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1.  Educational climate seems unrelated to leadership skills of clinical consultants responsible of postgraduate medical education in clinical departments 
BMC Medical Education  2010;10:62.
The educational climate is crucial in postgraduate medical education. Although leaders are in the position to influence the educational climate, the relationship between leadership skills and educational climate is unknown. This study investigates the relationship between the educational climate in clinical departments and the leadership skills of clinical consultants responsible for education.
The study was a trans-sectional correlation study. The educational climate was investigated by a survey among all doctors (specialists and trainees) in the departments. Leadership skills of the consultants responsible for education were measured by multi-source feedback scores from heads of departments, peer consultants, and trainees.
Doctors from 42 clinical departments representing 21 specialties participated. The response rate of the educational climate investigation was moderate 52% (420/811), Response rate was high in the multisource-feedback process 84.3% (420/498). The educational climate was scored quite high mean 3.9 (SD 0.3) on a five-point Likert scale. Likewise the leadership skills of the clinical consultants responsible for education were considered good, mean 5.4 (SD 0.6) on a seven-point Likert scale. There was no significant correlation between the scores concerning the educational climate and the scores on leadership skills, r = 0.17 (p = 0.29).
This study found no relation between the educational climate and the leadership skills of the clinical consultants responsible for postgraduate medical education in clinical departments with the instruments used. Our results indicate that consultants responsible for education are in a weak position to influence the educational climate in the clinical department. Further studies are needed to explore, how heads of departments and other factors related to the clinical organisation could influence the educational climate.
PMCID: PMC2955595  PMID: 20858255
2.  Athletic Training Clinical Instructors as Situational Leaders 
Journal of Athletic Training  2002;37(4 suppl):S-261-S-265.
Objective: To present Situational Leadership as a model that can be implemented by clinical instructors during clinical education. Effective leadership occurs when the leadership style is matched with the observed followers' characteristics. Effective leaders anticipate and assess change and adapt quickly and grow with the change, all while leading followers to do the same. As athletic training students' levels of readiness change, clinical instructors also need to transform their leadership styles and strategies to match the students' ever-changing observed needs in different situations.
Data Sources: CINAHL (1982–2002), MEDLINE (1990–2001), SPORT Discus (1949–2002), ERIC (1966–2002), and Internet Web sites were searched. Search terms included leadership, situational leadership, clinical instructors and leadership, teachers as leaders, and clinical education.
Data Synthesis: Situational Leadership is presented as a leadership model to be used by clinical instructors while teaching and supervising athletic training students in the clinical setting. This model can be implemented to improve the clinical-education process. Situational leaders, eg, clinical instructors, must have the flexibility and range of skills to vary their leadership styles to match the challenges that occur while teaching athletic training students.
Conclusions/Recommendations: This leadership style causes the leader to carry a substantial responsibility to lead while giving power away. Communication is one of the most important leadership skills to develop to become an effective leader. It is imperative for the future of the profession that certified athletic trainers continue to develop effective leadership skills to address the changing times in education and expectations of the athletic training profession.
PMCID: PMC164435  PMID: 12937555
leadership; Situational Leadership; teacher as leader; clinical education
3.  Implementing a pilot leadership course for internal medicine residents: design considerations, participant impressions, and lessons learned 
BMC Medical Education  2014;14(1):257.
Effective clinical leadership is associated with better patient care. We implemented and evaluated a pilot clinical leadership course for second year internal medicine residents at a large United States Academic Medical Center that is part of a multi-hospital health system.
The course met weekly for two to three hours during July, 2013. Sessions included large group discussions and small group reflection meetings. Topics included leadership styles, emotional intelligence, and leading clinical teams. Course materials were designed internally and featured “business school style” case studies about everyday clinical medicine which explore how leadership skills impact care delivery. Participants evaluated the course’s impact and quality using a post-course survey. Questions were structured in five point likert scale and free text format. Likert scale responses were converted to a 1-5 scale (1 = strongly disagree; 3 = neither agree nor disagree; 5 = strongly agree), and means were compared to the value 3 using one-way T-tests. Responses to free text questions were analyzed using the constant comparative method.
All sixteen pilot course participants completed the survey. Participants overwhelmingly agreed that the course provided content and skills relevant to their clinical responsibilities and leadership roles. Most participants also acknowledged that taking the course improved their understanding of their strengths and weaknesses as leaders, different leadership styles, and how to manage interpersonal conflict on clinical teams. 88% also reported that the course increased their interest in pursuing additional leadership training.
A clinical leadership course for internal medicine residents designed by colleagues, and utilizing case studies about clinical medicine, resulted in significant self-reported improvements in clinical leadership competencies.
Electronic supplementary material
The online version of this article (doi:10.1186/s12909-014-0257-2) contains supplementary material, which is available to authorized users.
PMCID: PMC4261637  PMID: 25433680
Leadership development; Management; Quality of care; Teamwork; Patient safety
4.  Teambuilding and Leadership Training in an Internal Medicine Residency Training Program 
The purpose of this report is to describe and evaluate the impact of a 1-day retreat focused on developing leadership skills and teambuilding among postgraduate year 1 residents in an internal medicine residency.
