in the healthcare domain. The current study proposes a framework for the healthcare sector to enable experiential leadership development for young clinicians. The authors identify developmental assignments (DAs) and explore those characteristics [developmental assignment characteristics; DACs] therein that help develop leadership competencies in young clinicians.

METHODS

As part of a qualitative exploratory study in Pakistan, the authors conducted 16 semi-structured interviews with senior clinicians in leadership positions with post-graduate residents under their supervision from different medical specialties. The participants were selected through purposive sampling, ensuring a maximum variation sample. Focusing on participants' experiences and perspectives related to experience-driven leadership development, the authors used a multi-level theoretical framework for analysis.

RESULTS

The thematic analysis resulted in 19 subthemes with four overarching themes for both objectives. The authors categorized the developmental assignments (DAs) into clinical, academic, and administrative assignments. These assignments can be utilized for leadership development by ensuring that they have the requisite characteristics built into their context and structure. These developmental assignment characteristics (DACs) can range from learner-driven to supervisor-driven. The learner-driven characteristics include autonomy, high levels of responsibilities, unfamiliar assignments, working across boundaries, managing diversity, making a commitment, and creating change. The supervisor-driven characteristics include briefing, debriefing, accountability, and learner-assignment matching. The authors also developed a learner-assignment matching (LAM) framework to guide supervisors in customizing and adjusting the level of each DAC in a DA.

CONCLUSION

A modern healthcare educational system can utilize studies like this to enable supervisors to develop required leadership skills in young clinicians along with clinical skills.

Decentralized Identity Management for E-Health Applications: State-of-the-Art and Guidance for Future Work

BACKGROUND

The increasing use of various online services requires an efficient digital identity management (DIM) approach. Unfortunately, the original Internet protocols were not designed with built-in identity management, which creates challenges related to privacy, security, and usability. There is an increasing societal concern regarding the management of these sensitive data, access to it, and where it is stored. Blockchain technology can potentially offer a secure solution to address these issues in a decentralized manner without centralized authority. This is important for e-health services where the patient and the healthcare provider often are required to prove their identity. Blockchain technology can be utilized for creating digital identities and making its management easier, thus giving a higher degree of control to the user than what current solutions offer. It can be used to create a digital identity on the blockchain, making it easier for individuals and entities to manage, giving them greater control over who has their personal information and how they handle it. In addition, it might be utilized to create a higher degree of trust and security for e-health applications.

OBJECTIVE

The aim of this research work was to review the state-of-the-art regarding blockchain-based decentralized identity management for healthcare applications. Based on this summary, we provide a viewpoint on how blockchain-based decentralized identity frameworks might be utilized for virtualized healthcare applications.

METHODS

This research study applied a scoping, semi-systematic review approach to summarize the state-of-the-art. Included identity management systems were evaluated based on seven criteria: autonomy, authority, availability, approval, confidentiality, tenacity, and Interoperability.

RESULTS

Seven blockchain-based identity management systems were included and evaluated in this work: these include solutions built with Ethereum, Hyperledger Indy, Hyperledger Fabric, Hedera, and Sovrin blockchains.

CONCLUSIONS

DIM is crucial for virtual health care. Decentralized identity management for healthcare purposes is currently being explored in both academia and the private sector. More work is needed with the aim of improving the efficiency of current DIM solutions and to fully understand what technical frameworks are best suited for e-health applications.

Family members as hybrid owner-managers in family-owned newspaper companies: handling multiple institutional logics

Purpose

This article aims to increase the understanding of the role of individual actors and arenas in dealing with multiple institutional logics in family firms.

Design/methodology/approach

This study follows a case-study approach of two family-owned newspaper companies. Based on interviews and secondary sources, the empirical material was analysed focussing on three institutional logics, that is, family logic, management logic and journalistic logic.

Findings

First, the authors show how and in which arenas competing logics are balanced in family-owned newspaper companies. Second, the authors highlight that family owners are central actors in the process of balancing different institutional logics. Further, they analyse how family members can become hybrid owner-managers, meaning that they have access to all institutional logics and become central actors in the balancing process.

Originality/value

The authors reveal how multiple institutional logics are balanced in family firms by including formal actors and arenas as additional lenses. Therefore, owning family members, especially hybrid owner-managers, are the best-suited individual actors to balance competing logics. Hybrid owner-managers are members of the owner families who are also skilled in one or several professions.

Just a leader? Leadership work challenges and identity contradiction experienced by Finnish physician leaders

Purpose

This study seeks to improve the understanding of physician leaders' leadership work challenges.

Design/methodology/approach

The subjects of the empirical study were physician leaders ( n  = 23) in the largest central hospital in Finland.

