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Abstract Background Clinical leadership competencies for effective teamwork differ between Western cultures, where an independent self-construal prevails, and Japanese society, where the self-construal is rooted in interdependence. Although 27 out of 82 Japanese medical schools have ‘leadership’ as an educational outcome, specific competencies are poorly described, hindering the development of contextually-relevant leadership education. This study aimed to identify clinical leadership competencies and articulate the attributes and skills fundamental to leadership as perceived by Japanese physicians. Methods The 80 items of the UK clinical leadership competency framework (CLCF) formed the stimulus in a modified Delphi. Participants, comprising 26 Japanese physicians, rated the importance of each item using a 5-point Likert scale with free-text comments regarding the modification of competencies and suggestions for new items. Items were eliminated if the Likert mean was less than 4.0 and if fewer than 70% of participants considered them to be important. Newly described or modified items derived from free-text comments were rated for importance in a second round with reflective thematic analysis of the free-text descriptions. Results A CLCF of 84 items, reflective of Japanese clinical leadership, was created by eliminating three items describing tasks rarely involving Japanese physician leaders, revising seven items to emphasize understanding of members, and adding seven items to maximize feelings of team comfort. Seven skills and attributes emerged to construct Japanese clinical leadership from thematic analysis. “Humility” was viewed as a fundamental to leadership. Humility-driven “self-discipline” and “attentive listening”, “supporting members” and “guiding members” with humility-based compassion, were essential elements to create “psychological safety” for freedom of expression. Achieving “unity” through emotional integration was identified as the overall goal of leadership. Conclusions The reorganized CLCF has embedded more member-centered behaviors that build rapport and comfort for the members than the original CLCF. Modeling the Confucian virtue of humility and building unity by acting with compassion toward members are characteristics of Japanese clinical leadership that reflect an interdependent social context. These findings are a step toward the development of leadership education aligned with a Japanese context.

Abstract Background Nursing homes face a critical need for competent healthcare professionals to deliver high-quality care. Focusing on clinical leadership is crucial for equipping healthcare professionals with the skills necessary to manage complex care needs, collaborate effectively within multidisciplinary teams, and improve care quality in nursing homes. Developing clinical leadership fosters professional growth and enhances healthcare professionals’ ability to tackle the challenges unique to the nursing home environment. However, the concept of clinical leadership in nursing homes remains poorly defined and investigated. This study aimed to explore and define influencing factors for the development of clinical leadership within healthcare professionals in nursing homes. Methods A qualitative study was conducted in Flanders, Belgium, using semi-structured focus group interviews (n = 5) with healthcare professionals (n = 41), including nurse assistants, licensed practical nurses, registered nurses, occupational therapists, recreational therapists, psychologists, and gerontologists. Interviews were audio-taped, transcribed, analysed and interpretated by using a thematic analysis based on descriptive phenomenology. Results Clinical leadership development within healthcare professionals’ hinges on four pivotal themes: (1) Cultivating an empowering working environment that fosters open feedback, encourages peer learning, and champions a stimulating learning climate. (2) Nurturing a supportive leadership style in formal leaders that exemplifies role modeling, accessibility, and a coaching approach. (3) Elevating well-developed professional identity through targeted training, experience, and a talent-oriented work approach. (4) Fostering team dynamics marked by commitment, collaboration, support, and trust. Conclusions The study’s findings on the influencing factors for clinical leadership development should be actively applied in nursing homes and guide the creation of targeted training programs and leadership development initiatives. Awareness of these factors are crucial to optimise and to support the development and implementation of clinical leadership in nursing homes in an attempt to reduce the workforce shortages.

Background: Postgraduate leadership education is an evolving field. Locally we have an established ‘Chief Residency’ programme where centres have two to four senior trainees completing leadership duties alongside clinical workload, supported by local directors of medical education. This is twinned with a 4-day central training programme and peer-support network. Methods: To assess perspectives of the CR role, we adopted a qualitative case-study design using an electronic questionnaire delivered to previous chief residents between 2020 and 2023. Results were analysed using thematic analysis. Results: Trainees valued involvement within quality improvement and trainee support, demonstrating successful multi-departmental projects. Leadership education was viewed ubiquitously positively but participants felt further work is needed to address role legitimacy locally. A proposed solution was junior doctor leadership teams to address workload and emotional challenges. Conclusion: This model provides further evidence of the value in investing in trainee leadership positions, demonstrating organisational impact. Future work will research hospital peer leadership teams.