A group of organizers, including members of the staff, the chief medical residents, administrative individuals in the residency office, and an internal organizational development consultant convened to organize an off-site retreat with activities that would provide experiential learning regarding teamwork and leadership, including a “reef survival exercise” and table discussions regarding the characteristics of ideal leaders. In addition, several energizing activities and recreational free time was provided to enhance the interaction and teamwork dimensions of the retreat. To evaluate the impact of the retreat, attendees completed baseline and follow-up questionnaires regarding their experience of the retreat.
Attendees universally regarded the retreat as having value for them. Comparison of baseline to postretreat responses indicated that attendees felt that the retreat enhanced their abilities to be better physicians, resident supervisors, and leaders. Follow-up responses indicated significant increases in attendees’ agreement that good leaders challenge the process, make decisions based on shared visions, allow others to act, recognize individual contributions, and serve as good role models. Results on the survival exercise indicated a high frequency with which team-based decisions surpassed individual members’ decisions, highlighting the importance and value of teamwork to attendees.
Our main findings were that: participants universally found this 1-day retreat beneficial in helping to develop teamwork and leadership skills and the experiential learning aspects of the retreat were more especially highly rated and highlighted the advantages of teamwork.
In the context that this 1-day retreat was deemed useful by faculty and residents alike, further study is needed to assess the impact of this learning on actual clinical practice and the durability of these lessons.
PMCID: PMC1492383  PMID: 15209609
leadership; residency training; teambuilding
5.  Training of Leadership Skills in Medical Education 
Background: Effective team performance is essential in the delivery of high-quality health-care. Leadership skills therefore are an important part of physicians’ everyday clinical life. To date, the development of leadership skills are underrepresented in medical curricula. Appropriate training methods for equipping doctors with these leadership skills are highly desirable.
Objective: The review aims to summarize the findings in the current literature regarding training in leadership skills in medicine and tries to integrate the findings to guide future research and training development.
Method: The PubMED, ERIC, and PsycArticles, PsycINFO, PSYNDEX and Academic search complete of EBSCOhost were searched for training of leadership skills in medicine in German and English. Relevant articles were identified and findings were integrated and consolidated regarding the leadership principles, target group of training and number of participants, temporal resources of the training, training content and methods, the evaluation design and trainings effects.
Results: Eight studies met all inclusion criteria and no exclusion criteria. The range of training programs is very broad and leadership skill components are diverse. Training designs implied theoretical reflections of leadership phenomena as well as discussions of case studies from practice. The duration of training ranged from several hours to years. Reactions of participants to trainings were positive, yet no behavioral changes through training were examined.
Conclusions: More research is needed to understand the factors critical to success in the development of leadership skills in medical education and to adapt goal-oriented training methods. Requirements analysis might help to gain knowledge about the nature of leadership skills in medicine. The authors propose a stronger focus on behavioral training methods like simulation-based training for leadership skills in medical education.
PMCID: PMC3839077  PMID: 24282452
Education Medical (MeSH [I02.358.399]); Leadership (MeSH [F01.752.609]); training
6.  Leadership Frames and Perceptions of Effectiveness among Health Information Management Program Directors 
Leadership is important to health science education. For program effectiveness, directors should possess leadership skills to appropriately lead and manage their departments. Therefore, it is important to explore the leadership styles of programs' leaders as health science education is undergoing reform. Program directors of two and four-year health information management programs were surveyed to determine leadership styles. The study examined leadership styles or frames, the number of leadership frames employed by directors, and the relationship between leadership frames and their perceptions of their effectiveness as a manager and as a leader. The study shows that program directors are confident of their human resource and structural skills and less sure of the political and symbolic skills required of leaders. These skills in turn are correlated with their self-perceived effectiveness as managers and leaders. Findings from the study may assist program directors in their career development and expansion of health information management programs as a discipline within the health science field.
As academic health centers receive greater pressure from the Institute of Medicine and accrediting agencies to reform health science education, the question of leadership arises. These centers have taken a leadership role in reforming health professional education by partnering with educational institutions to improve the health of communities.
To achieve health education reform, health sciences educators must apply effective leadership skills.1 College and university leadership is challenged on how to best approach educational reform across health science fields. This article discusses leadership styles employed by program directors of one health science department, health information management, in directing programs for health science education reform.
PMCID: PMC2047298  PMID: 18066358
Leadership frames; health information management; program effectiveness
7.  An Educational Intervention to Enhance Nurse Leaders' Perceptions of Patient Safety Culture 
Health Services Research  2005;40(4):997-1020.
To design a training intervention and then test its effect on nurse leaders' perceptions of patient safety culture.
Study Setting
Three hundred and fifty-six nurses in clinical leadership roles (nurse managers and educators/CNSs) in two Canadian multi-site teaching hospitals (study and control).
Study Design
A prospective evaluation of a patient safety training intervention using a quasi-experimental untreated control group design with pretest and posttest. Nurses in clinical leadership roles in the study group were invited to participate in two patient safety workshops over a 6-month period. Individuals in the study and control groups completed surveys measuring patient safety culture and leadership for improvement prior to training and 4 months following the second workshop.
Extraction Methods
Individual nurse clinical leaders were the unit of analysis. Exploratory factor analysis of the safety culture items was conducted; repeated-measures analysis of variance and paired t-tests were used to evaluate the effect of the training intervention on perceived safety culture (three factors). Hierarchical regression analyses looked at the influence of demographics, leadership for improvement, and the training intervention on nurse leaders' perceptions of safety culture.