Findings

A total of five largely identity-related, partially paradoxical dilemmas appeared regarding why working as “just a leader” is challenging for physician leaders. First, the dilemma of identity ambiguity between being a physician and a leader. Second, the dilemma of balancing the expected commitment to clinical patient work by various stakeholders and that of physician leadership work. Third, the dilemma of being able to compensate for leadership skill shortcomings by excelling in clinical skills, encouraging physician leaders to commit to patient work. Fourth, the dilemma of “medic discourse”, that is, downplaying leadership work as “non-patient work”, making it inferior to patient work. Fifth, the dilemma of a perceived ethical obligation to commit to patient work even if the physician leadership work would be a full-time job. The first two issues support the findings of earlier research, while the remaining three emerging from the authors’ analysis are novel.

Practical implications

The authors list some of the practical implications that follow from this study and which could help solve some of the challenges.

Originality/value

This study explores physician leaders' leadership work challenges using authentic physician leader data in a context where no prior empirical research has been carried out.

Orthopedist involvement in the management of clinical activities: a case study

BACKGROUND

The rapid shift in hospital governance in the past few years suggests greater orthopedist involvement in management roles, would have wide-reaching benefits for the efficiency and effectiveness of healthcare delivery. This paper analyzes the dynamics of orthopedist involvement in the management of clinical activities for three orthopedic care pathways, by examining orthopedists' level of involvement, describing the implications of such involvement, and indicating the main responses of other healthcare workers to such orthopedist involvement.

METHODS

We selected four contrasting cases according to their level of governance in a Canadian university hospital center. We documented the institutional dynamics of orthopedist involvement in the management of clinical activities using semi-structured interviews until data saturation was reached at the 37th interview.

RESULTS

Our findings show four levels (Inactive, Reactive, Contributory and Active) of orthopedist involvement in clinical activities. With the underlying nature of orthopedic surgeries, there are: (i) some activities for which decisions cannot be programmed in advance, and (ii) others for which decisions can be programmed. The management of unforeseen events requires a higher level of orthopedist involvement than the management of events that can be programmed.

CONCLUSIONS

Beyond simply identifying the underlying dynamics of orthopedists' involvement in clinical activities, this study analyzed how such involvement impacts management activities and the quality-of-care results for patients.

The Chief Registrar role in the UK: leadership capacity and development of hybrid leaders

PURPOSE

The purpose of the study is to evaluate the first cohort of the Royal College of Physicians' (RCP) Chief Registrar programme in 2016/7. Chief Registrars provide medical leadership capacity through leadership development posts.

DESIGN/METHODOLOGY/APPROACH

The study adopted a mixed methods design, comprising a monthly survey of the 21 Chief Registrars in the first cohort, interviews with Chief Registrars, and six cases studies where Chief Registrars and colleagues were interviewed.

FINDINGS

Chief Registrars enjoyed high levels of practical, professional, and leadership support from their employing organisations, the RCP, and the Faculty of Medical Leadership and Management. They had high degrees of autonomy in their roles. As a result, roles were enacted in different ways, making direct comparative evaluation problematic. In particular, we identified variation on two dimensions: first, the focus on medical leadership generally, or quality improvement more specifically, and second, the focus on personal development or organisational leadership capacity.

RESEARCH LIMITATIONS/IMPLICATIONS

The data are limited and drawn from the first cohort's experience. The Chief Registrar scheme, unlike many other leadership fellowships, maintains a high level of clinical practice (with a minimum 40 per cent leadership work). This suggests a clearer preparation for future hybrid leadership roles.

PRACTICAL IMPLICATIONS

This paper may offer some support and guidance for Chief Registrars and those who work with and support them.

ORIGINALITY/VALUE

This study adds to the literature on leadership development for doctors in hybrid roles, and highlights the distinctiveness of the scheme compared with other schemes.

Cultural dynamics and tensions when applying design thinking for improving health-care quality

Purpose

The purpose of this paper is to contribute knowledge concerning the dynamics and potential cultural tensions that occur when applying user involvement and design thinking (DT) for improving quality in a health-care setting.

Design/methodology/approach

This paper is based on a case study following a quality improvement (QI) project in a medium-sized Swedish county council in the field of somatic care. The project involved eight health-care professionals, one designer, four patients and two relatives. A multiple data collection method over a period of ten months was used. It included individual interviews, e-mail correspondence and observations of workshops that covered the QI project.

Findings

The result shows tensions between QI work and the daily clinical work of the participants. These tensions primarily concern the conflict between fast and slow processes, the problem of moving between different fields of knowledge, being a resource for the individual clinic and the system and the participants’ expectations and assumptions about roles and responsibilities in a QI project. Furthermore, these findings could be interpreted as signs of a development culture in the health-care context.

Practical implications

There are several practical implications. Among others, the insights can inspire how to approach and contextualize the current concepts, roles and methods of DT and user involvement so that they can be more easily understood and integrated into the existing culture and way of working in the health-care sector.

