Dimensions, Discourses and differences: trainees
conceptualising healthcare leadership and
followership
Lisi J Gordon1*, Charlotte E Rees1, Jean S Ker1, Jennifer
Cleland2
1Medical
Education Institute, School of Medicine, University of Dundee;
2Division of Medical and Dental Education, School of Medicine and
Dentistry, University of Aberdeen
*Address
for correspondence:
Lisi J Gordon, Centre for Medical Education, University of Dundee,
MacKenzie Building, Kirsty Semple Way, Dundee, Scotland, DD2 4BF
Telephone: +44 (0)1382 381974
Email: [email protected]
Abstract
Introduction
As doctors in all specialties are expected to undertake leadership within healthcare
organisations, leadership development has become an inherent part of medical education. While
the leadership literature within medical education remains mostly focused on individual,
hierarchical leadership, contemporary theory posits leadership as a group process, which
should be distributed across all levels of healthcare organisations. This gap between theory and
practice indicates that there is a need to understand what leadership and followership means to
medical trainees working in today’s interprofessional healthcare workplace.
Methods
Epistemologically grounded in social constructionism, this research involved 19 individual and
11 group interviews with 67 UK medical trainees across all stages of training and a range of
specialties. Semi-structured interviewing techniques were employed to capture medical
trainees’ conceptualisations of leadership and followership. Interviews were audiotaped,
transcribed verbatim and analysed using thematic framework analysis to identify leadership
and followership dimensions which were subsequently mapped onto leadership Discourses
found in the literature.
Results
Although diversity existed in terms of medical trainees’ understandings of leadership and
followership, unsophisticated conceptualisations focusing on individual behaviours, hierarchy
and personality were commonplace in trainees’ understandings. This indicated the dominance
of an individualistic Discourse. Patterns in understandings across all stages of training and
specialties, and whether definitions were solicited or unsolicited, illustrated that context heavily
influenced trainees’ conceptualisations of leadership and followership.
1
Conclusions
Our findings suggest that UK trainees typically hold traditional understandings of leadership
and followership, which are clearly influenced by the organisational structures in which they
work. While education may change these understandings to some extent, changes in leadership
practices to reflect contemporary theory are unlikely to be sustained if leadership experiences
in the workplace remain based on individualistic models.
2
Introduction
Contemporary healthcare leadership is seen as something that should be distributed across
many levels of an organisation, undertaken by those most appropriate to the situation
regardless of position or profession (1-3). This is reported to improve the patient experience;
reduce errors, infection and mortality; increase staff morale; and reduce staff absenteeism and
stress. (4, 5) However, reports from different worldwide contexts have illustrated fundamental
failures in leadership in healthcare, highlighting that issues are related to traditional leadership
hierarchies (e.g. The 2013 Frances Report in the UK and the 2008 Garling Report in Australia).
In other words, there is a gap between theory and practice in healthcare leadership. With this in
mind, and with awareness of both the many different approaches to, and costs of, leadership
development, better understanding of how leadership is experienced in the interprofessional
healthcare workplace is essential to inform future leadership development practices.
Before considering the most effective ways in which leadership can be developed, it is
essential to consider the healthcare literature on this topic. We were particularly interested in
the broad Discourses of leadership in the healthcare literature. The word ‘Discourse’ with a
capital ‘D’ means adopting the Foucaldian view that Discourse is a system of thought that is
historically situated. (6-8) Using Discourse in this way characterises a way of thinking and
talking about a concept (such as leadership) that appears in a range of contexts (for example, in
research literature or policy documents) at a given time. (9) Although we did not conduct a
formal Discourse analysis of the literature, we identified four broad Discourses of leadership in
the grey and academic literature: individual, contextual, relational, and complexity discourses
(see Box 1 for a summary of these discourses).
