IOP 460: Discussion Question, Response 1

RESEARCH ARTICLE Open Access

Identifying the context, mechanisms and outcomes underlying collective leadership in teams: building a realist programme theory Aoife De Brún* and Eilish McAuliffe

Abstract

Background: There is accumulating evidence for the value of collective and shared approaches to leadership. However, relatively little research has explored collective leadership in healthcare and thus, there is a lack understanding of the mechanisms that promote or inhibit the practice of collective leadership in healthcare teams. This study describes the development of an initial programme theory (IPT) to provide insight into the mechanisms underpinning the enactment of collective leadership.

Methods: This IPT was informed by a multiple-method data collection process. The first stage involved a realist synthesis of the literature on collective leadership interventions in healthcare settings (n = 21 studies). Next, we presented initial findings to receive feedback from a realist research peer support group. Interviews with members of teams identified as working collectively (n = 23) were then conducted and finally, we consulted with an expert panel (n = 5). Context-mechanism-outcome configurations (CMOCs) were extrapolated to build and iteratively refine the programme theory and finalise it for testing.

Results: Twelve CMOCs were extrapolated from these data to form the initial programme theory and seven were prioritised by the expert panel for focused testing. Contextual conditions that emerged included team training on-site, use of collaborative/ co-design strategies, dedicated time for team reflection on performance, organisational and senior management support, inclusive communication and decision-making processes and strong supportive interpersonal relationships within teams. Mechanisms reported include motivation, empowerment, role clarity, feeling supported and valued and psychological safety which led to outcomes including improvements in quality and safety, staff and patient satisfaction, enhanced team working, and greater willingness to share and adopt leadership roles and responsibilities.

Conclusions: This study has identified preliminary support for the contexts, mechanisms and outcomes underpinning the practice of collective leadership. However, it must be noted that while they may appear linear in presentation, in reality they are independent and interlinked and generative of additional configurations. This paper contributes to the nascent literature through addressing an identified gap in knowledge by penetrating below the surface level inputs and outputs of an intervention to understand why it works or doesn’t work, and for whom it may work.

Keywords: Collective leadership, Realist synthesis, Programme theory, Healthcare, Teams

© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

* Correspondence: [email protected] University College Dublin Centre for Interdisciplinary Research, Teaching and Innovation in Health Systems (UCD IRIS), School of Nursing, Midwifery & Health Systems, Health Sciences Centre, University College Dublin, Dublin 4, Ireland

De Brún and McAuliffe BMC Health Services Research (2020) 20:261 https://doi.org/10.1186/s12913-020-05129-1

Background Effective leadership in healthcare settings has long been acknowledged as a driver of quality care delivery, work engagement and achievement of performance targets [1]. In a recent review of the evidence for leadership in health settings, it was concluded that leadership is the most influential factor in determining organisational cul- ture and is crucial for health services improvement [2]. In healthcare contexts, a traditional approach to leader- ship is prevalent, where the focus is on the individual as leader, and that person leads and is accountable for the work of the team. However, leadership with a strong em- phasis on hierarchy can inhibit a positive safety climate due to fear of blame and repercussions for voicing con- cerns [3] and can potentially give rise to bullying and in- timidation of more junior colleagues [4]. Moreover, healthcare is increasingly delivered by multidisciplinary teams, where medical staff, nursing staff, health and social care professionals, and other professional groups are ex- pected to collaborate and contribute their expertise to de- liver optimal care to the patient. Thus, the traditional hierarchical approach to leadership is no longer appropri- ate in the current healthcare environment [5, 6] as leader- ship is increasingly considered a skillset that should not be limited to senior managers in formal positions, but some- thing to be embraced by staff at all levels [7]. This paradigm shift reflects a move in focus from the in-

dividual as leader to the emergent and informal leadership evident within a team or group [8]. Collective leadership and other plural approaches to leadership (e.g., shared or distributed leadership) have been associated with en- hanced team effectiveness and team performance out- comes [9, 10]. Such approaches emphasise the relational aspects of leadership. Implicit in this is the acknowledge- ment that leadership is not necessarily the responsibility of, or located in, one individual, but leadership may be considered as a property of a team or work group. In such instances, there are inclusive and shared approaches to re- sponsibility and accountability for the team’s performance and operations. This approach to leadership may be defined as a dynamic team phenomenon, where the interaction of team members lead the team by sharing leadership roles and responsibilities [9, 11], with individuals adopting leadership roles where they have the expertise and motivation to do so [12]. Whilst there is accumulating evidence for the effective- ness of collective leadership in healthcare [13], that is, the outcomes of collective leadership, there is a lack of under- standing about how collective leadership interventions oper- ate (reactions and reasonings of actors, i.e., mechanisms), and the conditions which promote or inhibit these outcomes (contextual conditions) [14]. The focus of this study is the context-mechanisms-outcome configurations observed that enable/inhibit the outcomes observed when collective leader- ship is in practice. Scholars have identified the role of context