Principal Findings
A statistically significant improvement in one of three safety culture measures was shown for the study group (p<.001) and a significant decline was seen on one of the safety culture measures for the control group (p<.05). Leadership support for improvement was found to explain significant amounts of variance in all three patient safety culture measures; workshop attendance explained significant amounts of variance in one of the three safety culture measures. The total R2 for the three full hierarchical regression models ranged from 0.338 and 0.554.
Sensitively delivered training initiatives for nurse leaders can help to foster a safety culture. Organizational leadership support for improvement is, however, also critical for fostering a culture of safety. Together, training interventions and leadership support may have the most significant impact on patient safety culture.
PMCID: PMC1361187  PMID: 16033489
Patient safety; safety culture; leadership; training intervention
8.  Leadership and management in the undergraduate medical curriculum: a qualitative study of students’ attitudes and opinions at one UK medical school 
BMJ Open  2014;4(6):e005353.
To explore undergraduate medical students’ attitudes towards and opinions about leadership and management education.
Between 2009 and 2012 we conducted a qualitative study comprising five focus group discussions, each devoted to one of the five domains in the Medical Leadership Competency Framework, (Personal Qualities, Working with Others, Managing Services, Improving Services and Setting Direction). Each discussion examined what should be learnt, when should learning occur, what methods should be used, how should learning be assessed, what are the barriers to such education.
28 students from all three clinical years (4–6) of whom 10 were women.
2 inter-related themes emerged: understanding the broad perspective of patients and other stakeholders involved in healthcare provision and the need to make leadership and management education relevant in the clinical context. Topics suggested by students included structure of the National Health Service (NHS), team working skills, decision-making and negotiating skills. Patient safety was seen as particularly important. Students preferred experiential learning, with placements seen as providing teaching opportunities. Structured observation, reflection, critical appraisal and analysis of mistakes at all levels were mentioned as existing opportunities for integrating leadership and management education. Students’ views about assessment and timing of such education were mixed. Student feedback figured prominently as a method of delivery and a means of assessment, while attitudes of medical professionals, students and of society in general were seen as barriers.
Medical students may be more open to leadership and management education than thought hitherto. These findings offer insights into how students view possible developments in leadership and management education and stress the importance of developing broad perspectives and clinical relevance in this context.
PMCID: PMC4078777  PMID: 24965917
Medical Education & Training; Qualitative Research
9.  Key Elements of Clinical Physician Leadership at an Academic Medical Center 
A considerable body of literature in the management sciences has defined leadership and how leadership skills can be attained. There is considerably less literature about leadership within medical settings. Physicians-in-training are frequently placed in leadership positions ranging from running a clinical team or overseeing a resuscitation effort. However, physicians-in-training rarely receive such training. The objective of this study was to discover characteristics associated with effective physician leadership at an academic medical center for future development of such training.
We conducted focus groups with medical professionals (attending physicians, residents, and nurses) at an academic medical center. The focus group discussion script was designed to elicit participants' perceptions of qualities necessary for physician leadership. The lead question asked participants to imagine a scenario in which they either acted as or observed a physician leader. Two independent reviewers reviewed transcripts to identify key domains of physician leadership.
Although the context was not specified, the focus group participants discussed leadership in the context of a clinical team. They identified 4 important themes: management of the team, establishing a vision, communication, and personal attributes.
Physician leadership exists in clinical settings. This study highlights the elements essential to that leadership. Understanding the physician attributes and behaviors that result in effective leadership and teamwork can lay the groundwork for more formal leadership education for physicians-in-training.
PMCID: PMC3186276  PMID: 22379520
10.  A State-Wide Obstetric Hemorrhage Quality Improvement Initiative 
The mission of the California Maternal Quality Care Collaborative is to eliminate preventable maternal death and injury and promote equitable maternity care in California. This article describes CMQCC’s statewide multi-stakeholder quality improvement initiative to improve readiness, recognition, response, and reporting of maternal hemorrhage at birth and details the essential role of nurses in its success.
Project Design and Approach
In partnership with the State Department of Maternal, Child, and Adolescent Health, CMQCC identified maternal hemorrhage as a significant quality improvement opportunity. CMQCC organized a multi-disciplinary, multi-stakeholder task force to develop a strategy for addressing obstetric (OB) hemorrhage.
Project Description
The OB Hemorrhage Task Force, co-chaired by nurse and physician team leaders, identified four priorities for action and developed a comprehensive hemorrhage guideline. CMQCC is using a multi-level strategy to disseminate the guideline, including an open access toolkit, a minimal support mentoring model, a county partnership model, and a 30-hospital learning collaborative.
Clinical Implications
In participating hospitals, nurses have been the primary drivers in developing both general and massive hemorrhage policies and procedures, ensuring the availability of critical supplies, organizing team debriefing after a stage 2 or greater hemorrhage, hosting skills stations for measuring blood loss, and running OB hemorrhage drills. Each of these activities requires effort and leadership skill, even in hospitals where clinicians are convinced that these changes are needed. In some hospitals, the burden to convince physicians of the value of these new practices has rested primarily upon nurses. Thus, the state-wide initiative where nurse and physician leaders work together models the value of teamwork and provides a real-time demonstration of the potential for effective interdisciplinary collaboration to make a difference in the quality of care that can be achieved. Nurses provide significant leadership in multi-disciplinary, multi-stakeholder quality projects in California. Ensuring that nurses have the opportunity to participate in formal leadership of these teams and are represented at all workgroup levels is critical to the overall initiative. Nurses brought key understanding of operational issues within and across departments, mobilized engagement across the state through the regional perinatal programs, and developed innovative approaches to solving clinical problems during implementation. Nursing leadership and integrated participation was especially critical in considering the needs of lower-resource settings, and was essential to the toolkit’s enthusiastic adoption at the unit/service level in facilities across the state.
