Background Over recent years, there has been increasing recognition that effective leadership is critical to establishing positive organisational culture and improving patient outcomes. In maternity, there is a unique interplay between different specialties and disciplines in providing high-quality services.
Methods Review of literature pertaining to leadership and maternity.
Results Good leadership is the key determinant in ensuring that our multi-professional teams function effectively. The relational aspects of teamworking, linked to safer delivery of services, have been explored in great detail in maternity services. However, there has been less focus on the application of leadership theory in this environment and the impact of interventions used in developing leadership skills within maternity teams.
Conclusions In this paper, we discuss how leadership theory can be used to understand high profile maternity service failures and how effective team culture, clinical team building and individual leadership skill-development are strong contributors to this thinking. Specific examples are used to describe ongoing work in our drive for improvement and to highlight the current lack of evidence in this area.
- medical leadership
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Why good leadership is fundamental in maternity
Several national maternity reports now focus on the importance of good clinical leadership and its impact in maternity care. Leadership not only affects clinical care but also impacts on other crucial elements of good maternity care, including a team culture of good relationships, effective communication and escalation. The Each Baby Counts programme is a national quality improvement programme that aims to reduce brain injuries at birth. In their 2020 report, the authors noted that there was a failure to escalate care in 36% of reports and associated with poor leadership. Similarly, the Healthcare Safety Investigation Branch (HSIB) has reported a reluctance to escalate concerns, particularly during periods of handover, leading to delays in care and subsequent avoidable outcomes. Such failures result in mothers and their babies being put at risk and this is further evidenced by the Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK.
Key factors in failures of care within national reports have persisted in recent independent enquiries of maternity units and demonstrate the importance of effective clinical leadership. The Ockenden report into maternity services at Shrewsbury and Telford NHS Trust highlighted problems that arose due to a lack of timely escalation and involvement of other members of the multi-disciplinary team (MDT). It demonstrated the vulnerabilities of maternity services due to the unique composition of maternity teams. When timely escalation was absent, errors were made and subsequently harm arose. Likewise, the HSIB maternity investigation of East Kent Hospitals University Foundation Trust identified a failure in MDT working, describing ‘professional team alliances’ and a reluctance for midwifery escalation of concerns to obstetric and neonatal colleagues.
Dysfunctional working relationships between staff groups have been attributed to a lack of clear and effective leadership. The ‘Safe Births: Everybody’s Business’ inquiry reported that maternity teams were often poorly managed. The Kirkup report into failings at Morecombe Bay demonstrated that poor working relationships and toxic environments had major impacts on women’s care. The authors reported that there was an inability of leadership systems within the trust to identify and challenge these problems, further exacerbating the situation. A similar finding was reported at Shrewsbury and Telford hospitals. The Ockenden report concluded that the maternity service had developed a culture of defensiveness, denial and lack of openness. These were all key themes which contributed to, and conversely, also attributed to, poor leadership.
An MDT approach to leadership
Leadership has taken a fundamental role in the system-level governance of maternity services. It is becoming apparent that the key features of safe maternity teams are interdependent and leadership is now becoming the lynchpin of these relationships. The Care Quality Commission has recently developed focused maternity inspections with a specific focus on clinical and strategic leadership, culture and teamwork. The aim of this specific examination is to drive standards and improve awareness of these interdependencies on safe maternity care.1
The stability and tenacity of leadership have been shown to ensure an organisational focus on patient safety2 and there has been a drive by the Royal Colleges of Midwives to strengthen midwifery leadership within maternity services to incorporate their unique perspectives.3 As such, there is an increasing number of Consultant Midwives, board representation of midwives through Directors of Midwifery, regional chief midwives and a Chief Midwifery Officer in England. Board-level maternity safety champions, now present in 90% of Trusts, are an example of how we are striving for improvements in organisational culture and maternity safety. They support multi-disciplinary collaboration and communication between a Trust Board and midwifery and obstetric champions to ensure senior support in improvement in maternity care.
Despite these positive initiatives there has not been a proactive approach to developing formal leadership programmes for clinical directors and obstetric clinical leads. This gap in service development is even more unsettling given the scrutiny and pressure maternity services are currently facing. Perhaps the future for improvement would be to develop collaborative multidisciplinary leadership programmes for service leads in complex maternity systems. This would serve to address the complexity of leading maternity services and may also resolve wider problems with MDT working.
