Advancing leadership in surgery: a realist review of interventions and strategies to promote evidence-based leadership in healthcare

Investment in leadership development in healthcare is substantial. Reports indicate an estimated annual spend on leadership development in the USA at $50 billion (USD) [1, 2]. In 2019, the National Health Service (NHS) in England invested £2 million to help boost leadership development [3] and made individual leadership and capability development fundamental to delivery of the NHS Long-Term Plan [4]. Over the last three decades, we have seen a growing trend in health systems around the world placing great emphasis and resource on improving ‘clinical leadership’ [5]. Traditionally, clinical leadership encompassed leadership delivered by doctors and nurses [6]. More recently, clinical leadership has expanded to comprise anyone trained to deliver frontline care [6].

In the context of surgery, the surgical profession has increasingly recognised the need for high quality leadership both in and outside of the operating theatre [7, 8]. For example, the Royal College of Surgeons of England recommend that consultant surgeons have the responsibility to develop an effective team through leadership and teambuilding [7]. The necessity for surgeons and surgical teams to lead, inspire, and manage a team to meet the needs of patients, however, is not a substantial, or evidence-based component of the surgical curriculum.

In the UK, the Department for Health and Social Care (DHSC) recently called for more inclusive leadership in the healthcare professions, which aims to adopt a collaborative approach to leadership practice [9]. However, evidence for endorsing this approach was lacking. It was not clear how inclusive collaborative leadership could or should be achieved in practice. Within healthcare literature, the focus tends towards leadership development which advances the leadership skills of individuals–not collective teams [10]. This skills-based approach, promoted by Mumford and colleagues (2007), categorises leadership into types of skills, for example, cognitive, interpersonal, business, and strategic skills [10]. NHS England, alternatively, describe leadership development as confidence building, understanding practical levers, widening perspectives, and talent management [6]. Whilst these are more generic terms, they are still person centric. Nonetheless, these individualist approaches target the ability and motivation of surgeons to improve their own leadership. Little attention is given to the multidisciplinary teams, organisation, and environmental contexts in which leadership plays out in. Skills-based leadership, therefore, fails to account for the contextual opportunities which enable leadership to be enacted in the inherently social conditions of the healthcare sector.

In contrast, Ability, Motivation, and Opportunity (AMO) theory describes how the interplay between ability, motivation, and opportunity (of a person, a team, or a department) to enact leadership, gives us a measure of an leadership performance and performance-related outcomes [11]. This enables us to embrace leadership as a distributed and collective process [12]. In the distributed leadership literature, leadership becomes a shared process across a collective group, where people have common organisational perspectives, goals, and shared actions [12]. Framing leadership in this way allows us to move away from traditional heroic leadership tropes, to recognise the contribution that groups of people, such as a surgical team, make to leadership processes and practices [13].

Despite the significant investment in healthcare leadership development, and the numerous systematic reviews which have been conducted to determine the effectiveness of specific leadership interventions (such as team-training and co-leadership) [14‐19], there is no agreement on what surgical leadership is, what leadership capabilities are, or how we can ensure they are developed and implemented effectively. Most important for the healthcare sector is that leadership development is viewed as a workforce intervention, and if funded by public money, should be underpinned by a rigorous evidence-base. Therefore, it is vital that workforce interventions, aimed to improve leadership processes, are appropriate and able to achieve effective outcomes. Not only to justify the significant expenditure, but to ensure that advanced leadership can improve the quality of patient care. This is a challenge in many areas of healthcare delivery, including surgery [20].

We aimed to fill this gap by conducting a realist review of interventions and strategies to promote evidence-based leadership in healthcare. The goal of our review, is to develop a programme theory to answer the following question: In which context and for whom, can interventions and strategies improve the leadership of surgical trainees, surgeons, and surgical teams and why?

Thirty-three articles were included in our review [32‐64] (see Fig. 1). An overview of the characteristics of included studies is provided in Table 3. Studies included in our realist review were judged on their rigour, i.e. whether we considered the reported method used to generate the piece of data credible and/or trustworthy [21]. The overall quality of included studies varied: 21 studies were rated as high, eight studies as medium and four as low quality (see Table 3).

Realist review methods were used to review the literature describing interventions and strategies which aim to promote evidence-based leadership in healthcare. We aimed to generate a programme theory to explain in which context and for whom surgical leadership interventions work and why. Thirty-three studies and seven stakeholders contributed towards the development of our programme theory which consists of 19 CMOCs. Our findings suggest that surgical leadership interventions improve leadership when feedback is delivered in a timely manner, on multiple occasions and by a range of trusted and respected people. With regard to negative or more developmental feedback, we identified that it is best provided privately. Feedback from seniors to juniors or peers should be delivered directly, whereas feedback from juniors to seniors should be provided anonymously.