Originality/value

This study provides a unique insight into a case, trying to uncover what actually is going on and perhaps, why certain things are not happening at all, when user involvement and design practices are applied for improving health-care quality.

Managerial Strategies for Long-Term Care Organization Professionals: COVID-19 Pandemic Impacts

This paper aims to analyze the strategies that healthcare professionals have adopted during the coronavirus pandemic (COVID-19) in long-term care organizations in Rio de Janeiro city, Brazil, by investigating their competencies—mainly managerial ones. To reach its goals, this paper performs empirical research and theoretical research. For the empirical research, the plans of professionals during COVID-19 pandemic in long-term care organizations are observed, and a questionnaire is applied to analyze observed data integrity. The data are analyzed through the Python and IBM SPSS Statistic programming languages, and descriptive analyses use descriptive statistic proportions, rates, minimum, maximum, mean, median, standard deviation, and coefficient of variation (CV). A non-parametric approach performs repeated measure comparisons using Wilcoxon’s test, while the McNemmar test is used to repeat the categorical variables. Statistical significance is assumed at the 5% level. For the theoretical research, a literature review is developed using scientific databases. The results show that for the searched period, the number of deaths and the number of people infected by COVID-19 in these organizations are low when compared to general statistics of Rio de Janeiro city. This paper concludes that these strategical adoptions have brought significant benefits to long-term care organizations, and it might motivate researchers to develop future studies related to long-term care organizations, helping to fill the literature gap on the subject.

Identity and relationship frames in medical leadership communication

PURPOSE

A frame is an interpretive scheme of meanings that guide participants' interpretations of social interaction and their actions in social situations (Goffman, 1974). By identifying early-career physicians' identity and relationship frames, this study aims to produce information about socially constructed ways to interpret leadership communication in a medical context.

DESIGN/METHODOLOGY/APPROACH

The data consist of essays written by young physicians (n = 225) during their specialization training and workplace learning period. The analysis was conducted applying constructive grounded theory.

FINDINGS

Three identity and relationship frames were identified: the expertise frame, the collegial frame and the system frame. These frames arranged the meanings of being a physician in a leader-follower relationship differently.

ORIGINALITY/VALUE

The findings suggest that identity questions discussed recently in medical leadership studies can be partly answered with being aware of and understanding socially constructed and somewhat contradictory frames.

Changing to improve? Organizational change and change-oriented leadership in hospitals

PURPOSE

This paper aims to fill gaps in one's knowledge of the impact of organizational change on two outcomes relevant to hospital service quality (performance obstacles and physician job satisfaction) and in one's knowledge of the role of middle manager change-oriented leadership in relation to the same outcomes. Further, the authors aim to identify how physician participation in decision-making is impacted by organizational change and change-oriented leadership, as well as how it mediates the relationships between these two variables, performance obstacles and job satisfaction.

DESIGN/METHODOLOGY/APPROACH

The study adopted a cross-sectional survey design including data from Norwegian hospital physicians (N = 556). A hypothetical model was developed based on existing theory, confirmatory factor analysis was carried out in order to ensure the validity of measurement concepts, and the structural model was estimated using structural equation modelling.

FINDINGS

The organizational changes in question were positively related to performance obstacles both directly and indirectly through participation in decision-making. Organizational change was also negatively related to job satisfaction, both directly and indirectly. Change-oriented leadership was negatively related to performance obstacles, but only indirectly through participation in decision-making, whereas it was positively related to job satisfaction both directly and indirectly.

ORIGINALITY/VALUE

The authors developed a theoretical model based on existing theory, but to their knowledge no other studies have tested these exact relationships within one model. These findings offer insights relevant to current and ongoing developments in the healthcare field and to the question of how hospitals may deal with continuous changes in ways that could contribute positively towards outcomes relevant to service quality.

Motivating doctors into leadership and management: a cross-sectional survey

Purpose

Calls for doctors to enter management are louder as the benefits of medical leadership become clearer. However, supply is not meeting demand. This study asks doctors (physicians): what might encourage you to go into leadership, and what are the disincentives? The same was asked about leadership training. First, the paper tries to understand doctors’ motivation to lead, specifically, to explore the job characteristics that act as incentives and disincentives. Second, the study points to organisational obstacles that further shrink the medical leadership pipeline.

Method

Doctors were surveyed through the Organization of Danish Medical Societies. Our key variables included: (1) the incentives and disincentives for doctors of going into leadership and management and (2) the motivation to participate in leadership training. Our sample of 3534 doctors (17% response) is representative of the population of doctors in Denmark.

Findings

The main reason why doctors are motivated towards leadership is to make a difference. They are put off by fears of extra administration, longer hours, burnout, lack of resources and by organisational cultures resistant to change. However, doctors are aware of their need for leadership development prior to entering management.