Abstract Aim(s) To conceptualise and identify characteristics of clinical leadership in the nursing home setting. Design A qualitative study using semi‐structured focus group interviews and a thematic analysis. Methods Five semi‐structured focus group interviews were conducted with 41 healthcare professionals from nursing and other healthcare disciplines working in nursing homes (such as nurse assistants, licensed practical nurses, registered nurses (RNs), occupational therapists, recreational therapists, psychologists and gerontologists). Qualitative thematic content analysis of the gathered data was done. Results Clinical leaders in nursing homes can be defined as passionate healthcare professionals providing person‐centred care with strong communication skills. They are clinical experts in their field and motivated to engage in lifelong learning. They are team players with informal leadership skills. They are visionary, committed, resilient and responsive. Awareness of the definition and the main characteristics of clinical leadership is necessary to facilitate the identification, support and development of healthcare professionals. Focussing on the development of competencies, training courses and monitoring and assessment methods is necessary to improve the evidence of clinical leadership in nursing homes.

Abstract Aim To understand the current application and benefits of coaching practice in nursing and identify potential areas for future research. Design An integrative literature review was conducted using Whittemore and Knalf integrative review methods. Data sources A search of the literature from Medline (PubMed) and CINHAL platform for abstracts and/or full‐text articles from 2012 to 2022. Methods A systematic approach was used to screen and analyse the literature. Inclusion and exclusion criteria were applied, a quality appraisal of the literature was undertaken and summarised into themes. Eighteen articles were selected, two articles were different aspects of the same studies. Coaching was found to have benefits to the individual related to performance, role effectiveness, role transitions and confidence in performing in the role. The outcomes for individuals add to the overall organisational benefits with performance, support, teamwork, communication and culture. Results This literature review sought to understand the current use of coaching in nursing and identify any gaps in the application of coaching within the discipline. Supporting, developing staff knowledge and skills and nurturing nursing staff into the profession has occurred in several ways and evolved to include coaching. Coaching provides capabilities to enhance nursing leadership, performance improvement and to provide support to staff. The findings from this literature review found a need to conceptually define coaching in nursing and the opportunity to explore the use of coaching to support both the clinical and managerial workforce (job satisfaction, intention to stay and building resilience). The benefits of coaching in nursing extend beyond the leadership level and there is opportunity to extend the operationalisation of coaching practice and coaching training within the discipline of nursing. This integrative review explains how coaching has been utilised in nursing to be a valuable tool in developing nurse leaders and clinical staff.

Using the balanced scorecard approach, Strategic Management Initiative (SMI) driven Key Performance Indicators (KPIs) have allowed measurable data regarding various clinical, medical, patient and logistic outputs for healthcare leadership to manage an ongoing improvement system in real-time. We underwent a comprehensive search to have 168 articles with the keywords "Balanced Scorecard in healthcare". We applied filters for the last ten years only. We shortlisted 14 studies. The study highlighted various KPIs utilised in different healthcare settings, with most authors favouring BSC methodology as a comprehensive strategy to deal with multi-dimensional hospital processes. The most utilised KPIs included service quality, patient safety, increased healthcare literacy, empowering patients, developing the empathic attitude and social skills in medical staff, professional human resource management and financial management and interests of stakeholders. In short, the BSC strategy is suggested for implementation to improve healthcare-related processes.

Background In this study, we explore how doctors in training perceive mentorship and leadership and whether they believed that mentoring influences the development of leadership skills. The study also addressed whether certain leadership styles lend themselves better to mentoring. Methods A qualitative research method was employed in this study and ethical approval was granted by the Research Ethics Committee (REC) at King Faisal Specialist Hospital and Research Centre (KFSH&RC), after which twelve hospital residents were recruited using purposive sampling. Semi-structured interviews were conducted by the authors and thematic data analysis was performed. Results Three themes emerged and were later refined, using Braun and Clarke’s 2006 thematic analysis method: 1. Purpose of mentorship, with sub themes: a. Expectations, b. Perception of mentorship as supervision, and c. The role of mentorship, including informal mentoring in leadership development 2. Role of mentorship in leadership development. 3. Perceptions of a leader, with sub-themes: a. The leader as a manager, b. The leader as a role model, and c. The merits of different leadership styles. Discussion Most of the residents (doctors in training) viewed mentorship in a positive way. However, when the mentor was perceived more as a supervisor, the usefulness of mentoring was less clear. However, they found that informal mentoring would contribute to leadership skills and would inspire them to become leaders themselves. They were likely to be influenced positively when they saw the leader as a role model, rather than a manager.