While numerous systematic reviews have described the effectiveness of individual leadership interventions in healthcare settings [14‐18, 65], we are only aware of one realist review which aimed to understand and explore context and mechanisms; however, this included all medical and surgical specialties [15]. De Brún’s and Auliffe’s review found that training in teams is important for leadership intervention success, suggesting that [it engenders] “the development of a shared understanding and appreciation of skills of others” [15]. A mechanism we further conceptualise narrowly as trust, rapport, friendship, and mutual respect which we also found enables leadership to flourish. De Brún described “open and inclusive communication,” as important [15]. We identified this as a speak-up culture. However, our analysis and consultation with stakeholders suggest that this speak-up culture triggers “feeling equally valued and a sense of engagement” which creates an opportunity for effective leadership to develop [15].

As we anticipated, most of the leadership interventions identified in our review targeted the leadership development of individual surgeons. Many studies in our review report surgeons learning leadership skills through standalone interventions, for example in the studies by Pradarelli et al. and Ramjeeawon et al., but there was very little evidence to describe how and whether this skill-based approach to learning extends into clinical practice [57, 58]. Training surgeons in leadership will only get us so far in making improvements. It is comparable to learning surgery using a textbook, but not letting surgical trainees into the operating theatre to practice and hone their skills in real environments, interacting with team members seniors and patients.

This individualised focus reflects the proliferation of clinical leadership programmes and courses targeted at medical professionals across the globe [3‐6]. For example, many papers describe leadership development via nontechnical skills training. These high profile 1-day courses aim to optimise and enhance the performance of individual surgeons [29], yet the evidence for their effectiveness is limited to attendees or peers self-reports of changes in leadership skills [44, 57]. For example, authors asked surgeons ‘do you believe you are a better leader’ and surgeons often replied positively. This provides little sense of the surgeons’ actual capacity and capacity to enact effective leadership. Where leadership improvement was measured objectively, evidence of improvement was captured using tools such as 360° feedback reports, or surgery specific scales including the Nontechnical Skills for Surgeons (NOTSS) and Oxford Nontechnical Skills (NOTECHS) assessment or the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) scoring. Most studies included in our review did not have a longitudinal design or include multiple sources of evaluation for example, multi-method case study. Hence, it is not clear what impact or for how long any impact of leadership interventions is sustained, let alone whether it can be scaled.

Some might argue that more rigorous approaches to the measurement and evaluation of leadership interventions are required. Firstly, to overcome the apparent responder bias in the literature and secondly, to move a step closer to determining whether the large investment the healthcare sector makes in developing leaders is delivering a return. Yet, we recognise that studies which have sought to establish links between leadership and performance have long been criticised as circumstantial or an anecdotal [66]. Indeed, the causal link have been characterised as an 'act of faith' rather than an empirically proven fact [67]. In part, this is due to a poor conception of what leadership is, and what leadership is not, in public services such as healthcare [67, 68]. There are also methodological problems, such as compounding variables (increased funding for the NHS during the Blair Labour Government resulted in an improved performance effect in the NHS not necessarily attributable to the influence of leadership), and the effect of time lag between leadership actions and their effect that is difficult to discern [69]. Hence, we might best consider ‘effective’ leadership as that aligning with ideal type skill-based models as set out in literature, such as a transformational variant, but one that encompasses an individualistic and distributed configuration of leadership influence, rather than one that focuses upon a ‘heroic’ individual [70].

Nevertheless, the interventions and strategies shown to be most effective in our review include those which aim to raise awareness of the importance of leadership for surgical practice, those that attract people with established confidence in their technical surgical skills, and interventions aimed at surgeons who have been labelled with leadership deficits. Our findings suggest that perceived openness to leadership development, whether that be because surgeons’ have identified deficits or because their technical surgical skills are becoming more innate, was motivational for leadership development. Therefore, leadership interventions can build abilities and capabilities and give surgeons time to focus on their leadership, and an opportunity to practice leadership in the context of clinical practice.

The timing of leadership interventions in surgical careers seems to be a key aspect to their effectiveness. Traditionally, the literature on the timing for the implementation of innovations and behavioural change interventions has focused on discrete events such as triggers to Acton [71, 72]. However, the concept of timing in our review reflected timing relative to a surgical career trajectory, i.e. when mastery of basic and or advanced technical surgical skills have been achieved in earlier years and surgeons have mental capacity to develop in other areas. Our expert stakeholders confirmed that the demands of surgical training in the early stages means that surgeons and surgical teams often have no capacity for non-technical developments. One surgeon described that when training juniors in theatre, patient safety is a first, and that leadership development is not a priority. This highlights specifically the need to practice leadership development in the context of surgery, not in classrooms. The evidence suggests that interventions delivered at key transition points in surgical careers may be more beneficial to surgeons and teams when they have the capacity to undertake additional learning and development.

We found that for interventions to improve leadership in surgery, they need to be delivered in contexts where there is an intimate learning environment within a speak up culture, provide a variety of interactive learning activities, show a genuine investment in the intervention, and be customised to surgeons’ needs. Therefore, leadership of surgical teams may be best developed by allowing mixed discipline surgical teams to train together, rather than training distinct professional groups in isolation, which was the case in most of the literature we reviewed. This was reinforced by expert stakeholders who emphasised that healthcare leadership is rarely enacted in isolation or in distinct professional groups.