as an important avenue of study [9] and the “conditions under which particular aspects of team leadership affect spe- cific mechanisms” at the team, unit, system and organizational level of analysis [15]. This study adopts a real- ist methods approach to provide insight into the mecha- nisms that are triggered or inhibited by collective leadership in specific contexts to elucidate how certain outcomes (such as improvements in quality and safety, effective teamworking and staff satisfaction) are achieved. Realist evaluation is a theory-driven approach to re-

search emanating from scientific realism. Realist ap- proaches offer a means of conducting applied evaluation that recognises that research is being conducted in com- plex, open systems and considers the significant role of pre-existing social contexts in implementation and evaluation [16, 17]. Realist methods understand social programmes as social systems, characterised by the interplay of micro and macro social processes, and of structure and agency [17]. Pawson and Tilly asserted that there was a need to understand more than interven- tion effectiveness alone and argued that in order for evaluations to be useful, it was crucial to examine ‘what works for whom, in what context, to what extent, how and why’ [17]. Programmes are theories incarnate [18] and realist evaluation appreciates that interventions may operate in different ways for people in different contexts. Thus, realist evaluation is a logic of inquiry that goes further than merely exploring the surface level inputs and outputs of an intervention, by discerning the psy- chosocial mechanisms (M), that is, the internal reactions and reasonings, that trigger intervention outcomes (O) in specific contexts (C) of implementation [14]. Mecha- nisms have been defined as the unobservable implicit processes that occur in individuals’ minds due to the intervention; they elucidate what it is about a programme that makes it work [16, 17, 19]. The realist approach demands that the relationship between

the context, mechanisms and outcomes in an implementation setting be explored. The context-mechanism-outcome config- urations (‘CMOCs’; i.e., C + M = O) that are uncovered be- come part of an explanatory theory (the initial programme theory; IPT) to be tested and refined. The function of the IPT is to describe and explain insofar as possible how and why the programme (i.e., the intervention) may be working for some people and not others, depending on which mechanisms are or are not triggered in specific contexts. These chains of infer- ence enable the exploration of generative causation, by expli- citly linking the triggering of mechanisms to contextual conditions and specific outcomes. Through elicitation of the patterns of CMOCs that are evident across settings (‘demi-re- gularities’), one can establish the CMOCs that operate as the common thread of an intervention across various contexts. The evaluation of an intervention then should test and refine these theories and hypotheses.

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To our knowledge, this is the first study to adopt realist approaches to explore why and how collective leadership interventions operate to trigger mechanisms that lead to certain outcomes. This study builds an explanatory theory to interrogate the key contextual conditions, mechanisms and outcomes and their interactions to provide insight into how collective leadership can be effectively imple- mented to lead to desired outcomes, including practice of collective leadership, improved team working, and im- provements in quality and safety culture [14].

Methods Design: programme theory development The development of the programme theory to explicate how collective leadership interventions operate to produce outcomes will be guided by the realist evaluation cycle ap- proach [17] previously outlined in the published protocol paper describing this research [14]. The four stages of the research to inform and finalise the IPT involved a realist synthesis of the literature on collective leadership inter- ventions in healthcare; presentation and feedback on ini- tial findings to a realist research peer support group; interviews with members of teams who have been identi- fied as successfully working collectively in the healthcare system; and expert panel input to refine and finalise the IPT (see Table 1). This paper reports on the development of the programme theory to explore implementation of collective leadership interventions in healthcare: what works, for whom, why, to what extent, and in what cir- cumstances? The methods and results are described in ac- cordance with RAMESES II guidelines on the reporting of realist evaluation research [18].

Realist synthesis of the extant literature A realist synthesis of the literature was conducted on studies retrieved during a systematic review of interven- tions to develop collective leadership in healthcare set- tings (full search strategy available in published paper) [13]. Twenty-one papers were assessed for rigour and ability to add to the developing programme theory and 19 were included in the final analysis (two were excluded due to insufficient information to inform IPT). Informed by previous research [20, 21], an extrapolation template was designed to identify contextual conditions that en- abled or inhibited mechanisms or psychosocial drivers for collective leadership in practice and related interven- tion outcomes. Context-mechanism-outcome configura- tions (CMOCs) were extrapolated from each paper and demi-regularities (patterns across studies) were identi- fied to inform the first iteration of the IPT. This initial IPT was presented to a realist research peer support group for feedback and advice.

