Article Text
Abstract
Objective A state-of-the-art (SotA) literature review—a type of narrative review— was conducted to answer: What historical developments led to current conceptualisations of followership in interprofessional healthcare teams (IHTs)?
Design Working from a constructivist orientation, SotA literature reviews generate a chronological overview of how knowledge evolved and presents this summary in three parts: (1) this is where we are now, (2) this is how we got here and (3) this is where we should go next. Using the SotA six-stage methodology, a total of 48 articles focused on followership in IHTs were used in this study.
Results Articles about followership within IHTs first appeared in 1993. Until 2011, followership was framed as leader-centric; leaders used their position to influence followers to uphold their dictums. This perspective was challenged when scholars outside of healthcare emphasised the importance of team members for achieving goals, rejecting a myopic focus on physicians as leaders. Today, followership is an important focus of IHT research but two contradictory views are present: (1) followers are described as active team members in IHTs where shared leadership models prevail and (2) conceptually and practically, old ways of thinking about followership (ie, followers are passive team members) still occur. This incongruity has generated a variable set of qualities associated with good followership.
Conclusions Leadership and followership are closely linked concepts. For leaders and followers in today’s IHTs to flourish, the focus must be on followers being active members of the team instead of passive members. Since theories are increasingly encouraging distributed leadership, shared leadership and/or situational leadership, then we must understand the followership work that all team members need to harness. We need to be cognizant of team dynamics that work within different contexts and use leadership and followership conceptualisations that are congruent with those contexts.
- followership
- development
- effectiveness
Data availability statement
Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as online supplemental information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Healthcare education has tended to focus on leadership development, not followership development. Yet, healthcare functions as teams where members of the team (ie, physicians, nurses, techs) will need to shift into leadership positions when they are not team leaders. Therefore, it is important to explore how followership skills might need to evolve to effectively support the future of interprofessional healthcare team (IHT) collaboration.
WHAT THIS STUDY ADDS
Much of the focus for development has been on leader and leadership development. Very little has been discussed around followers and their roles on these IHTs. Having this understanding of where we are today with the more contemporary conceptualisations of followership can allow us to move away from the traditional conceptualisations of leadership that may be hindering interprofessional collaboration.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Followership within clinical contexts may be different and there is not a one-size-fits all solution. The skills required of followers may vary depending on the clinical context. However, a psychologically safe environment is a universally needed contextual consideration. Yet, if we are aware of new conceptualisations and ways to move between leader and follower roles as needed, IHTs will be more effective. Active followers and models of shared leadership can be taught within educational settings to prepare learners to be active members of the team and be able to shift into leadership roles even when they do not hold the leadership position. Future research should focus on these team dynamics focusing on leadership and followership within different healthcare contexts.
Introduction
Research has established that effective interprofessional healthcare teams (IHTs) can reduce medical errors, leading to improved patient outcomes and more efficient utilisation of resources.1 2 Healthcare education scholarship addressing how to prepare healthcare professionals for team collaboration has tended to focus on leadership development.3–9 Less attention has been given to followership responsibilities and the ability to transition between leadership and followership roles.10 Both leadership and followership are required of healthcare professionals for optimal healthcare team functioning to occur.11–21
IHTs are defined as collaborations between two or more individuals from different healthcare professions ‘who are recognised by others as well as by themselves as having a collective identity and shared responsibility for a patient or group of patients.(Interprofessional Education Collaborative, 22 p8)’ Historically, theories of leadership in IHTs have not been complimented with considerations of followership; leadership and followership are topics largely siloed apart from one another. Within IHTs there are both leaders and followers and their collaboration is essential to delivering patient care. Yet, little is discussed about being a follower in IHTs. We suggest that followers are key determinants of IHT performance. Therefore, team performance could be optimised if we better understood the dynamics between leadership and followership, especially given that research into IHT leadership has increasingly endorsed power sharing across team membership (eg, shared leadership23 24). This focus will likely have important implications when members (ie, physicians, nurses, techs) will need to shift into leadership positions when they do not hold the position of the team leader.