This review represents the first use of realist review methodology to explore how surgical leadership interventions need to be designed to improve the leadership of surgeons, their teams, and trainees. The strengths of the study stem from adopting rigorous methodological guidance for realist reviews as described in the RAMESES quality standards [21] (see Additional file 1). Use of a realist approach has allowed us to place emphasis on how contexts influence outcomes and to focus on identifying generative mechanisms, thereby producing findings that are transferrable across different types of surgical leadership interventions. Whilst we have followed the realist review method and documented the steps that we took to arrive at our programme theory, we are fully aware that (in common with other qualitative research) this method is subjective, iterative, and interpretive, involving many more people than the core review team.

Our study limitations lie in the topic under consideration. The leadership literature is extensive (to crudely illustrate this, there were 330,583 hits for the term ‘leadership’ in MEDLINE at the time of searching). For this reason, we did not include articles which focused on distal outcomes outlined in our initial programme theory (e.g. patient outcomes, or organisational change) [26]. This decision was ratified through discussions with the wider research team and expert stakeholders who concluded that improvements to patient safety may result from advancing leadership but would only ever be considered as indirect evidence.

Our decision to limit distal outcomes was not just a pragmatic choice to prevent being overwhelmed by literature, but a methodological one. The further we extend outcomes, the less confident we can be that the cause can be attributed to the leadership intervention. Organisational and patient level outcomes are likely more affected by a complex set of variables. Hence, our design to limit our study to outcomes that are proximate to the setting in which leadership intervention took place, the surgical unit. Nevertheless, our decision to reduce our focus had consequences for the review as it limited our ability to fully achieve our initial aim, which was to understand how surgical interventions work and generating a strong evidence base to support use of surgical interventions. We may have excluded effective leadership interventions due to their setting, for example interventions delivered at a national scale, such as those programmes offered by the NHS Leadership Academy in the UK [73]. That being said, we recognise that studies which have sought to establish causal links between leadership and performance—whether through improved patient outcomes or organisational change—have been criticised as circumstantial or anecdotal [66]. Having completed the realist review, it would be futile to argue against this narrative. We are in a stronger position to demonstrate the nonlinear relationships between leadership interventions and leadership improvement in surgery. Our programme theory highlights the complexity of the conceptualisations of leadership identified in our review. Our theory is inherently complex and indirect. In developing this work, we have produced evidence which highlights the limitations of expecting to see a causal relationship between the implementation of a leadership intervention—and service improvement; the approach often adopt by the NHS and outlined in the NHS Long Term Plan [4].

In secondary research, the resulting synthesis is only as good as the primary data on which the synthesis is built. Whilst most included studies were of medium and high quality, a major limitation we encountered in our review was that most primary studies included only insight into the impact of surgical leadership interventions on individual leadership in isolation and did not consider the impact on the team or wider department. Because of this limitation in the literature scope, we adopted an individual skills-based framework to summarise the results in Table 4. Whilst this framework facilitates simple presentation of the results, it highlights a wider problem of how narrowly leadership is often conceptualised in surgery. We also found that primary studies often did not provide enough interventional detail to determine fidelity and understand how different aspects of leadership interventions influenced which outcomes and why.

In some cases, our CMOCs had gaps that could not be filled via the literature; most notably, this included a lack of mechanisms evidenced in the literature. This is a not uncommon when conducting realist reviews, and something faced by Price and colleagues in their review of patient safety [28]. They found mechanisms were underdeveloped in the literature. In that research they investigated the processes of meetings and e-mail exchanges to verify and explicate mechanisms with their stakeholder group. A strength of our review is the extent to which we consulted professional and academic experts in this field to review and refine and fill the gaps of our CMOCs.

Ideally, we would have conducted the stakeholder consultations in person as this can help build trust and rapport between participants. However, doing the consultations online was crucial to ensure surgeons could attend and fit the consultations around their work. Further, we would have liked to have consulted a more diverse range of stakeholders, and we acknowledge, for example, that we did not have any female surgeons or early-stage surgical trainees (e.g., training years 1–7) sharing their views. We acknowledge that doing this may have led to changes in the CMOCs. We did invite a range of surgeons and surgical trainees to our stakeholder events, but many declined due to availability.

In healthcare, evidence-based practice reigns. Yet, when it comes to leadership development in surgery, the same approach to building and adopting the evidence-base in practice falters. Investment in leadership development in healthcare is substantial. To see a return on this investment we need to ensure that the interventions we implement in practice to improve the leadership of surgeons and surgical teams are evidence based and theoretically informed.

Our realist review identified 19 CMOCs which are the starting point for this evidence base. We used the CMOCs to develop the first programme theory to explain in which context and for whom leadership interventions in surgery work and why. The programme theory provides evidence-based guidance for those who are conducting research on leadership in surgery or who are planning or designing evidence-based leadership interventions in surgery.