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The journey of leadership learning in healthcare

Insight Article - September 23, 2021

Leadership Development

Marcella M. Pyke RDH, MHS, FACMPE
Editor’s note: This article is adapted from a larger work. Click below for the full work and supporting data tables.

Download the full work (PDF)

Healthcare continues to face more difficult demands and magnified challenges each year. With the increasing pressure from internal and external sources, leadership significantly contributes to the success of an organization. The recent COVID-19 pandemic demonstrates how healthcare is an all-encompassing industry.

Each region of the world was affected by the pandemic. While the research, medical implications and treatment of the pandemic were viewed as a public health event, each community was required to immediately tackle this devastating healthcare matter. COVID-19 caused a dramatic shift in the focus of healthcare and increased the demands on healthcare workers.1 It was imperative for healthcare leadership to tackle this disaster in an effective and competent manner. Regardless of the setting, executive leadership is relied on for guidance through any dilemma. The COVID-19 pandemic highlighted the need for well-trained and prepared leaders within the healthcare delivery system.

The effective assessment, decision-making and delivery of appropriate care is crucial. Operative leadership is required for this to be achieved; however, the level of leadership knowledge and skills is not consistent among healthcare practices or institutions. In the past, healthcare professionals required leadership training through a graduate degree program (such as an MBA or MHA), which were considered sufficient for their combined managerial and administrative skills content.2 More recently, however, the awareness for the fundamental need of leadership in healthcare and the importance of formal leadership education has increased significantly. Today’s leaders must possess the commitment to acquire and maintain the skills necessary to be valuable to their organization.

Since healthcare leadership entails such a dynamic responsibility, individuals with varying backgrounds and education enter the field to serve in these key positions. While the general topic of leadership is prevalent, reports focusing on comprehensive healthcare leadership programs are still insufficient,3 with notable fluctuations in program design, curriculum content and competencies. This presents a problem within the healthcare industry as there are few professional standards for leadership education for executives in the field.

Due to the lack of formal leadership education requirements, medical groups do not have a benchmark to determine the knowledge or skill set of their executive team members. It is difficult to measure the impact of leadership programs as content varies and is rarely based on a specific leadership competency model.4

It is difficult to evaluate the performance prerequisites of top-level executives. There is considerable work published around formal leadership education but very little that demonstrates the effectiveness of formal leadership education in healthcare.5 All provider structures, whether a small physician office or a multi-state healthcare system, depend on the quality of their leadership team. Based on this identified gap, the research question becomes: “Within healthcare organizations, how can leadership education influence the leaders’ effectiveness?” This review presents variables that relate to leadership education and the constructive impact leaders have on their institutions.

Directing employees and institutions through the ever-changing healthcare landscape requires talent, experience and vision. “Leaders who believe that they can do it without any formal training often succeed for some time but eventually encounter critical situations that they are not prepared to handle alone,” as noted by Roberta E. Sonnino, MD, FACS, FAAP.6 All levels of leadership should be equipped with the knowledge and skill set to facilitate their organization to meet their mission, reach their goals and excel through demanding circumstances.

Conceptual framework

In conjunction to the need for executives to obtain formal and ongoing leadership development for their personal growth, it is crucial for individual training to be impactful to others and benefit the organization. Healthcare organizations need to be “learning organizations” to keep up with the rapid changes occurring at all levels and in all areas of the organization’s processes.7 This transfer of leadership knowledge and experience is a process intended to enhance the abilities of others and enrich global performance. The Organizational Learning Theory (Figure 1) illustrates this concept.8 While on faculty at Harvard University, Chris Argyris collaborated with Professor Donald Schon of Massachusetts Institute of Technology to postulate a theory on learning as the detection and correction of error with the research shifting from individual to group, which eventually expanded to include organizational learning.9



Organizational learning is key for the transfer and sharing of information and actions within complex structures. As Ratnaplalan and Uleryk note, “[o]rganizational learning in healthcare is not a onetime intervention, but a continuing organizational phenomenon that occurs through formal and informal, which has reciprocal association with organizational change and improved performance.”10 Organizational learning describes the process by which an organization improves over time through gaining experience and using that experience to create knowledge. Through observation of behaviors and outcomes, the knowledge continues to be transferred within the organization and creates a “learning continuum.”11

 As shown in Figure 1, the Organizational Learning Theory represents a framework that illustrates process/principles (leadership training) intended to produce desired results. The consequences of the leader’s behaviors are monitored and determined to be effective. If necessary, a series of corrective actions may be required to achieve the desired organizational outcome.12 This refers to the double-loop learning that may be experienced when single-loop learning is ineffective in an extremely complicated situation or task.

