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RESEARCH ARTICLE Open Access
Interventions to develop collectivistic leadership in healthcare settings: a systematic review Aoife De Brún, Roisin O’Donovan and Eilish McAuliffe*
Abstract
Background: Collective or shared leadership approaches have been associated with team performance outcomes in several sectors. Based on this evidence, there have been calls for more inclusive approaches to leadership in healthcare settings, but guidance on how to achieve collective leadership is lacking. This study synthesised knowledge of interventions to introduce collectivistic leadership in healthcare settings.
Methods: The databases of PubMed, PsychInfo, ABI Inform, Cochrane and CINAHL and three grey literature databases were searched. Studies from any country were included if they reported on the development and evaluation and/or implementation of training/interventions to develop collectivistic leadership and reported individual and/or team-level outcomes. Results were synthesised using a narrative approach.
Results: The searches yielded 4448 records of which 21 met the eligibility criteria and were reviewed. Studies used a variety of interventions; eleven employed a team training approach, four described co-leadership, three explored service improvement, two detailed co-design approaches and one described an individual team development intervention. Most demonstrated moderate to good success in enabling collectivistic leadership, with benefits reported in staff engagement, satisfaction, and team performance.
Conclusions: Whilst collectivistic leadership interventions have demonstrated positive outcomes, there is a need for more rigor and consistency in the evaluation of interventions aimed at developing collectivistic leadership approaches in health settings.
Keywords: Collectivistic leadership, Collective leadership, Shared leadership, Healthcare, Systematic review
Background Traditionally, the concept of a leader and of leadership has focused on individuals, where leaders are trained to lead a work group or team as part of a hierarchical or- ganisational structure. Accordingly, leadership research has conventionally focused on vertical leadership and leader-follower interactions, where one focal leader in- teracts with subordinates or followers in dyads or small groups with clear lines of authority and power across levels of the hierarchy [1, 2]. Leadership has been con- sidered as an individual attribute, and contested as either trait-like or a state-like quality, or both [3, 4]. This body of research has focused on the single leader, with the
team or group outputs (e.g., performance, quality tar- gets) and staff outcomes (e.g., satisfaction, engagement) considered as reflective of leader effectiveness. Gibb, in 1954, was among the first to recognise the potential for leadership at the group or team level, rather than at the individual level, asserting that “leadership is probably best conceived as a group quality, as a set of functions which must be carried out by the group” ([5]; 884). However, it is only more recently that collectivistic or distributed approaches to leadership have garnered in- creased attention [1, 6]. Collective approaches to leadership are evident
where the leadership roles and responsibilities are shared, distributed or rotated amongst team members. Various forms of collectivistic leadership exist, includ- ing distributed, shared, team, co-leadership, rotated,
* Correspondence: [email protected] School of Nursing, Midwifery & Health Systems, Health Sciences Centre, University College Dublin, Dublin 4, Ireland
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. 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.
De Brún et al. BMC Health Services Research (2019) 19:72 https://doi.org/10.1186/s12913-019-3883-x
and collective leadership, to name a few. Distributed leadership [7, 8], for instance, is indicated by various patterns of distributed roles and responsibilities shared among multiple individuals where there is conjoint action by the group. Similarly, shared leader- ship has been described as “an emergent team prop- erty that results from the distribution of leadership influence across multiple team members” [9]. Friedrich et al. characterise collective leadership as “a dynamic leadership process in which a defined leader, or set of leaders, selectively utilise skills and expertise within a network, effectively distributing elements of the leadership role as the situation or problem at hand re- quires” ([10]: 933). Central to collective leadership is the principle that team members interact to lead the team by sharing in leadership responsibilities at different times [11, 12]. Although the various terms represents distinct theor- etical approaches, even with multiple proposed frame- works within each approach [13], it is important to note that often the terms have been used interchangeably, and the relative usage of terms has varied over time [13]. Ul- timately however, these forms of leadership defy the trad- itional, hierarchical, single leader view of leadership and represent a shift towards these more collectivistic approaches. A meta-analysis of shared leadership and team effective-
ness developed a composite definition for these various forms of shared leadership as “an emergent and dynamic team phenomenon whereby leadership roles and influence are distributed among team members” ([14]: 5). For the purposes of this review, we use the term ‘collectivistic leadership’ to include various non-traditional approaches to leadership, including shared, distributed, collective, and related or similar concepts, that share the roles and re- sponsibilities across more than one member of a work group or team over time, through both formal and infor- mal mechanisms [1, 15]. Since the 1990s, there has been increased interest in
collectivistic approaches to leadership [14] and there is accumulating evidence of the positive impact of such ap- proaches from many settings. Two meta-analyses explor- ing the impact of collective, shared and/or distributed leadership in teams have found that, across sectors, shared leadership predicts team effectiveness and team performance outcomes [14, 16]. Furthermore, shared leadership has been found to be a better predictor of team performance and organisational outcomes than vertical leadership structures [17, 18]. In a recent review of the evidence base for leadership in
health settings, it was concluded that “leadership is the most influential factor in shaping organisational culture and so ensuring the necessary leadership behaviours, strat- egies and qualities are developed is fundamental to health services improvement” [19]. Research has linked effective
leadership behaviours in a health setting to quality and safety and patient outcomes [20] and has highlighted poor leadership as potential causal factors in patient safety fail- ures [21]. Furthermore, leadership with a strong emphasis on hierarchy potentially inhibits a positive safety climate due to fear of blame and repercussions for reporting safety-related problems [22]. Research in the UK has indi- cated that the best performing hospitals were those in which staff demonstrated high levels of engagement in decision-making and where there was evidence of distrib- uted leadership in the organisation [23]. Given this emer- ging evidence base, there have been calls to move from traditional models to shared and distributed models of leadership in healthcare settings [6, 8, 19], where increas- ingly, care is delivered via multidisciplinary teams. Whilst collectivistic approaches to leadership have
been linked with positive outcomes, there is little guid- ance on how best to introduce and develop collective leadership in practice. The field is still developing and as a result, the literature is sparse and disparate; thus, we do not yet know how we can effectively develop col- lectivistic leadership approaches [1]. Furthermore, be- cause such approaches are relatively novel in healthcare settings there is a lack of understanding on how best to achieve collective ways of working in this context. To address this gap and to inform future research in this area, this paper aims to synthesise scientific knowledge of evaluated interventions that sought to introduce col- lectivistic leadership in healthcare settings. The paper provides insight into the type and content of interven- tions that have been designed and tested, their theoret- ical underpinnings, means of evaluation, and efficacy. The aim of this systematic review is to address the fol- lowing research question: What interventions are the most effective for the development of collective leader- ship in healthcare teams, what outcomes have been measured, and what evaluation approaches have been adopted? We are interested in exploring both the means of evaluation and evaluation outcomes to ex- plore interventions designed to enhance the practice of collectivistic forms of leadership. As discussed above, the terms ‘collectivistic’ will be employed in this review as a broad term to capture the various forms of non-hierarchical approaches to leadership.
Methods Systematic reviewing A systematic review was conducted to explore the topic. Systematic reviewing is a method to synthesise the avail- able scientific evidence to address a clearly formulated re- search question. It enables researchers to collate relevant studies, assess the quality of evidence, and generate con- clusions and/or identify knowledge gaps. The current re- view employed methods informed by Cochrane guidance
De Brún et al. BMC Health Services Research (2019) 19:72 Page 2 of 22
on conducted reviews [24] and results are reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [25, 26]. The protocol for this systematic review was published in the PROSPERO Database in May 2017 (reference: CRD42017065007).
Search and section strategy As recommended by the Evidence for Policy and Practice Information and Co-ordinating Centre [27], the search strategy attempted to balance sensitivity with specificity in its results. Initial scoping searches revealed that the search strategy was highly sensitive and returned large numbers of studies not relevant to the topic. This indicated that MeSH terms were too broad for the purposes of this re- view. Instead keywords were used to ensure more specifi- city in the search. Previous systematic reviews conducted on collectivistic approaches to leadership from other sec- tors helped to inform the search strategy [14, 16]. The electronic databases of PubMed, PsychInfo, ABI Inform, Cochrane and CINAHL were searched on 8-10th February 2017 to find relevant studies. The complete search strings are included in Additional file 1. Some of the keywords and terms used included ‘collective leadership’, ‘shared lead- ership’, ‘distributed leadership’, ‘health’, ‘clinical’, ‘intervention’, and ‘training’. Groups of keywords relevant to a specific category (for instance, setting) type were combined using the ‘OR’ Boolean term (e.g., health OR clinical OR med- ical) and categories of keywords were then combined using
the AND Boolean operand (see Tables 1 and 2). The search strategy was reviewed by a researcher with exten- sive systematic reviewing experience who was not involved in the study. No restrictions were placed on country of origin or
language, although searches were restricted to papers, technical reports, and accessible dissertations published since 2000. The academic database searches were sup- plemented with searchers of grey literature databases OpenDOAR, OpenGrey and OAIster. These databases are amongst those recommended due to their broad scope and their ability to enable specific searches that return the most relevant records [28, 29]. Additionally, the research team scanned the reference lists of included papers and contacted experts in the field to help identify other potentially relevant studies.
Inclusion/exclusion criteria Experimental and observational research studies from a healthcare setting, including quantitative, mixed methods and qualitative studies related to plural or collectivistic forms of leadership (shared, collective, distributed leadership, etc.) from any country were eligible for inclusion in the review. Studies were eli- gible if they reported on the development, evaluation and/or implementation of training or interventions to foster collectivistic approaches to leadership. Studies had to report individual and/or team level changes related to leadership roles and responsibilities,
Table 1 Database search results
Database Population Intervention focus Intervention Setting Combined search results
Team* Group*
Collective leadership Collectivistic leadership Distributed leadership Shared leadership Collaborative leadership Participatory leadership Inclusive leadership Democratic leadership Plural leadership Dispersed leadership Empowering leadership Compassionate leadership Informal leadership Peer leadership Team leadership
Skill* Intervention* Development Education* Training Strateg* Program* Module* Course* learning framework* competenc* capabilit* model* curricul* e-learning workshop*
Health healthcare medical clinical nursing hospital primary care community
PsychInfo 509,397 10,447 1,363,982 782,683 1904
PubMed 2,125,773 532 4,477,818 3,549,729 216
ABI Inform 887,718 17,550 2,298,042 674,818 1304
Cochrane 6976 130 9186 9232 118
CINAHL 402,321 1227 960,749 1,185,768 539
TOTAL 4081
* Represents the use of the 'wildcard' Boolean truncation symbol to return all results with this root, and can represent any number of letters following this in the word, e.g., group. Will retrieve records relating to group, groups, groupings, etc
De Brún et al. BMC Health Services Research (2019) 19:72 Page 3 of 22
experiences of working, or health, team, patient, safety outcomes or outcomes relevant to team per- formance or team effectiveness. Given the potential range of variables and outcomes across different healthcare settings, specific outcome measures were not predetermined.
Study screening and data extraction The online specialised systematic review website, Covi- dence, was employed to manage the review [30]. Covi- dence enables two reviewers to independently screen records, it displays conflicts and tracks the number of papers excluded and reason for exclusion at each phase of the systematic review. Two reviewers independently screened record titles and abstracts based on the eligibil- ity criteria. Where there was any disagreement or ambi- guity, a third reviewer assessed the relevant records and consensus was reached on eligibility through discussion, and, where appropriate, retrieval and review of the full-text document. A structured data extraction form to capture infor-
mation from the relevant records was developed. Consistent with recommendations for best practice for systematic reviews of interventions [31, 32], the data extraction template collected information rele- vant to: study details (country of study, setting/con- text, sample size); theory, framework or model underpinning the intervention; mode of delivery of intervention; the specific content of intervention(s); duration of intervention(s); measures/variables of interest used to evaluate impact of interventions; out- comes of interventions/training programmes related to: impact on leadership (roles and responsibilities) for individuals and teams, impact on individual/team performance, other measured outcomes (likely to vary between studies and therefore not stated in advance); and reported/hypothesised determinants of (non-)e- ffectiveness of interventions/programmes. Where in- formation was missing or incomplete in studies included in the review, efforts were made to contact authors and/or funders to access further details. The
data extraction form was hosted on SurveyMonkey and allowed both reviewers to extract data independ- ently and enabled comparisons between reviewers.
