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    Successful clinical team leadership:

    competences and assessmentA research concerning the competences and existing assessment instruments on

    successful clinical team leadership by using literature and professional opinions in the

    Radboud University Nijmegen Medical Centre

    Student: Loes Custers

    Student number: I502170Master Public Health: Health Services Innovation

    Supervisor 1: Dr. Wil Buntinx

    Supervisor 2: Drs. Louk Hollands

    Placement coordinator: Ger Brouns

    Placement: Scientific Institute for Quality of Healthcare (IQ healthcare)Nijmegen - UMC St Radboud Nijmegen

    Placement supervisors: Dr. Marille Ouwens and Dr. Mirjam Harmsen

    Period internship: April 2009 December 2009

    Date: 10 December 2009 Faculty of Health, Medicine & Life SciencesUniversity Maastricht

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    Acknowledgements

    After my graduation in nursing in June 2007 at the HAN University of Applied Sciences, I

    wanted to expand my knowledge about health care more in depth by applying for another

    academic study. I soon found an appropriate study, namely Health Sciences at the Maastricht

    University. Because of my nursing background, it was possible to skip the bachelor of Health

    Sciences, after achieving a methodology and statistics test, an application essay, and a letter

    of expectations. Eventually, I started the master Public Health, specialization Health Services

    Innovation, in September 2008. An interesting master for me, because of its practical

    interfaces with my nursing background. Indeed, the course was developed to equip health

    professionals for the challenges of innovation in the health care field.

    This thesis is the final result of the master study Public Health, and the final product with

    regard to my graduation project. The graduation period at the Scientific Institute for Quality

    of Healthcare (IQ healthcare) UMC St Radboud Nijmegen, had its ups and downs, but overall

    it was very instructive to me. The internship has given me a good impression of the practice

    of health care research.

    I would like to thank some people in realizing this master thesis:

    - Dr. W. Buntinx and Drs. L. Hollands for supervising my graduation project;

    - Dr. M. Ouwens for providing a placement for my internship and her help during my

    graduation project;

    - Dr. M. Harmsen for her practical guidance during my graduation project;

    - IQ healthcare for the use of its workplace and facilities;

    - All professionals in the UMC St Radboud who have contributed to the study;

    - All colleagues and students at IQ healthcare who were interested in my work and

    provide sociability during the breaks.

    Finally, I want to thank my family and friends for their support, which was of great

    importance during the study.

    Loes Custers

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    Summary

    Health care today routinely fails to deliver its potential benefits. The Institute of Medicine

    talks about a chasm between the care patients receive and they actually should receive. To

    overcome this chasm, several quality improvement programmes are introduced in health care

    practice. Leadership is frequently mentioned as an essential principle in achieving quality

    improvement at all levels of the chain of effect. Clinical team leadership is focused on the

    microsystems, the basic building blocks of the entire organisation. The competences of

    clinical team leadership should be defined to assess the performance of clinical team leaders,

    and eventually to improve shortcomings in leadership that could affect also other levels in the

    health care system.IQ healthcare and the integral intern audit team of the UMC St Radboud searched for

    opportunities to assess clinical team leadership. The following problem statement was

    formulated in this study: What are important competences of successful clinical team

    leadership in health care and how can these competences be assessed in clinical practice?

    The problem statement was answered using literature gathered by PubMed and, in addition,

    an expert panel of 10 clinical team leaders of the UMC St Radboud replied a questionnaire

    about the most important competences of clinical team leadership.

    A total of 13 competences were identified using literature on quality improvement models and

    clinical team leadership. Sixteen competences were identified on the basis of professional

    opinions. Of these competences, 69% were identified by both the literature and professional

    opinions, which resulted in a total of 18 competences. The Multifactor Leadership

    Questionnaire (MLQ), the Leadership Practice Inventory (LPI), The Malcolm Baldrige

    National Quality Award criteria for organizational performance (MBNQA) and the

    Microsystem Assessment Tool (MAT), were the most common existing assessment

    instruments in the literature that are useful in measuring clinical team leadership. However,

    none of these instruments is able to measure all competences of clinical team leadership, so a

    different tool might be needed. Further analysis of the existing assessment instruments on

    leadership is also recommended. In case of the UMC St Radboud, the MBNQA, in particular

    the INK-management model, is useful since it is able to measure the largest amount of

    competences, and provides future opportunities by offering a framework to evaluate the

    performance at all organizational levels. However, the UMC St Radboud should investigate

    how this framework can integrate within the implemented Team Climate Inventory (TCI).