PMCID: PMC3203841  PMID: 21857200
Quality Improvement; Implementation; Hemorrhage; Practice Guidelines
11.  Rationale and study protocol for the supporting children’s outcomes using rewards, exercise and skills (SCORES) group randomized controlled trial: A physical activity and fundamental movement skills intervention for primary schools in low-income communities 
BMC Public Health  2012;12:427.
Many Australian children are insufficiently active to accrue health benefits and physical activity (PA) levels are consistently lower among youth of low socio-economic position. PA levels decline dramatically during adolescence and evidence suggests that competency in a range of fundamental movement skills (FMS) may serve as a protective factor against this trend.
The Supporting Children’s Outcomes Using Rewards Exercise and Skills (SCORES) intervention is a multi-component PA and FMS intervention for primary schools in low-income communities, which will be evaluated using a group randomized controlled trial. The socio-ecological model provided a framework for the 12-month intervention, which includes the following components: teacher professional learning, student leadership workshops (including leadership accreditation and rewards, e.g., stickers, water bottles), PA policy review, PA equipment packs, parental engagement via newsletters, FMS homework and a parent evening, and community partnerships with local sporting organizations. Outcomes will be assessed at baseline, 6- and 12-months. The primary outcomes are PA (accelerometers), FMS (Test of Gross Motor Development II) and cardiorespiratory fitness (multi-stage fitness test). Secondary outcomes include body mass index [using weight (kg)/height (m2)], perceived competence, physical self-esteem, and resilience. Individual and environmental mediators of behavior change (e.g. social support and enjoyment) will also be assessed. The System for Observing Fitness Instruction Time will be used to assess the impact of the intervention on PA within physical education lessons. Statistical analyses will follow intention-to-treat principles and hypothesized mediators of PA behavior change will be explored.
SCORES is an innovative primary school-based PA and FMS intervention designed to support students attending schools in low-income communities to be more skilled and active. The findings from the study may be used to guide teacher pre-service education, professional learning and school policy in primary schools.
Trial registration
Australian New Zealand Clinical Trials Registry No: ACTRN12611001080910
PMCID: PMC3490777  PMID: 22691451
12.  Policy options to improve leadership of middle managers in the Australian residential aged care setting: a narrative synthesis 
The prevalence of both chronic diseases and multi-morbidity increases with longer life spans. As Australia's population ages, the aged care sector is under increasing pressure to ensure that quality aged care is available. Key to responding to this pressure is leadership and management capability within the aged care workforce. A systematic literature review was conducted to inform the policy development necessary for the enhancement of clinical and managerial leadership skills of middle managers within residential aged care.
Using scientific journal databases, hand searching of specialist journals, Google, snowballing and suggestions from experts, 4,484 papers were found. After a seven-tiered culling process, we conducted a detailed review (narrative synthesis) of 153 papers relevant to leadership and management development in aged care, incorporating expert and key stakeholder consultations.
• Positive staff experiences of a manager's leadership are critical to ensure job satisfaction and workforce retention, the provision of quality care and the well-being of care recipients, and potentially a reduction of associated costs.
• The essential attributes of good leadership for aged care middle management are a hands-on accessibility and professional expertise in nurturing respect, recognition and team building, along with effective communication and flexibility. However, successful leadership and management outcomes depend on coherent and good organisational leadership (structural and psychological empowerment).
• There is inadequate preparation for middle management leadership roles in the aged care sector and a lack of clear guidelines and key performance indicators to assess leadership and management skills.
• Theory development in aged care leadership and management research is limited. A few effective generic clinical leadership programs targeting both clinical and managerial leaders exist. However, little is known regarding how appropriate and effective they are for the aged care sector.
There is an urgent need for a national strategy that promotes a common approach to aged care leadership and management development, one that is sector-appropriate and congruent with the philosophy of person-centred care now predominant in the sector. The onus is on aged care industries as a whole and various levels of Government to make a concerted effort to establish relevant regulation, legislation and funding.
PMCID: PMC2910696  PMID: 20602798
13.  Leadership in rural medicine: The organization on thin ice? 
To explore the personal experiences of and conceptions regarding leading rural primary care in Northern Norway.
Qualitative content analysis of focus-group interviews.
Lead primary care physicians in the three northernmost counties.
Four groups with 22 out of 88 municipal lead physicians in the region.
Three main categories were developed and bound together by an implicit theme. Demands and challenges included the wide leadership span of clinical services and public health, placed in a merged line/board position. Constraints of human resources and time and the ever changing organizational context added to the experience of strain. Personal qualifications indicates the lack of leadership motivation and training, which was partly compensated for by a leader role developed through clinical undergraduate training and then through the responsibilities and experiences of clinical work. In Exercising the leadership, the participants described a vision of a coaching and coordinating leadership and, in practice, a display of communication skills, decision-making ability, result focusing, and ad hoc solutions. Leadership was made easier by the features of the small, rural organization, such as overview, close contact with cooperating partners, and a supportive environment. There was incongruence between demands and described qualifications, and between desired and executed leadership, but nevertheless the organization was running. Leadership demonstrated a “working inadequacy”.