Quality appraisal As appropriate to the study design, methodological qual- ity assessment frameworks including an adapted version of the CASP Quantitative cohort study tool [33], the Critical Appraisal Skills Programme (CASP) Qualitative tool [34], and the Mixed Method Appraisal Tool (MMAT) [35] were used to evaluate the quality of in- cluded studies. These tools have been widely used and are considered a valid indicator of methodological qual- ity. Due to the small number of relevant studies that met the inclusion criteria and the variety of study de- signs included, no studies were excluded from the review based on the quality assessment outcome.
Data synthesis As this review includes studies with large heterogeneity in interventions and measures, a statistical analysis was inappropriate. Results were synthesised using a narrative approach [36] and results reported in accordance with PRISMA guidelines [25, 26] and current recommenda- tions on the description of interventions in systematic reviews [31].
Results Search results The databases searches yielded a total of 4448 studies. Of these, 317 duplicates were removed, 4064 were ex- cluded after title and abstract screening and a further 46 were excluded for reasons including not providing a suf- ficiently detailed description of the intervention, not tak- ing place in a healthcare setting and/or not reporting an intervention outcome. Figure 1 depicts the PRISMA flow chart and summarises the screening and selection phases of the review process. In total, 21 studies met the eligi- bility criteria and were included in the review.
Table 2 Grey literature search results
Grey literature search engine Search strategy No. of items screened No. of items for full text review
No. of items included
OpenGrey collective leadership OR shared leadership OR distributed leadership AND healthcare
77 0 0
OpenDOAR collective leadership OR shared leadership OR distributed leadership AND healthcare
First 100 records (results sorted by relevance)
3 2
OAIster kw: collective leadership OR shared leadership OR distributed leadership kw: healthcare
160 2 0
Other (hand searching and studies identified through experts)
[various] 30 5 2
Total 367 10 4
De Brún et al. BMC Health Services Research (2019) 19:72 Page 4 of 22
Overview of included studies Table 3 summarises the studies included in the review and details the study characteristics, including year published, study location, aim, participant details, methodological characteristics and key findings. Of the 21 studies, four were found through grey literature search engines and these four represent work conducted as part of a doctoral dissertation. The majority of included studies were con- ducted in the USA [37–46] and the UK [47–50] with stud- ies from Australia [51, 52], Sweden [53, 54], Canada [55, 56], and Germany [57] also included. Primarily, these studies were conducted in hospital settings [37, 39–47, 50, 53–57], with one taking place in primary care [38] and across other health settings [51, 52] or multiple sectors [48, 49]. Eleven of the studies used a team training ap- proach [38, 41–44, 48–52, 55], four described co-leadership interventions [46, 54, 57], three explored service improvement interventions [37, 45, 47], two de- tailed co-design interventions [39, 40], and one related to an individual team development intervention [56].
Quality assessment Tables 4, 5 and 6 summarise the results of the quality appraisal of articles using various tools, as appropriate to study design [33–35]. Tables are arranged to list the studies in order of quality appraisal, with those of higher quality appearing first.
Among the qualitative papers included in the review, two studies met all ten quality criteria on the CASP qualitative checklist while the remaining studies met be- tween nine and three criteria (Table 4). While all ten studies stated a clear objective, included qualitative data that was relevant to the objectives and had an appropri- ate research design, only two studies considered the rela- tionship between researcher(s) and participants. Of the five quantitative papers included in the review,
there was no study which met all 11 quality criteria based on the CASP cohort study checklist. The studies met between nine and five criteria (Table 5). All studies addressed a clearly focused issue. The lack of consider- ation of confounding factors was an issue in the studies, as none reflected on this issue. Among the eight mixed-methods papers included in
the review, no study met all 13 quality criteria on the MMAT. Seven studies met between ten and six criteria with one study meeting only two criteria (Table 6). All eight papers stated a clear objective; however, no study considered the potential limitations associated with the integration of qualitative and quantitative data.
Theoretical underpinnings As evident from Table 3, the studies included in the re- view were based on a range of approaches to collectivis- tic leadership, including shared leadership [39–41, 53,
Fig. 1 PRISMA flow diagram
De Brún et al. BMC Health Services Research (2019) 19:72 Page 5 of 22
T a b le
3 Su m m ar y ch ar ac te ris ti cs
o f in cl u d ed
st u d ie s
A u th o r, Ye ar
A im
Pa rt ic ip an ts
(s et ti n g ,l o ca ti o n )
U n d er p in n in g Th eo
ry In te rv en
ti o n D u ra ti o n
In te rv en
ti o n C o n te n t
M et h o d s o f Ev al u at io n
(E va lu at io n ap p ro ac h )
Ke y Fi n d in g s
M ac Ph
ai l
et al ., 20 15
[5 1]
To in cr ea se
st af f
w ill in g n es s to
ta ke
o n le ad er sh ip
ro le s
11 in
fir st ro u n d ,
20 in
se co n d
ro u n d (r eg
io n al
h ea lt h ca re
ce n tr e,
A u st ra lia )
Tr an sf o rm
at io n al ,
d is tr ib u te d an d sy st em
s- b as ed
le ad er sh ip
9– 10
m o n th s;
2- h se ss io n s
o n -s it e o n ce
a m o n th
(~ 20
h to ta l)
Se ss io n s in cl u d ed
a g u es t
sp ea ke r an d g ro u p
d is cu ss io n ;o
n e se lf-
o rg an is ed
ex te rn al si te
vi si t an d o n e m in i-p
ro je ct
in sm
al l, in te rd is ci p lin ar y
g ro u p s; an d a p re se n ta ti o n
to p ee rs an d ex ec u ti ve
st af f o f le ar n in g .
Su rv ey
o n st af f w ill in g n es s
to ta ke
o n a le ad er sh ip
ro le ;n
ew le ad er sh ip
ro le s
af te r 18
m o n th s; Se n io r
ex ec u ti ve
fe ed
b ac k o n
p ro g ra m m e
(M ix ed
m et h o d s)
‘T h e cl in ic al le ad er sh ip
p ro g ra m m e si g n ifi ca n tl y
in cr ea se d w ill in g n es s to
ta ke
o n le ad er sh ip
ro le s
… (9 3%
) re p o rt ed
th at
th ey
w er e m o re
w ill in g to
ta ke
o n a le ad er sh ip
ro le
w it h in
th ei r te am
.’
Bu ck le y et
al .
20 09
[3 7]
To b u ild
p h ys ic ia n -
n u rs e le ad er sh ip
p ar tn er sh ip s
b as ed
o n sh ar ed
re sp o n si b ili ty
an d
ac co u n ta b ili ty
fo r
in cr ea si n g q u al it y
an d p at ie n t sa fe ty
28 p eo
p le ac ro ss
7 cl in ic al ca re
te am
s (h o sp it al se tt in g ,
U SA
)
N o n e re p o rt ed
O n e- m o n th
p ilo t p er io d
C o n su lt an ts p ar tn er ed
w it h te am
s to
h el p
b u ild
sk ill s in
g o al -
se tt in g ,m
an ag in g st af f,
p ro m o ti n g p o si ti ve
ch an g es
in w o rk
cu lt u re ,
an d n eg
o ti at in g an d
re so lv in g co n fli ct s. Te am
m em
b er s le ar n ed
h o w
to st ru ct u re
p ro je ct s, co lle ct
an d an al ys e d at a an d
d ev el o p ac ti o n p la n s fo r
im p ro ve m en
t. To
th e
ex te n t p o ss ib le ,p
h ys ic ia n
an d n u rs e le ad er s
co m p le te d tr ai n in g to g et h er .
U nc le ar re ga rd in g qu al ita tiv e
fin d in g s – no
m et ho d s
re po rt ed ,j us t re su lts .
In d iv id u al im
p ro ve m en
t p ro je ct
ca se
st u d ie s an d
o u tc o m es
p ro vi d ed
as ex am
p le s o f ef fic ac y o f
in te rv en
ti o n .
(M ix ed
m et h o d s)
‘R es u lt ed
in b re ak th ro u g h
im p ro ve m en
ts in
q u al it y an d
p at ie n t sa fe ty ,b
u t al so
fo rg ed
b et te r p h ys ic ia n -n u rs e co lla b
o ra ti o n an d jo b sa ti sf ac ti o n .’
‘P h ys ic ia n s an d n u rs es
al so
ca m e to
b et te r ap p re ci at e
ea ch
o th er ’s p re ss u re s an d
ch al le n g es .’
Bo ak
et al .,
20 15
[4 7]
To an al ys e th e
in tr o d u ct io n o f
d is tr ib u te d le ad er sh ip
an d te am
w o rk in g in
a p h ys io th er ap y
d ep
ar tm
en t, an d to
ex p lo re
th e fa ct o rs
th at
en ab le d su cc es s.
26 st af f m em
b er s
p h ys io th er ap y
d ep
ar tm
en t
(h o sp it al ,U
K)
D is tr ib u te d le ad er sh ip
an d sh ar ed
le ad er sh ip
8 m o n th s to
p la n se rv ic e
re -d es ig n
Se rv ic e re -d es ig n w it h
q u al it y im
p ro ve m en
t. Re st ru ct u rin
g to
sp ec ia lit y
te am
-b as ed
se rv ic e
d el iv er y. C o -d es ig n o f
n ew
st ru ct u re s an d
p ro ce ss es ,s ta n d ar d is ed
as se ss m en
t an d
tr ea tm
en t p ro to co ls ,
w it h te am
m em
b er
ro ta ti o n .
W ai ti n g ti m es
fo r ro u ti n e
n ew
p at ie n t ap p o in tm
en ts ;
Pa ti en
t Sa ti sf ac ti o n ;s ta ff
ex p er ie n ce s o f ch an g es
(M ix ed
m et h o d s)
C o n cl u d ed
d is tr ib u te d
le ad er sh ip
w as
su cc es sf u lly
in tr o d u ce d .D
is tr ib u te d
le ad er sh ip
an d te am
w o rk in g
w er e ce n tr al to
a n u m b er
o f
sy st em
s ch an g es
th at
w er e
in it ia te d b y th e d ep
ar tm
en t
an d le d to
im p ro ve m en
ts in
p at ie n t w ai ti n g ti m es
fo r
th er ap y. Si x fa ct o rs id en
ti fie d
th at
in flu en
ce d su cc es s.
G ib b et
al .,
20 16
[5 2]
To st an d ar d is e an d
im p ro ve
te am
co m m u n ic at io n an d
te am
le ad er sh ip
in ca re
d el iv er ed
in a
re si d en
ti al ag ed
ca re
fa ci lit y.
4 ca re
u n it s/ te am
s (r es id en
ti al ag ed
ca re
fa ci lit y,
A u st ra lia )
D is tr ib u te d le ad er sh ip
N o t re p o rt ed
(i) H u d d le :3 – 5 m in
‘ti m e o u t’ in
th e w o rk
si te
fo r sh ar ed
p ro b le m -
so lv in g ;4 -s te p p ro to co l.
(ii ) G iv in g p o si ti ve
an d
co n st ru ct iv e fe ed
b ac k,
u si n g fe ed
b ac k.
(ii i) Br ie fin g :a
le ad er -
fa ci lit at ed
d is cu ss io n p rio
r to
st ar ti n g sh ift .D
eb rie f:
3– 5 m in
af te r- ac ti o n re vi ew
(iv ) IS BA
R to
en h an ce
cl ea r co m m u n ic at io n .