Executives can provide continuous leadership education to others that triggers a loop process that can become self-sustaining for the entire organization. Through ongoing behavior modification of leadership action and monitoring outcomes, top executives can have a positive impact on the organization. What begins as leadership education at the individual executive level inflates to an umbrella effect over groups and teams. This pervasiveness can eventually contribute to the overall performance of the organization.

Systemic review

A qualitative systemic review of literature used Boolean operators and quotations for two search strings:
  • (“leadership training” or “leadership development”) AND (“competencies” or “skills”) AND healthcare
  • (“leadership education” or “leadership training” or “leadership development”) AND healthcare AND (“effectiveness” or “efficacy” or “effective”)


Table 1 provides the inclusion and exclusion criteria for studies published in a scholarly journal in the past five years.

Study selection

Utilizing the University of Maryland Global Campus Library One Source database and Google Scholar, 21 eligible articles were selected after initial identification, duplicate removal and application of inclusion/exclusion criteria.

While leadership development describes the professional growth of an individual leader, the evidence introduced various perspectives on the curriculum of leadership education, the influence on others and the ongoing comprehensive impact of leadership training on an organization. The findings are summarized along with the thematic analysis and practice implications in the following sections.

Results

This qualitative systematic review produced findings that address leadership education, the impact of leadership training, and its effectiveness in healthcare organizations. The results were compiled into four categories. Each topic is presented below along with relevant supportive studies.

Gaps in leadership education

The review of the studies highlights gaps in leadership education and design of training programs. There is a lack of preparation and formal training for leadership roles among clinicians.13 This is also substantiated by interviews conducted by Abraham, et al., (2021) that reveal healthcare leaders recognize the voids and differences in formal training as significant barriers to effective healthcare leadership.14 These findings show that comprehensive leadership education is being sought by healthcare executive. There is a recurrent demand for leaders to be better equipped to handle uncertainty and issues that they have not yet experienced.

Leadership fosters relationships

Leadership training for executives is beneficial for organizations because it can substantially improve the ability to lead effectively, as a passionate leader identity motivates individuals to form high-quality relationships linked to leader effectiveness.15 Having positive relationships throughout the organization stimulates open communication that creates a sense of shared vision. This relationship impacts the supervisory and middle management level who can significantly affect the efficiency of hospital operations and the quality of patient care.16 

Organizational leadership learning                             

These leadership skills and values permeate an organization. Educational leadership knowledge can contribute to team effectiveness.17 While leader identity can evolve for an individual to gain confidence and expertise through leadership training, engaging team-based leadership development can benefit the organization.18 Having the interpersonal skills at various levels helps the staff to be more confident and effective at overcoming the difficulties and unanticipated issues they encounter in their daily practice. These relationship-building attributes are valuable to possess when a problem needs to be resolved.19

Leadership development continuum                                                                                         

Those in leadership roles have a responsibility to foster a climate that adapts to the ever-changing healthcare environment. A leader is in the position to influence employees who are affected by leadership behavior, which promotes leadership practices and the operation of knowledge management through the organizational culture.20 However, leaders at all levels influence the organization’s integration of learning within a complex organization.21 The findings from these studies reveal that there are various factors associated with leadership education acquired by leaders and its overall impact on an organization.  