How to develop MDT leadership skills
There has been a recent change in focus of perceptions and understanding of leadership in healthcare, away from the preoccupation of leader-centric individual development for designated leaders and managers, to the need to build collective, distributive leadership. This is described in the NHS Leadership Framework, where acts of leadership should come from all team members of staff rather than those appointed as leaders, for example, to empower individuals in decision-making.
The medical and midwifery communities are aware of the need for leadership training and it is now a distinct training topic in both undergraduate and postgraduate curricula.4 The regulatory bodies of the General Medical Council and the Nursing and Midwifery Council have recognised the need for formal leadership training and have incorporated leadership skills into their standards of proficiency. The Royal College of Obstetricians and Gynaecologists, the Royal College of Paediatrics and Child Health and the Royal College of Anaesthetists have all now included specific leadership competencies within their trainee curriculums. However, there exists limited evidence as to whether the inclusion of these themes in curricula has any impact on improving patient care.4–6
More focused leadership courses or fellowships might be better placed to allow long-term learning and understanding of the complex processes of leadership4 and leadership fellowship schemes have increased in popularity. Self-reported outcomes of schemes, such as ‘confidence and knowledge of leadership’ improved, however, the long-term effects of completing these programmes on patient outcomes have not yet been assessed. Furthermore, these opportunities have only recently become available to all multi-professional colleagues, previously being for medical and midwifery professionals only. As a result, there is a need for further research into the impact of developing leadership competency frameworks and whether this leads to measurable improvements in safety outcomes.
Leadership in clinical practice
While the foundations of good leadership can be developed through formal undergraduate and postgraduate education, a significant proportion of leadership development occurs while working in the clinical environment. Good teamworking is reliant on good team leadership to give vision, inspiration, and direction to the team. Consequently, high-performing healthcare organisations are those whom exhibit distributive leadership, with appropriately formed teams which are bonded, have a clear purpose and objectives and interdependent roles.2 Labour ward can be a particularly challenging, fast-paced environment and a leader must have different approaches available to deal with the unexpected scenarios which occur.
Amy Edmondson describes ‘teaming’ as a theory of flexible team working, where in contrast to stable teams, team members who may not have previously worked together form a team to solve a problem, requiring rapid or immediate action. Teams are dynamic and the composition may change at any given time. Teaming can be applied to maternity services. Due to shift patterns and siloed working, team members who have not previously met must have the capability to rapidly adopt specified roles and function cooperatively. Similarly, the obstetric team comes together to share and produce the same common goal, the safe care of mother and baby, through undertaking acts of leadership.
Formal teamwork training and skills programmes are invaluable for ‘teaming’ and inter-professional skills development, particularly for such events which are rare but require urgent, coordinated actions by a multi-professional team. Teamwork training programmes have been associated with improved patient outcomes and more effective team processes such as communication, coordination and cooperation. In recent years we have seen a widespread adoption of simulation training as a vital part of medical education, particularly for the management of clinical emergencies.
Courses such as Managing Obstetrical Risk Efficiently, Practical Obstetric Multi-Professional Training (PROMPT) and Managing Medical Emergency and Trauma, allow a team to improve competencies in the management of obstetric emergencies through a systematic process while developing their own technical and non-technical skills. There is growing research that training together, in multi-professional teams, improves both team-working and clinical outcomes.7 Such approaches to training have improved neonatal outcomes and maternal postpartum haemorrhage rates.8 9 In North Bristol Trust, introduction of PROMPT training has led to a 50% reduced in hypoxic brain injury, 100% reduced permanent brachial plexus injury and a 40% quicker delivery at emergency caesarean section. It has also been found to have a significant financial impact with a 91% reduction in litigation costs.7 Unfortunately, such promising results have not been replicated in Apgar scores of neonates as part of ‘THISTLE: trial of hands-on Interprofessional simulation training for local emergencies’, the first prospective randomised control trial of PROMPT implementation in Scottish maternity units. The authors conclude that local implementation at scale is challenging and more research is needed.10
Low fidelity local simulation compliments formal courses at relatively low cost and enables live drills to be conducted by teams who may work together regularly. Anecdotally, these are increasingly being used to allow for collaborative learning and embedding formalised training courses into clinical practice as bonded teams, following recommendations of the Ockenden report; ‘staff who work together must train together’.11 RCOG, in conjunction with the Norfolk and Norwich University Hospitals NHS Trust and Atrainability, have produced a practical toolkit to improve human factors in local maternity teams. In this unit, they promoted multi-professional training on human factors which led to improvements in safety culture.12 The transformational leadership approach which focuses on working with teams to create change through inspiration, empowerment and a motivation to achieve a shared objective can be of particular value on labour ward.13 This is important as it can drive team reflexivity14; the process by which teams collectively reflect on their processes and outcomes and by changing these accordingly, demonstrate an increase in innovation.15 On labour ward, this flexibility is paramount and leads to a culture of trust, psychological safety and the ability to flatten hierarchies to enable escalation.