Therefore, it is important to explore how conceptualisations of followership and the necessary skills of followers might need to evolve to effectively support the future of IHTs. This also entails understanding historical and current conceptualisations of leadership in IHTs—conceptualisations that draw heavily on the literature about leadership in general—and of followership in IHTs. This study set out to conduct a state-of-the-art (SotA) literature review—a type of narrative review—to answer the following research question: What historical developments led to current conceptualisations of followership in IHTs? Understanding current thinking about followership will enable us to propose new research directions for IHTs to guide education, training and development.
Methods
Working from a constructivist research orientation, SotA literature reviews generate a chronological overview of how knowledge about a phenomenon evolved and presents this summary in three parts: (1) why current thinking holds (this is where we are now), (2) how current thinking evolved (this is how we got here) and (3) how future research might be usefully directed (this is where we should go next).25 26 We adhered to Barry et al’s six stage SotA review process.25
Stages 1–3: determine initial question and field of inquiry, determine time frame and finalise research question to reflect time frame
Our preliminary searches were guided by a broad question: What is the role of followership in IHTs? Our search revealed that the concept of followership did not have a long history in the IHT literature—first appearing in the 1990s—and that followership was often not the sole focus. Therefore, we chose not to impose time limits and looked at all IHT collaborators. Our finalised research question was: What historical developments led to current conceptualisations of followership in IHTs?
Stage 4: develop search strategy to find relevant articles
In consultation with a medical librarian, we searched the English literature in five databases: PubMed, Embase, CINAHL, PsycINFO and Web of Science. These databases were chosen to capture a broad scope of literature about followership in IHTs. Database searches are described in detail in online supplemental appendix A. Searches identified 679 articles; 383 remained when duplicates were removed.
Supplemental material
The research team reviewed the titles and abstracts of all articles (n=383) and excluded those that did not address followership in IHTs. This reduced the corpus of articles included in the review to 88. We reviewed the full manuscript of all 88 articles and further excluded those that did not address teams of collaborators (n=32), followership (n=4) or teams working in healthcare contexts (n=4). The remaining 48 articles focused on followership in IHTs and comprised the final corpus of manuscripts included in the analysis (see figure 1 for Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA] flow chart).
Stage 5: analysis
We followed a two-part analysis process. In part 1, a data extraction tool was created to capture four types of information from each paper (see online supplemental appendix B for extraction tool): (1) article demographic data were collected, (2) data were extracted capturing direct quotes on followership (eg, definition, how it was framed, skills/qualities/behaviours discussed, follower styles discussed within the article and theories/conceptualisations), (3) all references and/or descriptions of leadership (eg, styles, theories and/or conceptualisations) were captured and (4) data looking at other theories/conceptualisations that tie leadership and followership together were collected.
Supplemental material
In part 2, using an inductive approach, the research team charted the historical development of followership in IHTs, including: how followership had changed between articles in the corpus; how followership had evolved across time in the research and of gaps and assumptions that underpinned the corpus and individual articles. Through this process, we began to construct an understanding of SotA thinking about followership in IHTs and of the history that gave rise to this understanding. Using these interpretive notes and preliminary timeline, we examined individual articles to test our analyses and modified our interpretations when needed.
Stage 6: reflexivity
Given that SotA literature reviews are based in a subjectivist orientation,25 it is important to report our personal reflexivity,27 acknowledging that each team member came to this research from a unique orientation. EB is a leadership and followership educator in an American undergraduate medical school where she has been teaching in the leadership curriculum for the past 8 years. Her interests in followership come from a family member’s journey with cancer and the breakdown of effective team collaboration that she observed therein. Her academic work and personal experiences have shaped her perception of effective IHTs as being based in a fluid movement between leadership and followership roles without rigid hierarchies. PT is a Dutch gynaecologist and health professions education researcher. He is both academically and practically involved in workplace learning involving IHTs. His interest in followership in IHTs is rooted in the belief that effective teamwork rests on every team members’ commitment and engagement to collaborate with and for patients. For that to happen, IHTs need dynamic role divisions including shifting leadership and followership roles, although heavily influenced by cultural and professional expectations. LV is a health professions education researcher who has conducted research into IHTs since 2005. In her research and personal experiences, she has witnessed collaboration failures when leader-follower shifts have not taken place. As a research team, we began this study with the attitude that (A) leader and follower roles should change during IHT collaboration depending on the situation and (B) followership is an active role where the follower engages in support of the team mission by working in support of the team leader. As part of our second level analysis, we intentionally questioned these assumptions, looking for articles that contradicted these premises and modified our interpretations to fit the findings from the literature.