[Insert Box 1 about here]
In medical education, leadership is often defined as a skill to be learned or a set of behaviours to
be developed. Training programmes often focus on the development of personal and
interpersonal leadership competencies through the use of competency frameworks. (24,-26)
For example, within the UK context, a ‘Medical Leadership Competency Framework’ was
3
developed in 2010 and more recently a ‘Healthcare Leadership Model’ has been created. (24,
27) In addition, the UK General Medical Council (GMC) document ‘Leadership and Management
for all Doctors’ pinpoints ways in which leadership ‘competencies’ can be met. (28)Perhaps
related to this competency focus, a recent systematic review of leadership education
programmes describes only a “modest” impact of training on knowledge, skills, attitudes and
behaviours. (29)
Traditionally, followers are understood to be the “recipients” of leadership who act on
and “moderate” the leader’s vision or goals. (30) Within the wider leadership literature there is
an acknowledged lack of specific discussion about followership, which is reflected in healthcare
educational research. (31, 32) For example, an interview study with community nurses
concluded that “following” was a complex process that contributed to the social construction of
leadership, suggesting that any future research should consider both leadership and
followership as interdependent concepts. (30)
Healthcare grey literature commonly argues for shared and distributed leadership,
mapping to a relational Discourse. (33, 34) However, empirical studies in healthcare have
focused on establishing leader traits, behaviours and styles, aligned with an individualist
Discourse (e.g. 35, 36). Other research perpetuates this individualism through focusing on
defining what makes a good leader or what attributes belong to whom (e.g. 37- 39). Fairhurst
and Uhl-Bein (40, p. 1044) however argue for leadership research approaches that ‘go beyond
individual based theorising and survey approaches to the interactional processes at the heart of
leadership’. Others have called for more distinct articulation of the definitions of leadership,
recognising the important role of context and organisational systems. (41, 42)
Often, participants of interview studies have already attained leadership roles within
healthcare or academic medicine. (43- 45) For example, interviewing sixteen medical education
leaders, Leiff and Albert (45) found four key areas of leadership practice (intrapersonal,
interpersonal, organisational and systemic) and that leaders preferred to link leadership
4
development to the workplace. Representing a departure from the perpetuity of individualist
approaches, this research takes into account wider contexts, relationships and systems that are
inherent parts of leadership processes. (44, 45)
There is however limited evidence on those who could be seen to be “developing” as
leaders (i.e. medical trainees or residents) and how they conceptualise leadership and
followership. This is despite the importance of leadership development at all stages of medical
careers being endorsed by medical regulators worldwide (46- 49). One of the few studies
published exploring early career doctors and nurses’ understandings of leadership found that
they conceptualised leadership differently. (39) These conceptualisations were influenced by a
range of sources, including educational background; professional roles; professional bodies; and
organisational expectations (see also 50). In contrast to the single specialty focus of much
research (51, 52), studies suggest that there is a need to explore variations in conceptualisations
of leadership across different groups and indeed contexts.
Souba (53) argues that the way in which leadership is conceptualised in a context,
affects how it is talked about and indeed, enacted. To date, no study has explored how medical
trainees conceptualise leadership and followership and how these conceptualisations map to
the differing leadership Discourses common to the grey and academic literature. In addition,
there is a need to explore how different contexts might influence trainees’ understandings of
leadership and followership. Therefore, this paper aims to answer the following research
questions: What do medical trainees most commonly understand by the terms “leadership” and
“followership”? What leadership Discourses do trainees’ definitions of leadership and
followership map to? Thinking about the importance of context, how do conceptualisations of
leadership and followership vary according to stage of training and specialty?
Methods
Based on the premise that meaning is constructed through social interaction, this research is
epistemologically grounded in social constructionism. (54) This epistemological stance aligns
5
with our theoretical viewpoint that leadership is a socially constructed process that is both
relational and contextual. (40) In order to answer the research questions aiming to understand
multiple perspectives and interpretations of reality, an interpretive approach using thematic
framework analysis of group and individual interviews was employed. (54, 55)
Sampling and recruitment
Upon receiving ethical approval and appropriate institutional consents, medical trainees from
two UK Deaneries (covering both urban and rural locations), were invited to participate in
either a group or individual interview. In order to elicit as broad a range of understandings as
possible, maximum variation sampling was used to ensure diversity in terms of gender,
ethnicity, training stage, specialty and location. Recruitment was initially by email through
relevant gatekeepers within the Deaneries. Following this, further recruitment was achieved by
presenting flyers at trainee teaching sessions and snowballing. (56)
Data collection
A series of group and individual interviews were carried out at a time and place convenient for
participants. Individual interviews were offered when group interviews were not possible (e.g.
due to work schedules). Following written consent, participants were asked to complete an
individual written data sheet, which included demographic questions, plus space to provide free
text answers to the questions: “What is leadership?” and “What is followership?” An interview
schedule was designed to provide guidance to the interviewers as to the structure of the
interview for consistency in approach. Relevant to this paper, participants were asked about
how they defined leadership and followership and to explore their experiences of healthcare
leadership and followership (at this point narrative interview techniques were used and are
reported elsewhere: 57). All interviews were audio-recorded (with permission) and along with
the written answers to the free text questions, transcribed.
6
Data analysis
Thematic framework analysis was undertaken. (55, 58) Familiarisation of data occurred by
listening to audio-recordings while reading transcripts. At this point, all transcripts were
checked for accuracy and paralinguistic features (e.g. pauses, laughter) were added and data
were anonymised. The research team then developed a thematic framework through discussion
and negotiation of key themes. An initial coding framework was drafted which included both
what participants said and how they said it (this was done by listening to the interviews whilst
reading transcripts). All data pertaining to trainees’ definitions of leadership and followership
were coded as dimensions of leadership and followership (‘dimensions’ being akin to the
‘themes’ of the definitions) using Atlas-Ti version 7.0. New dimensions were added as and when
identified (and agreed through further discussion within the research team).
In addition, we coded these definitions as either solicited, when participants were
specifically asked to define leadership and followership, or unsolicited, when participants
volunteered a definition of leadership or followership as part of the general discussion or within
narratives. Differentiating between solicited and unsolicited definitions allowed us to make
comparisons between structured and unstructured parts of the interviews and perhaps identify
differences in explicit/conscious and tacit/unconscious understandings of leadership and
followership. (59) These definitions were then mapped to the Discourses of leadership common
in the literature: individual, contextual, relational and complexity (see Box 1).