Appropriate escalation of care and failure to challenge inappropriate de-escalation has been sighted in numerous reports as a fundamental component of safety in maternity.1 11 It requires an ability to communicate effectively, promptly escalate concerns and for these to be acknowledged and acted on effectively across professions and levels of seniority. At times, it could be argued that autocratic leadership has a role to play in emergency situations to ensure the helicopter view is maintained and timely decisions are acted on. However, there is little role for this type of leadership in the wider context of working in maternity services and this can inadvertently cause poor working relationships leaving team members reluctant to speak up.16
An escalation tool using graded assertiveness has been developed by RCOG to empower individuals within maternity teams to speak up, challenge actions and request a second opinion. The Probe, Alert, Challenge, Escalate model or ‘P.A.C.E’ uses a sequence of phrases across four escalating levels of intervention, however there are also other well described communication strategies such as the ‘two-challenge rule’ and critical language ‘CUS’; ‘I’m concerned, I’m uncomfortable, this is unsafe’.17 Standardised intervention tools create a common language, whereby teams are immediately alerted to a serious concern.18
Despite increasing evidence of the impact training has on outcomes, the ‘Mind the Gap’ report in 2018 demonstrated no consistent standardised way of prioritising training so that it is appropriately provided, funded, assessed or attended. The provision of maternity training had increased, however, staffing and funding were key barriers to widespread adoption. More recently, the maternity incentive scheme as part of Clinical Negligence Scheme for Trusts standards guide training needs and act as an incentive for midwifery teams to take ownership and responsibility in improving maternity safety. Specifically, a trust should be able to evidence that 90% of each maternity unit staff group have attended an ‘in-house’ multi-professional maternity emergencies training session within the last training year.19
Improving team culture
As well as dealing with acute emergencies, leadership on labour ward requires an understanding of cultures within the maternity service. One of the key features of safe maternity units, is psychological safety, a phenomenon whereby members of the team feel safe to speak without fear of retaliation, embarrassment and punishment. This is a key feature of safe units.20 Inclusive leadership, which promotes openness, can enhance this environment leading to subsequent safety benefits.21 Fostering a culture of openness can improve incident reporting and hence facilitate system learning, improve standards of care and positively impact on the responsiveness of units to future problems.22 23 Moreover, an open environment with a conscientious leader can also lessen the development of harmful ‘blame cultures’. Due to the medicalisation of maternity care, women are risk assessed for the type of care that is most appropriate for them. As medical teams have become more risk averse, however, unavoidable adverse occurrences have been increasingly attributed to errors in risk assessment.24 As a result, ‘blame cultures' have developed which can be highly damaging to the clinicians, healthcare systems and ultimately the patients involved.24–26 Organisational structures where hierarchy predominates has been associated with a culture of blame27 and so collaborative leadership approaches which flatten hierarchies can be beneficial in reducing this phenomenon.28
Unfortunately, despite thorough risk assessment and competent care, poor outcomes do occur. Following an adverse unanticipated outcome, healthcare professionals can themselves feel that they are personally to blame and have been described as ‘second victims’, developing personal and professional stress.29 This has been well-documented in maternity teams.26 30 Christoffersen et al undertook a qualitative study to describe the leadership style and behaviours of front-line managers to support midwives preventing such crisis.27 The authors concluded that proactive transformational leadership and individualised support and learning were paramount as it encouraged learning, diverse thinking and innovation. As such, ensuring full MDT participation in serious incident analysis is a proactive way of involving individuals in risk management and assists with the acceptance that human errors sadly occur despite best clinical management and intentions. Furthermore, it helps to develop a ‘just culture’ which is essential to improve safety and organisational performance through allowing transparency, learning from error and the avoidance of individual blame.31