Interviews with individuals on teams working collectively Senior leaders in the healthcare system assisted the re- searchers in identifying effective healthcare teams in the healthcare systems. We asked managers to identify those teams with a flattened hierarchy and where collective leadership was evident within the teams. Individuals from these teams were provided with an overview of the research and were invited to take part in a one-on-one interview with a researcher to explore their experiences of working within the team, team processes, why and how the team was working collectively, and the impact on team working and safety culture (paper in prepar- ation). Twenty-three individuals from three teams took part in interviews. Informed consent was sought from all participants in advance of being interviewed. Participants were from a range of backgrounds, working in various roles within the health system. Table 2 summarises the characteristics of interviewees. Interviews were audio- recorded and transcribed verbatim and NVivo11 was used to manage and analyse the data [22]. Data analysis employed a retroductive approach using both induct- ive and deductive logic to interrogate the causal fac- tors that may have operated to produce outcomes [23]. Interview data was first deductively analysed to support and refute CMOCs that had been extracted from the literature and an inductive analytical ap- proach also enabled the extrapolation of new CMOCs. The approach aligns with the methodo- logical approach elaborated in detail elsewhere [24]. Briefly, NVivo enabled the creation of nodes (codes) and memos (to document reflections and ideas) rele- vant to each data source and nodes were created for each hypothesised CMOC and new child nodes were added if new contextual conditions, mechanisms or outcomes were identified. The use of NVivo to sup- port the analysis enabled transparency in the process through the tracking of the iterative refinement of the IPT. The first author conducted this analysis and 20% of the data were double coded by the second author to ensure confidence in the findings. Through discussion, the co-authors refined and finalised the CMOCs prior to presentation to the expert panel.

Expert panel input Programme designers and experts in the fields of team working, collective leadership and safety culture (n = 5) provided individual feedback to the research team to in- form and refine the IPT. Further details on the expertise of the panel members is included in Appendix. The 12 CMOCs extrapolated from the previous stages of devel- opment were presented and feedback sought regarding prioritisation of CMOCs for testing. Following this con- sultation, minor amendments were made and no add- itional potential CMOCs were identified. The panel also

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engaged in a ranking exercise to establish the relative im- portance of CMOCs to the implementation (or not) of collective leadership. As a result of this, seven CMOCs were prioritised by the expert panel and are presented in detail in this paper as the programme theory.

Results This section describes the results following the iterative process to develop and refine the IPT. The seven CMOCs prioritised for further testing are considered in

detail below, with accompanying evidence for each de- rived from one or more of the development stages (see Table 3). We also present Fig. 1 which more accurately depicts the complexity of the relationships between con- texts, mechanisms and outcome. It is important to note that whilst the CMOCs are often presented as ostensibly lin- ear relationships, the reality is much more complex, as many of the CMOCs are interdependent and interacting. The CMOCs extrapolated and presented here are the major rela- tional patterns (demi-regularities) that have been observed

Table 1 Summary of steps to develop and refine IPT

Stages of consultations Source of expertise Date

Early iteration of IPT following realist synthesis presented Realist methods peer support group March 2018

Discussion of IPT Research team and programme developers April 2018

Refinement following analysis of interview data Key informants (interviewees) May–June 2018

Refinement of IPT Research team and programme developers July–September 2018

Input from expert panel; prioritisation of CMOCs for testing Programme developers; experts in collective leadership November – December 2018

IPT finalised for testing Programme developers January 2019

Table 2 Sample characteristics of interviewees from effective teams

Participant number Role Time on team

Team 1

F01 Head of Clinical Services and Business Planning 2 years

F02 Pharmacist 12 months

F03 Occupational Therapy Clinical Specialist 18 months

F04 Occupational Therapy staff 18 months

F05 Medical social worker 15 months

F06 Occupational Therapy staff 10 months

F07 Senior Physiotherapist 15 months

F08 Occupational Therapy staff 18 months

F09 Physiotherapist 1 month

F10 Senior Physiotherapist 2 months

F11 Dietician 18 months

F12 Speech and Language Therapist 18 months

Team 2

C01 Consultant 4 years

C02 Senior Mental Health Social Worker 6 years

C03 Senior Social Worker 11 years

C04 Clinical Psychologist 9 months

C05 Social Care Leader 17 years

C06 Occupational Therapist 10 years

Team 3

P01 Research Coordinator 3.5 years

P02 Research Scientist 12 years

P03 Consultant 7 years

P04 Clinical Psychologist 6 years

P05 Project Manager 7 years

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across multiple contexts. We will elaborate on this further in the discussion of findings.

One of the most powerful and frequently observed con- textual enablers of intervention success was contexts in which multiple professionals received training together as a team and where training was conducted on-site with teams. Often, additional resources were required to enable suc- cessful implementation of collective leadership in the set- ting, such as internal or external coaching, organisational support to ensure teams are released and supported to at- tend training together, as well as renumeration and meals when training was delivered over an extended period.

“The greatest success was bringing together physi- cians and nurses to lead in ways that reinforced that patient care is truly about partnership.” (p. 26) [25]

In such contexts, seven studies suggested that the mechan- ism triggered was the development a shared understanding among the team that partnership among various profes- sions on the team is required for effective and high-quality patient care. With this shared understanding, contexts where training

occurred together as a team was purported to break down the ‘silo mentality’ (a narrow focus on one’s own profession or work unit to the extent that there is little consideration of the views of those outside the profession or unit) that may exist among professions on a team and encourage a shift in mindset toward collective rather than individual achievement. Once this silo mentality was challenged, team members had a greater understanding and appreciation of each other’s roles on the team. This led to positive out- comes for staff, patients and the organisation. In such con- texts, staff job satisfaction was enhanced through more effective interdisciplinary teamworking and collaboration, with reported improvements in patient safety and quality indicators. There was a perceived flattening of the hierarchy in the team, with increased staff engagement and enact- ment of collective leadership behaviours reported at all levels (from both formal and informal leaders).