Elizabeth A Fradgley,1,2 Kate Booth,1 Christine Paul,1,2 Nicholas Zdenkowski,1 Nicole M Rankin3 1School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia; 2Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, New South Wales, Australia; 3Faculty of Medicine and Health Sciences, University of Sydney, Camperdown, New South Wales, AustraliaCorrespondence: Christine Paul Level 4 West, HMRI Building, Callaghan, New South Wales, 2308, AustraliaTel +61 2 4042 0693Email chris.paul@newcastle.edu.auAim: Multidisciplinary team meetings (MDMs) are a critical element of quality care for people diagnosed with cancer. The MDM Chairperson plays a significant role in facilitating these meetings, which are often time-poor environments for clinical decision making. This study examines the perceptions of MDM Chairpersons including their role and the factors that determine the quality of a Chair, as well as the Chairperson’s perception of the value of personally attending meetings.Methods: This qualitative study used telephone interviews to explore the experiences of MDM Chairpersons from metropolitan and regional New South Wales, Australia. Using a state-wide register, 43 clinicians who chaired lung, genitourinary, gastrointestinal, and breast cancer meetings were approached to participate. Thematic data analysis was used to develop and organise themes.Results: Themes from the 16 interviews identified the perceived need for an expert and efficient MDM Chairperson with emphasis on personal rather than technical skills. The remaining themes related to the benefits of meetings to ensure quality and consistency of care; improve inter-professional relationships; and provide communication with and reassurance for patients.Conclusion: The role of the MDM Chairperson requires expert management and leadership skills to ensure meetings support quality patient-centred care. MDMs are perceived to provide multiple benefits to both clinicians and patients. Efforts to train Chairs and to maximise clinician and patient benefits may be warranted given the costly and time-consuming nature of MDMs.Keywords: multidisciplinary care, oncology, quality outcomes, cancer, clinical leadership

This paper presents a study from Sierra Leone that explored the experiences of doctors as they endeavored to improve the health care systems in which they worked. Twenty-eight interviews were conducted with doctors in Sierra Leone, complemented by long-standing experience of national health provision and research by the authors. Drawing on Hirschman's theory of ‘exit, voice and loyalty’, the paper's framework analysis elaborates the doctor's career decisions and choices under systematic political and economic constraints, and in particular, the specter of retribution, including posting to undesirable jobs and withholding of salaries. This retribution was considered a driver of exit by doctors from the system, and few examples were given of doctors successfully advocating for change through advocacy (‘voice’). We suggest that the relevance of Hirschman's theory to this setting is in drawing attention to the critical themes of retribution, opportunity, loyalties, and partial exits, ones often neglected in efforts to reduce emigration of doctors and strengthen their leadership. Ultimately, this paper critiques the overemphasis of mechanistic ‘capacity building’ in global health and recommends that health system strengthening must be viewed as a jointly political as well as technical exercise.

Bibi Hølge-Hazelton,1,2 Line Zacho Borre,1 Mette Kjerholt,3 Brendan McCormack,1,2,4 Elizabeth Rosted2,5 1Zealand University Hospital, Research Support Unit, Zealand University Hospital, Roskilde, Denmark; 2University of Southern Denmark, Department of Regional Health Research, University of Southern Denmark, Odense C, Denmark; 3Department of Hematology, Zealand University Hospital, Roskilde, Denmark; 4Centre for Person-Centred Practice Research, Queen Margaret University Edinburgh, Musselburgh, East Lothian, EH21 6UU, UK; 5Department of Oncology and Palliative Care, Zealand University Hospital, Roskilde, DenmarkCorrespondence: Bibi Hølge-HazeltonZealand University Hospital, Research Support Unit, Zealand University Hospital, Roskilde, DenmarkTel +45 27124286Email bibh@regionsjaelland.dkPurpose: To identify the differences in experiences during wave I and II of the COVID-19 pandemic among healthcare leaders.Background: It is expected, that working conditions for COVID-19-pandemic frontline staff will change, as health care organizations have gained experience with handling the consequences of the disease.Methods: An online survey was sent out to Danish health care leaders during the first and the second pandemic wave. Comparative analyses were performed in relation to three key characteristics: management level, management education and experiences as a leader.Results: Eighty-nine health care leaders completed both surveys. Significant differences were found within the entire group across the key characteristics as they felt more prepared for each stage of the situation, they had more influence on the decisions taken, and they felt more concerned about the quality of treatment and care and their own health. Further significant results related to the three key characteristics were found at 1) Management level: The heads of department experienced being better informed, having more overview of their tasks and that these were meaningful. The ward managers experienced being more able to work in consistency with own beliefs and values, though they felt more overloaded. 2) Level of management education: Leaders, without a formal management education, experienced being more supported by staff. 3) Years of experiences as leader: Leaders with more than five years of experience, experienced being more prepared and informed, had more influence on decision-making, and were more worried about their own health.Conclusion: The learning from experience that happens naturally in crisis situations is the reason why the leaders feel more prepared. However, there is a need for further leadership and practice development, to create contexts where leaders feel more ready for all aspects of their role.Keywords: follow-up, clinical leadership, management, communication, online survey

