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Leadership in healthcare: a bibliometric analysis of 100 most influential publications
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  1. Nizar Bhulani1,
  2. Timothy L Miao2,
  3. Alexander Norbash3,
  4. Mauricio Castillo4,
  5. Faisal Khosa5
  1. 1 Medical Oncology, Harvard University, Boston, Massachusetts, USA
  2. 2 Western University, London, Ontario, Canada
  3. 3 Radiology, University of California San Diego, La Jolla, California, USA
  4. 4 Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  5. 5 Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
  1. Correspondence to Dr Faisal Khosa, Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada; fkhosa{at}hotmail.com

Abstract

Aim We analysed the 100 most influential articles on leadership in healthcare via a bibliometric analysis to better understand categories and topics in leadership science and their relationship to healthcare. Leadership in healthcare is ever evolving and needs to be robust like any another profession.

Methods A bibliometric analysis was performed. Articles were ranked by citation counts and three independent reviewers screened the abstracts for inclusion. Common themes were categorised.

Results Citations for articles ranged from 53 to 487 and were published across 50 journals. Articles focused primarily on three leadership subjects: team building, quality improvement and healthcare delivery. Of healthcare provider groups, articles were directed to or concerning primarily: nursing, academic medicine and critical care medicine.

Conclusions We identified gaps in healthcare leadership development literature. There is an opportunity to effectively identify areas of interest and demand for organised leadership education and training.

  • medical leadership
  • career development
  • clinical leadership
  • mentoring

Data availability statement

Data are available in a public, open access repository. All data relevant to the study are included in the article or uploaded as supplementary information.

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Introduction

Healthcare consumes larger budgets in increasingly complex environments challenged by interpersonal, economic and political influences. These factors underline the need for effective leadership among healthcare professionals and educators in academic and non-academic healthcare facilities. Recently, responsibilities for healthcare professionals have gone beyond clinical duties as they are now expected to demonstrate business savvy traits in times of limited resources and higher expectations for quality of services.1–3

In 2015, the USA spent over US$3 trillion on healthcare, which represents nearly 18% of its gross domestic product (GDP).4 This amount of spending places healthcare expenditures in the USA as the highest in the world in terms of both percentile of GDP and absolute cost, yet its healthcare system underperforms relative to those of comparable industrialised nations.5 A lack of leadership in addition to misaligned incentive systems has contributed to the mismatch between spending and outcomes.6–10 Healthcare providers as leaders are considered by many to have the potential for improving the value of healthcare through cost containment and by improving hospital performance with efficient, effective and accountable governance.11 12 Effective and responsible clinical leadership can influence cohesiveness in multiparty teams in healthcare, such as in operating rooms, resuscitation teams and intensive care units.13–15 Clinical leadership training can empower and positively affect diverse constituents such as medical students and trainees, nurses, public health workers and hospital management.16–19 Indeed, the literature indicates that effective clinical leadership is highly desirable within diverse healthcare settings.

Bibliometric analysis is a statistical method to quantitatively assess academic impact of published articles in individual fields.20 Specifically, citation count is a bibliometric parameter that uses the number of citations of an article as a measure of its impact.21 Recent bibliometric studies have been conducted in several fields including internal medicine,22–26 surgery,27–31 nursing,32 radiology,33–38 obstetrics39 and critical care40 to determine characteristics of the most influential research publications in each of these fields.

To the best of our knowledge, there is no bibliometric analysis available on leadership in healthcare. Thus, the main objective of our study was to provide an overview of leadership-related literature in multiple healthcare settings by analysing the 100 most influential articles on leadership in healthcare to identify areas of focus.