“‘We used to be in silos. Not a lot got done. No one took ownership for progressing things. Now we are getting things done, there is delegation, we have re- sponsibilities within the team’” [26]

“The response to the programme was highly positive; engagement exceeded our expectations. Most survey

respondents reported improved willingness to take on a leadership role within their team (93 per cent)... The “in-house” training model promotes development of social capital across different disciplines and levels of management. This overcomes the organisational bar- rier of inter-professional tension commonly recognised as hindering leadership development ” [27]

Collective leadership introduced to contexts where teams are involved in, and responsible for, improving staff experience, patient care services and/or teamwork- ing through collaborative or co-design approaches (and where staff are resourced with time and space for reflec- tion and discussion), fosters a sense of shared account- ability and responsibility for the team to enhance patient care. Team members become more interdependent as the team becomes more autonomous in improvement efforts. Contexts characterised by collaborative and co- design approaches empower staff and can trigger enhanced motivation and a commitment to improve- ment. One study observed “a change in the way people thought about care rather than just a change in the process” [32].

“A crucial part of the new team-based approach has been the greater distribution of leadership responsi- bilities to the teams, providing authority to those “individuals who are willing to engage in change ef- forts” (Fitzgerald et al., 2013).” [33]

“We were told by senior management at the begin- ning that we could do whatever we felt was necessary to improve the outcome for patients – quality and safety – and I think that was really important that we were supported in that.” (Interview, Team 1, F04)

Outcomes observed as a result included teams became more effective, innovative and adaptable, and a culture of learning and continuous quality improvement was embedded when there was a sense of a shared responsi- bility for the team’s performance. This in turn was asso- ciated with improved staff satisfaction, the adoption and sharing of leadership roles and patient satisfaction with care services.

“Another benefit is the increase in personal ac- countability evident in staff behaviours. No longer are problems and issues left for management to ‘fix’

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… The turnover rate was the most dramatic change that the department experienced as a result of en- gaging staff using shared leadership principles. The rate has decreased from 40% in 2001 to 4% in 2004.” [34]

“We’re always striving to be better and to do better.” (Interviews, Team 1, F06)

“Participants reported a new way of working with patients, families and staff as co-producers of the service.” [32]

Contexts in which teams were supported by organisa- tions with dedicated time and space to reflect on their practice and their team operations, including development of patient pathways and team processes, was highlighted in several papers as an important contextual enabler that facilitated intervention success.

Table 3 Initial Programme Theory and supporting evidence

CMOC Context + Mechanism = Outcome Evidence

1 Team training on-site • Shared understanding and appreciation of others

• Confidence in enhanced knowledge and skills in collective leadership

• Greater staff satisfaction through enhanced interdisciplinary teamworking

• Improvements in quality and safety • Enactment of shared leadership behaviours

[25–31]

2 Team given permission/encouragement to self-manage and use co-design or collabora- tive approaches for improvement

• Empowerment and motivation through sense of shared responsibility for team performance

• Teams more innovative and adaptable, characterised by a culture of learning, collaboration and continuous quality improvement

• Staff satisfaction • Patient satisfaction • Adoption and sharing of leadership roles and responsibilities

[26, 32–36] Interview data

3 Dedicated time to reflect on and discuss team operations

• Greater role clarity • System improvements, such as improvements/greater efficiencies in team processes around patient care

• Enhanced teamworking; increased productivity

• Effective team communication • Greater involvement of frontline staff in decision-making

[26, 27, 32, 33, 37] Interview data

4 Open, regular and inclusive communication and decision-making processes

• Enhanced trust and psychological safety

• Sense of shared responsibility

• Effective communication, knowledge sharing and conflict management

• Safety culture characterised by greater safety awareness and open discussion of issues

• Team leaders willing to share leadership responsibilities and adoption of leadership responsibilities by team members

[26, 28, 31, 33, 38, 39] Interview data

5 Lack of organizational support/resources, senior clinical support, or a strong hierarchical culture

• Disempowerment • Lack of confidence in approach

• Avoidance of team working [28, 32, 40]

6 Strong, supportive interpersonal relationships (formal and informal)

• Motivation to support others due to shared burden/ responsibility

• Trust and confidence in others’ expertise

• Enactment of proactive helping behaviours (role blurring) that enhance team performance

• Staff satisfaction and retention

Interview data

7 Collective leadership is practiced • Understanding that partnership needed for effective patient care

• Internalization of collective leadership concepts; shared sense of responsibility for team

• Recognition and understanding of skills and expertise of others

• Patient satisfaction • Improvements in patient safety and care quality

• Willingness to speak up • Senior colleagues more open and accessible • Inclusive and collaborative team working characterised by a ‘give and take’ approach

[25, 28, 30, 31, 35, 36, 39, 40]

