# data[].attributes.attachment_link.title
What do midwifery leaders need in order to be effective in contributing to the reform of maternity services

# data[].attributes.attachment_link.title
Characteristics of strong midwifery leaders and enablers of midwifery leadership

# data[].attributes.body
Ruby Jackson Student midwife develops app to combat skin tone bias

# data[].attributes.attachment_link.title
Student midwife develops app to combat skin tone bias | Nursing Times

# data[].attributes.attachment_link.description
Read about a new app being developed by a student midwife who wants to tackle skin tone bias in maternity care.

# data[].attributes.body
CQC Maternity review Sept 2024

# data[].attributes.attachment_link.title
Leadership and culture - Care Quality Commission

# data[].attributes.attachment_link.description
Effective leadership, governance and culture can drive and improve the delivery of high-quality, person-centred maternity care and help to drive a culture of safety and improvement.

# data[].attributes.body
A midwife’s exploration into how power & hierarchy influence both staff and patient safety

# data[].attributes.body
Inclusive Leadership in action

# data[].attributes.attachment_link.title
NHS England » West Yorkshire and Harrogate Partnership: Moving diverse leadership forward

# data[].attributes.attachment_link.description
West Yorkshire and Harrogate Partnership (WY&HP) is putting diverse leadership at the heart of its ICS workforce strategy, to address the disproportionately high poor experiences in the workplace for BAME staff.

# data[].attributes.attachment_link.title
Compassionate and Inclusive Leadership Resource

# data[].attributes.attachment_link.description
We all want to feel valued, supported and enabled to do our best work. Sometimes we have cultures and micro cultures in our organisations that don't fully support that. Compassionate and inclusive leadership is embedded in high quality, high performing systems and drives improvement in their overall performance, meaning better outcomes for patients, better population health and better value for money.

# data[].attributes.attachment_link.title
Building Leadership For Inclusion – Leadership Academy

# data[].attributes.attachment_caption
Novel Solutions to the midwifery retention crisis in England

# data[].attributes.body
Novel solutions to the midwifery retention crisis in England: an organisational case study of midwives’ intentions to leave the profession and the role of retention midwives - ScienceDirect

# data[].attributes.body
Leah Hazard

# data[].attributes.attachment_link.readable_text
I'm Leah Hazard, a practising NHS midwife, author, activist and mother of two girls.

As a proud member of my profession, I'm passionate about bringing midwifery and reproductive health into the public eye. As a firm believer that midwives lay the foundation for lifelong wellness, I'm committed to providing evidence-based information in a way that's accessible, relatable and relevant to our times.

Take a look around this site to find out more about my work, some of the services I provide and how we can connect.

# data[].attributes.attachment_link.description
Find out more about the author of Hard Pushed, Womb and The Father's Home Birth Handbook. Explore midwifery services available to you remotely and in person.

# data[].attributes.body
Claire Feeley

# data[].attributes.body
Rachel Reed

# data[].attributes.attachment_link.readable_text
I've tried to avoid tackling this issue for months now but it won't go away. It seems that the 'bundle' is one of the main topics of concern amongst midwives and students at the moment. So here goes - my answer to "what can we do about the bundle?"

Note: I am using the abbreviation SPT to refer to Severe Perineal Trauma ie. 3rd and 4th degree tears.

Women's Healthcare Australasia (WHA) is implementing a "range of initiatives to support members to achieve the highest possible standards of maternity & newborn care, including benchmarking, networking, and collaborative improvement projects." One of the initiatives is a WHA National Collaborative Improvement Project aimed at "reducing by 20% the number of women harmed by a third or fourth degree tear [SPT] by the end of 2018". This is much needed with rates of around 3-4% in some hospitals. The WHA state that: "Teams from twenty six maternity services... are participating. Teams are receiving regular coaching and support to reliably implement a bundle of evidence based practices known to reduce risk harm from tears." A similar project is underway in the UK. However this post focuses on the Australian bundle.

The bundle has been rolled out in hospitals across Australia and has changed midwifery practice and the experience of birth for women. The bundle is not adequately supported by evidence and the WHA did not obtain ethical clearance for this experiment.

Before we go any further it is important to note what 'controllable' factors are known to increase the chance of severe perineal tearing (SPT) during birth according to research: hospital birth, particular positions (supine, lithotomy, squatting); directed pushing; syntocinon with multips; hands on for multips; and instrumental birth. See this post for more information, discussion and references about particular interventions. None of those evidence-based factors are included in the WHA bundle. In addition, in the leaflet provided to women about the bundle there is no mention of care provider / intervention factors, only those relating to the woman and her body (age, ethnicity, size of baby, etc.). Essentially, laying the blame for SPT on women and their malfunctioning bodies, rather than what care providers do to women. The leaflet also contains no references to support its statements.

Dahlen et al. (2015) comment on why interventions that cause of SPT have been ignored: "The cascade of intervention in hospital (induction of labour, epidural use, instrumental birth, episiotomy) as a probably cause of higher rates of [SPT] is often not considered in the obstetric discourse around this issue. Perhaps philosophical frameworks and deeply held beliefs around women's bodies and capacity carry a greater weight at the end of the day than does scientific evidence. Perhaps it is ultimately through this lens of 'belief' around women and birth that we select the evidence [or not] that fits most comfortably within our paradigmatic positioning."

I will address each of the 5 practices in the WHA perineal bundle:

1: Apply warm perineal compresses during the second stage of labour at the commencement of perineal stretching (for all women).

A Cochrane Review = "Moderate-quality evidence suggests that warm compresses, and massage, may reduce third- and fourth-degree tears but the impact of these techniques on other outcomes was unclear or inconsistent". It would be nice if it was worded a little differently ie. 'offer all women...' You can find more information about how to apply warm perineal compresses here. Unfortunately, anecdotal reports suggest that women are being told to get into a semi supine position (which increases tearing) so that the midwives can apply the compress and view the perineum.

2: With a spontaneous vaginal delivery [birth!], using gentle verbal guidance, to encourage a slow controlled birth of the fetal head and shoulders: a) support the perineum with the dominant hand; b) apply counter pressure on the fetal head with the non-dominant hand; c) if the shoulders do not delivery spontaneously, apply gentle traction to release the anterior shoulder; d) allow the posterior shoulder to be released following the curve of Carus.

Slow birth does reduce the chance of tearing and supporting physiology assists with this. However, 'hands on' does not reduce tearing according to a Cochrane Review. (best evidence). In addition, a recent study conducted in Australian hospitals found that 'hands on' made no difference for primips, and increased the chance of tearing for multips. The study concluded that: "A hands poised/undirected approach could be utilised in strategies for the prevention of moderate and severe perineal injury." The 'hands on' recommendation also contradicts Queensland Health Normal Birth Guidelines which state that 'hands on' makes no difference to tearing and increases the chance of an episiotomy.

Of course there are always situation in which 'hands on' is appropriate. You can see me using hands on at this birth. However, 'hands off' ie. non-intervention should be default as per evidence and midwifery professional standards.

3: When episiotomy is indicated it should be performed: a) at crowning of the fetal head; b) using a medio-lateral incision; c) at a minimum 60 degree angle from the fourchette. NB. An episiotomy is indicated for all women requiring a forceps or vacuum assisted delivery having their first vaginal birth.

A hands on approach as dictated above increases the chance of the care provider carrying out an episiotomy ( Aasheim et al. 2017); and the implementation of the bundle itself has caused a rise in rates ( Thornton & Dahlen 2020). The type of episiotomy recommend is based on limited evidence and markets a particular type of scissor now shown to be ineffective in reducing SPT ( Thornton & Dahlen 2020). However, midwives are being 'up-skilled' in how to cut women using these new (very expensive) scissors. One midwife reported that:

At my hospital the PPH rate went up rapidly when we got the new episcissors as they were like hot knives in butter and women were having buttectomies with them. They are sharp and dreadful with a flexible guide tail to ensure the correct angle is cut. Plus the training guide on them stops practitioners from using clinical judgement so there's been some labial episiotomies by medical staff because the practitioners are not looking at the woman physiology but following the guide. - Anonymous (midwife)

An episiotomy wound is more painful and heals less well than a spontaneous tear. There is insufficient evidence to support claims that episiotomy reduces the chance of SPT. A mid-line episiotomy actually contributes to the risk of severe perineal trauma ( Lappen & Gossett 2014). Whereas a medio-lateral episiotomy cuts through more nerves and perineal structures than mid-line ( Patel et al. 2018). These nerves contribute to our sexual sensations. We are also only just beginning to understand the complex anatomy of the clitoris , a structure that is more likely to be damaged during 60 degree episiotomy. It is not surprising that a medio-lateral episiotomy is associated "with a decreased sexual functioning as well as sexual desire, arousal and orgasm within postpartum five years" ( Dogan et al. 2017).

In relation to episiotomies for instrumental birth, this is an obstetrician directed recommendation. I'm sure there are some OBs a bit miffed at being told to cut every woman during instrumental births rather than use their clinical judgement for individual women. I've worked with many OBs who are able to carry out a ventouse birth with an intact perineum. However, overall, instrumental birth does increase the risk of SPT. It is interesting that there is no recommendation to avoid adherence to non-evidence based timeframes for 'progress' that result in unnecessary instrumental births and perineal tearing ( WHO).

4: Genito-anal examination following birth needs to: a) be performed by an experienced clinician; b) include a PR [rectal] examination on all women, including those with an intact perineum.

Rectal examination has always been part of assessing a perineal tear, particularly a 2nd degree tear. It is carried out to identify if the tear is a 3rd or 4th degree. If clinicians are missing 3rd / 4th degree tears then they need to be supported to improve their assessment of tears. The main issue with this recommendation is doing a rectal examination on a woman with an intact perineum. I have been unable to get any stats on the incidence of 3rd/4th degree tears with an intact vaginal wall. I have never seen this. I have heard rumours that it has happened. However, it must be extremely rare. Considering only around 1% of women having non-instrumental vaginal births have SPT, the proportion of those women who have a 'hidden' SPT must be less than 0. of a %. The incidence of this rare situation needs to be shared with women who have an intact perineum so that they can make an informed decision to consent to a rectal examination. Anyone with the stats - please share them! A blog post by Jim Thornton (an OB) about this invasive intervention concludes: "Routine rectal examination in the presence of an intact perineum fails all the criteria of a useful screening test. Most midwives wisely don't do it. Those that do, should stop."

5: All perineal trauma should be: a) graded according to the RCOG grading guideline; b) reviewed by a second experienced clinician to confirm the diagnosis and grading.

Yep.

As midwives we are supposed to adhere to professional and legal standards. Our professional standards require us to be woman-centred, evidence-based and promote and support physiology ( ICM; NMBA - Australia). The ICM position statement on the 'appropriate use of intervention childbirth' provides guidance about the use of intervention by midwives and states that: "Women have the right to make informed decisions about the use or non-use of intervention" and "urges midwives to only use or promote the use of intervention during childbirth when indicated." The law requires us to gain consent for any proposed intervention, consent involves providing adequate information. The mother-midwife relationship requires that midwives share information with women and support their decisions. This is where midwives and students are struggling. Aspects of the bundle conflict with their professional responsibilities.

So back to the initial question "what can we do about the bundle". The recommendations that are causing the most upset are the 'hands on' approach for all births, and the rectal examination with an intact perineum.

Suggestions re. 'hands on' for all births

We could just refuse to comply with 'hands on' based on our professional and legal requirements for evidence-based care. Our professional and legal standards trump any workplace directive or employee contract. If all midwives supported each other in this stance practice would change.

and/or

Ensure that women are given adequate information to consent to this intervention, preferably in the antenatal period so that their wishes can be clearly documented before labour. This information needs to include the fact that the intervention is not supported by evidence, may interfere with physiology, and for multips it may increase the chance of them tearing.

Suggestions re. rectal examination for intact perineum

Demand the evidence to support this intervention ie. the incidence of 3rd / 4th degree tearing with an intact perineum. Without this we cannot...

Ensure that women are given adequate information to consent. Including a statement along the lines of (after initial assessment of the perineum post birth): "Your perineum is intact and I can't see any evidence of a tear. In rare circumstances (quantify here eg. 1: 1000) there is a tear in the rectum despite the perineum being intact. I can check your rectum for you if you'd like, or I can leave you to get on with x [feeding baby, etc.]. What would you like me to do?"

We could also use the bundle as an opportunity to get back to basics (woman-centred, evidence-based care) and reclaim midwifery as an autonomous profession (ICM). It is about time that midwives said 'enough' to the bombardment of non-evidence based medicalisation of birth. Solidarity (with each other and women) and activism is long overdue in maternity care.

Since the publication of this post WHA have publicly challenged my critic of the bundle. Below is a record of this 'debate':

In May WHA responded to this blog post with a public mediarelease . The media release later required a log-in (transparency is not on the agenda of WHA). Essentially, the media release re-iterated the intention of WHA to improve outcomes. It did not provide any evidence for the bundle or address any of the issues I raised. It did state that financial penalties for hospital have been removed for 3rd and 4th degree tears. However, these penalties are being implemented, reinforcing the rise in episiotomies as there is no fine for cutting rates. I responded to WHA with the questions below, which remain unanswered:

Which members of the expert panel had the final say regarding which interventions were included in the bundle? Were all of the experts in agreement about the final bundle?

Could WHA provide a statement from the consumers involved that they approved the final bundle; and provide information about whether consumers withdrew from the working party (and what proportion withdrew)?

WHA state that they are "happy to share any of the evidence reviewed by the expert panel in the development of the bundle". Could you please share the evidence relating to a 'hands on' approach for all women during birth, and explain why this recommendation contradicts the QH Normal Birth guidelines.

Why were other evidence-based approaches that align with clinical guidelines not included in the bundle eg. spontaneous pushing, encouraging/discouraging particular birthing positions?

Will WHA monitor episiotomy rates during this intervention. Anecdotally midwives and students are reporting increased use of episiotomy during normal birth, particularly for primips.

Could WHA provide an estimated risk of a 3rd/4th degree tears WITH AN INTACT PERINEUM. Gaining consent for a rectal examination with an intact perineum is problematic without adequate information.

Readers please email WHA (admin2017@wcha.asn.au) with your concerns and experiences relating to the bundle. It is important that WHA are made aware of how the bundle is impacting on the care of women in the clinical setting.

In December 2018 WHA made the mediarelease about this post public again due to 'ongoing interest' (see comment below by 'Adele' ? WHA). The comment also provides a link to a promotional video of various professionals marketing the bundle. A very different perspective to the one I am hearing from practitioners on the 'shop floor'! The media release has since been removed from the website again. Unfortunately WHA have still not answered the questions posed above.

WHA Celebration?

The WHA bundle is firmly established as routine care in many hospitals across Australia. The website spins the narrative of damaged women (with heart-wrenching personal stories of SPT) and the hero care providers who can use their special powers (interventions) to save these women. The webpage (no longer available) titled 'CelebratingSuccess' provides scant information about outcomes and raises more questions that answers:

No methodology is provided so the reader cannot determine if the findings are valid.

WHA claim they are working on peer reviewed journal articles to present the full findings. However, there is no evidence of ethical approval for their 'experiment' and you cannot publish in any decent journal without ethics.

Very limited findings (claims) are presented and there is no public access to the full report.

The claims of reduced SPT are not placed into context, therefore are meaningless. For example, the claim of an 11% reduction of SPT for women having a spontaneous vaginal birth... 11% of what? The rate of SPT for this group of women in Australia was 2.5% in 2015 (Wilson & Homer 2020). So, if the bundle reduced that rate by 11% it amounted to a 0.25% reduction ie. to a rate of 2.25%.

Most importantly, there is no data shared about the episiotomy rates post bundle implementation. Why? They most certainly will have collected this data. Episiotomy is perineal damage and needs to be included in any evaluation of a bundle aimed at reducing perineal damage.

I am unsure what exactly WHA are celebrating. Even if we accept their unsubstantiated statistics, the bundle has reduced the SPT by less than half a % while most likely significantly increasing the rates of episiotomy trauma. The bundle has significantly changed midwifery practice, back towards routine intervention during birth and liberal cutting of women. I don't see how that is any cause for celebration.

Research into the effectiveness of the bundle

Quantitative research is being published that reports a small reduction in SPT with the implementation of the bundle. Borrman et al. 2019 carried out an observational study comparing outcomes before the implmentation of the bundle with afterwards in an Australian hospital. They reported that SPT reduced by 26% during spontaneous birth (stats include induction and epidurals). The article does not provide details about what 26% represents ie. from what % to what %. However, the article does reported a 40% increase in the episiotomy rates during spontaneous birth (7.4% to 10.4%). A large UK-based quantitative study reported that the bundle reduced SPT (3.3% to 3.0%) without increasing the use of episiotomy ( Gurol-Urganci 2020). This study is currently the 'best available' quantitative research about the impact of the perineal bundle within a medicalised birth setting. However, Scamell et al. 2021 wrote the journal that published the study to voice their disappointment on the quality of the evidence. They raise a number of concerns: 1) The selective nature of the evidence quoted, undermines the credibility of inferences that can be made from the findings. 2. The failure to account for the surprisingly small positive effect of the care bundle compared with the Scandinavian studies they quote. 3. The lack of evidence regarding informed consent for the women subjected to the bundle and no consideration of their experience. They conclude that "we are not only disappointed with the BJOG article but with the professional stake- holder investment in the intervention which seems to have been widely and uncritically supported, with some support even being somewhat evangelical, despite the limited evidence for support."

I agree with Scamell et at., we need some good quality research into the impact of the intervention on women's birth experiences. We also need to acknowledge that the research being carried out can only tell us about medicalised birth in hospital settings. We do not have research into outcomes for women having spontaneous, unmedicated and undisturbed physiological births. Therefore, we cannot apply research findings to this group of women.

Here we are five years after the widespread roll out of the perineal bundle, and still do not have good quality evidence that the bundle reduces the rates of SPT. However, we have good quality evidence about the impact of the bundle on women and midwives.

The impact of the bundle on women's experiences of birth

Barnett et al. 2023 carried out a qualitative study exploring how the introduction of the perineal bundle impacted women's birth experiences in Queensland (Australia) maternity hospitals. What they found will not surprise to anyone familiar with maternity service culture and practice. Women reported that they received a lack of information about the bundle elements. Interventions were carried out without consent and some women reported disrespectful treatment.

One woman described the midwife putting her 'hands on' despite being asked not to. The midwife refused to stop and said "No, I have to do this". The woman was a sexual assault survivor and experiences a 'freeze' response as she experience the midwife's treatment as abuse.