A cu ltu ra ls ca n co n d uc te d
p re -in te rv en tio n in vo lv ed
th e co lle ct io n o f in te rv ie w ,
fo cu s gr ou p an d ob se rv at io na l
da ta ,w
ith th e ai m
of tri an gu la tin g da ta on
th e
cu rre nt cu ltu re ,t he n re pe at in g
po st in te rv en tio n to pr of ile
ch an ge s em
er gi ng
fro m
th e
in te rv en tio n. Sh or t su rv ey
pr e/ po st tra in in g to m ea su re
kn ow
le dg e, co nf id en ce
an d
us e of sk ills .I nt er vi ew
s an d
fo cu s gr ou ps
w ith
st af f.
(M ix ed
m et h o d s)
‘O f th e fo u r te am
s in vo lv ed
in tr ai n in g ,o
n ly o n e su cc es sf u lly
tr an si ti o n ed
to w o rk in g w it h
th e n ew
p ro to co ls …
d is tr ib u te d le ad er sh ip
w as
cr it ic al to
th e h ig h
p er fo rm
an ce
ac h ie ve d in
Te am
A .’
Re su lt s su g g es te d th at
th e
p ro je ct
h ad
m o re
g en
er al
im p ac t o n cu lt u ra l va lu es
an d in te rp er so n al b eh
av io r
an d le ss
o n th e as si m ila ti o n
o f st an d ar d co m m u n ic at io n
an d te am
w o rk in g .
De Brún et al. BMC Health Services Research (2019) 19:72 Page 6 of 22
T a b le
3 Su m m ar y ch ar ac te ris ti cs
o f in cl u d ed
st u d ie s (C on
tin u ed )
A u th o r, Ye ar
A im
Pa rt ic ip an ts
(s et ti n g ,l o ca ti o n )
U n d er p in n in g Th eo
ry In te rv en
ti o n D u ra ti o n
In te rv en
ti o n C o n te n t
M et h o d s o f Ev al u at io n
(E va lu at io n ap p ro ac h )
Ke y Fi n d in g s
H o w ar d et
al .,
20 12
[3 8]
To d el iv er
a fa ci lit at ed
, te am
-b as ed
q u al it y
im p ro ve m en
t in te rv en
ti o n to
en co u ra g e le ad er sh ip
in cl u si ve n es s.
60 q u al it y
im p ro ve m en
t te am
s; 8 o f th es e
ca se s se le ct ed
an d
h ig h lig h te d in
p ap er
(p rim
ar y
ca re ,U
SA )
In cl u si ve
le ad er sh ip
an d
co lla b o ra ti o n
3 m o n th s
U se d th e M u lt i-M
et h o d
A ss es sm
en t Pr o ce ss
(M A P)
an d th e Re fle ct iv e A d ap ti ve
Pr o ce ss
(R A P) .T h e M A P
m o d el w as
a b as el in e
as se ss m en
t in
w h ic h th e
fa ci lit at o r- re se ar ch er
sp en
t 5– 7 d ay s o b se rv in g
o p er at io n s an d re la ti o n sh ip s,
in te rv ie w in g p ra ct ic e
m em
b er s, an d d ev el o p in g
ra p p o rt .T h is w as
fo llo w ed
b y th e RA
P, w h ic h in vo lv ed
u p to
12 w ee kl y, fa ci lit at ed
te am
m ee ti n g s w it h
re p re se n ta ti ve s fr o m
d iff er en
t ar ea s o f th e p ra ct ic e.
Ex te rn al fa ci lit at o rs m o d el le d
in cl u si ve
le ad er sh ip ,
en co u ra g in g re fle ct io n an d
o p en
co m m u n ic at io n ,
su p p o rt in g im
p le m en
ta ti o n
o f im
p ro ve m en
t p la n an d
d is cu ss ed
p rin
ci p le s o f
in cl u si ve
le ad er sh ip .
D at a so u rc es
in cl u d ed
o b se rv at io n al fie ld
n o te s,
in te rv ie w s, an d au di o-
re co rd ed
qu al ity
im pr ov em
en t
m ee tin gs
to ex pl or e ex em
pl ar
an d no n- ex em
pl ar ca se s
(Q u al it at iv e)
A na ly sis
ex te nd ed
ca se
illu st ra tio ns
of 3 ph ys ic ia n
le ad er sh ip be ha vi ou rs
th at ex em
pl ifi ed
le ad er sh ip
in cl us iv en es s (e xp lic itl y
so lic iti ng
te am
in pu t; en ga gi ng
in pa rti ci pa to ry de ci sio n m ak in g;
an d fa ci lit at in g th e in cl us io n of
no n– te am
m em
be rs )a s w el la s
3 be ha vi ou rs th at ar e co un te r to
in cl us iv en es s
Ro se n g re n
et al ., 20 10
[5 3]
To d es cr ib e th e
vi ew
s o f st af f af te r
in tr o d u ct io n o f
sh ar ed
le ad er sh ip
b et w ee n tw
o n u rs e
m an g er s fo r al l ta sk s
in th e u n it .
64 /8 1 o f IC U te am
(h o sp it al ,S w ed
en )
Sh ar ed
le ad er sh ip
“a 3- ye ar
p ro je ct ”
In tr o d u ct io n o f co -le ad er sh ip
m o d el :t w o le ad er s to
sh ar e
le ad er sh ip
re sp o n si b ili ti es .
In d iv id u al ’s p er ce p ti o n o f
th e w o rk
si tu at io n ;q
u al it y
o f le ad er sh ip ;s ta ff vi ew
s o n sh ar ed
le ad er sh ip
(M ix ed
m et h o d s)
St af f re p o rt ed
p o si ti ve
vi ew
s o f w o rk
an d th e
m o d el sh ar ed
le ad er sh ip
in te rm
s o f co n fid
en ce
an d in
re la ti o n to
o rg an iz at io n al cu lt u re ,
so ci al in te ra ct io n s, w o rk
sa ti sf ac ti o n ,l ea d er sh ip ,
Sh ar ed
le ad er sh ip
& w o rk
m o ti ve s.
Sa n d er s et
al .,
20 13
[3 9]
To cr ea te
a sh ar ed
le ad er sh ip
m o d el
(S ta ff N u rs e C o u n ci l
w it h cl in ic al n u rs e
re p re se n ta ti o n fr o m
al l d ep
ar tm
en ts an d
se rv ic es
ac ro ss
th e
h o sp it al ) to
in tr o d u ce
in it ia ti ve s to
en h an ce
th e w o rk
en vi ro n m en
t.
N u rs in g te am
s th ro u g h o u t
o rg an is at io n ;
n u m b er
n o t
re p o rt ed
(h o sp it al ,
U SA
)
Sh ar ed
le ad er sh ip
N o t re p o rt ed
D ev o lv in g le ad er sh ip
an d
d ec is io n -m
ak in g to
d ev el o p
sh ar ed
le ad er sh ip
m o d el
w h er e em
p lo ye es
w er e
ta sk ed
w it h in tr o d u ci n g
in it ia ti ve s to
p o si ti ve ly
sh ap e th e w o rk
en vi ro n m en
t
St af f sa ti sf ac ti o n an d
en g ag em
en t; le ve ls o f
st re ss
an d fa ti g u e; p at ie n t
sa ti sf ac ti o n sc o re s; n u rs e-
p h ys ic ia n re la ti o n sh ip s
(Q u an ti ta ti ve )
‘A hi gh ly en ga g ed ,w
el l-
ed uc at ed ,a nd
co m m itt ed
nu rs in g w or kf or ce ,n ur tu re d
by a st ro ng
le ad er sh ip te am
, ha s cr ea te d a p os iti ve
w or k
en vi ro nm
en t ch ar ac te ris ed
b y lo w tu rn ov er an d hi g h
re te nt io n’
M ill er
et al .,
20 07
[4 8]
To su p p o rt th e
d ev el o p m en
t o f
sh ar ed
le ad er sh ip
in th e te am
s th ro u g h
th e in te rv en
ti o n o f
sp ec ia lly
tr ai n ed
an d
su p p o rt ed
le ad er sh ip
d ev el o p m en
t
6 d ia b et es
te am
s (p rim
ar y an d
se co n d ar y ca re ,U
K)
Sh ar ed
le ad er sh ip ;
d is tr ib u te d le ad er sh ip ;
co lle ct iv e le ad er sh ip ;
b le n d ed
le ad er sh ip
13 d ay s o ve r
18 m o n th s
Pr o ce ss
h ad
3 re si d en
ti al
le ar n in g se ss io n s w h ic h
b ro u g h t th e te am
s to g et h er
at th e o u ts et ,i n th e m id d le
an d at
th e en
d o f th e
sc h em
e fo r sh ar in g le ar n in g
an d ex p er t in p u t; an d w as
al so
in p ar t ta ilo re d to
te am
s.
Ea ch
te am
id en
ti fie d it s o w n
cr it er ia fo r su cc es s an d te am
m em
b er s re co rd ed
th is at
re g u la r in te rv al s.
Th e ev al u at io n u se d ra n g e
o f m et h o d o lo g ie s in cl u d in g
in te rv ie w s w ith
te am
m em
be rs
at tw o se p ar at e tim
e p oi nt s;
‘S tr o n g ev id en
ce fr o m
th e
te am
s th at
th ey
w er e
w o rk in g b et te r to g et h er
… an d b ec o m in g m o re
ef fe ct iv e as
te am
s. ’
H o w ev er ,t ea m s re m ai n ed
co n vi n ce d th at
ev er y
te am
n ee d s a le ad er ,f el t
De Brún et al. BMC Health Services Research (2019) 19:72 Page 7 of 22
T a b le
3 Su m m ar y ch ar ac te ris ti cs
o f in cl u d ed
st u d ie s (C on
tin u ed )
A u th o r, Ye ar
A im
Pa rt ic ip an ts
(s et ti n g ,l o ca ti o n )
U n d er p in n in g Th eo
ry In te rv en
ti o n D u ra ti o n
In te rv en
ti o n C o n te n t
M et h o d s o f Ev al u at io n
(E va lu at io n ap p ro ac h )
Ke y Fi n d in g s
co n su lt an ts w h o
w o rk ed
w it h cl in ic al
te am
s d el iv er in g
d ia b et es
ca re
Ea ch
le ad er sh ip
d ev el o p m en
t co n su lt an t w o rk ed
w it h th ei r
te am
to ag re e o p p o rt u n it ie s
to b rin
g te am
s to g et h er
to ad d re ss
te am
p ro ce ss es ,a n d
ea ch
em er g ed
w it h an
in d iv id u al sc h ed
u le o f h o w
to u se
th e 30
d ay s al lo ca te d
o ve r th e 18
m o n th s o f th e
sc h em
e.
a q ue st io nn ai re su rv ey
of al l
te am
m em
b er s at tw o tim
e p oi nt s; a q ue st io nn ai re su rv ey
of co m p ar at or
te am
s at th e
sa m e tim
e po in ts ;i nt er vi ew
s w ith
th e le ad er sh ip d ev el op m en t;
in te rv ie w s w ith
pa tie nt s; an d
a re vi ew
of na tio na lm
ed ic al
d at a.
(M ix ed
m et h o d s – th o u g h
o n ly q u al it at iv e re su lt s
re p o rt ed
)
th at
le ad er sh ip
w as
n o t
sh ar ed
. Se ns e th at th e in te rv en tio n
ha d en ab le d ea ch
of th em
to d ev el op
as le ad er s an d
m ad e le ad er s m or e w illi ng
to lis te n to
th em
.