Abstract Background Medical ethics has recently seen a drive away from multiple prescriptive approaches, where physicians are inundated with guidelines and principles, towards alternative, less deontological perspectives. This represents a clear call for theory building that does not produce more guidelines. Phronesis (practical wisdom) offers an alternative approach for ethical decision-making based on an application of accumulated wisdom gained through previous practice dilemmas and decisions experienced by practitioners. Phronesis, as an ‘executive virtue’, offers a way to navigate the practice virtues for any given case to reach a final decision on the way forward. However, very limited empirical data exist to support the theory of phronesis-based medical decision-making, and what does exist tends to focus on individual practitioners rather than practice-based communities of physicians. Methods The primary research question was: What does it mean to medical practitioners to make ethically wise decisions for patients and their communities? A three-year ethnographic study explored the practical wisdom of doctors (n = 131) and used their narratives to develop theoretical understanding of the concepts of ethical decision-making. Data collection included narrative interviews and observations with hospital doctors and General Practitioners at all stages in career progression. The analysis draws on neo-Aristotelian, MacIntyrean concepts of practice- based virtue ethics and was supported by an arts-based film production process. Results We found that individually doctors conveyed many different practice virtues and those were consolidated into fifteen virtue continua that convey the participants’ ‘collective practical wisdom’, including the phronesis virtue. This study advances the existing theory and practice on phronesis as a decision-making approach due to the availability of these continua. Conclusion Given the arguments that doctors feel professionally and personally vulnerable in the context of ethical decision-making, the continua in the form of a video series and app based moral debating resource can support before, during and after decision-making reflection. The potential implications are that these theoretical findings can be used by educators and practitioners as a non-prescriptive alternative to improve ethical decision-making, thereby addressing the call in the literature, and benefit patients and their communities, as well.

Bibi Hølge-Hazelton,1,2 Mette Kjerholt,3 Elizabeth Rosted,2,4 Stine Thestrup Hansen,5 Line Zacho Borre,1 Brendan McCormack6 1Research Support Unit, Zealand University Hospital, Roskilde 4000, Denmark; 2Department of Regional Health Research, University of Southern Denmark, Odense C 5000, Denmark; 3Department of Hematology, Zealand University Hospital, Roskilde 4000, Denmark; 4Department of Oncology and Palliative Care, Zealand University Hospital, Roskilde 4000, Denmark; 5Department of Plastic Surgery and Breast Surgery, Zealand University Hospital, Roskilde 4000, Denmark; 6Centre for Person-Centred Practice Research, Queen Margaret University Edinburgh, Musselburgh, East Lothian EH21 6UU, UKCorrespondence: Bibi Hølge-HazeltonZealand University Hospital, Research Support Unit, Munkesøvej 14, Roskilde 4000, DenmarkTel +45 27124286Email bibh@regionsjaelland.dkPurpose: The aim was to identify the differences in experiences of Danish healthcare leaders in the beginnning of the coronavirus (COVID-19) pandemic and to generate knowledge for future leadership during and post crises.Background: The global spread of COVID-19 has affected healthcare systems worldwide and has forced healthcare leaders to face challenges few were prepared for. It is expected that the pandemic may hit in several waves within the next year and therefore healthcare leaders must be prepared for these waves.Methods: An online survey was developed, and comparative analyses were performed.Results: One hundred and sixty hospital leaders were invited, and 72% completed the questionnaire. Significant differences were found within three selected characteristics: 1) Management level: significantly more heads of departments experienced taking complex decisions (P=0.05), being able to work in a way consistent with their beliefs and values (P=0.05), and they were less likely to experience that collaboration with other leaders was adversely affected by the COVID-19 situation compared to ward managers (P=0.04). On the other hand, ward managers were significantly more often worried about both their own health (P=0.01) and their family’s health (P=0.04). 2) Management education: those with a formal management education more often experienced having the managerial competences to effectively manage the COVID-19 situation (P=0.00), and performing meaningful tasks during the situation (P=0.04). 3) Years of experience: significantly more leaders with more than five years of experience identified having the managerial competences to effectively manage the situation (P=0.01).Conclusion: Leadership support during a healthcare crisis like the COVID-19 pandemic should strategically focus on ward managers, leaders with no formal management education and leaders with less than two years of experience. Hospital leaders may use this knowledge to re-contextualize what is already known about targeted leadership support during healthcare crises and to act accordingly.Keywords: assessment, clinical leadership, management, communication

