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Leadership development of health and social care professionals: a systematic review
  1. Emer McGowan1,
  2. Jennifer Hale2,
  3. Janet Bezner2,
  4. Kenneth Harwood3,
  5. Jennifer Green-Wilson4,
  6. Emma Stokes5
  1. 1Discipline of Physiotherapy, University of Dublin Trinity College, Dublin, Ireland
  2. 2Physical Therapy, Texas State University, Round Rock, Texas, USA
  3. 3Clinical Research and Leadership, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
  4. 4Health Care Administration, SUNY Brockport, Brockport, New York, USA
  5. 5Department of Physiotherapy, College of Health Sciences, QU Health, Qatar University, Doha, Ad Dawhah, Qatar
  1. Correspondence to Dr Emer McGowan, Physiotherapy, University of Dublin Trinity College, Dublin, Ireland; emcgowan{at}tcd.ie

Abstract

The need to develop leaders across all levels of the health system including clinical staff has been recognised. Investments are made by healthcare organisations each year to develop leadership within their workforce hence there is a need to evaluate these development programmes to investigate whether the stated objectives have been achieved. The aim of this review was to systematically review published literature on the effect of leadership development for health and social care professionals (HSCPs). The databases, CINAHL, EMBASE, ERIC, Medline, PsychInfo, Scopus and Web of Science, were systematically searched. After screening and quality analysis, nine full-text articles were included in the review. The included studies demonstrated a range of methodological quality and there was high variability in the leadership development programmes in terms of programme length, content, structure, participants and evaluation methods. Transformational leadership was the leadership model most frequently employed. The reported results suggest that these educational interventions have positive effects on participants such as improved leadership behaviours, increased confidence and workplace engagement. However, the mixed methodological quality of the studies and high variability between the courses mean that definitive recommendations for leadership development programmes for HSCPs cannot be made. High-quality, longitudinal studies using rigorous evaluation methods are needed to provide the necessary evidence to inform the development of future programmes.

  • leadership assessment
  • research
  • development
  • continuous improvement
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Introduction

In recent years, there has been growing attention paid to the importance of leadership within healthcare.1 Effective leadership is needed at all levels of the health system to address challenges of assuring quality and safety,2 3 drive service development,4 5 ensure favourable clinical outcomes2 4 and foster employee engagement.6 7 The need to develop leaders in today’s rapidly changing healthcare environment has been recognised.5 8 9 This has led to a growing evidence base on leadership development, leadership approaches and their effect on health outcomes.3 5 10 Despite this, there are limited studies which have evaluated leadership development for health and social care professionals (HSCPs).11–13 HSCPs are highly qualified and skilled health professionals who work in a range of healthcare settings including acute, primary care, community, residential, disability, specialist and services for older persons.14 HSCPs include allied health professionals and social workers. They provide interventions in rehabilitative, therapeutic, re-enablement and diagnostic services.14

Leadership development practices have been defined as ‘educational processes designed to improve the leadership capabilities of individuals’.15 In leadership development the emphasis has traditionally been on formal training and education programmes, but more recently there has been increasing recognition of the role of a wider range of knowledge and skill generating activities both formal and informal.16 Since significant investments can be made by healthcare organisations to develop leaders, there is a need to evaluate these leadership development programmes to assess whether the stated intentions have been achieved.17 Blumenthal et al8 argued that the ad hoc approach taken to leadership development in medicine has created accidental leaders and that to properly prepare tomorrow’s clinical leaders thoughtful, engaged and purposely crafted leadership programmes are needed.8 Effective leadership development is context specific,18 however, the effectiveness of these programmes can be difficult to measure as feedback is largely based on the self-reports of participants. To establish best practice and maximise the use of resources expended on this important area, high-quality research evaluating these programmes should be conducted.19

In healthcare, leadership development programmes have conventionally been evaluated based on the feedback given by programme participants, often expressed at the end of the programme.17 However, the retrospective nature of this evaluation approach makes it difficult to gain an accurate impression of the impact that a programme may have had on its participants and their work.17 20 Attempts to quantify precisely the benefits of leadership development programmes have remained elusive and historically most organisations have not closed the loop between linking leadership development, changes in behaviour and organisational outcomes.21 A review of the literature of health education programmes that teach collaborative leadership found that only 6.8% of the 250 articles reviewed assessed the effectiveness of their programme based on patient-centred outcomes and 3.6% on system change.22 Similarly, in a systematic review of physician leadership development programmes, Frich et al23 found that the programmes were associated with increased self-assessed knowledge and expertise but that few studies examined outcomes at a system level.23 To date, there have been no systematic literature reviews of leadership development programmes for HSCPs.