Atlas.ti software allowed us to explore patterns in the data in terms of differences
between trainee groups. It is increasingly common within qualitative research to numerically
explore such patterns through the use of computer assisted qualitative data analysis software
(CAQDAS). (60) We interrogated the data according to four specialty groupings: surgical
(including trauma and orthopaedics, general surgery, ENT, obstetrics and gynaecology); medical
(including general medicine, emergency medicine, psychiatry, cardiology, renal medicine, acute
medicine, paediatrics and core medical training); General Practice; and service specialties
7
(including anaesthetics, radiology and pathology). We also explored patterns in the data
according to training stage: early-stage (including foundation trainees, core trainees and
specialty trainees who were up to and including the half-way point of specialty training); and
higher-stage (which included trainees who were beyond the half-way point of their specialty
training up to certificate of completion of training.
Results
We conducted eleven group and nineteen individual interviews with 67 medical trainees (25
male: 42 female; 53 white: 14 non-white) from early-stage (34) and higher-stage (33)
postgraduate medical training. Participants included 23 GP trainees, 13 medical trainees, 11
surgical trainees, 10 service trainees and eight foundation doctors (who had not yet entered
specialty training). Individual interviews lasted between 29 and 52 minutes (average 37.9) and
group interviews lasted between 37 and 80 minutes (average 52.5), totalling nearly 22.5 hours
of transcribed audio data.
Definitions
Discussion about leadership and/or followership focused on patient care or how the clinical
environment in which trainees worked was led and managed. Leadership of the wider NHS was
only occasionally mentioned. Across the dataset, we identified 347 explanations of leadership
and 131 explanations of followership (‘explanations’ refer to sections of talk that were
specifically linked to defining leadership and followership). Within these broad explanations, we
identified multiple, distinct definitions of leadership and followership. In total, we coded 757
definitions of leadership (414 solicited and 343 unsolicited) and 317 definitions of followership
(302 solicited and 15 unsolicited).
Dimensions of leadership
Through our analysis of what trainees said, we identified 15 leadership dimensions. These
included leadership as: behaviour; role; hierarchy; group process; personality; principles and
8
values; responsibility; skills; emergent; management; knowledge; gender; exclusive; not
management; and followership. Table 1 presents the eight most commonly used (and therefore
arguably the most robust) leadership dimensions, with associated illustrative quotes 1-8.
Within solicited definitions, leadership behaviours were seen to be conducive to good
leadership. Behavioural descriptors included coordinating; delegating; supporting; facilitating;
clear decision-making; directing; setting an example; optimising performance and efficiency
(see Table 1, Quote 1). Leadership as behaviours was often coded alongside leadership as a
group process (see Table 1, Quote 4). Leadership was also seen to come through designated
interprofessional roles, identifying “doctor” with automatic “leader-status”. Within their own
profession, trainees saw “role” and “hierarchy” as linked. “Clinical leader” was associated with
the most senior person present, which could be a trainee, particularly during out-of-hours care
(see Table 1, Quote 3). Effective leadership was related to good team performance and a sense
of belonging. Also popular was ‘leadership as personality’, with trainees talking about certain
individuals being ‘naturally’ drawn to leadership and being charismatic or dominant (see Table
1, Quote 5). Some expressed anxiety that they may not possess these qualities and therefore
may not be ‘the right person’ to undertake leadership.
The data revealed differences in dimensions between solicited and unsolicited talk (see
Table 1, third and fourth columns). In solicited talk, trainees spoke more about leadership as a
group process. In unsolicited talk, however, trainees focussed on leadership being an inherent
personality trait. Also central to unsolicited discussion were hierarchical leadership
relationships (see Table 1; Quotes 3 and 5).
[Insert Table 1 around here]
9
Dimensions of followership
Trainees found it more challenging to define followership, often explicitly stating that they had
not heard of the term. Paralinguistic features such as pauses, hesitations and laughter were
indicative of this challenge to articulate their understandings. Through discussion, trainees
began to define the term and we identified thirteen dimensions of followership, including
followership as: behaviour; active participant; group process; unknown term; passive;
hierarchy; personality; role; non-leadership; negative; emergent; responsibility; and
responsibility-free. Table 2 depicts the eight most commonly identified followership
dimensions, again chosen as most robust (with illustrative quotes 1-8).
Across the dataset, trainees commonly referred to followers as a group of people rather
than individuals. Unlike the definitions of leadership behaviours, which had positive
connotations, trainees described followership behaviours in both positive and negative ways.
Definitions of positive follower behaviour included working constructively and actively
engaging with leadership (see Table 2, Quote 1). More negative follower behaviour descriptions
included following instructions ‘blindly’ and perceiving followership to be more ‘cult-like’
behaviour than team working. Followers were seen to be able to facilitate or inhibit the move
toward a goal according to whether they agreed or disagreed with the leader’s vision.
