Article Text
PDF
Abstract
Background Emergency medicine (EM) consultants are expected to provide leadership to facilitate optimal clinical results, effective teamwork and learning. To foster leadership skills, the Emergency Medicine Leadership Programme (EMLeaders) was launched in 2018 by the Royal College of Emergency Medicine (RCEM), Health Education England and National Health Service England. A mixed-methods evaluation of EMLeaders was commissioned to assess the impact at the strategic, team and individual levels. This paper reports the qualitative evaluation component.
Methods Qualitative data collected from 2021 to 2022 were drawn from an online survey of RCEM members in England, which included four open questions about leadership training. At the end of the survey, participants were asked to share contact details if willing to undertake an in-depth qualitative interview. Interviews explored perceptions of the programme and impact of curriculum design and delivery. Data were analysed thematically against the Kirkpatrick framework, providing in-depth understanding.
Results There were 417 survey respondents, of whom 177 had participated in EMLeaders. Semistructured interviews were completed with 13 EM consultants, 13 trainees and 1 specialty and associate specialist doctor. EMLeaders was highly valued by EM consultants and trainees, particularly group interaction, expert facilitation and face-to-face practical scenario work. Consultant data yielded the themes: we believe in it; EM relevance is key; on a leadership journey; shaping better leaders; and a broken system. Challenges were identified in building engagement within a pressured workplace system and embedding workplace role modelling. Trainees identified behavioural shift in themselves following the programme but wanted more face-to-face discussions with senior colleagues. Key trainee themes included value in being together, storytelling in leadership, headspace for the leadership lens and survival in a state of collapse.
Conclusion The development of leadership skills in EM is considered important. The EMLeaders programme can support leadership learning but further embedding is needed.
- management
- qualitative research
- education
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
WHAT IS ALREADY KNOWN ON THIS TOPIC
Effective leadership is one of the most influential factors in shaping a positive healthcare organisational culture where high-quality teamwork and clinical care are enabled and staff well-being is prioritised.
The Emergency Medicine Leadership Programme (EMLeaders) was launched in 2018. It is the first UK, emergency medicine (EM)-specific leadership training initiative of its kind and aims to address the unique demands of EM practice as well as broader issues of burnout and retention.
WHAT THIS STUDY ADDS
This qualitative study sheds light on the nuances of leadership training within EM, highlighting challenges, benefits and the need for tailored, contextualised training for effective leadership in the EM healthcare setting.
EMLeaders contains several effective components, and trainees who engaged in it felt supported in the EM environment and more satisfied in their role than before, indicating the potential of the programme to support trainee retention.
Trainees wanted more opportunities to engage in the 70% ‘on the job’ shop floor training component.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study creates a foundation for further research into the impact of EM leadership training on trainee and clinical outcomes, but ongoing support from leaders and managers is needed to fully embed the programme.
Introduction
Internationally, EDs are busier than ever1 and the issue of clinician burnout2 and workforce attrition has become universal.3 It has been suggested that emergency medicine (EM) consultants are pivotal to tackling these challenges,4 through ‘clinical leadership’ within front-line teams as well as via leadership roles at executive or director level.5 Effective leadership in EM can increase worker support,6–9 psychological safety,10 staff retention11 and well-being, since leaders set the tone, culture and behaviours within the work environment.12
Leadership is a complex and evolving concept13 14 considered poorly developed,15 16 articulated,5 supported17 and undervalued in EM.4 Structured leadership programmes have been lacking7 18 and it has been assumed that leadership capability develops informally over time, through observation and experience.15 Recently, however, leadership has been identified as a key ‘human factors’ skill that should be developed and nurtured during a doctor’s early career,19 not least to improve patient outcomes20 21 but also to better prepare doctors for the realities of clinical practice.18 19
Inattention to leadership training may result in an array of problems, including confusion about the clinical leadership role16 and reluctance to take on leadership responsibilities.12 Internationally, the need has been articulated for specialised EM leadership programmes to increase emphasis on crucial leadership skills such as communication, interaction, mentoring, collaboration, reflection and self-awareness.7 15 17 18
In the UK, a bespoke Emergency Medicine Leadership Programme (EMLeaders) was launched in 2018 through collaboration between the Royal College of Emergency Medicine (RCEM), Health Education England and National Health Service (NHS) England (see figure 1). As the first EM-specific leadership programme, EMLeaders was designed to provide leadership training to address the unique demands of EM practice plus issues of burnout and retention.22 23
Development and roll-out phases of the Emergency Medicine Leadership Programme (EMLeaders). EM, emergency medicine.