Dina Radenkovic,1,* Rebecca Mackenzie,1,* Sophie Bracke,1 Anthony Mundy,2 Duncan Craig,3 Deborah Gill,1 Marcel Levi2 1Faculty of Medical Sciences, University College London, Medical School, London, UK; 2Chief Executive Office, University College London Hospital, London, UK; 3Faculty of Life Sciences, University College London, School of Pharmacy, London, UK*These authors contributed equally to this workCorrespondence: Dina RadenkovicAcademic Department, St Thomas Hospital, Westminster Bridge Road, London, SE1 7EH, UKTel +44 781 867 3663Email dina.radenkovic@gmail.comBackground: Quality improvement (QI) is considered a duty of every doctor and, as such, it is fundamental that medical schools nurture QI skills of medical students. At a London medical school, a novel initiative was designed to involve medical students in QI. Such novel aspects include its student leadership, multidisciplinary approach and extra-curricular nature. The aim of this study is to evaluate the effectiveness of the initiative, and thus add to the experiences of existing medical student QI programs, as well as provide guidance to other institutions wishing to involve medical students in QI.Methods: The key features of the initiative’s design is described. Its effectiveness was evaluated by the collection of retrospective data on the quality of the initiative’s QI projects (QIPs), including the proportion which: 1) reached completion; 2) resulted in a significant improvement in their primary outcome; 3) had sustained results at follow-up; 4) achieved publication; and 5) contributed towards a prize or conference presentation.Results: There were 109 students involved throughout 10 projects from 14 different undergraduate and postgraduate courses from 2015–2019. 50% of the initiative’s projects achieved a significant improvement in their primary outcome, and the proportion of projects which sustained these improvements at follow-up was 100%. Furthermore, 20% of projects were published, and 60% contributed towards a prize or conference presentation.Conclusion: The results of this study show that the initiative was effective at involving medical students in QI. As such, other groups establishing medical student QI programs may benefit from replicating positive elements of its design and operation.Keywords: quality improvement, clinical leadership, medical education

Background: Health systems around the world have their own unique challenges. Today,competence in clinical leadership is often seen as more important than clinical competence.Given the important role of physicians in health systems, how do they acquire clinical leadership competencies? In this research, valid scientific articles were reviewed for insight. Methods: In this research, databases including Science Direct, ProQuest, PubMed, SCOPUS,and Emerald, as well as Google Scholar, the Scientific Information Database, and Magiran for Iranian articles were searched for valid evidence-based English and Persian articles published between 2010 and 2018 using combination of keywords such as "physician," "leadership," and"competency" singly and in combination with the terms "AND" and "OR" as research strategy.Studies that focused on "physicians leadership competency" were selected. Search results were limited to the years 2010-2018. After reviewing the papers, 18 relevant articles were selected. Results: In the first phase, 350 articles were selected and after careful examination, 18 papers were approved at the final stage. It was found that education and leadership development courses are the most important factor for enhancing managerial competencies for physicians.It should be noted that the researchers found that in Iran research on competence in clinical leadership has also been less relevant than others. Conclusion: It is imperative that managers and planners of medical curricula design courses to develop management skills for physicians. In the post-graduate period, for physicians’ continuing education, courses that address applied management and leadership should be identified and included in the continuing education curricula to address the real needs of the country’s health systems. Leadership development programs can also be useful as projects to be modeled with the help of the world’s top medical universities.

Abstract Background The provision of safe, high quality healthcare in the Emergency Department (ED) requires frontline healthcare personnel with sufficient competence in clinical leadership. However, healthcare education curriculum infrequently features learning about clinical leadership, and there is an absence of experienced doctors and nurses as role models in EDs for younger and less experienced doctors and nurses. The purpose of this study was to explore the activities performed by clinical leaders and to identify similarities and differences between the activities performed by charge nurses and those performed by doctors on-call in the Emergency Department after completion of a Clinical Leadership course. Methods A qualitative exploratory design was chosen. Nine clinical leaders in the ED were shadowed. The data were analyzed using a thematic analysis. Results The analysis revealed seven themes: receiving an overview of the team and patients and planning the shift; ensuring resources; monitoring and ensuring appropriate patient flow; monitoring and securing information flow; securing patient care and treatment; securing and assuring the quality of diagnosis and treatment of patient; and securing the prioritization of patients. The last two themes were exclusive to doctors on-call, while the theme “securing patient care and treatment” was exclusive to charge nurses. Conclusions Charge nurses and doctors on-call perform multitasking and complement each other as clinical leaders in the ED. The findings in this study provide new insights into how clinical leadership is performed by charge nurses and doctors on-call in the ED, but also the similarities and differences that exist in clinical leadership performance between the two professions. Clinical leadership is necessary to the provision of safe, high quality care and treatment for patients with acute health needs, as well as the coordination of healthcare services in the ED. More evaluation studies of this Clinical Leadership course would be valuable.