Unlike their definitions of leadership which trainees related to the context of the
healthcare workplace, talk about followership was more hypothetical in nature. In fact, as
discussion moved on and trainees were not responding to direct questioning about
followership, explanations of followership became scarce. In total, we identified only eight
specific explanations of followership within unsolicited discussion, coding a total of 15
definitions across all data (see Table 2; fourth column). The focus of these unsolicited
definitions revolved around how an individual’s personality or the medical hierarchy could
define a person as a follower (see Table 2; Quote 6).
[Insert Table 2 about here]
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Discourses of leadership and followership
Trainees’ talk mapped to all four leadership Discourses identified within the literature (see
Table 3). Differences in Discourses were noted between solicited and unsolicited talk (discussed
below).
Individual Discourse
As the most commonly identified Discourse mapped to talk across the dataset (see Table 3, 1st
column), trainees would single out “the leader” within their workplace. Individualistic ideas
about defining leadership were articulated through descriptions of individual behaviours,
personality and leadership style. Trainees also described leaders individualistically with
relation to designation and role, defining an individual as the leader through their knowledge
and expertise (see Table 2, Quote 8).
Contextual Discourse
Trainees explained that they might approach certain leaders for certain things (e.g. to resolve
conflict) and others for different issues (e.g. career planning). Trainees also described how in
certain contexts (e.g. surgical theatre), different individuals would take on leadership as it was
appropriate to their position and responsibilities within that context (see Table 1, Quote 7).
Leaders were also seen to adapt their leadership style according to the situation, for example, as
they moved from routine clinical care to an acute cardiac arrest.
Relational Discourse
Effective team working and how leaders coordinated and facilitated this was the focus of much
discussion, particularly within solicited definitions. Trainees saw team members (or followers)
as key to influencing a leader’s decisions; and who the leaders and followers were in their
workplaces were thought to remain static (see Table 2, Quote 3). Trainees also aligned with a
relational Discourse when discussing the medical hierarchy, in particular from the perspective
of defining their own position within that hierarchy (see Table 2, Quote 6).
11
Complexity Discourse
Trainees talked about leadership and followership being a process rather than something
attributed to an individual. Leadership was seen as a dynamic entity that moved around the
healthcare team and was negotiated according to the situation. Trainees talked about the
complex interplay between individuals, relationships and context and described “stepping
forward” or “stepping back” into leadership or followership roles according to the needs of the
immediate situation at hand. Complexity was the Discourse least mapped to talk across the
dataset.
[Insert Table 3 about here]
Solicited and unsolicited Discourses
Differences between solicited and unsolicited discussion were noted (as mentioned above). As
interviews progressed to talk about workplace experiences of leadership, trainees’ dimensions
typically turned to personality, role and hierarchy. Thus, in unsolicited discussion, there was an
increase in participants’ talk aligning with an individualistic Discourse, with a simultaneous
reduction in the extent to which they aligned with a relational Discourse (see Table 3, column
1).
Differences in dimensions of leadership and followership
Finally, we present differences and similarities by training stage and specialty group.
Differences by training stage
In solicited discussion, early-stage trainees described leadership as behaviours, personality, role
and hierarchy and were more likely to align with an individual Discourse (see Table 3). In
contrast, higher-stage trainees were more likely to align with a relational Discourse (see Table
3). However, in unsolicited talk, similar to early-stage trainees, higher-stage trainees’ definitions
turned to personality and an individual’s “ability” to lead or their position within the medical
hierarchy, aligning more prominently with the individual Discourse (see Table 3).
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For higher-stage trainees, leadership was seen to come with increasing clinical
responsibility, experience and time served. Some higher-stage trainees expressed concern about
preparation for the transition to consultant. Despite feeling ready clinically to take on the
“leadership role”, they expressed feelings of unpreparedness for the non-clinical responsibilities
of the trained doctor role.
Early-stage trainees defined leadership as something one could ‘step into’ or ‘step down’
from according to what was right for patient care at the time. Often this definition was in the
context of interprofessional working and leadership could come from a different (and perceived
as non-traditional) professional such as a nurse. Some saw this as a dilemma, stating that in
their role as “doctor” they should be taking the lead. Early-stage trainees were also more likely
to state that they had not heard of the term followership.
Differences by specialty group
Differences were noted in the types of behaviours typically described by different specialty
trainees. For example, GP, medical and service trainees linked leader behaviours with group
processes, principles and values and most commonly aligned with a relational Discourse to
define leadership behaviours, describing coordination, supporting and listening to group
members as important leader behaviours (see Table 1; Quotes 4 & 6). In contrast, surgical
trainees saw decision-making, providing direction, setting an example, optimising performance
and efficiency as important leader behaviours. The surgical specialty group did talk about the
leader-follower relationship in the context of “providing support and guidance” but this talk was
focussed on an individual’s influence on another with the aim of persuading them to do
something (see Table 1; Quote 1). Surgical trainees also stated that there was a clear-cut
hierarchy within theatre with the consultant at the top as ‘ultimate leader’.