Under resource constraints, leadership based on clinical skills favours management by exception which, in the long run, appears to make the leadership less effective. Leadership training which takes into account the prominent features of rural and decentralized primary care is strongly needed.
PMCID: PMC3347941  PMID: 21526921
Clinician; focus-group interviews; physician leadership; rural primary health care
14.  Implementing a provider-initiated testing and counselling (PITC) intervention in Cape town, South Africa: a process evaluation using the normalisation process model 
Provider-initiated HIV testing and counselling (PITC) increases HIV testing rates in most settings, but its effect on testing rates varies considerably. This paper reports the findings of a process evaluation of a controlled trial of PITC for people with sexually transmitted infections (STI) attending publicly funded clinics in a low-resource setting in South Africa, where the trial results were lower than anticipated compared to the standard Voluntary Counselling and Testing (VCT) approach.
This longitudinal study used a variety of qualitative methods, including participant observation of project implementation processes, staff focus groups, patient interviews, and observation of clinical practice. Data were content analysed by identifying the main influences shaping the implementation process. The Normalisation Process Model (NPM) was used as a theoretical framework to analyse implementation processes and explain the trial outcomes.
The new PITC intervention became embedded in practice (normalised) during a two-year period (2006 to 2007). Factors that promoted the normalising include strong senior leadership, implementation support, appropriate accountability mechanisms, an intervention design that was responsive to service needs and congruent with professional practice, positive staff and patient perceptions, and a responsive organisational context. Nevertheless, nurses struggled to deploy the intervention efficiently, mainly because of poor sequencing and integration of HIV and STI tasks, a focus on HIV education, tension with a patient-centred communication style, and inadequate training on dealing with the operational challenges. This resulted in longer consultation times, which may account for the low test coverage outcome.
Leadership and implementation support, congruent intervention design, and a responsive organisational context strengthened implementation. Poor compatibility with nurse skills on the level of the clinical consultation may have contributed to limiting the size of the trial outcomes. A close fit between the PITC intervention design and clinical practices, as well as appropriate training, are needed to ensure sustainability of the programme. The use of a theory-driven analysis promotes transferability of the results, and the findings are therefore relevant to the implementation of HIV testing and to the design and evaluation of complex interventions in other settings.
Trial registration
Current controlled trials ISRCTN93692532
PMCID: PMC3765808  PMID: 23972055
Routine ‘opt-out’ HIV testing; Process evaluation; Normalisation process model; Sexually transmitted infection; Qualitative method
15.  Guiding Principles for Student Leadership Development in the Doctor of Pharmacy Program to Assist Administrators and Faculty Members in Implementing or Refining Curricula 
Objective. To assist administrators and faculty members in colleges and schools of pharmacy by gathering expert opinion to frame, direct, and support investments in student leadership development.
Methods. Twenty-six leadership instructors participated in a 3-round, online, modified Delphi process to define doctor of pharmacy (PharmD) student leadership instruction. Round 1 asked open-ended questions about leadership knowledge, skills, and attitudes to begin the generation of student leadership development guiding principles and competencies. Statements were identified as guiding principles when they were perceived as foundational to the instructional approach. Round 2 grouped responses for agreement rating and comment. Group consensus with a statement as a guiding principle was set prospectively at 80%. Round 3 allowed rating and comment on guidelines, modified from feedback in round 2, that did not meet consensus. The principles were verified by identifying common contemporary leadership development approaches in the literature.
Results. Twelve guiding principles, related to concepts of leadership and educational philosophy, were defined and could be linked to contemporary leadership development thought. These guiding principles describe the motivation for teaching leadership, the fundamental precepts of student leadership development, and the core tenets for leadership instruction.
Conclusions. Expert opinion gathered using a Delphi process resulted in guiding principles that help to address many of the fundamental questions that arise when implementing or refining leadership curricula. The principles identified are supported by common contemporary leadership development thought.
PMCID: PMC3872940  PMID: 24371345
delphi; leadership; instruction; principles; curriculum
16.  Managerial leadership and ischaemic heart disease among employees: the Swedish WOLF study 
To investigate the association between managerial leadership and ischaemic heart disease (IHD) among employees.
Data on 3122 Swedish male employees were drawn from a prospective cohort study (WOLF). Baseline screening was carried out in 1992–1995. Managerial leadership behaviours (consideration for individual employees, provision of clarity in goals and role expectations, supplying information and feedback, ability to carry out changes at work successfully, and promotion of employee participation and control) were rated by subordinates. Records of employee hospital admissions with a diagnosis of acute myocardial infarction or unstable angina and deaths from IHD or cardiac arrest to the end of 2003 were used to ascertain IHD. Cox proportional-hazards analyses were used to calculate hazard ratios for incident IHD per 1 standard deviation increase in standardised leadership score.
74 incident IHD events occurred during the mean follow-up period of 9.7 years. Higher leadership score was associated with lower IHD risk. The inverse association was stronger the longer the participant had worked in the same workplace (age-adjusted hazard ratio 0.76 (95% CI 0.61 to 0.96) for employment for 1 year, 0.77 (0.61 to 0.97) for 2 years, 0.69 (0.54 to 0.88) for 3 years, and 0.61 (0.47 to 0.80) for 4 years); this association was robust to adjustments for education, social class, income, supervisory status, perceived physical load at work, smoking, physical exercise, BMI, blood pressure, lipids, fibrinogen and diabetes. The dose–response association between perceived leadership behaviours and IHD was also evident in subsidiary analyses with only acute myocardial infarction and cardiac death as the outcome.