In 2021, a mixed-methods, 10-month independent evaluation of EMLeaders was commissioned to assess the impact at the strategic, team and individual levels. This paper reports qualitative survey and interview data, sharing programme participants’ experiences and perceptions of EMLeaders, further informing the programme’s future development. The multicomponent evaluation is reported elsewhere.24
The EMLeaders programme
The EMLeaders programme establishes leadership knowledge, skills, behaviours, attitudes and competencies, referenced against the different stages of EM training. It is structured into five areas of clinical leadership, namely EM leader skills, working in teams, managing the emergency service, growth and collaboration and developing excellence within the team. Programme outcomes met during training (up to 6 years) include: (1) enhanced leadership capability and knowledge and (2) improved social support among trainees and supervisors.
Informed by the Lombardo model for workplace learning and social learning theory, the programme has three weighted components: (1) Work-based ‘shop-floor’ training (70%), delivered by EM consultants working in the ED team. Shop floor training activities include bite-sized leadership exercises, supervised learning events, simulations and the use of leadership assessment tool, for example. (2) Self-directed learning via nine e-learning leadership modules addressing self, systems, teams, change, culture, people, quality, service and strategy (20%). Topics include leadership theory, managing difficult decisions in a challenging workplace, handling conflict and creating a learning culture. (3) Formal learning (regional study days and specific EM training events) (10%).
Notably, EM consultants tasked with delivering work-based ‘shop-floor’ training are not formal trainers. Rather, these consultants are encouraged to implement leadership learning activities via regular regional ‘train-the-trainer’ development days, led by regional EM faculty staff and leadership champions, who shared training ideas, methods and knowledge. Since inception, programme scope has expanded from EM trainees to include all clinicians and multidisciplinary staff working in ED. While not mandatory, completing the EMLeaders programme is highly recommended, providing evidence to map against the relevant Specialty Learning Outcomes and Generic Professional Capabilities within the RCEM curriculum.
Methods
Study design
A multidisciplinary research team with EM clinical advisors (CL, CT) undertook this mixed-methods, summative impact and utilisation-focused study. Reporting adheres to the Standards for Reporting Qualitative Research checklist.25 The Kirkpatrick framework26 provided a practical structure to evaluate the potential effects of training, considering the reach of the programme, participant reactions to it, learning attributed to training, resultant behaviour changes and overall results and impact. Ultimately, this allowed us to assess the perceptions of the value of training, the satisfaction of trainees and consultants, the learning participants reported, whether learning could be applied in the workplace and impact on organisations.
Setting and participants
Members of the RCEM in England, specifically consultants and EM trainees, were recruited. The term ‘trainee’ refers to a doctor undergoing EM specialty training (ST), which typically spans a 6-year period. As indicated by the abbreviation ST for ‘specialty training’, ST1 refers to a doctor in their first year of specialist EM training, while ST6 refers to a doctor in their sixth year of training.
Methods of recruitment
Invitations to participate in an online survey were disseminated via email by RCEM to its membership on 20 December 2021, one reminder was sent and the survey closed on 31 January 2022. At the end of the survey, participants were asked to share contact details if willing to undertake a further in-depth qualitative interview.
Development of tools
A bespoke cross-sectional, online survey hosted on the Joint Information Systems Committee was developed by SP, RK and ARAA and piloted following feedback from CT and CL, based on their experience of leadership training and operational EM leadership. 16 survey items were developed, answered via a strongly agree to disagree Likert scale, plus four open survey questions (reported below):
Since taking part in the EMLeaders/other leadership training:
How has your knowledge of leadership in EM changed?
How has your confidence and/or competence as a leader changed?
Regarding the content and delivery of the EMLeaders/other training:
What worked well?
What would ideal leadership training look like?
The survey had study information, a privacy statement and in-built explicit informed consent. Participants could withdraw consent by closing their internet browser. The survey focused on three participant groups: those who had undertaken or been involved in delivering ‘EMLeaders Training’, those who had undertaken ‘Other Leadership Training’ and those who had undertaken ‘No Leadership Training’. Only the first group is reported in this paper.
The semistructured interview topic guide (online supplemental file 1) was piloted and revised following feedback from CL and CT, using Kirkpatrick levels as an initial structure but allowing further probing. Interviews were undertaken via ‘Microsoft Teams’ videoconferencing in 2022.