Midwives assumed that because women had consented to a post-birth perineal assessment, they had also agreed to a rectal examination. One woman described her experience of having a rectal examination by an obstetrician who walked into the room without introducing herself "It was a bit shocking, because I wasn't pre-warned, so I didn't know. And all of a sudden I was like "Woah, what the hell's going on?". ... Then I asked her to stop. She got a bit cranky. And then really didn't say any- thing else to me. And when she was finished she got up and walked out."

The researchers concluded: "While the intention of the bundle was for women's benefit, in practice its implementation appears to have condoned clinicians' compliance to the detriment of supporting childbearing women's decision-making autonomy. In some respects, the unintended negative consequences for women were largely foreseeable, given the broader maternity services culture within which the bundle was implemented."

The impact of the bundle on midwifery practice

Another Australian qualitative study explored how the perineal bundle impacted midwifery practice in an Australian maternity hospital ( Allen et al. 2021). They found that midwives were told to carry out the bundle without being provided with evidence to support the interventions. Midwives were subjected to surveillance to ensure they complied with the bundle and they responded with "obedience, subversion or compliance ". The midwives in the study noted that the bundle was much easier to carry out with the woman supine and on the bed. This conflicted with their promotion of upright, active birth positions.

The researchers concluded: "The introduction of the perineal bundle acts as an exemplar of obstetric dominance in Australian maternity care. We recommend midwives advocate autonomy - women's and their own - by using clinical judgement, evidence, and woman-centred care."

Cast your mind back to 2018 when the perineal bundle was implemented without research. At that time elements of the bundle were known to increase the chance of episiotomy for women having their first baby, and perineal tearing for women who had previously given birth.

Five years after the roll out of this intervention package, we have research into the outcomes. This research was not carried out by the WHA, who seem to have moved on from this, job done. The study compared outcomes before and after the implementation of the bundle into Australian hospitals ( Lee et al. 2023). The findings reflect what was known before the bundle was rolled out. That the bundle:
"...did not result in a significant reduction in the likelihood of women experiencing a SPT, but did increase the probability of receiving an episiotomy in nulliparous women and second degree trauma in multiparous women."
The researchers also state: "Why, and how, the bundle was introduced at scale without a research framework to test efficacy and safety is a key concern."

Whilst this study validates those of us who were shouting about it at the time, I doubt anything will change. Just like all the other interventions implemented without evidence that continue despite evidence.

Summary

In summary, the perineal bundle has become a cultural norm in many maternity settings. This was inevitable because the bundle aligns with the philosophical underpinnings of the maternity system. Women's bodies are dangerous and need to be managed and controlled to reduce risk. Medical experts and their technology and techniques provide safety. However, carrying out routine interventions during birth prevents care providers from observing and learning about physiological birth. With very low rates of physiological births occurring within institutions, research is carried out on medicalised births. Therefore, any outcomes cannot tell us about the impact of interventions on physiological births. The bundle is here to stay because it meets the needs of the maternity system.

Further Resources

If you enjoyed this post, you can find more of my work in the following resources:

Join my Mailing List to stay up to date with new content and news.

# data[].attributes.body
Sara Wickham

# data[].attributes.attachment_link.description
Dr Sara Wickham - author, speaker, researcher. Evidence-based pregnancy and birth information for women, families, midwives and birth folk.

# data[].attributes.attachment_link.title
How to turn a group of strangers into a team

# data[].attributes.attachment_link.description
Business school professor Amy Edmondson studies “teaming,” where people come together quickly (and often temporarily) to solve new, urgent or unusual problems. Recalling stories of teamwork on the fly, such as the incredible rescue of 33 miners trapped half a mile underground in Chile in 2010, Edmondson shares the elements needed to turn a group of strangers into a quick-thinking team that can nimbly respond to challenges.

# data[].attributes.body
Learning Leadership

# data[].attributes.attachment_link.title
13. Improving choices and care for women; groups, resources and services

# data[].attributes.attachment_link.description
Listen to this episode from The Maternity & Midwifery Hour on Spotify. It is really important that midwives listen to and work with women, organisations, and individuals who will enrich their care.

# data[].attributes.body
Love Led Leadership

# data[].attributes.attachment_link.title
11.1 Does Love Have a Role in Midwifery?

# data[].attributes.attachment_link.description
Episode · The Maternity & Midwifery Hour · Does love have a role in midwifery? If so, what is that role? While the concept of love in nursing has been widely explored, this has not been the case in midwifery and maternity care.

# data[].attributes.body
‘She sort of shines’: midwives’ accounts of ‘good’ midwifery and ‘good’ leadership

# data[].attributes.attachment_link.readable_text
Abstract

Objective

to explore midwives' accounts of the characteristics of 'good' leadership and 'good' midwifery.

Design and methods

a phenomenological interview survey. Participants were asked about what made both good and poor midwives and leaders.

Participants

qualified midwives, selected by random sampling stratified to encompass senior and junior grades.

Analysis

thematic analysis, carried out manually.

Findings

ten midwives were interviewed. Sixteen codes and six sub-themes were generated. Across the responses, two clear dimensions (themes) were identified, relating on the one hand to aspects of knowledge, skill and competence (termed 'skilled competence'), and on the other hand to specific personality characteristics (termed 'emotional intelligence'). This study suggests that the ability to act knowledgeably, safely and competently was seen as a basic requirement for both clinical midwives and midwife leaders. The added element which made both the midwife and the leader 'good' was the extent of their emotional capability.

Conclusions and implications for practice

this small-scale in-depth study could form the basis for hypothesis generation for larger scale work in this area in future. The findings offer some reinforcement for the potential applicability of theories of transformational leadership to midwifery management and practice.

Introduction

... everyone likes watching her deliver babies ... she sort of shines. (Alice).

In the World Health Report, the World Health Organization (WHO) devotes a chapter to the importance of strong leadership. WHO has also developed a programme for potential dynamic leaders in an attempt to combat poverty and health inequalities (WHO, 2005). In the UK, the Department of Health (DoH) developed a leadership centre as part of the National Health Service (NHS) Modernisation agency, in the belief that leaders within the NHS could motivate staff and improve patient care (Department of Health, 2003).

A meta-synthesis of 'expert' intrapartum maternity care identified three emergent concepts in the published literature in this area. These were wisdom, skilled practice and enacted vocation (Downe et al., 2007). An earlier synthesis of studies of the 'good' midwife resulted in eight key concepts, encompassing affective, cognitive and psychomotor domains (Nicholls and Webb, 2006). Examination of emotion work in midwifery (Hunter, 2000, Hunter, 2005) and of the importance of a positive relationship between the mother and the midwife (Kirkham, 2000) indicates that emotional intelligence (Goleman, 1996) and the capacity to form effective relationships relatively quickly might be important attributes for midwifery care.

Examination of the literature on leadership and on that relating to midwifery reveals some evolutionary similarities. The dominant theories in both areas appear to be moving away from hierarchical models, and towards those based on relationships. In the case of leadership, this has led to concentration on transformational philosophies, in contrast to earlier approaches based on command and control (Conger, 1991; Barker, 1994; Carless, 1998). In midwifery, woman-centred care has become the ideology of choice, theoretically replacing hierarchies built on professional power bases (WHO, 1997; Department of Health, 2004, Department of Health, 2007).

However, a systematic search undertaken by the authors of the current study for primary research that encompassed the areas of both midwifery and leadership together did not locate any relevant studies. In the light of this apparent deficit, this study aims to examine how a certain group of midwives (the participants) conceptualise the phenomenon of the 'good' midwife and the 'good' leader.

Section snippets

Findings

The codes and themes generated by the analysis are summarised in Table 1.

Two clear dimensions, or meta-themes, evolved from the data, relating on the one hand to aspects of knowledge, skill and competence (termed 'skilled competence'), and on the other hand to specific intrapersonal and interpersonal traits (termed 'emotional intelligence'). The findings are discussed below under these two meta-themes.

The good midwife: 'good clinically'

For the participants in this study, it was taken for granted that basic practical midwifery skills were a fundamental component of good midwifery. Experience, clinical skills and competence were all seen to be part of an effective knowledge base. The words of the participants suggest that the 'good' midwife was a trusted practitioner, who generated justified feelings of safety in those she cared for:

... it has to be the midwifery skills and the way you feel comfortable ... I would have complete

An emerging leadership paradigm: transformational leadership

Carless, S.A., 1998. Gender differences in transformational leadership: an examination of superior, leader, and...

Psychological research as the phenomenologists views it

Conger, J.A., 1991. Inspiring Others: the Language of Leadership Academy of Management Executive 5 No....

C. Cottingham
Transformational leadership: a strategy for nursing

Crotty, M., 1998. The Foundations of Social Research; Meaning and Perspective in the Research Process. Sage...

Department of Health, 2003. The Leadership Centre....

Department of Health, 2004. National Service Framework for Children, Young People & Maternity Services, Department of...

Department of Health, 2007. Maternity Matters: Choice, Access and Continuity of Care in a Safe Service, Department of...

Expert intrapartum maternity care: a meta-synthesis

New technologies and Post-Taylorist regulation models. The introduction and use of production planning systems in French, Italian and German enterprises

View full text

# data[].attributes.attachment_link.title
'She sort of shines': midwives' accounts of 'good' midwifery and 'good' leadership

# data[].attributes.attachment_link.description
to explore midwives' accounts of the characteristics of 'good' leadership and 'good' midwifery.a phenomenological interview survey. Participants were ...

# data[].attributes.body
Prof Hannah Dahlen's lecture at KCL Sep 2022: A journey of leadership

# data[].attributes.body
NHSE Collective leadership

# data[].attributes.attachment_link.readable_text
Our purpose is to create compassionate and inclusive cultures in organisations and systems because delivering high quality care depends on creating positive, inclusive work environments where people want to come to work.

Supporting staff: because our NHS is made up of 1.3 million people who care for the people of this country with skill, compassion and dedication.

Supporting change teams: because the current thinking about how culture change happens shows it needs to be led and owned locally and supported from above.

Learning together: because enabling understanding of environments where staff thrive and can perform to the best of their ability using an evidence base.

Strengthening compassionate and inclusive leadership: because leading with compassion and inclusion delivers sustainably healthy places to work.

# data[].attributes.attachment_link.title
Changing healthcare cultures - through collective leadership

# data[].attributes.attachment_link.description
Our purpose is to create compassionate and inclusive cultures in organisations and systems because delivering high quality care depends on creating positive, inclusive work environments where people want to come to work. Supporting staff: because our NHS is made up of 1.3 million people who care for the people of this country with skill, compassion and dedication.

# data[].attributes.body
The Collective Leadership for Safety Culture (Co-Lead) Team Intervention to Promote Teamwork and Patient Safety

# data[].attributes.attachment_link.readable_text
UCD Centre for Interdisciplinary Research, Education, and Innovation in Health Systems (UCD IRIS), School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin 4, Ireland

Transformation Office, Mater Misericordiae University Hospital, Eccles St, Dublin 7, Ireland

School of Medicine, University of Limerick, V94 T9PX Limerick, Ireland

Author to whom correspondence should be addressed.

1. Introduction

There has been increasing focus on the crucial role of leadership to promote effective patient safety. Patient safety has become a focus of research and intervention internationally as a result of major investigations in the US [ 1] and the UK [ 2] emphasising the significant impact of errors and system failures on patient safety, morbidity and mortality. Leadership is often suggested as a viable and powerful target for intervention, given its influential role in shaping healthcare cultures that provide high quality and safe care [ 3]. While leadership approaches have emerged that represent a shift away from the single-leader approaches (for example, transformational leadership and adaptive leadership), historically leadership development in healthcare has primarily focused on the heroic, individual-as-leader model [ 4], often taking individuals out of the system, training them in a university environment, and expecting that they will be equipped to deploy their newly-acquired skills upon return to the healthcare setting. It is challenging for one individual to enact change in a large complex system, and the appropriateness of this model is questionable, given healthcare delivery is almost wholly dependent on multidisciplinary team (MDT) effort [ 5, 6].

Recent systematic reviews demonstrate that there is increasing and strong evidence for effectiveness of team-based and collective approaches to leadership in healthcare settings [ 7, 8, 9]. For instance, Wu et al. [ 8] found that shared leadership played a "crucial role" in fostering positive team outcomes in multiple domains, including group behavior processes, attitudinal outcomes, team cognition, and team performance (p. 60). Despite this accumulating evidence for shared and collective approaches to leadership, there is limited guidance or training on how to support teams in working more collectively to enhance safety [ 9]. To address this gap, we embarked on a lengthy research process to: (a) understand the challenges to working collaboratively that are encountered in healthcare teams; (b) utilise the best available evidence to co-design a targeted intervention to help teams to work collectively to improve their performance; and (c) implement and assess the impact of this intervention on healthcare teams. The Co-Lead team intervention is the result of this five-year programme of work. The intervention is currently being deployed and widely tested. Our objective in this paper is to provide a sufficiently detailed description of this open-access intervention to enable adoption and further testing in other settings in light of calls to enable the comparability and replicability of implementation and testing of interventions of this nature [ 9]. This paper provides an overview of the design, development, and testing of this complex intervention, describes the content and resources offered by the intervention and reflects on its contribution as well as the potential for this intervention to promote safety culture and effective teamworking through supporting teams to lead collectively.

Teamwork and Collective Leadership

In modern healthcare settings, teamwork is integral to fostering a working environment that supports and enhances safe and high-quality person-centred cultures of care. Although not mandatory in most health systems, team training is recognised as crucial to optimise team-based approaches to the delivery of healthcare [ 10, 11, 12, 13]. Team training programmes aim to equip team members with the knowledge and skills necessary to communicate, collaborate, and coordinate with healthcare professionals of various levels of experience and of diverse disciplinary backgrounds. Several healthcare team training interventions exist, TeamSTEPPS [ 14] (developed by the US Department of Defence and the Agency for Healthcare Research and Quality) and Crew Resource Management (adapted from the aviation industry) [ 15, 16] being amongst the most popular. While team training has proven beneficial for individual staff members, teams and healthcare organisations [ 10, 16], there is an absence of training packages aimed at promoting safety culture and team effectiveness through enhancing collective leadership skills among team members. This novel collective leadership focus was a deliberate and critical element of our work, because of the multidisciplinary nature of modern healthcare teams and the fact that traditional leadership models have been implicated in patient safety failures [ 2, 17].

A collective leadership approach may be defined as one that recognises leadership is not necessarily the sole responsibility of one individual, but may be considered a team property, where roles and responsibilities are shared as the task demands [ 18]. While there is accumulating evidence for the benefit and value of this more inclusive and collective approach to team outcomes in healthcare [ 6, 8, 9], there was a dearth of guidance on how to develop collective leadership in practice. The Co-Lead intervention was designed to address this gap by creating a set of resources that teams could self-deliver to support the development of the team's skills in collective leadership. The intervention aimed to collectively improve teams' safety culture and performance. During development, we adhered to Salas et al.'s key principles for effective team training in healthcare [ 13]. Among these eight principles are: (i) identification of critical teamworking competencies; (ii) emphasising teamwork over task work; (iii) recognising one size does not fit all; (iv) providing opportunity to apply learning; (v) ensuring relevance to transfer environment; (vi) ensuring timely, relevant feedback; (vii) evaluating outcomes and learning; and (viii) reinforcing designed behaviours [ 13]. We will reflect further on the alignment of Co-Lead to these principles in our discussion of the intervention.

A review of the evidence on leadership research in healthcare concluded that contextual, organisational and team-based elements have a meaningful impact on leadership in practice [ 19]. Therefore, to account for the impact of context on collective leadership, a realist evaluation was adopted to test the intervention. Realist evaluation is a methodological approach that acknowledges the role of context when implementing complex interventions. It is a theory-driven approach that explores generative causation through exploring the psychological mechanisms that trigger specific intervention outcomes in certain contextual conditions [ 20]. This supported the investigation of the impact of the resources offered by the intervention on four heterogeneous teams to help understand what worked for whom, to what extent, how and in what circumstances.

2. Materials and Methods

2.1. Development of Co-Lead

We undertook a co-design process to inform the development of the collective leadership intervention. In the healthcare context, co-design in healthcare involves the equal partnership of healthcare professionals, those with lived experience of a healthcare system or service (such as patients, families and carers) and the other stakeholders and experts relevant to the specific problem or service (e.g., researchers, IT professionals, etc.) [ 21]. To inform the design of this intervention, we partnered with a team of twenty-one people that included health systems researchers, healthcare professionals, managers, and patient representatives to co-design the Co-Lead intervention. Experts in collective leadership, team training, healthcare delivery, human factors, and implementation science also contributed their expertise. We held six half-day co-design workshops with one full final day over a seven-month period. At these workshops, frontline staff, managers, patients, and experts contributed their knowledge and expertise to inform, identify, and prioritise relevant content and topics that were agreed to represent crucial components of a team training intervention to promote collective leadership for safety (in line with Salas et al.'s principle [ 13]). Topics included experiences of teamworking, frustrations and barriers to effective teamwork, patient safety and safety monitoring, feasibility of training modalities and types of, and the measurement of, impact and outcomes. The research team informed these sessions through extensive literature reviews on key topics including collective leadership interventions, safety culture in healthcare, and case studies of effective teams working collectively. Additionally, the research invited expert presentations on safety to contribute to the co-design team discussions. A paper describing this co-design process in detail, including steps in the process, inputs, strategies to enable collaboration during sessions, and an overview of the workshop aims, content, and co-design outcomes is available [ 21]. The result of the co-design process was an agreed template and set of priorities to inform, build and test the final Co-Lead intervention. We have also drawn on (with appropriate permissions) existing evidence-based interventions or team training programmes and materials.

2.2. The Co-Lead Intervention: Overview and Module Descriptions

The full intervention may be downloaded as an open access resource from www.ucd.ie/collectiveleadership. It comprises a series of modules designed to enhance collective leadership in multidisciplinary healthcare teams to promote safety cultures. These take the form of team workshops, in the team's workplace setting, each lasting approximately one hour. There are initially six "core" modules, focusing on team performance and safety culture. These introduce the principles and outcomes of collective leadership and provide tools to achieve them. The focus of these core modules is on team performance and safety cultures. Teams may then select an additional two modules from thirteen "targeted" modules grouped into 4 main themes: team processes; well-being; patient safety; and sustaining improvements. Each module focuses on a specific area for improvement (all employing a collective leadership approach), based on what teams feel is most relevant and useful to help them achieve their goals ( Figure 1). Given the Co-Lead intervention is aimed at all types of MDT, this flexibility was cited as important by the co-design team and therefore incorporated into the intervention design. This ensures the intervention does not adopt a "one size fits all approach" and can be adapted appropriately as required by the needs and priorities of teams [ 13]. This also allows teams to opt not to focus on practices already embedded, e.g., safety pause. The hour-long workshop structure arose since the co-design team noted that sessions longer than one hour were not practicable during a typical healthcare team's working day. As the training is focused on the team learning and applying learning together [ 13], and it is neither practical nor feasible for an entire team to be away from the care delivery setting, the intervention was designed to be delivered within the workplace setting.