Practical implications

To improve succession planning, health systems should adapt to reflect the incentives of their potential medical leaders. Leadership training is also essential. These changes are especially important now; medical leaders are linked positively to organisational and patient outcomes and have been central in responding to COVID-19, stress and burnout among clinical staff continues to rise, and health systems face recruitment and retention challenges.

Providing healthcare through “value shops”: impact on professional fulfilment for physicians and nurses

Purpose

The purpose of this paper is to empirically explore and demonstrate the ability of healthcare professionals to attain professional fulfilment when providing healthcare inspired by “value shops”.

Design/methodology/approach

A qualitative case study incorporating interviews and observations was conducted.

Findings

The empirical data suggest that the professional fulfilment of both physicians and nurses is facilitated when care is organized through “value shops”. Both groups of professionals state that they are able to return to their “professional core”.

Originality/value

The beneficial outcomes of organizing healthcare inspired by the “value shop” have previously been explored in terms of efficiency and quality. However, the professional fulfilment of healthcare professionals when providing such care has not been explicitly addressed. Professional fulfilment is vital in order to safeguard high-quality care, as well as healthcare professionals' involvement and engagement in implementing quality improvements. This paper highlights the fact that care provision inspired by the “value shop” may facilitate professional fulfilment, which further strengthens the potential positive outcomes of the “value shop” when utilized in a healthcare setting.

From context to contexting: professional identity un/doing in a medical leadership development programme

Physicians are known for safeguarding their professional identities against organisational influences. However, this study shows how a medical leadership programme enables the reconstruction of professional identities that work with rather than against organisational and institutional contexts to improve quality and efficiency of care. Based on an ethnographic study, the results illustrate how physicians initially construct conflicting leadership narratives - heroic (pioneer), clinical (patient's guardian) and collaborative (linking pin) leader - in reaction to changing organisational and clinical demands. Each narrative contains a particular relational-agentic view of physicians regarding the contexts of hospitals: respectively as individually shapeable; disconnected or collectively adjustable. Interactions between teachers, participants, group discussions and in-hospital experiences led to the gradual deconstruction of the heroic -and clinical leader narrative. Collaborative leadership emerged as the desirable new professional identity. We contribute to the professional identity literature by illustrating how physicians make a gradual transition from viewing organisational and institutional contexts as pre-given to contexting, that is, continuously adjusting the context with others. When engaged in contexting, physicians increasingly consider managers and directors as necessary partners and colleague-physicians who do not wish to change as the new 'anti-identity'.

Distributed Ledger Technology for eHealth Identity Privacy: State of The Art and Future Perspective

Electronic healthcare (eHealth) identity management (IdM) is a pivotal feature in the eHealth system. Distributed ledger technology (DLT) is an emerging technology that can achieve agreements of transactional data states in a decentralized way. Building identity management systems using Blockchain can enable patients to fully control their own identity and provide increased confidence in data immutability and availability. This paper presents the state of the art of decentralized identity management using Blockchain and highlights the possible opportunities for adopting the decentralized identity management approaches for future health identity systems. First, we summarize eHealth identity management scenarios. Furthermore, we investigate the existing decentralized identity management solutions and present decentralized identity models. In addition, we discuss the current decentralized identity projects and identify new challenges based on the existing solutions and the limitations when applying it to healthcare as a particular use case.

Physician leadership style predicts advanced practice provider job satisfaction

Purpose

This paper aims to examine the relationship between physician leadership style and advanced practice health-care provider job satisfaction.

Design/methodology/approach

A total of 320 advanced practice providers (nurse practitioners and physician assistants) in Texas rated their supervising/collaborating physicians’ leadership style using the Multifactor Leadership Questionnaire 5X Short (Bass and Avolio, 2000) and assessed their own job satisfaction using the Abridged Job Descriptive Index (Smith, Kendall and Hulin, 1969). Regression models tested the relationships between physician leadership styles and several facets of job satisfaction of advanced practice providers while controlling for advanced practice provider age, gender, ethnicity, years of experience, salary level, clinical practice setting, level of physician supervision/collaboration and advanced practice provider type.

Findings

The results demonstrated that physician transformational leadership accounted for between 4.4 and 49.1 per cent of the variance in job satisfaction depending on the aspect of job satisfaction. Satisfaction with job supervision and satisfaction with job in general were those in which transformational leadership was found to have the most impact, explaining 49.1 and 15.5%, respectively. Demographic variables such as advanced practice provider type, age, years of experience and number of hours per week of physician collaboration/supervision had small but statistically significant associations with job satisfaction.

Practical implications

Recommendations for physician leadership development focusing on transformational leadership as a way to increase the satisfaction among other providers on health-care teams are discussed.