Consequently, the aim of this review was to systematically review published literature on leadership development for HSCPs. The objectives of this systematic review were:

  1. To identify the settings, educational content, programme structure and evaluation methods of leadership development programmes for HSCPs.

  2. To determine the effects of interventions for developing leadership behaviours in HSCPs.

A secondary aim of the review was to elicit information that can inform the design and evaluation of future leadership development programmes for HSCPs.

Methods

The protocol for the systematic review was registered on PROSPERO (CRD42017060340). The search strategy for the review was developed with the guidance of a medical librarian. The databases included in this review were: CINAHL, EMBASE, ERIC, Medline, PsychInfo, Scopus and Web of Science. The full search terms used for each of the search engines are detailed in online supplementary annex 1. No date limitations were placed on the inclusion of studies. The reference lists of all included articles were also searched for relevant studies.

Study selection

The search strategy was initially conducted in August 2017 and was re-run in July 2019. The results of the searches of each database were uploaded into the web software programme, Covidence (covidence.org). Duplicates were identified and removed by the Covidence software. The list of titles and abstracts generated by the search were independently screened to identify potentially relevant articles. Three reviewers worked to complete this screening with each title being screened by two reviewers. To be included in the analysis, each article had to meet all three selection criteria: an education-based programme or intervention with explicit objectives related to leadership; a population of learners from the HSCPs and evaluation of the leadership programme.

The screening process was conducted as follows. Each reviewer read their portion of titles and abstracts to determine which papers met the selection criteria. When the reviewers had a different opinion about a paper, a third team member would also screen the title so that a decision could be made. If the third team member indicated that they were unsure whether a paper should be included or not, the paper was moved forward to the next round of screening so that it could be further considered. In the next round of screening, full-text articles were independently assessed by three reviewers for eligibility in accordance with inclusion and exclusion criteria described in box 1. Again, each article was screened by two reviewers. Differences in opinion between the reviewers were resolved through discussion.

Box 1

Inclusion and exclusion criteria

Inclusion criteria

  • Articles focused on the development, structure or content and evaluation of a leadership programme.

  • Studies must have included health and social care professionals (HSCPs) (physiotherapists, occupational therapists, dietitians, speech and language therapists, radiographers, radiation therapists, optometrists, podiatrists, orthotists/prosthetists, orthoptists, paramedics, drama/music/art therapists, social workers).

  • Studies that also included other healthcare professionals (eg, nurses, physicians, pharmacists, dentists, healthcare managers) were also eligible for inclusion.

  • Studies of programmes that specifically targeted particular competencies associated with leadership, for example, communication skills or professionalism, were included only if they measured leadership outcomes.

  • Due to the inseparable nature of leadership and management in practice, interventions that aimed to develop skills related to both concepts were included.

  • Studies published in English.

Exclusion criteria

  • Studies that solely included nursing, pharmacy, dentistry or medical professionals and do not include HSCPs.

  • Studies of leadership development programmes in an academic rather than clinical context, ie, aimed at academics rather than professionals who do clinical work.

  • Studies focused on leadership development at undergraduate or entry-to-practice level education.

  • Interventions solely focused on managerial rather than leadership competencies.

  • Studies on efforts to improve the performance of healthcare workers, including the management and leadership workforce, but which did not address leadership competencies.

  • Conference papers for which there was no full text available.

  • Magazine articles.

Quality assessment

The articles included in the review were assessed for quality using two measures. First, the Crowe Critical Appraisal Tool (CCAT)24 was used to appraise the quality of the studies. The CCAT consists of eight categories (preliminaries, introduction, design, sampling, data collection, ethical matters, results and discussion) divided into 22 items, which are made up of 98-item descriptors.24 It has demonstrated validity25 and reliability26 and the numerous categories, items and item descriptors make this tool suitable for appraising a wide range of both qualitative and quantitative research. Studies which scored very poorly on the CCAT (<30%) were excluded from the study. The studies were independently scored using the CCAT by two reviewers. After scoring the studies, the two reviewers met to discuss the studies and reach consensus on the score awarded to each study.