Each module session has a corresponding set of instructions to support session delivery. These guides enable team members to facilitate the sessions themselves, requiring no advance preparation. Open access supports available for download include materials for facilitators, a session outline, and handouts (where applicable). In some cases, there are also links to download other materials such as presentations or tools for use during the session. Adhering to Salas et al.'s principles, activities are embedded to enable team members to immediately practice learning and to support rapid transfer of learning to practice [ 13]. Furthermore, teams are encouraged and supported to collect meaningful measurements of improvement targets, enabling the team to reflect on performance outcomes and feedback and how to sustain new process and desirable behaviours [ 13].

3. Results

3.1. Intervention Mechanisms of Action

We employed a mixed methods realist evaluation in the pilot testing of the Co-Lead intervention [ 22]. This involved a multiple forms of data collection, including non-participant observation of team sessions, one-on-one interviews with team members and a survey to evaluate collective leadership, team working and safety culture. The realist evaluation approach required careful consideration and unpacking of the constituent elements of the intervention, the resources it offered, how it was anticipated to impact on participants and the expected outcomes, based on the extant literature. In collaboration with experts in the field of collective leadership, safety culture, quality improvement and health systems research, we developed a programme theory to understand and test how the intervention was received and the resulting impact of its implementation. This programme theory is described in detail elsewhere [ 18] and has been tested and refined through multiple methods of data collection [ 23], lending support to the mechanisms and outcomes hypothesised to occur as a result of a team's engagement in the Co-Lead programme.

Table A1 (see Appendix A) summarises the Co-Lead modules, provides a brief overview of the aim of each one, and consistent with the realist approach to understanding how an intervention operates [ 20], describes the resource mechanisms offered by the intervention and the psychological mechanisms triggered in responses to the resources offered [ 24]. A resource mechanism refers to the component of the intervention introduced into the context and the reasoning mechanisms relate to the participant's implicit reactions and (unobservable psychological) reasonings in response to the intervention resources [ 24]. For instance, in Figure 2, the theory depicted proposes that the intervention (as a package) offers teams dedicated time to reflect on how the team operates. This is the new offering or resource provided by the Co-Lead intervention and when that resource is introduced to the context in which teams are working, it triggers the reasoning mechanisms of a shared understanding and a greater appreciation of other team members, their roles, and expertise [ 23]. This in turn promotes intervention outcomes including enhanced teamworking, staff satisfaction, improvements in quality and safety and the practice of collective leadership.

We conducted a similar mapping process for each intervention module, identifying the resource mechanisms they offer (e.g., knowledge, skills, support, etc.) that may help trigger the reasoning mechanisms that lead to the desired outcomes relating to the enactment of collective leadership in teams. This process ensured the topics and priorities identified by the co-design team were linked to the final intervention design and to targeted individual and team outcomes. This resource mapping process was conducted independently by five members of the research team to ensure interrater reliability in the identification of mechanisms of resource and action. A high degree of agreement was achieved. Table A1 displays the results of this mapping process and identifies some examples of the targeted psychological mechanisms and behavioural outcomes of specific modules.

3.2. Realist Evaluation of Intervention

While the focus of this paper is to outline the development and key mechanisms of action underpinning the intervention, this section reflects briefly on the findings of the realist evaluation. The realist evaluation explored the impact of the implementation of the Co-Lead intervention across four heterogeneous healthcare teams, ranging in size from small cross-organisational teams to large unit-based teams in large urban teaching hospitals. The intervention was successfully implemented in all four cases. We found that the intervention promoted a positive internal team environment, fostered the recognition that partnership is required for effective patient care and a more collective mindset was reported. This in turn led to improvements in teamworking, team performance and quality and safety [ 23]. This resonates with previous research identifying the importance of a positive internal team environment and the development of shared mental models and reflective practice to promote teamworking and collective leadership [ 8, 25]. The provision of structured intervention materials to support and promote inclusivity and interdisciplinary working was strongly linked to enhanced empowerment, motivation and a shared sense of responsibility for team performance. The intervention's collective focus aimed at highlighting expertise on the team helped to dissolve the barriers between professions on teams and enhanced psychological safety. Through creating a culture of psychological safety, participants developed interpersonal trust, felt better equipped to share leadership, were more open to voicing opinions, and senior leaders were more willing to listen and seek input [ 23].

4. Discussion

The healthcare environment requires training supports that align with contemporary demands and realities and that support the modernisation of healthcare delivery. In a review of the evidence base for leadership in healthcare by West and colleagues, they described leadership as the most influential factor in shaping organisational culture [ 3]. This highlights the importance of leadership as a target for quality and safety in healthcare. Despite strong evidence for its efficacy in improving staff satisfaction, team performance and organisational outcomes [ 10, 11, 13, 16], healthcare has been slow to adopt team training. Given the high-risk and complex nature of healthcare delivery and the increasing complexity of patient presentations, multidisciplinary teamwork is required more than ever to help mitigate risk and adverse outcomes, and to optimise quality and safety of healthcare delivery and patient outcomes. The Co-Lead intervention has been designed with the remit of improving safety culture and team performance through the promotion of collective leadership in teams. In this discussion, we reflect on the co-design and development process and contextualise this work with reference to Salas et al.'s key principles for teamwork training development in healthcare settings [ 13].

Whilst there are many good examples of team training interventions to improve team performance, no existing programme focused on collective leadership as a means to promote safety and performance. We sought to harness existing resources and develop new intervention modules to meet this need. Key to the effective design of a team training intervention is ensuring its relevance: dedicating time to confirm that its design and resources meet the needs of the targeted population (i.e., frontline healthcare teams). Through bringing together a diverse group of researchers, healthcare professionals, managers, and patients, and adopting a co-design approach, we collectively identified critical teamwork competencies. Additionally, by grounding the interventions within the competing demands of healthcare teams we ensured that the realities of practice guided intervention content and structure.

Secondly, the co-design of the intervention prioritised teamwork competencies over task-based competencies, helping to ensure the broader relevance of the intervention. Aligned with this was the recognition that team training had to be flexible; beyond the six core modules, teams can tailor the intervention to suit their own prioritised needs and goals. Broad teamworking competencies, including communication, coordination, and collaboration, are emphasised through a collective leadership lens and by highlighting the need for individual and collective responsibility for the team's quality and safety performance. In addition, where feasible, we sought to enable participants to practice newly acquired skills (e.g., in communication) through guided and practical experiences during training sessions. This approach helps to ensure that training is perceived as relevant and transferrable to the work environment [ 13].

The content and structure of the intervention enables team members to develop a sense of ownership for team operations, supported by shared leadership approach towards improvement. The creation of dedicated time for team reflection fostered a shared mental model among team members, created a psychologically safe environment where individuals felt secure in voicing their opinions, demonstrating that team members were more willing to offer solutions and "rise to the occasion to exhibit leadership" [ 26]. This resonates with previous research demonstrating that when collective leadership is practiced, team members are more likely to contribute ideas and share information [ 27]. Consequently, teams collaboratively and successfully implemented quality and safety initiatives (e.g., safety huddles).

The importance of a strong internal team environment to promote collective leadership has been established [ 8, 28]. Elements underpinning this environment include a shared purpose, social support, voice and team trust [ 28]. Impactful efforts towards collective action are driven by foundational relationships, with aligned vision and values [ 29]. Collective identity is also particularly relevant to the development and enactment of collective leadership [ 30]. Evidence from the realist evaluation indicates that the Co-Lead intervention can foster the development of a shared mental model among team members, which can enhance coordination among team members.

Finally, the Co-Lead intervention emphasises the importance of meaningful measurement and metrics that are relevant to teams themselves. We have modules specifically to support teams to understand what is being measured by the organisation and the wider healthcare system. The intervention also helps teams to learn how they can use clinical outcome and process data to determine and improve how they operate as a team and to determine how they are performing against their key objectives over time.

In our testing of the impact of the Co-Lead intervention, a mixed-methods realist evaluation of four case studies was adopted to explore what works for whom, how, and under what circumstances. Eight context-mechanism-outcome configurations (theories) were extrapolated that explain the mechanisms triggered to drive outcomes in particular contexts [ 23]. This provides the first evidence for the positive impact of Co-Lead on individual (staff and patients) and team-level outcomes, including key quality and safety metrics. The next phase will explore the impact of the intervention at the organisational level and will assess the impact of team training on organisations' safety and key performance indicators.

5. Conclusions

Given the highly interdependent nature of healthcare teams, collective leadership can be considered even more important for healthcare settings [ 8]. In light of the strong evidence base in support of collective leadership as a means to improve team performance [ 8, 9], it is imperative that health systems move from the traditional practice of focusing on the individual as a leader and to consider a stronger focus on the leadership potential of teams This paper presents a robust, evidence-based, co-designed intervention that addresses many of the challenges being encountered by healthcare teams in their daily efforts to deliver safe, high quality care. The co-designed, flexible nature of the intervention ensures it can be easily utilised by any team or organisation that recognises the importance of a collective, collaborative approach to improving healthcare. The pilot and formative research we have conducted with teams to date confirms the value of the intervention for team development. Although we have not completed our testing on the impact of the intervention at scale, our realist evaluation of the pilot is indicative of the intervention's potential to positively impact team performance and patient safety. We would therefore encourage other health systems, quality improvement and patient safety researchers to collaborate with healthcare organisations to implement and evaluate this intervention in their own contexts. Just as large-scale multi-national trials are utilised to test new drugs or treatments, it is time for organisational researchers to address the many systems challenges through large-scale multi-national organisational studies. We have a collective responsibility to advance promising interventions towards the goal of delivering safe care for all.

Author Contributions

Conceptualization, E.M., A.D.B.; methodology, E.M., A.D.B.; formal analysis, A.D.B., S.A., U.C., Z.K., S.M., R.O., L.R., E.M.; investigation, A.D.B., S.A., U.C., Z.K., S.M., R.O., L.R., E.M.; writing-original draft preparation, A.D.B.; writing-review and editing, A.D.B., S.A., U.C., Z.K., S.M., R.O., L.R., E.M.; visualization, A.D.B.; funding acquisition, E.M. All authors have read and agreed to the published version of the manuscript.

Funding

This research is being funded by the Health Research Board (RL-2015-1588) and is also supported by the Health Service Executive.

Acknowledgments

We would like to extend our thanks to our clinical and organisation partners and the teams that took part in this research.

Conflicts of Interest

The authors declare no conflict of interest.

Appendix A

Table A1. Co-Lead intervention modules: summary, mechanisms of action and target behavioural outcomes.

Co-Lead Intervention Modules

Aim/Description

Resource Mechanisms Offered by Module

Reasoning Mechanisms Triggered by Module

Examples of Targeted Behaviours

Team Values, Vision and Mission
The aim of this session is for the team to collectively establish and agree team values, team vision, and a team mission statement. These statements will guide and drive the work and goals of the team.

Enables team time and structured process to agree and make explicit a set of values, vision, and mission statements that represent the team's goals and ways of working.

Collective action towards achievement of goals, e.g., monitoring, improvement efforts.

Team Goal Setting
The aim of this session is for the team to collectively establish the team's goals and priorities for the coming months. These goals should align with the outputs from the previous session on creating the team's vision and mission statements.

Opportunity to clarify and understand each other's goals. Enabling team members to propose team goals and reach consensus on team targets, to establish a sense of ownership of team goals.

Collaborative goal setting.
Implementation of action plan for sub-teams to work towards agreed goals and improvements. Implementation of new processes or ways of working.

Role Clarity
This session explores the concepts of role clarity, and the way that improved role clarity can enhance the work done by teams. Participants discuss and reflect on their perceptions and expectations of the roles of different team members.

Materials enhance learning on the importance of role clarity. Provides a structure that supports staff to reflect on their role and that of others on the team.

Explicitly recognising and appreciating skills of others.
Collaboration across professional boundaries.

Collective Leadership for Safety Skills
This session focuses on collective leadership and responsibility for safety. The objective is to think about the team's level of awareness of safety, and the safety skills that are strong in the team as well as those that need to be developed.

Materials provide evidence and learning about collective responsibility for patient care and offer the time to collectively reflect and prioritise the safety skills for improvement.

Adopting new roles and responsibilities in safety management.

Risk and Safety Management at the Team Level
The aim of this session is to create an understanding among all team members of the nature of risk and safety at the team level and how to understand if care has been safe in the past, is safe in the present, and will be safe in the future.

Materials provide learning around risk and safety and offer the time and structure to collectively focus on current safety measures and possible risks for the team.

Shared understanding of, and responsibility for, risks and what the team can do to mitigate them.

Empowerment and motivation through sense of shared responsibility for team performance.

Adopting new roles and responsibilities in safety management.
Identifying risks and safety issues.

Monitoring and Communicating Safety at Team level
This module builds on the Risk and Safety Management module, to provide team members with a structured tool and overarching perspective on the ways in which they can track the team's safety performance.

Time and opportunity for staff to collectively decide a wide range of performance and improvement measures specific to the team that would be meaningful for them to understand/improve performance.
Materials provide a structure to drive improvement.

Adopting a role in data collection or analysis of safety metrics identified as important to the team.
Providing feedback to team members on safety performance.

Effective Team Meetings
This module facilitates teams to collectively discuss and agree on the best structure to make the most effective use of meeting times.

Materials provide team members with tools to support effective team functioning. Time and opportunity to collectively decide how to support/improve future meetings.

Attendance at and contribution to team meetings.
Information sharing.

Removing Frustrations/ Blockers
Build-up of frustrations and barriers in everyday work in healthcare can reduce team and individual efficiency and contribute to safety issues. This module helps teams identify and find possible solutions to the frustrations and barriers commonly occurring in their working practice.

Material provides structure to collectively reflect and identify problems and troubleshoot team specific operations. Provides safe space and dedicated time to discuss barriers, frustrations, blockers to team processes.

Collective action towards implementation or de-implementation of processes or ways of working.
Problem solving as a team.

Building Trust
This module provides a space where team members can get to know each other better and build trust through creation of an environment where they can share concerns and provide mutual support during times of difficulty.

Providing a safe space and dedicated time to get to know team members, share ambitions and stories, identify strengths and weaknesses, and build mechanisms of support.

Seeking support and advice from other colleagues.
Anticipating and supporting others' needs.
Learning from mistakes.

Structured Interdisciplinary Rounds
Structured interdisciplinary rounds (SIDRs) are a way for interdisciplinary teams to enhance their teamwork and collaboration, by strengthening communications between members around care plans for patients.

Materials provide the evidence and learning to heighten staff awareness of the benefits of inclusiveness. Provides time and opportunity for staff to collectively decide how to best implement the initiative and tailor it to their needs as a team.

Implementation of SIDRs.
Attendance from all relevant professionals.
Speaking up and providing input to collaborate towards development of patient care plans.

Challenging Unsafe Behaviours (CUSS) [14,31]
Staff may occasionally be concerned when they witness unconventional or unsafe practices in the workplace but may lack the structure and tools to raise the issue with colleagues. This module provides a standardised method to support interdisciplinary communication which can be used to speak about safety concerns when they arise and encourage all staff to challenge unsafe behaviour.

Group exposure and practice of graded assertiveness method for communicating safety concerns. Agreement on a standard method for raising concerns within the team to ensure team members will be heard/understood.

Enhanced trust and psychological safety

Sense of shared responsibility

Understanding that partnership needed for effective patient care

Consensus and shared understanding of CUSS words (shared mental model)

Speaking up and voicing safety concerns.
Seeking input from others.
Using agreed CUSS terms when communicating about safety.
Effective communication between team members.

Communication at Safety Critical Moments (ISBAR₃) [32] #

Safety-critical moments regularly arise during clinical practice, for example during staff handovers. In this module, teams become familiarised with a structured and focused tool to enhance communication of important information during such times.

Group exposure to tools that facilitate focused communication between team members to deliver information in a structured and effective way. Understanding of the importance of clear, standardised communication

Sense of responsibility to team members and patients

Understanding that partnership is needed for effective patient care

Use of ISBAR communication tool in daily practice.

Talking about Safety (PlayDecide serious game) [33]
In this module, team members engage in structured discussions on patient safety and error reporting, using a "serious game" learning tool that has been co-designed with input from health professionals, patients, and researchers. The game creates a safe space to encourage deep discussion about patient safety to develop a shared understanding of the importance of error reporting in strengthening patient safety culture.

Offers staff a safe structure to learn through other people's real experiences and acknowledge challenges inherent in safety management and reporting.

Reporting of safety events.
Team reflexivity and learning from safety events and near misses (time for reflection and learning).

Safety Pause Huddles [34]
This module familiarises team members with the Safety Pause, which is designed to facilitate the sharing of critical information among teams to maximise patient safety following clinical handovers, with the goal of adopting it for use in everyday practice.

Offers the evidence and learning to support the Safety Pause Huddle. Provides a tool to identify and highlight safety concerns to the team. Time and a structure to collectively decide how to use the tool as a team. Demonstrates importance of regular, focused communication

Implementation of huddles into practice (e.g., during clinical handover).
Improved MDT communication.

High Reliability at the Team Level
This module focuses on building high reliability among teams, to ensure delivery of high-quality care in a consistent manner, and with minimal errors, despite healthcare's complex and challenging work environment.

Provides staff with evidence and learning to achieve higher collective safety awareness through reflecting individually and collectively on the reliability of the team, the factors that impact this reliability of the team and how to improve.

Understanding that partnership needed for effective patient care

Shared mental models and shared understanding of how cooperation and coordination between team members can help achieve better team reliability.

Collaboration to ensure reliability in care processes.
Identify opportunities for improvement.
Adapting to challenges.

Developing a positive work environment
This module focuses on engaging the whole team to find solutions that will help foster a positive work environment which will in turn provide the support necessary to reduce stress, avoid burnout, and improve job satisfaction among staff members.

Provides affirmation of the importance of caring for self and team and a structure that enables the team time to reflect and collectively develop improvements.

Implementation of initiatives to develop positivity and improve experience for staff and patients.

Emotional Support in Teams
This module focuses on the ways in which team members can create an environment of support during challenging times, and introduces a tool which can be used by line managers, colleagues, and peers to hold meaningful and supportive conversations with staff after an adverse event has occurred.

Provides practical guidance to support colleagues after a traumatic event, time to practice using the model and an opportunity to collectively reflect and agree on how to best support each other.

