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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.
Background
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.
Methods
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.
Results
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).
Conclusions
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.
doi:10.1186/1472-6920-10-62
PMCID: PMC2955595  PMID: 20858255
2.  Do plastic surgery division heads and program directors have the necessary tools to provide effective leadership? 
Plastic Surgery  2014;22(4):241-245.
Evidence has shown that leadership abilities are not entirely innate and can, in many respects, be learned. Leaders in the corporate world are often trained and assessed for proficiency in several areas including finance, business acumen, accounting, and human resource strategizing and planning, among others. Whether this is true among individuals who assume leadership positions in plastic surgery remains largely unexplored. This study investigated the practice profiles, education/training and challenges of leaders in academic plastic surgery.
BACKGROUND:
Effective leadership is imperative in a changing health care landscape driven by increasing expectations in a setting of rising fiscal pressures. Because evidence suggests that leadership abilities are not simply innate but, rather, effective leadership can be learned, it is prudent for plastic surgeons to evaluate the training and challenges of their leaders because there may be opportunities for further growth and support.
OBJECTIVE:
To investigate the practice profiles, education/training, responsibilities and challenges of leaders within academic plastic surgery.
METHODS:
Following research ethics board approval, an anonymous online survey was sent to division heads and program directors from all university-affiliated plastic surgery divisions in Canada. Survey themes included demographics, education/training, job responsibilities and challenges.
RESULTS:
A response rate of 74% was achieved. The majority of respondents were male (94%), promoted to their current position at a mean age of 48 years, did not have a leadership-focused degree (88%), directly manage 30 people (14 staff, 16 faculty) and were not provided with a job description (65%). Respondents worked an average of 65 h per week, of which 18% was devoted to their leadership role, 59% clinically and the remainder on teaching and research. A discrepancy existed between time spent on their leadership role (18%) and related compensation (10%). Time management (47%) and managing conflict (24%) were described as the greatest leadership challenges by respondents.
CONCLUSIONS:
Several gaps were identified among leaders in plastic surgery including predominance of male sex, limitations in formal leadership training and requisite skill set, as well as compensation and human resources management (emotional intelligence). Leadership and managerial skills are key core competencies, not only for trainees, but certainly for those in a position of leadership. The present study provides evidence that academic departments, universities and medical centres may benefit by re-evaluating how they train, promote and support their leaders in plastic surgery.
PMCID: PMC4271752  PMID: 25535461
Leadership; Management; Plastic surgery; Skill set
3.  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
4.  Implementing a pilot leadership course for internal medicine residents: design considerations, participant impressions, and lessons learned 
BMC Medical Education  2014;14:257.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/s12909-014-0257-2
PMCID: PMC4261637  PMID: 25433680
Leadership development; Management; Quality of care; Teamwork; Patient safety
5.  Do 360-degree Feedback Survey Results Relate to Patient Satisfaction Measures? 
Background
There is evidence that feedback from 360-degree surveys—combined with coaching—can improve physician team performance and quality of patient care. The Physicians Universal Leadership-Teamwork Skills Education (PULSE) 360 is one such survey tool that is used to assess work colleagues’ and coworkers’ perceptions of a physician’s leadership, teamwork, and clinical practice style. The Clinician & Group-Consumer Assessment of Healthcare Providers and System (CG-CAHPS), developed by the US Department of Health and Human Services to serve as the benchmark for quality health care, is a survey tool for patients to provide feedback that is based on their recent experiences with staff and clinicians and soon will be tied to Medicare-based compensation of participating physicians. Prior research has indicated that patients and coworkers often agree in their assessment of physicians’ behavioral patterns. The goal of the current study was to determine whether 360-degree, also called multisource, feedback provided by coworkers could predict patient satisfaction/experience ratings. A significant relationship between these two forms of feedback could enable physicians to take a more proactive approach to reinforce their strengths and identify any improvement opportunities in their patient interactions by reviewing feedback from team members. An automated 360-degree software process may be a faster, simpler, and less resource-intensive approach than telephoning and interviewing patients for survey responses, and it potentially could facilitate a more rapid credentialing or quality improvement process leading to greater fiscal and professional development gains for physicians.
Questions/purposes
Our primary research question was to determine if PULSE 360 coworkers’ ratings correlate with CG-CAHPS patients’ ratings of overall satisfaction, recommendation of the physician, surgeon respect, and clarity of the surgeon’s explanation. Our secondary research questions were to determine whether CG-CAHPS scores correlate with additional composite scores from the Quality PULSE 360 (eg, insight impact score, focus concerns score, leadership-teamwork index score, etc).