The second quality assessment categorised the studies based on level of evaluation used in assessing the leadership programme. When reviewing the literature around leadership development programmes, different frameworks can be used to classify the different levels of evaluation employed in assessing the outcomes of the programme. In this review, Kirkpatrick’s four-level evaluation model was used for classification.27 There are four evaluation levels in this model: reaction (level 1), knowledge (level 2), behavioural change (level 3) and system results (level 4). In accordance with a review of physician leadership programmes conducted by Frich et al, the levels (except for level 1) were differentiated into subjective and objective assessment of outcomes.23

Data extraction

Once the screening and quality assessments were completed, data were extracted by two reviewers and checked for accuracy and completeness by a third reviewer. Study data were extracted using a standard form and entered into an Excel spreadsheet. Data were extracted on: study design, objectives, setting, participants’ professions, educational content, programme structure, evaluation methods and key findings with respect to outcomes. The data extracted from each article were entered into the Excel spreadsheet data form to constitute the review database. The extracted data from the included articles were summarised under the following headings: programme details, quality analysis, leadership models, evaluation methods and results and limitations, to allow patterns to be observed and conclusions to be made.

Results

An overview of the article selection process is demonstrated in figure 1. The search strategy yielded 7245 titles of which 1162 were removed by Covidence because they were duplicates. Of the 6083 remaining articles, 5807 were excluded because they were not relevant. Reasons for exclusion included articles that focused exclusively on students or nurses or articles that described programmes that did not expressly set out to build leadership capabilities. This meant that 276 potentially relevant articles were included in the full-text review. Screening of the full texts resulted in the selection of 10 articles to include in the quality assessment. One of these articles was then excluded from the review as it scored <30% on the CCAT. Hand-searching of the reference list of the included articles resulted in no further articles being included.

Figure 1

Flow chart showing the article retrieval process of the articles to be included in the systematic review. HSCP, health and social care professional.

The nine studies included in this systematic review are listed and summarised in table 1. All the studies had been conducted in the last 20 years and the majority (n=5) within the last 5 years. Descriptive data of the included studies are displayed in table 2. Specific demographic details of the participants were not provided in five of the studies. However, from the details provided, it was possible to deduce that two of the programmes were unidisciplinary programmes (n=1 for physiotherapists, n=1 for social workers). The participants in one study were from HSCPs and in six studies were from HSCPs and other professions (nursing, pharmacy, medicine and support services). The duration of the programmes ranged from 3 days to 10 months. Most of the courses were conducted over at least a 6-week period (n=8) and in four studies the programme ran over several months.

Table 1

Summary of included studies

Table 2

Descriptive data of the included studies

The leadership models and evaluation methods used in each of the studies are displayed in table 3. In terms of participants’ feedback on the leadership programmes, responses were generally positive with participants broadly indicating that they enjoyed the courses and found them to be beneficial. However, 9% of respondents (n=10) in the study by Woolnough and Faugier rated the course as ‘average’ and 4% rated the programme as ‘poor’.28 These responses were attributed to participant level of experience (should have been delivered to staff at less senior levels) and to material presentation, respectively. Feedback from participants’ colleagues and other stakeholders was generally positive. Aarons et al found a greater increase in supervisee ratings of the intervention group from baseline to 6-month follow-up compared with the control group.29 Senior stakeholders (eg, members of the Trust executive team) in the study by Crofts rated the programme positively30 and, similarly, senior executive feedback was positive in the study by MacPhail et al, especially in relation to engagement and building staff confidence.31 Block and Manning found that supervisors rated the programme positively in terms of its effect on participants, however supervisors’ ratings were significantly lower than those of the participants themselves.32 In contrast, ratings of participants by colleagues on the Multifactor Leadership Questionnaire in the study by Bradd et al demonstrated no significant change from baseline to after the leadership programme.33

Table 3

Leadership models and evaluation methods employed in the studies

Discussion

This systematic review examined the effectiveness of leadership development programmes for HSCPs. The results suggest that these educational interventions have positive effects on participants such as improved leadership behaviours, increased confidence and workplace engagement. However, these findings must be interpreted with caution, as large heterogeneity was evident among study designs and methodology. Overall, the methodological quality of the included studies was mixed as demonstrated by the wide range of scores on the Crowe Critical Appraisal tool (table 1). Many of the studies scored poorly and six were rated below the 60% threshold suggested by Doyle et al.34 These studies lacked quality in research design, sampling and management of bias. Data analysis and comprehensive reporting of participant demographics, results and ethical matters were also identified as poor quality for some studies.

