Table 5 Context-mechanism-outcome configurations with example quotes
Feedback | |
|---|---|
Timeliness of feedback | |
CMO1 | Leadership interventions are successful in improving leadership (O) if feedback is delivered timely (C) as this makes feedback more relevant and focused as it is fresh in the memory (M) |
Vu, 2020 [63] | “Formal written feedback was often received in a delayed fashion, limiting its usefulness to help residents change their behavior in a timely fashion” |
Somasundram, 2018 [60] | “In addition, immediate critique from consultant urologists and freeze-frames to discuss performances were also highlighted as useful for the participants’ learning” |
Stakeholder | “Feedback is most effective if it is done in real-time rather than a week later or two weeks later.” |
CMO2 | Leadership interventions are successful in improving leadership (O), if feedback are being provided in a timely fashion (C) as this increases surgeons’ faith that their problems recognised and prioritised (M) |
Brindle, 2018 [34] | “Feedback on the issues raised in the debrief was commonly regarded by the clinical leaders as the cornerstone to successful debriefing” “Providing caregivers with early and meaningful feedback on identified problems gave the participants the satisfaction of seeing their problems recognized and prioritized, allowed repetitive issues to be addressed and gave the participants faith that the de- brief achieved a purpose.” |
Stakeholder | “For example, in the theatre environment it is much better if members of staff are speaking up early as this mean you can address them early before they become a real problem.” |
Recurrent feedback | |
CMO3. Leadership interventions are successful in improving leadership (O) if feedback is delivered multiple times (C) as this reinforces learning (M) | |
Gregory et al., 2018 [42] | “Conduct a short follow-up survey of the same raters within 3 to 6 months of the baseline to provide feedback about any behavioral changes to reinforce improvement.” |
Vu, 2020 [63] | “Formal feedback often omitted any mention of a resident’s leadership performance and was too infrequent to be useful.” |
Sinclair, 2015 [59] | “The ideal frequency of mentoring sessions is monthly, although flexibility is required.” |
Hart, 2020 [43] | “There was a significant relationship (p < 0.0001) between satisfaction with mentorship and frequency of meetings with a mentor, as well as with how mentors were selected (assigned versus found on their own). Those who found their own mentor and met annually reported the lowest average mentor satisfaction (26%), while those who met every 6 months or more reported an average satisfaction of ≥ 80%, regardless of whether their mentor was self-identified or assigned. Residents who met weekly or monthly with their mentors reported 100% satisfaction regardless of how the mentor was selected.” |
Stakeholder | “A snapshot is that – a snapshot. Over time, if you spend more time with people – it is very hard to maintain a façade indefinitely. If you ever meet someone once and then you never see them again – it is easy. Multisource feedback should happen over time-dependent process as opposed to one-off-judgement.” “Feedback has to be delivered multiple times not only because it reinforces learning but I think it encourages trust and it improves the whole processes, communication, trust, team building all of that I think. Cannot happen just as a one-off snapshot.” “I have been on quite a few leadership courses now and even the one that […} The (……) programme – I think what helped with that is that initially it was just a one off – two day course and that’s it – you never see them again – I think it is of less value than over a period of time with the same group of people that you go to,engage with more people are much more – find it much easier to open up and talk freely after the first few sessions cause we got to know each other (….) |
Feedback delivery by a trusted, respected person | |
CMO4. Interventions are successful in improving leadership skills (O) if feedback is delivered by a trusted, respected person (C) as this makes participants want to improve to maintain the trust and respect (M) | |
Pradarelli, 2016 [57] | “Some of the coaches with less experience tended to not be able to “make an impression, [and were] too generic.” In contrast, surgeons who had more experienced and reputable coaches found the coaching sessions “insightful and … nice to have [an] objective person to go over 360 [evaluations].” Having a thoughtful, outside perspective provided a “reality check” for participating surgeons.” |
Gregory et al. 2018 [42] | “Use a trained mentor or coach to review results, address any pushback, and set leadership excellence goals” |
Vu, 2020 [63] | “One resident pointed out, “You’d want to pick people very carefully. Having people...involved where it’s going to feel like any feedback you get is very much constructive and not intended to make you feel bad about anything.” Second, the mentor could provide a valuable third-party perspective to corroborate or reflect on comments from evaluations. As one resident noted, “You could have the opportunity to sit down with someone...who sees everyone’s results and can say, ‘Here’s how you seem to be standing among your peers.” |
Stakeholder | “I think by trusting and respecting something I think there’s almost this sort of need or feeling that you actually want to try and accomplish something partly because you want sort of positive feedback from the person that you trust.” “If a trusted colleague of mine said oh actually I think this is an issue or giving feedback I am more likely to take that seriously because I trust and value that individual’s judgement and relationship more than someone who I have never met before.” |