In the ‘Evidence’ column, ‘Interview data’ refers to evidence from the interview data we collected for this study, where a CMOC was evident across at least two of the three teams. The numbers relate to supporting references from the published literature

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“The months of preparation gave members of the de- partment an opportunity to talk at length about the new approach, decide on how the teams would work together, and experiment with changes to systems as to the timing of appointments, and methods of arran- ging follow up appointments. The experiments then enabled the department, as a whole team, to decide which approaches seemed best.” [33]

Positive outcomes were triggered through fostering role clarity among team members. When this mechanism was triggered, system changes and improvements such as re- duction in waiting lists, enhanced teamworking and “an in- crease in productivity” [33] were observed. There was more effective communication reported between team members and broader team involvement in decision-making.

“[The intervention] gave the teams the opportunity to meet together as a cross-disciplinary team with dedicated time out, a facilitator to work with them and an expectation that they would set goals and work towards them. This was a new experience for groups. As a mechanism of change, this bringing to- gether of a specialised team and the provision of

facilitated time out for them could be seen as a powerful model for improvement in the NHS [Na- tional Health Service], particularly in those areas where multi-professional teams need to co-operate. It creates space and combines this space with the provision of operational tools and techniques. This seems to be a powerful combination and to be ef- fective in contributing to changes in practices and procedures.” [26]

In implementation settings where there is open, regular communication and team members have the opportunity to engage in inclusive decision-making processes to encourage contribution and collabor- ation, teams develop trust between members, enhance psychological safety within the team and foster a sense of shared responsibility. This may occur through structured processes to enable input from all

Fig. 1 Initial Programme Theory for collective leadership, depicting context-mechanism-outcome configuration

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team members, such as team safety huddles or multi- disciplinary team meetings, or can occur in settings characterised by a “fundamental orientation towards inclusiveness” [38]. One example from the literature describes the benefit of team huddles as a feature of the context that enabled effective communication and knowledge sharing.

“When this reciprocity and mutual influence is ac- knowledged and formalized, it can become an insti- tutional feature of work (Gronn 2002), such as a new model of care. An example is the use made of huddles by Team A, to harness every member’s in- put when a situation is analyzed, for which a plan needs to be developed or a change to care needs to be made” [28]

When trust and psychological safety are activated through inclusive communication and mutual influ- ence in decision-making, this results in the emergence of a culture of learning in teams, where team mem- bers have enhanced safety awareness and feel com- fortable openly discussing patient safety issues and concerns.

“The hierarchical structures of hospitals are hard to break down and I think we are further along the way to get to a place where people feel there is a level playing field for everybody.” (Interview, Team 3, P03)

“I think it is that no blame culture. It is being able to actively reflect on something rather than ‘Why didn’t you?’ or ‘You should have’ – dialogue is quite different, it is: ‘Lets learn from this and move on.’” (Interview, Team 1, F08)

“You are not afraid to ask and that is a very good culture to have”. (Interview, Team 3, P01)

Once trust and psychological safety was fostered, it re- sulted in team members adopting more leadership re- sponsibilities and with team leaders more open to input from team members.

“Senior physiotherapists discussed patients more with junior physiotherapists; team members would look at referrals together before they went into a new patient clinic, and talk about the assessment beforehand … In other words, team members took on more leadership responsibilities” [33]

“Team leaders were more willing to listen to others, to take on board ideas put forward by those from

other professional backgrounds, and to relinquish some control.” [26]

In contexts where there is a lack of organizational sup- port/resources, senior clinical support/engagement, or a strong hierarchical culture, when collective leadership is introduced, mechanisms triggered serve to operate as a barrier to change. Mechanisms include feelings of disem- powerment and a lack of confidence in the approach. Such contexts prevent the internalisation of collective leader- ship concepts, result in a resistance to teamworking and reduce the likelihood of successful implementation.

“Some participants felt they lacked the necessary support and appropriate climate to implement new ways of working. Although the programme recog- nised the importance of distributed leadership, it may be that this is difficult to achieve in organisa- tions that are hierarchical in structure.” [32]

Across the three teams interviewed, strong, support- ive interpersonal relationship were explicitly linked to a motivation to support others and share the burden of the team’s work. This team-based approach to workload management encouraged the enactment of proactive helping behaviours where team members would explicitly offer each other support if they per- ceived someone to be managing an excessive work- load or having a bad day. In such instances, participants described how others would “rally around” (Interview, Team 2, C03) those who may have need help and described a process of “give and take” (Interview, Team 2, C01; Team 1, F06), where team members were happy “venturing into each other’s spheres” (Interview, Team 1, F07) to provide support and assistance. This supportive work culture was asserted to enhance team performance.

“I think it is that willingness to help each other out. It is not just seen as my role or your role. I think it is kind of that we are all there to help the patients” (Interview, Team 1, F06).