St ei n er t et
al .,
20 06
[5 7]
To cr ea te
a n ew
sh ar ed
le ad er sh ip
o f
m ed
ic o -t h er ap eu ti c
st af f an d n u rs in g st af f
o n al l cl in ic al le ve ls
13 1/ 16 5 st af f
m em
b er s
(p sy ch ia tr ic
h o sp it al ,G
er m an y)
Sh ar ed
le ad er sh ip
an d
sh ar ed
g o ve rn an ce
N o t re p o rt ed
In tr o d u ct io n o f co -le ad er sh ip
m o d el b et w ee n m ed
ic o -
th er ap eu ti c st af f an d n u rs in g
st af f sh ar in g le ad er sh ip
ro le s
an d re sp o n si b ili ti es
St af f sa ti sf ac ti o n w it h
sh ar ed
le ad er sh ip
(c o n cr et e p er so n al
ex p er ie n ce s an d g en
er al
ex p er ie n ce s w it h th e
h o sp it al ); ap p ea l o f
ad o p ti n g a le ad er sh ip
p o si ti o n
Q ua nt ita tiv e (s el f-d es ig ne d
su rv ey )
‘S ta ff m em
b er s w er e
sa ti sf ie d w it h th e sh ar ed
le ad er sh ip
m o d el b o th
in th ei r o w n cl in ic al p ra ct ic e
an d in
g en
er al .N
o n -
m ed
ic al st af f m em
b er s
w er e si g n ifi ca n tl y m o re
in fa vo u r o f se ve ra l as p ec ts
o f sh ar ed
le ad er sh ip
th an
p h ys ic ia n s. ’
Ev id en
ce th e m o d el m ay
h av e ad va n ta g es
in th e
m an ag em
en t o f
p sy ch ia tr ic h o sp it al s.
C as ad y & D o w d ,
20 05
[4 0]
Se rv ic e re -d es ig n to
cr ea te
n ew
co -f ac ili ta te d
g ro u p s to
d ev el o p st ra te g ie s
an d co -d es ig n in te r
ve n ti o n s to
en h an ce
em p lo ye e
en g ag em
en t,
in vo lv em
en t in
d ec is io n -m
ak in g
an d in cr ea se
st af f
re te n ti o n .
O n e m ed
ic al
im ag in g
d ep
ar tm
en t
(h o sp it al ,U
SA )
Sh ar ed
le ad er sh ip
Se rv ic e
re -d es ig n
o ve r 5- ye ar
p er io d
Se rv ic e re -d es ig n an d re -
st ru ct u rin
g w it h n ew
o ve rs ig h t
co m m it te e an d st ra te g ic
th in ki n g g ro u p (t w o co -
fa ci lit at o rs ) to
co -d es ig n
in it ia ti ve s to
en h an ce
st af f
en g ag em
en t, cr ea te
m o re
ef fe ct iv e le ad er sh ip ,e n ab le
g re at er
p ar ti ci p at io n b y st af f
in th e d ec is io n - m ak in g
p ro ce ss ,a n d en
su re
co m p et it iv e sa la rie s.
O n -g o in g si n ce
20 01 .
G al lu p p o ll su rv ey
re su lt s
re la te d to
em p lo ye e
tu rn o ve r/ re te n ti o n ,
em p lo ye e en
g ag em
en t
an d p at ie n t sa ti sf ac ti o n
(Q u an ti ta ti ve )
‘D ra m at ic ch an ge
in tu rn ov er ra te as a re su lt of
en ga gi ng
st af fu sin g sh ar ed
le ad er sh ip pr in ci pl es .’
Tu rn ov er ra te de cr ea se d
fro m
40 % in 20 01
to 4%
in 20 04
w ith
im pr ov em
en t in
em pl oy ee
en ga ge m en t fro m
44 th pe rc en til e in 20 02
to 69 th
pe rc en til e in 20 04 .
A lle n ,2 01 0
[4 1] a
To ev al u at e th e
ef fe ct iv en
es s o f a
w o rk
b as ed
sh ar ed
le ad er sh ip
tr ai n in g
p ro g ra m
12 U n it -b as ed
n u rs in g te am
s (n
= 39 )
(h o sp it al ,U
SA )
Sh ar ed
le ad er sh ip
2– 3 m o n th s
W o rk -b as ed
ac ti o n le ar n in g
p ro g ra m
co n si st ed
o f fo u r
se ss io n s, w h ic h in cl u d ed
as si g n m en
t o f an
ac ti o n
le ar n in g p ro je ct ,c o g n it iv e
in st ru ct io n ,c o ac h in g ,a n d
re fle ct io n .
Se lf- d es ig n ed
su rv ey
in st ru m en
t m ea su re d
te am
d yn am
ic kn o w le d g e,
u se
o f sh ar ed
le ad er sh ip
b eh
av io u rs ,a n d
en g ag em
en t.
(Q u an ti ta ti ve )
Re su lt s in d ic at ed
th e
tr ai n in g p ro g ra m
w as
su cc es sf u l in
d ev el o p in g
sh ar ed
le ad er sh ip :
si g n ifi ca n t ch an g es
in kn o w le d g e o f sh ar ed
le ad er sh ip ,s h ar ed
le ad er sh ip
b eh
av io u rs
an d te am
en g ag em
en t
w er e o b se rv ed
.
Ro b er ts ,
20 09
[4 2]
a To
fa ci lit at e n et w o rk
d ev el o p m en
t th at
b rid
g es
d is ci p lin ar y
si lo s an d fo st er s
Le ad er s, m an ag er s,
su p er vi so rs ,t ea m
le ad er s an d
co o rd in at o rs
C o lle ct iv e an d co lla b o ra ti ve
le ad er sh ip
A p p ro x. 5– 6
m o n th s p er
co h o rt
3- h se ss io n s ev er y se co n d
m o n th
fo r 6 m o n th s.
2 ve rs io n s:
LE A D 1: U se
o f p er so n al it y
Q u al it at iv e ap p ro ac h
u si n g re fle ct io n ,
in te rv ie w s, fo cu s g ro u p s,
fie ld
n o te s an d
Fi n d in g s su g g es t th at
th e in te rv en
ti o n ca n
st re n g th en
sk ill s o f
in d iv id u al le ad er s an d
De Brún et al. BMC Health Services Research (2019) 19:72 Page 8 of 22
T a b le
3 Su m m ar y ch ar ac te ris ti cs
o f in cl u d ed
st u d ie s (C on
tin u ed )
A u th o r, Ye ar
A im
Pa rt ic ip an ts
(s et ti n g ,l o ca ti o n )
U n d er p in n in g Th eo
ry In te rv en
ti o n D u ra ti o n
In te rv en
ti o n C o n te n t
M et h o d s o f Ev al u at io n
(E va lu at io n ap p ro ac h )
Ke y Fi n d in g s
co lle ct iv e le ad er sh ip
ca p ac it y
(h o sp it al ,U
SA )
p ro fil es
to d ev el o p
u n d er st an d in g ,s es si o n o n
re vi ew
an d d eb
rie fin g o n
le ad er sh ip ,e ff ec ti ve
co m m u n ic at io n ,c o ac h in g
fo r su cc es s, d el eg
at io n
an d em
p o w er m en
t, ti m e
an d m ee ti n g m an ag em
en t,
th en
a fin al re vi ew
,r ef le ct io n ,
ac ti o n p la n n in g se ss io n .
LE A D 2: In fo rm
at io n on
se rv an t
le ad er sh ip ,a pp
re ci at iv e in q ui ry ,
ch an ge
m an ag em
en t, an d
re vi ew
,r ef le ct io n an d ac tio n
p la nn in g
‘L u n ch ti m e in q u iry
g ro u p ’
w h o m et
m o n th ly o ve r a
fiv e- m o n th
p er io d .
o b se rv at io n to
ex p lo re
co lle ct iv e le ad er sh ip ,
in cl u si ve n es s,
em p o w er m en
t, co lla b o ra ti o n ac ro ss
u n it s, le ad in g at
al l le ve ls .
(Q u al it at iv e)
fo st er
co lle ct iv e
le ad er sh ip
Va n Z w an en
b er g ,
20 09
[4 9]
C o -d es ig n o f n ew
co lla b o ra ti ve
le ad er sh ip
p ro g ra m m e to
fin d
w ay s o f ac h ie vi n g
ap p lic at io n o f
le ar n in g ar o u n d
co lla b o ra ti ve
le ad er sh ip
an d
su st ai n ab ili ty
o f
le ar n in g .
7 te am
s (m
u lt is ec to r
m en
ta l h ea lt h
te am
s, U K)
C o lla b o ra ti ve
/ te am
le ad er sh ip
12 m o n th s
2- da y in tro du ct io n (e st ab lis hi ng
go al s, m en to r, se le ct in g pr oj ec ts );
12 x m on th ly le ar ni ng
se ts on
pe rs on al qu al iti es
fo r le ad in g
ch an ge ;6
x bi -m on th ly
fu nc tio na ll ea ni ng
se ts fo cu se d
on pe rs on al de ve lo pm
en t,
le ad in g ch an ge ,d ev el op in g
co lla bo ra tiv e re la tio ns hi ps ;
e- re so ur ce s (p er fo rm an ce ,
fin an ci al ,r isk ,m
an ag em
en t
an d le ad er sh ip th eo ry ); 1- da y
pr og ra m m e re vi ew
an d
ev al ua tio n.
In te rv ie w s w it h p ar ti ci p an ts ,t h e
p ro je ct
g ro u p ,a n d ke y
st ak eh
o ld er s, an d q u es ti o n n ai re
re sp o n se s an d fo cu s g ro u p
se ss io n s fo r b o th
p ar ti ci p an ts
an d le ar n in g se t fa ci lit at o rs .
(M ix ed
m et h o d s)
‘P os iti ve
sh ift s in pa rti ci pa nt s’
co m pe te nc e as co lla bo ra tiv e
pa rtn er s, pa rti cu la rly
re ga rd in g
w or ki ng
ac ro ss tra di tio na l
bo un da rie s.’
D ew
ar & C o o k,
20 14
[5 0]
In te rv en
ti o n ai m ed
to su p p o rt st af f to
w o rk
to g et h er
to d ev el o p a cu lt u re
o f
in q u iry
th at
w o u ld
en h an ce
d el iv er y o f
co m p as si o n at e ca re
86 n u rs in g st af f
m em
b er s( h o sp it al ,U
K) D is tr ib u te d an d co lla b o ra ti ve
le ad er sh ip
12 m o n th s
Re fle ct iv e sp ac es
w it h in
th e p ro g ra m m e,
co m m u n it y o f p ra ct ic e, A ct io n
Le ar n in g ,W
o rk
b as ed
ac ti vi ti es .
St af f cu lt u re
q u es ti o n n ai re ,
re fle ct io n s fo llo w in g ac ti o n
le ar n in g ,d
es cr ip ti o n s o f
re p o rt ed
st af f d ev el o p m en
ts ,
ca se
st u d ie s, st af f in te rv ie w s
to el ic it im
p ac t o f tr ai n in g
(M ix ed
m et h o d s)
‘E n h an ce d se lf- aw
ar en
es s,
b et te r re la ti o n sh ip s,
g re at er
ab ili ty
to re fle ct
o n p ra ct ic e, d iff er en
t co n ve rs at io n s in
th e
w o rk p la ce
th at
w er e m o re
co m p as si o n at e an d
re sp ec tf u l, an d an
et h o s
o f co n ti n u in g le ar n in g an d
im p ro ve m en
t …
su p p o rt ed
p ar ti ci p an ts …
to b e
re fle ct iv e an d en
g ag ed
.’
A w ad
et al .,
20 04
[4 3]
C u rr ic u lu m
im p le m en
te d w it h
o b je ct iv es
o f tr ai n in g
re si d en
ts to
h av e th e
ca p ac it y/ ab ili ty
to cr ea te
an d m an ag e
p o w er fu l te am
s th ro u g h al ig n m en
t, co m m u n ic at io n ,a n d
in te g rit y
Su rg ic al re si d en
ts (n u m b er
n o t
re p o rt ed
) (h o sp it al ,
U SA
)
C o lla b o ra ti ve
le ad er sh ip
“o ve r th e
co u rs e o f a
su rg ic al
re si d en
cy ”
Fo cu se d p ro g ra m
w as
im p le m en
te d w it h o b je ct iv es
o f tr ai n in g th e re si d en
ts to
h av e th e ca p ac it y/ ab ili ty
to cr ea te
an d m an ag e p o w er fu l
te am
s th ro u g h al ig n m en
t, co m m u n ic at io n ,a n d
in te g rit y w h ile
w o rk in g 80
h p er
w ee k. Sp ec ifi c st ra te g ie s
w er e: (1 ) to
fo cu s o n q u al it y
Pr e/ p o st su rv ey
as se ss in g
re si d en
t’s vi ew
o f le ad er sh ip
in th e ar ea s o f al ig n m en
t, co m m u n ic at io n , a n d in te g rit y.
