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Table 3 Summary characteristics of included studies

From: Interventions to develop collectivistic leadership in healthcare settings: a systematic review

Author, Year Aim Participants (setting, location) Underpinning Theory Intervention Duration Intervention Content Methods of Evaluation
(Evaluation approach)
Key Findings
MacPhail et al., 2015 [51] To increase staff willingness to take on leadership roles 11 in first round, 20 in second round (regional healthcare centre, Australia) Transformational, distributed and systems-based leadership 9–10 months; 2-h sessions on-site once a month (~ 20 h total) Sessions included a guest speaker and group discussion; one self-organised external site visit and one mini-project in small, interdisciplinary groups; and a presentation to peers and executive staff of learning. Survey on staff willingness to take on a leadership role; new leadership roles after 18 months; Senior executive feedback on programme
(Mixed methods)
‘The clinical leadership programme significantly increased willingness to take on leadership roles … (93%) reported that they were more willing to take on a leadership role within their team.’
Buckley et al. 2009 [37] To build physician-nurse leadership partnerships based on shared responsibility and accountability for increasing quality and patient safety 28 people across 7 clinical care teams (hospital setting, USA) None reported One-month pilot period Consultants partnered with teams to help build skills in goal-setting, managing staff, promoting positive changes in work culture, and negotiating and resolving conflicts. Team members learned how to structure projects, collect and analyse data and develop action plans for improvement. To the extent possible, physician and nurse leaders completed training together. Unclear regarding qualitative findings – no methods reported, just results.
Individual improvement project case studies and outcomes provided as examples of efficacy of intervention.
(Mixed methods)
‘Resulted in breakthrough improvements in quality and patient safety, but also forged better physician-nurse collaboration and job satisfaction.’
‘Physicians and nurses also came to better appreciate each other’s pressures and challenges.’
Boak et al., 2015 [47] To analyse the introduction of distributed leadership and team working in a physiotherapy department, and to explore the factors that enabled success. 26 staff members physiotherapy department (hospital, UK) Distributed leadership and shared leadership 8 months to plan service re-design Service re-design with quality improvement. Restructuring to speciality team-based service delivery. Co-design of new structures and processes, standardised assessment and treatment protocols, with team member rotation. Waiting times for routine new patient appointments; Patient Satisfaction; staff experiences of changes
(Mixed methods)
Concluded distributed leadership was successfully introduced. Distributed leadership and team working were central to a number of systems changes that were initiated by the department and led to improvements in patient waiting times for therapy. Six factors identified that influenced success.
Gibb et al., 2016 [52] To standardise and improve team communication and team leadership in care delivered in a residential aged care facility. 4 care units/teams (residential aged care facility, Australia) Distributed leadership Not reported (i) Huddle: 3–5 min ‘time out’ in the work site for shared problem-solving; 4-step protocol.
(ii) Giving positive and constructive feedback, using feedback.
(iii) Briefing: a leader-facilitated discussion prior to starting shift. Debrief: 3–5 min after-action review
(iv) ISBAR to enhance clear communication.
A cultural scan conducted pre-intervention involved the collection of interview, focus group and observational data, with the aim of triangulating data on the current culture, then repeating post intervention to profile changes emerging from the intervention. Short survey pre/post training to measure knowledge, confidence and use of skills. Interviews and focus groups with staff.
(Mixed methods)
‘Of the four teams involved in training, only one successfully transitioned to working with the new protocols … distributed leadership was critical to the high performance achieved in Team A.’
Results suggested that the project had more general impact on cultural values and interpersonal behavior and less on the assimilation of standard communication and team working.