Methods
We retrospectively analyzed existing quality improvement data from CG-CAHPS patient surveys as well as from a department quality improvement initiative using 360-degree survey feedback questionnaires (Quality PULSE 360 with coworkers). Bivariate analyses were conducted to identify significant relationships for inclusion of research variables in multivariate linear analyses (eg, stepwise regression to determine the best fitting predictive model for CG-CAHPS ratings). In all higher order analyses, CG-CAHPS ratings were treated as the dependent variables, whereas PULSE 360 scores served as independent variables. This approach led to the identification of the most predictive linear model for each CG-CAHPS’ performance rating (eg, [1] overall satisfaction; [2] recommendation of the physician; [3] surgeon respect; and [4] clarity of the surgeon’s explanation) regressed on all PULSE scores with which there was a significant bivariate relationship. Backward stepwise regression was then used to remove unnecessary predictors from the linear model based on changes in the variance explained by the model with or without inclusion of the predictor.
Results
The Quality PULSE 360 insight impact score correlated with patient satisfaction (0.50, p = 0.01), patient recommendation (0.58, p = 0.002), patient rating of surgeon respect (0.74, p < 0.001), and patient impression of clarity of the physician explanation (0.69, p < 0.001). Additionally, leadership-teamwork index also correlated with patient rating of surgeon respect (0.46, p = 0.019) and patient impression of clarity of the surgeon’s explanation (0.39, p = 0.05). Multivariate analyses supported retention of insight impact as a predictor of patient overall satisfaction, patient recommendation of the surgeon, and patient rating of surgeon respect. Both insight impact and leadership-teamwork index were retained as predictors of patient impression of explanation. Several other PULSE 360 variables were correlated with CG-CAHPS ratings, but none were retained in the linear models post stepwise regression.
Conclusions
The relationship between Quality PULSE 360 feedback scores and measures of patient satisfaction reaffirm that feedback from work team members may provide helpful information into how patients may be perceiving their physicians’ behavior and vice versa. Furthermore, the findings provide tentative support for the use of team-based feedback to improve the quality of relationships with both coworkers and patients. The 360-degree survey process may offer an effective tool for physicians to obtain feedback about behavior that could directly impact practice reimbursement and reputation or potentially be used for bonuses to incentivize better team professionalism and patient satisfaction, ie, “pay-for-professionalism.” Further research is needed to expand on this line of inquiry, determine which interventions can improve 360-degree and patient satisfaction scores, and explain the shared variance in physician performance that is captured in the perceptions of patients and coworkers.
Electronic supplementary material
The online version of this article (doi:10.1007/s11999-014-3981-3) contains supplementary material, which is available to authorized users.
doi:10.1007/s11999-014-3981-3
PMCID: PMC4385380  PMID: 25287521
6.  Enhancing capabilities in health professions education 
Objectives
This article documents the results of ongoing summative program evaluation of a suite of postgraduate courses at The University of Western Australia designed to enhance the educational capabilities, academic leadership and scholarly output of health professionals.
Methods
Commencing students were invited to participate in this descriptive, longitudinal study that surveyed students at commencement and subsequently over a seven year period. Data was collected at baseline and follow-up in relation to the respondents’ educational leadership responsibilities, promotions, involvement in new educational programs, and recognition for contributions towards student learning, educational scholarly outputs and involvement in training programs.
Results
The respondents came from a wide range of health professions and worked in various roles, with a quarter already holding leadership positions. During the follow-up period, half reported receiving a new promotion or moving to new positions requiring educational leadership. Those identifying as being involved with the development of new educational programs doubled and 34% received a new teaching award. Scholarly productivity doubled with 45% giving an oral presentation related to education, 21% publishing and 29% being successful in obtaining funding related to an education project. 
Conclusions
These postgraduate courses in health professions education appear to be positively influencing graduates’ capabilities, especially in the areas of educational leadership skills and scholarly productivity. For those looking to develop a community of leaders in health professions education, the authors offer some suggestions.
doi:10.5116/ijme.5641.060c
PMCID: PMC4662867  PMID: 26590857
Faculty development; postgraduate; health professions
7.  Teambuilding and Leadership Training in an Internal Medicine Residency Training Program 
OBJECTIVE
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.
METHOD
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.
RESULTS
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.