(Q u an ti ta ti ve )
Th er e w as
a si g n ifi ca n t i
n cr ea se
in th e sc o re s w it h
re g ar d s to
al ig n m en
t, co m m u n ic at io n ,a n d
in te g rit y af te r co m p le ti o n
o f th e le ad er sh ip
tr ai n in g
p ro g ra m
in d ic at in g th e
p ro g ra m
w as
su cc es sf u l
in it s ai m s
De Brún et al. BMC Health Services Research (2019) 19:72 Page 9 of 22
T a b le
3 Su m m ar y ch ar ac te ris ti cs
o f in cl u d ed
st u d ie s (C on
tin u ed )
A u th o r, Ye ar
A im
Pa rt ic ip an ts
(s et ti n g ,l o ca ti o n )
U n d er p in n in g Th eo
ry In te rv en
ti o n D u ra ti o n
In te rv en
ti o n C o n te n t
M et h o d s o f Ev al u at io n
(E va lu at io n ap p ro ac h )
Ke y Fi n d in g s
o f p at ie n t ca re / se rv ic e w h ile
re ce iv in g a h ig h ed
u ca ti o n -t o -
se rv ic e ra ti o ,a n d (2 ) to
m ax im
iz e ef fic ie n cy
th ro u g h
ti m e m an ag em
en t.
Ja ck so n ,2 00 0
[5 5]
Se rv ic e re -d es ig n to
sh ar e le ad er sh ip
ac ro ss
cl in ic al u n it s
69 in d iv id u al s
w it h in
4 w o rk
g ro u p s( h o sp it al ,
C an ad a)
Sh ar ed
le ad er sh ip
In tr o d u ce d ac ro ss
o rg an is at io n o ve r
tw o -y ea r p er io d
A g ro u p o f st af f m em
b er s
an d m an ag er s as se m b le d in
19 97
to fo rm
a sh ar ed
le ad er sh ip
re so u rc e g ro u p ,
w it h fu n ct io n o f p ro vi d in g
su p p o rt to
in d iv id u al s an d
te am
s as
th ey
in cr ea se d th ei r
d ec is io n m ak in g .T h e sh ar ed
le ad er sh ip
re so u rc e g ro u p
g av e th e re sp o n si b ili ty
o f
im p le m en
ti n g th e m o d el
o n ea ch
o f th e cl in ic al u n it s
to th e te am
le ad er
m an ag er s/
p ro g ra m
d ire ct o rs .
Fo cu s g ro u p s an d in te rv ie w s
to ex p lo re
st af f ex p er ie n ce s
an d p er ce p ti o n s o r se rv ic e
re -d es ig n (Q u al it at iv e)
D riv er s an d b ar rie rs
af fe ct in g im
p le m en
ta ti o n
ar e ex p lo re d .
‘In te rn al is at io n o f th e
co n ce p ts sp ec ifi c to
th e
sh ar ed
le ad er sh ip m o d el …
w as
vi ta l…
Pr o ce ss es
an d in te ra ct io n s w h ic h
m ee t th e d em
o n st ra te d
n ee d o f al ls ta ff to
fe el
va lu ed ,u ni qu e, co nn ec te d,
an d a se ns e of b el on g in g ar e
d es ira b le w he n pr om
ot in g
th e m od el .’
Pe la yo ,2 00 8
[4 4] a
Se rv ic e re -d es ig n to
te am
-b as ed
le ad er sh ip
to en
h an ce
ef fe ct iv e
fu n ct io n in g o f
h o sp it al
O rg an is at io n -w
id e
te am
-b as ed
w o rk in g ,1 70 0
em p lo ye es
(h o sp it al ,U
SA )
Te am
-b as ed
le ad er sh ip
Ph as ed
sh ift
to te am
- b as ed
m o d el
o ve r 8- ye ar
p er io d
A s d es cr ib ed
b y th e cu rr en
t C EO
,t h e st ra te g ie s ar e
re p o rt ed
in p h as es :( a)
im m ed
ia te
re ac ti o n ar y p h as e
(c o n tr o lli n g fin an ce s, re m o vi n g
w as te
in sy st em
), (b ) b u ild in g
p h as e (h iri n g th e rig
h t p eo
p le ,
tr ai n in g th em
,e n su rin
g th at
th e te am
s w er e fu n ct io n in g
ef fic ie n tl y) ,a n d (c ) se lf-
g o ve rn in g p h as e (t ea m s
ta sk ed
to d ev el o p sp ec ifi c
g o al s al ig n ed
to o rg an is at io n ’s g o al s) .
A q u al it at iv e ca se
st u d y
(in te rv ie w s, d o cu m en
t re vi ew
s, o b se rv at io n s)
ex p lo ra ti o n o f th e st ra te g ie s
o rg an is at io n al le ad er s
ad o p te d to
d ev el o p a
10 -y ea r te am
-b as ed
le ad er sh ip
st ru ct u re .
(Q u al it at iv e)
Fo u r co n cl u si o n s o n th e
te am
-b as ed
le ad er sh ip :( i)
p h en
o m en
o n th at
o cc u rr ed
o ve r ti m e an d
ev o lv ed
fr o m
va rio
u s
st ra te g ie s to
ad d re ss
fin an ci al ch al le n g es ;( ii)
n o n e o f th e st ra te g ie s
em pl oy ed
w er e co ns id er ed
a fa ilu re ;( iii) m ul tid isc ip lin ar y
te am
s po sit iv el y in flu en ce d
th e b us in es s as pe ct of th e
or g an isa tio n’ s p er fo rm
an ce
w hi le in cr ea sin g th e qu an tit y
an d q ua lit y of se rv ic es ;a nd
(iv )t he
or g an isa tio n’ s te am
s pa ra lle le d th e fu nc tio ns
an d
g oa ls of th e m an ag em
en t
te am
.
Kl in g a et
al .,
20 16
[5 4]
Se rv ic e re -d es ig n o f
o rg an is at io n to
p ro m o te
sh ar ed
tr ea tm
en t an d
sh ar ed
le ad er sh ip
O rg an is at io n -w
id e
in te g ra te d h ea lt h
an d so ci al ca re
o rg an is at io n
(h o sp it al ,S w ed
en )
C o -le ad er sh ip
Se rv ic e re -d es ig n in
o p er at io n si n ce
19 95
Se rv ic e re -d es ig n w h er e
ea ch
ce n tr e is m an ag ed
th ro u g h co -le ad er sh ip
sh ar ed
b y tw
o eq
u al
le ad er s (‘p ai r- le ad er sh ip ’),
w h er e re sp o n si b ili ty
o f
u n it m an ag em
en t
sh ar ed
b y tw
o co -le ad er s.
In te rv ie w s w it h ei g h t
m an ag er s ex er ci si n g
co -le ad er sh ip
to id en
ti fy
es se n ti al
p re co n d it io n s in
fu lfi lli n g
th e m an ag em
en t
as si g n m en
t, o p er at io n al is at io n an d
im p ac t o n in te g ra ti o n
o f h ea lt h an d so ci al
ca re .(Q
u al it at iv e)
Id en tif ie d co nt ex tu al
pr ec on di tio ns
w er e an
or ga ni sa tio n- w id e m od el
su pp or tin g co -le ad er sh ip
an d co -lo ca tio n of se rv ic es .
Pe rc ep tio n of th e
m an ag em
en t ro le as
a co lle ct iv e ac tiv ity ,c o n tin
u o u s
co m m u n ic at io n an d la ck
o f
p re st ig e w er e es se n tia l
p er so n al an d in te rp er so n al
p re co n d iti o n s. In d ai ly p ra ct ic e,
o ffi ce
sh ar in g ,b ei n g ab le to
g iv e an d ta ke
an d su p p o rt
ea ch
o th er
co n tr ib u te d to
su cc es s.
De Brún et al. BMC Health Services Research (2019) 19:72 Page 10 of 22
T a b le
3 Su m m ar y ch ar ac te ris ti cs
o f in cl u d ed
st u d ie s (C on
tin u ed )
A u th o r, Ye ar
A im
Pa rt ic ip an ts
(s et ti n g ,l o ca ti o n )
U n d er p in n in g Th eo
ry In te rv en
ti o n D u ra ti o n
In te rv en
ti o n C o n te n t
M et h o d s o f Ev al u at io n
(E va lu at io n ap p ro ac h )
Ke y Fi n d in g s
Sw en
se n et
al .,
20 16
[4 5]
To d ev el o p a
q u al it at iv e
d es cr ip ti ve
ca se
st u d y o f th e M ay o
C lin ic le ad er sh ip
d ev el o p m en
t p h ilo so p h y, ap p ro ac h
an d m o d el ;t o
u n d er st an d th e
fe at u re s o f te am
- b as ed
le ad er sh ip
d ev el o p m en
t
O rg an is at io n -w
id e
(h o sp it al ,U
SA )
C o lle ct iv e le ad er sh ip ;
te am
-b as ed
le ad er sh ip
O n -g o in g
(in tr o d u ct io n d at e n o t
re p o rt ed
)
O rg an is at io n -w
id e p o lic ie s
an d p ro g ra m m es
in cl u d in g
le ad er sh ip
p ro g ra m m e,
ro ta ti n g le ad er sh ip
p o si ti o n s,
an d a co lla b o ra ti ve
le ad er sh ip
st ru ct u re .
St af f en
g ag em
en t; p at ie n t
sa ti sf ac ti o n ;s ta ff tu rn o ve r; q u al it y
o u tc o m es (Q u al it at iv e ca se
st u d y
u si n g q u an ti ta ti ve
d at a as
ev id en
ce o f ef fe ct iv en
es s)
O rg an isa tio na la nd
go ve rn an ce
sy st em
s ar e
de sig ne d to
de ve lo p
cu ltu ra lly
al ig ne d le ad er s,
bu ild
so ci al ca pi ta l, gr ow
em p lo ye e en g ag em
en t,
fo st er co lla b or at io n,
nu rt ur e co lle g ia lit y an d
en ge nd er tr us t.
Bl ac k & W es tw
o o d ,
20 04
[5 6]
To ev al u at e th e
ef fe ct iv en
es s o f a
g ro u p -b as ed
te am
le ad er sh ip
d ev el o p m en
t w o rk sh o p
7 (o f 9)
in vi te d
p ar ti ci p at ed
. A d m in is tr at io n
te am
in ca n ce r
ca re
(h o sp it al ,
C an ad a)
Te am
-b as ed
(n o n -
h ie ra rc h ic al ) le ad er sh ip
35 h o ve r 3- m o n th
p er io d
3 w o rk sh o p s (3 5 fa ci lit at ed
h o u rs )
W o rk sh o p 1 – te am
b u ild in g /
g et ti n g to
kn o w
te am
,r o le
p la y, A m u n d so n in d iv id u al
st yl es
su rv ey
W o rk sh o p 2 – Ro
le cl ar ifi ca ti o n u si n g en
ac tm
en t,
d is cu ss io n o n m is ta ke s/
d ea th s in
h ea lt h ca re ,
W o rk sh o p 3 – Re vi ew
g ro u p
g o al s, Jo h ar i w in d o w
se lf-
aw ar en
es s ex er ci se ,g
ro u p
co m m u n ic at io n ex er ci se
an d d is cu ss io n ,e n ac tm
en t
an d d em
o n st ra ti o n o f
cr it ic al te am
m ee ti n g ,
d eb
rie f.
In te rv ie w s 3- m o n th s p o st -
in te rv en
ti o n to
el ic it in fo rm
at io n
re la te d to
th ei r p ar ti ci p at io n in
th e w o rk sh o p s an d co m m un ic at io n ,
m o ra le ,s up
p o rt an d th e ab ili ty to
p ro vi d e m o re h o lis tic
su p p o rt .