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Trust and confidence in each other’s expertise and skills were also enabled through the development of strong and supportive interpersonal relationships. Participants stated that development of close working relationships over time was directly linked to their confidence in the clinical judgement of others. It was often mentioned that team members attended informal outings together and regularly celebrated each other’s successes and personal milestones. This resulted in greater staff satisfaction and retention, as team members felt supported and comfort- able with their colleagues.

“I suppose the months and years you spend together you just kind of trust people’s kind of, like, clinical judgement really well.” (Interview, Team 1, F12)

“[Its] the sense that I’m never completely on my own with something that is causing me anxiety and that’s because of the interpersonal relationships … I don’t want to go anywhere, I’m happy here. I mean that’s a sign of a good team” (Interview, Team 2, C04)”

In contexts where shared/collective leadership is prac- ticed, there was strong evidence from the literature that this enabled a shift from an individual towards a more collective mindset, whereby team members internalised the concepts of collective leadership and developed an understanding of the importance of interdisciplinary partnership for effective patient care.

“Our study generated evidence of spontaneous collab- oration and a genuine shared role space existing be- tween nurses and PCWs [personal care workers] in Team A … evidence of the close understanding be- tween team members, leading to more sensitivity in care delivery.” [28]

This led to positive outcomes for patients, including im- provements in safety and quality of care, as well as en- hanced patient satisfaction with care. Positive outcomes for staff were also observed. Several studies reported that team members were more willing to speak up, perceived their team leader and senior colleagues as more open and accessible and reported a more inclusive and collab- orative team working.

“Co-leadership exerted in an integrated and co- located centre allowed the managers to deal with

service users’ needs and problems in a more holistic and efficient way.” [39]

“They also felt that the award had helped enable each of them to develop as leaders in their own spheres, had made the team leader more willing to listen to them, and had given them the confidence to put their own ideas forward more” [26]

An enhanced recognition of the skills and expertise of team members, and a sense of being valued, were triggered in contexts where collective or shared leadership was prac- ticed included and for their expertise and judgement. This resulted in interdisciplinary collaboration in patient care.

“Being interested in and willing to invest time in collaboration and in learning about each other’s re- sponsibilities and sector-specific [health and social care] activities was crucial to understanding and managing the big picture … By the advantage of be- ing two managers with different knowledge and re- sponsibilities, the managers could complement each other’s areas of expertise.” [39]

Discussion This paper describes the results of a rigorous and iterative approach to the development of an initial programme the- ory to evaluate the impact of a collective leadership inter- vention. Through realist synthesis of the extant literature on collective leadership in healthcare, interviews with indi- viduals on teams that are leading collectively, feedback from a realist research group and expert panel input, we extracted and refined seven CMOCs that together offer an initial programme theory of how collective leadership trig- gers mechanisms in specific contexts that lead to patient, staff and organisational outcomes. The impact of holding team training in collective leader-

ship on-site was a contextual enabler that emerged strongly from the literature (CMOC1). This facilitated a shared un- derstanding and appreciation of colleagues and confidence and skills to enact collective leadership in practice. Typically in healthcare, professions are trained in silos, with little (if any) training on how to operate as a member of a multidis- ciplinary team [26]. Yet, this team training is crucial for the practice of collective leadership, as a shared understanding of the skills and expertise of others in a pre-requisite for the sharing of leadership roles, which is defined by as appropri- ate when individuals have the relevant motivation and ex- pertise to do so [12]. The busyness of the healthcare environment precludes prospects to develop this under- standing without dedicated team training opportunities. Additionally, in healthcare settings there can be a percep-

tion that protected time for teams to review their perform- ance is not feasible, given the demanding environment and

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high workload [41]. Yet, there is strong evidence that teams that take time to reflect on their processes and objectives are more effective [42] and demonstrate better individual and or- ganisational outcomes [43]. This team reflexivity has been as- sociated with innovation, even in busy and demanding healthcare contexts [44]. Our research found that when teams have dedicated time to reflect on team operations, this can trigger role clarity among team members and clarity re- garding the sources of various types of expertise and skills within the team (CMOC3). This reflexivity enables teams to effectively self-monitor and identify improvement targets and link those to team members, given their role or skill set [45]. In contexts where there is open, regular and inclusive

communication and decision-making processes, implemen- tation of collective leadership enhances trust and psycho- logical safety and instils a shared sense of responsibility for the team’s performance (CMOC4). A key characteristic of an effective team is psychological safety and the willingness to speak up to senior colleagues and the enactment of in- clusive and openness on the part of senior clinicians and leaders [46, 47]. When psychological safety is evident, teams are more innovative are more engaged in quality improve- ment work [47]. Psychological safety serves to promote a safety culture within the team, where is there greater safety awareness brought about by openness to discussion of problems and challenges, thereby facilitating communica- tion and knowledge sharing. Building trust and psycho- logical safety enhances the adoption of leadership roles and makes leaders more willing to share leadership. When collective leadership was observed as an outcome,