Solange Mianda, Anna S Voce Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa Background: In South Africa, inadequately skilled health care providers and poor clinical leadership are continually linked to preventable perinatal and maternal mortality, which calls for improved clinical skills among health care providers and for strong clinical leadership at the bedside. Very little has been done to ensure clinical leadership at the bedside in the labor ward of district hospitals. One strategy implemented has been the appointment of District Clinical Specialist Teams, introduced to improve the quality of maternal and child health care in district hospitals and clinics through the provision of clinical leadership as an outreach activity. However, the strengthening of clinical leadership at the bedside remains neglected. Further, clinical leadership in the literature is not conceptualized in the same way across settings.Aim: To explore midwife conceptualizations of clinical leadership in the labor ward of district hospitals in KwaZulu-Natal.Methods: Iterative data collection and analysis, following the Corbin and Strauss grounded theory approach, was implemented. In-depth interviews were carried out with the midwifery members of the District Clinical Specialist Teams in KwaZulu-Natal. The emergent theoretical framing of clinical leadership was presented and discussed at a workshop with broader midwifery representation, leading to a final proposition of the conceptualization of clinical leadership among midwives.Results: The emergent conceptualization of clinical leadership comprised five major dimensions: the definition of clinical leadership, the context in which clinical leadership takes place, the conditions related to clinical leadership, the actions and interactions involved in clinical leadership, and the effects of clinical leadership.Conclusion: Clinical leadership is an emergent phenomenon arising from dynamic interactions in the labor ward and the broader health system, which converge to attain optimal patient care. Clinical leadership is not being understood from a traditional hierarchical perspective, as vested only in a positional leader. Keywords: bedside care, clinical leadership, frontline health workers, midwives, grounded theory, leadership, qualitative research, patient outcomes

Solange Mianda, Anna S Voce Department of Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa Introduction: Poor patient outcomes in South African maternal health settings have been associated with inadequately performing health care providers and poor clinical leadership at the point of care. While skill deficiencies among health care providers have been largely addressed, the provision of clinical leadership has been neglected. In order to develop and implement initiatives to ensure clinical leadership among frontline health care providers, a need was identified to understand the ways in which clinical leadership is conceptualized in the literature.Design: Using the systematic quantitative literature review, papers published between 2004 and 2016 were obtained from search engines (Google Scholar and EBSCOhost). Electronic databases (CINHAL, PubMed, Medline, Academic Search Complete, Health Source: Consumer, Health Source: Nursing/Academic, ScienceDirect and Ovid®) and electronic journals (Contemporary Nurse, Journal of Research in Nursing, Australian Journal of Nursing and Midwifery, International Journal of Clinical Leadership) were also searched.Results: Using preselected inclusion criteria, 7256 citations were identified. After screening 230 potentially relevant full-text papers for eligibility, 222 papers were excluded because they explored health care leadership or clinical leadership among health care providers other than frontline health care providers. Eight papers met the inclusion criteria for the review. Most studies were conducted in high-income settings. Conceptualizations of clinical leadership share similarities with the conceptualizations of service leadership but differ in focus, with the intent of improving direct patient care. Clinical leadership can be a shared responsibility, performed by every competent frontline health care provider, regardless of the position in the health care system.Conclusion: Conceptualizations of clinical leadership among frontline health care providers arise mainly from high-income settings. Understanding the influence of context on conceptualizations of clinical leadership in middle- and low-income settings may be required. Keywords: clinical leadership, conceptualizations, frontline health care providers