(Q u al it at iv e)
A ll pa rti ci pa nt s re po rte d
un de rs ta nd in g ot he rs /b ei ng
un de rs to od ;f or m at io n of
co nn ec tio ns
w ith
ot he rs ;
se ns e of be lo ng in g/
ac ce pt an ce ;s en se
of sa fe ty
an d tru st in co m m un ic at io n;
ap pr ec ia tio n of fa ci lit at io n
of th e gr ou p; ex pe rie nc e of
gr ou p m or al e (in cr ea se d
an d de cr ea se d) ;r ec ip ro ci ty
an d de m on st ra tio n of
su pp or t.
Se n n ,2 01 4
[4 6] a
To ex p lo re
fa ct o rs
th at
h in d er ed
o r
en h an ce d th e
ro le d ev el o p m en
t o f co -le ad er s; an d
th e n at u re
an d
d yn am
ic s o f th e
co -le ad er s’ w o rk in g
re la ti o n sh ip .
8 co -le ad er s
(h o sp it al ,U
SA )
C o -le ad er sh ip
C o -le ad er sh ip
o p er at io n al
fo r m o re
th an
5 ye ar s
p rio
r to
d at a
co lle ct io n .
Se rv ic e re -d es ig n – n u rs e
an d p h ys ic ia n co -le ad er sh ip
m o d el ,s h ar in g re sp o n si b ili tie s
an d le ad in g a h o sp ita lu n it
In d iv id u al in te rv ie w s w it h
co -le ad er s ab o u t th ei r sh ar ed
ro le an d re sp o n si b ili ti es ,a n d
th ei r co lla b o ra ti ve
w o rk
to g et h er
w it h in
a co -le ad er sh ip
st ru ct u re
(Q u al it at iv e)
Tw o th em
es em
er g ed
: ‘S h ar ed
Ro le Sp ac e:
M o vi n g fr o m
I to
W e’
an d ‘P ar tn er ed
Le ad er sh ip :
D yn am
ic In te rp la y o f
C o m p le m en
ta ry
C o m p et en
ci es ’. Fa ct o rs th at
en h an ce d /h in d er e d
th e ro le id en
ti fie d .
N o te : a in d ic at es
st u d y fo u n d th ro u g h g re y lit er at u re
se ar ch es
De Brún et al. BMC Health Services Research (2019) 19:72 Page 11 of 22
T a b le
4 Re su lt s o f C A SP
Q u al it at iv e C h ec kl is t
A u th o r, Ye ar
St at em
en t o f ai m s
Q u al it at iv e
m et h o d o lo g y
ap p ro p ria te
Re se ar ch
d es ig n
ap p ro p ria te
Re cr u it m en
t st ra te g y
ap p ro p ria te ?
D at a co lle ct io n
ap p ro p ria te
Re la ti o n sh ip
b et w ee n
re se ar ch er
an d p ar ti ci p an t
co n si d er ed
Et h ic al is su es
co n si d er ed
D at a an al ys is
rig o ro u s
St at em
en t
o f fin d in g s
Is re se ar ch
va lu ab le
O u tc o m e o f
ch ec kl is t
(Y es /C an ’t
te ll/
N o )
Ro b er ts ,2 00 9 [4 2]
Ye s
Ye s
Ye s
Ye s
Ye s
Ye s
Ye s
Ye s
Ye s
Ye s
10 /0 /0
Se n n ,2 01 4 [4 6]
Ye s
Ye s
Ye s
Ye s
Ye s
Ye s
Ye s
Ye s
Ye s
Ye s
10 /0 /0
H o w ar d et
al ., 20 12
[3 8]
Ye s
Ye s
Ye s
Ye s
Ye s
C an ’t te ll
Ye s
Ye s
Ye s
Ye s
9/ 1/ 0
Kl in g a et
al ., 20 16
[5 4]
Ye s
Ye s
Ye s
Ye s
Ye s
C an ’t te ll
Ye s
Ye s
Ye s
Ye s
9/ 1/ 0
Bl ac k & W es tw
o o d ,2 00 4 [5 6]
Ye s
Ye s
Ye s
Ye s
Ye s
C an ’t te ll
C an ’t te ll
Ye s
Ye s
Ye s
8/ 2/ 0
Pe la yo ,2 00 8 [4 4]
Ye s
Ye s
Ye s
Ye s
Ye s
C an ’t te ll
Ye s
Ye s
Ye s
C an ’t te ll
8/ 2/ 0
Ja ck so n ,2 00 0 [5 5]
Ye s
Ye s
Ye s
C an ’t te ll
Ye s
C an ’t te ll
C an ’t te ll
Ye s
Ye s
Ye s
7/ 3/ 0
Sw en
se n et
al ., 20 16
[4 5]
Ye s
Ye s
Ye s
C an ’t te ll
C an ’t te ll
C an ’t te ll
C an ’t te ll
C an ’t te ll
C an ’t te ll
C an ’t te ll
3/ 7/ 0
De Brún et al. BMC Health Services Research (2019) 19:72 Page 12 of 22
T a b le
5 Re su lt s o f C A SP
Q u an ti ta ti ve
St u d y C h ec kl is t
A u th o r, Ye ar
Fo cu se d is su e
ad d re ss ed
A cc ep
ta b le
re cr u it m en
t Ex p o su re
m ea su re d
to m in im
is e
b ia s
O u tc o m e
m ea su re d to
m in im
is e b ia s
C o n fo u n d in g
fa ct o rs
id en
ti fie d
D es ig n / an al ys is
co n si d er s
co n fo u n d in g
va ria b le s
Fo llo w
u p o f
su b je ct s
co m p le te
en o u g h
Fo llo w
u p o f
su b je ct s lo n g
en o u g h
Re su lt s
b el ie ve d
C an
re su lt s b e
ap p lie d to
lo ca l p o p u la ti o n
Re su lt s fit
w it h o th er
ev id en
ce
O u tc o m e o f
ch ec kl is t
(Y es / C an ’t
te ll /N o )
A lle n ,2 01 0 [4 1]
Ye s
Ye s
Ye s
Ye s
N o
N o
Ye s
Ye s
Ye s
Ye s
Ye s
9/ 0/ 2
C as ad y & D o w d ,2 00 5
[4 0]
Ye s
C an ’t te ll
Ye s
Ye s
N o
N o
Ye s
Ye s
Ye s
Ye s
Ye s
8/ 1/ 2
A w ad
et al ., 20 04
[4 3]
Ye s
Ye s
Ye s
Ye s
C an ’t te ll
N o
C an ’t te ll
Ye s
Ye sa
C an ’t te ll
Ye s
7/ 3/ 1
St ei n er t et
al ., 20 06
[5 7]
Ye s
Ye s
C an ’t te ll
Ye s
N o
N o
Ye s
Ye s
Ye s
C an ’t te ll
Ye s
7/ 2/ 2
Sa n d er s et
al ., 20 13
[3 9]
Ye s
C an ’t te ll
C an ’t te ll
Ye s
N o
N o
Ye s
Ye s
C an ’t
te ll
C an ’t te ll
Ye s
5/ 4/ 2
a Li m it ed
in fo rm
at io n g iv en
o n co m p o n en
ts o f in te rv en
ti o n
De Brún et al. BMC Health Services Research (2019) 19:72 Page 13 of 22
T a b le
6 Re su lt s o f M ix ed
M et h o d s A p p ra is al To o l (M
M A T)
A u th o r, Ye ar
C le ar
o b je ct iv e
D at a re le va n t
to ad d re ss in g
o b je ct iv es
Q u al it at iv e
d at a so u rc es
re le va n t to
o b je ct iv es
Q u al it at iv e
d at a an al ys is
re le va n t to
o b je ct iv es
C o n si d er at io n
g iv en
to h o w
fin d in g s re la te
to co n te xt
C o n si d er at io n
g iv en
to h o w
fin d in g s re la te
to re se ar ch er s’
in flu en
ce
Sa m p lin g st ra te g y
re le va n t to
ad d re ss
q u an ti ta ti ve
re se ar ch
q u es ti o n
Sa m p le
re p re se n ta ti ve
o f p o p u la ti o n
Q u an ti ta ti ve
m ea su re
ap p ro p ria te
A cc ep
ta b le
re sp o n se
ra te
a
M ix ed
m et h o d s
d es ig n
re le va n t to
o b je ct iv e
In te g ra ti o n o f
q u al it at iv e an d
q u an ti ta ti ve
re le va n t to
o b je ct iv e
Li m it at io n s o f
in te g ra ti n g
fin d in g s
co n si d er ed
O u tc o m es
o f ch ec kl is t
(Y es /C an ’t
te ll/ N o )
D ew
ar &
C o o k, 20 14
[5 0]
Ye s
Ye s
Ye s
Ye s
Ye s
C an ’t te ll
Ye s
Ye s
C an ’t te ll
Ye s
Ye s
Ye s
N o
10 /2 /1
Ro se n g re n et
al ., 20 10
[5 3]
Ye s
Ye s
Ye s
C an ’t te ll
Ye s
C an ’t te ll
Ye s
Ye s
Ye s
Ye s
Ye s
Ye s
N o
10 /2 /1
M ac Ph
ai l et
al ., 20 15
[5 1]
Ye s
Ye s
Ye s
C an ’t te ll
C an ’t te ll
C an ’t te ll
Ye s
Ye s
C an ’t te ll
Ye s
Ye s
Ye s
N o
8/ 4/ 1
Bo ak
et al .,
20 15
[4 7]
Ye s
Ye s
Ye s
C an ’t te ll
C an ’t te ll
C an ’t te ll
Ye s
Ye s
C an ’t te ll
Ye s
Ye s
C an ’t te ll
N o
7/ 5/ 1
G ib b et
al .,
20 16
[5 2]
Ye s
Ye s
Ye s
C an ’t te ll
C an ’t te ll
C an ’t te ll
Ye s
Ye s
C an ’t te ll
Ye s
Ye s
C an ’t te ll
N o
7/ 5/ 1
Va n
Z w an en
b er g ,
20 09
[4 9]
Ye s
Ye s
Ye s
C an ’t te ll
C an ’t te ll
C an ’t te ll
Ye s
C an ’t te ll
C an ’t te ll
C an ’t te ll
Ye s
Ye s
N o
6/ 6/ 1
M ill er
et al .,
20 07
[4 8]
Ye s
Ye s
Ye s
C an ’t te ll
C an ’t te ll
Ye s
Ye s
C an ’t te ll
C an ’t te ll
C an ’t te ll
Ye s
N o
N o
6/ 5/ 2
Bu ck le y et
al .
20 09
[3 7]
Ye s
C an ’t te ll
C an ’t te ll
C an ’t te ll
C an ’t te ll
C an ’t te ll
C an ’t te ll
C an ’t te ll
C an ’t te ll
C an ’t te ll
Ye s
N o
N o
2/ 9/ 2
a 6 0 %
o r ab
o ve
De Brún et al. BMC Health Services Research (2019) 19:72 Page 14 of 22
55], collective leadership [45], distributed leadership [52], collaborative or team leadership [43, 44, 49, 56], co-leadership [46, 54], or a combination of approaches (or used terms were used interchangeably) [38, 42, 47, 48, 50, 51, 57]. Only one included study [37] did not dis- cuss or cite any conceptual framework or theoretical basis for the intervention reported.
Intervention evaluation Seven of the included studies were evaluated using a qualitative approach [38, 42, 44, 46, 54–56], six using a quantitative approach [39–41, 43, 45, 57], and eight conducted a mixed methods evaluation [37, 47–53]. Table 3 details the specific evaluation approach for each study. All included studies reported some posi- tive effects of the interventions described, but many studies offered caveats to this; this is further expli- cated in the narrative review.