Originality/value

This paper examines the impact of supervising/delegating physician leadership style on other nonphysician members of the health-care team, specifically advanced practice health-care providers.

Exploring medical leader identity and its formation

PURPOSE

"Becoming" a doctor involves the acquisition of medical knowledge, skills and professional identity. Medical professional identity formation (MPIF) is complex, multi-factorial and closely linked to societal expectations, personal and social identity. Increasingly, doctors are required to engage in leadership/management involving significant identity shift. This paper aims to explore medical professional identity (MPI) and MPIF in relation to doctors as leaders. Selected identity theories are used to enrich the understanding of challenges facing doctors in leadership situations and two concepts are introduced: medical leader identity (MLI) and medical leader identity formation (MLIF) and consideration given to how they can be nurtured within medical practice.

DESIGN/METHODOLOGY/APPROACH

A rapid conceptual review of relevant literature was carried out to identify a set of relevant concepts and theories that could be used to develop a new conceptual framework for MLI and MLIF.

FINDINGS

MLIF is crucial for doctors to develop as medical leaders, and, like MPIF, the process begins before medical school with both identities influenced, shaped and challenged throughout doctors' careers. Individuals require support in developing awareness that their identities are multiple, nested, interconnected and change over time.

ORIGINALITY/VALUE

This paper draws on concepts from wider literature on professional identity, in relation to how doctors might develop their MLI alongside their MPI. It offers a new perspective on MPI in the light of calls on doctors to "become and be healthcare leaders" and introduces the new concepts of MLI and MLIF.

The state-of-play in physician health systems leadership research

Purpose

This paper aims to review a decade of evidence on physician participation in health system leadership with the view to better understand the current state of scholarship on physician leadership activity in health systems. This includes examining the available evidence on both physicians’ experiences of health systems leadership (HSL) and the impact of physician leadership on health system reform.

Design/methodology/approach

A state-of-the-art review of studies (between 2007 and 2017); 51 papers were identified, analyzed thematically and synthesized narratively.

Findings

Six main themes were identified in the literature as follows: (De)motivation for leadership, leadership readiness and career development, work demands and rewards, identity matters: acceptance of self (and other) as leader, leadership processes and relationships across health systems and leadership in relation to health system outcomes. There were seemingly contradictory findings across some studies, pointing to the influence of regional and cultural contextual variation on leadership practices as well entrenched paradoxical tensions in health system organizations.

Research limitations/implications

Future research should examine the influence of varying structural and psychological empowerment on physician leadership practices. Empirical attention to paradoxical tensions (e.g. between empowerment and control) in HSL is needed, with specific attention to questions on how such tensions influence leaders’ decision-making about system reform.

Originality/value

This review provides a broad synthesis of diverse papers about physician participation in health system leadership. Thus, it offers a comprehensive empirical synthesis of contemporary concerns and identifies important avenues for future research.

What makes an ideal hospital-based medical leader? Three views of healthcare professionals and managers: A case study

Medical leadership is an increasingly important aspect of hospital management. By engaging physicians in leadership roles, hospitals aim to improve their clinical and financial performances. Research has revealed numerous factors that are regarded as necessary for ‘medical leaders’ to master, however we lack insights into their relative importance. This study investigates the views of healthcare professionals and managers on what they consider the most important factors for medical leadership. Physicians (n = 11), nurses (n = 10), laboratory technicians (n = 4) and managers (n = 14) were interviewed using Q methodology. Participants ranked 34 statements on factors elicited from the scientific literature, including personal features, context-specific features, activities and roles. By-person factor analysis revealed three distinct views of medical leadership. The first view represents a strategic leader who prioritizes the interests of the hospital by participating in hospital strategy and decision making. The second view describes a social leader with strong collaboration and communication skills. The third view reflects an accepted leader among peers that is guided by a clear job description. Despite these differences, all respondents agreed upon the importance of personal skills in collaboration and communication, and having integrity and a clear vision. We find no differences in views related to particular healthcare professionals, managers, or departments as all views were defined by a mixture of departments and participants. The findings contribute to increased calls from both practice and literature to increase conceptual clarity by eliciting the relative importance of medical leadership-related factors. Hospitals that wish to increase the engagement of physicians in improving clinical and financial performances through medical leadership should focus on selecting and developing leaders who are strong strategists, socially skilled and accepted by clinical peers.

Leader identity development in healthcare: an existential-phenomenological study

PURPOSE

The purpose of this study is to take an existential-phenomenological perspective to understand and describe the experienced leader identity development of healthcare leaders working in dual roles. Leader identity development under the influence of strong professional identities of nurses and doctors has remained an under-researched phenomenon to which the study contributes.

DESIGN/METHODOLOGY/APPROACH

Existential-phenomenology serves as a perspective underpinning the whole research, and an existential-phenomenological method is applied in the interview data analysis.