Results
Early years of followership in IHTs: 1993–2010
Followership in IHTs was first addressed in an article published in 199328; only one manuscript per year was published on the topic for the next 6 years (see figure 2). These early articles were exclusively authored by American research teams and consisted of five commentaries11–13 29 30 and one literature review.28 The concern was raised that followership had largely been ignored within healthcare leadership education, training, research and discussion,13 29 30 yet it was clear that followership was becoming more valued since effective team collaboration required both leaders and followers.11–13 28–30
In the articles published between 1993 and 2010, followership was framed as leader-centric—that is, followers were subservient to leaders. Leaders were described in active terms and followers with passive language. In the 1997 manuscript by Treister and Schultz, a follower was defined as someone ‘who accepts guidance and, on receiving it, takes the appropriate action.’(Treister NW, 30 p2) Ten years later, in 2007, this same view of followers as passive team members was echoed by Miller who defined followership as ‘a position of submission to a leader.’(Miller LA, 12 p76) This leader-centric view still held sway in 2010 when Hertig described a follower as ‘someone who supports the leader.’(Hertig J, 13 p1412) In this early period, leaders were described as using their position in IHT hierarchies to influence followers to uphold leader dictums.
Turning point for followership focus
While the manuscripts in these early years framed followers as passive recipients of and enactors of leader dictums, followership theories presented in books and popular magazines (eg, Harvard Business Review31–33) outside of healthcare were forwarding a different perspective on the work of followers and these perspectives became the common foundational theories that were drawn on and presented in manuscripts later in the corpus. Three scholars from outside the healthcare lens—who’s work informed and was enacted in the literature about followership in IHTs—posed a new perspective on followership: Robert Kelley, Ira Chaleff and Barbara Kellerman.
In 1988, Kelley32 34 proposed five different types of followers that were spread across two dimensions: (1) an axis of passive to active and (2) an axis of dependent, uncritical thinking to individual, critical thinking. In these works, Kelley sowed the seeds for a new way of conceptualising followers: not passive enactors of leader orders, but more active contributors to team efforts. In 1995, Chaleff35 36 proposed five different dimensions of courageous followers who were able to ‘join leaders fully as stewards of the group’s trust.’(Chaleff I, 36 p15) Chaleff’s courageous follower could: (1) assume responsibility, (2) serve, (3) challenge, (4) participate in transformation and (5) to take moral action. In 2009, Chaleff added that courageous followers also needed the courage to (6) speak to the hierarchy and (7) leaders need to listen to followers. Then in 2008, Kellerman37 proposed five types of followers along an axis of low engagement (those who are feeling and doing nothing) through high engagement (those who are passionately committed and active).
The theories of these three scholars slowly permeated into the peer-reviewed literature on followers in IHTs. In the early years of our corpus (ie, up to 2010), Chaleff was cited once in 1997 and in 2007, and Kelley was cited once in 2007 and in 2010. It was not until 2015 that these theorists became commonly cited in the literature addressing followership in IHTs (58% of articles since 2015 referenced one of these three theories—see figure 3).
After 2011, followership in IHTs was receiving steadily increasing attention in the literature from research teams around the world (see figure 2). This increase in publication numbers also follows the publication of several sentinel reports from healthcare organisations including the Institute of Medicine’s 2000 report ‘To Err is Human’38 and Interprofessional Education’s 2011 policies ‘Core Competencies for Interprofessional Collaborative Practice.’22 with other important reports in between.39–41 Aligned with the increased focus on the active contributions of followers in these reports, we posit that these reports and the followership scholars helped to push focus away from leader-centric team mentalities and towards a more collaborative perspective on IHT practices.
Followership in IHTs today: 2011 to today
From 2011, multiple articles with a focus on followership were published each year (see figure 2). While Americans were still dominant authors, scholars in the UK, Canada and Australia also authored multiple articles. New Zealand, Japan, Saudi Arabia, South Africa and Sweden also began to contribute. These articles consisted of 6 literature reviews,42–47 16 commentaries/perspective articles10 14–17 19 20 48–56 and 20 research articles.18 21 57–74
Currently, followership is established as an important focus of IHT research. Two contradictory features are present across the corpus: (1) followers are described as active team members in today’s IHTs where shared leadership models prevail and (2) conceptually (eg, in terms of underlying theories) and practically (eg, in terms of required skills), old ways of thinking about followership (ie, followers are passive members of the team) are still upheld. This incongruity has generated a highly variable set of qualities associated with good followership.