Narrative review Given the heterogeneity of included papers, studies were therefore categorised by intervention type: co-design in- terventions, co-leadership interventions, service improve- ment interventions, team training interventions and individual team development interventions. and are de- scribed using a narrative synthesis approach. Co-design interventions are those that involves the equal partner- ship of individuals to improve efficiency or design inter- ventions or pathways of care. It is a method that is inclusive of various perspectives and employing each other’s knowledge, resources and contributions, to achieve better outcomes or re-design processes for im- provement [58]. Service improvement interventions de- scribed herein are those that had a clear and explicit focus on enhancing quality and safety outcomes or to fix identified problems in service delivery. Team train- ing interventions are those delivered to and aimed at an entire team to train them together to acquire the same skills and often involved workshops, facilitated learning through seminars and/or learning sets. Finally, the indi- vidual team development includes the one study that sought to establish collective leadership in developing and shaping a new team.
Co-design interventions Two studies employed co-design approaches which enabled teams to develop solutions to address local problems [39, 40]. Casady and Dowd [40] employed shared leadership approaches to enhance the engage- ment of staff in participative decision making about initiatives that impact on their jobs in a medical im- aging department in the US. Management established new strategic thinking teams in the department which were co-facilitated and led by staff. Each team
operated for a 12-week period to address various spe- cific issues relevant to staff and to co-develop solu- tions. In a similar study, Sanders et al. [39] reported efforts to create a shared leadership model among nurses from various hospital departments where employees were tasked with co-designing and introdu- cing initiatives to make positive changes to the work environment. The former study attributed a reduction in the department’s turnover rate, from 40 to 14.5% within 18 months to this delegation of decision-mak- ing and empowerment for improvement across these teams [40]. The turnover rate further declined to 4% after 3 years. The department also observed improve- ments in employee engagement over this period. In the latter study, it was reported that the new way of working created a more positive work environment and also resulted in reduced staff turnover [39].
Co-leadership interventions Four studies reported on the introduction of a co-leadership model, where leadership was shared across two individuals on the team, either a physician-nurse partnership [46, 57], partnership between two nurses [53], or partnership between a nursing manager and a managers with a background in social and welfare-related education [54]. Two studies [53, 57] ex- plored the impact of co-leadership using survey ap- proaches and two employed qualitative interviews to examine the impact of the model [46, 54]. The studies using surveys to evaluate the model achieved high re- sponse rates (> 79%) and the qualitative studies each interviewed individuals in eight co-leadership positions. Both studies reported an overall favourable view of the shared leadership approach, particularly among nurses, though one study reported greater scepticism of the model among physicians and therapists [57]. The studies reported that shared leadership increased staff confi- dence [53, 54] and the model was viewed positively in relation to the dimensions of organisational culture, social interaction, work satisfaction, and shared lead- ership [53]. It was also found that co-leadership fos- tered a better working environment for staff [53]. Overall, the results indicated strong support from staff for the model, and in one study 94% of partici- pants responded positively to keeping shared leader- ship and did not want to return to a traditional single leader model [53]. Role clarity was described as important for the
model to be effective [46], the leaders’ personality characteristics [54], knowledge and skills [46], sharing similar values [46, 54], and demonstrating mutual re- spect [46, 54] were considered important. Good com- munication [46, 54] and transparency fostered trusting relationships [54]. Successful co-leadership
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was described as requiring flexibility from leaders en- gaging alternatively in moments of ‘give and take’ and occasionally stepping back from decision-making and allowing the team to find solutions [54]. From a prac- tical perspective, regular meetings, co-location and or- ganisational support were highlighted as valuable enablers of the co-leadership model [46, 54].
Service improvement interventions Three studies describe interventions aimed at sharing re- sponsibility for quality and patient safety outcomes [37, 45, 47]. Two studies adopted mixed methods approaches to evaluation and one used a quantitative assessment. One study explored the introduction of distributed lead- ership and team working in a therapy department through service re-design [47], another aimed at enhan- cing quality through building physician-nurse relation- ships through working with external consultants [37] and the third describes an organisation-level approach to initiative to enhance collective leadership for quality and safety [45]. As a result of these interventions, there was evidence of a flattening of the hierarchy and en- hanced collaboration [37, 47], communication [47], mu- tual support [47], staff satisfaction [37, 45], retention [45], and adoption of leadership responsibilities [47]. Staff perceived the interventions as enabling a more sup- portive work environment and served to enhance clarity and focus amongst participants [47]. The introduction of the new model was reported to be associated with mul- tiple service quality improvements [45], including a re- duction in patient waiting times for therapy [47] and increased patient satisfaction [45, 47].
Team training interventions Eleven studies in the review described team training in- terventions aimed at enhancing collectivistic leadership [38, 41–44, 48–52, 55]. Study designs included quantita- tive, qualitative and mixed methods studies and a variety of methodologies were employed. Three studies employed a work-based action research approaches [41, 42, 50], two studies utilised case study approaches [38, 44] and two worked with external consultants or coa- ches [38, 48]. Most interventions included a series of workshops, facilitated sessions or learning sets [41, 42, 48–50] exploring topics including leadership theory, per- sonality profiling, goal setting, communication, conflict management, cognitive instruction, reflection, time and meeting management, performance management, group dynamics, building collaborative relationships, apprecia- tive inquiry, and change management. Other interven- tion components included developing a team charter [44], introduction of team huddles, mechanisms to en- courage feedback, after action reviews to develop shared
mental models/vision and standardised communication protocols [52]. Most studies reported moderate to good success in
fostering shared leadership behaviours and/or fostering willingness to lead among individuals [41–44, 50–52]. However one study reported that although participants felt the intervention had enabled them to develop as leaders, “the teams all remained convinced that every team needs a leader and felt that leadership was not shared in that sense” ([48]: 34). Similarly, of the four teams involved in another team training intervention, only one successfully transitioned to distributed leader- ship and effectively collaborating [52]. This suggests such interventions may not work in the same way for all types of teams, yet there was little reflection on why this may be the case. Other common outcomes of team training interven-
tions were more effective team working [48, 50], evi- dence of a flattening of hierarchy [49], increased staff engagement [41, 42, 51], greater confidence and em- powerment among participants [42, 51], enhanced communication [42–44, 50, 55] and more collabora- tive problem solving and decision-making [38, 42, 49]. Valuing others’ input and contribution was described as a positive outcome of three studies [38, 50, 55] and greater delegation [42], increased trust [50], and innovation were also reported [44]. Among the rec- ommendations arising from these studies were the need for adequate resources, senior leadership buy-in, physician engagement and continuing education to support shared leadership [55].
Individual team development interventions One study evaluated the development of a multidiscip- linary team in a Canadian cancer care centre [56]. Con- sultants were hired to facilitate a series of three, two-day workshops over a three-month period to enhance team leadership development. Interviews were conducted with participants 3 months post-intervention (n = 7). Analysis found that, because of the workshops, participants felt they had learned how to communicate, relate to and support one another. There was also an increased sense of solidarity and cohesion among the group. However, the researchers conclude that there is need for on-going team support to maintain gains.
Overview of drivers of intervention success across studies Many studies commented on the factors which facili- tated the success of their intervention. Physician and se- nior management support and engagement was purported to play a vital role in success [47, 53, 55]. Studies which included the appointment of two or more leaders to share responsibilities noted that the personal characteristics of the co-leaders impacted on the success
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of the intervention [37, 45, 46, 53, 54]. Continuous edu- cation and communication of outcomes were seen as important in order to internalise shared leadership con- cepts among staff [55]. This internalisation and engage- ment from staff was also achieved by interventions which used co-design or co-development which gave team members responsibility in developing the direction and content of the intervention [42, 44, 47]. Finally, pro- viding teams with time and space to discuss the new ap- proach to leadership, how their team works and clarify their goals was considered an important component of successful interventions [47, 48].
Discussion This systematic review examined interventions that have been employed with the aim of developing col- lectivistic approaches to leadership in healthcare set- tings. Most of the studies included in this review highlight at least moderate success in the enactment of collectivistic leadership approaches and although the studies were heterogeneous, limited initial pro- gress has been made indicating the value of such in- terventions in healthcare settings. One of the main findings of this review is the paucity of research on interventions to develop collectivistic forms of leader- ship in healthcare and a concomitant lack of rigor and replication in the field. Additionally, this review highlights the range of approaches to intervention de- sign and varied evaluative methods employed in the field. Consequently, there are no studies included that evaluated the same intervention in the same way, meaning there is a lack of comparability both between and within these categories of studies. This limits the ability to synthesise findings and draw meaningful conclusions from the studies included. The advancement of field of collectivistic leadership
development is inhibited by the variation in study de- signs and approaches. This is made more problematic by the lack of consensus on the best means of measurement evaluation of collectivistic leadership interventions [1, 59]. Further, the studies in this review were of mixed quality, raising concerns about methodological rigor and completeness of reporting. Due to the small number of papers included however, this review did not exclude pa- pers based on quality appraisal. Journal space constraints and different reporting conventions in various disciplines may explain some of this heterogeneity, as the higher quality of studies included were often dissertations. There was also heterogeneity observed in the theoret-
ical underpinnings of the interventions/approaches de- scribed in the studies, with many studies basing their research on shared leadership, collaborative/team-based leadership models, using multiple approaches or using terms interchangeably. Despite this, it was evident that
most of the studies included demonstrated moderate to good success in delivering on the aims of developing col- lectivistic leadership in healthcare settings. Nearly all studies reported positive outcomes in terms of leader- ship, engagement, team or organisation performance and specific team-relevant outcomes.
Intervention content Team development activities and team training may be required to enable and enhance collectivistic leadership [1], particularly as shared mental models, working to- wards common goals and role clarity are components of both effective team working and collectivistic leadership approaches. Several studies included components which would be typical of team building and team development programmes [60]. These included interventions related to the development of shared understanding, goal set- ting, role clarity, communication and recognising com- petencies among team members [37, 41, 44, 47–49, 56] and interventions which aimed to explicitly value the contribution of others on the team [50, 55]. Many inter- ventions included an aspect of co-design or co-development, whereby team members were given the responsibility to help re-design their service, co-develop their own goals and team charter, or inform the content/ direction of the intervention [42, 44, 47]. This was re- ported to enhance engagement and give ownership to staff, effectively enabling them to take control of, and re- sponsibility for, the intervention. One crucial feature of many of these interventions was
the provision of time and space for teams to physically come together and have dedicated time to reflect on how they do their work and what they are working to- wards, thus enabling their improved functioning as teams [47, 48]. Increasingly, healthcare is delivered by multidisciplinary teams, with high interdependency be- tween team members and need for co-operation and ef- fective team working to ensure patient safety [61]. Yet, rarely do healthcare teams receive training as a team. As noted by Miller et al., this protected time for team devel- opment “was a new experience” for the teams ([48]: 36). Whilst this time to come together as a team may seem a rudimentary or obvious requirement, the reality within which many healthcare teams operate, and the increas- ing pressures on healthcare services, means that this time is no longer available, and it is considered a low priority for teams to develop elementary team working competencies. However, these basic team working competencies may
be critical to the development of collectivistic leadership in teams. Research by Carson et al. [9] demonstrated that fostering a positive ‘internal team environment’ (that is shared purpose, social support, voice and team trust) had a direct relationship with the emergence of
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shared leadership in teams and therefore was suggested as an antecedent condition for shared leadership. This is echoed by Yammarino et al. who contend that having these effective team-working competencies in place “should help foster climates where collectivistic leader- ship may be enacted successfully” ([1]: 399). Given that collectivistic leadership is a relational process where in- fluence and leadership are shared, building interpersonal relationships and shared mental models across the team appears to be an important step to developing collective ways of working in practice.