Feedback from a range of trusted and respected people | |
CMO5. Leadership can be improved if (O) feedback and insights are delivered from a range of trusted and respected people (C) as this provides a broader picture of yourself (M) | |
Gregory et al., 2018 [42] | “Balance the rater selection process by inviting both participants as well as their leaders to select from a large pool of potential raters to help ensure both comprehensive and diverse feedback perspectives” |
Vu et al. 2020 [63] | “On the whole, residents desired a formalized system to collect and deliver feedback on their leadership performance, especially from multiple sources including junior residents, advanced practice providers, and nurses.” |
Cochran, 2019 [36] | All participants described the need for multiple mentors across time and professional roles, providing an overarching them Thirteen participants described a process of developing an intricate and complex system of multiple advisors rather than having 1 mentor who provided all necessary career guidance across the professional lifespan. Participants sought multiple mentors, each with a particular area of expertise, who could provide direction, for example, to their unique phase of career development, discipline and institution, and specific clinical and scholarly needs |
Kaderli, 2015 [49] | “In the present study, each mentee had a mean of 1.7 mentors, which has been described as an asset in several publications.” |
Stakeholder | “In a providing feedback for how someone working for example, then multisource feedback can be helpful cause you see people in different sources in a different range of environment – and that may show you how people behave in a different way -a trainee may behave and act in a different way with me whereas they behave in a terrible way with others, e.g. the porter or nurse a secretary because of whatever preconceptions that they may have. People to see that difference and getting feedback from different people is important.” “Different mentors at different stages or professional life might be beneficial.” |
Delivery of anonymous feedback from juniors to seniors | |
CMO6. Leadership interventions are successful in improving leadership (O) if feedback is delivered anonymously from juniors to seniors (C) as this allows juniors to give honest feedback as they feel safe (M) | |
Gregory et al., 2018 [42] | “Provide anonymity protections for raters’ anecdotal comments by grouping them into behavioral themes as well as to help leaders to focus more on feedback content rather than its source” |
Stakeholder | “In a situation where a more junior is providing feedback to someone more senior they may feel intimidated about saying what they thought.” “I think it would be accepted that juniors give feedback anonymously to more seniors (..) If I was a junior giving feedback to a senior I think I would rather want it to be anonymised – and that is just purely because of that mismatch in the relationship.” |
Delivery of direct feedback from a peer or someone more senior | |
CMO7. Having feedback from your ranks or from someone more senior (C) is more effective in improving leadership (O) if it is delivered directly as this makes surgeon want to improve to maintain the trust and respect (M) | |
Stakeholder | “Having only recently finished being a trainee, I would have valued feedback from my mentors and my supervisors rather than having it come from an anonymous source.” |
Negative feedback delivered privately | |
CMO8. Leadership interventions are successful in improving leadership (O) if accurate negative feedback is delivered privately (C) as this increases the openness to self-improvement (M) | |
Mutabdzic, 2015 [53] | “Some surgeons suggested they would be more comfortable reviewing videos of their surgical procedures with a coach in private, rather than being critiqued in the OR.” |
Dominguez, 2021 [37] | “One should definitely exalt the good things publicly and correct privately …. One should not take the resident to the morbidity and mortality meeting to crucify him/her …. When one punishes him/her publicly, the resident will depart from his/her learning curve. If he/she is underperforming, their performance will become worse. If they avoid complex cases, then he/she will avoid more cases to prevent punishment.” |
Stakeholder | “I would agree that where possible feedback, especially negative feedback should be delivered on a one-to-one individual basis – I think giving negative feedback in front of other people is – I am go so far to say unprofessional – I think that undermined that individual especially in front of other colleagues – I think there are so many repercussions to saying that I think it can – it causes that person to just withdraw. Now there may be times where feedback needs to be given very quickly and there is no time to do it privately etc. etc. but in large I think negative feedback should be say to do it in an appropriate time – not delay it but do it in a private setting.” |
Characteristics | |
Peer to peer approach | |
CMO9. Leadership interventions are successful in improving leadership (O) if a peer-to-peer approach is taken (C) as this increases an openness to self-improvement (M) | |
Greenberg, 2018 [41] | “During implementation, we discovered that some of the concepts and terminology that were adopted from the professional coaching literature needed refinement. The concepts of ‘‘encouraging’’ and ‘‘motivating’’ were somewhat abstract for surgeons. Terms such as ‘‘developing’’ and ‘‘guiding’’ also seemed to reinforce a hierarchical relationship rather than a peer-to-peer relationship. Our initial training focused on these abstract concepts and lacked concrete tactics and approaches that our novice surgical coaches required. We therefore adapted our process and changed the activities of ‘‘encourage/ motivate’’ and ‘‘develop/guide’’ to inquiry, constructive feedback, and action planning.” |
