Clinical leaders, the first step for emotionally intelligent leadership
=======================================================================

* Oriol Yuguero
* Marco Inzitari
* Gustavo Tolchinsky

*   clinical leadership
*   emotional intelligence
*   empathy
*   medical leadership
*   professionalism

## Introduction

Burnout is a syndrome characterised by exhaustion, cynicism and reduced effectiveness. At this moment, professional burnout among healthcare professionals is a serious threat to healthcare around the world. Burnout is known to decrease quality of care and is associated with mental health problems or drug abuse.1 If we add the overwhelming and sustained workload and emotional impact during the SARS-CoV-2 pandemic, moral distress and burnout have increased since then.2 

To the date, especially at the end of 20th century, different leadership models have been developed with a core objective: being part of an organisation’s transformation. Most common leadership models are divided into transformational and transactional. The transactional leader usually follows a practice based on reinforcement of his team and trying to satisfy its own interests. This model uses the team to achieve specific objectives without considering professional satisfaction and benefits. This model probably achieves its goals but does not care about colleagues’ satisfaction. On the other hand, the transformational leader inspires, motivates and engage its team. Transformational leader can be directive or participatory, and requires more moral development.3 4 

Nowadays, leaders see relationship with their teams as colleague relations more than a subordinate one. Emotional leadership could be considered as a variant of transformational leadership.

The leadership model of healthcare institutions has always been heterogeneous. Leaders and managers have been largely chosen for merits which divert from their ‘core business’, for example, clinical knowledge and practice, focusing rather on aspects such as organisational, financial or academic matters. In any case, the perception is that little value has been given to aspects related to healthcare and to clinical practice. This distancing from daily life, often involving technocratic language, ends up in decisions that are often neither understood nor shared by health professionals, since the centre of their discourse addressed neither them nor patients. In our country, in the light of the SARS-CoV-2 pandemic, one thing is clear: the leadership of healthcare professionals has been fundamental in adapting organisations and dealing with the crisis. Leaders who knew what goals they pursue, who guide their team motivated by values, and a determined clinical practice that sets it apart from the rest.

Without knowing the members of the team, their values and virtues, there is no clear direction in which to guide them, and therefore the leader resorts to imposing. To become a leader, serving the group and peers, and not resorting to their power for their own benefit or to harm others.5 

The involvement of healthcare professionals in management has been proven to be positive not only for institutions6 but also for patients.7 

Despite the rigidity of many healthcare structures, a new type of healthcare leaders is beginning to change old habits and routines. During the pandemic, a different way of leading reinforced the idea and opened a new opportunity for this new transformative leadership.

A recent article8 outlined some of the fundamental elements of clinician leadership: culture of the organisation to which it belongs, teamwork and a clear strategy to follow. Teamwork is essential to achieve goals. Healthcare professionals have been working in a multidisciplinary way for a long time. When a leader needs to understand and know his team, emotional intelligence becomes essential.

Hence, we believe it is timely to analyse the key elements of this new model of leadership, and this is the main goal of this article.

## Leadership as protection against burnout

Clinicians’ leadership has proven significant benefits, especially in terms of improving organisational reputation, better involvement with the decisions of the institution and the empowerment of clinicians.9 A review in 2020 analysed recently published articles on clinical leadership. Medical leaders can use their knowledge to interpret and explain the consequences of management decisions,10 making those decisions understandable and more easily shared by the team.

The growing concern for healthcare professionals’ satisfaction has changed the usual models of health management in organisations, and it is beginning to be included at the same level as the interest in healthcare costs or quality.11 In the USA, there are hospitals such as the Mayo Clinic that have started projects to reduce the burnout in their professionals and are a distinguishing feature of new leadership models.12 These new leaderships must put professional satisfaction as part of the strategy to achieve higher quality of care at a lower cost as part of a shift from triple aim to quadruple Aim.

Since burnout is a problem that affects healthcare professionals and organisations, and despite the figures in the USA being higher,13 our country14 and Europe15 in general are not far behind. It is relevant that organisations and their leaders undestand the drivers behind burnout. Maslach and Leiter16 identified the main factors involved in the mismatch between professionals and their workplace that lead to burnout:

1.  Sense of control on workload: facing an amount of work bigger than one can manage and having to give up other tasks that may be considered important or even personal time.

2.  Promote mechanisms that enable influencing work organisation and conveying this sense of control.

3.  Acknowledge a well-done job and, if possible, for this to be recognised monetarily. Positively reinforce the professionals.

4.  Create a good atmosphere among workmates.

5.  Be fair towards professionals and patients.

6.  Align the values of the organisation and of the professionals, especially when dealing with health professionals. The values shared by the team strengthen this, but conversely, when not shared, they lead to exhaustion and cynicism.

In 2018,17 West *et al* described that leaders and managers have a key role in managing the burnout of health professionals. A leader understands the teams’ needs, promotes them or simply takes an interest in knowing how they are. Moreover, to be able to detect these assertiveness are key elements and habilities. However, as we will expose, so too are the leaders’ honesty and responsibility.

Assuming, as we just mentioned, that there are many factors that can cause burnout in healthcare professionals, a leader can influence most of the factors involved, from controlling the work overload and distributing tasks fairly to creating a positive work atmosphere in which achievements are recognised and teamwork is worked on. Involving colleagues in the organisation’s culture to make it their own will have a positive impact on professionals and their patients1.

Table 1 sets out some of the characteristics that we believe should be fundamental in emotional-based leadership that can assume the challenges posed. In fact, honesty and credibility are two elements that are key to ethical leadership.18 

View this table:
[Table 1](http://bmjleader.bmj.com/content/6/3/219/T1)

Table 1 
Key characteristics of emotional-based leadership.