If the observed associations were causal then workplace interventions should focus on concrete managerial behaviours in order to prevent IHD in employees.
PMCID: PMC2602855  PMID: 19039097
17.  The Development, Implementation, and Assessment of an Innovative Faculty Mentoring Leadership Program 
Effective mentoring is an important component of academic success. Few programs exist to both improve the effectiveness of established mentors and cultivate a multi-specialty mentoring community. In 2008, in response to a faculty survey on mentoring, leaders at Brigham and Women’s Hospital developed the Faculty Mentoring Leadership Program (FMLP) as a peer-learning experience for mid-career and senior faculty physician and scientist mentors to enhance their skills and leadership in mentoring and create a supportive community of mentors. A planning group representing key administrative, educational, clinical, and research mentorship constituencies designed the nine-month course.
Participants met monthly for an hour and a half during lunchtime. Two co-facilitators engaged the diverse group of 16 participants in interactive discussions about cases based on the participants’ experiences. While the co-facilitators discussed with the participants the dyadic mentor-mentee relationship, they specifically emphasized the value of engaging multiple mentors and establishing mentoring networks. In response to post-session and post-course (both immediately and after six months) self-assessments, participants reported substantive gains in their mentoring confidence and effectiveness, experienced a renewed sense of enthusiasm for mentoring, and took initial steps to build a diverse network of mentoring relationships.
In this article, the authors describe the rationale, design, implementation, assessment, and ongoing impact of this innovative faculty mentoring leadership program. They also share lessons learned for other institutions that are contemplating developing a similar faculty mentoring program.
PMCID: PMC3924178  PMID: 23095917
18.  Engagement and Action for Health: The Contribution of Leaders’ Collaborative Skills to Partnership Success 
A multi-site evaluation (survey) of five Kellogg-funded Community Partnerships (CPs) in South Africa was undertaken to explore the relationship between leadership skills and a range of 30 operational, functional and organisational factors deemed critical to successful CPs. The CPs were collaborative academic-health service-community efforts aimed at health professions education reforms. The level of agreement to eleven dichotomous (‘Yes/No’) leadership skills items was used to compute two measures of members’ appreciation of their CPs’ leadership. The associations between these measures and 30 CPs factors were explored, and the partnership factors that leadership skills explained were assessed after controlling. Respondents who perceived the leadership of their CPs favourably had more positive ratings across 30 other partnership factors than those who rated leadership skills less favourably, and were more likely to report a positive cost/ benefit ratio. In addition, respondents who viewed their CPs’ leadership positively also rated the operational understanding, the communication mechanisms, as well as the rules and procedures of the CPs more favourably. Leadership skills explained between 20% and 7% of the variance of 10 partnership factors. The influence of leaders’ skills in effective health-focussed partnerships is much broader than previously conceptualised.
PMCID: PMC2672331  PMID: 19440289
Partnership; coalition; community-based; inter-professional; multi-site evaluation; health professions education; leadership
19.  Leadership competencies for medical education and healthcare professions: population-based study 
BMJ Open  2012;2(2):e000812.
To identify and empirically investigate the dimensions of leadership in medical education and healthcare professions.
A population-based design with a focus group and a survey were used to identify the perceived competencies for effective leadership in medical education.
The focus group, consisting of five experts from three countries (Austria n=1; Germany n=2; Switzerland n=2), was conducted (all masters of medical education), and the survey was sent to health professionals from medical schools and teaching hospitals in six countries (Austria, Canada, Germany, Switzerland, the UK and the USA).
The participants were educators, physicians, nurses and other health professionals who held academic positions in medical education. A total of 229 completed the survey: 135 (59.0%) women (mean age=50.3 years) and 94 (41.0%) men (mean age=51.0 years).
A 63-item survey measuring leadership competencies was developed and administered via electronic mail to participants.
Exploratory principal component analyses yielded five factors accounting for 51.2% of the variance: (1) social responsibility, (2) innovation, (3) self-management, (4) task management and (5) justice orientation. There were significant differences between physicians and other health professionals on some factors (Wilk's λ=0.93, p<0.01). Social responsibility was rated higher by other health professionals (M=71.09) than by physicians (M=67.12), as was innovation (health professionals M=80.83; physicians M=76.20) and justice orientation (health professionals M=21.27; physicians M=20.46).
The results of the principal component analyses support the theoretical meaningfulness of these factors, their coherence, internal consistency and parsimony in explaining the variance of the data. Although there are some between-group differences, the competencies appear to be stable and coherent.
Article summary
Article focus
The major focus was to identify and empirically investigate the dimensions of leadership in medical education and healthcare professions.
A 63-item survey was developed and administered via electronic mail to 229 healthcare professional educators and leaders in six countries (Austria, Canada, Germany, Switzerland, the UK and the USA).
Key messages
Exploratory principal component analyses yielded five dimensions of leadership: (1) social responsibility, (2) innovation, (3) self-management, (4) task management, and (5) justice orientation.
Social responsibility was rated higher by other health professionals compared with physicians, as was innovation and justice orientation.