While this review highlights the limited number of studies that have explored leadership development for HSCPs, a number of reviews of research on medical leadership education have been conducted.5 23 35 36 As reported by Stoller,37 there have been three meta-analyses which have examined the impact of physician leadership programmes.5 23 35 The results of these meta-analyses were in agreement that the evidence for clinical or organisational benefits of physician leadership development programmes is relatively weak and that studies that objectively evaluate these factors are needed. More recently, a systematic review by Keijser et al36 advocated that medical leadership development should consider multifaceted and multilevel approaches and take into account the changes in position and professional identity associated with leadership development. Along with the comparative lack of research conducted in HSCPs, this finding demonstrates that to date leadership development of healthcare providers has been relatively neglected in the literature.

There was high variability among the leadership programmes evaluated in the studies included in this review but there were also several similarities. Most of the leadership development programmes included an experiential or active learning component. Experiential learning refers to learning from experience and reflecting on that experience.38 Bradd et al included action learning sets in their programme.33 These action learning sets involved groups meeting regularly to explore solutions to real problems and decision-making. Another example of experiential learning was applied projects. In several of the leadership courses, participants engaged in individual or group projects where they applied principles learnt in the course to projects within their workplace or community.31 32 39 Assigned project-work elements within leadership development correspond with Kolb’s experiential learning process in which the individual moves from concrete experiences to reflection, abstract conceptualisation and, finally, active experimentation.38 This form of adult learning is considered to be powerful.38 In a review of leadership programmes for healthcare leaders, Sonnino concluded that healthcare leadership training is most effective when it incorporates individual or organisational projects that allow participants to put their newly acquired learning into practice.9

Mentoring and coaching were components of some of the leadership programmes.29 33 39 Coaching differs from mentoring in that it is more goal oriented, focused on enhancing performance in specific areas and typically a relatively short-term process.9 In the programme evaluated by Aarons et al, participants received weekly coaching while they put what they had learnt in the course into practice.29 The three studies which included coaching recognise the need identified by Block and Manning32 to provide workplace supports for the developing leader to ensure leaders receive ongoing guidance and effective feedback after the programme. In the wider literature on healthcare leadership development, the important role of mentoring has been highlighted. Mentoring, along with experiential learning, were found to be preferred pedagogies for medical students and medical faculty members in interviews conducted by Bharwani et al.20 Similarly, the importance of mentoring for the leadership development of physiotherapists12 40 and occupational therapists41 42 has previously been recognised. The literature on the effectiveness of leadership coaching in the healthcare setting is more limited but, in a study investigating coaching for healthcare professionals, Grant et al43 found that the benefits of coaching included improved goal attainment, resilience and self-efficacy.

Most of the studies were multidisciplinary in nature and only two studies involved only single profession groups; social workers44 and physiotherapists.39 However, only one study explicitly stated that the programme was interdisciplinary in nature. Barr et al outlined the differences between multidisciplinary and interdisciplinary education describing multidisciplinary learning as different disciplines working alongside each other in the same task but functioning independently, and interdisciplinary learning as disciplines engaging in learning with, from and about each other in an interactive way.45 In the literature review conducted by Careau et al, of the 250 programmes analysed, most used a uniprofessional approach with 22% taking a multidisciplinary approach and only 10% an interdisciplinary approach.22 The findings suggested that interprofessional learning is not yet widely understood or used in leadership education. Similarly, in a review of physician leadership development, Frich et al found that the leadership development programmes focused more on the skills of individual professionals than on cultivating greater levels of communication and collaboration across professional groups.23

None of the included studies incorporated e-learning or took a blended learning approach to the leadership development programme. However, webinars were used by Aarons et al as the control group intervention in their study.29 This contrasted with the findings of a systematic review of leadership development programmes in the health sector,22 where a blended learning approach incorporating face-to-face activities and e-learning delivery formats was found to be the most commonly employed delivery format. Literature supports the use of e-learning and blended learning methods for adult learners. For healthcare providers, research suggest that learners access online learning experiences because of increased accessibility, flexibility and self-direction and found related benefits including increased interactivity among participants and improved costs.46–48 Cook et al found a positive effect on learning outcomes when comparing e-learning to no instruction and similar outcomes compared with more traditional methods.49