Showing support and concern for others.
Role blurring and task sharing behaviours.

Enhancing Person-Centred Care
This module focuses on developing awareness among health professionals of the importance of featuring the patient as the focal point in the care that they provide and working collectively to build a person-centred environment in their workplace.

Emphasising humanity in care and offers teams the time to reflect on their own care, providing a structure that encourages team members to incorporate person-centred thinking into their daily practice

Implementation of initiatives to develop positivity and improve experience for staff and patients.

Sustaining Improvements
This module focuses on the next steps after teams have taken part in the Co-Lead intervention, and wish to carry forward any useful tools, information, and lessons learned.

Offers team time and structure to reflect on achievements, progress, and enables the team to collectively plan for and ensure sustainability of changes.

Shared sense of responsibility, purpose.

Internalisation of collective leadership concepts

Confidence in enhanced knowledge and skills in collective leadership

Putting plan or processes in place to support the team to sustain improvements.
Successful maintenance of new ways of working.

References

1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century; The National Academies Press: Washington, DC, USA, 2001; p. 360. [Google Scholar]

2. Francis, R. Report of the Mid Staffordshire NHS Foundation Trust public Inquiry: Executive Summary; The Stationery Office: London, UK, 2013. [Google Scholar]

3. West, M.; Armit, K.; Loewenthal, L.; Eckert, R.; West, T.; Lee, A. Leadership and Leadership Development in Healthcare: The Evidence Base; The Kings Fund: London, UK, 2015. [Google Scholar]

4. West, M.; Eckert, R.; Steward, K.; Pasmore, B. Developing Collective Leadership for Health Care; The King's Fund: London, UK, 2014. [Google Scholar]

5. King, H.B.; Battles, J.; Baker, D.P.; Alonso, A.; Salas, E.; Webster, J. TeamSTEPPS™: Team strategies and tools to enhance performance and patient safety. In Advances in Patient Safety: New Directions and Alternative Approaches (Performance and Tools); Agency for Healthcare Research and Quality: Rockville, MD, USA, 2008; Volume 3. [Google Scholar]

6. Maynard, M.T.; Marshall, D.; Dean, M.D. Crew resource management and teamwork training in health care: A review of the literature and recommendations for how to leverage such interventions to enhance patient safety. In Annual Review of Health Care Management: Strategy and Policy Perspectives on Reforming Health Systems; Emerald Group Publishing Limited: Bingley, UK, 2012. [Google Scholar]

7. Hartmann, C.W.; Meterko, M.; Rosen, A.K.; Zhao, S.; Shokeen, P.; Singer, S. Relationship of Hospital Organizational Culture to Patient Safety Climate in the Veterans Health Administration. Med. Care Res. Rev. 2009, 66, 320-338. [Google Scholar] [PubMed]

8. Pawson, R.; Tilley, N. Realistic Evaluation; Sage: Thousand Oaks, CA, USA, 1997. [Google Scholar]

9. De Brun, A.; Rogers, L.; O'Shea, M.; McAuliffe, E. Understanding the impact of a collective leadership intervention on team working and safety culture in healthcare teams: A realist evaluation protocol. HRB Open Res. 2019, 2, 5. [Google Scholar] [PubMed] [Green Version]

10. De Brún, A.; McAuliffe, E. "The hierarchical days aren't going to work any longer": A realist evaluation of a collective leadership intervention (Co-Lead) in healthcare teams. 2020. under review. [Google Scholar]

11. Schön, D.A. The Reflective Practitioner: How Professionals Think in Action; Routledge: Abingdon, UK, 2017. [Google Scholar]

12. Pearce, C.L.; Conger, J.A. Shared Leadership: Reframing the Hows and Whys of Leadership; Sage: Thousand Oaks, CA, USA, 2002. [Google Scholar]

13. TeamSTEPPS 2.0 Curriculum [Internet]. Agency for Healthcare Research and Quality. 2019. Available online: https://www.ahrq.gov/teamstepps/instructor/index.html (accessed on 25 July 2020).

14. Health Service Executive (HSE) Quality and Patient Safety. The Safety Pause Information Sheet: Health Service Executive. Available online: https://www.lenus.ie/handle/10147/293915 (accessed on 2 April 2020).

Publisher's Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

De Brún, A.; Anjara, S.; Cunningham, U.; Khurshid, Z.; Macdonald, S.; O'Donovan, R.; Rogers, L.; McAuliffe, E. The Collective Leadership for Safety Culture (Co-Lead) Team Intervention to Promote Teamwork and Patient Safety. Int. J. Environ. Res. Public Health 2020, 17, 8673. https://doi.org/10.3390/ijerph17228673

De Brún A, Anjara S, Cunningham U, Khurshid Z, Macdonald S, O'Donovan R, Rogers L, McAuliffe E. The Collective Leadership for Safety Culture (Co-Lead) Team Intervention to Promote Teamwork and Patient Safety. International Journal of Environmental Research and Public Health. 2020; 17(22):8673. https://doi.org/10.3390/ijerph17228673

Chicago/Turabian Style

De Brún, Aoife, Sabrina Anjara, Una Cunningham, Zuneera Khurshid, Steve Macdonald, Róisín O'Donovan, Lisa Rogers, and Eilish McAuliffe. 2020. "The Collective Leadership for Safety Culture (Co-Lead) Team Intervention to Promote Teamwork and Patient Safety" International Journal of Environmental Research and Public Health 17, no. 22: 8673. https://doi.org/10.3390/ijerph17228673

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

# data[].attributes.attachment_link.title
The Collective Leadership for Safety Culture (Co-Lead) Team Intervention to Promote Teamwork and Patient Safety

# data[].attributes.attachment_link.description
Traditional hierarchical leadership has been implicated in patient safety failings internationally. Given that healthcare is almost wholly delivered by multidisciplinary teams, there have been calls for a more collective and team-based approach to the sharing of leadership and responsibility for patient safety.

# data[].attributes.body
Interventions to develop collectivistic leadership in healthcare settings: a systematic review

# data[].attributes.attachment_link.readable_text
Research article

Open Access

Published:

BMC Health Services Research 19, Article number: 72 (2019) Cite this article

17k Accesses

39 Citations

32 Altmetric

Metrics

Abstract

Background

Collective or shared leadership approaches have been associated with team performance outcomes in several sectors. Based on this evidence, there have been calls for more inclusive approaches to leadership in healthcare settings, but guidance on how to achieve collective leadership is lacking. This study synthesised knowledge of interventions to introduce collectivistic leadership in healthcare settings.

Methods

The databases of PubMed, PsychInfo, ABI Inform, Cochrane and CINAHL and three grey literature databases were searched. Studies from any country were included if they reported on the development and evaluation and/or implementation of training/interventions to develop collectivistic leadership and reported individual and/or team-level outcomes. Results were synthesised using a narrative approach.

Results

The searches yielded 4448 records of which 21 met the eligibility criteria and were reviewed. Studies used a variety of interventions; eleven employed a team training approach, four described co-leadership, three explored service improvement, two detailed co-design approaches and one described an individual team development intervention. Most demonstrated moderate to good success in enabling collectivistic leadership, with benefits reported in staff engagement, satisfaction, and team performance.

Conclusions

Whilst collectivistic leadership interventions have demonstrated positive outcomes, there is a need for more rigor and consistency in the evaluation of interventions aimed at developing collectivistic leadership approaches in health settings.

Peer Review reports

Background

Traditionally, the concept of a leader and of leadership has focused on individuals, where leaders are trained to lead a work group or team as part of a hierarchical organisational structure. Accordingly, leadership research has conventionally focused on vertical leadership and leader-follower interactions, where one focal leader interacts with subordinates or followers in dyads or small groups with clear lines of authority and power across levels of the hierarchy [ 1, 2]. Leadership has been considered as an individual attribute, and contested as either trait-like or a state-like quality, or both [ 3, 4]. This body of research has focused on the single leader, with the team or group outputs (e.g., performance, quality targets) and staff outcomes (e.g., satisfaction, engagement) considered as reflective of leader effectiveness. Gibb, in 1954, was among the first to recognise the potential for leadership at the group or team level, rather than at the individual level, asserting that "leadership is probably best conceived as a group quality, as a set of functions which must be carried out by the group" ([ 5]; 884). However, it is only more recently that collectivistic or distributed approaches to leadership have garnered increased attention [ 1, 6].

Collective approaches to leadership are evident where the leadership roles and responsibilities are shared, distributed or rotated amongst team members. Various forms of collectivistic leadership exist, including distributed, shared, team, co-leadership, rotated, and collective leadership, to name a few. Distributed leadership [ 7, 8], for instance, is indicated by various patterns of distributed roles and responsibilities shared among multiple individuals where there is conjoint action by the group. Similarly, shared leadership has been described as "an emergent team property that results from the distribution of leadership influence across multiple team members" [ 9]. Friedrich et al. characterise collective leadership as "a dynamic leadership process in which a defined leader, or set of leaders, selectively utilise skills and expertise within a network, effectively distributing elements of the leadership role as the situation or problem at hand requires" ([ 10]: 933). Central to collective leadership is the principle that team members interact to lead the team by sharing in leadership responsibilities at different times [ 11, 12]. Although the various terms represents distinct theoretical approaches, even with multiple proposed frameworks within each approach [ 13], it is important to note that often the terms have been used interchangeably, and the relative usage of terms has varied over time [ 13]. Ultimately however, these forms of leadership defy the traditional, hierarchical, single leader view of leadership and represent a shift towards these more collectivistic approaches.

A meta-analysis of shared leadership and team effectiveness developed a composite definition for these various forms of shared leadership as "an emergent and dynamic team phenomenon whereby leadership roles and influence are distributed among team members" ([ 14]: 5). For the purposes of this review, we use the term 'collectivistic leadership' to include various non-traditional approaches to leadership, including shared, distributed, collective, and related or similar concepts, that share the roles and responsibilities across more than one member of a work group or team over time, through both formal and informal mechanisms [ 1, 15].

Since the 1990s, there has been increased interest in collectivistic approaches to leadership [ 14] and there is accumulating evidence of the positive impact of such approaches from many settings. Two meta-analyses exploring the impact of collective, shared and/or distributed leadership in teams have found that, across sectors, shared leadership predicts team effectiveness and team performance outcomes [ 14, 16]. Furthermore, shared leadership has been found to be a better predictor of team performance and organisational outcomes than vertical leadership structures [ 17, 18].

In a recent review of the evidence base for leadership in health settings, it was concluded that "leadership is the most influential factor in shaping organisational culture and so ensuring the necessary leadership behaviours, strategies and qualities are developed is fundamental to health services improvement" [ 19]. Research has linked effective leadership behaviours in a health setting to quality and safety and patient outcomes [ 20] and has highlighted poor leadership as potential causal factors in patient safety failures [ 21]. Furthermore, leadership with a strong emphasis on hierarchy potentially inhibits a positive safety climate due to fear of blame and repercussions for reporting safety-related problems [ 22]. Research in the UK has indicated that the best performing hospitals were those in which staff demonstrated high levels of engagement in decision-making and where there was evidence of distributed leadership in the organisation [ 23]. Given this emerging evidence base, there have been calls to move from traditional models to shared and distributed models of leadership in healthcare settings [ 6, 8, 19], where increasingly, care is delivered via multidisciplinary teams.

Whilst collectivistic approaches to leadership have been linked with positive outcomes, there is little guidance on how best to introduce and develop collective leadership in practice. The field is still developing and as a result, the literature is sparse and disparate; thus, we do not yet know how we can effectively develop collectivistic leadership approaches [ 1]. Furthermore, because such approaches are relatively novel in healthcare settings there is a lack of understanding on how best to achieve collective ways of working in this context. To address this gap and to inform future research in this area, this paper aims to synthesise scientific knowledge of evaluated interventions that sought to introduce collectivistic leadership in healthcare settings. The paper provides insight into the type and content of interventions that have been designed and tested, their theoretical underpinnings, means of evaluation, and efficacy. The aim of this systematic review is to address the following research question: What interventions are the most effective for the development of collective leadership in healthcare teams, what outcomes have been measured, and what evaluation approaches have been adopted? We are interested in exploring both the means of evaluation and evaluation outcomes to explore interventions designed to enhance the practice of collectivistic forms of leadership. As discussed above, the terms 'collectivistic' will be employed in this review as a broad term to capture the various forms of non-hierarchical approaches to leadership.

Methods

Systematic reviewing

A systematic review was conducted to explore the topic. Systematic reviewing is a method to synthesise the available scientific evidence to address a clearly formulated research question. It enables researchers to collate relevant studies, assess the quality of evidence, and generate conclusions and/or identify knowledge gaps. The current review employed methods informed by Cochrane guidance on conducted reviews [ 24] and results are reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 25, 26]. The protocol for this systematic review was published in the PROSPERO Database in May 2017 (reference: CRD42017065007).

Search and section strategy

As recommended by the Evidence for Policy and Practice Information and Co-ordinating Centre [ 27], the search strategy attempted to balance sensitivity with specificity in its results. Initial scoping searches revealed that the search strategy was highly sensitive and returned large numbers of studies not relevant to the topic. This indicated that MeSH terms were too broad for the purposes of this review. Instead keywords were used to ensure more specificity in the search. Previous systematic reviews conducted on collectivistic approaches to leadership from other sectors helped to inform the search strategy [ 14, 16]. The electronic databases of PubMed, PsychInfo, ABI Inform, Cochrane and CINAHL were searched on 8-10th February 2017 to find relevant studies. The complete search strings are included in Additional file 1. Some of the keywords and terms used included 'collective leadership', 'shared leadership', 'distributed leadership', 'health', 'clinical', 'intervention', and 'training'. Groups of keywords relevant to a specific category (for instance, setting) type were combined using the 'OR' Boolean term (e.g., health OR clinical OR medical) and categories of keywords were then combined using the AND Boolean operand (see Tables 1 and 2). The search strategy was reviewed by a researcher with extensive systematic reviewing experience who was not involved in the study.

No restrictions were placed on country of origin or language, although searches were restricted to papers, technical reports, and accessible dissertations published since 2000. The academic database searches were supplemented with searchers of grey literature databases OpenDOAR, OpenGrey and OAIster. These databases are amongst those recommended due to their broad scope and their ability to enable specific searches that return the most relevant records [ 28, 29]. Additionally, the research team scanned the reference lists of included papers and contacted experts in the field to help identify other potentially relevant studies.

Inclusion/exclusion criteria

Experimental and observational research studies from a healthcare setting, including quantitative, mixed methods and qualitative studies related to plural or collectivistic forms of leadership (shared, collective, distributed leadership, etc.) from any country were eligible for inclusion in the review. Studies were eligible if they reported on the development, evaluation and/or implementation of training or interventions to foster collectivistic approaches to leadership. Studies had to report individual and/or team level changes related to leadership roles and responsibilities, experiences of working, or health, team, patient, safety outcomes or outcomes relevant to team performance or team effectiveness. Given the potential range of variables and outcomes across different healthcare settings, specific outcome measures were not predetermined.

Study screening and data extraction

The online specialised systematic review website, Covidence, was employed to manage the review [ 30]. Covidence enables two reviewers to independently screen records, it displays conflicts and tracks the number of papers excluded and reason for exclusion at each phase of the systematic review. Two reviewers independently screened record titles and abstracts based on the eligibility criteria. Where there was any disagreement or ambiguity, a third reviewer assessed the relevant records and consensus was reached on eligibility through discussion, and, where appropriate, retrieval and review of the full-text document.

A structured data extraction form to capture information from the relevant records was developed. Consistent with recommendations for best practice for systematic reviews of interventions [ 31, 32], the data extraction template collected information relevant to: study details (country of study, setting/context, sample size); theory, framework or model underpinning the intervention; mode of delivery of intervention; the specific content of intervention(s); duration of intervention(s); measures/variables of interest used to evaluate impact of interventions; outcomes of interventions/training programmes related to: impact on leadership (roles and responsibilities) for individuals and teams, impact on individual/team performance, other measured outcomes (likely to vary between studies and therefore not stated in advance); and reported/hypothesised determinants of (non-)effectiveness of interventions/programmes. Where information was missing or incomplete in studies included in the review, efforts were made to contact authors and/or funders to access further details. The data extraction form was hosted on SurveyMonkey and allowed both reviewers to extract data independently and enabled comparisons between reviewers.

Quality appraisal

As appropriate to the study design, methodological quality assessment frameworks including an adapted version of the CASP Quantitative cohort study tool [ 33], the Critical Appraisal Skills Programme (CASP) Qualitative tool [ 34], and the Mixed Method Appraisal Tool (MMAT) [ 35] were used to evaluate the quality of included studies. These tools have been widely used and are considered a valid indicator of methodological quality. Due to the small number of relevant studies that met the inclusion criteria and the variety of study designs included, no studies were excluded from the review based on the quality assessment outcome.

Data synthesis

As this review includes studies with large heterogeneity in interventions and measures, a statistical analysis was inappropriate. Results were synthesised using a narrative approach [ 36] and results reported in accordance with PRISMA guidelines [ 25, 26] and current recommendations on the description of interventions in systematic reviews [ 31].

Results

Search results

The databases searches yielded a total of 4448 studies. Of these, 317 duplicates were removed, 4064 were excluded after title and abstract screening and a further 46 were excluded for reasons including not providing a sufficiently detailed description of the intervention, not taking place in a healthcare setting and/or not reporting an intervention outcome. Figure 1 depicts the PRISMA flow chart and summarises the screening and selection phases of the review process. In total, 21 studies met the eligibility criteria and were included in the review.

Overview of included studies

Quality assessment

Tables 4, 5 and 6 summarise the results of the quality appraisal of articles using various tools, as appropriate to study design [ 33, 34, 35]. Tables are arranged to list the studies in order of quality appraisal, with those of higher quality appearing first.

Among the qualitative papers included in the review, two studies met all ten quality criteria on the CASP qualitative checklist while the remaining studies met between nine and three criteria (Table 4). While all ten studies stated a clear objective, included qualitative data that was relevant to the objectives and had an appropriate research design, only two studies considered the relationship between researcher(s) and participants.

Of the five quantitative papers included in the review, there was no study which met all 11 quality criteria based on the CASP cohort study checklist. The studies met between nine and five criteria (Table 5). All studies addressed a clearly focused issue. The lack of consideration of confounding factors was an issue in the studies, as none reflected on this issue.

Among the eight mixed-methods papers included in the review, no study met all 13 quality criteria on the MMAT. Seven studies met between ten and six criteria with one study meeting only two criteria (Table 6). All eight papers stated a clear objective; however, no study considered the potential limitations associated with the integration of qualitative and quantitative data.