In terms of followership, GP, medical and service trainees in particular, described a
follower as an active member of the group who contributes to team goals and the group’s
direction. These trainee groups saw that although the decision-making would often come from
13
the leader, it was up to a follower to participate in the process and often decide how to
‘implement’ those decisions. A follower was seen to be responsible for their actions, but
ultimately needed to undertake the leader’s instructions. Similar to their definitions of
leadership, service trainees understood skill, job role and experience as dependent on how
active a follower could be (see Table 2; Quote 8). It was common for these trainee groups to
align with a relational Discourse when defining followership (see Table 3). Surgical trainees
used the medical hierarchy and roles within that to define who the followers were; very few saw
the leader-follower relationship as a two-way process. Types of behaviours attributed to
followers by surgical trainees included deference, compliance, taking instruction or asking for
help (see Table 2; Quote 5). For some surgical trainees, the word ‘follower’ indicated inaction
rather than active team membership.
Discussion
This research focused on how medical trainees conceptualise leadership and followership. At
the outset, trainees concentrated on the clinical environment and clinical leadership, which is
perhaps unsurprising given the point at which participants were in their careers. (61)
We framed our questions differently from previous leadership research. Rather than
focusing on an individual’s behaviour, traits and skills, (40), we asked participants ‘what is
leadership’ and ‘what is followership’ rather than ‘what’ or ‘who’ makes a good leader. Through
this approach, we explored the multiple ways leadership and followership can be defined.
Despite the breadth of dimensions identified, the preference was for more unsophisticated ways
of understanding leadership (such as behaviours, hierarchy, and personality), particularly in
unsolicited talk, highlighting that an individualistic focus dominates medical trainees’
understandings. This suggests that educational approaches, which emphasise leader-follower
relationships and distributed leadership processes are required to narrow the theory-practice
gap. (5, 33, 34)
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Initial difficulties in trainees defining followership gave way to descriptions echoing
contemporary definitions of leader-follower relationships in the literature; for example, with
followers sometimes constructed as active participants in the leadership process. (62) However,
much of this talk was hypothetical in nature and as discussion moved on to unsolicited talk,
explanations of followership became scarce. This may be related to our observation that use of
the terms ‘follower’ and ‘followership’, although commonplace within contemporary leadership
literature, are not widely utilised within healthcare spheres. The term for ‘follower’ and
‘followership’ in healthcare is arguably ‘teams’. (4, 24, 26) For example, within the UK, the
Healthcare Leadership Model uses ‘team’ and the promotion of ‘teamwork’ when talking about
leader-follower relationships. (24) Interestingly, trainees commonly recognised that leadership
was a group process, thus indicating an awareness of the importance of relationships. Medical
educators should therefore ensure that consideration of followers and followership is an
integral part of any educational intervention.
We found that trainees’ talk aligned with all four leadership Discourses when
articulating their conceptualisations. Although participants’ talk most commonly aligned with
an individualistic Discourse across the data, they were more likely to align with the more
sophisticated relational Discourse within solicited talk. Similar to current definitions of
leadership in the literature, many trainees identified that the aim of leadership was to
coordinate or influence a team to move in a particular direction. (20, 21) In unsolicited talk,
however, we identified a clear focus on individual leaders.
As discussions progressed within the interviews to talk about workplace experiences of
leadership, trainees’ definitions aligned even more closely with traditional, historical
conceptualisations in which personality, roles and hierarchies defined who a leader was (or was
not) perceived to be. (63) The differences between solicited and unsolicited talk may be
indicative of the overarching Discourses within healthcare literature of a “shared” approach to
leadership, which may have influenced trainees’ solicited definitions. (4, 5, 34, 35, 46) This
15
contrasts with their unsolicited talk, which instead may reflect trainees’ actual workplace
experiences of leadership and followership, which would seem to reinforce individualism.
Similar influences have been found in medical students’ understandings of professionalism and
thus it highlights the importance of workplace experiences in learning about leadership. (58)
Exploring differences in conceptualisations between training stages, revealed earlystage trainees held less sophisticated conceptualisations of leadership than higher-stage
trainees. This could reflect their limited workplace experiences of leadership and their inability
to yet draw on any formal leadership development programmes (these being typically reserved
for higher-stage trainees in the UK). (64)
Our research also highlighted the influence of context (in terms of specialty grouping)
on trainees’ conceptualisations of leadership. Willcocks identified six factors that influence
cultural context within different medical specialties including historical background; nature of
the work and use of technology; internal/external relationships; individualism and motivation;
inter-specialty interaction and communication; and values and socialisation, and argued that
different specialty cultures experience “management” (and thus possibly leadership) in
different ways. (50) For example, surgery is well known for its traditional hierarchical practices.
The use of various tools to rate surgeons’ leadership behaviours, including example setting and
individual performance indicators, might, for example, perpetuate an individualistic Discourse
with respect to surgical leadership (51, 52, 65). Educational practices within specialties may
also influence conceptualisations of leadership and followership, for example, within
anaesthesia leadership is seen as a non-technical skill to be learned. (66) Given these factors, it
is perhaps unsurprising that differences in conceptualisations were identified across specialties.
(50) The differences in specialty groups, again, highlight the important role that context and
educational influence can play on how leadership and followership is conceptualised.
