Introduction
Health systems in the 21st century face increasing complexity. Technological advances, changing patient demographics and expectations, fiscal pressures, accelerated information flow, and health human resource challenges, among others, are exacerbating the complexity.1 The pandemic has added a layer of interconnectedness that leaders in health care have not seen before. Concomitantly, the pandemic has created ‘wicked problems’2, challenges of such intricacy and breadth that current leadership practice is unprepared for, and therefore has exposed leadership gaps in academic health centres. We need models to support emerging and practicing leaders in navigating multiple professional identities often required to deal with such issues. New leaders must better understand the emerging complexities of their jobs across both academia and health care. This will help healthcare leaders navigate competing priorities, understand the nuances of inter-personal dynamics and organizational politics, also climb the ranks in both academic and health care settings.
This paper explores the nuanced roles and career paths of health systems leaders within academic health centres (AHCs, clinical units that are affiliated with academic institutions/universities). In matrix organizations,3 such as AHCs, there are at least two entities at play: a hospital and a university. Matrix organizations are interdependent organizations with separate cultures and systems that are connected by individuals who cross between groups, seeking to enact common outcomes across an organization. Based on its strategic and operational realities, each entity within an AHC has unique goals, values, and priorities. Each enterprise also presents different challenges and knowledge users. The interconnectedness of hospital systems and academic institutions within AHCs results in individuals holding multiple roles and, across these, multiple identities. Leaders working within each entity are often left to navigate competing needs, goals, values and perspectives.4 Wicked problems – demanding a multiplicity of organizational interests and perspectives – confuse identities further. This is exemplified in different exhibited behaviors, leadership, and management styles, trade-offs, and ways of thinking based on context.
As individuals advance in their career, they are often challenged to develop both personally and professionally. The capacity to do so is variable between individuals. Leadership roles may include professional identities as a clinician, administrator, researcher, educator, opinion leader, among many other professional (and personal) identities. Regardless of their professional identity, we argue that each person must engage in both leadership and followership (i.e. a phenomenon in which individuals support the leader through assuming responsibility for given objectives, serving the requests made of them, challenging/debating the leader when appropriate, participating in organizational transformation, and taking moral action as needed5,6) with increasing nuance as they advance their roles.
The LEADS in a Caring Environment framework (LEADS framework) was developed in 2006 to articulate and promote core leadership capabilities in health care.7,8 Today, the LEADS framework (or adapted versions) is one of the most popular leadership frameworks for health systems in Canada9,10 with adoption in Australia11, Belgium12, India13, Israel8,14 and has strongly influenced the United Kingdom’s Faculty of Medical Leadership and Management’s certification standards. Leaders who inhabit multiple roles may grapple with how to apply the LEADS capabilities across their multiple roles of varying seniority. For example, while - case in point, the “L” in the LEADS framework refers to Leading Self (implying a singular identity), this poses a challenge when multiple identities have to be managed and integrated into one’s notion of self. However, it does not explicitly guide leaders navigating multiple roles within integrated systems, where seniority and complexity vary. Indeed, an individual may have an executive role in hospital administration, serve as a clinical supervisor, and be a mid-career faculty member in an academic department; and the same wicked problem around hospital staff wellness may be seen differently from each role’s vantage point. The LEADS framework can help an individual to employ their leadership within a defined system. Without adaptation, it is unlikely that the current LEADS framework, nor any other health care leadership framework, will explicitly address the context of an AHC leader who has multiple roles and, more broadly, the fluidity that must exist between leadership and followership.
Considering the strengths of the LEADS framework and the need to explore new ways to encapsulate the multiple roles of leader-follower, we set forth to build upon this prior work. Our new framework (the LEADS+ Developmental Model) articulates leadership and followership practice when serving in multiple leadership roles of varying seniority.15,16 Four styles of engagement within an AHC are described: two followership styles (essential, strategic) and two leadership styles (role- and complexity-based). We propose that advanced leadership requires fluid shifts for the Leading Self domain of LEADS, as leaders must reconceptualize themselves from a leadership/followership perspective as appropriate for given roles, organizations, and context.
Methods
An integrative conceptual review17 was conducted to explore how a leader’s development interfaces with a leading health care leadership framework, the LEADS in a Caring Environment framework. Similar to the process used by Gottlieb and colleagues, sequential iterative cycles of divergent and convergent thinking were employed, exploring various vantage points and theories within the literature.18 Ultimately, the perspectives of the authors coalesced into a singular conceptual framework. Figure 1 depicts our workflow.