Stakeholder | “Even in competitive environments, peer to peer can motivate individuals to improve.” “When it comes to intervention you need to take away as far as you can the hierarchy because if there is a self-composed mismatch in the relationship, I think you are less likely to get openness in terms of the person you are teaching on the leadership courses being able to open up.” |
Self-awareness of the need for leadership skills | |
CMO10. Interventions are more successful in improving leadership (O) of surgeons when they are bare self aware of needing leadership skills (C) (e.g., beginning a new senior role) as they are more motivated and the intervention has great personal relevance (M) | |
Jaffe, 2016 [47] | “Many participants felt that the timing of the program was particularly opportune, as they were at critical junctures in their careers where it was becoming necessary to take on leadership roles to continue to grow.” “This is a key time in my career. Where do I go next?” Another reported that “to get to the next level, I need more skills.” |
Stakeholder | “As you get more senior in the organisation you have a greater awareness for leadership skills” “I think there is a stage of career in which leadership intervention is most effective. If you think to improve your leadership you need to have the disposition to do it and you need to have the credibility and legitimacy to get things done. To be relatively senior, but if you are too senior you are probably used to the status quo too much, you are not driving the sort of change that leadership tends to influence.“ “I think they can relate to that leadership intervention more closely because they are imagining themselves more..that they are gonna be doing this particular role sooner rather than later.” |
Having confidence in technical skills | |
CMO11. Interventions are more successful in improving leadership (O) of those with more confidence in their technical skills (C) as they can fully focus on leadership skills (M) | |
Nicksa, 2015 [54] | “Our PGY 2 residents showed improvements on the NOTECHS surveys between the first and second halves of the academic year, correlating to more simulation sessions and more experience going into the simulations. They were able to take more away from it because their focus was on the whole experience rather than just their lone experience within the simulation. In contrast, PGY 1 residents did not demonstrate a significant improvement in their simulation scores over the year.” |
Jaffe, 2016 [47] | “To get to the next level, I need more skills.” “[The program] times well for where I’m at. [It’s] time for me to have a clear avenue about what I want to do, create my own road.” “[The] timing is good for my roles as a… fetal program leader… higher leadership things need to be engaged.” |
Stakeholder | “If you are more self-confidence and capable technically in terms of technical skills you may have more space to think about leadership.” “If your resources were limited or fixed I think you would be better of giving it to those at the end of the training and early consultant years.” |
Others awareness of development needs | |
CMO12. Leadership interventions are successful in improving leadership (O) of those with identified leadership deficits (C) as they have more room for improvement (M) | |
Gregory et al., 2018 [42] | “In subgroup analysis, the eight chiefs who scored above average (high LTI) at baseline did not improve at follow-up, but the four chiefs who scored below average (low LTI) at baseline had significant improvement after a year of coaching and practice” |
J. Hu, 2020 [45] | “LTI (Leadership-teamwork index) scores for surgeons, on average, were lower at baseline and had the greatest on average change compared with primary care and specialists” |
Stakeholder | “If they have identified leadership deficits and we have an intervention that is effective that it is expected that they improve when they are insightful of their deficits. Because they have insight and motivation and resource.” “If you start with someone who is poorly on their leadership score, yes, I agree, they are more likely to be able to show an improvement than someone who is already scoring highly on a leadership score.” “I think it is more in my head that there is more room for improvement as opposed to that basically they feel a need to try harder to catch up.” |
Atmosphere | |
A variety of interactive learning activities | |
CMO13. Leadership interventions are effective in improving leadership (O) if they include a variety of interactive learning activities (C) as this engages participants (M) | |
Vitous, 2019 [62] | “A lot of these are, you know, sort of business school principles that are not very available to you in medical education, and so it broadens perspectives. And then, when you have a whole group of people broadening their perspectives, the conversation changes.” |
Pradarelli et al. 2016 [57] | “The inaugural program curriculum was structured around 4 major domains: leadership, team building, business acumen, and health care context.” |
Jaffe et al. 2016 [47] | “Participants felt that in order to fully comprehend the demands on a leader in this healthcare system, they needed sound foundation in the economic forces and business aspects that influence hospitals. One participant referred to his interest in leadership training as obtaining “mini-MBA.” Another reported wanting to “build a strategy for [a hospital setting].” A few participants recognized that “technical” business skills were what they needed most, admitting that they were frequently given financial statements and other documents but did not understand how to analyze or use them for decision making” “Another major desire for participants was to learn how to integrate leadership into the greater healthcare context, both at the hospital level and at the larger policy level. One participant mentioned wanting to know more about “how the [Affordable Care Act] will influence surgery.” Others mentioned learning “how to succeed in the [local] environment,” where there are a “great group of people at all levels” at a given hospital that could learn to “[integrate] across departments.” |
