Is there evidence for leadership in healthcare?

The concept of leadership is considered important for clinical practice, but the research evidence for the benefits of leadership, particularly on patient care are sparse. There are some explanations for this…

The management literature is heavy with theoretical articles describing different leadership attributes and hypothesising how leadership is enacted in the workplace. In general, most theorists consider leadership as a reflexive attribute where individuals use their own experience, insights and self-knowledge to match their personal strengths to the demands of the work situation. In short, while there is agreement on basic principles of leadership and there is a long but not very discriminative list of leadership skills, the actual implementation of leadership will vary across individuals, and with respect to their organisational environment.

Therefore, traditional methods of experimental research cannot consistently isolate leadership behaviours, and it is difficult to ‘deliver’ leadership to one group of participants while restricting it from others. Leadership is both a formal and informal activity that is difficult to turn on or off. This is demonstrated in a Cochrane review of randomised controlled trials that were designed to investigate the effectiveness of local opinion leaders in delivering education to encourage health professionals to use more evidence in their practice.  The authors, who are all very experienced systematic reviewers, concluded that it was difficult to identify the actual activities of opinion leaders. They also said it was difficult to separate out the effects of being an opinion leader from other types of educational intervention. They concluded that an opinion leader was as successful as more traditional forms of education, such as distributing educational materials, carrying out audit and feedback, and using educational outreach activities.
Observational studies make comparisons between environments where there are different types of leadership, and certain outcomes. Often, it is difficult to separate out the effects of leadership from leadership styles and behaviours. A survey of social workers summarised that leaders who were charismatic, considered individual needs, inspired and intellectually stimulated their staff were perceived as more effective and their staff were more satisfied and prepared to put in extra effort. However, while these results support a well recognised model of transformational leadership, they are likely to be biased and causation can not be inferred.

This pattern of identifying patterns and impacts of leadership can also be seen when observational studies are synthesised together. When the relationship between nursing leadership and patient outcomes was investigated, there was a trend for  transformational nursing leaders to improve patient satisfaction and reduce adverse events and complications. It was suggested that leaders manage the context, staffing and financial resources. They create appropriate staffing levels for the work being done. They retain and support experienced staff, by working in teams, maintaining job satisfaction and keeping staffing levels stable.While these suggestions fit with the theory of transformational leadership and make logical sense, it is difficult to prove these mechanisms of action, using randomised controlled trials.

So we are left being able to identify key leadership styles and skills, but unable to ‘prove’ why and how this is so. Perhaps we need to recognise patterns and emphasise the art of leadership,  when successful individuals have read the organisational context accurately, and used their own skills to achieve outcomes of benefit to those who are following…




I conduct and supervise research that promotes the translation of quality research evidence for use in clinical practice.

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Posted in clinical outcomes, clinical practice, evidence, healthcare professional, leadership, management

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