Supplemental material
Data analysis
Using the Kirkpatrick levels as an initial framework, a combination of deductive and inductive coding was applied to survey and interview data and the researchers’ reflexive notes to generate a thematic content analysis (see online supplemental file 1).27 Open-ended survey responses were downloaded and analysed by AM. Interview recordings were transcribed, and data were pseudonymised and identified with consecutive codes. Participant personal details were stored separately in a password-protected document accessible to AM and RK. Researchers AM and RK discussed the analysis with BP to refine it. We compared the analysis by respondent group to explore similarities and differences in perspective between consultants involved in course design or delivery, consultant supervisors and EM trainees. NVivo software organised the data and helped confirm themes were sufficiently developed. Interviewees were not contacted for member checking to minimise demands on them.
Results
Of the 417 survey respondents, 177 had experience with the EMLeaders, and 76 (42.9%) shared details and agreed to be further contacted for interview. All 76 were invited to a single semistructured interview and provided with further information (eg, interview questions and funding source). No incentives were offered. Of the 76 interview invitations, 27 people replied (response rate 35.5%) and online interviews were scheduled. Reasons for non-participation are unknown. Individual 30–40 min interviews were undertaken to fit participant availability and ease scheduling, and were conducted by AM or RK, both experienced female doctoral-qualified qualitative researchers. We interviewed 13 EM consultants, 13 trainees and 1 specialty and associate specialist doctor. Participants were unknown to researchers. Tables 1 and 2 detail participant demographics. Respondents were broadly representative of RCEM members in terms of career grade, ethnicity, sex and disability.
Survey participant demographics
Interview participant demographics
Findings from the four open survey questions and interviews are presented together using Kirkpatrick levels to structure the reporting. Figure 2 summarises interview themes and online supplemental file 2 provides additional depth to interview analysis.
Supplemental material
Summary of qualitative themes arising from interviews. EM, emergency medicine; EMLeaders, Emergency Medicine Leadership Programme.
Reach of EMLeaders
Leadership faculty consultants interviewed reflected that EMLeaders had good reach among the trainee community, but it had been challenging to engage the wider consultant supervisor body. Key themes identified were: ‘The programme has amplitude’ and ‘Train the trainers: a challenge’. All recognised that further work was needed to engage more EM consultants to provide shop floor supervision and support on-the-job learning.
I’m not getting other consultants start to want to talk about it on the shop floor. It’s not become the language. (ID13, consultant interview)
Delivery should be on the shop floor, this is the biggest challenge for the programme. It is difficult to persuade trainers to engage when there are so many pressures on them. (Consultant, survey 88064947)
Trainee interviews confirmed variable exposure to EMLeaders. Some had experienced only one training session, not all had initiated e-learning modules and few had experienced shop floor reinforcement. Many struggled with embedding leadership learning because it was taught virtually. Almost universally, trainees considered EMLeaders would be more impactful if it involved more face-to-face and practical experiential learning. Where workplace support for leadership had been received it was hugely valued, even career changing, but specific shop floor reinforcement of EMLeaders was not experienced by many trainees.
Since that training session, I haven’t really heard that much more. (ID18, trainee interview)
Reaction to EMLeaders
Reactions from consultants and trainees to EMLeaders were extremely positive with both groups indicating improved leadership knowledge and understanding. Consultants felt the programme boosted confidence, improved self-awareness and reflective ability, enhanced feelings of professionalism and credibility and increased their ability to de-escalate conflict or challenge poor practice.
I am now more knowledgeable in a way that I could not have achieved through normal clinical practice. My vocabulary has widened allowing me to express leadership concepts to others in a more coherent way. (Consultant supervisor, survey ID88818689)
I am able to engage with conflict better, lead junior colleagues more effectively and use feedback developmentally. (Consultant supervisor, survey ID88607647)
Key themes from the consultant interviews were engaging for some but not for all, we believe in it and the EM relevance is key. Consultants who connected deeply with the programme gained personal benefit and could see its value to trainees and EM. However, while consultants reported positive trainee responses to EMLeaders, many remarked that not all trainees were ready for or dedicated the time to learn about leadership. Reasons given included trainee expectations of EM, other training requirements, willingness, learning preferences and reluctance to participate in reflective group learning. Some consultants considered early career trainees lacked insight into the importance of leadership, which underscored the need for specific EM focus in leadership training.
Certain trainees, just the topic of emotional intelligence….I don’t know whether their insight is ever going to change. (ID12, consultant interview)
Trainee reactions to EMLeaders were similar, with all respondents agreeing on the importance of EM-specific leadership development. While online learning was considered convenient, trainees ‘valued being in the room together’, preferring face-to-face training since it signified commitment. ‘Mixed reactions to delivery format’ spoke to concerns about over-reliance on e-learning and the desire for more shop floor teaching.