Feature 1: followers are active team members in today’s IHTs where shared leadership models prevail
Since 2011, articles are increasingly defining followership as active participation in all team work (including patient care decision-making) and focusing on the relational role between leaders and followers.10 12 15 17 19–21 45 46 48 49 52 55–57 59 62 63 68 69 71 72 74 In 2013, authors focused on ‘upward influence making it (followership) an active process that, alongside good leadership, can create conditions that are conducive to increased safety and high performance.’(Whitlock J, 15 p20) With the increased focus on followership, authors have stressed the reciprocal relationships between leaders and followers.16 46 48 61 As Raso summarised, leaders and followers, ‘need each other to reach goals, push the envelope, and, in general, look good and do well. It can’t be just about leadership; none of us works alone to accomplish goals.’(Raso R, 51 p6)
In keeping with this feature, articles in the corpus also increasingly rely on the concept of shared leadership. Shared leadership has been defined as, ‘an emergent team property that results from the distribution of leadership influence across multiple team members and focuses on understanding the emergent, informal and dynamic ‘leadership’ brought about by the members of the collective itself.’(Barry ES, 21 p13) The construct of shared leadership first appeared in the corpus in 2011,57 and it remains an important aspect of how followers in IHTs are conceptualised. Today’s literature commonly recognises how individuals can shift between leader and follower roles,10 12 16 20 21 44–47 55–57 59 60 62 65 68 69 74 75 emphasising that ‘no one leads all the time, and followers are very rarely passive, especially where they are professionals for whom autonomy is a desired attribute.’(Barrow M, 57 p18)
Feature 2: current conceptualisations of followership uphold both old and new ideas
Despite this common recognition of followers as active IHT members, the followership literature largely focuses on traditional views of ‘bold leaders’ and ‘blind followers.’ Traditional framings of passive followers have tenaciously stayed in the corpus (see figure 4).
For instance, in 2015, Mannion et al described followers as ‘passive, obedient subordinates’ and acknowledged that the term follower was a ‘somewhat derogatory [role] or secondary to that of ‘leader’.’(Mannion H, 48 p270). In spite of increasing literature about followers as active roles, there are voices in the corpus that construct a more passive/less agentic role for followers in teams. For instance, in 2014, authors discussed that ‘healthcare staff will be directed by, and quite literally, follow the leader.’(Coombs M, 16 p268) In 2021, authors mentioned that the focus on developing leaders over followers may be due to the fact that our culture ‘values individual achievement above teamwork.’(Rowland M, 47 p6) Therefore, a mix of old expectations has combined with newer theories, concepts, and interpretations of followership.
This mix of attitudes towards followers has contributed to an array of skills expected of IHT team members. The focus earlier in the literature had been on developing physician leaders; today, this focus has shifted to develop all members of the team to be leaders, followers and effective team members.52 55 57 62 71 74 What is expected of these roles, however, is not always consistent across the literature, but more active roles as a team member have grown in importance. In the corpus, followers are depicted as needing to understand the larger goal of the team and organisation,10 13–15 19 21 29 45 49 53 55 70 71 be more involved in decision-making and critical thinking,13 19 29 43 47 55 56 70 communicate effectively with others,13 15 29 42 44 47 55 67 69 74 have a growth mindset,13–16 29 43 49 53 55 65 69–71 73 and adapt to contexts.21 29 71–73 The literature also highlights the importance of being self-aware and able to manage emotions effectively while also being aware of other’s emotions and managing those emotions when working with others.14–16 49 53 55 70 72 Current research into followership in IHTs also argues for the importance of creating a psychologically safe environment13 15 21 42–44 51 53 55 61 69–72 to empower followers. And yet, while many publications encourage followers to be courageous14 16 30 43 45 49 53 55 70 in taking on this new active collaborator role, several manuscripts also highlight the need to be honest,13 14 16 49 51 53 55 70 73 credible14 49 70 and trustworthy.15 49 Thus, while many of the skills expected of followers support the new agentic role proposed by Kelley, Chaleff and Kellerman, we can still hear echoes of older conceptualisations of passive followers who are valued for being unassuming but reliably competent. It should be noted that these skills are not universally expected of followers; in the corpus, different skills are highlighted in different contexts.