Howard et al., 2012 [38] To deliver a facilitated, team-based quality improvement intervention to encourage leadership inclusiveness. 60 quality improvement teams; 8 of these cases selected and highlighted in paper (primary care, USA) Inclusive leadership and collaboration 3 months Used the Multi-Method Assessment Process (MAP) and the Reflective Adaptive Process (RAP). The MAP model was a baseline assessment in which the facilitator-researcher spent 5–7 days observing operations and relationships, interviewing practice members, and developing rapport. This was followed by the RAP, which involved up to 12 weekly, facilitated team meetings with representatives from different areas of the practice. External facilitators modelled inclusive leadership, encouraging reflection and open communication, supporting implementation of improvement plan and discussed principles of inclusive leadership. Data sources included observational field notes, interviews, and audio-recorded quality improvement meetings to explore exemplar and non-exemplar cases
Analysis extended case illustrations of 3 physician leadership behaviours that exemplified leadership inclusiveness (explicitly soliciting team input; engaging in participatory decision making; and facilitating the inclusion of non–team members) as well as 3 behaviours that are counter to inclusiveness
Rosengren et al., 2010 [53] To describe the views of staff after introduction of shared leadership between two nurse mangers for all tasks in the unit. 64/81 of ICU team (hospital, Sweden) Shared leadership “a 3-year project” Introduction of co-leadership model: two leaders to share leadership responsibilities. Individual’s perception of the work situation; quality of leadership; staff views on shared leadership
(Mixed methods)
Staff reported positive views of work and the model shared leadership in terms of confidence and in relation to organizational culture, social interactions, work satisfaction, leadership, Shared leadership & work motives.
Sanders et al., 2013 [39] To create a shared leadership model (Staff Nurse Council with clinical nurse representation from all departments and services across the hospital) to introduce initiatives to enhance the work environment. Nursing teams throughout organisation; number not reported (hospital, USA) Shared leadership Not reported Devolving leadership and decision-making to develop shared leadership model where employees were tasked with introducing initiatives to positively shape the work environment Staff satisfaction and engagement; levels of stress and fatigue; patient satisfaction scores; nurse-physician relationships
‘A highly engaged, well-educated, and committed nursing workforce, nurtured by a strong leadership team, has created a positive work environment characterised by low turnover and high retention’
Miller et al., 2007 [48] To support the development of shared leadership in the teams through the intervention of specially trained and supported leadership development consultants who worked with clinical teams delivering diabetes care 6 diabetes teams (primary and secondary care, UK) Shared leadership; distributed leadership; collective leadership; blended leadership 13 days over 18 months Process had 3 residential learning sessions which brought the teams together at the outset, in the middle and at the end of the scheme for sharing learning and expert input; and was also in part tailored to teams. Each leadership development consultant worked with their team to agree opportunities to bring teams together to address team processes, and each emerged with an individual schedule of how to use the 30 days allocated over the 18 months of the scheme. Each team identified its own criteria for success and team members recorded this at regular intervals.
The evaluation used range of methodologies including interviews with team members at two separate time points; a questionnaire survey of all team members at two time points; a questionnaire survey of comparator teams at the same time points; interviews with the leadership development; interviews with patients; and a review of national medical data.
(Mixed methods – though only qualitative results reported)
‘Strong evidence from the teams that they were working better together … and becoming more effective as teams.’
However, teams remained convinced that every team needs a leader, felt that leadership was not shared.
Sense that the intervention had enabled each of them to develop as leaders and made leaders more willing to listen to them.
Steinert et al., 2006 [57] To create a new shared leadership of medico-therapeutic staff and nursing staff on all clinical levels 131/165 staff members (psychiatric hospital, Germany) Shared leadership and shared governance Not reported Introduction of co-leadership model between medico-therapeutic staff and nursing staff sharing leadership roles and responsibilities Staff satisfaction with shared leadership (concrete personal experiences and general experiences with the hospital); appeal of adopting a leadership position
Quantitative (self-designed survey)
‘Staff members were satisfied with the shared leadership model both in their own clinical practice and in general. Non-medical staff members were significantly more in favour of several aspects of shared leadership than physicians.’
Evidence the model may have advantages in the management of psychiatric hospitals.
Casady & Dowd, 2005 [40] Service re-design to create new co-facilitated groups to develop strategies and co-design interventions to enhance employee engagement, involvement in decision-making and increase staff retention. One medical imaging department (hospital, USA) Shared leadership Service re-design over 5-year period Service re-design and re-structuring with new oversight committee and strategic thinking group (two co-facilitators) to co-design initiatives to enhance staff engagement, create more effective leadership, enable greater participation by staff in the decision- making process, and ensure competitive salaries. On-going since 2001. Gallup poll survey results related to employee turnover/retention, employee engagement and patient satisfaction
‘Dramatic change in turnover rate as a result of engaging staff using shared leadership principles.’ Turnover rate decreased from 40% in 2001 to 4% in 2004 with improvement in employee engagement from 44th percentile in 2002 to 69th percentile in 2004.