I can tell people just skip through to the answers…It (elearning) just doesn't have the same impact that face-to-face training does. (ID26, trainee interview)
Shop floor leadership is very much ‘get on with it’. (ID16, trainee interview)
E-learning was considered time consuming. Trainees wanted to feel inspired by credible facilitators who could bring the programme to life. Though most trainees valued the course, a lack of uniform delivery across the regions resulting from COVID-19 meant some had experienced little training. Senior trainees were least positive.
How has your knowledge or confidence changed as a result of EMLeaders training? ‘Barely’, ‘minimally’, ‘not significantly’. (All ST6, survey)
We asked survey respondents what worked well in EMLeaders (summarised in figure 3). Three areas were highlighted: facilitators with expertise and enthusiasm; content that was considered practical and reflective of ‘real-life’ scenarios; and delivery in a face-to-face format and which enabled group interaction.
Survey responses—Regarding the content and delivery of the EMLeaders training, what worked well? EMLeaders, Emergency Medicine Leadership Programme.
Learning from EMLeaders
Trainee survey respondents confirmed that leadership knowledge and confidence were increased by EMLeaders, for example, changes in self-awareness, theoretical knowledge of leadership, understanding of the wider NHS, how to run teams, manage busy shifts and contribute to the team. The over-riding sense was the applicability of the programme, with some trainees feeling inspired to ‘step up’. Some indicated that the tailored programme made them feel more valued, better connected and more supported. This was an important finding as many trainees interviewed explained that workplace pressures reduced their mental health, but leadership training mitigated this.
During trainee interviews, we asked what information had been absorbed, what parts of training were meaningful and whether intended knowledge and skills were acquired. Five themes emerged: ‘the power of human factors’, ‘putting things in boxes’, ‘the storytelling of leadership’, ‘frameworks and theory’ and the ‘value of workplace learning’. The most recalled and valued learning was human factors training. Being aware of different communication strategies, personality types, leadership styles, negotiation and compromise were highlighted. Trainees reflected on the empowering nature of becoming self-aware.
How I interact, conflict, how I support a junior…has been useful learning for me. I’m personally really interested in self-development and the psychology behind leadership & personality types. (ID15, trainee interview)
While leadership ‘frameworks and theory’ were acknowledged, trainees most valued listening to consultants’ experiences (stories) and wanted more practical workplace leadership scenarios:
A lot of consultants will really throw themselves into an ESLE (extended supervised learning event) and give you really good feedback…but you can do two a year…trying to get more than that is basically impossible…most places don’t have time for it. (ID21, trainee interview)
More so than trainees, consultants described embarking on a deep, surprising, personal learning journey because of EMLeaders, which enriched their understanding of leadership.
EMLeaders and behaviour change
Participants struggled to define how their behaviour had changed because of EMLeaders, but there were tangible examples suggesting that individual leadership styles became more empowered, compassionate and self-reflective. The key themes from trainees were: ‘having that leadership lens’, ‘giving you headspace’ and ‘shaping interactions’. For trainees, the influence on behaviour was less about being in the position of a leader and more about skills and attitudes which contributed to a leadership mindset, sharing ideas and discussing scenarios and alternate perspectives.
It has helped me tremendously in handling difficult situations. (Trainee, survey ID87882039)
Leading Self (e-module) has prompted me to consider how your self-management impacts on the clinical environment and your role within a team of people with different strengths. So, when I work clinically, I’m not just thinking about individual patients but also…the other members of my team. It’s just sort of smoothing day to day work practices. (ID18, trainee interview)
Consultants interviewed considered EMLeaders had brought compassion and balance to their teaching and supervisory behaviour, particularly through train-the-trainer events. The two themes were Shaping better, balanced, compassionate leaders and Scaffolding for supervisors.
Results and impact of EMLeaders
EM leadership training was considered valuable and necessary by both trainees and consultants in developing the specialty and positively shaping the EM environment. Themes from trainee interviews were: ‘Survival in a state of collapse’ and ‘It is necessary for our specialty’. Consultant interviews yielded the theme ‘the system is broken’, reflecting the relentless pressure on EM and its staff. This clearly impacted trainees, affecting job satisfaction, stress levels, feelings of control and optimism. A number reported going part-time for mental well-being and to complete training requirements, which were described as ‘brutal’. Junior trainees reported demoralisation among senior trainee colleagues: ‘quite a lot of higher trainees are …looking to get out’ (ID16, trainee interview). Within this context, leadership training was considered vital to ensure ‘survival’ and to engender a compassionate and civil work environment. It seemed EMLeaders had a protective function:
It will open up our brains to a different culture, which will slowly trickle through. Whether it will have definable measurement on patient outcomes, I don’t know… but it could make us happier and our jobs easier, which will affect patient outcomes, then yes, I think there is potential. (ID16, trainee interview)
The second theme established the benefit of leadership training in enhancing the credibility and reputation of the specialty.