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Methodological strengths and challenges
To our knowledge, this is the first study that has sought to explore medical trainees’
understandings of leadership and followership; what Discourses of leadership and followership
dimensions align with; and what similarities and differences exist between trainees from
different stages of training and specialties. Our study was multi-site and drew participants from
a wide range of specialties. Therefore, we suggest that our study has a degree of transferability.
(67) Although our team-based approach to data analysis encouraged rigour, we acknowledge
the lower proportion of male doctors and non-white trainees in our sample. Although
demographically reflective of trainees within this UK country, it may mean that our findings are
less transferable to these groups. (68) In addition, our findings are likely to be specific to UK
training programmes, and may not therefore be transferable outside of the UK where there are
different healthcare practices, systems and education. We only interviewed medical
professionals and future research should consider broadening our approach to include the
wider interprofessional team. Also, although our data suggests differences between early- and
late-stage trainees, our study was cross-sectional rather than longitudinal. There is a gap in the
literature therefore in terms of exploring how conceptualisations of leadership change as
doctors move through their different training experiences and as they become socialised into
specialty-specific cultures and practices.
Educational Implications
Our study has implications for future educational approaches to leadership in the
interprofessional healthcare workplace. In terms of designing leadership programmes and
frameworks, medical educators should acknowledge that a “one-size-fits-all” approach based on
individualism is inappropriate for complex healthcare systems (24, 26), and should instead
consider how best to introduce and embed more contemporary leadership practices which have
the potential to improve practice. (4, 5) However, given that we found that UK trainees’
outdated understandings of leadership and followership are clearly influenced by the context
and organisational structures in which they work, formal education itself is unlikely to lead to
17
change. Rather, change, in terms of the enactment of leadership playing out differently in
healthcare environments, is required before more sophisticated understandings of leadership
and followership can evolve. There is therefore a need for workplace-based learning where
trainees can develop their understandings of leadership and followership and better align those
with modern theoretical thinking, underpinned by the complexities of workplace context,
relationships and organisational structures.
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Contributors
All authors contributed to the study conception and design. LG contributed to data collection
and analysis and wrote the first draft of the paper and edited various iterations. All interviews
bar one were undertaken by LG. CER undertook one of the group interviews and listened back
to the audio recordings of several initial interviews in order to provide feedback on interview
technique to LG. CER also contributed to the data analysis and edited each iteration of the
article. JK and JC contributed to data analysis and also commented on various iterations of the
paper.
Acknowledgements
The authors wish to thank all participants in this study, the Scottish Medical Education Research
Consortium (SMERC), NHS Education for Scotland (Scottish Deanery) and Professor Tim
Dornan, Queens University Belfast, who contributed to the initial stages of data analysis in his
role as Visiting Professor for SMERC.
Funding
This research was part of LG’s PhD research at the Centre for Medical Education, Dundee, which
was generously funded by NHS Education for Scotland through SMERC.
Conflicts of Interest
None.
Ethical approval
This study was approved by the University of Dundee Human Research Ethics Committee.
19
Box 1: Discourses of leadership
Discourse
Definition
Example Theories
Individualistic
Focus is on leaders as individuals
exerting ‘power’ over others to
meet leader-defined goals.
Context determines how a leader
behaves: either the leader ‘flexes’
to the context or the context
‘flexes’ for the leader.
Focus is on the leader-follower
relationship. Relationship is either
based on exchanges between
leaders and followers
(transactional) or the leader’s
ability to ‘inspire’ followers to act
(transformational).
Leadership is a process generated
through interactions between
team members. Leaders are thus
socially constructed through this
interaction. Leadership is available
to all. Included in this are followercentric theories.
Leadership is an emergent process
occurring within complex adaptive
systems. The leadership process is
affected by relationships, context,
systems (local and organisational)
and time. Leadership is distributed
across an organisation at all levels.
-Trait theory (10, 11)
-Skills theory (12)
-Styles theory (13)
-Situational leadership theory (14)
-Least preferred co-worker theory
(15, 16)
Contextual
Early relational
Current relational
Complexity
20
-Leader-member exchange theory
(17, 18)
-Transformational leadership
theory (19)
-Shared leadership (20)
-Distributed leadership (21)
-The romance of leadership (22)
-Complexity leadership theory (23)
Table 1: Top 8 dimensions of leadership*
*Please note that although these quotes are used to illustrate a particular dimension of leadership, many were multi-coded and
it is therefore possible for the reader to associate the quotes with additional dimensions.
Leadership
Dimension
Overall
No.
Solicited
No.
Unsolicited
No.
Definition
Illustrative quote (Quotes 1-8)
Leadership as
behaviour
176
114
62
Leadership is defined as behaviour including:
effective communication; effective delegation;
confidence; coordination; setting example;
decision-making etc.
54
52
Trainees describe the expectation by
themselves and others in the
interprofessional workplace that as doctors,
they are the leader. Trainees also talk about
leader as a named role or described as stagespecific e.g. GP or consultant equals leader.
94
42
52
Leadership is talked about as something that
is part of the medical or interprofessional
hierarchy. This includes when a junior
trainee, as the most senior person within a
context, will automatically be the leader.