Allen, 2010 [41]a To evaluate the effectiveness of a work based shared leadership training program 12 Unit-based nursing teams (n = 39)
(hospital, USA)
Shared leadership 2–3 months Work-based action learning program consisted of four sessions, which included assignment of an action learning project, cognitive instruction, coaching, and reflection. Self-designed survey instrument measured team dynamic knowledge, use of shared leadership behaviours, and engagement.
Results indicated the training program was successful in developing shared leadership: significant changes in knowledge of shared leadership, shared leadership behaviours and team engagement were observed.
Roberts, 2009 [42] a To facilitate network development that bridges disciplinary silos and fosters collective leadership capacity Leaders, managers, supervisors, team leaders and coordinators
(hospital, USA)
Collective and collaborative leadership Approx. 5–6 months per cohort 3-h sessions every second month for 6 months. 2 versions:
LEAD 1: Use of personality profiles to develop understanding, session on review and debriefing on leadership, effective communication, coaching for success, delegation and empowerment, time and meeting management, then a final review, reflection, action planning session.
LEAD 2: Information on servant leadership, appreciative inquiry, change management, and review, reflection and action planning
‘Lunchtime inquiry group’ who met monthly over a five-month period.
Qualitative approach using reflection, interviews, focus groups, field notes and observation to explore collective leadership, inclusiveness, empowerment, collaboration across units, leading at all levels.
Findings suggest that the intervention can strengthen skills of individual leaders and foster collective leadership
Van Zwanenberg, 2009 [49] Co-design of new collaborative leadership programme to find ways of achieving application of learning around collaborative leadership and sustainability of learning. 7 teams (multisector mental health teams, UK) Collaborative / team leadership 12 months 2-day introduction (establishing goals, mentor, selecting projects); 12 x monthly learning sets on personal qualities for leading change; 6 x bi-monthly functional leaning sets focused on personal development, leading change, developing collaborative relationships; e-resources (performance, financial, risk, management and leadership theory); 1-day programme review and evaluation. Interviews with participants, the project group, and key stakeholders, and questionnaire responses and focus group sessions for both participants and learning set facilitators.(Mixed methods) ‘Positive shifts in participants’ competence as collaborative partners, particularly regarding working across traditional boundaries.’
Dewar & Cook, 2014 [50] Intervention aimed to support staff to work together to develop a culture of inquiry that would enhance delivery of compassionate care 86 nursing staff members(hospital, UK) Distributed and collaborative leadership 12 months Reflective spaces within the programme, community of practice, Action Learning, Work based activities. Staff culture questionnaire, reflections following action learning, descriptions of reported staff developments, case studies, staff interviews to elicit impact of training
(Mixed methods)
‘Enhanced self-awareness, better relationships, greater ability to reflect on practice, different conversations in the workplace that were more compassionate and respectful, and an ethos of continuing learning and improvement … supported participants … to be reflective and engaged.’
Awad et al., 2004 [43] Curriculum implemented with objectives of training residents to have the capacity/ability to create and manage powerful teams through alignment, communication, and integrity Surgical residents (number not reported) (hospital, USA) Collaborative leadership “over the course of a surgical residency” Focused program was implemented with objectives of training the residents to have the capacity/ability to create and manage powerful teams through alignment, communication, and integrity while working 80 h per week. Specific strategies were: (1) to focus on quality of patient care/ service while receiving a high education-to-service ratio, and (2) to maximize efficiency through time management. Pre/post survey assessing resident’s view of leadership in the areas of alignment, communication, and integrity.
There was a significant increase in the scores with regards to alignment, communication, and integrity after completion of the leadership training program indicating the program was successful in its aims
Jackson, 2000 [55] Service re-design to share leadership across clinical units 69 individuals within 4 work groups(hospital, Canada) Shared leadership Introduced across organisation over two-year period A group of staff members and managers assembled in 1997 to form a shared leadership resource group, with function of providing support to individuals and teams as they increased their decision making. The shared leadership resource group gave the responsibility of implementing the model on each of the clinical units to the team leader managers/program directors. Focus groups and interviews to explore staff experiences and perceptions or service re-design(Qualitative) Drivers and barriers affecting implementation are explored.