CONCLUSIONS
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.
doi:10.1111/j.1525-1497.2004.30247.x
PMCID: PMC1492383  PMID: 15209609
leadership; residency training; teambuilding
8.  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
9.  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
10.  An Educational Intervention to Enhance Nurse Leaders' Perceptions of Patient Safety Culture 
Health Services Research  2005;40(4):997-1020.
Objective
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.
Conclusions
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.
doi:10.1111/j.1475-6773.2005.00401.x
PMCID: PMC1361187  PMID: 16033489
Patient safety; safety culture; leadership; training intervention
11.  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.
Objective
To explore undergraduate medical students’ attitudes towards and opinions about leadership and management education.
Design
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.
Participants
28 students from all three clinical years (4–6) of whom 10 were women.
Results
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.
Conclusions
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.
doi:10.1136/bmjopen-2014-005353
PMCID: PMC4078777  PMID: 24965917
Medical Education & Training; Qualitative Research
12.  Assessment of leadership training needs of internal medicine residents at the Massachusetts General Hospital 
Internal medicine (IM) physicians, including residents, assume both formal and informal leadership roles that significantly impact clinical and organizational outcomes. However, most internists lack formal leadership training. In 2013 and 2014, we surveyed all rising second-year IM residents at a large northeastern academic medical center about their need for, and preferences regarding, leadership training. Fifty-five of 113 residents (49%) completed the survey. Forty-four residents (80% of respondents) reported a need for additional formal leadership training. A self-reported need for leadership training was not associated with respondents' gender or previous leadership training and experience. Commonly cited leadership skill needs included “leading a team” (98% of residents), “confronting problem employees” (93%), “coaching and developing others” (93%), and “resolving interpersonal conflict” (84%). Respondents preferred to learn about leadership using multiple teaching modalities. Fifty residents (91%) preferred to have a physician teach them about leadership, while 19 (35%) wanted instruction from a hospital manager. IM residents may not receive adequate leadership development education during pregraduate and postgraduate training. IM residents may be more likely to benefit from leadership training interventions that are physician-led, multimodal, and occur during the second year of residency. These findings can help inform the design of effective leadership development programs for physician trainees.
PMCID: PMC4462209  PMID: 26130876
13.  Key Elements of Clinical Physician Leadership at an Academic Medical Center 
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.4300/JGME-D-10-00017.1
PMCID: PMC3186276  PMID: 22379520
14.  A State-Wide Obstetric Hemorrhage Quality Improvement Initiative 
Purpose
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.
doi:10.1097/NMC.0b013e318227c75f
PMCID: PMC3203841  PMID: 21857200
Quality Improvement; Implementation; Hemorrhage; Practice Guidelines
15.  Nurses’ evaluation of physicians’ non-clinical performance in emergency departments: advantages, disadvantages and lessons learned 
Background
Peer evaluation is increasingly used as a method to assess physicians’ interpersonal and communication skills. We report on experience with soliciting registered nurses’ feedback on physicians’ non-clinical performance in the ED of a large academic medical center in Lebanon.
Methods
We utilized a secondary analysis of a de-identified database of ED nurses’ assessment of physicians’ non-clinical performance coupled with an evaluation of interventions carried out as a result of this evaluation. The database was compiled as part of quality/performance improvement initiatives using a cross-sectional design to survey registered nurses working at the ED. The survey instrument included open ended and closed ended questions assessing physicians’ communication, professionalism and leadership skills. Three episodes of evaluation were carried out over an 18 month period. Physicians were provided with a communication training carried out after the first cycle of evaluation and a detailed feedback on their assessment by nurses after each evaluation cycle. A paired t-test was carried out to compare mean evaluation scores between the three cycles of evaluation. Thematic analysis of nurses’ qualitative comments was carried out.
Results
A statistically significant increase in the averages of skills was observed between the first and second evaluations, followed by a significant decrease in the averages of the three skills between the second and third evaluations. Personalized feedback to ED physicians and communication training initially contributed to a significant positive impact on improving ED physicians’ non-clinical skills as perceived by the ED nurses. Yet, gains achieved were lost upon reaching the third cycle of evaluation. However, the thematic analysis of the nurses’ qualitative responses portrays a decrease in concerns across the various dimensions of non-clinical performance.
Conclusions
Nurses’ evaluation of the non-clinical performance of physicians has the potential of improving communication, professionalism and leadership skills amongst physicians. For improvement to be realized in a sustainable manner, such programs may need to be offered in a staged and incremental manner over a long period of time with proper dedication of resources and timely monitoring and evaluation of outcomes. Department directors need to be trained on providing peer evaluation feedback in a constructive manner.
doi:10.1186/s12913-015-0733-3
PMCID: PMC4348160  PMID: 25885442
Peer evaluation; Nurses; Physicians; Emergency Department; Lebanon
16.  A questionnaire survey exploring healthcare professionals’ attitudes towards teamwork and safety in acute care areas in South Korea 
BMJ Open  2015;5(7):e007881.