It fits really well with the ethos of RCEM and of our specialty in general…No one goes into EM for an easy ride but to try and look after patients… I certainly feel it will help us be a better team and look after patients better. (ID18, consultant interview)
Considering future enhancements to the programme, survey respondents were asked what ideal EM leadership training would look like, indicated in figure 4.
Survey responses—Regarding the content and delivery of the EMLeaders training, what would ideal leadership training look like? EM, emergency medicine; EMLeaders, Emergency Medicine Leadership Programme.
Discussion
This national, independent evaluation produced a rich qualitative dataset enabling a detailed assessment of this new programme. Respondents felt that participating in EMLeaders increased their skills, knowledge and awareness of leadership behaviours—an important finding, since many healthcare professionals feel inadequately prepared for leadership roles.28 All participants considered that structured leadership development was most beneficial and effective when specifically designed for EM to engender a compassionate and civil work environment, contextualised with clear examples, as opposed to generic leadership courses. Trainees wanted more shop floor teaching, identifying the busy ED environment as a barrier to consultants’ engaging in their personal leadership development. Perhaps most importantly, participating in EMLeaders led to trainees feeling valued and connected. This factor may, in the long term, support intention to stay in EM.
We found that the reach of EMLeaders was patchy and not all trainees and consultants had fully engaged with the multiple components. Wong et al 16 caution that when leadership development is left to chance, doctors may experience doubt about their leadership credibility. Since it is recognised that effective leadership skills in EDs can improve patient care quality and health professionals’ well-being, it is important that further embedding of EMLeaders occurs and consultant supervisors are invested in the programme. Govindasamy and Hilbig29 discuss the need for organisational support to ensure EM leadership development is undertaken in psychologically safe settings. It is possible that lack of space and opportunity for reflective practice, within a ‘real-world’ context of clinical risk and staff tensions, may inhibit senior clinicians from role modelling positive leadership activities.
An array of leadership theories have been articulated, including trait, behavioural, situational, transactional and transformative, and continue to evolve.30 Today, emphasis turns to adaptive leadership, learning, person-centredness, genuineness and moral values, along with follower trust and engagement. Leader behaviours are considered important to creating psychological safety in clinical teams. Yet, within the EM literature, a full explanation of ‘leadership’ is lacking.5 Daniels et al 12 identify that where negative blame cultures exist, compassionate leaders are needed, equipped to model effective behaviours, creating a climate conducive to well-being and learning. Participants indicated that EMLeaders went some way in preparing leaders of this type.
The RCEM has developed a unique and important leadership programme. Recommendations are suggested to shape future programme enhancements and implementation (see online supplemental file 3).
Supplemental material
Limitations
Recency and recall bias could have affected survey and interview responses. Survey responses occurred between December 2021 and January 2022 and interviews between January and May 2022, while some participants undertook EMLeaders training in 2019. Specifically, of the 177 survey respondents (including interview subset), 37.3% (66) completed training in 2019, 14.1% (25) in 2020, 37.9% (67) in 2021 and 10.7% (19) were unsure when they did training. Respondents may have been more positive than non-participants, but we cannot quantify this. The COVID-19 pandemic may have affected responses as less face-to-face training took place than originally planned.
Conclusion
Based on the perceived training gains reported by participants involved with EMLeaders, further embedding the programme in EM practice would seem beneficial. Maximising the involvement of shop floor consultants tasked with facilitating real-time work-based leadership learning will be integral to the future impact of the programme.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the Coventry University Ethics Service (reference P124919). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We acknowledge Elizabeth Goldsmith for her assistance during the evaluation period in understanding the programme and Professor Lorna O’Doherty for critical feedback during manuscript preparation.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Handling editor Edward Carlton
X @ProfSheaPalmer, @leechcaroline
Contributors RK, AM, SP, AS, GH, CL, CT and ARAA contributed to all stages of the study, including conception, design, development of data collection tools, data collection, analysis and drafting the manuscript. BP assisted with data analysis. AK was involved with interpretation of findings and drafting the manuscript. RK is guarantor.
Funding This research was supported by a grant from Health Education England.
Competing interests AK was employed by Health Education England during the research and was part of the team that awarded the research grant. AK was only involved with the interpretation of the findings and in the drafting and final approval of the manuscript. All authors were responsible for designing, conducting, analysing and reporting the work in a completely independent manner.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
Linked Articles
- In perspective