Methods

We performed a bibliometric analysis using Elsevier’s Scopus (www.scopus.com) to identify studies published between 1985 and 2016 focusing on leadership in healthcare. A keyword search was formulated in consultation with a medical information specialist that consisted of a series of healthcare-related search terms combined with a series of keywords relating to leadership. Our search terms were intentionally broad and comprehensive to prevent accidental exclusion of studies through an overly narrow definition of leadership. An initial broad search yielding 60 449 results included the following keywords:

(TITLE-ABS-KEY (leader*) AND TITLE-ABS-KEY (health OR clinical OR medicine OR surgery OR physician OR nurse OR hospital OR medical school))

Narrower searches were then performed, yielding 9006, 8978 and 1008 total results using the following keywords, respectively:

(TITLE-ABS-KEY (leader*) AND TITLE-ABS-KEY (medicine OR hospital OR medical OR doctor* OR healthcare OR faculty OR professor* OR department* OR nursing OR nurse OR surgery OR surgical OR clinical OR health OR director* OR chair*) AND TITLE ABS-KEY (pattern* OR path* OR network*))

(TITLE (leader* OR manager* OR director OR chair OR professor* OR faculty) AND TITLE-ABS KEY (medicine OR hospital OR medical OR doctor* OR healthcare OR nursing OR nurse OR surgery OR surgical OR clinical) AND TITLE-ABS-KEY (pattern* OR path* OR network* OR role OR roles OR barrier*))

(TITLE (leader*) AND TITLE-ABS-KEY (medicine OR hospital OR medical OR doctor* OR healthcare OR faculty OR professor* OR department* OR nursing OR nurse OR surgery OR surgical OR clinical OR health) AND TITLE-ABS-KEY (pattern* OR path* OR network*))

All accessible journals (over 22 600 titles) from the Scopus database were selected for inclusion regardless of date of publication, study type, country of origin, language, medical discipline or electronic availability of articles or abstracts. The retrieved articles from each of the above four searches, including the one broad and three narrower ones were sorted according to the option ‘times cited’ on Scopus from the most to the least cited. Three reviewers (TM, NB and FK) independently screened the titles and abstracts of all articles to compile and verify a list of the 100 most influential articles on leadership in healthcare. Articles were included if they (1) examined leadership in the context of healthcare and if (2) leadership was the primary focus of the article. Articles were excluded if they did not relate to healthcare or if their primary focus was not leadership. For each article, citation count, area within healthcare, specific leadership subject, journal name, journal type (either science or social science, as classified by Thomson Reuters’ Journal Citation Reports database), number of authors, year of publication and country of origin were documented. Institutional Review Board approval was not required as this study was a retrospective review of publicly available online articles. There was no source of funding for this study.

Results

Online supplementary appendix table 1 shows the 100 most influential articles on leadership in healthcare. The number of citations ranged from 53 to 487, with a median of 76 citations. Only 3 articles were cited more than 300 times. One-third of articles had over 100 citations. The top 100 articles were published in 50 different journals, with 16 journals publishing more than 1 article (figure 1). The journals with the highest numbers of articles were Journal of Nursing Management (n=13), Academic Medicine (n=10) and Journal of Nursing Administration (n=10). Most articles were from biological science journals (85%) while the remainder were from social science journals. The number of authors ranged from 1 to 13, with a median of 3 authors. There were 15 different countries of origin for the top 100 cited articles (figure 2) with most articles originating from North America (71%) followed by Europe (24%). The years of publication ranged from 1984 to 201 with the majority published after 2000 (n=81; figure 3). Slightly over one-half of articles were original articles (n=51), 30 of which were questionnaires or surveys. The remaining one-half of articles were reviews (n=49), including five systematic reviews.

Supplemental material

Figure 1

Journal of publication of the top 100 most cited articles on leadership in healthcare.

Figure 2

Country of origin of the 100 most cited articles on leadership in healthcare.

Figure 3

Publication year (in 5-year intervals) of the 100 most cited articles on leadership in healthcare.

Articles focused on six specific leadership subjects: team building (33%), quality improvement (23%), healthcare delivery (15%), principles of leadership (13%), education (9%) and gender disparity (7%). Articles on leadership were directed to or concerning any of nine healthcare provider groups: nurses (40%), critical care medicine (14%), medical education (14%), healthcare organisations (11%), physicians (8%), patient safety (5%), healthcare professionals other than nurses and physicians (4%), operating room (3%) and public health (1%). The three main topics best described by the articles were: nursing leadership (40%), followed by leadership in medical education (14%) and critical care medicine (14%).