Theoretical underpinnings

Intervention evaluation

Narrative review

Given the heterogeneity of included papers, studies were therefore categorised by intervention type: co-design interventions, co-leadership interventions, service improvement interventions, team training interventions and individual team development interventions. and are described using a narrative synthesis approach. Co-design interventions are those that involves the equal partnership of individuals to improve efficiency or design interventions or pathways of care. It is a method that is inclusive of various perspectives and employing each other's knowledge, resources and contributions, to achieve better outcomes or re-design processes for improvement [ 58]. Service improvement interventions described herein are those that had a clear and explicit focus on enhancing quality and safety outcomes or to fix identified problems in service delivery. Team training interventions are those delivered to and aimed at an entire team to train them together to acquire the same skills and often involved workshops, facilitated learning through seminars and/or learning sets. Finally, the individual team development includes the one study that sought to establish collective leadership in developing and shaping a new team.

Co-design interventions

Two studies employed co-design approaches which enabled teams to develop solutions to address local problems [ 39, 40]. Casady and Dowd [ 40] employed shared leadership approaches to enhance the engagement of staff in participative decision making about initiatives that impact on their jobs in a medical imaging department in the US. Management established new strategic thinking teams in the department which were co-facilitated and led by staff. Each team operated for a 12-week period to address various specific issues relevant to staff and to co-develop solutions. In a similar study, Sanders et al. [ 39] reported efforts to create a shared leadership model among nurses from various hospital departments where employees were tasked with co-designing and introducing initiatives to make positive changes to the work environment. The former study attributed a reduction in the department's turnover rate, from 40 to 14.5% within 18 months to this delegation of decision-making and empowerment for improvement across these teams [ 40]. The turnover rate further declined to 4% after 3 years. The department also observed improvements in employee engagement over this period. In the latter study, it was reported that the new way of working created a more positive work environment and also resulted in reduced staff turnover [ 39].

Co-leadership interventions

Role clarity was described as important for the model to be effective [ 46], the leaders' personality characteristics [ 54], knowledge and skills [ 46], sharing similar values [ 46, 54], and demonstrating mutual respect [ 46, 54] were considered important. Good communication [ 46, 54] and transparency fostered trusting relationships [ 54]. Successful co-leadership was described as requiring flexibility from leaders engaging alternatively in moments of 'give and take' and occasionally stepping back from decision-making and allowing the team to find solutions [ 54]. From a practical perspective, regular meetings, co-location and organisational support were highlighted as valuable enablers of the co-leadership model [ 46, 54].

Service improvement interventions

Team training interventions

Most studies reported moderate to good success in fostering shared leadership behaviours and/or fostering willingness to lead among individuals [ 41, 42, 43, 44, 50, 51, 52]. However one study reported that although participants felt the intervention had enabled them to develop as leaders, "the teams all remained convinced that every team needs a leader and felt that leadership was not shared in that sense" ([ 48]: 34). Similarly, of the four teams involved in another team training intervention, only one successfully transitioned to distributed leadership and effectively collaborating [ 52]. This suggests such interventions may not work in the same way for all types of teams, yet there was little reflection on why this may be the case.

Individual team development interventions

One study evaluated the development of a multidisciplinary team in a Canadian cancer care centre [ 56]. Consultants were hired to facilitate a series of three, two-day workshops over a three-month period to enhance team leadership development. Interviews were conducted with participants 3 months post-intervention ( n  = 7). Analysis found that, because of the workshops, participants felt they had learned how to communicate, relate to and support one another. There was also an increased sense of solidarity and cohesion among the group. However, the researchers conclude that there is need for on-going team support to maintain gains.

Overview of drivers of intervention success across studies

Discussion

This systematic review examined interventions that have been employed with the aim of developing collectivistic approaches to leadership in healthcare settings. Most of the studies included in this review highlight at least moderate success in the enactment of collectivistic leadership approaches and although the studies were heterogeneous, limited initial progress has been made indicating the value of such interventions in healthcare settings. One of the main findings of this review is the paucity of research on interventions to develop collectivistic forms of leadership in healthcare and a concomitant lack of rigor and replication in the field. Additionally, this review highlights the range of approaches to intervention design and varied evaluative methods employed in the field. Consequently, there are no studies included that evaluated the same intervention in the same way, meaning there is a lack of comparability both between and within these categories of studies. This limits the ability to synthesise findings and draw meaningful conclusions from the studies included.

The advancement of field of collectivistic leadership development is inhibited by the variation in study designs and approaches. This is made more problematic by the lack of consensus on the best means of measurement evaluation of collectivistic leadership interventions [ 1, 59]. Further, the studies in this review were of mixed quality, raising concerns about methodological rigor and completeness of reporting. Due to the small number of papers included however, this review did not exclude papers based on quality appraisal. Journal space constraints and different reporting conventions in various disciplines may explain some of this heterogeneity, as the higher quality of studies included were often dissertations.

There was also heterogeneity observed in the theoretical underpinnings of the interventions/approaches described in the studies, with many studies basing their research on shared leadership, collaborative/team-based leadership models, using multiple approaches or using terms interchangeably. Despite this, it was evident that most of the studies included demonstrated moderate to good success in delivering on the aims of developing collectivistic leadership in healthcare settings. Nearly all studies reported positive outcomes in terms of leadership, engagement, team or organisation performance and specific team-relevant outcomes.

Intervention content

One crucial feature of many of these interventions was the provision of time and space for teams to physically come together and have dedicated time to reflect on how they do their work and what they are working towards, thus enabling their improved functioning as teams [ 47, 48]. Increasingly, healthcare is delivered by multidisciplinary teams, with high interdependency between team members and need for co-operation and effective team working to ensure patient safety [ 61]. Yet, rarely do healthcare teams receive training as a team. As noted by Miller et al., this protected time for team development "was a new experience" for the teams ([ 48]: 36). Whilst this time to come together as a team may seem a rudimentary or obvious requirement, the reality within which many healthcare teams operate, and the increasing pressures on healthcare services, means that this time is no longer available, and it is considered a low priority for teams to develop elementary team working competencies.

However, these basic team working competencies may be critical to the development of collectivistic leadership in teams. Research by Carson et al. [ 9] demonstrated that fostering a positive 'internal team environment' (that is shared purpose, social support, voice and team trust) had a direct relationship with the emergence of shared leadership in teams and therefore was suggested as an antecedent condition for shared leadership. This is echoed by Yammarino et al. who contend that having these effective team-working competencies in place "should help foster climates where collectivistic leadership may be enacted successfully" ([ 1]: 399). Given that collectivistic leadership is a relational process where influence and leadership are shared, building interpersonal relationships and shared mental models across the team appears to be an important step to developing collective ways of working in practice.

Intervention outcomes

As noted previously, all studies included in this review reported positive outcomes and there was some commonality in the type of outcomes reported. In several studies, the decentralisation of power to enable collaborative decision-making and problem solving was associated with increased staff engagement, satisfaction and empowerment [ 41, 42, 44, 47, 50, 51] and reduced turnover [ 40]. The shared nature of problem solving and collaborative decision-making were viewed positively by participants in many studies [ 38, 42, 54, 56], and although described as difficult, the benefits were perceived to outweigh the challenges [ 54].

There is some evidence from this review that different configurations of collectivistic leadership may be more or less appropriate for various teams. Whilst it was clear many of the interventions demonstrated success in fostering distributed approaches to leadership, these interventions did not always work for every team in the same way [ 38, 48, 52]. Yammarino et al. [ 1] suggest that using 'collectivistic' leadership as a broad lens through which interventions are evaluated may be more appropriate than one (relatively) narrowly defined theoretical approach.

Methodological rigour

In several studies included in this review, there was poor reporting of intervention content, little detail on analytical procedures, lack of consideration of potential confounding variables, and gaps evident in the reporting of results. Some studies only collected data post-intervention, resulting in a lack of comparison data and limiting the conclusions that may be drawn. One key concern from the studies in this review is that frequently there was no attempt made to evaluate whether the leadership intervention had been successful in the enactment of collectivistic leadership behaviours. Whilst this was captured or specifically sought in some qualitative and mixed methods studies [ 48, 50, 51, 52], only two quantitative studies measured this [ 41, 57]. Thus, less than half of included studies assessed the enactment of the desired behaviours post-intervention. Additionally, where there was quantitative measurement undertaken pre- and post-intervention, these studies used bespoke survey instruments to evaluate the intervention, minimising the opportunity for replication and limiting comparability with similar studies [ 41, 57]. While we acknowledge there is no established valid and reliable instrument that has been well-tested for the purpose of assessing collectivistic approaches to leadership [ 1, 59], a number of scales have been developed and psychometrically tested and/or have been used in multiple studies [ 11, 18, 62]. Moving forward, this must be a priority to enable comparability and relative efficacy of interventions aimed at developing collectivistic leadership.

Finally, there was little evidence of the use of a systems lens to fully if or how the intervention may have had a broader impact on the system or other parts of the organisation. Measurement of outcomes was, often, narrowly focused on the team or the specific outcomes of interest and little consideration given to the potential for unintended consequences of interventions.

Strengths and limitations

A key strength of this review is that it addresses a gap in knowledge and has collated the studies conducted to develop collectivistic approaches to leadership in healthcare settings. The review used both academic and grey literature databases, as well as literature identified by experts, to ensure insofar as possible that publication bias was minimised and that a wide range of studies were considered for inclusion against the eligibility criteria. However, one challenge with this topic is the multitude of terms used to capture collectivistic approaches to leadership and the fragmented and disparate nature of these bodies of literature. However, we hope to have limited the impact of this by looking to previous systematic reviews conducted on collectivistic approaches to leadership from other sectors to help inform the search strategy [ 14, 16].

Whilst most studies reported positive outcomes in terms of the effect of collectivistic approaches to leadership, an additional limitation of this review is our inability to draw strong causal inferences, based on the relatively small number of studies, heterogeneous nature of the studies, inconsistencies in measurement, and the lack of consideration of confounding variables.

Recommendations

For implementation and practice

There have been calls for the 'modernisation' of healthcare, and for more emphasis on training and developmental programmes that facilitate the sharing of leadership and influence among all members of a team [ 6, 8]. Although tentative, findings from two studies suggest that nurses tend to be more supportive of collectivistic approaches to leadership compared to physicians [ 57]. This may be due to differences in how these professional groups are trained or how they typically work. Given their influence within the traditional medical hierarchy, several researchers emphasise the necessity of physician engagement in interventions of this nature [ 47, 53, 55]. Furthermore, studies in this review state that a lack of organisational resources, support, or commitment to collectivistic leadership interventions is a risk to the success of implementation and to sustainability [ 52, 55]. Thus, it appears for collectivistic approaches to be successful, there is a need to work through and within the relevant hierarchies to first garner support for implementation. Healthcare organisations are typically very hierarchical organisations and operate within traditional 'command and control' models of leadership [ 19]. Therefore, as suggested by O'Toole et al., the notion of shared leadership may initially be "simply counter intuitive" to some ([ 63]:249) and this lack of familiarity with the concept may help explain some of the scepticism and reluctance to adopt shared models of leadership. Legal issues around accountability may also present challenges, especially to clinical leaders. However, from the studies included, interventions aimed at developing the practice can be effective and can enhance team and organisation performance, once the intervention has organisational support and buy-in from senior management and clinical leaders.

Recommendations for research

Several of the authors in this review call for better practices to ensure greater rigor in research of this nature. Recommendations include multidimensional longitudinal designs to ensure measurement at multiple time points to understand impact over time [ 56], more objective measures of staff engagement, trust and accountability [ 52], and for research to seek to compare the efficacy of various collectivistic leadership development programmes [ 51]. Future research must also ensure there is assessment of interventions in terms of the impact on the enactment of collectivistic leadership behaviours and on the healthcare quality and safety. This basic check of intervention validity must be conducted to evaluate if the intervention has been successful in its aims. To realise this, there is a need to address the gap around measurement and working towards common use of a well-tested and psychometrically valid instrument, potentially based on promising initial efforts [ 17, 18, 64, 65]. Furthermore, the potential unintended consequences of interventions must be considered during evaluation to understand if there may be an impact on other parts of the system.

Surprisingly, none of the studies included in this review employed social network analysis methods in evaluating the impact of interventions. This approach is one that has been advocated and used widely in studies of shared leadership in other settings [ 14, 59, 66, 67]. Employing the approach in healthcare would offer a useful means of understanding how patterns of leadership and influence may evolve as a result of interventions with teams.

Whilst there is considerable value in establishing commonalities in interventions of this nature, there is also need to consider the balance between the need to compare different collectivistic leadership interventions across different samples and the need to tailor interventions to teams or organisations based on local demands [ 48, 50]. This will be an important exercise for researchers during implementation in terms of how interventions may be adapted and which elements should be deemed 'core' intervention components [ 68].

It is important to note that empirical research in collectivistic leadership has emerged from various disciplines and this likely accounts for the heterogenous nature of studies in this review. Given that the empirical work in this field is in its infancy, contributions from diverse disciplines enables a breadth and richness of perspectives and approaches as the theoretical work in the field is still developing. Most of the interventions captured in this review can best be described as complex interventions aimed at changing processes and practices to enhance and support collectivistic leadership with these interventions being implemented in complex adaptive health systems [ 69]. The range of intervention types and methods, on the one hand pose challenges for synthesis and generation of definitive conclusive statements, but on the other hand provide rich insights into how healthcare professionals can and do adopt collectivistic approaches and the many benefits that ensure from this way of working. This review has found little evidence of empirical testing of collective leadership but given that this is an emerging area of scientific inquiry, this is not surprising. In order to advance our understanding of collective leadership it may be necessary to take a broader lens to understanding how teams work as a collective to make things happen, i.e., developing an understanding of the team and collective within complex interventions aimed at the team level. The studies that are included in this review make an important contribution to this understanding. However, as the field of study of collectivistic approaches to leadership matures, the advancement of knowledge and the ability to draw strong conclusions from empirical research will require that researchers reach some consensus on definitions and methods to allow comparability and replicability of studies. We therefore urge researchers in this field to engage in discussion and debate towards informing standardisation of measurement and assessment approaches, adoption of a common framework for complex intervention design and evaluation [ 70, 71], and the development of some consensus as to the optimal approach or important core intervention components to advance knowledge on how to successfully implement collectivistic approaches to leadership in healthcare settings.

While there is a considerable body of evidence for traditional approaches to leadership, this is not yet the case for non-hierarchical approaches. The shift from one focal leader to collectivistic approaches to leadership will require both a shift in the way individuals and teams are trained and in how performance is evaluated. Beirne [ 8] suggests that established approaches to leadership development could be reformulated to encourage collective processes that enable a more inclusive and collaborative style and facilitate both formal and informal sharing of leadership. This approach may offer greater opportunities to contrast and compare results with traditional leadership development programmes and their outcomes for teams, but it also runs the risk of continuation of the traditional model of leadership development with the focus remaining on the individual leader. Raelin [72; 4] contends that that if we are to enhance collective leadership in practice, "the entire face of leadership development needs to change" and a different learning model would be required, one characterised by collective and on-going reflection and dialogue. It is also recommended that such interventions should take place in individuals' work environments [ 72] to maximise relevance and transferability of learning.

Conclusions

This systematic review has detailed the intervention content, theoretical underpinning and outcomes of interventions to develop collectivistic approaches to leadership in healthcare settings. It has highlighted the heterogeneity of studies in terms of design, evaluation approach, quality and rigor. Nonetheless, most interventions aimed at introducing collective approaches to leadership demonstrated success with benefits observed in terms of staff engagement, staff satisfaction, and team performance. Whilst this offers a valuable starting point in understanding progress towards the development of interventions to develop collectivistic leadership, there is a need for further research and greater consistency in terms of intervention content and measurement to effectively compare various approaches and draw meaningful conclusions.

Abbreviations

CASP:

Critical Appraisal Skills Programme

PROSPERO:

Database for protocol details for systematic reviews relevant to health and social care, welfare, public health, education, crime, justice, and international development, where there is a health-related outcome

UK:

United Kingdom

US:

United States

References

Download references

Acknowledgements

This research is funded by the Irish Health Research Board, grant reference number RL-2015-1588. This research is also supported by the Health Service Executive.

Funding

This research is funded by the Irish Health Research Board, grant reference number RL-2015-1588. This research is also supported by the Health Service Executive. The funding bodies had no role in the design of the study, data collection, analysis, interpretation of data or in drafting of the manuscript.

Availability of data and materials

Data used in this study is available through the journal articles cited herein.

Author information

Authors and Affiliations

School of Nursing, Midwifery & Health Systems, Health Sciences Centre, University College Dublin, Dublin 4, Ireland

Aoife De Brún, Roisin O'Donovan & Eilish McAuliffe

Contributions

ADB, ROD and EMA designed the search strategy. ADB and ROD retrieved and screened titles and abstracts against inclusion criteria and EMA resolved disagreements. ADB and ROD extracted data, conducted the analysis, and drafted the paper. All contributed to and approved the final version of the manuscript.

Corresponding author

Correspondence to Eilish McAuliffe.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Additional file

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Reprints and Permissions

About this article

Cite this article

De Brún, A., O'Donovan, R. & McAuliffe, E. Interventions to develop collectivistic leadership in healthcare settings: a systematic review. BMC Health Serv Res 19, 72 (2019). https://doi.org/10.1186/s12913-019-3883-x
Download citation

Received:

Accepted:

Published:

DOI: https://doi.org/10.1186/s12913-019-3883-x

Keywords

Collectivistic leadership

Collective leadership

Shared leadership

Healthcare

Systematic review

# data[].attributes.attachment_link.title
Interventions to develop collectivistic leadership in healthcare settings: a systematic review - BMC Health Services Research

# data[].attributes.attachment_link.description
Background Collective or shared leadership approaches have been associated with team performance outcomes in several sectors. Based on this evidence, there have been calls for more inclusive approaches to leadership in healthcare settings, but guidance on how to achieve collective leadership is lacking. This study synthesised knowledge of interventions to introduce collectivistic leadership in healthcare settings.

# data[].attributes.body
King's Fund

# data[].attributes.attachment_link.title
Developing Collective Leadership For Health Care | The King’s Fund

# data[].attributes.attachment_link.description
Our paper argues that collective leadership, as opposed to command-and-control structures , provides the optimum basis for caring cultures.