Leadership as
group
process
82
66
16
Leadership as
personality
80
28
52
This dimension is focussed around team
working that is both uni-and interprofessional. Trainees talk about leadership
as a process that is part of team working and
closely related to team performance through
a sense of belonging and with a focus on
group goals.
Examples of this include trainees’ talk about
dominant personalities or individuals being
“natural” leaders. Other data talks about
people who prefer to be in21
leadership
positions. Often within this dimension there
Quote 1: P33 (Female/surgical/higher-stage):
“I think communication probably is a huge part, erm, in being
able to ask or tell people to do things, erm, but also maybe
just sort of show by example or, erm, gently sort of move
people or, you know, cajole them to give information or do
things, erm, that kind of thing…”
[Solicited conceptualisation]
Quote 2: P4 (Male/GP/higher-stage):
“General practice is… a funny beast compared to… the
hospital you can see where the leadership comes, they [the
consultants]… go on the ward rounds, they have a the lead,
their junior doctors with them… In general practice it’s a
team of one so I’ll, I’ll see 20-odd people in here during the
course of a day, and I’m I am the, the single lead for
recognising and investigating, and passing out to other
individuals for further information…”
[Unsolicited conceptualisation]
Quote 3: P5(Female/surgical/higher-stage):
“When I do on-call out-of-hours, I am the leader, I guess, of
the medical team running [specialty name] ward. So I have a
junior trainee who might be looking to me for advice and
guidance”
[Unsolicited conceptualisation]
Quote 4: P56(Female/service/higher-stage):
“…if you’re working within a group, then, I think, you have to,
to make the right decisions, you have to be aware of what the
overall opinion of the group is…you’ve got to be very attuned
to people’s feelings within it…”
[Solicited conceptualisation]
Leadership as
role
106
Leadership as
hierarchy
Quote 5: P53 (Female/medical/higher-stage):
“it (a leadership course) makes you understand the
theory…but even a day’s course they say, ‘You know, you
realise that you need to be more assertive,’ that’s all very well
P55 (Female/medical/higher-stage): Uh-huh, yeah.
was discussion about whether leaders were
“born” or “made.
Leadership as
principles
and values
59
31
28
Trainees talked about a leader being fair,
approachable, coaching and supportive, and
allowing followers to develop and learn.
Leadership as
responsibility
56
29
27
Trainees describe how leadership equates to
clinical responsibility. The person who has
ultimate clinical responsibility within a given
situation was perceived to be the leader.
Leadership as
skills
35
15
20
Trainees describe leadership as skills such as
e.g. negotiation skills, delegation skills. This
differs from behaviours in that there is
specific mention of skills. Trainees also
describe specific clinical skills that identify a
person as the clinical leader.
22
P53: but if you’re not that by nature, how do you go and put
that into practice?
P55: Yeah.
R53: You can’t suddenly stand up to somebody.
P51 (Female/medical/early-stage): Um, you can’t change
your personality.” [Unsolicited conceptualisation]
Quote 6: P37 (Female/GP/early-stage):
“You have to be seen to be fair, the leader as well, I think...You
can’t be seen to be putting your friends and yourself above
the other people”
[Unsolicited conceptualisation]
Quote 7: P50 (Male/service/higher-stage):
“because it’s as in medicine leadership is a, or superiority is
with responsibilities so if somebody is responsible then there
the buck stops. It’s buck stops at the leader so whoever is the,
so I’ve had a consultant who just jokingly saying, he said,
“Why I get more paid because if this patient dies I’m the one
who gets to go to coroner, not you so why I’m a consultant
and you are a trainee.”
[Unsolicited conceptualisation]
Quote 8: P3 (Male/surgical/higher-stage):
“on a surgical point of view is, is your operating skill and the
things that you do that are different from others that you
think are better.”
[Solicited conceptualisation]
Table 2: Top 8 dimensions of followership
Followership
Dimension
(n=13)
Followership
as behaviours
Overall
No.
Solicited
No.
Unsolicited
No.
Definition
Illustrative Quote (Quotes 9-16)
76
73
3
This dimension focuses on followership
being a set of individual behaviours which
trainees perceive to be typical within the
healthcare workplace.
Quote 1: P51 (Female/medical/early-stage):
“working constructively under somebody but if you’re
something that you were completely thought was wrong
then you don’t necessarily have to do it even though you’re
not the leader of the team. Like, as long as you’ve you gone
about it appropriately.”
[Solicited conceptualisation]
Followership
as active
participant
44
43
1
Trainees described followers choosing who
the leaders are in a given situation or
through actively supporting (or not
supporting) the leader.
43
42
1
Followership
as unknown
term
35
35
0
Followership
as passive
24
24
0
This dimension describes trainees’
understandings of the role that followers
have to play within a team. Within this,
followers are seen to be team members and
team players. Some trainees described the
term “follower” and “team member”
interchangeably.
Here, trainees explicitly state that
“followership” is an unknown or new term.
Some trainees questioned whether the term
had been made up for the purpose of this
study.
Here, trainees see followership as passive.
Trainees describe following instructions
“blindly” and with no participation in
decision-making about group goals.