Thematic synthesis 

While there is sufficient research pertaining to leadership development, the volume of research related to the effectiveness of leadership education among healthcare executives is not as prevalent. There is considerable work published around formal leadership education but very little that demonstrates the effectiveness of formal leadership education in healthcare.22 It is difficult to measure the impact of leadership programs as the content is variable and rarely based on a specific leadership competency model.23 It would be beneficial for organizations to be more informed as to the knowledge and skill set that their leadership team should possess. While graduate degree programs offer extensive subject content, they are not standardized in their leadership curriculum. 
                                                                                                                                          
The design of leadership programs varies significantly among academic institutions. Establishing common, evidence-based, required leadership curriculum across teaching institutions would fill an educational need. The traditional MBA curriculum presents a spectrum of courses that address the business aspects of an operational entity. An academic institution is limited to introducing students to real-world experience and potentially produce graduates who are ill-prepared for working in an atmosphere influenced by politics, public policy, legalities, regulation and community relations, which are all components of the healthcare environment.24 Instead of focusing on generic scholarly learning, academic institutions could redesign curricula to embrace a more practice-based method. The approach to healthcare education could incorporate expanded modalities to include coaching, mentoring, internships, administrative residencies, networking and other hands-on techniques to nurture the practice-based nature of leadership.

Medical groups question if leadership courses at a university level can fill the gap between theory and application. Research conducted by Middleton, et al. (2020), demonstrates the importance of learning leadership skills through formal postgraduate education, which can then be translated into practice within the workforce — these academic programs provide the supportive foundation for participants to “learn to lead,” which converts knowledge into practice.25 The leadership wisdom and teachings learned by the participant should be shared with others within the organization. This process can be achieved through direct training and indirect role modeling of leadership behavior.

While leadership training is obtained by an individual, benefit extends to others and the organization. Leadership within the healthcare arena serves to inspire, motivate and connect diverse stakeholders and organizations with the aim of achieving a shared vision.26 Through model behavior a leader can generate a broader scope of value from their leadership training. This is the mechanism on how leadership learning can be instilled at all levels of healthcare organizations.

While it is productive for leadership development to be imparted as personal growth among staff members, it is also essential for top executives to continue their journey of leadership development. Following the philosophy that effective leadership constitutes “lifelong learning” promotes the positive perspective of organizational learning. When behaviors are modified as a result of leadership training, communication is improved, which encourages a more supportive culture with the distributed leadership.27

Practice implications

Leadership education content should be appropriate for the target audience and level of participant. Academic institutions incorporating a blended design to combine traditional classroom learning and resourceful experience opportunities would provide a more practical education for less-experienced students. Similar to a variety of complex decisions and difficult issues that healthcare leaders manage each day, teaching institutions must adjust their teaching structures to meet the dynamic and vigorous needs of leaders and close the gap between classroom and practice. Leadership programs should be modified to be more applicable to the different levels of individuals within an organization. Senior leadership should remain motivated to continue their personal learning continuum, as it has a larger impact on the organization than solely their own professional development. Healthcare organizations that offer a strategic leadership curriculum kindle a community culture that sustains shared goals to improve the overall performance of the institution.

Conclusion

Leadership, development of effective leaders and leadership behavior are prominent concerns in every organization.28 The focus is not on which leadership theory or model is applied, but like other industries, healthcare is more interested in how to develop leaders and leadership as effectively and efficiently as possible.29 Closing the gap of effective leadership education could improve the retention of skilled and knowledgeable healthcare leaders, reduce the costs associated with training, and lead to improvements in healthcare delivery — which is the priority of any medical practice, hospital or health system.30

Ongoing leadership development of the senior executive team serves as an example to others, as well as a relationship-builder that produces a communicative culture. This organizational learning environment propels others to adopt leadership behavior that can mature and effectively generate positive results for the organization.

What begins as an individual executive’s search for leadership development has the potential to transition into an organizational journey of leadership learning. 

Notes:

1. Shingler-Nace A. “COVID-19: When Leadership Calls.” Nurse Leader. 2020;18(3):202-203. doi:10.1016/j.mnl.2020.03.017.
2. Sonnino R. “Health care leadership development and training: progress and pitfalls.” Journal of Healthcare Leadership. 2016;8:19-29. doi.org/10.2147/JHL.S68068.
3. Ibid.
4. Lucas R, Goldman EF, Scott AR, Dandar V. “Leadership development programs at academic health centers: Results of a national survey.” Academic Medicine, 93(2), 229-236. doi.org/10.1097/ACM.0000000000001813.
5. Middleton R, Jones K, Martin M. “The impact and translation of postgraduate leadership education on practice in healthcare.” Collegian, 18(1), 89-96. doi.org/10.1016/j.colegn.2020.01.002.
6. Sonnino.
7. Herd AM, Adams-Pope BL, Bowers A, Sims B. “Finding what works: Leadership competencies for the changing healthcare environment.” Journal of Leadership Education, 15(4), 217-233. doi.org/10.12806/V15/I4/C2.
8. O’Connor N, Kotz B. “Learning organizations: A clinician’s primer.” Leadership and Management in Australian Psychiatry, 16(3), 173-178. doi.org/10.1080/10398560801888639.
9. Crossan M. “Altering theories of learning and action: An interview with Chris Argyris.” Academy of Management Executive, 17(2), 40-46. doi.org/10.5465/ame.2003.10025189.
10. Ratnapalan S, Uleryk E. “Organizational learning in health care organizations.” Systems, 2, 24-33. doi.org:10390.systems2010024.
11. Sonnino.
12. O’Connor, Kotz.
13. Spehar I, Sjovik H, Karevoid KI, Rosvold EO, Frich J. “General practitioners’ views on leadership roles and challenges in primary health care: a qualitative study.” Scandinavian Journal of Primary Health Care, 35(1), 105-110. doi.org/10.1080/02813432.2017.1288819.
14. Abraham TH, Stewart GL, Solimeo SL. “The importance of soft skills development in a hard data world: Learning from interviews with healthcare leaders.” BMS Medical Education, 21(147), 1-7. doi.org:10.1186/s12909-021-02567-1.
15. Kragt D, Guenter H. “Why and when leadership training predicts effectiveness.” Leadership & Organization Development Journal, 39(3), 406-418. doi.org/10.1108/LODJ-11-2016-0298.
16. Choi EH, Kim EK, Kim PB, “Effects of the educational leadership of nursing unit managers on team effectiveness: Mediating effects of organizational communication.” An Asian Nursing Research, 12, 99-105. doi.org/10.1016/j.anr.2018.03.001.
17. Ibid.
18. Ayeleke RO, North NH, Dunham A, Wallis KA. “Impact of training and professional development on health management and leadership competence.” Journal of Health Organization and Management, 33(4), 354-379. doi.org:10.1108/JHOM-11-2018-0338.
19. Graham RNJ, Woodhead T. “Leadership for continuous improvement in healthcare during the time of COVID-19.” Clinical Radiology, 76, 67-72. doi.org/10.1016/j.crad.2020.08.008.
20. Tang H. “Effects of leadership behavior on knowledge management and organization innovation in medicine and health sciences.” EURASIA Journal of Mathematics Science and Technology Education, 13(8), 5425-5433. doi org/10.12973/eurasia.2017.00840a.
21. Berson Y, Nemanich LA, Waldman DA, Galvin BM, Keller RT. “Leadership and organizational learning: A multiple levels perspective.” The Leadership Quarterly, (17), 577-594. doi.org:10.1016/j.leaqua.2006.10.003.
22. Middleton, et al.
23. Lucas, et al.
24. Edmonstone JD. “Escaping the healthcare leadership cul-de-sac.” Leadership in Health Services, 30(1), 76-91. doi.org.10.1108/LHS-02-2016-0012.
25. Middleton, et al.
26. Car LT, Kyaw BM, Atun R. “The role of eLearning in health management and leadership capacity building in health system: A systematic review.” Human Resources for Health, 16(44), 1-9. doi.org/10.1186/s12960-018-0305-9.
27. LeComte LL, McClelland B. “An evaluation of a leadership development coaching and mentoring programme.” Leadership in Health Services, 30(3), 309-329. doi.10.1108-LHS-07-2016-0030.
28. Day DV, Fleenore JW, Atwater LE, Sturm RE, McKee RA. “Advances in leader and leadership development: A review of 25 years of research and theory.” The Leadership Quarterly, 25, 63-82. doi.org.10.1016/j.leaqua.2013.00.004.
29. Ibid.
30. Abraham, et al.

About the Author

Marcella M. Pyke RDH, MHS, FACMPE
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