# data[].attributes.attachment_link.title
With Woman: the high stakes for a home-birth midwife in the US

# data[].attributes.attachment_link.description
Star is a Black midwife who helps Black women give birth in the comfort of their homes, in the state of Illinois. She is part of a long-established African-American tradition of home-birth midwifery, which is currently in a legal gray area across a number of US states, with midwives unable to obtain…

# data[].attributes.body
An analysis of the transformational leadership theory

# data[].attributes.body
King's Fund

# data[].attributes.attachment_link.readable_text
We hear from the leaders from our four case study sites - in Birmingham, Bromley by Bow, Northumbria and Buurtzorg -about their transformational change projects, what made them a success, what impact they had on patients and staff, and their advice for implementing transformational change in health and social care settings.

The definition of transformational change is the emergence of an entirely new state prompted by a shift in what is considered possible or necessary which results in a profoundly different structure, culture or level of performance. In health and care, the concept of transformational change is complicated by the context. It calls into question what is meant by the term 'transformational change' in health and care.

The stories of Bromley by Bow, Birmingham, Northumbria and Buurtzorg illustrate that transformation is multi-layered, messy, fluid and emergent. It is not merely about changing how a service operates, but also about shifting mindsets, changing relationships and re-distributing power. Our stories suggest that transformational change requires the use of organic methods that centre around a core purpose of improving people's lives, allowing models and plans to develop around this. This resonates with Don Berwick's advice to favour 'curiosity and invitation' rather than 'command and control'.

There is a tension in the current system between the time needed for transformation and the sense of urgency for it to happen. Therefore, two things are key:

a strengthened focus on how we learn together as a health and care system, understanding and connecting efforts, and building from this rather than starting afresh. This requires time and support to build skills, relationships and confidence

a form of leadership that is collaborative and distributed, bringing together people from disparate groups to harness their collective potential.

Challenges to face

Our stories show that staff working in health and care are motivated by a vision of safe care and better ways to deliver quality. But in the face of a need to transform, there can also be a sense of inertia and preservation of the status quo. This needs further study to understand and address the underlying causes.

The nature and uses of power to ensure positive impact is important. Our stories show examples of old power (held by a few, closely guarded and inaccessible) colliding with new power (enabled by people at a grassroots level who have agency). However, they also demonstrate how old power can enable new power. There is a need to develop skilful leadership practices that can work across both domains.

A pressing dilemma for those we interviewed was how to work effectively within current system constraints while also championing fundamentally different structures to support transformation. It is likely, in the short term, that a dual focus is needed by working within existing limitations while also nurturing new ways. In the longer term, wider debate is needed about how best to propagate these efforts through the presence of a learning and supportive system that can enable and sustain great change.

When organisations or services embark on transformational change there are often tensions between radical innovation and protecting people from harm; between pace of change and taking time to engage people fully; between focusing on frontline care now or the less 'visible' opportunity to prevent ill health in the future. Hence, there are questions about the scale of transformation and what 'success' looks like. Our stories imply that the answers lie with communities and frontline staff. If that is the case, there is a need to reconsider who is leading and driving current transformational change.

Across our examples, transformations were sparked by people seeing and acting on local needs. The human motivation to make a difference was very powerful. Previous experiences of leaders, their access to broad networks of experts, and the skills to understand academic resources helped the 'sparks' to become 'flames'. More needs to be done to help people to nurture change sparks and bring about change.

Communities also displayed the power to make change: driving health and care innovations, providing ideas that shaped new primary care models, reshaping plans for hospital provision, sparking career choices that transformed care across cities, regions and countries. There is a need to reconsider the relationship between health and care organisations and communities and service users.

Our stories suggest that technology that makes it easier and simpler for staff to do their work to provide quality support for the people who need it is critical. Data can be a powerful tool in transformation, as can stories, experiences and relationships. Transformational efforts can be strengthened by building on this.

Our stories show the need for individuals with skills to kick-start and drive through transformation in a way that is inspiring, approachable and supportive. They also show the importance of 'sponsorship' by forward-thinking commissioners, politicians, managers and those willing to work around system constraints to enable testing of these new ways.

The stories show the need to understand staff and create positive cultures that enable transformational change. Maintaining a focus on team members' motivation, which often draws on a desire to make meaningful improvements for patients, can be a source of personal joy. Our work on collective leadership shows the importance of developing cultures to support effective teamworking.

Our stories show the importance of proactively identifying invisible forces with an open and enquiring mind. For example, recognising the value of physical spaces and personal contact, the impact of job titles, the diversity of attitudes and preferences, or the presence of less visible needs in the community. These forces can be both invisible and impassable, terminating transformational change efforts or steering them towards difficulty unless surfaced early and dealt with skilfully.

We also heard about the power of staff and communities to drive transformation: the importance of giving people time and space to think through the purpose of transformation; to understand the struggles and worries they face; to offer support instead of demanding change with no time to prepare or engage. More fundamentally, our stories show the need to reconsider the structures that impact on their ability to do this - regulation, funding, training, organisational cultures - and to create ways to make it easier for staff to lead transformational change efforts.

A collective focus

Transformational change in health and care requires our collective focus to address the areas highlighted in this report: to strengthen understanding and approaches, to create effective ways of dealing with the barriers, to unlock the tremendous human potential of staff and communities, to optimise the environment to ensure it supports them, and to foster the collaborative leadership that can bring about transformation.
Read the report.

# data[].attributes.attachment_link.title
Transformational change in health and care: reports from the field

# data[].attributes.attachment_link.description
We hear from the leaders from our four case study sites - in Birmingham, Bromley by Bow, Northumbria and Buurtzorg -about their transformational change projects, what made them a success, what impact they had on patients and staff, and their advice for implementing transformational change in health and social care settings.

# data[].attributes.body
King's Fund

# data[].attributes.body
About and beyond leading uniqueness and belongingness: A systematic review of inclusive leadership research

# data[].attributes.attachment_link.readable_text
Highlights

*
Systematic review of 107 academic articles on inclusive leadership

*
Inclusive leadership goes beyond fostering uniqueness and strengthening belongingness

*
Inclusive leadership is a multi-level concept (i.e., employee, team, organizational)

*
More focus on antecedents of inclusive leadership is needed to understand how to facilitate inclusive leadership

*
Multiple theoretical lenses should be considered in concert to understand inclusive leadership thoroughly

Abstract

The purpose of this systematic review of 107 papers is to address the conceptual confusion about what inclusive leadership (IL) behavior entails and understand the theoretical development of IL. Synthesizing the divergent conceptualizations of inclusive leader behaviors, we propose a multi-level (i.e., employee, team, organizational) model of IL behavior consisting of four dimensions namely, fostering employee's uniqueness (e.g., promoting diversity); strengthening belongingness within a team (e.g., building relationships); showing appreciation (e.g., recognizing efforts and contributions); and supporting organizational efforts (e.g., promoting organizational mission on inclusion). Further, we provide a summary of studied variables as a nomological network in relation to inclusive leadership and an overview of the different theories (e.g., social exchange, intrinsic motivation) supporting the respective relationships and explaining the underlying mechanisms (e.g., reciprocity, motivation). We propose future research to empirically test the multi-level model of IL and examine the predictive value in terms of employee and organizational outcomes.

# data[].attributes.attachment_link.title
About and beyond leading uniqueness and belongingness: A systematic review of inclusive leadership research

# data[].attributes.attachment_link.description
The purpose of this systematic review of 107 papers is to address the conceptual confusion about what inclusive leadership (IL) behavior entails and u...

# data[].attributes.body
Making it safe: the effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams

# data[].attributes.body
So close to love: compassionate leadership in healthcare

# data[].attributes.body
Actions, style and practices: how leaders ensure compassionate care delivery

# data[].attributes.attachment_link.readable_text
Abstract

Demands for more patient-centred care necessitate that leadership creates the conditions for more compassionate care that is sustainable even in periods of acute crisis. We draw on a growing body of empirical research in health services, management and medicine to highlight how the combination of interpersonal acts, leadership style and organisational structures underpins leading with compassion. We further detail how this benefits care provider well-being and patient outcomes through fostering integrative thinking and prosocial motivation. We conclude with implications for practice.

This article is made freely available for use in accordance with BMJ's website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

https://bmj.com/coronavirus/usage

Introduction

Healthcare organisations increasingly recognise the importance of providing patient-centred care -care that is customised and compassionate in order to meet the whole-person needs of patients and in turn, achieve better health outcomes. 1 By compassionate care, we mean care that notices, feels and responds to the suffering of others to attempt to alleviate it. 2 Clinician well-being continues to be a chronic problem in healthcare organisations and patients highly desire compassionate care, but both become more difficult and compassion more essential during periods of acute crisis. 3 Pandemics like COVID-19 create conditions that heighten the already high demands placed on clinicians and make it even more difficult to deliver high-quality care, safely. Specifically, inadequate capacity (eg, intensive care unit beds), personal protective equipment and staffing (eg, unsafe patient-staff ratios, sustained patient surges, lack of personal protective equipment, rationing medical care and repeated trauma from patient deaths). These extreme circumstances undermine the physical (eg, hospital-acquired COVID-19 or other infections, exhaustion) and mental (eg, moral distress, post-traumatic stress and depression) well-being of clinicians and their patients.

Specifically, we focus on workplace suffering of both the patients and those delivering their care. Research shows that compassionate care benefits patients 4 and that patients recognise its value, despite only receiving it about half the time. 4 Despite inconsistently demonstrating compassion, clinicians value compassion too. In fact, nearly two-thirds of doctors and nurses believe that compassion is a critical aspect of high-quality patient care, 4 and in the UK, it is a core value of healthcare according to the National Health Service Constitution and compassionate leadership has particularly been detailed and emphasised in an influential report from the King's Fund. 5 Instead, evidence increasingly suggests that high and increasing rates of burnout and depression among doctors and nurses 6 7 may significantly impede clinician capacity to show compassion perhaps by causing them to miss emotional clues from patients that compassion is desired or needed. 8

Although the demands of their work may make expressing compassion more difficult, clinicians benefit from experiencing and even expressing compassion. When clinicians experience compassion at work, it functions as a buffer against strain, and is associated with higher levels of well-being. 9 10 Leaders must play a crucial role in creating conditions that enable workplace compassion in order to buffer clinicians and provide care that best meets the whole-person needs of all patients. We view compassion as subsuming related concepts of empathy and sympathy. Specifically, when an individual or organisation is compassionate, it notices the pain of others (ie, sympathy), feels the pain (ie, empathy), but also includes taking action to alleviate pain (and suffering). 11 Leaders set the tone for a compassionate organisation. 12 Specifically, top leaders and administrators broadly design and diffuse practices (eg, hiring) whereas clinical and mid-level managers typically foster compassion through implementation of these practices and their role modelling of compassionate behaviour (ie, actions and interactions). However, in all cases, clinical, frontline (ie, mid-level) and top managers' influence on patient experience of compassion is mostly mediated through the actions and interactions of frontline care professionals with their patients. For the organisation as a whole, top managers and administrators influence and shape an organisation's culture-a system of shared values that define what is important. 13 They do so by personally setting expectations and norms for desired and appropriate behaviours through both role modelling compassionate behaviours 14 and implementing policies, practices and structures that enable compassion. 2 Clinical and frontline managers do so by setting the microcultures of teams and units. In both cases, these policies and practices indicate what the organisation supports, values and rewards. 15

We primarily draw on empirical studies from health services, management and medicine on compassion to illuminate how leading with compassion encompasses three interrelated processes-leader interpersonal acts of compassion, compassionate leadership style and finally how leaders implement practices and structures to systematically enable compassion and sustain a culture of compassion.

Leader compassionate acts and interactions

Leaders' interpersonal acts of compassion in everyday encounters with patients and employees positively benefit patients 4 as well as fuel expressions of compassion by employees and generate positive employee outcomes. 9 16 17 For top managers, their interpersonal acts may have influence across the organisation, for clinical and frontline managers, their influence may be more locally circumscribed, but no less influential. Specifically, prior research finds that compassionate statements to patients, and leader inclusiveness with employees, are two conversational mechanisms through which compassion is transmitted. Lastly, compassionate interpersonal acts shown to employees also benefit employees in a variety of ways. We discuss each of these below.

Compassionate statements from care providers that express realistic understanding of a patient's circumstance and a commitment to support them in their treatment have been associated with better adherence to treatment and improved functional outcomes. 18-20 For example, statements like the following reduce patient anxiety:

I know this is a tough experience to go through and I want you to know that I am here with you. Some of the things that I say to you today may be difficult to understand so I want you to feel comfortable in stopping me if something I say is confusing or doesn't make sense. We are here together, and we will go through this together ( 21, p373).

But even simpler formulations that convey compassion-that is, notice and empathise with suffering-'I can understand how difficult low back pain must be for you' 22 or non-verbal connection (eg, leaning in, less interpersonal distance, direct eye contact, smiling and nodding) yield positive emotional and functional outcomes. 23 More generally, communication that confirms (conveying the legitimacy of the concern or emotion) and pursues (asks a follow-up question or offers support) compassion 24 is associated with better patient outcomes. In turn, when a care provider engages compassionately, that person is viewed as more clinically competent and trustworthy by other care providers and patients. 25 In fact, when clinical and frontline leaders (eg, unit directors) display compassion and otherwise emphasise the importance of a compassionate relationship with patients, they are more likely to be seen as a role model by their subordinates. 26

Leader inclusiveness or "words and deeds exhibited by leaders that invite and appreciate others' contributions" ( 17, p941) is another interpersonal action through which leaders can model compassion to their subordinates. In other words, inclusiveness notices, empathises with and acts on information about challenges and suffering of the frontline care providers. In a study of Neonatal Intensive Care Units, 17 acts of inclusiveness shown towards employees were associated with higher levels of psychological safety, meaning they help subordinates feel more willing to take an interpersonal risk. Specifically, inclusiveness activated psychological safety, diminished the inhibiting effects of status differences and was associated with greater engagement in quality improvement work. Such empathy and increased feelings of similarity (via reduced status distance) are critical for fostering compassion among employees and between employees and their patients. 27

Compassionate acts of leaders are also valuable because they enhance the motivation and information processing of those expressing (eg, leaders) and receiving (eg, subordinates) compassion. Specifically, compassion expresses a prosocial motivation (ie, "the desire to expend effort to benefit other people", 28, p49) that connects an individual to suffering 29 and heightens sensitivity to the pain and needs of other. 30 That is, compassion and emotional connection to others' suffering can create a prosocial identity-images of the self as helpful, caring and benevolent-that individuals are motivated to verify and act on 31 by alleviating others' (eg, patients' and/or colleagues') suffering. Cognitively, higher levels of prosocial motivation increase the diligence and meticulousness applied to tasks. 28 Prosocial motivation also elicits more integrative thinking. That is, prosocially motivated individuals consider others' perspectives more comprehensively. 32 The enhanced perspective taking increases cognitive flexibility and creativity both of which expand the individual's access to ideas and potential solutions to effectively help others. 33 34 Leader inclusiveness and interpersonal compassion are useful tools for clinical, frontline and top leaders to foster compassion and its benefits.

Compassionate leadership style

Leader compassionate acts, inclusiveness and role modelling of compassion are influential, but become more widespread when they are part of a pattern of practice or coherent leadership style. 35 Leadership style is a means of fostering compassion for a leader at any organisational level (ie, frontline, top) clinical or non-clinical. One style of leadership that is inherently compassionate and other oriented is servant leadership. 36 Servant leadership seeks to develop and engage followers on multiple dimensions-emotional, ethical, relational and spiritual. 37 Therefore, servant leadership emerges in one-on-one interactions that recognises an individual follower's uniqueness and elevates their goals, interests and needs. 37 This engagement is pursued as an end in and of itself, not as a means to other instrumental outcomes (eg, higher performance). 38 As such, servant leadership is highly consistent with the description of compassionate leadership in healthcare-listening to, empathising with and supporting employees. 39

Although not the explicit focus of servant leadership, there is substantial evidence that when leaders prioritise follower growth and well-being, followers are more engaged and effective in their work in ways that benefit themselves and others. 37 Specifically, prior research consistently finds that servant leadership is positively associated with individual employee discretionary effort (ie, citizenship behaviour) directed towards the community, 40 coworkers 41 and customers. 42 Servant leadership is also positively related with positive behaviours that facilitate effectively working among employees including proactively collaborating and helping. 43-45 The positive, other-oriented employee behaviours associated with servant leadership are consequential for customers in terms of service quality and performance, 42 customer satisfaction, 46 customer value cocreation 47 and servant leadership is further related to a positive service climate overall. 48 In healthcare contexts, servant leadership enables and empowers patients such that they feel an enhanced ability to cope with, understand and manage their illness.

At the same time, servant leadership is positively associated with better work experiences for employees including engagement, 49 job satisfaction, 50 meaningfulness 51 psychological well-being 52 and thriving. 53 Servant leadership is negatively linked with emotional exhaustion, 54 job cynicism 55 and turnover intentions, 56 perhaps because they feel empowered, psychologically safe and supported. 57 Overall, as a compassionate leadership style, servant leadership elicits positive attitudes among followers regarding their work as well as coworker and customer-oriented behaviours that result in higher quality service and outcomes, including in healthcare contexts. 44

Leader structures and a culture of compassion

Leaders also enable workplace compassion by creating and supporting organisational structures that encourage, reinforce and support the expression of compassion. Dutton et al 2 refer to these structures as the social architecture of an organisation that enables compassion organising-collective noticing, collective feeling and coordinated responses to suffering. For leaders to consistently foster compassion-both interpersonally and organisationally-leaders must create, enact and champion practices that systematically enable compassion. An organisation's top leaders have greater ability to adopt and spread such practices, but clinical and frontline leaders can elicit compassion by the ways in which they customise and implement these practices in their clinical areas or units.