Strengths and limitations of this study
The results of the principal component analyses support the theoretical meaningfulness of these factors, their coherence, internal consistency and parsimony in explaining the variance of the data.
Our five-factor leadership competency model needs to be replicated and extended with larger representative samples from other cultures.
Notwithstanding the limitations of the present study, it is one of the few that has explicitly defined and provided empirical evidence for leadership competencies considered to be the most important in medical education.
PMCID: PMC3323822  PMID: 22457482
20.  Physicians’ leadership styles in rural primary medical care: How are they perceived by staff? 
Aim. This study investigates which leadership styles can be identified among general practice lead physicians and how they are associated with and predicted by staff and context characteristics like profession, gender, age, work experience, and team size. Method/material. In a cross-sectional study self-administered questionnaires were distributed to staff physicians (42% females) and support staff (98% females) at 101 primary health care centres in North Norway. A total of 127 and 222, respectively, responded (response rate 59%). Items were ranked on Likert scales (range 1–5). Results. Analysis revealed three significantly different styles (mean scores/Cronbach's alpha): change style (3.36/0.898), task style (3.17/0.885), and relation style (2.88/0.900). The lead physicians were perceived as practising change style the most and relation style the least. Males experienced significantly more of all three styles. Support staff scored lowest for all styles. Age was negatively correlated with relation style and change style, while work experience was negatively correlated with change style. No significant association was found between styles and team size. Conclusion. Leadership in rural general practice can be identified in terms of task, relation, and change styles. Change style is the most perceived style. Males seem to be most attentive to leadership styles. However, within the staff physician group, there is less difference between genders. Support staff scores lowest for all styles; this might indicate either less need for leadership or dissatisfaction with leadership. Age and work experience seem to reduce employees’ attention to relation and change styles, indicating that maturity reduces needs for these leadership styles. Due to growing demands for leaders to take care of efficiency and change in general practice, more young female physicians, and more diverse staff groups, these findings may be useful to understand leadership and leadership training for general practice.
PMCID: PMC4137902  PMID: 24533846
Context; general practice; lead physicians; leadership style; Norway; rural medicine; staff gender; staff maturity; staff profession
21.  Learning Clinical Versus Leadership Competencies in the Emergency Department: Strategies, Challenges, and Supports of Emergency Medicine Residents 
Emergency medicine residents are expected to master 6 competencies that include clinical and leadership skills. To date, studies have focused primarily on teaching strategies, for example, what attending physicians should do to help residents learn. Residents' own contributions to the learning process remain largely unexplored. The purpose of this study was to explore what emergency medicine residents believe helps them learn the skills required for practice in the emergency department.
This qualitative study used semistructured interviews with emergency medicine residents at a major academic medical center. Twelve residents participated, and 11 additional residents formed a validation group. We used phenomenologic techniques to guide the data analysis and techniques such as triangulation and member checks to ensure the validity of the findings.
We found major differences in the strategies residents used to learn clinical versus leadership skills. Clinical skill learning was approached with rigor and involved a large number of other physicians, while leadership skill learning was unplanned and largely relied on nursing personnel. In addition, with each type of skills, different aspects of the residents' personalities, motivation, and past nonclinical experiences supported or challenged their learning process.
The approaches to learning leadership skills are not well developed among emergency medicine residents and result in a narrow perspective on leadership. This may be because of the lack of formal leadership training in medical school and residency, or it may reflect assumptions regarding how leadership skills develop. Substantial opportunity exists for enhancing emergency medicine residents' learning of leadership skills as well as the teaching of these skills by the attending physicians and nurses who facilitate their learning.
PMCID: PMC3179228  PMID: 22942956
22.  Leadership Behaviors of Athletic Training Leaders Compared With Leaders in Other Fields 
Journal of Athletic Training  2007;42(1):120-125.
Context: Athletic trainers are in positions of leadership.
Objective: To determine self-reported leadership practices of head athletic trainers (HATCs) and program directors (PDs).
Design: Cross-sectional study.
Setting: Respondents' academic institutions.
Patients or Other Participants: A total of 238 athletic training leaders completed the Leadership Practices Inventory. Of these, 50.4% (n = 120) were HATCs and 49.6% (n = 118) were PDs; 69.3% (n = 165) were men and 30.7% (n = 73) were women; almost all respondents (97.1%, n = 231) were white. Respondents typically reported having 11 to 15 years of experience as an athletic trainer (n = 57, 23.9%) and being between the ages of 30 and 39 years (n = 109, 45.8%).
Main Outcome Measure(s): Categories of leadership behaviors (ie, Model, Inspire, Challenge, Encourage, and Enable) were scored from 1 (almost never) to 10 (almost always). Item scores were summed to compute mean category scores. We analyzed demographic information; used t ratios to compare the data from athletic training leaders (PDs and HATCs) with normative data; compared sex, age, position, ethnicity, and years of experience with leadership practices; and computed mean scores.
Results: Athletic training leaders reported using leadership behaviors similar to those of other leaders. The PDs reported using inspiring, challenging, enabling, and encouraging leadership behaviors more often than did the HATCs. No differences were found by ethnicity, age, years of experience, or leadership practices.
Conclusions: Athletic training leaders are transformational leaders. Athletic training education program accreditation requirements likely account for the difference in leadership practices between PDs and HATCs.