the mechanisms of empowerment and motivation were ob- served in contexts where teams co-designed or were given permission to self-manage their team processes and im- provement efforts (CMOC2). Staff engagement is critical to organisational outcomes in healthcare. West et al. have demonstrated the profound impact of staff engagement on patient satisfaction, patient mortality, infection rates and staff absenteeism [48], underlining the value of a collective leadership approach that can engage staff and encourage them to adopt a leadership role in ensuring optimal team performance. At the group level, collective leadership inter- ventions may foster climate of psychological empowerment climate, which may be defined as a shared perception of empowerment related to “meaningfulness, competence, self-determination and impact” [49]. The engagement fos- tered through co-design and collaborative efforts enables teams to become innovative and adaptable and create cul- tures of learning and continuous quality improvement and is promoted by cultivation of a climate of empowerment. In contexts where teams were characterised by strong

and supportive interpersonal relationships, motivation to support others was triggered due to a perceived shared burden of work (CMOC6). Strong relationships also

engendered trust and confidence in the skills and expertise of others. Research demonstrates that social support is a critical antecedent to the effective sharing of leadership roles and responsibilities [50]. In instances where this so- cial support was evident, team members were likely to en- gage in proactive helping behaviours and role blurring to support each other and share the workload. Houghton et al. have proposed group-level caring as a process whereby team members actively look out for the interests on one another [51]. In line with social exchange theory, they assert that the norm of reciprocity operates to en- courage peers to reciprocate the behavioural investments of others and this can lead to proactive helping behaviours which can impact positively on team performance [51]. This resonates with previous research which demon- strated that shared leadership was a predictor of team- work, altruism and helping behaviour [52]. It is not surprising, therefore, that when strong supportive rela- tionships are evident, collective leadership interventions can generate a climate of empowerment that leads to greater staff satisfaction and staff retention. It was strongly evident from the extant literature that a

lack of organisational or senior management support for collective leadership programmes resulted to unsuccessful implementation and an avoidance of teamworking, due to the disempowerment and lack of confidence of staff in the collective leadership approach (CMOC5). This resonates with previous research which emphasises the necessity of effective management-staff relations in translating evi- dence into action and change [53]. Due to the strong hier- archical culture in healthcare organisations, it has previously been observed that collective approaches to leadership can appear counter-intuitive and be met with scepticism [54]. Furthermore, organisations may state their support for the practice of collective leadership, but not implement the organisational changes that may be ne- cessary to enact its practice. For example, research has il- lustrated how organisational structures and professional and managerial hierarchies can constrain participants’ leadership capacity and opportunities [55]. Such contexts can produce negative effects as staff may develop a ‘learned helplessness’, where they feel powerless to im- prove some aspect of the work experience or environ- ment. This may lead to a reluctance to engage and has been identified as a contributory factors to allowing poor care to continue [56]. The final CMOC extrapolated related to contexts in

which collective leadership was practiced (CMOC7). This may be considered a ‘ripple’ CMOC as it emerges after a programme has been successfully implemented and illus- trates the additional impacts observed when collective leadership is practiced. When collective leadership is evi- dent, there is a recognition of the need to partner with other experts to deliver optimal patient care. In turn, this

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results in improved patient safety and quality of care and enhanced team working. Effective team-based working in healthcare is associated with meaningful improvements in patient mortality. One study concluded that 5% more staff working in structured well-functioning teams was associ- ated with a 3.6% lower patient mortality rate [48]. Another key outcome observed was willingness to speak up. Given our findings, we contend that collective leadership training can be a beneficial resource to promote psychological safety, a patient safety culture and effective teamworking. This research contributes to the emerging research

around collective leadership in healthcare settings by ex- ploring the extant literature and collecting empirical data to interrogate the mechanisms and causal factors driving outcomes in specific contexts of implementation. Whilst previous research has explored the efficacy and effective- ness of collective leadership interventions, there has been little attention on the mechanisms of action and how spe- cific contexts may operate to trigger or inhibit mecha- nisms from firing. The focus on mechanisms of action is a key feature of the realist approach to explore the ‘black box’ of evaluation. Dalkin et al. [19] define mechanisms as “a combination of resources offered by a social programme under study and stakeholders reasonings in response” (p.3). These invisible reactions and reasonings drive specific programme outcomes and thus, understand- ing how these mechanisms are triggered (or not) in spe- cific contexts helps explain how and why a collective leadership programme is operating to drive outcomes. The programme theory presented here offers plausible, evidence-based hypotheses of how collective leadership in- terventions operate to drive specific outcomes. These plausible hypotheses provide a platform for the next stage of testing to enable further refinement. There are, inevitably, limitations to this research. Firstly,

there were relatively few studies on collective leadership interventions in healthcare retrieved and this may have limited our ability to identify additional significant CMO patterns across studies. Given that this is the first study using realist methods to explore collective leadership in healthcare, this work represents a first step to support the field in furthering our collective knowledge of the contexts and mechanisms underpinning the success (or otherwise) of such interventions. Within the realist approach, theory building is an on-going process. This programme theory offers a practical guide and starting point for researchers in the field to operationalise and evaluate interventions of this nature. Future research implementing and evaluating collective leadership interventions should test the hypoth- eses derived to further inform and refine the programme theory towards development of a middle range theory. This middle range theory should capture the ‘core’ aspects of how the intervention operates at the individual, team and organisational levels and will be broadly generalisable