Hill et al. 2018 [44] | “The curriculum was based on readings from the book "The Founding Fathers on Leadership" by Donald Philips. Senior surgical residents were randomly assigned to lead chapter discussions. Emphasis was placed on the characteristics of famous individuals instrumental in the emergence of our nation, with concrete examples of how these people demonstrated their roles as admirable leaders. Residents were also instructed to relate these skills back to how they could be incorporated into their everyday role as a physician. At the end of each presentation, the audience expressed their interpretations of the chapter to add to the overall educative experience Sessions took place over a three-week time span with five chapters reviewed weekly.” |
Stakeholder | “You need a mixed programme. There is a place for didactic teaching [..] but they need to be kept to a minimum and really focus on key principles [..] because I think we all know we switch off lecture after lecture. The leadership course I was on – I got the most out of it when we broke into smaller groups where we were able to discuss, challenge -even ono-to-one, roleplaying, getting up in front of people to act, when it was much more interactive. I think that is very important” “That links to learning styles. Some people like theory, some people are more practically oriented, some people like to read and reflect and even with an individual it is good to do different things. I think this relates to different learning styles.” |
Implementation of speak-up culture | |
CMO14. Leadership interventions are successful in improving leadership (O) if they implement a speak up culture (C) as this makes participants feel equally valued and provides a sense of engagement (M) | |
Brindle, 2018 [34] | “Levelling the playing field allowed all members to recognize and report threats to patient safety and improve communication” “Even if it was a medical student in the room, I would ask the medical student [to speak first in the debrief] and half the time they had no clue what we had done; but sometimes they might have seen some-thing; and then it was on to the next level trainee, moving all the way up in to the most experienced people; and I usually went last.” |
Jayasuriya-Illesinghe, 2016 [48] | “Because junior surgeons and nurses would not speak up and/or raise any concerns they may have with the senior surgeons, there was potential for communication barriers between team members.” |
Stakeholder | “An example would be in surgical theatre. I often say if someone sees something that is not right, please say something because […] I am only human – we are all human and ten eyes are better than one…” “The environment should be that as a team every member of the team feels able to say something free to contribute and say something.” “Everyone should be allowed to speak up – end of story. We are all in it together […] Everyone is equally valued in terms of right and responsibility to speak up.” “Where something is not right or could be improved all members of the team should feel that they can contribute and speak up.” |
Customised delivery to surgeons’ needs | |
CMO15. Leadership interventions are successful in improving leadership (O), if they are customised to surgeons’ needs (C) as this makes the training feel more relevant (M) | |
Sinclair, 2015 [59] | “According to respondents, the ideal mentor is one who (…) is chosen by the mentee and has received mentoring training.” |
Mutabdzic, 2015 [53] | “This desire for control manifested itself in almost every aspect of the situation including who might be chosen as a coach, the areas of learning that might be addressed, and the decision of how, and even whether, to incorporate the coach’s advice into practice.” “me that would be real coaching where it’s self-identified, I’m motivated, I find the person and then they coach me. Then I decide when I have had enough coaching.” |
Pradarelli, 2016 [57] | “Developing a leadership-training program is a personalized and iterative process for individual institutions, and participant feedback is critical to exploring the benefits and weaknesses of the program in detail.” |
Stakeholder | “To improve yourself you have to go out of your comfort zone. I think it has to be customised because it then provides insights for your own practice and your organisation’s practice.” “It is gonna be either tailored or required insights from the people providing the intervention for them to reflect and go away and say “ I have learnt this, I have tried this in practice. Unfortunately, it has not worked, do I need to reflect on where I have gone wrong and have that reinforcement with sort of modification to allow for that development for that individuals. Does running the same programme over and over again is likely to improve the outcome.” |
Safe learning environment | |
CMO16 | Intervention are successful in improving leadership (O) if they provide an intimate learning environment (C) as this gives participants a sense of a safe space where they participants speak openly (M) |
Sinclair, 2015 [59] | “Ideally, trainees would prefer face-to-face mentoring (94.7%), although email (50.6%) and telephone (30.6%) were also acceptable media. SMS mobile phone messaging (14.7%) and audio/teleconference facilities such as Skype (10.4%) were less popular options.” “Most mentors also wanted to meet face to face (66.8%).” |
