Leadership development theory

Healthcare, like many other industries, often falls victim to the ‘great training robbery’.^{Reference Beer, Finnstrom and Schrader23} Organisations frequently support and encourage individuals to undertake externally provided leadership development programmes, and yet often fail to provide appropriate conditions on their return for them to contextualise and apply their learning within their clinical environment. Although this can be successful in developing their knowledge, skills and competencies, it effectively sets them up to fail, and leads to the continuation of entrenched and established ways of working.^{Reference Edmondson, Woolley, Easterby-Smith and Lyles24}

If exclusively developed within the ‘classroom’, development will largely remain ‘horizontal’,^{Reference Petrie25} and leaders will fail to learn how to change and adapt to ever-changing circumstances.^{Reference Beer, Finnstrom and Schrader23} Alternatively, an ‘in vivo’ approach, with the right conditions coordinated throughout a programme, can harness ‘vertical’ leadership development through the delivery of ‘heat experiences’, ‘colliding perspectives’ and ‘elevated sense-making’.^{Reference Petrie26}

Heat experiences involve organisations taking calculated risks, and exposing leaders, who themselves must take a risk, to complex uncomfortable first-time challenges. Here, they are forced to grow, not just because they want to, but because there is a chance of failure, people are watching, and results matter. They are ‘the what’ that compels leaders to disrupt and disorient their traditional thinking styles, to discover new and better ways to make sense of the challenges they face. Caution must be excised, however, to get the ‘temperature right’, and control the heat within a safe space, with the right support, available at the right time, to help the individual stay within that learning ‘sweet spot’. Importantly, there also needs to be an appropriate level of both individual and organisational tolerance of failure.^{Reference Waltz27}

Colliding perspectives expand the number of lenses through which a leader can analyse complexity and challenge their existing mental models.^{Reference Isles and Sutherland28} Individuals are encouraged to view the world through the eyes of different stakeholders, including that of patients, carers and other members of the multidisciplinary team, and by standing in their shoes, learn to identify and manage conflicting paradigms. Ideally combined with peer coaching, partnered with different disciplines, these colliding perspectives provide ‘the who’ that is inclusive and embraces a range of diverse thought.^{Reference Diaz-Uda, Medina and Schill29}

Elevated sense-making is the final piece, ‘the how’, that leads to transformational change.^{Reference Rooke and Torbert30} Not only must structured reflection (through reflective practice groups or action learning sets) be facilitated to allow leaders to reflect on their development over time and integrate their experiences with new found perspectives, but their development should be guided by experienced coaches or mentors.

It is vital that these three conditions are provided within postgraduate medical training, whether through activities embedded informally within the work environment, or formally via a targeted approach within leadership development programmes. Although value can still be extracted from opportunities that do not provide these conditions, leadership talent will remain untapped and dormant within healthcare organisations unless these are met.^{Reference Rafferty and Till31}

Informal leadership development

The common perception of leadership as an optional extra remains pervasive throughout the medical workforce. Combined with a ‘curriculum lag’, whereby there is a delay in implementing and adopting the latest evidence into training, the development of leadership competencies remains somewhat tokenistic.^{Reference Till, Anandaram, Dapaah, Ibrahim, Kansagra and Prasad32} The stars are aligning, however, and the importance of leadership development in both undergraduate and postgraduate medical curricula is slowly being realised.^{Reference Till, McKimm and Swanwick33}

The message is clear. Leadership development does not begin or end at any particular stage of training. Leadership is for all doctors, at every stage, and should not be postponed until doctors are formally appointed to a leadership or management position. Leadership is rather a developmental process on a lifelong continuum, with individuals nurtured to help recognise and fulfil leadership roles, especially in the earliest of stages of their careers.^{Reference Swanwick34}

Everyday leadership experiences are commonplace within psychiatric clinical settings, where decision-making is complex and ethical tensions arise through divergent views, roles and responsibilities within teams.^{Reference Silva, Till and Adshead35} Although often undervalued, these present opportune leadership development experiences where, among a range of other activities, leadership can be developed through acute crisis situations, multidisciplinary meetings, mentoring junior colleagues, medical education, clinical governance and quality improvement projects. It is important to recognise, name and make sense of these everyday leadership experiences within training, through supervision, and allow trainees to recognise the value of ‘little l’ leadership within their teams.^{Reference Bohmer36}

More formal opportunities also exist through representative roles available locally, regionally and nationally, that can all lead on to providing more enhanced leadership experiences and the three primary conditions of vertical leadership development in their own right. Likewise, voluntary and additional professional activities can provide excellent leadership experience. For example, roles available within Royal Colleges, special interest groups, trade unions, healthcare regulators, the General Medical Council, or as a governor for healthcare and affiliated organisations.

Irrespective of the particular opportunity, whether formal or informal, obtaining feedback is critical for gaining insight into the trainees’ own perception of their leadership capabilities, and the perceptions held by others of their behaviours and performance.

Integral tools within psychiatric training for facilitating such structured feedback are the Mini-Peer Assessment Tool and Direct Observation of Non-Clinical Skills (DONCS) workplace-based assessments. These are used across the General Medical Council-approved curricula for both core and specialty psychiatric training within the UK, to assess a trainees performance and allow trainees to demonstrate their leadership capabilities.^37,38

Originally founded on The CanMEDS 2005 Physician Competency framework,^{Reference Frank39} DONCS are applicable to a range of diverse non-clinical skills, and structuring feedback on leadership experiences around the seven domains can at times feel convoluted and ambiguous.

Table 1 has been conceptualised from the evidence base to help suggest key competencies for psychiatric leaders within a DONCS assessment, and aims to support both trainees and trainers attaining and delivering feedback.^{Reference Frank39–42}

Table 1 Your guide to a Leadership and Management DONCS

DONCS, Direct Observation of Non-Clinical Skills.

Formal leadership development

There are a plethora of leadership development programmes, schemes and other opportunities available throughout the UK. This can be confusing for both trainees and trainers alike, occurring both in and out of training programmes, with a diverse range of requirements, levels of involvement and financial commitment.

Attempting to provide a brief description of these opportunities, Table 2 outlines a sample of the variety of leadership and management training that is currently available to psychiatric trainees within the UK. It is important to remember, however, that there is an almost constantly evolving stream of new opportunities depending on interests and geography, and that this table is likely to be quickly outdated.

Table 2 Leadership and management training availability to psychiatric trainees (correct as of 2020/21)

NIMDTA, Northern Ireland Medical & Dental Training Agency; NHS, National Health Service; PGCert, Postgraduate Certificate; MBA, Master of Business Administration; MSc, Master of Science; PGDip, Postgraduate Diploma.

a. Predominantly non-clinical (although some do allow limited ongoing clinical activity), and therefore often require an extension to training via out-of-programme experience approval.

Such formal leadership development could be conceptualised through a tiered approach (Fig. 1). Firstly, basic generic professional capabilities are provided in leadership for all doctors via an integrated approach within local training programmes. A second tier then provides enhanced local and regional leadership development offers for future service and divisional leaders. Then finally, at the upper tier, nationally coordinated, advanced programmes and fellowships, are delivered for aspiring organisational- and system-level leaders.

Fig. 1 A tiered approach to leadership development. FMLM, Faculty of Medical Leadership and Management.