to other contexts. Thus, further testing of this IPT using realist evaluation is a natural next step. Whilst the elaboration of the CMOCs is ostensibly lin-

ear, the reality is far more complex. Rarely are CMOCs neatly discrete as presented in realist evaluation of com- plex phenomena. There is inevitably interaction and inter- dependencies between CMOCs: they influence each other by their presence or absence. The CMOCs explicated here represent the over-arching relational patterns or ‘patterns of aliveness’ [57] that emerged through the study of mul- tiple data sources and research contexts. As advised by Braithwaite et al. [58], we should not ignore this complex- ity but rather embrace and document it. Despite the chal- lenges it presents: “we must grapple with the world we actually inhabit, not the one we wish we did” [58]. Pattern-based approaches in intervention contexts can be effective to bring into focus various dimensions of com- plexity and enable sense-making [59] using a realist lens. Another point it is important to acknowledge is that

by presenting and testing CMOCs as quasi-linear chains, they are vulnerable to becoming self-reinforcing. It is therefore crucial for researchers not to be too prescrip- tive in testing and be open and receptive to new or alter- native explanations. It is such an approach that will facilitate advancement in our understanding of the mechanisms underpinning collective leadership, and how different contexts will trigger or inhibit different mechanisms and outcomes at various times.

Conclusions While collective leadership is not a panacea to solve the wicked problems inherent in healthcare settings, and there are inevitably occasions that require a more hierarchical leadership approach [60], the evidence strongly suggests that collective leadership interventions can promote more effect- ive teamworking, enhance quality of care and patient safety and improve staff and patient satisfaction [13]. This study has gone beyond the question of effectiveness by interrogat- ing the causal and generative mechanisms that result in the outcomes observed when collective leadership is practiced. This paper contributes to the nascent literature through ad- dressing an identified gap in knowledge by penetrating below the surface level inputs and outputs of an intervention to understand why it works or doesn’t work, and for whom it may work. It provides a starting point for researchers in the field to test these plausible hypotheses to refine and deepen our understanding of how collective leadership in- terventions operate. A key strength of this study was the multi-step, multiple method processes delineated, an ap- proach which incorporates best evidence from the literature, empirical data where collective leadership is in routine prac- tice, and methodological and subject matter expertise through use of reference panels. Future work should seek to refine and expand this IPT through further testing.

De Brún and McAuliffe BMC Health Services Research (2020) 20:261 Page 11 of 13

Abbreviations CMOC: Context-mechanism-outcome configuration; IPT: Initial programme theory; RAMESES: Realist And MEta-narrative Evidence Syntheses: Evolving Standards; NHS: National Health Service (UK); PCWs: Personal Care Workers

Acknowledgements We would like to thank Ms. Marie O’Shea for conducting the interviews analysed as part of this work. We would also like to extend our sincere thanks to the members of the Expert Panel who have advised and support this work. Finally, we are thankful for the support and feedback from the Realist Peer Support Group in Dublin, Ireland at various phases of this research.

Authors’ contributions EMA received funding to support this study. ADB and EMA designed the study. ADB performed the literature review and data analysis. ADB draft the manuscript and EMA provided input. Both authors have read and agreed the final content of this manuscript.

Funding This work is funded by the Irish Health Research Board, grant reference number RL-2015-1588. This research is also supported by the Health Service Executive. The funders had no role in the conduct and analysis of this re- search, or in preparation of this manuscript.

Availability of data and materials Data is openly available from the published papers reviewed in this paper. Interview data are not publicly available due to their containing information that could compromise the privacy of research participants.

Ethics approval and consent to participate Favourable ethical opinion for the research has been obtained from the University College Dublin Research Ethics Committee (ref: HREC-LS-16- 116397). Written consent was obtained from interview participants.

Consent for publication Not applicable.

Competing interests The authors have no competing interests to declare.

Received: 11 July 2019 Accepted: 19 March 2020

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Appendix Table 4 Further details about expertise among members of Expert Panel

Panel Member Background/Role Areas of Expertise

Programme Designer 1

Psychologist, experienced health systems and services researcher, Professor of Health System

Leadership, evaluation, healthcare safety, staff engagement, healthcare management

Programme Designer 2

Speech and Language Therapist, senior hospital manager, PhD candidate Healthcare management, transformation and change management, team working

Programme Designer 3

Psychologist, experienced healthcare researcher Collective leadership, research evaluation, team working.

External Advisor 1

Professor of Work and Organisational Psychology, experienced healthcare and leadership researcher

Team working, collective leadership, safety culture, staff engagement, organisational innovation

External Advisor 2

Founder of the Collective Leadership Institute, systems scientist, consultant, strategic advisor in complex multi-stakeholder setting

Collective leadership, transformation, scaling-up collective stewardship skills, collaboration, sustainability.

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