Background The need for competence training and development in health management and leadership workforces has been emphasised. However, evidence of the outcomes and impact of such training and development has not been systematically assessed. The aim of this review is to synthesise the available evidence of the outcomes and impact of training and development in relation to the competence of health management and leadership workforces. This is with a view to enhancing the development of evidence-informed programmes to improve competence. Methods and Analysis A systematic review will be undertaken using a mixed-methods research synthesis to identify, assess and synthesise relevant empirical studies. We will search relevant electronic databases and other sources for eligible studies. The eligibility of studies for inclusion will be assessed independently by two review authors. Similarly, the methodological quality of the included studies will be assessed independently by two review authors using appropriate validated instruments. Data from qualitative studies will be synthesised using thematic analysis. For quantitative studies, appropriate effect size estimate will be calculated for each of the interventions. Where studies are sufficiently similar, their findings will be combined in meta-analyses or meta-syntheses. Findings from quantitative syntheses will be converted into textual descriptions (qualitative themes) using Bayesian method. Textual descriptions and results of the initial qualitative syntheses that are mutually compatible will be combined in mixed-methods syntheses. Discussion The outcome of data collection and analysis will lead, first, to a descriptive account of training and development programmes used to improve the competence of health management and leadership workforces and the acceptability of such programmes to participants. Secondly, the outcomes and impact of such programmes in relation to participants’ competence as well as individual and organisational performance will be identified. If possible, the relationship between health contexts and the interventions required to improve management and leadership competence will be examined.

Abstract Objective: To develop clinical leadership among health professionals working in public sector organisations to improve their skills in ensuring high quality and safe health services. Methods: A longitudinal pre‐post‐intervention mixed methods study that included 60 health professionals working in one state in Australia. Results: The program was successful in the development of clinical leaders. Conclusions: An interdisciplinary, inter‐sectoral leadership development program involving health professionals from metropolitan, regional and rural areas can be successful in developing knowledge, skills and competencies among these health professionals in health service quality and safety. Implications: Health professionals can participate in a development program to enhance their clinical leadership skills. While this was a post‐qualification course, targeting experienced health professionals, the learnings could be applied to pre‐qualification education of health professionals.

Robert McSherry,1 Paddy Pearce2 1School of Health and Social Care, University of Teesside, Middlesbrough, 2PKP Consulting, Yarm, United Kingdom Abstract: The presence and/or absence of effective leaders in health care can have a stark consequence on the quality and outcomes of care. The delivery of safe, quality, compassionate health care is dependent on having effective clinical leaders at the frontline. In light of the Kirkup and Francis reports, this article explores some ways of translating clinical leadership into health care quality improvement. This is achieved by exploring what is clinical leadership and why and how this is important to health care quality improvement, clinical leadership, and a duty of candor, along with the importance clinical leadership plays in the provision of quality care improvement and outcomes. Clinical leaders are not predefined roles but emerge from the complex clinical setting by gaining an acquired expertise and from how they then internalize this to develop and facilitate sound relationships within a team. Clinical leaders are effective in facilitating innovation and change through improvement. This is achieved by recognizing, influencing, and empowering individuals through effective communication in order to share and learn from and with each other in practice. The challenge for health care organizations in regard to creating organizational cultures where a duty of candor exists is not to reinvent the wheel by turning something that is simple into something complex, which can become confusing to health care workers, patients, and the public. By focusing on the clinical leader's role and responsibilities we would argue they play a crucial and pivotal role in influencing, facilitating, supporting, and monitoring that this duty of candor happens in practice. This may be possible by highlighting where and how the duty of candor can be aligned within existing clinical governance frameworks. Keywords: governance, candor, safety, outcomes

Background: A core component of the Health and Social Care Act 2012 (Great Britain. Health and Social Care Act 2012. London: HMSO; 2012) was the idea of devolving to general practitioners (GPs) a health service leadership role for service redesign. For this purpose, new Clinical Commissioning Groups (CCGs) were formed in the English NHS. Objectives: This research examined the extent to which, and the methods by which, clinicians stepped forward to take up a leadership role in service redesign using CCGs as a platform. Design: The project proceeded in five phases: (1) a scoping study across 15 CCGs, (2) the design and administration of a national survey of all members of CCG governing bodies in 2014, (3) six main in-depth case studies, (4) a second national survey of governing body members in 2016, which allowed longitudinal comparisons, and (5) international comparisons. Participants: In addition to GPs serving in clinical lead roles for CCGs, the research included insights from accountable officers and other managers and perspectives from secondary care and other provider organisations (local authority councillors and staff, patients and the public, and other relevant bodies). Results: Instances of the exercise of clinical leadership utilising the mechanism of the CCGs were strikingly varied. Some CCG teams had made little of the opportunity. However, we found other examples of clinicians stepping forward to bring about meaningful improvements in services. The most notable cases involved the design of integrated care for frail elderly patients and others with long-term conditions. The leadership of these service redesigns required cross-boundary working with primary care, secondary care, community care and social work. The processes enabling such breakthroughs required interlocking processes of leadership across three arenas: (1) strategy-level work at CCG board level, (2) mid-range operational planning and negotiation at programme board level and (3) the arena of practical implementation leadership at the point of delivery. The arena of the CCG board provided the legitimacy for strategic change; the programme boards worked through the competing logics of markets, hierarchy and networks; and the practice arena allowed the exercise of clinical leadership in practical problem-solving, detailed learning and routinisation of new ways of working at a common-sense everyday level. Limitations: Although the research was conducted over a 3-year period, it could be argued that a much longer period is required for CCGs to mature and realise their potential. Conclusions: Despite the variation in practice, we found significant examples of clinical leaders forging new modes of service design and delivery. A great deal of the service redesign effort was directed at compensating for the fragmented nature of the NHS – part of which had been created by the 2012 reforms. This is the first study to reveal details of such work in a systematic way. Future work: Further focus is needed on the emergent sustainability and transformation plans and the locality/hubs/primary care homes that integrate care across population groups. Funding: The National Institute for Health Research Health Services and Delivery Research programme.