Objectives
Although human factors are important in terms of patient safety, there have been very few reports on the attitudes of healthcare professionals working in acute care settings in South Korea. In the present study, we investigated the attitudes of such professionals, their cultures and their management systems.
Design
A questionnaire survey with 65 items covering nine themes affecting patient safety. Nine themes were compared via a three-or-more-way analysis of variance, with interaction, followed by multiple comparisons among several groups.
Setting
Intensive care units, emergency departments and surgical units of nine urban hospitals.
Participants
592 nurses and 160 physicians.
Intervention
None.
Outcome measures
Mean scores using a five-point scale and combined response scores for each of the nine themes.
Results
The mean score for information-sharing was the highest (3.78±0.49) and that for confidence/assertion was the lowest (2.97±0.34). The mean scores for teamwork, error management, work value, organisational climate, leadership, stress and fatigue level, and error/procedural compliance were intermediate. Physicians showed lower scores in leadership and higher scores in information-sharing than nurses. Respondents with 24 months or less of a clinical career showed higher scores in leadership, stress and fatigue, and error scores and lower scores in work value than more experienced respondents.
Conclusions
Our results suggest that medical personnel in Korea are relatively reluctant to disclose error or assert their different opinions with others. Many did not adequately recognise the negative effects of fatigue and stress, attributed errors to personal incompetence, and error-management systems were inadequate. Discrepancies in leadership and information-sharing were evident between professional groups, and leadership, stress, fatigue level, work value and error scores varied with the length of work experience. These can be used as baseline data to establish training programmes for patient safety in Korea.
doi:10.1136/bmjopen-2015-007881
PMCID: PMC4521544  PMID: 26209120
INTENSIVE & CRITICAL CARE; EDUCATION & TRAINING (see Medical Education & Training)
17.  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.
Background
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.
Methods/design
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.
Discussion
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
doi:10.1186/1471-2458-12-427
PMCID: PMC3490777  PMID: 22691451
18.  Policy options to improve leadership of middle managers in the Australian residential aged care setting: a narrative synthesis 
Background
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.
Methods
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.
Results
• 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.
Conclusions
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.
doi:10.1186/1472-6963-10-190
PMCID: PMC2910696  PMID: 20602798
19.  Leadership in rural medicine: The organization on thin ice? 
Objective
To explore the personal experiences of and conceptions regarding leading rural primary care in Northern Norway.
Design
Qualitative content analysis of focus-group interviews.
Setting
Lead primary care physicians in the three northernmost counties.
Subjects
Four groups with 22 out of 88 municipal lead physicians in the region.
Results
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”.
Conclusion
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.
doi:10.3109/02813432.2011.577148
PMCID: PMC3347941  PMID: 21526921
Clinician; focus-group interviews; physician leadership; rural primary health care
20.  Implementing a provider-initiated testing and counselling (PITC) intervention in Cape town, South Africa: a process evaluation using the normalisation process model 
Background
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.
Method
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.
Results
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.
Conclusion
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
doi:10.1186/1748-5908-8-97
PMCID: PMC3765808  PMID: 23972055
Routine ‘opt-out’ HIV testing; Process evaluation; Normalisation process model; Sexually transmitted infection; Qualitative method
21.  Leadership Development Programs for Physicians: A Systematic Review 
Background
Physician leadership development programs typically aim to strengthen physicians’ leadership competencies and improve organizational performance. We conducted a systematic review of medical literature on physician leadership development programs in order to characterize the setting, educational content, teaching methods, and learning outcomes achieved.
Methods
Articles were identified through a search in Ovid MEDLINE from 1950 through November 2013. We included articles that described programs designed to expose physicians to leadership concepts, outlined teaching methods, and reported evaluation outcomes. A thematic analysis was conducted using a structured data entry form with categories for setting/target group, educational content, format, type of evaluation and outcomes.
Results
We identified 45 studies that met eligibility criteria, of which 35 reported on programs exclusively targeting physicians. The majority of programs focused on skills training and technical and conceptual knowledge, while fewer programs focused on personal growth and awareness. Half of the studies used pre/post intervention designs, and four studies used a comparison group. Positive outcomes were reported in all studies, although the majority of studies relied on learner satisfaction scores and self-assessed knowledge or behavioral change. Only six studies documented favorable organizational outcomes, such as improvement in quality indicators for disease management. The leadership programs examined in these studies were characterized by the use of multiple learning methods, including lectures, seminars, group work, and action learning projects in multidisciplinary teams.