PMCID: PMC1896069  PMID: 17597953
management; leadership style; transformational leadership; Leadership Practices Inventory; survey research
23.  Improving quality of care through improved audit and feedback 
The Department of Veterans Affairs (VA) has led the industry in measuring facility performance as a critical element in improving quality of care, investing substantial resources to develop and maintain valid and cost-effective measures. The External Peer Review Program (EPRP) of the VA is the official data source for monitoring facility performance, used to prioritize the quality areas needing most attention. Facility performance measurement has significantly improved preventive and chronic care, as well as overall quality; however, much variability still exists in levels of performance across measures and facilities. Audit and feedback (A&F), an important component of effective performance measurement, can help reduce this variability and improve overall performance. Previous research suggests that VA Medical Centers (VAMCs) with high EPRP performance scores tend to use EPRP data as a feedback source. However, the manner in which EPRP data are used as a feedback source by individual providers as well as service line, facility, and network leadership is not well understood. An in-depth understanding of mental models, strategies, and specific feedback process characteristics adopted by high-performing facilities is thus urgently needed.
This research compares how leaders of high, low, and moderately performing VAMCs use clinical performance data from the EPRP as a feedback tool to maintain and improve quality of care.
We will conduct a qualitative, grounded theory analysis of up to 64 interviews using a novel method of sampling primary care, facility, and Veterans Integrated Service Network (VISN) leadership at high-, moderate-, and low-performing facilities. We will analyze interviews for evidence of cross-facility differences in perceptions of performance data usefulness and strategies for disseminating performance data evaluating performance, with particular attention to timeliness, individualization, and punitiveness of feedback delivery.
Most research examining feedback to improve provider and facility performance lacks a detailed understanding of the elements of effective feedback. This research will highlight the elements most commonly used at high-performing facilities and identify additional features of their successful feedback strategies not previously identified. Armed with this information, practices can implement more effective A&F interventions to improve quality of care.
PMCID: PMC3462705  PMID: 22607640
24.  The Cleveland Clinic: a distinctive model of American medicine 
The Cleveland Clinic is a large healthcare system based in Cleveland, Ohio (USA) with an extensive American (throughout Northeast Ohio; Weston, Florida; and Las Vegas, Nevada) and global presence (in Abu Dhabi, UAE; and with training alumni in >70 countries). Cleveland Clinic was founded in 1921 as a distinctive medical model with a tripartite mission of “better care of the sick, investigation of their problems, and more teaching of those who serve” which has been vibrantly maintained. Distinctive aspects of the Clinic include its being a closed staff, salaried, group practice which is physician-led and which features 1-year faculty appointments and a vigorous annual review process for all physicians and leaders. Regarding its tripartite mission, the Clinic has demonstrated longstanding clinical excellence, e.g., with consistent ranking as first in cardiovascular care in U.S. News and World Report and top-10 rankings in at least 12 other specialties. A longstanding tradition of research has contributed landmark discoveries, including performance of the first coronary revascularization procedure, the first intra-coronary angiogram, the world’s third face transplant, ongoing development of a breast cancer vaccine, etc. Regarding education, the Clinic serves many educational audiences excellently through its Education Institute. These audiences include medical students, graduate medical trainees, faculty physicians, nurses, and allied health providers (both within the Cleveland Clinic and from other institutions worldwide), and patients. The Education Institute also includes the Cleveland Clinic Academy, which offers training in leadership competencies to physicians, nurses, and healthcare administrators both within the Cleveland Clinic and to visitors from abroad (through the Executive Visitors Program and the Samson Global Leadership Academy for Healthcare Executives). The latter program is an intensive 2-week residential leadership development course for emerging healthcare leaders focusing on both personal leadership competencies and on healthcare system thinking ( Participants from 18 countries have attended to date.
PMCID: PMC4200609  PMID: 25333009
Cleveland Clinic; model of medicine; excellence; clinical care; research; education
25.  Attitudes of medical students to medical leadership and management: a systematic review to inform curriculum development 
BMC Medical Education  2011;11:93.
There is a growing acknowledgement that doctors need to develop leadership and management competences to become more actively involved in the planning, delivery and transformation of patient services. We undertook a systematic review of what is known concerning the knowledge, skills and attitudes of medical students regarding leadership and management. Here we report the results pertaining to the attitudes of students to provide evidence to inform curriculum development in this developing field of medical education.
We searched major electronic databases and citation indexes within the disciplines of medicine, education, social science and management. We undertook hand searching of major journals, and reference and citation tracking. We accessed websites of UK medical institutions and contacted individuals working within the field.
26 studies were included. Most were conducted in the USA, using mainly quantitative methods. We used inductive analysis of the topics addressed by each study to identity five main content areas: Quality Improvement; Managed Care, Use of Resources and Costs; General Leadership and Management; Role of the Doctor, and Patient Safety. Students have positive attitudes to clinical practice guidelines, quality improvement techniques and multidisciplinary teamwork, but mixed attitudes to managed care, cost containment and medical error. Education interventions had variable effects on students' attitudes. Medical students perceive a need for leadership and management education but identified lack of curriculum time and disinterest in some activities as potential barriers to implementation.
The findings from our review may reflect the relatively little emphasis given to leadership and management in medical curricula. However, students recognise a need to develop leadership and management competences. Although further work needs to be undertaken, using rigorous methods, to identify the most effective and cost-effective curriculum innovations, this review offers the only currently available summary of work examining the attitudes of students to this important area of development for future doctors.
PMCID: PMC3247079  PMID: 22082174

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