FINDINGS

The study showed leader identity development in healthcare to be most strongly influenced and affected by clinical work and its meanings and followers' needs and leader-follower relationships. In addition, four other key categories were presented as meaningful in leader identity development; leader identity development is an ongoing process occurring in relations of the key categories.

ORIGINALITY/VALUE

The existential-phenomenological approach and analysis method offer a novel way to understand leader identity development and work identities as experienced.

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.

Professional employees’ strategic employment of the managerial logic in healthcare

Purpose

The purpose of this paper is to describe and analyze how physicians and nurses strategically employ the managerial logic.

Design/methodology/approach

A qualitative case study incorporating interviews and observations.

Findings

Neither physicians nor nurses were prone to strategically employing the managerial logic. However, when doing so nurses were able to acknowledge the legitimacy of managerial impact on practice, whereas the physicians were not. Consequently, physicians might find other, more subtle, ways to strategically employ the managerial logic.

Originality/value

This paper argues for and makes explicit the applicability of qualitative methods in order to delineate actors’ strategic use of available and accessible institutional logics, the conditions for such usage, as well as the multiplicity of actors’ interactions that needs to be taken into account when conducting qualitative data analysis of such occurrences. By the merits of the qualitative research approach utilized in this study, novel insights concerning the strategic use of the managerial logic in the everyday work of physicians and nurses were obtainable. These insights emphasize the necessity of acknowledging situational, organizational and institutional context, incorporating inter-professional power discrepancies and relationsvis-à-vismanagers.

The resident physician as leader within the healthcare team

Purpose The purpose of this study was to explore inter-professional clinicians' perspectives on resident leadership in the context of inter-professional teams and to identify a definition for leadership in the clinical context. In 2015, CanMEDS changed the title of one of the core competencies from manager to leader. The shift in language was perceived by some as returning to traditional hierarchical and physician-dominant structures. The resulting uncertainty has resulted in a call to action to not only determine what physician leadership is but to also determine how to teach and assess it. Design/methodology/approach Focus groups and follow-up individual interviews were conducted with 23 inter-professional clinicians from three pediatric clinical service teams at a large, Canadian tertiary-level rehabilitation hospital. Qualitative thematic analysis was used to inductively analyze the data. Findings Data analysis resulted in one overarching theme: leadership is collaborative - and three related subthemes: leadership is shared; leadership is summative; and conceptualizations of leadership are shifting. Research limitations/implications Not all members of the three inter-professional teams were able to attend the focus group sessions because of scheduling conflicts. Participation of additional clinicians could have, therefore, affected the results of this study. The study was conducted locally at a single rehabilitation hospital, among Canadian pediatric clinicians, which highlights the need to explore conceptualization of leadership across different contexts. Practical implications There is an evident need to prepare physicians to be leaders in both their daily clinical and academic practices. Therefore, more concerted efforts are required to develop leadership skills among residents. The authors postulate that continued integration of various inter-professional disciplines during the early phases of training is essential to foster collaborative leadership and trust. Originality/value The results of this study suggest that inter-professional clinicians view clinical leadership as collaborative and fluid and determined by the fit between tasks and team member expertise. Mentorship is important for increasing the ability of resident physicians to develop collaborative leadership roles within teams. The authors propose a collaborative definition of clinical leadership based on the results of this study: a shared responsibility that involves facilitation of dialog; the integration of perspectives and expertise; and collaborative planning for the purpose of exceptional patient care.

Healthcare quality improvement work: a professional employee perspective

Purpose The purpose of this paper is to describe and analyze conditions that influence how employees engage in healthcare quality improvement (QI) work. Design/methodology/approach Qualitative case study based on interviews ( n=27) and observations ( n=10). Findings The main conditions that influence how employees engage in healthcare QI work are professions, work structures and working relationships. These conditions can both prevent and facilitate healthcare QI. Professions and work structures may cement existing institutional logics and thus prevent employees from engaging in healthcare QI work. However, attempts to align QI with professional logics, together with work structures that empower employees, can make these conditions increase employee engagement, which can be accomplished through positive working relationships that foster institutional work, which bridge different competing institutional logics, making it possible to overcome barriers that professions and work structures may constitute. Practical implications Understanding the conditions that influence how employees engage in healthcare QI work will make initiatives more likely to succeed. Originality/value Healthcare QI has mainly been studied from an implementer perspective, and employees have either been neglected or seen as passive resisters. Weak employee perspectives make healthcare QI research incomplete. In our research, healthcare QI work is studied closely at the actor level to understand healthcare QI from an employee perspective.