In healthcare organisations, recent research finds evidence of the use of compassion practices-organisational practices that reward acts of compassion, and organisational practices that provide compassionate support to employees who are suffering. 16 In subsequent work, McClelland and Vogus 58 found evidence that organisations also use hiring practices, specifically behavior-based interview questions regarding compassion, to select employees who are more likely to show compassion. These compassion practices are associated with higher patient experience ratings and patients reporting higher levels of caring and concern by members of the organisation. 10 16

In addition to rewarding and recognising compassion, compassion practices aid care providers by creating 'holding environments' that allow employees to individually or collectively process their grief and regroup. 59 As such, McClelland et al 10 find that compassion practices are associated with higher levels of caregiver psychological vitality and lower levels of emotional exhaustion. Healthcare organisations are actively experimenting with new means of deploying existing emotional support personnel (eg, pastoral care staff) to compassionately help employees cope with the demands, stress and trauma of their work. For example, the Cleveland Clinic developed Code Lavenders that activate a kind of rapid response team to attend to healthcare professionals experiencing emotional distress. 60 Many healthcare organisations, like the University of Virginia Health System, have instituted 'the Pause', a contemplative practice wherein a clinician calls for a moment of silence after a patient dies, in order to help the clinical team process and honour the loss of life. 61 In so doing, clinicians report feeling more connected, replenished and better able to interact with the next patient or patient family member. 61 Schwartz Rounds have been introduced at hundreds of healthcare organisations in order to help clinicians discuss the difficult (eg, emotional) non-clinical aspects of a patient's case as well as to build community, foster learning and increase mutual support. 62

Grant et al 31 examine how employee support programmes that provide financial grants to meet emergent needs of employees express compassion and instil prosocial motivation throughout an organisation. In addition, employee support programmes also provide a structural vehicle for employees to acts on their feelings of compassion. That is, employees contribute to the employee support programme as an expression of their compassion towards their peers who are in need. 31

In addition to practices that process trauma or attend to hardship, other research finds the importance of everyday practices that cultivate connection and joy also enhance compassion among employees. 63 Specifically, Lilius et al find a set of positive practices that include bounded play (eg, decorating the work environment), celebrating (each other's personal and professional milestones), collective decision-making and help offering (monitoring and acting on perceived need for help) build a compassion capability that fosters high-quality connections among coworkers in a hospital department. These connections motivate them to compassionately help their colleagues when difficult circumstances arise. 63

Taken separately, each compassion practice has the capacity to foster interpersonal compassion. However, more recent evidence suggests that it is a 'bundle' of compassion practices enacted jointly that fosters and sustains organisational compassion. 58 63 Bundles of practices are especially influential because they create consistent, distinct and mutually reinforcing signals regarding what the organisation expects, supports and values. 64 That is, such combinations of practices shape a 'strong' culture that offers clear guidance for employees. 64 A strong culture of compassion makes clear that acting compassionately towards colleagues and patients is a foundational part of what being at work means and what makes one a good employee. 9

When combined, the range of practices detailed above work to shape a culture of compassion by-(1) infusing organisations with people likely to show compassion, increasing the organisation's collective capability, (2) sustaining the system of compassion by further normalising expectations that compassion is a valued and required behaviour at work (towards colleagues and patients), (3) replenishing the organisation's collective capacity to respond to suffering by directly attending to workplace suffering and (4) fostering high-quality connections among employees that increase attunement to suffering, the likelihood of showing empathic concern and willingness to help. 58 63 At the same time, a culture of compassion permeates the social architecture of an organisation-its social networks, values and practices and routines-to enable collective coordinated responses to suffering. 2 Employees experience these cultures as caring, connected and warm. 7 The compassion practices and culture of compassion are reinforced and even strengthened by each behavioural enactment by local leaders and the workforce. 2 58 Not surprisingly, the benefits that accrue to these organisations and their members are significant-better patient and employee outcomes (eg, higher job satisfaction, lower absenteeism, improved teamwork and even fewer common physical ailments). 65

Taken together, we see how top leaders critically shape-through individual actions and style as well as bundles of practices and structures-the extent to which an organisation has a culture of compassion. Leader compassionate acts are important symbols, reminding employees of how they should act, legitimating and giving attention to noticing and responding to suffering are available to all leaders. These acts also become shared compassion stories that spread in the organisation, as a kind of artefact, reaffirming the organisation's commitment to compassion as an important organisational value. 2 63 Leaders also play a crucial role in creating and enacting the structural conditions for compassion. Top leaders mobilise resources, and create and activate the social architecture of an organisation-practices, routines, policies and the social network that makes compassion organising possible-with frontline leaders playing a critical role in how it is deployed. 2 Compassion capabilities derived from bundles of practices enable a compassionate culture and a virtuous cycle that deepens collective compassion capability.

Conclusion

Increasing demands for highly customised and tailored patient-centred care, delivered in a cost-effective manner, creates a vexing challenge for healthcare organisations and the people who work in them even in periods of normalcy. Regional disasters (eg, earthquakes, mass shootings) and ongoing crises like the COVID-19 pandemic reveal the shockingly precarious nature of the healthcare delivery system-a system whose functioning for the communities and patients they serve relies on the sustained well-being of the workforce required to deliver care. Our review of empirical research from health services, management and medicine reveals that increasing the expression of compassion and organisational capability for compassion results in better experiences and outcomes for patients and more meaningful, rewarding and sustainable work for care providers. In other words, compassion is mutually beneficial for employees, patients and organisations. We identify how leaders at all levels play a crucial role in realising these benefits. Specifically, clinical, frontline and top leaders' interpersonal actions, their overarching styles and the practices and policies they implement combine to instil a culture of compassion that influences and increases employees' behavioural and verbal expressions of compassion to the benefit of all. However, despite mounting evidence, interventions to foster compassion remain scattered, underused, and, at times, even counterproductive. We offer two overarching recommendations for all leaders to put into practice to cultivate compassionate care and a culture of compassion in the clinical areas, units or organisations they lead.

# data[].attributes.attachment_link.title
Actions, style and practices: how leaders ensure compassionate care delivery

# data[].attributes.attachment_link.description
Demands for more patient-centred care necessitate that leadership creates the conditions for more compassionate care that is sustainable even in periods of acute crisis. We draw on a growing body of empirical research in health services, management and medicine to highlight how the combination of interpersonal acts, leadership style and organisational structures underpins leading with compassion.

# data[].attributes.body
The Importance of Being a Compassionate Leader: The Views of Nursing and Midwifery Managers From Around the World

# data[].attributes.body
King's Fund

# data[].attributes.attachment_link.readable_text
The most important starting point is compassion - a core value of the NHS as a whole and its NHS staff. Sustaining the NHS as a culture of high-quality compassionate care requires compassionate leadership at every level and in interactions between all parts of the system - from national leaders to local teams. Compassionate leadership in practice means leaders listening with fascination to those they lead, arriving at a shared (rather than imposed) understanding of the challenges they face, empathising with and caring for them, and then taking action to help or support them. Such leadership will help us begin to address the problems the service faces because top down national solutions are not working. Meanwhile, patient care and staff health are being undermined.

But there are some myths that must be addressed to ensure people see the value of compassionate leadership. These are that compassionate leadership will mean:

loss of commitment to purpose and high-quality performance

tough performance management and conversations won't be allowed or will be labelled as bullying

always taking the easy, consensus way forward rather than putting patients and communities first

not being able to challenge the status quo and make the radical changes our patients and communities need

team work and system working will be controlled by whoever has the most power and is most ruthless.

Virtually all NHS staff are committed to providing high quality and compassionate care. They represent probably the most motivated and skilled workforce in the whole of industry. However, we impose on them a dominant command and control style that has the effect of silencing their voices, suppressing their ideas for new and better ways of delivering patient care and suffocating their intrinsic motivation and fundamental altruism. Released, their motivation and creativity will ensure commitment to purpose and performance. Their voices are needed to tell us how care can best be improved as the endless remote top-down plans often fail because they ignore the reality of day to day care.

Compassionate leadership means creating the conditions - through consistently listening, understanding, empathising and helping - to make it possible to have tough performance management and tough conversations when needed. Staff complain they only see their leaders when something goes wrong and that even if they do listen, nothing changes after the conversation. Compassionate leadership ensures a collective focus and a greater likelihood of collective responsibility for ensuring high-quality care.

At The King's Fund's annual leadership and management summit in July, the distinguished Harvard professor Amy C Edmondson will reflect on her work linking compassionate leadership with what she calls 'psychological safety' in health care teams. This helps staff feel safe to talk about their errors and near misses, to address concerns about work overload, to talk about worries over lack of competence, and to call out bullying, harassment and discrimination, all of which leads to health care team innovation and effectiveness, as Amy's research demonstrates.

The only way to respond to the challenges that face us in the NHS is through radical innovation - transformational change. That can only come through releasing staff from the rigidities of bureaucracies, command and control hierarchies, and relentless top-down scrutiny and control. And the evidence from research is clear that compassionate leadership is the vital cultural element for innovation in organisations.

Compassionate leadership creates the conditions where the collective good - the needs of patients and communities and staff wellbeing and development - are prioritised over individual agendas, regardless of status, aggression, or undermining. Such leadership creates the conditions where it is possible to identify and challenge inappropriate use of power, hierarchy or control over resources that are inconsistent with the values and vision of our health services.

As Don Berwick, Prerana Issar (new Chief People Officer) and Sam Allen (CEO of Sussex Partnership Trust) commented in the recent King's Fund online event, compassionate leadership requires courage. The courage to listen to tough messages from those we lead. The courage to explore their understanding of the challenges they face and to have our own interpretations challenged and rejected. The courage to feel how draining it is to work a 70-hour week, to not have time to go to the toilet on a shift, to have no access to food and drink on a night shift, or to be on the receiving end of violence or abuse from members of the public. And the courage to accept that practicing compassionate leadership will first and foremost address the most apparently intractable workplace challenges such as excessive workload, staff shortages and ever-increasing demand.

We hear some saying 'let's just talk about positive leadership rather than compassionate leadership'. But that's a cop-out. Positive leadership means all things to all people. And it can be a fig leaf for pretending that problems don't exist and then failing to address the endemic problems of bullying, harassment, discrimination, lack of equal opportunities and an increasingly beleaguered and damaged workforce. And it is meaningless - it doesn't identify what the key leadership behaviours that constitute positivity are.

Compassionate leadership requires huge courage, resilience and belief - it requires a commitment by you as a leader (and all staff should be considered leaders in the NHS) to be the best that you can be. It begins with self-compassion so that by attending to yourself, understanding the challenges you face in your own work (and life more generally), empathising or caring for yourself, and then taking wise action to help yourself, you are able to stay close to the core values that give our lives and work meaning - compassion, wisdom, courage, justice - we are able to have deeper, more authentic and more effective interactions with all those we work with and offer care for. Putting such leadership into action demonstrates not the myths, but the magic of compassionate leadership.

# data[].attributes.attachment_link.description
Compassionate leadership is needed now more than ever in the NHS, but there is a reluctance to put it into practice. Michael West and Suzie Bailey dispel five common myths surrounding compassionate leadership and explain how it is essential for alleviating the current workforce crisis.

# data[].attributes.body
Improving homebirth confidence with compassionate leadership

# data[].attributes.attachment_link.title
quality improvement homebirth with compassionate lead

# data[].attributes.body
King's Fund

# data[].attributes.attachment_link.readable_text
Introduction

Before you read this explainer, we invite you to ask yourself two questions...

What do I hope to learn from reading this?

What assumptions have I made before I start?

Compassion can be defined as 'a sensitivity to suffering in self and others with a commitment to try to alleviate and prevent it' ( Gilbert 2013). We can experience compassion in different ways: we can feel compassion for other people; we can experience compassion from others; and there is also the compassion we can direct towards ourselves.

Compassionate leadership involves a focus on relationships through careful listening to, understanding, empathising with and supporting other people, enabling those we lead to feel valued, respected and cared for, so they can reach their potential and do their best work. There is clear evidence that compassionate leadership results in more engaged and motivated staff with high levels of wellbeing, which in turn results in high-quality care ( West 2021).

How do compassionate leaders behave? They empathise with their colleagues and seek to understand the challenges they face; they are committed to supporting others to cope with and respond successfully to work challenges; and they are focused on enabling those they lead to be effective and thrive in their work. Compassionate leaders don't have all the answers and don't simply tell people what to do, instead they engage with the people they work with to find shared solutions to problems.

For leadership to be compassionate, it must also be inclusive. Compassion blurs the boundaries between self and other, promoting belonging, trust, understanding, mutual support and, by definition, inclusion ( West 2021). This creates an inclusive, psychologically safe environment in which diversity in all forms is valued and team members can contribute creatively and enthusiastically to team performance.

It is evident that the NHS has struggled over many years to sustain inclusive, people-centred cultures and our research suggests that it is local action in teams, departments and organisations (big and small), where the work to create these types of cultures is most effective, because that is where the people are ( Ross et al 2020). Developing compassionate leadership approaches helps leaders hold crucial conversations about inclusion, ensuring they hear and reflect deeply on what staff are telling them and then take necessary action to help address inequities and discrimination in the workplace.

Attending

This means being present with and focusing on others - 'listening with fascination' ( Kline 2002). Listening is probably the most important leadership skill and compassionate leaders take time to listen to the challenges, obstacles, frustrations and harms colleagues experience as well as listening to accounts of their successes and joys ( West 2021).

Understanding

This involves taking time to properly explore and understand the situations people are struggling with. It implies valuing and exploring conflicting perspectives rather than leaders simply imposing their own understanding ( Gallo 2017).

Empathising

This involves mirroring and feeling colleagues' distress, frustration, joy, etc, without being overwhelmed by the emotion and becoming unable to help (West and Chowla 2017).

Helping

This involves taking thoughtful and intelligent action to support individuals and teams. Removing obstacles that get in the way of people doing their work (eg, chronic excessive workloads, conflicts between departments) and providing the resources people and services need (eg, staff, equipment, training) are the most important tasks for leaders ( McCauley and Fick-Cooper 2020).

Research shows that compassionate leadership has wide-ranging benefits for both staff and organisations.

For staff

People who work in supportive teams with clear goals and good team leadership, have dramatically lower levels of stress ( West et al 2015). Compassionate leadership increases staff engagement and satisfaction, resulting in better outcomes for organisations including improved financial performance ( Dawson and West 2018).

In NHS trusts where staff report the absence of such leadership, staff also report higher levels of work overload and less influence over decision-making ( West et al 2022) and organisations have poorer outcomes ( West and Dawson 2012; West et al 2011).

For patients

Staff who are treated with compassion are better able to direct their support and care giving to others ( Goetz et al 2010). This results in higher-quality care and higher levels of patient satisfaction ( West and Dawson 2012; West et al 2011). Where staff generally report the absence of such leadership there are lower levels of patient satisfaction ( West et al 2022), there is poorer-quality care and (in the acute sector) higher patient mortality ( West and Dawson 2012; West et al 2011)

Meeting people's core needs at work is important in supporting their wellbeing and motivation. Compassionate leaders constantly strive to understand and meet the core needs of the people they work with ( West 2021).

The Health and Care Select Committee recently conducted an inquiry on workforce burnout and resilience in the NHS and social care ( House of Commons Health and Social Care Committee 2021). It concluded that burnout is a widespread reality in today's NHS and has negative consequences for the mental health of individual staff, which has an impact on their colleagues and the patients and service users they care for.

Recent studies on doctors ( West and Coia 2019) and nurses and midwives ( West et al 2020), including those in training, have shown that the wellbeing, flourishing and work engagement of health and care staff, is affected by eight key factors that can be organised into three core needs (see figure below). Meeting the core needs of health and care staff can help transform their work lives and in turn, the safety and quality of the care that they deliver.

An introduction to leading with kindness and compassion in health and social care

Develop your understanding of how to lead with compassion and kindness within the health and social care sectors on this free online course delivered in partnership with FutureLearn.

# data[].attributes.attachment_link.description
Research shows that compassionate leadership has wide-ranging benefits for both staff and organisations. Learn more in this explainer.

# data[].attributes.body
The Impact of Rudeness on Medical Team Performance: A Randomized Trial 2015.

# data[].attributes.attachment_link.title
The Impact of Rudeness on Medical Team Performance: A Randomized Trial

# data[].attributes.attachment_link.description
BACKGROUND AND OBJECTIVES:. Iatrogenesis often results from performance deficiencies among medical team members. Team-targeted rudeness may underlie such performance deficiencies, with individuals exposed to rude behavior being less helpful and cooperative. Our objective was to explore the impact of…

# data[].attributes.body
Rachel Crowe Resources for D/Deaf women

# data[].attributes.attachment_link.readable_text
Inequalities AND Unreasonable Adjustments: Are D/deaf women being given a detrimental care pathway in the name of risk assessment?

Rachel Crowe - Second-year midwifery student, Bournemouth University and Yeovil District Hospital

Published in The Practising Midwife Volume 23 Issue 8 September 2020

Summary

In the UK, pregnant women who are hearing impaired or D/deaf (sign language users) and deaf (who are hard of hearing but who have English as their first language and may lipread and/or use hearing aids) are often labelled as high risk and offered a care pathway that is unsuitable and detrimental to their care. Identifying the gaps in maternity that exist in current guidelines and practice can help midwives to ensure women get appropriate, high-quality woman-centred care. This article provides an overview to the needs of D/deaf birthing people with a number of recommendations and tools for use in clinical practice.

Background

Definitive statistics for the number of D/deaf women accessing maternity care are hard to find but in 2016, the Office for National Statistics ¹ reported there were approximately 61,800 people of childbearing age living in the UK whose main health concern was hearing loss. D/deaf awareness is therefore vital for all of us in the maternity profession, even though the number of women we encounter each year may be small. D/deaf women face many challenges such as: lack of appropriate communication or reasonable adjustments, ² lack of appropriate time for consultations, ³ poor attitudes of staff and a lack of D/deaf awareness. ⁴ Misperception of D/deafness by healthcare professionals was identified as a common experience for D/deaf women, which engendered or re-confirmed a sense of isolation - in particular, assumptions about English as a preferred language. ⁵ Signhealth ⁶ illustrate the ways in which the NHS system creates barriers for D/deaf people, relying on auditory methods to arrange appointments and failing to provide interpreters.

Adjustments for communication

It is understood that D/deaf people access English in a similar way to someone for whom it is their second language. ⁷ It is common for D/deaf children to experience a delayed response to language and an increased dependence on visual cues for communication. ⁸ However, the aetiology of D/deafness is extensive and varied, therefore an individualised needs assessment is important. There are two main challenges this creates: one of language and a more subtle one of literacy comprehension. Therefore, D/deaf people need reasonable adjustments ⁹ in order to communicate with their maternity team effectively ¹⁰ - this could mean British Sign Language (BSL) or Sign Supported English (SSE) through an interpreter.

D/deafness and maternity guidelines

Many D/deaf people consider their D/deafness a normal part of life rather than a disability and themselves to be part of a unique, linguistic-culture minority group. ¹¹ However, many D/deaf women find their pregnancies labelled high risk due to D/deafness. This appears to be because of lack of training and D/deaf awareness among staff. ¹² Further research is needed to determine the real attitudes of staff, as the occurrences in the current research are self-reported and it was not the focus of the research. The NICE guidelines have no clear maternity care pathway for D/deaf women, which could be confusing for staff. Section 1.3 of guideline CG110 applies to some D/deaf women, ¹⁰ and yet appears to be focused on ethnicity. D/deafness itself is not a medical condition needing obstetric intervention, ¹³ however, D/deaf women are at higher risk of developing mental health problems, of which practitioners need to be aware. ¹⁴

Solutions

1. Considering the accessibility issues to postnatal discharge videos led me to ask the matron at Yeovil District Hospital (YDH) if I could facilitate a BSL interpreter into the filming of postnatal hospital discharge videos. The videos will be available on the YDH website (creation and release of these videos has been delayed by COVID-19 and will be accessible in due course) and through their use, ensure women who communicate through BSL get the information in their first language.