Intervention outcomes As noted previously, all studies included in this re- view reported positive outcomes and there was some commonality in the type of outcomes reported. In several studies, the decentralisation of power to en- able collaborative decision-making and problem solv- ing was associated with increased staff engagement, satisfaction and empowerment [41, 42, 44, 47, 50, 51] and reduced turnover [40]. The shared nature of problem solving and collaborative decision-making were viewed positively by participants in many studies [38, 42, 54, 56], and although described as difficult, the benefits were perceived to outweigh the chal- lenges [54]. Improved communication between team members
was a key outcome in several studies, with enhanced communication described both as an enabler of shared leadership [54, 55] and a by-product of the intervention or model [46, 47, 50, 56]. As a result of the interven- tions implemented, many observed improvements in role and goal clarity and a shared understanding of the work of the team [46, 47, 54]. The effect of working to- gether through the interventions helped to foster mu- tual respect, trust and support among team members, building cohesion and solidarity [47, 50, 56]. Efforts to explicitly value and recognise the contribution of others resulted in team members feeling valued and feeling their contributions would be welcome and acknowl- edged [50, 55]. It was reported that individuals felt more self-confident in contributing to the work of the team, in adopting leadership roles and in voicing opin- ions [48, 51, 53]. There is some evidence from this review that different
configurations of collectivistic leadership may be more or less appropriate for various teams. Whilst it was clear many of the interventions demonstrated success in foster- ing distributed approaches to leadership, these interven- tions did not always work for every team in the same way [38, 48, 52]. Yammarino et al. [1] suggest that using ‘col- lectivistic’ leadership as a broad lens through which inter- ventions are evaluated may be more appropriate than one (relatively) narrowly defined theoretical approach.
Methodological rigour In several studies included in this review, there was poor reporting of intervention content, little detail on analytical procedures, lack of consideration of potential confounding variables, and gaps evident in the reporting of results. Some studies only collected data post-intervention, result- ing in a lack of comparison data and limiting the conclu- sions that may be drawn. One key concern from the studies in this review is that frequently there was no at- tempt made to evaluate whether the leadership interven- tion had been successful in the enactment of collectivistic leadership behaviours. Whilst this was captured or specif- ically sought in some qualitative and mixed methods stud- ies [48, 50–52], only two quantitative studies measured this [41, 57]. Thus, less than half of included studies assessed the enactment of the desired behaviours post-intervention. Additionally, where there was quantita- tive measurement undertaken pre- and post-intervention, these studies used bespoke survey instruments to evaluate the intervention, minimising the opportunity for replica- tion and limiting comparability with similar studies [41, 57]. While we acknowledge there is no established valid and reliable instrument that has been well-tested for the purpose of assessing collectivistic approaches to leadership [1, 59], a number of scales have been developed and psy- chometrically tested and/or have been used in multiple studies [11, 18, 62]. Moving forward, this must be a prior- ity to enable comparability and relative efficacy of inter- ventions aimed at developing collectivistic leadership. Finally, there was little evidence of the use of a systems
lens to fully if or how the intervention may have had a broader impact on the system or other parts of the or- ganisation. Measurement of outcomes was, often, nar- rowly focused on the team or the specific outcomes of interest and little consideration given to the potential for unintended consequences of interventions.
Strengths and limitations A key strength of this review is that it addresses a gap in knowledge and has collated the studies conducted to de- velop collectivistic approaches to leadership in health- care settings. The review used both academic and grey literature databases, as well as literature identified by ex- perts, to ensure insofar as possible that publication bias was minimised and that a wide range of studies were considered for inclusion against the eligibility criteria. However, one challenge with this topic is the multitude of terms used to capture collectivistic approaches to leadership and the fragmented and disparate nature of these bodies of literature. However, we hope to have lim- ited the impact of this by looking to previous systematic reviews conducted on collectivistic approaches to leader- ship from other sectors to help inform the search strat- egy [14, 16].
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Whilst most studies reported positive outcomes in terms of the effect of collectivistic approaches to leader- ship, an additional limitation of this review is our inabil- ity to draw strong causal inferences, based on the relatively small number of studies, heterogeneous nature of the studies, inconsistencies in measurement, and the lack of consideration of confounding variables.
Recommendations For implementation and practice There have been calls for the ‘modernisation’ of health- care, and for more emphasis on training and develop- mental programmes that facilitate the sharing of leadership and influence among all members of a team [6, 8]. Although tentative, findings from two studies sug- gest that nurses tend to be more supportive of collectiv- istic approaches to leadership compared to physicians [57]. This may be due to differences in how these profes- sional groups are trained or how they typically work. Given their influence within the traditional medical hier- archy, several researchers emphasise the necessity of physician engagement in interventions of this nature [47, 53, 55]. Furthermore, studies in this review state that a lack of organisational resources, support, or com- mitment to collectivistic leadership interventions is a risk to the success of implementation and to sustainabil- ity [52, 55]. Thus, it appears for collectivistic approaches to be successful, there is a need to work through and within the relevant hierarchies to first garner support for implementation. Healthcare organisations are typically very hierarchical organisations and operate within trad- itional ‘command and control’ models of leadership [19]. Therefore, as suggested by O’Toole et al., the notion of shared leadership may initially be “simply counter intui- tive” to some ([63]:249) and this lack of familiarity with the concept may help explain some of the scepticism and reluctance to adopt shared models of leadership. Legal issues around accountability may also present challenges, especially to clinical leaders. However, from the studies included, interventions aimed at developing the practice can be effective and can enhance team and organisation performance, once the intervention has or- ganisational support and buy-in from senior manage- ment and clinical leaders.
Recommendations for research Several of the authors in this review call for better prac- tices to ensure greater rigor in research of this nature. Recommendations include multidimensional longitu- dinal designs to ensure measurement at multiple time points to understand impact over time [56], more ob- jective measures of staff engagement, trust and account- ability [52], and for research to seek to compare the efficacy of various collectivistic leadership development
programmes [51]. Future research must also ensure there is assessment of interventions in terms of the im- pact on the enactment of collectivistic leadership behav- iours and on the healthcare quality and safety. This basic check of intervention validity must be conducted to evaluate if the intervention has been successful in its aims. To realise this, there is a need to address the gap around measurement and working towards common use of a well-tested and psychometrically valid instrument, potentially based on promising initial efforts [17, 18, 64, 65]. Furthermore, the potential unintended conse- quences of interventions must be considered during evaluation to understand if there may be an impact on other parts of the system. Surprisingly, none of the studies included in this re-
view employed social network analysis methods in evalu- ating the impact of interventions. This approach is one that has been advocated and used widely in studies of shared leadership in other settings [14, 59, 66, 67]. Employing the approach in healthcare would offer a use- ful means of understanding how patterns of leadership and influence may evolve as a result of interventions with teams. Whilst there is considerable value in establishing
commonalities in interventions of this nature, there is also need to consider the balance between the need to compare different collectivistic leadership interven- tions across different samples and the need to tailor interventions to teams or organisations based on local demands [48, 50]. This will be an important exercise for researchers during implementation in terms of how interventions may be adapted and which ele- ments should be deemed ‘core’ intervention compo- nents [68]. It is important to note that empirical research in
collectivistic leadership has emerged from various dis- ciplines and this likely accounts for the heterogenous nature of studies in this review. Given that the empir- ical work in this field is in its infancy, contributions from diverse disciplines enables a breadth and rich- ness of perspectives and approaches as the theoretical work in the field is still developing. Most of the inter- ventions captured in this review can best be described as complex interventions aimed at changing processes and practices to enhance and support collectivistic leadership with these interventions being implemented in complex adaptive health systems [69]. The range of intervention types and methods, on the one hand pose challenges for synthesis and generation of defini- tive conclusive statements, but on the other hand provide rich insights into how healthcare professionals can and do adopt collectivistic approaches and the many benefits that ensure from this way of working. This review has found little evidence of empirical
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testing of collective leadership but given that this is an emerging area of scientific inquiry, this is not sur- prising. In order to advance our understanding of col- lective leadership it may be necessary to take a broader lens to understanding how teams work as a collective to make things happen, i.e., developing an understanding of the team and collective within com- plex interventions aimed at the team level. The stud- ies that are included in this review make an important contribution to this understanding. How- ever, as the field of study of collectivistic approaches to leadership matures, the advancement of knowledge and the ability to draw strong conclusions from em- pirical research will require that researchers reach some consensus on definitions and methods to allow comparability and replicability of studies. We there- fore urge researchers in this field to engage in discus- sion and debate towards informing standardisation of measurement and assessment approaches, adoption of a common framework for complex intervention de- sign and evaluation [70, 71], and the development of some consensus as to the optimal approach or im- portant core intervention components to advance knowledge on how to successfully implement collect- ivistic approaches to leadership in healthcare settings. While there is a considerable body of evidence for
traditional approaches to leadership, this is not yet the case for non-hierarchical approaches. The shift from one focal leader to collectivistic approaches to leadership will require both a shift in the way individ- uals and teams are trained and in how performance is evaluated. Beirne [8] suggests that established ap- proaches to leadership development could be refor- mulated to encourage collective processes that enable a more inclusive and collaborative style and facilitate both formal and informal sharing of leadership. This approach may offer greater opportunities to contrast and compare results with traditional leadership devel- opment programmes and their outcomes for teams, but it also runs the risk of continuation of the trad- itional model of leadership development with the focus remaining on the individual leader. Raelin [72; 4] contends that that if we are to enhance collective leadership in practice, “the entire face of leadership development needs to change” and a different learn- ing model would be required, one characterised by collective and on-going reflection and dialogue. It is also recommended that such interventions should take place in individuals’ work environments [72] to maximise relevance and transferability of learning.
Conclusions This systematic review has detailed the intervention content, theoretical underpinning and outcomes of
interventions to develop collectivistic approaches to leadership in healthcare settings. It has highlighted the heterogeneity of studies in terms of design, evalu- ation approach, quality and rigor. Nonetheless, most interventions aimed at introducing collective ap- proaches to leadership demonstrated success with benefits observed in terms of staff engagement, staff satisfaction, and team performance. Whilst this offers a valuable starting point in understanding progress towards the development of interventions to develop collectivistic leadership, there is a need for further re- search and greater consistency in terms of interven- tion content and measurement to effectively compare various approaches and draw meaningful conclusions.
Additional file
Additional file 1: Search engine search strings. Contains the full searches used in each search engine. (DOCX 22 kb)
Abbreviations CASP: Critical Appraisal Skills Programme; PROSPERO: Database for protocol details for systematic reviews relevant to health and social care, welfare, public health, education, crime, justice, and international development, where there is a health-related outcome; UK: United Kingdom; US: United States
Acknowledgements This research is funded by the Irish Health Research Board, grant reference number RL-2015-1588. This research is also supported by the Health Service Executive.
Funding This research 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 funding bodies had no role in the design of the study, data collection, analysis, interpretation of data or in drafting of the manuscript.
Availability of data and materials Data used in this study is available through the journal articles cited herein.
Authors’ contributions ADB, ROD and EMA designed the search strategy. ADB and ROD retrieved and screened titles and abstracts against inclusion criteria and EMA resolved disagreements. ADB and ROD extracted data, conducted the analysis, and drafted the paper. All contributed to and approved the final version of the manuscript.
Ethics approval and consent to participate Not applicable.
Consent for publication Not applicable.
Competing interests The authors declare that they have no competing interests.
Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
De Brún et al. BMC Health Services Research (2019) 19:72 Page 20 of 22
Received: 26 January 2018 Accepted: 7 January 2019
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- Abstract
- Background
- Methods
- Results
- Conclusions
- Background
- Methods
- Systematic reviewing
- Search and section strategy
- Inclusion/exclusion criteria
- Study screening and data extraction
- Quality appraisal
- Data synthesis
- Results
- Search results
- Overview of included studies
- Quality assessment
- Theoretical underpinnings
- Intervention evaluation
- Narrative review
- Co-design interventions
- Co-leadership interventions
- Service improvement interventions
- Team training interventions
- Individual team development interventions
- Overview of drivers of intervention success across studies
- Discussion
- Intervention content
- Intervention outcomes
- Methodological rigour
- Strengths and limitations
- Recommendations
- For implementation and practice
- Recommendations for research
- Conclusions
- Additional file
- Abbreviations
- Acknowledgements
- Funding
- Availability of data and materials
- Authors’ contributions
- Ethics approval and consent to participate
- Consent for publication
- Competing interests
- Publisher’s Note
- References