Discussion
The purpose of this study was to determine the historical developments that led to current conceptualisations of followership relating to IHTs. This SotA review revealed that early articles, published by American research teams, focused on a leader-centric view of followership. Kelley, Chaleff and Kellerman—in addition to sentinel reports from healthcare organisations—pushed for a focus on follower-centric views within IHTs and so helped advance a follower-centric approach to IHT collaboration. Starting in 2011, there was an increase in articles around followership in IHTs from scholars across the world. Today, followership has become an important focus within IHT research focusing on two key features: (1) followers are described as active team members in today’s IHTs where shared leadership models prevail and (2) conceptually and practically, old ways of thinking about followership are still present.
We suggest that followership is an important factor contributing to IHT efficacy since shared leadership is increasingly replacing older, hierarchy-based team collaboration expectations. A recent systematic review highlighted the benefits of shared leadership on team performance within healthcare action teams and emergency situations.23 They noted that most studies reported benefits associated with shared leadership, but few articles critically evaluated shared leadership and IHT performance.23 If followership skills are to inform medical education, we need to be aware of both the benefits and drawbacks to shared leadership and its required followership skills. Indeed, training healthcare providers to be both leaders and followers would enable IHTs to adopt more modern egalitarian collaboration designs. As our literature review revealed, the skills required of followers are deeply affected by context. Therefore, it is not possible to recommend the same set of followership skills for all healthcare contexts. However, a psychologically safe environment is a universally needed contextual consideration. Furthermore, old hierarchical ways of conceptualising followers have persisted in the literature. Until such conceptualisations are changed, realising modern collaboration designs will remain frustrated regardless of the educational efforts provided.
Furthermore, the ways in which individual healthcare providers move across leader and follower roles has yet to be thoroughly studied. If shared leadership is the new IHT normal, then insights are needed into how this sharing works and the skills required to move between leader and follower roles. This gap in the literature needs to be addressed if we are to train the next generation of healthcare leaders—and augment the skills of practicing healthcare professionals—to be effective IHT collaborators.
The future of followership in IHTs
This study found that leadership and followership are closely linked concepts. For leaders and followers in today’s IHTs to flourish, more contemporary conceptualisations of followership must be adopted into practice, and traditional conceptualisations of leadership must be abandoned. Active followers and models of shared leadership can be taught within educational settings to prepare learners to be active members of the team and be able to shift into leadership roles even when they do not hold the leadership position. We acknowledge that followership in different clinical contexts may look different; it is not a one-size-fits all solution. We need to be cognizant of the team dynamics that work within different contexts and harness leadership and followership conceptualisations that are congruent with those contexts. Future research should focus on these team dynamics focusing on leadership and followership within different healthcare contexts to determine how to best educate IHT members.
Limitations
This SotA review focused on turning points in views around followership. Limitations to this study include the use of only peer-reviewed, English articles from three databases. Further investigations could look at the grey literature as well as non-English articles to determine if other publications support our findings. Additionally, our research team brings a specific perspective to this research. Given that SotA reviews are within the narrative tradition and so are shaped by the subjective orientation of the team members, we acknowledge that our perspectives shaped our analyses; other teams may make different interpretations of our corpus.
Conclusion
Effective IHT collaboration is a cornerstone of today’s healthcare. While there are still conceptually and practically old ways of thinking about followers, the more contemporary conceptualisations of followership must be embraced where followers are active members of the team and shared leadership models are used effectively. With this knowledge, education and training around developing leaders and followers, as well as future research, can better optimise shared leadership in IHTs.
Data availability statement
Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as online supplemental information.
Ethics statements
Patient consent for publication
References
Supplementary materials
Supplementary Data
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Footnotes
X @erinsbarry
Contributors All authors were a part of the study design, data collection, data analysis, manuscript writing, editing, and reviewing, and revising. All authors approve this version. ESB is the guarantor for this work.
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.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.