2. To facilitate the booking appointment, I developed the following resource (see Figure 1), which can be used with women with any disability to decide a woman-centred care plan.

3. To facilitate care pathway decision-making, I developed a flow chart to help midwives (see Figure 2).

4. To facilitate ongoing communication with D/deaf women and for their labour needs should they birth in a hospital or birth centre, I have created a list of top tips to guide maternity professionals (see Figure 3). Be aware that the woman may have a long relationship with the audiology department, which can be involved in facilitating this.

Conclusion

Many midwives will have a reasonable amount of D/deaf awareness, but even this may not be enough for a woman to access the most appropriate pathway of care, especially where there is a lack of clarity from national guidelines. Empowering midwives to make considered decisions with D/deaf women can facilitate the best care pathway for the woman. The ability to show this clinical judgement, partnered with women's own preferences, safeguards the midwife by demonstrating the process in the documentation. This should begin to disassemble the inequalities that D/deaf women face and lead to better outcomes and a better experience of maternity services for them and their families. TPM

Figure 1: Booking resource (downloadable PDF button further down page)

Equalities and Reasonable Adjustments

Part 1: This tool is for you and your midwife to discuss. It's to help us know you better and be able to decide what pathway of care would be most suitable for you. Don't worry if you're not sure what you need, this is designed to help you start the discussion - it's not a final decision and can change with you!

Figure 2: Flow chart for care planning (downloadable PDF button further down page)

This is a guide to help your midwife decide who might need to be involved in your care and how we make that as accessible for you as possible.
Reasonable adjustments are modifications that will overcome challenges caused by disability, e.g. physical aids, changes to policy, assistance, translators, extra time etc.
Figure 3: Resources for consistent communication (downloadable PDF button further down page)

Acknowledgement

Many thanks to Janet Thomas (BSL and lipreading teacher) and Stella Rawnson (University lecturer at BU) for your support in my research and writing.
References

1. Difficulty in hearing and the Annual Population Survey. Office for National Statistics. https://www.ons.gov.uk/aboutus/transparencyandgovernance/freedomofinformationfoi/difficultyinhearing
andtheannualpopulationsurvey. Published 19 February, 2018. Accessed March 26, 2020.

2. Walsh-Gallagher D, McConkey R, Sinclair M, Clarke R. Normalising birth for women with a disability: The challenges facing practitioners. Midwifery. 2013;29(4):294-299.

3. Malouf R, Henderson J, Redshaw M. Access and quality of maternity care for disabled women during pregnancy, birth and the postnatal period in England: data from a national survey. BMJ. 2017;7(7):e016757.

4. Lawler D, Begley C, Lalor J. (Re)constructing myself: the process of transition to motherhood for women with a disability. Journal of Advanced Nursing. 2015;71(7):1672-1683.

5. Parsons J. Deafness, pregnancy and sexual health. The Practising Midwife. 2014;17(4):12-14.

6. Sick of it. How the health service is failing deaf people. The Deaf Health Charity. Signhealth. https://signhealth.org.uk/wp-content/uploads/2019/07/Sick-Of-It-Report.pdf. Published 2014. Accessed May 19, 2020.

7. Deuchar M, James H. English as the second language of the deaf. Language & Communication. 1985;5(1):45-51.

8. Scott J, Dostal H. Language development and deaf/hard of hearing children. Education Sciences. 2019;9(2):135.

9. Equality Act 2010. Legislation.gov.uk. http://www.legislation.gov.uk/ukpga/2010/15/contents. Updated 26 June 2020.

10. Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors. Clinical guideline CG110. National Institute for Health and Care Excellence (NICE). https://www.nice.org.uk/guidance/cg110/chapter/1-Guidance. Published September 22, 2010. Accessed May 19, 2020.

11. Marschark M, Zettler I, Dammeyer J. Social dominance orientation, language orientation and deaf identity. Journal of Deaf Studies and Deaf Education. 2017;22(3):269-277.

12. Sporek P. The deaf nest project. A report into deaf and hard of hearing people's experiences of maternity care. Deaf nest. https://b4b72140-ebb4-4d31-9f7a-a025d84f2143.filesusr.com/ugd/ddfcd5_94e2a9c779a846cc8e6bd495d6b52d68.pdf. Published 2014. Accessed May 19, 2020.

13. Antenatal care for uncomplicated pregnancies. Appendix C: Women requiring additional care. Clinical Guidance CG62. NICE. https://www.nice.org.uk/guidance/cg62/chapter/Appendix-C-Women-requiring-additional-care. Updated February 4, 2019. Accessed May 19, 2020.

14. Jackson M. Deafness and antenatal care: Understanding issues with access. British Journal of Midwifery. 2011;19(5):280-285.

15. Deaf awareness. Action On Hearing Loss. https://beta.actiononhearingloss.org.uk/information-and-support/deaf-awareness/. Published 2020. Accessed May 19, 2020.

# data[].attributes.attachment_link.title
Inequalities AND Unreasonable Adjustments: Are D/deaf women being given a detrimental care pathway in the name of risk assessment? | All4Maternity

# data[].attributes.attachment_link.description
Inequalities AND Unreasonable Adjustments: Are D/deaf women being given a detrimental care pathway in the name of risk assessment? Rachel Crowe - Second-year midwifery student, Bournemouth University and Yeovil District Hospital Published in The Practising Midwife Volume 23 Issue 8 September 2020 Summary In the UK, pregnant women who are...

# data[].attributes.body
Ali Brindle Theatre cap challenge

# data[].attributes.attachment_link.readable_text
The theatre cap challenge is a campaign promoting the idea of writing your name and job title on your theatre cap in order to improve recognition and personalisation of care in theatres.

Alison Brindle, Student Midwife at Lancashire Teaching Hospitals, came up with this idea and was the first person to add her name and role to her own theatre cap.

Alison said: "The idea of the theatre cap challenge came about through conversations with my colleague Emma Gornall, our Delivery Suite Ward Manager. The campaign started through our discussions about humanising care and giving women and their partners or families a better birthing experience, which is really important to us at Lancashire Teaching Hospitals. We spoke about how everyone in theatres looks the same, and it is hard for patients to identify us despite having had conversations previously. Being able to recognise someone when you're in a theatre can make you feel a little more comfortable and feel that you can put your trust into someone. It also makes the patient aware of what each person is responsible for as they have their job role on their cap too."

Alison then decided to take this initiative more widely and created a hashtag #TheatreCapChallenge to share on social media to encourage more staff to participate. A huge amount of people began to get involved with the campaign, including an anaesthetist from Australia who wanted to implement a similar campaign to improve patient safety through easier identification of colleagues.

Alison said: "The campaign went viral very quickly and the initiative is now being used in NHS hospitals throughout the UK, and beyond. I am so pleased that this idea has been so well received and that we are able to improve experiences for our patients in theatres in this way."

Alison and Emma will be presenting their abstract for the #TheatreCapChallenge at the national Royal College of Midwives Annual Conference in October. Gail Naylor, Nursing, Midwifery and Allied Health Professionals Director at Lancashire Teaching Hospitals said: "The theatre cap challenge is a fantastic campaign and we are delighted with how successful it has been not just in our own hospitals, but in other organisations too. We are always looking for ways to improve experiences for our patients, and being able to create a more personalised experience will enable patients in theatres to feel that little bit more comfortable. We are incredibly proud that one of our student midwives came up with this idea."

# data[].attributes.attachment_link.description
The theatre cap challenge is a campaign promoting the idea of writing your name and job title on your theatre cap in order to improve recognition and personalisation of care in theatres. Alison Brindle, Student Midwife at Lancashire Teaching Hospitals, came up with this idea and was the first person to add her name and role to her own theatre cap.

# data[].attributes.body
Hannah Tizard Optimal cord clamping

# data[].attributes.attachment_link.readable_text
Physiological transition of the newborn with optimal cord clamping

Hannah Tizard - Midwife at Blackpool Teaching Hospitals NHS Foundation Trust and Midwifery Media Consultant at All4Maternity and The Practising Midwife

This blog post provides an update about the progress and validity of the #BloodtoBaby campaign. Progress is evolutionary and whilst continuing to promote optimal cord clamping for newborns, focus also considers how practice can be improved in other areas;

delayed cord clamping and cord milking at cesarean section

optimal cord clamping at instrumental deliveries

optimal cord clamping to reduce preterm mortality

resuscitation with an intact cord

Hence the new title which encompasses all of the above; physiological transition of the newborn with optimal cord clamping. Today I want to focus on optimal cord clamping at instrumental deliveries and resuscitation with an intact cord.

Continued efforts

The #BloodtoBaby campaign, facilitated by sponsor Inspiration Healthcare continues to be a huge success with over 18K resources printed and delivered free of charge, to individuals across the world, including Australia, New Zealand, Sweden, India and Palestine. The campaign has and continues to support changes to the practice of immediate cord clamping.

UK NICE guidelines now recommend delayed or optimal cord clamping, so some people question why a campaign like this is necessary. The answer is fairly straightforward:

Change to practice takes time

In February 2018 Tommy's reported on a survey completed by The Positive Birth Movement. The survey questioned over 3500 women and families which highlighted that many clinicians are not waiting for the recommended 1-5 minutes before clamping the umbilical cord, contrary to guidance from NICE and consequently

40% of UK babies are not having delayed/optimal cord clamping.

Case study example - optimal cord clamping at instrumental delivery

Student midwives continue to report that delayed/optimal cord clamping is not happening in practice.

Recently qualified midwife Gemma Dickinson used her degree dissertation module to complete 'An audit to assess the rates of deferred cord clamping in a central London Trust Hospital and to explore whether factors surrounding birth may impact on timing of cord clamping'. As a consequence she made a poster highlighting the need for practitioners to consider delayed/optimal cord clamping particularly at instrumental deliveries.

Gemma comments:

"As a 2nd year student midwife in 2016, I was captivated by Amanda Burleigh and her presentation on optimal cord clamping at King's College University. I started to become silently outraged at the endless births I witnessed with early cord clamping when on placement, especially at instrumental deliveries. Whenever I asked doctors after instrumental births why they didn't leave the cord to pulsate when the newborn didn't need resuscitation, I was greeted with rolling eyes and patronising, feeble excuses. In January 2017 we were given a Public Health assignment to create a poster to display in hospitals, reminding staff of a key issue regularly being forgotten in practice. Naturally I jumped at the idea and created this poster. After wonderful feedback from my hospital and university, I went on to do an audit on cord clamping for my 3rd year dissertation. The Hospital is keen to act upon my significant results and plans are being set in place to develop a local cord clamping guideline, change the hospital computer documentation system and arrange education for the staff! My poster is currently being copied and laminated and I can't wait to see it displayed.. more importantly I can't wait to see more and more beautiful umbilical cords left to pulsate."

Resuscitation with an intact cord

Optimal cord clamping for all babies is the fundamental aim of the #BloodtoBaby campaign and this includes those babies born needing resuscitation at birth. In clinical practice, discussion about newborn resuscitation with an intact cord is fairly infrequent, sometimes contentious, however the evidence to support it is mounting.

New study:

Delayed Cord Clamping in Newborns Born at Term at Risk for Resuscitation: A Feasibility Randomized Clinical Trial by Katheria, A., Brown, M., Faksh, A., Hassen, K., Rich, W., & Lazarus, D. et al. (2017). The Journal Of Pediatrics, 187, 313-317.e1.

Helping to expand knowledge base and understanding in this area (other studies provided as references at the end), this randomised clinical trial suggests infants may benefit if resuscitation could be provided with an intact umbilical cord. Infants identified at risk for resuscitation were randomised to 1- or 5-minute cord clamping. The 5-minute group had greater cerebral oxygenation and blood pressure. The authors acknowledge that further studies are needed to determine whether this translates into improved outcomes over the long term.

As with all change comes challenge. These need to be examined. Indeed lack of appropriate resources in an already underfunded NHS may cause frustration to those seeking to make early change in line with evidence. Bedside resuscitation trolleys such as the LifeStart are priced attractively to compete with traditional stand alone resuscitaires, however there will, for some Trusts, be a long wait for the old models to be discontinued before new improved models can be purchased.

These images are provided by © 2018 Katheria, Sorkhi, Hassen, Faksh, Ghorishi and Poeltler and demonstrate positioning of the bedside resuscitaire, which can be used in any number of positions, two shown below. Their study was focused in an obsteric led hospital setting in the US where vaginal birth is tended to by an obstetrician in lithotomy. Indeed we know that this is not optimal for the birth of the baby, but that's another issue.

The same principals can be applied to birth centre and home birth settings where a bag and mask resuscitation can occur ensuring physiological transition with an intact cord.

In respect of the clinical challenges to bedside resuscitation, practitioners describe concerns about:

Short cords

Poor access to the baby

Accessing necessary equipment

Uncomfortable with parents watching

These concerns are highlighted in

Katheria, A., Sorkhi, S., Hassen, K., Faksh, A., Ghorishi, Z., & Poeltler, D. (2018). Acceptability of Bedside Resuscitation With Intact Umbilical Cord to Clinicians and Patients' Families in the United States. Frontiers In Pediatrics, 6.

In this study about 50% of neonatal providers, including obstetricians, expressed some concerns regarding sub-optimal access to the baby and adverse impact on the delivery of care. It is postulated that these issues can be easily rectified with appropriate space design and adequate training for all clinical staff.

It is important to highlight that the challenges faced by practitioners should not be used as justification for not providing optimal cord clamping for all neonates, particularly those most at risk. Given all the evidence of the benefits of delayed cord clamping, the bedside resuscitaire seems to provide the highest standard of care in an obstetric setting.

The responses from parents were much more positive, most parents were able to see and make contact with their baby in the first few minutes of life. All parents had positive impression of both resuscitation at bedside and on a radiant warmer. No parent felt uncomfortable with neonatal interventions being provided at bedside. They also perceived that their close proximity improved communication.

Case study example - optimal cord clamping for all

Trusts such as Northumbria Specialist Emergency Care Hospital in Cramlington; a medium sized consultant led unit have been facilitating optimal clamping for all, including bedside resuscitation since 2009. Their audit review provides a leading case study example demonstrating improved neonatal outcomes, decreased need for resuscitative measures at birth and reduced admissions to the neonatal unit since implementation of delayed cord clamping for all.

Some of the secrets to the successful implementation of this included, having an experienced midwife of neonatal practitioner attend every birth to advocate for the baby and for optimal cord clamping, that allowing for normal physiological transition, most babies will resuscitate themselves. Those that do need additional support can be managed on a specially designed Lifestart resuscitaire, of which there is one in every birth room. In order to ensure the change in practice becomes embedded actions to ensure junior staff and trainee doctors are reminded at induction.

An in depth look...

David Hutchon is a retired Obstetrician and Gynaecologist. His research investigating the true effect of prematurely closing the placental circulation with a cord clamp is extensive and seminal. Please see this informative powerpoint presented at the 4th International Neonatal Conference in Poland, 2016 from Professor Hutchon.

Moving forward with the evidence

This is a perfect time to highlight that the #BloodtoBaby website has had a revamp. I have worked tirelessly on this over the past few weeks and I'm really pleased with the results. Here are some of the new features:

Over and out - Hannah x

References

Batey, N., Yoxall, C., Fawke, J., Duley, L., & Dorling, J. (2017). Fifteen-minute consultation: stabilisation of the high-risk newborn infant beside the mother. Archives Of Disease In Childhood - Education & Practice Edition, 102(5), 235-238. http://dx.doi.org/10.1136/archdischild-2016-312276

Finn, D., Roehr, C., Ryan, C., & Dempsey, E. (2017). Optimising Intravenous Volume Resuscitation of the Newborn in the Delivery Room: Practical Considerations and Gaps in Knowledge. Neonatology, 112(2), 163-171. http://dx.doi.org/10.1159/000475456

Fulton, C., Stoll, K., & Thordarson, D. (2016). Bedside resuscitation of newborns with an intact umbilical cord: Experiences of midwives from British Columbia. Midwifery, 34, 42-46. http://dx.doi.org/10.1016/j.midw.2016.01.006

Katheria, A., Brown, M., Faksh, A., Hassen, K., Rich, W., & Lazarus, D. et al. (2017). Delayed Cord Clamping in Newborns Born at Term at Risk for Resuscitation: A Feasibility Randomized Clinical Trial. The Journal Of Pediatrics, 187, 313-317.e1. http://dx.doi.org/10.1016/j.jpeds.2017.04.033

Katheria, A., Sorkhi, S., Hassen, K., Faksh, A., Ghorishi, Z., & Poeltler, D. (2018). Acceptability of Bedside Resuscitation With Intact Umbilical Cord to Clinicians and Patients' Families in the United States. Frontiers In Pediatrics, 6. http://dx.doi.org/10.3389/fped.2018.00100

Lefebvre, C., Rakza, T., Weslinck, N., Vaast, P., Houfflin-debarge, V., Mur, S., & Storme, L. (2017). Feasibility and safety of intact cord resuscitation in newborn infants with congenital diaphragmatic hernia (CDH). Resuscitation, 120, 20-25. http://dx.doi.org/10.1016/j.resuscitation.2017.08.233

Thomas, M., Yoxall, C., Weeks, A., & Duley, L. (2014). Providing newborn resuscitation at the mother's bedside: assessing the safety, usability and acceptability of a mobile trolley. BMC Pediatrics, 14(1). http://dx.doi.org/10.1186/1471-2431-14-135

# data[].attributes.attachment_link.title
A campaign re-born: physiological transition of the newborn with optimal cord clamping | All4Maternity

# data[].attributes.attachment_link.description
A campaign re-born Physiological transition of the newborn with optimal cord clamping Hannah Tizard - Midwife at Blackpool Teaching Hospitals NHS Foundation Trust and Midwifery Media Consultant at All4Maternity and The Practising Midwife This blog post provides an update about the progress and validity of the #BloodtoBaby campaign. Progress is...

# data[].attributes.body
Deepa Santhosh Upright birth QI project

# data[].attributes.body
Alicia Burnett Student voices during COVID-19

# data[].attributes.attachment_link.title
Alicia Burnett: Voices from Student Midwives during the COVID-19 Crisis #MidwiferyHour

# data[].attributes.body
Alicia Burnett  Dismantling Racism & Inequalities in Midwifery Education

# data[].attributes.attachment_link.title
9. Alicia Burnett - Dismantling Racism & Inequalities in Midwifery Education