*Empathy* 19 is essential to pick up on patients’ and workmates’ feelings by being able to identify the needs and perceptions of others, helping to become professionally accomplished.

However, just as in clinical scenarios, an excess of empathy without scientific basis is dangerous; a highly empathetic leader without clear goals may create a good working environment but will not enable progress.

*Assertiveness*,20 when applied appropriately, enables people to disagree respectfully with others and to improve and strengthen their beliefs. Respect enables creating a good work environment.

Frequently, leaders do not admit mistakes or just do not accept that it is impossible to master all of the information that surrounds us. This *honesty* is basic in ethical leadership towards colleagues. Just as patients are grateful to their physician for an ‘I don’t know’ answer, leaders should be able to do the same. Asking for help is acknowledging the strengths of team members that will help us reach our goal and being aware of the real potential, but not with blind optimism either.

However, there are other elements that also play an important role. Technical competencies and conceptual skills are very important. Relational competence is fundamental to develop emotional leadership. Relational competence is understood as the ability to understand needs and to monitor the effects of our behaviours as a team as well as interpersonal skills (the ability to solve conflicts and/or reduce tension). It is important to train in leadership so that we have new models, but it is essential that leaders have scientific and technical knowledge.21 

Emotional intelligence is a very powerful tool to build bridges and cement alliances, as well as to repair relationships when they are affected. In addition, physicians with higher emotional intelligence are better leaders, and they achieve greater professional and personal fulfilment.22 

However, this model also has some downsides and limitations. The burden of responsibility in front of the group and those functions that ‘must be done’ often involve more work, greater dedication in time and exposure to prevent overloading the team. It comes along with ethical responsibility and being worthy of respect by peers. The limits, however, are being paternalistic and having overprotective attitudes that can prevent the involvement of team members, leading them to excessive comfort or even being perceived as a lack of confidence by their leader, as well as being unable to delegate tasks and responsibilities.

In addition, involvement and an excess of empathy can lead to empathy stress for leaders, and they end up being victims of burnout. So they should also be taught what warning signs should be identified to prevent from suffering empathic stress.

## Training good clinical leaders should also improve emotional competencies

The recent COVID-19 pandemic has shown that clinical leadership, through shared and even inclusive decision-making with different outstanding professionals in the organisation, has been crucial for organisations to duly respond.23 It has also reaffirmed that the path is the one of leaders who never get tired of learning, who rather than being content with the established system constantly seek to expand and to improve.24 Innovative and creative leaders who in the face of difficult situations can go one step further and take full advantage of the available resources. This concern for improvement, knowing everyone’s limitations, with willingness and a commitment to improve their patients’ health.25 

With the new profile of clinical leaders, prioritising improvement in patient care and understanding the needs of teammates, we have a great opportunity to promote emotionally intelligent leadership as a protection against burnout. Create a new leadership paradigm that changes with existing models based on technical and economic results, based on cold numbers and without knowing what is behind those figures.

Emotional intelligence can be developed, and there are tools that allow you to develop the four fundamental skills of emotional intelligence: perception, use, understanding and managing emotions.26 

The ability to perceive emotions of the others is not just about listening to the concerns of others but also being able to distinguish the body language of our team and their expressions.

Another skill is the use of emotions. It is not about manipulating but about identifying those emotions and taking advantage of emotional data in day-to-day management. Moreover, for that ability, developing empathic sensitivity and empathic competence is really important.

We have said that you have to perceive emotions, use them to improve team performance but also to understand them. Emotionally intelligent leaders try instead to understand the source of the emotion. They ask open questions intended to uncover the roots of the emotion.

Finally, the ability to manage emotions. But not to ignore or suppress them as many leaders have tried to survive to date. The core objective is to identify effective emotional strategies to lead the team.

The new model of clinical leadership is one of horizontal leadership that must manage complex situations, in many cases associated with population ageing, with a diverse but well-coordinated team.

The new leader must be able to listen to their colleagues and identify their strengths and guide their work towards them, thus preventing burnout; leaders must be an example and should implement shared decision models.

In times to come, leadership is more crucial than ever. In fact, there is widespread motivation to promote this new leadership.27 

In addition, a review in 201928 showed that this new leadership is critical in meso management, when changes can be made in health structures but also at micro level, improving the quality of professionals and developing new roles for team members.

Most of the skills that define emotional intelligence can be learnt and promoted.29 In fact, it has recently been published that undergraduate training of these skills and during residency trainning is essential and fosters better leadership than those who have not received such training.30 

To conclude, we could say that the new clinical leadership model brings together various factors. Leaders must know the reality where they seek to exercise leadership and must be realistic. They must possess emotional intelligence to understand their team and help them develop. However, they must also have management and organisational skills that will provide them with the tools to adequately manage generally scarce resources.

Emotionally intelligent leaders must be rational in their decisions but must be open to emotions, even though they are not comfortable. The medium-term benefit is positive for the leader and his team.

As Fleming and Delves say,31 people follow human leaders, leaders who inspire. Leaders who recognise mistakes and that they improve with the improvement of their team.

The combination of these factors is the recipe for a true team engagement, ultimately the goal of good leadership. That is the reason why at the time we live now, volatile, uncertain, complex and ambiguous, it is necessary to humanise leaderships more than ever, and it is in this context that emotionally intelligent leadership develops. Emotionally intelligent leaders are aware of their own emotions and intuitively aware of the emotions of others.

## Ethics statements

### Patient consent for publication

Not required.

## Acknowledgments

We thank our colleagues who, in addition to treating patients with COVID-19, have contributed to the change in the model in our health system.

## Footnotes

*   Contributors All the authors contributed to the design of the manuscript. OY and GT wrote the paper draft and MI reviewed and made significant contributions.

*   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.

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