‘Internalisation of the concepts specific to the shared leadership model … was vital … Processes and interactions which meet the demonstrated need of all staff to feel valued, unique, connected, and a sense of belonging are desirable when promoting the model.’
Pelayo, 2008 [44]a Service re-design to team-based leadership to enhance effective functioning of hospital Organisation-wide team-based working, 1700 employees (hospital, USA) Team-based leadership Phased shift to team-based model over 8-year period As described by the current CEO, the strategies are reported in phases: (a) immediate reactionary phase (controlling finances, removing waste in system), (b) building phase (hiring the right people, training them, ensuring that the teams were functioning efficiently), and (c) self-governing phase (teams tasked to develop specific goals aligned to organisation’s goals). A qualitative case study (interviews, document reviews, observations) exploration of the strategies organisational leaders adopted to develop a 10-year team-based leadership structure.
Four conclusions on the team-based leadership: (i) phenomenon that occurred over time and evolved from various strategies to address financial challenges; (ii) none of the strategies employed were considered a failure; (iii) multidisciplinary teams positively influenced the business aspect of the organisation’s performance while increasing the quantity and quality of services; and (iv) the organisation’s teams paralleled the functions and goals of the management team.
Klinga et al., 2016 [54] Service re-design of organisation to promote shared treatment and shared leadership Organisation-wide integrated health and social care organisation (hospital, Sweden) Co-leadership Service re-design in operation since 1995 Service re-design where each centre is managed through co-leadership shared by two equal leaders (‘pair-leadership’), where responsibility of unit management shared by two co-leaders. Interviews with eight managers exercising co-leadership to identify essential preconditions in fulfilling the management assignment, operationalisation and impact on integration of health and social care.(Qualitative) Identified contextual preconditions were an organisation-wide model supporting co-leadership and co-location of services. Perception of the management role as a collective activity, continuous communication and lack of prestige were essential personal and interpersonal preconditions. In daily practice, office sharing, being able to give and take and support each other contributed to success.
Swensen et al., 2016 [45] To develop a qualitative descriptive case study of the Mayo Clinic leadership development philosophy, approach and model; to understand the features of team-based leadership development Organisation-wide (hospital, USA) Collective leadership; team-based leadership On-going (introduction date not reported) Organisation-wide policies and programmes including leadership programme, rotating leadership positions, and a collaborative leadership structure. Staff engagement; patient satisfaction; staff turnover; quality outcomes(Qualitative case study using quantitative data as evidence of effectiveness) Organisational and governance systems are designed to develop culturally aligned leaders, build social capital, grow employee engagement, foster collaboration, nurture collegiality and engender trust.
Black & Westwood, 2004 [56] To evaluate the effectiveness of a group-based team leadership development workshop 7 (of 9) invited participated. Administration team in cancer care (hospital, Canada) Team-based (non-hierarchical) leadership 35 h over 3-month period 3 workshops (35 facilitated hours)
Workshop 1 – team building/getting to know team, role play, Amundson individual styles survey
Workshop 2 – Role clarification using enactment, discussion on mistakes/deaths in healthcare,
Workshop 3 – Review group goals, Johari window self-awareness exercise, group communication exercise and discussion, enactment and demonstration of critical team meeting, debrief.
Interviews 3-months post-intervention to elicit information related to their participation in the workshops and communication, morale, support and the ability to provide more holistic support.
All participants reported understanding others/being understood; formation of connections with others; sense of belonging/ acceptance; sense of safety and trust in communication; appreciation of facilitation of the group; experience of group morale (increased and decreased); reciprocity and demonstration of support.
Senn, 2014 [46]a To explore factors that hindered or enhanced the role development of co-leaders; and the nature and dynamics of the co-leaders’ working relationship. 8 co-leaders (hospital, USA) Co-leadership Co-leadership operational for more than 5 years prior to data collection. Service re-design – nurse and physician co-leadership model, sharing responsibilities and leading a hospital unit Individual interviews with co-leaders about their shared role and responsibilities, and their collaborative work together within a co-leadership structure
Two themes emerged: ‘Shared Role Space: Moving from I to We’ and ‘Partnered Leadership: Dynamic Interplay of Complementary Competencies’. Factors that enhanced/hindered the role identified.
  1. Note: aindicates study found through grey literature searches