Discussion

“To an extent, leadership is like beauty: It is hard to define, but you know it when you see it”.41

It is difficult to ‘limit’ the definition of leadership to a few words. Many consider it as an innate quality which needs an enabling environment to flourish while others regard it as a skill that can be learnt through a combination of theory and practical exposure to formative and often challenging situations. Leadership in healthcare, in our opinion, is unique from other professions as it is not only the act of ensuring task completion or directing a group of individuals to achieving goals. Leadership in healthcare is broader in scope encompassing planning and delivery of service, striving for quality improvement, appropriately allocating health resources and developing best practices to ensuring optimum outcomes for every patient.

In our study of the 100 most influential articles on leadership in healthcare, we found a diversity of related topics in many journals. Although one-third of articles in our top 100 were published in the Journal of Nursing Management, Academic Medicine or Journal of Nursing Administration, 47 other journals published the remaining articles. There were many information streams catering to diverse categories of groups and individuals even within healthcare leadership as a single broad topic.

The breadth of articles on leadership extended from the healthcare professional as an individual leader, to wide-ranging subjects such as managing healthcare organisations and influencing public health. A considerable proportion of articles in our list were found in the nursing literature. Nursing studies have shown that leadership among nurses is associated with reduced patient adverse events, improved job satisfaction and reduced burnout.42–46 The longstanding existence of a large group of distinctive nursing management positions such as nurse managers may account for the high proportion of nursing leadership articles in our top cited 100 list.

In contrast to the high proportion of nursing leadership articles, our study showed a relative lack of highly cited articles regarding physician leadership. Physician leadership is recognised as both a need and a void,47 and while many physicians believe that skills acquired in medical school and residency contribute to their future or potential proficiency as physician leaders,48 this may be a misperception that coexists with a lack of formal training in leadership competencies.10 With the recent emergence of formal programmes dedicated to training physician leaders such as master’s degrees in medical management and health administration and development of organisations that provide continuing education and support for physician leaders such as the American Association for Physician Leadership, the literature on physician leaders may grow in the future.

In addition to identifying groups within healthcare pursuing and discussing leadership, we also sought to identify the most frequently addressed leadership topics. We found that one-third of articles related to the subject of team building, with a common conclusion that leadership improves job satisfaction and working conditions among nurses and critical care teams. A second subject was quality improvement and most related articles concluded that leadership has an important role in positively transforming healthcare. A third subject was education including medical education, mentorship and training leaders of healthcare teams. Equity, diversity and inclusion are a subject which has gained attention and traction in the medical literature with one-half of articles in the medical education category discussing a ‘glass ceiling’ for women, a term referring to an invisible barrier to proportional professional advancement for women.49 One particularly important subject missing in these highly cited articles was succession planning in leadership which is vital to continued improvement and lasting excellence in healthcare organisations.

Conclusion

The top 100 articles were published over a span of 30 years, between 1984 and 2014, comparable to customary time spans and periods reported in other bibliometric analyses.22 32 40 Our results showcase a higher level of leadership knowledge and/or demand in the subjects of team building and quality improvement and a larger total body of widely cited articles addressing nursing leadership. The fact that most of these articles were published after the year 2000 echoes a recent increase in interest, awareness and demand for leadership-related literature among healthcare professionals.

Implications

It is vital that gaps in published literature regarding leadership in healthcare are identified. Addressing these gaps provides academic theoretical knowledge and allows healthcare professionals to measure the impact of everyday decisions on patient outcomes.

Limitations

A primary limitation of our study is an inherent limitation of bibliometrics: that is the ever-changing citation counts of articles over time. As a result, newer articles, and perhaps highly significant ones, may not have as many citations as older articles.50 51 Despite our desire to be comprehensive where our search terms were concerned, some related articles may have been inadvertently excluded. To mitigate this limitation, we performed broad comprehensive searches that ultimately produced nearly 80 000 articles. Lastly, the use of different bibliometric databases can produce different results. As an example, although Elsevier’s Scopus, the database used in this study, is considered a premier database, it nevertheless has been shown to omit older articles.52

Data availability statement

Data are available in a public, open access repository. All data relevant to the study are included in the article or uploaded as supplementary information.

References

Footnotes

  • NB and TLM are joint first authors.

  • Twitter @nizarbhulani, @khosafaisal

  • Contributors Planning of study: NB, TM, MC and FK. Reporting of work: NB and TM. Critical review of work: AN, MC and FK. Final review and edits: FK, NB and AN.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.