Foley, 2021 [39] | “Most participants reported that one-on-one coaching in an individual setting would be a useful form of CPD (73.7%, n = 87) with only a small proportion disagreeing that this would be beneficial (11.0%, n = 13).” |
Hill et al., 2018 [44] | “A key component of the course was the comradery amongst the people involved. Our residency program is fairly small and thus each session consisted of only 20 to 30 people. All participants were already very familiar with one another, and this fostered an open learning environment. The willingness to share personal examples of leadership techniques proved to be beneficial for the education of the entire group.” |
Somasundram, 2018 [60] | “In later questions, the larger group size was also mentioned as a negative feature; with participants suggesting that they should have been split into smaller groups.” |
Stakeholder | “The leadership course I was on – I got the most out of it when we broke into smaller groups where we were able to discuss, challenge -even ono-to-one, roleplaying, getting up in front of people to act, when it was much more interactive.” “Having an opportunity and an environment where people can speak openly without fear of blame or undue criticism – shouldn’t mean that people shouldn’t be challenged – but it should be a non-confrontational kind of way – not being being insulted […] As an example, one of the things that we do now more often is that we review in orthopaedic surgery – we have a weekly X-Ray meeting [….] to review operations that we do […] There is maybe 7 or 8 consultants plus maybe some trainees or fellows and I think this is a good opportunity to share learning and challenge potentially and I think the whole point about this it is a protected space, it is a safe space.” |
CMO 17 | Intervention are successful in improving leadership (O) if they provide a safe learning environment (C) as this allows interaction with learners which helps them to apply learning to their personal context (M) |
Stakeholders | “I think it is also about the ability to individualise your education. In an intimate learning environment you have a higher ratio of teachers to learner and that allows individualisation.” “Allows interaction with learners to help them apply this to their personal context.” |
Training in surgical teams | |
CMO18. Leadership interventions are effective in improving surgical team leadership (O) if they give surgical teams time to train together and to run through an operation (C) as this help to build trust, rapport, friendship, and mutual respect (M) | |
Stakeholder | “One of the things that we don’t do very well in surgical leadership is that we don’t train in teams, we train as individuals and I guess the difference is if you take this into the military. They train as a team together multiple teams and we don’t do this in surgery” “I would say one way to improve leadership in theatre, is for that theatre team should go and spend time practicing how to run through an operation, how to work as a team, developing and ideally continue to keep working in the same group. The problem is in reality, people are pulled, you don’t with the same person and then you wonder why team working and leadership faces such challenge.” |
Genuine investment in the intervention | |
CMO19. Leadership interventions are effective in improving leadership (O) if there is a genuine investment in the intervention (C) as this is increasing participants’ faith and engagement in the intervention (M) | |
Cochran, 2019 [36] | “Interviewees described 3 characteristics of effective mentoring relationships from a mentee perspective: working with a strategic advisor working with an unselfish mentor, and finding a mentor who engages with diverse mentees (in terms of demographics background and academic and clinical interest, different kind of personalities)” |
Brindle, 2018 [34] | “At McLeod and Memorial health, this engagement took the form of executive staff being physically present in the operating rooms and other areas where clinical care takes place. This physical presence performed two functions, 1) keeping the executive staff aware and more directly connected with the issues faced by the front-line staff, and 2) reinforcing to the front-line staff the genuine commitment of the institution to the process.” |
Ramjeewon, 2020 [58] | “A key strength of the study was the fully-immersive, high fidelity simulation suite which created a realistic environment to attempt to induce the type of behavior seen in the real situation. A fully immersive simulation allows an individual to have a full physical range of motion and interaction with objects and or people. When considering a fully immersive surgical simulation, this would feature a simulated operating theatre and operating theatre team.” |
Stakeholder | “If it is investment is sincere people will be able to tell and that does an impact on leadership but if it is not sincere people will disengage” “I think this is one of the biggest problems in certainly the NHS that people have withdrawn or disengaged from this process cause they feel that much of leadership/senior management is a tick-box-exercise…yes they may want to hear you views […] but there is very little done. And if you keep just doing it people just ignore it …and unfortunately that will come down to that particular person and their reputation of whether they act on things that they see or has it always been a show and tell.” “Leaders who truly go round […] and actually do take the time – and that is the problem with sincere investment is it is not a five-minute job – that’s the problem; if you really wanted to learn, the sincere investment does not only need time but also in energy and resources—but often they lack in all three.” |