Shining the light on the dark side of medical leadership - a qualitative study in Australia

Purpose The paper aims to explore the beliefs of doctors in leadership roles of the concept of "the dark side", using data collected from interviews carried out with 45 doctors in medical leadership roles across Australia. The paper looks at the beliefs from the perspectives of doctors who are already in leadership roles themselves; to identify potential barriers they might have encountered and to arrive at better-informed strategies to engage more doctors in the leadership of the Australian health system. The research question is: "What are the beliefs of medical leaders that form the key themes or dimensions of the negative perception of the 'dark side'?". Design/methodology/approach The paper analysed data from two similar qualitative studies examining medical leadership and engagement in Australia by the same author, in collaboration with other researchers, which used in-depth semi-structured interviews with 45 purposively sampled senior medical leaders in leadership roles across Australia in health services, private and public hospitals, professional associations and health departments. The data were analysed using deductive and inductive approaches through a coding framework based on the interview data and literature review, with all sections of coded data grouped into themes. Findings Medical leaders had four key beliefs about the "dark side" as perceived through the eyes of their own past clinical experience and/or their clinical colleagues. These four beliefs or dimensions of the negative perception colloquially known as "the dark side" are the belief that they lack both managerial and clinical credibility, they have confused identities, they may be in conflict with clinicians, their clinical colleagues lack insight into the complexities of medical leadership and, as a result, doctors are actively discouraged from making the transition from clinical practice to medical leadership roles in the first place. Research limitations/implications This research was conducted within the Western developed-nation setting of Australia and only involved interviews with doctors in medical leadership roles. The findings are therefore limited to the doctors' own perceptions of themselves based on their past experiences and beliefs. Future research involving doctors who have not chosen to transition to leadership roles, or other health practitioners in other settings, may provide a broader perspective. Also, this research was exploratory and descriptive in nature using qualitative methods, and quantitative research can be carried out in the future to extend this research for statistical generalisation. Practical implications The paper includes implications for health organisations, training providers, medical employers and health departments and describes a multi-prong strategy to address this important issue. Originality/value This paper fulfils an identified need to study the concept of "moving to the dark side" as a negative perception of medical leadership and contributes to the evidence in this under-researched area. This paper has used data from two similar studies, combined together for the first time, with new analysis and coding, looking at the concept of the "dark side" to discover new emergent findings.

The influence of leadership behavior, organizational commitment, organizational support, subjective career success on organizational readiness for change in healthcare organizations

Purpose The purpose of this study is to investigate the influence of leadership behavior, organizational commitment, organizational support and subjective career success on organizational readiness for change in the healthcare organizations. The authors want to determine if nurses who had higher levels of organizational commitment, organizational support and subjective career success relationships were more open and prepared for change. Design/methodology/approach Cross-sectional, descriptive-correlational survey design was conducted using self-reported questionnaires to collect data from registered nurses. Findings The subjective career success was the strongest predictors ( β = 0.36, p < 0.001) followed by leadership behavior ( β = -0.19, p = 0.03) and participants' age ( β = -0.13, p = 0.049). Research limitations/implications This study highlights the influence of leadership behavior, organizational commitment, organizational support and subjective career success on the organizational readiness for change in healthcare organizations. Therefore, this study forms baseline data for future local and national studies. Moreover, it will strengthen the research findings if future research includes a qualitative approach that explores other healthcare professionals regarding readiness for organizational change. Practical implications This study provides information to policymakers and healthcare leaders who seek to improve management and leadership skills and respond to organizational change efforts. Social implications It is important to know the extent to which healthcare professionals, especially nurses, understand how the influence of organizational support and organizational commitment on organizational readiness for change, as well as why specific leadership behavior and subjective career success, is important in implementing the change. Originality/value This study examined the nurses' readiness for change in hospitals. Organizational readiness for change could occur in situations where nurses can exert extra efforts at work because of leaders' behaviors and the relationship between nurses and the institution.

Paired learning – improving collaboration between clinicians and managers

Purpose

Close collaboration between NHS clinicians and managers is essential in providing effective healthcare, but relationships between the two groups are often poor. Paired learning is a peer-peer buddying tool that can break down barriers, increase knowledge and change attitudes. Paired learning has been used with doctors and managers but not for multi-professional clinicians. The purpose of this paper is to assess whether a paired learning programme (PLP) can improve knowledge and attitudes between multi-professional NHS clinicians and managers.

Design/methodology/approach

A PLP pairing clinicians and managers over a four-month period to participate in four buddy meetings and three group meetings was delivered. A mixed methods study was completed which collected quantitative and qualitative data in the form of pre- and post-course questionnaires and focus group discussions.

Findings

Participants reported increased understanding, changed attitudes and better communication between clinicians and managers following the PLP. Self-rated knowledge increased across all domains but was only statistically significant for ability to engage, ability to establish shared goals and knowledge of decision-making processes.