Background and objective: There is a need for young physicians to take a responsible role in clinical teams, comparable to a leadership role. However, today’s medical curricula barely consider the development of leadership competencies. Acquisition of leadership skills are currently a by-product of medical education, even though it seems to be a competency relevant for physicians’ success. Therefore, an innovative leadership training program for young physicians was developed and validated. Training conceptualisation were based upon Method: The training consists of four sessions (3-4 hours each) and provided evidence-based lectures of leadership theory and effective leader behaviors, interactive training elements and a simulation-based approach with professional role players focusing on interprofessional collaboration with care staff. Training evaluation was assessed twice after completion of the program (=37). Assessments included items from validated and approved evaluation instruments regarding diverse learning outcomes (satisfaction/reaction, learning, self-efficacy, and application/transfer) and transfer indicators. Furthermore, training success predictors were assessed based on stepwise regression analysis. In addition, long-term trainings effects and behavioral changes were analysed. Results: Various learning outcomes are achieved (self-reported training satisfaction, usefulness of the content and learning effects) and results show substantial transfer effects of the training contents and a strengthened awareness for the leadership role (e.g. self-confidence, ideas dealing with work-related problems in a role as responsible physician). We identified competence of trainer, training of applied tools, awareness of job expectations, and the opportunity to learn from experiences of other participants as predictors of training success. Additionally, we found long-term training effects and participants reported an increase in specific competencies, relevant for effective interprofessional collaboration (active perspective-taking, communication, conflict management, personal competencies).Conclusion: The training of leadership competencies for young physicians seems feasible to develop constructive influence strategies for a successful interprofessional collaboration in early career stages. The simulation-based approach is beneficial for residents to practice leadership behaviour in realistic job situations.

Aim: To identify how clinical leadership was perceived by Health Professionals (HPs) (excluding nurses and doctors) and to understand how effective clinical leadership relates to initiating and establishing a culture of change and progression in the health services. Methodology: This pilot study used a mixed methods approach, although quantitative methodological principles dominated. An on-line (SurveyMonkey) questionnaire was distributed via email links to HPs throughout the Western Australian Department of Health. Qualitative data was analysed by Statistical Product and Service Solutions (Version 21). Results: A total of 307 complete surveys were returned. Participants represented 6.1% of the total WA HP workforce and a wide range of HP disciplines. The majority of respondents were female (86.5%), the median age was 38.9 years and the majority of respondents worked in acute hospital environments (59.9%) and in a metropolitan location (73.7%). Most participants (79.2%) saw themselves or were reportedly seen by others (76.2%) as clinical leaders. The main attributes associated with clinical leadership were; effective communicator, clinical competence, approachability, role model and supportive. The main attribute identified least with clinical leadership was “controlling”. Only 22.2% saw clinical leaders as managers, while the majority saw a clinical focus as important (85.3%). Clinical leaders were perceived as having an impact on how clinical care is delivered, staff support and leading change and service improvement. Many respondents (81.4%) suggested barriers hindered their effectiveness as clinical leaders. Conclusions: Improvements in clinical care and changes in practice can be initiated by clinical leaders.

This phenomenological study is set in the context of leadership development in the National Health Service (NHS). The aim of the study was to provide an in-depth understanding of the Royal College of Nursing Clinical Leadership Development Programme (RCN CLP) participants’ experience of the coaching component of the programme. In-depth interviews were undertaken with eight clinical leaders who had recently completed the RCN CLP. The overarching theme emerging from the data suggested that coaching was seen as an opportunity for ‘stepping off the treadmill’. This main theme is underpinned by a further eighteen theme clusters, organised into 6 categories: out and in the comfort zone; mirror mirror; unconditional positive regard; creative conversations; ripple effect; and I’m OK, you’re OK. In this paper, the implications of the findings are discussed and recommendations for further research identified.