Quote 2: P57 (Male/service/early-stage):
“…you [as a follower] can have a huge influence and come up
with lots of ideas and, you know, by providing quality
control, you actually have a lot of influence on the leader…in
a group setting, you’re contributing to the overall
vision…ensuring that that particular all the goals, or aims
are are achieved.”
[Solicited conceptualisation]
Quote 3: P48 (Male/service/higher-stage):
“forming part of a team are, have bought into whatever the
vision is that the leader has set, and, er, are going to work as
a team with the same end goal in mind as to how they get
there. They may be taking on different roles, but the goal is
the same.”
[Solicited conceptualisation]
Quote 4: P42 (Female/foundation doctor):
“I don’t know, I was filling that (the form) out and it is like
‘what does that mean?’, I’m like I don’t really know like.”
[Solicited conceptualisation]
Followership
as group
process
23
Quote 5: P65 (Male/surgical/early-stage):
“…it's the implicit assumption that you would, I suppose,
well, so if my boss in theatre says, ‘do this’ and he has a
certain tone in his voice, I know it needs to be done
immediately and I'm not to discuss that. This is not, this is
not an open invitation, it's ‘you must do this now’ and, you
know, that's the message given. So is that followership that
Followership
as hierarchy
22
19
3
Trainees link followership talk about the
clear-cut assumption that if there is someone
more senior present trainees will defer to
them and are therefore followers.
Followership
as
personality
17
14
3
Followership
as role
16
14
2
Trainees talk about followership as
something relating to someone’s personality.
They were often seen to be lacking
leadership traits and therefore by default
they become a follower.
Trainees expect junior doctors to be the
followers within the interprofessional
healthcare workplace. This dimension is also
relevant when trainees are talking about
interprofessional roles and expectations of
who should lead and who should follow, e.g.
doctors as leaders and nurses as followers.
24
in certain situations I am going to just do what I'm told
basically.”
[Solicited conceptualisation]
Quote 6: P2 (Male/medical/early-stage):
”…the nature of our job is that there’s always an F- a junior
who’s just qualified, and there’s always someone that’s about
to retire, and you’re somewhere in the middle of that and the
further on you go, the more, sort of, people there are below
you to ask you to look to you for advice”
[Unsolicited conceptualisation]
Quote 7: P59 (Female/ foundation doctor):
“…if you’ve not had any training in leadership then it’s easier
just to be a follower if that’s your personality”
[Unsolicited conceptualisation]
Quote 8: “P46: (Male/service/higher-stage):
“Well there are situations where you just don't have the, you
know, ability or expertise to actually take on a leadership
role at, you think surgery, for example, you know, the scrub
nurse to the surgeon, you know, he knows what he’s doing,
they are all working for his one goal, so she’s going to follow
his instruction…”
[Unsolicited conceptualisation]
Note: This quote was also coded as followership as gender
Table 3: Discourses of leadership and followership*†
This table describes the distribution of the broad Discourses of leadership that aligned with trainees’ dimensions. We coded Discourses to each broad explanation
rather than each distinct dimension, thus the numbers within this table are lower than in Tables 1 and 2. In addition, the percentages within this table are rounded
to the nearest whole number and are depicted as a percentage of talk across the four Discourses.
*
†It
is useful to note that the numbers within the columns do not add up to the totals presented in the first column. This is for two reasons: (1) due to the nature of
the group interviews, an explanation of leadership could be attributed to more than one participant. An explanation resulting from discussion between an early and
a late-stage trainee for example would therefore be coded to both groups; and (2) Within the specialty groups, foundation trainees are excluded..
Overall
Discourses of leadership
Speciality
Training Stage
Total
% of talk
Solicited/
Unsolicited
GP
% of talk
Solicited/
Unsolicited
Surgical
% of talk
Solicited/
Unsolicited
Medical
% of talk
Solicited/
Unsolicited
Service
% of talk
Solicited/
Unsolicited
Early stage
% of talk
Solicited/
Unsolicited
Higher stage
% of talk
Solicited/
Unsolicited
Individual Discourse:
42/57
46/49
53/66
29/62
28/53
49/53
37/64
Contextual Discourse
10/15
6/11
3/20
14/10
25/23
8/15
12/14
Relational Discourse
41/21
40/32
37/10
51/23
38/15
37/24
43/16
Complexity Discourse
7/7
8/8
7/3
6/5
9/8
6/8
7/6
Total
% of talk
Solicited/
Unsolicited
GP
% of talk
Solicited/
Unsolicited
Surgical
% of talk
Solicited/
Unsolicited
Medical
% of talk
Solicited/
Unsolicited
Service
% of talk
Solicited/
Unsolicited
Early Stage
% of talk
Solicited/
Unsolicited
Higher Stage
% of talk
Solicited/
Unsolicited
41/50
35/100
55/67
45/0
40/0
42/40
43/67
Discourses of followership
Individual Discourse
Contextual Discourse
Relational Discourse
Complexity Discourse
(solicited/unsolicited)
4/0
3/0
9/0
0/0
8/0
2/0
6/0
48/25
55/0
32/33
55/0
44/0
47/20
46/33
7/25
7/0
4/0
0/0
8/100
11/40
5/0
25
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