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Abstract
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.
- clinical leadership
- learning
- medical leadership
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Introduction
There is a need for leadership capacity at all levels in health care.1–3 Physician leadership is essential for health system performance,4 5 and leadership development programmes for physicians have become commonplace.6–8 Programmes can be run internally or externally, and they could target various groups within the organisation.9 10 A recent review of physician leadership development programmes reported in the medical literature found that three out of four programmes targeted only physicians.10 The literature suggests that leadership development programmes involving multiple professional groups may promote teamwork, communication and understanding of organisational roles.9 Respecting and understanding different professional roles, and having a common language for communicating across professions may improve patient safety and health outcomes.11 Benefits of multidisciplinary education programmes are also highlighted in the interprofessional education literature. Khalili et al 12 13 argue that single-professional training environments promote a silo (or ‘uniprofessional’) identity, which makes interprofessional collaboration difficult. The authors argue that interprofessional education initiatives could assist professionals in adopting a dual identity, thus facilitating communication and teamwork. Some authors underline that physician-only approaches creates a safe environment for learning in which participants can speak openly and discard their expert role.14
There is a gap in the literature on multidisciplinary leadership development programmes targeting physicians and other professionals. A better understanding of the benefits and challenges associated with multidisciplinary leadership development may inform organisational decisions about leadership development programmes. We did a study to explore healthcare executives’ perspectives on physician leadership development, focusing on perceived benefits and negative effects associated with multidisciplinary programmes.
Methods
We found that a qualitative and explorative approach was suitable. A purposeful sample of 16 healthcare executives, 11 men and five women, were recruited. We identified participants through published literature and reports, through direct contact with relevant organisations, hospitals and health systems in USA and through snow-ball sampling. Participants’ background and role was Chief Executive Officer, Chief Medical Officer, Medical director, HR Director and Programme Director. All the individuals who we contacted agreed to be interviewed. The strategic sample represented a diversity of professional backgrounds, but a common denominator was that they were engaged in and supervised leadership development programmes and activities. Data were collected using semistructured interviews, following a thematic interview guide (box 1). The interviews were conducted by JCF by phone or face-to-face. The interviews lasted from 30 to 90 min, and they were all digitally recorded.
Thematic interview guide.
What is your professional background, your role in your organisation and your experience with leadership development?
Could you explain the governance structure in you organisation (unified leadership, management teams, etc)?
What leadership development initiatives for professionals with a clinical background are currently being conducted in your organisation?
What is the content and format of these initiatives/activities?
Are these initiatives grounded in any pedagogical/theoretical model or framework?
Is there a policy or model for leadership development in your organisation?
To what extent are professional groups and professionals from different levels in the organisation mixed?
Have there been systematic evaluations of leadership development initiatives, and what were the results?
What are, in your experiences, the main facilitators and barriers to building clinical leadership capacity in healthcare organisations? What characterises a successful programme?
What are the main challenges regarding recruitment and retention of individual leaders with a clinical background?
The digital recordings were transcribed by a professional transcription service. One of the authors (JCF) reviewed the transcription for accuracy. Interview data have been analysed with the assistance of NVivo, using a method for thematic content analysis. The material was analysed by both authors using a method for thematic qualitative analysis.15 The analysis followed four steps: (1) reading all the material to obtain an overall impression and bracketing previous preconceptions; (2) identifying units of meaning representing different aspects of leadership development policies and practices, and coding for these units; (3) condensing and summarising the contents of each of the coded groups and (4) generalising descriptions and concepts concerning leadership development policies and practices.
All participants were recruited through email, and they were given written information about the project. Verbal rather than written consent was requested as we did not collect personal health information.
Results
Perceived benefits of multidisciplinary programmes
One group of informants argued that multidisciplinary approaches to leadership development were in alignment with a health services that increasingly relied on collaboration and multidisciplinary teams. Multidisciplinary programmes were perceived by these informants as instrumental in building common understanding and networks across the organisation. One informant said:
[I]f we don’t understand each other’s thinking and acting and why, it just, it seems like we’re missing a key component [in leadership development], and so many fears that people have about mixing the two together, I mean, we’re mixing them in the workplace! (HR Director, manager).
One informant told that he had observed a shift from physicians-only programmes to multidisciplinary programmes in the organisation:
We’ve been moving more and more to interdisciplinary approaches to leadership development. Because in the front lines, they all have to work with each other, right? I mean, so if you just do professional leadership development, you know, on one side, and you do administrative leadership development on the other side, eventually they have to come together. So you may as well do the training together and get them to learn to work together from the get-go. (Chief Medical Officer, medical doctor)
In some organisations, partnership between physicians and operational management was emphasised as an essential dyad, and a multidisciplinary approach to leadership development was seen as a tool to build and maintain a collaborative organisational culture:
And by doing this work across disciplines, physicians, and administrators on multiple levels across the organisation, the hope is that you develop a cohesive organisational culture that looks at problem solving in a team-based way. (Chief Medical Officer, medical doctor).
One group of informants argued for an approach that acknowledged a common set of competencies, and at the same time addressing leadership issues that were specific to one professional group. Cultivating a psychologically safe environment that promoted openness and professional relationships among peers was underlined as important by some informants:
I think we’ve been very successful at identifying areas of common need and where we need to talk about issues specific to doctors and nurses. Once the community is formed in the course, it’s safe. It’s psychologically safe to discuss the individual communities within the course, which is in fact what’s happened. So, I think the success or failure of that has to do with how you charter with the group at the beginning of the course and how they all come to know one another and to work with one another. (Programme Director, medical doctor).