Another aspect where good clinical leadership can play a significant role within maternity, is promoting staff well-being. There has been consistent problems with stress and burnout within maternity services leading to high staff attrition rates in the medical and midwifery workforce.26 31 32 Factors associated with high levels of stress, anxiety and depression included a perceived low level of management support and professional recognition for their work.26 31 Collaborative leadership practices can ease these feelings as staff feel valued for their diverse skills and respected by their leaders and ultimately, can reduce stress and promote staff retention.33 An example of this is the use of ‘Schwartz Center Rounds’ which were created as a safe supportive space where colleagues can talk openly about emotional, social and moral aspects of working in a healthcare environment. There is limited evidence for their impact compared with alternative interventions, but it has been demonstrated that they can improve psychological well-being and increase empathy and compassion of colleagues and patients.34
There is also a role for system-wide intervention to prevent a workforce crisis as a result of burnout. ‘Each Baby Counts+Learn and Support’ is a joint collaborative of the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists, working alongside 16 selected NHS Trusts to test and develop initiatives specifically to develop positive workplace culture and well-being. These initiatives demonstrate the impact of staff well-being and engage systems in the widespread adoption and roll out of such measures.
Despite efforts to improve team working and cultures, there can be occasions where teams are faced with a ‘bad apple’; an individual who repeatedly demonstrates unprofessional behaviour or has issues relating to clinical capability.35 These occur very rarely in isolation and often part of a complex system-based failure, they can be challenging to manage and can result in individuals feeling undervalued, undermined and bullied. Incivility or rudeness is associated with a reduction in quality of work of the recipient and for innocent bystanders, a 50% reduction in willingness to help others.36 There has been widespread reporting of bullying within maternity and it has been reported as one of the recurrent themes of all independent inquiries. It is one of the hardest leadership challenges and Dame Clare Marx remarked that, ‘‘A big part of that is the development of leadership skills and crucially tackling unprofessional behaviour towards colleagues: anything from basic rudeness to outright bullying and undermining’.37 The RCOG and RCM have undertaken a ‘workplace behaviours project’ to address these behaviours, introducing initiatives such as workforce behaviour champions and an ‘undermining toolkit’ describing interventions to support in dealing with such situations at an individual and system level.
Well-led maternity units translate into safe maternity units. Effective and compassionate leadership improves patient outcomes and is a shared responsibility across system-leaders, teams and multi-professional individuals. As a cohort of professions, we recognise the importance of leadership in maternity services and as such there are significant efforts across the NHS to implement high-level strategies and local interventions to improve leadership abilities. There is a lack of evidence into the effectiveness of these measures and impact of translating these into practice. However, despite these limitations there are opportunities we can use to develop leadership capabilities. First and foremost, professionals considering leadership roles need to be given opportunities and dedicated time to develop leadership experience and skills, to truly drive forward a holistic model of care.
Protected funding to promote multi-professional training would enable healthcare professionals to develop the skills they require to work in such a unique environment partnered with the development of formal leadership training in relation to development and provision of safe of maternity services. We would advocate for the inclusion of junior trainees and midwives in policy development to ensure continuity and competence of leadership in the future.
There needs to be aligning of values that put women at the centre of the service and that allow codesigning of services tailored to women that are both equitable and kind. The role that effective leadership plays in driving positive cultures and safety needs careful consideration and understanding by trust boards. Last but not least, the leaders of the future need to be encouraged to understand these notions from the earliest stages of their careers. Leadership is not an afterthought, rather the foundation on which services either flourish or struggle.
Patient consent for publication
We would like to thank Nigel Acheson for contributing to our paper through his wealth of experience and significant insight into this emerging field of interest.
Contributors AAA and KK developed the idea, researched the content and wrote the article. TK-D, KT and NA supported the revision of the work critically for important intellectual content.
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 AAA and KK are current National Medical Director’s Clinical Fellows who are working at the Care Quality Commission and NHS England. TK-D is a previous Health Education England fellow and currently holds a role in the Care Quality Commission. KT is a band 7 midwife at King’s College, London. NA is a consultant obstetrician and head of service at University Hospitals Leicester.
Provenance and peer review Not commissioned; externally peer reviewed.
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