Research limitations/implications

This paper highlights the value of paired learning in encouraging collaboration between clinicians and managers but is of a small size. The PLP did not provide enough data to examine relationships and interaction between clinicians and managers, this should be considered in any future work.

Originality/value

To the authors’ knowledge, this is the only published paper showing data from a PLP involving multi-disciplinary health professionals.

Medical leaders or masters?-A systematic review of medical leadership in hospital settings

Medical leadership is increasingly considered as crucial for improving the quality of care and the sustainability of healthcare. However, conceptual clarity is lacking in the literature and in practice. Therefore, a systematic review of the scientific literature was conducted to reveal the different conceptualizations of medical leadership in terms of definitions, roles and activities, and personal-and context-specific features. Eight databases were systematically searched for eligible studies, including empirical studies published in peer-reviewed journals that included physicians carrying out a manager or leadership role in a hospital setting. Finally, 34 articles were included and their findings were synthesized and analyzed narratively. Medical leadership is conceptualized in literature either as physicians with formal managerial roles or physicians who act as informal 'leaders' in daily practices. In both forms, medical leaders must carry out general management and leadership activities and acts to balance between management and medicine, because these physicians must accomplish both organizational and medical staff objectives. To perform effectively, credibility among medical peers appeared to be the most important factor, followed by a scattered list of fields of knowledge, skills and attitudes. Competing logics, role ambiguity and a lack of time and support were perceived as barriers. However, the extent to which physicians must master all elicited features, remains ambiguous. Furthermore, the extent to which medical leadership entails a shift or a reallocation of tasks that are at the core of medical professional work remains unclear. Future studies should implement stronger research designs in which more theory is used to study the effect of medical leadership on professional work, medical staff governance, and subsequently, the quality and efficiency of care.

Involvement Drivers: A Study of Nurses and Physicians in Improvement Work

This article reports on the involvement of nurses and physicians in improvement work, with a special focus on the drivers. The purpose was to describe how the nurse and physician groups understand involvement drivers for improvement work and to explain the differences in how they understand involvement. The study was conducted at 2 Swedish hospitals, and a total of 20 nurses and 10 physicians were interviewed. The theoretical framework, developed by an interpretative approach, identifies and describes a number of involvement drivers. On clustering the drivers into larger involvement factors, the study shows clear differences and profiles in terms of the 2 groups' perception and understanding of the involvement-drivers. Each group's profile was then analyzed on the basis of concept of professional culture.

Exploring leadership in the context of dentistry in the UK

Purpose The purpose of this paper is to explore selective leadership approaches in the context of dentistry in the UK. Design/methodology/approach This is a conceptual paper utilising published sources from relevant literature about leadership theory and practice and the policy background to dentistry in the UK. Findings This paper suggests that there is merit in identifying and applying an eclectic mix of leadership theory to the case of dentistry. It offers insight into individual aspects of the leadership role for dentists and applies this to the dental context. It also contrasts these individual approaches with shared leadership and suggests this may also be relevant to dentistry. It highlights the fact that leadership will be of growing concern for dentistry in the light of recent policy changes. Research limitations/implications This paper points out that there are developmental implications depending on the particular approach taken. It argues that leadership development will become increasingly important in dentistry in the UK. Originality/value This paper addresses a topic that has so far received limited attention in the literature.

Perceptions of trust in physician-managers

PURPOSE

The purpose of this paper is to explore the dual role of physician-managers through an examination of perceptions of trust and distrust in physician-managers. The healthcare sector needs physicians to lead. Physicians in part-time managerial positions who continue their medical practice are called part-time physician-managers. This paper explores this dual role through an examination of perceptions of trust and distrust in physician-managers.

DESIGN/METHODOLOGY/APPROACH

The study takes a qualitative research approach in which interviews and focus group discussions with physician-managers and nurse-managers provide the empirical data. An analytical model, with the three elements of ability, benevolence and integrity, was used in the analysis of trust and distrust in physician-managers.

FINDINGS

The respondents (physician-managers and nurse-managers) perceived both an increase and a decrease in physicians' trust in the physician-managers. Because elements of distrust were more numerous and more severe than elements of trust, the physician-managers received negative perceptions of their role.

RESEARCH LIMITATIONS/IMPLICATIONS

This paper's findings are based on perceptions of perceptions. The physicians were not interviewed on their trust and distrust of physician-managers.

PRACTICAL IMPLICATIONS

The healthcare sector must pay attention to the diverse expectations of the physician-manager role that is based on both managerial and medical logics. Hospital management should provide proper support to physician-managers in their dual role to ensure their willingness to continue to assume managerial responsibilities.

ORIGINALITY/VALUE

The paper takes an original approach in its research into the dual role of physician-managers who work under two conflicting logics: the medical logic and the managerial logic. The focus on perceived trust and distrust in physician-managers is a new perspective on this complicated role.