Discussion
Physician leadership development programs are associated with increased self-assessed knowledge and expertise; however, few studies have examined outcomes at a system level. Our synthesis of the literature suggests important gaps, including a lack of programs that integrate non-physician and physician professionals, limited use of more interactive learning and feedback to develop greater self-awareness, and an overly narrow focus on individual-level rather than system-level outcomes.
doi:10.1007/s11606-014-3141-1
PMCID: PMC4395611  PMID: 25527339
physicians; leadership; program development; program evaluation; systematic review
22.  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.
doi:10.5688/ajpe7710221
PMCID: PMC3872940  PMID: 24371345
delphi; leadership; instruction; principles; curriculum
23.  Managerial leadership and ischaemic heart disease among employees: the Swedish WOLF study 
Objective:
To investigate the association between managerial leadership and ischaemic heart disease (IHD) among employees.
Methods:
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.
Results:
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.
Conclusion:
If the observed associations were causal then workplace interventions should focus on concrete managerial behaviours in order to prevent IHD in employees.
doi:10.1136/oem.2008.039362
PMCID: PMC2602855  PMID: 19039097
24.  Leadership Qualities Emerging in an Online Social Support Group Intervention 
Technology-delivered interventions addressing a broad range of problems for which clients present for therapy are proliferating. However, little is known of leadership dynamics that emerge in online group interventions. The purpose of this study was to assess the types of leadership qualities that would emerge in an online social support group intervention to improve medication adherence for men with HIV, and to characterize the demographic and psychosocial profiles of leaders. Written posts (n=616) from 66 men were coded using an adapted version of the Full Range Model of Leadership. Results showed that 10% (n=64) of posts reflected one of five leadership types, the most common of which was mentoring/providing feedback (40% of leadership posts). The next most common leadership style were instances in which encouragement was offered (30% of leadership posts). Leaders appeared to have lived with HIV longer and have higher Internet knowledge scores than non-leaders. Results indicate that online group interventions potentially may be useful to supplement traditional face-to-face treatment by providing an additional venue for group members to mentor and provide emotional support to each other. However, additional research is needed to more fully understand leadership qualities and group dynamics in other online group intervention settings.
doi:10.1080/14681994.2014.941346
PMCID: PMC4308045  PMID: 25642144
Internet; Group Intervention; Medication Adherence; Men who have Sex with Men; HIV
25.  Nutrition Leadership Development: Capacity-Building Initiatives in Iran and the Middle-East Region Since 2009 
Personal and organizational performance is determined by commitment and both technical and general competencies, including leadership skills. Academia, however, mainly targets technical aspects in its curricular programs. On the other hand, the inter-disciplinary and multi-sector nature of Nutrition necessitates high levels of collaboration between stakeholders. Leadership development is therefore required in Nutrition. This paper describes the endeavor made in Iran and the Middle-East region, aiming at building leadership capacity among nutrition professionals. The empowered human resource is expected to facilitate nutrition security at the national and regional levels. Since 2007, the development process of the initiative has begun through research, bench marking, and consultation. The “learning organizations,” “leadership from inside-out,” and “transformational leadership” frameworks have been employed as underpinning theories. Main topics have been self-awareness, effective communication, shared visioning, trust building, creativity, and motivating. Outbound team-building activities and coaching have also been included. The first workshop of the Iranian Food and Nutrition Leadership Program was held in 2009 in Tehran. The experience expanded to the region as the Middle-East Nutrition Leadership Program (MENLP). The Ph.D. Nutrition programs (at four leading Universities) and Iranian Nutrition Society have been taken as other opportunity windows to develop leadership competencies. Biannual Iranian nutrition congresses have been used as the main media for advocacy purposes. High-satisfaction rates obtained following each training activity. In short, the initiative on “nutrition leadership development” has received growing investment and positive feedback in Iran. Continuous improvement of the initiative, establishment of active alumni networks, building MENLP regional platform, and integrating a monitoring and evaluation system are required to increase the investment returns.
doi:10.3389/fpubh.2015.00184
PMCID: PMC4515594  PMID: 26284232
capacity building; empowerment; leadership competencies; nutrition discipline; nutrition professionals; Iran; the Middle-East

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