The Full-Range Leadership (FRL) model, or a dimension of it (transformational leadership), was the leadership model most frequently employed in the design of the leadership development programmes (table 3). The FRL model describes leadership behaviours within two primary dimensions: transformational and transactional leadership.50 This model has been comprehensively researched and validated as an approach for leadership development.50 51 Transformational leadership, as defined by Bass and Avolio, describes leadership in terms of motivation and development of followers to implement change.50 Transactional leadership is focused on achieving goals and the transactional exchange of reward contingent on an individual’s behaviour. Transformational leadership theory has been widely used in research investigating leadership in healthcare.52–55 A systematic review of leadership styles and patient outcomes by Wong et al concluded that organisations and individuals should develop transformational leadership to reinforce organisational efforts to improve patient outcomes.53 Transformational leadership seems well suited as a model for leadership development of healthcare leaders as excellence, motivation and altruism are at the core and consistent with the values of HSCPs’ codes of ethics.56–58

There were a range of approaches taken to evaluate the leadership programmes from simple participant feedback to colleagues’ ratings of participants’ behaviour. Bharwani et al advocated that evaluation should be built into leadership development programmes from the beginning.20 Most of the studies evaluated the leadership programme at level 3 (behavioural change) on the Kirkpatrick’s levels of evaluation.23 While this finding was positive in that it demonstrates that studies of leadership development have moved beyond merely evaluating programmes based on participant feedback, there is opportunity for further progress. As noted by Bharwani et al, evaluation should examine the outcomes of the programme as a whole and not just the individuals participating in it.20 While this type of outcome evaluation can be more difficult to conduct, it is necessary in order to discern whether the behavioural changes lead to organisational impact and demonstrate a return on the resources invested.8 20 22 Studies are needed to evaluate leadership development programmes with respect to patient outcomes and system change.22

Limitations

When interpreting the findings, it is important to keep in mind the limits of this systematic review. First, it does not represent all available publications on this topic since only peer-reviewed literature included in health-related databases was accessed. Although this constraint may have resulted in missing some programmes, this strategy was undertaken in an effort to ensure an adequate understanding of the methodologies of the studies included. Second, it is possible that some elements of the programmes analysed were misinterpreted because the description provided in the articles reviewed were at times unclear or incomplete. Many of the studies reviewed exhibited weak study design, small sample sizes and provided limited programme details. While these are acknowledged limitations, they also contribute to the portrait of the current evidence base and suggest opportunities for further research on leadership development for HSCPs. Finally, the findings may be affected by publication bias, in that negative studies showing no significant impact of leadership development are less likely to be published. This is a common challenge for reviews of peer-reviewed literature,23 nevertheless, the findings of this systematic review do provide valuable information on leadership education programmes for HSCPs.

Conclusion

These findings provide an initial picture of current practices in leadership development for HSCPs. The mixed methodological quality of the studies and high variability between the programmes mean that definitive recommendations for leadership development programmes for HSCPs cannot be made based on the results of this review. However, commonalities among the programmes suggest that experiential learning and assigned project work or action learning should be included in leadership development programmes for HSCPs. Mentoring and coaching of participants may be a beneficial way to provide ongoing support to participants as they put their newly developed knowledge and skills into practice in their own setting. The results of this review indicate that high-quality, longitudinal studies using rigorous evaluation methods are needed to provide the necessary evidence to inform the development of future programmes.

Acknowledgments

The authors would like to thank David Mockler for his assistance with developing the search strategy for this systematic review.

References

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Footnotes

  • Twitter @EmerMcGowan, @jbezner

  • Contributors All authors contributed to the planning of the review. EMcG was involved in all stages of the review. JH conducted screening, data extraction and contributed to the writing of the review. JB conducted screening and contributed to the writing of the review. KH conducted data extraction and contributed to the writing of the review. JG-W conducted data extraction and contributed to the writing of the review. ES conducted screening, quality analysis and contributed to the writing of the review.

  • 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 ES is the President of the World Confederation for Physical Therapy.

  • Patient consent for publication Not required.

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

  • Data availability statement Data sharing not applicable as no datasets generated and/or analysed for this article as it is a systematic review.

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