Perceived negative effects of multidisciplinary programmes
One group of informants voiced doubt about the value of multidisciplinary leadership development programmes, and in particular the idea of mixing physicians with other professional groups or managers. One informant argued that multidisciplinary programmes could have negative effects on ‘cross-silo networking’ across medical departments that could occur in a programme targeting physicians only:
We haven’t done [multidisciplinary programs], not because of a sense that doctors are exclusive or better or special, but because we feel like it’s a big part of what we’re doing here is trying to create enduring connections and enduring relationships between doctors in different areas that don’t see each other. And the concern is that the more you put in to the mix, the more you might diminish that, and the more complicated you make the messaging because you’re messaging to really very different role groups. (Medical director, medical doctor).
The informant argued that the peer group ‘camaraderie’ was an important effect that had to be weighed against the potential benefits of multidisciplinary leadership development:
So, I am deeply ambivalent about the mix. So, I…from a theoretical perspective, I think it should be mixed. You read all the literature. It’s about teams. It’s about cross-disciplinary. So, if you take a leadership development course, you should have mixed groups […]. But there’s another side to it that I find fascinating. So, I was really pushing on our group who is in the middle tier here and they really, really liked being with a group of peers that they don’t interact with on a regular basis. (Medical director, medical doctor).
Accordingly, informants emphasised that there were significant differences between nurses and physicians, arguing that one could risk diluting some of the educational experience in multidisciplinary programmes:
There’s a very basic difference between nursing and doctors. They just have different jobs, they have different education, and they have a different world view. And so, I believe that nurses and doctors ought to work together on a million things, but I don’t necessarily think that forcing them into this environment together artificially actually helps you achieve that. I think it would actually, in my mind, it would dilute the educational experience for both. (Medical director, medical doctor).
Among the challenges associated with multidisciplinary programmes were practicalities such as finding the time and a lack of knowledge about how to run such programmes:
If you can figure out how to get them together in some kind of multidisciplinary form, then that’s a good thing. Now that’s harder to do than it sounds for a variety of reasons. One is, people just don’t have a lot of time. And second, there hasn’t been very much work done on how a multidisciplinary training programme should work. (Programme director, medical doctor).
One informant argued for a ‘mixed approach’ in which some basic skills were developed in courses targeting one profession, before a multidisciplinary programme was introduced:
Our approach is that there are certain basic skills and understandings that each professional group requires before it really makes sense to put them together. And so, we want the physician to have a basic set of skills [and] the administrators and the financial clerks to have a basic set of skills before we put them together. Otherwise, it can be problematic. (Programme director, medical doctor).
Discussion
In this study, we sought to explore healthcare executives’ perspectives on physician leadership development, focusing on potential benefits and challenges associated with multidisciplinary programmes. We found different views on mixing professional groups. 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.
The literature suggests that multiprofessional approaches to leadership development can result in positive organisational outcomes.10 Our study identifies programme directors’ and top managers’ perceived positive and negative effects of multidisciplinary approaches to leadership development. Among the concerns that we identify are practicalities, but also issues related to organisational and managerial structures and views on professional groups and teamwork. The different views on multidisciplinary programmes was therefore in part determined by organisational structure, culture and how leadership roles are defined.16–18 Our findings suggest that organisations that have a stronger culture for interprofessional collaboration might be more likely to embrace multidisciplinary approaches to leadership development. Multidisciplinary leadership development programmes may be more efficient if they are anchored in organisational values and policy.19
Our study found that programme directors and top managers underlined a psychologically safe environment that promoted openness, ‘cross-silo networking’ and professional relationships among peers as an important outcome of leadership development. The interprofessional education literature highlights how non-threatening learning environments are a key requirement for effective learning.20 Institutional support and a cooperative atmosphere are among the conditions that may support students to express themselves openly.
Hesselbein and Shinseki have presented the ‘be-know-do’ framework of leadership development.21 ‘Be’ refers to the internal values and attributes that shape a leaders’ character, while ‘know’ refers to the knowledge and mastery of interpersonal, conceptual and technical skills. ‘Do’ denotes the ability to combine the ‘be’ and ‘know’ dimensions into action in order to solve problems and reach goals. There might be a need for more focus on the ‘be’ dimension for physicians specifically, as previous studies have found that physicians may struggle with taking on a new leadership role and identity.22–26 Bridges and colleagues27 suggest that a multiprofessional curriculum enables students to share and practice collaborative skills together. The ‘know’ dimension could therefore be addressed through shared competency frameworks and through classroom teachings and seminars in mixed groups. The ‘do’ dimension could incorporate action learning projects which utilise collaboration between different professions.
This study identifies issues and challenges that can inform organisational policies and decisions about leadership development activities. While not in the scope of our study, there are other tensions that should also be addressed in future studies, such as gender, race and seniority.28 29 We acknowledge that organisational structures, policies and roles differ, but we think the considerations and arguments we have identified may help programme directors to understand concerns and resistance.
Multidisciplinary leadership development programmes in healthcare have the potential to build understanding across professional groups and organisational leadership capacity, but more research is needed to identify the areas in which one should target physicians only. This includes studies using larger samples with control groups and measured outcomes.
Acknowledgments
Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and should not be attributed to The Commonwealth Fund or its directors, officers, or staff. Thanks to Elizabeth Bradley for input to this work.
References
Footnotes
Contributors JCF designed the study, analysed the data and drafted the manuscript. IS analysed the data, contributed in drafting the manuscript and revising it. Both authors have approved the final version to be published and are accountable for all aspects of the work.
Funding This study was funded by the Commonwealth Fund (Norwegian Harkness fellowship 2013-2014) and The Research Council of Norway (grant number 232215).
Competing interests None declared.
Patient consent Not required.
Ethics approval Human Subjects Committee of Yale University. The study qualified for exemption (IRB protocol number 1310012927).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Transcribed interviews.