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    Table of Contents

    Acknowledgements .................................................................................................................II

    Summary.................................................................................................................................III

    Table of Contents ...................................................................................................................IVIntroduction............................................................................................................................VI

    1.1 Introduction of the research topic ..................................................................................VI

    1.2 Research setting ............................................................................................................VII

    1.3 Problem statement en research questions .....................................................................VIII

    1.4 Structure of the thesis ...................................................................................................VIII

    1Theoretical framework........................................................................................................IX

    1.5 Quality improvement in the health care system ............................................................ IX

    1.6 Leadership and quality improvement in health care ....................................................... X1.7 Leadership at the microsystem level ............................................................................... X

    1.8 Improvement models on leadership ...............................................................................XI

    1.9 Definition of clinical team leadership .........................................................................XIV

    Methods................................................................................................................................XVI

    1.10 Research design ........................................................................................................XVII

    1.11 Data collection ........................................................................................................ XVIII

    1.12 Research population ...................................................................................................XIX

    1.13 Data analysis ..............................................................................................................XIX

    1.14 Trustworthiness ........................................................................................................... XX

    2Results..................................................................................................................................XX

    1.15 Competences of successful clinical team leadership ................................................XXI

    1.16 Competences of successful clinical team leadership according to professionals . XXVII

    * Non underlined competences of clinical team leadership: comptences that were also

    identified in literature on clincal team leaderhsip an models of quality improvement

    (paragrapth 4.1)* Underlined competences of clinical team leadership: competences that were not

    recognized previously ................................................................................................. XXVIII

    1.17 Existing assessment instruments useful for measuring clinical team leadership?

    XXVIII

    1.18 Assessment of successful clinical team leadership competences by existing

    instruments ....................................................................................................................XXXII

    Discussion.........................................................................................................................XXXV

    1.19 Discussion ............................................................................................................. XXXV

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    1.20 Conclusion ......................................................................................................... XXXVIII

    1.21 Recommendations ...............................................................................................XXXIX

    1.22 Limitations ..................................................................................................................XL

    References..............................................................................................................................XL

    Appendix: Description of assessment instruments on clinical team leadership ............LII

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    Introduction

    This introductory chapter clarifies firstly the importance of the research topic, clinical team

    leadership and its related components in health care. The second paragraph gives information

    about the Radboud University Nijmegen Meidcal Centre (UMC St Radboud) and Scientific

    Institute for Quality of Healthcare (IQ healthcare), the institute that has raised the research

    questions of this thesis. In addition, the relevance of the study from the institutes perspective

    is motivated. The third paragraph describes the problem statement, the assumptions, the aim

    and the research questions. In the final paragraph, the structure of the master thesis is

    presented.

    1.1 Introduction of the research topic

    Health care today harms too frequently, and fails to deliver its potential benefits. Quality

    problems are everywhere, affecting many patients (Institute of Medicine, 1999). The Institute

    of Medicine (2001) even talks about a chasm between the care patients receive and the care

    they actually should receive. In bridging this chasm, the interest in quality improvement

    raised to strive for optimal patient safety in health care.

    There are several principles that contribute to overcoming the quality chasm. Patient

    centeredness, multidisciplinary care, care coordination, evidence-based medicine, continuous

    quality improvement, and efficient care are examples that are recognized in various health

    care improvement programmes, such as the integrated care model or disease management

    (Ouwens, 2007), the chronic care model (Wagner, Austin, Davis, Hindmarsh, Schaefer, &

    Bonomi, 2001), and the paradigm for health care quality (Massoud et al., 2001). Using their

    principles, all those programmes underline the essence of teamwork or teamwork components

    like leadership.Leadership plays a vital role when it comes to the progress of health care. It is mentioned as

    the enterprise of quality improvement needed at all levels of the health care system (Leape &

    Berwick, 2000). Special attention should be paid to clinical team leadership, that focuses on

    the microsystem level, where the front-line health care professionals do their work. The

    performance of a microsystem can be optimized when the clinical team leader performs his

    tasks adequately. Since the microsystems are the composed building blocks of the entire

    organisation, the overall performance will be improved by improving the microsystems

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    (Nelson et al., 2002). However, to improve the performance of a clinical team leader, more

    insight is needed. The competences of clinical team leadership should be known to assess the

    performance of clinical team leaders. The competences of clinical team leadership and their

    assessment are discussed in this study with regard to the Radboud University Nijmegen

    Medical Centre (UMC St Radboud).

    1.2 Research setting

    UMC St Radboud is a leading academic centre with expertise in medical science and health

    care. Expertise plays an essential part in the organization and connects research, education,

    and patient care. The more than 8500 staff and 3000 students are committed and ambitious,helping to shape the future of health care and medical science (UMC St Radboud, 2009).

    IQ healthcare, the centre where this study about leadership in health care was executed, is

    directly connected to the UMC St Radboud. IQ healthcare is one of the leading centres for

    health services research related to quality improvement in healthcare in Europe. It aims to

    help different parties in health care with their decisions and activities related to quality and

    safety by performing scientific studies and evaluations. Research is mainly organized in four

    domains: implementation science, quality in hospital and integrated care, quality of nursing,

    and allied health care and health care ethics (Scientific Institute for Quality of Healthcare,

    2009).

    One of the studies Ouwens (2007) conducted for IQ healthcare was about integrated care for

    patients with head and neck cancer. In a doctoral thesis she described that a team climate in

    which team members are encouraged to develop and implement new ideas, can lead to better

    health care and health outcomes. To assess team climate and the team areas that could be

    improved, Ouwens (2007) used a multidimensional measure called the Team Climate

    Inventory (TCI) by Anderson and West (1996). This 44-question measure consists of four

    scales that are essential for developing and implementing innovations: team vision,

    participative safety, task orientation, and support for innovation. The TCI-tool proved to be a

    valid, reliable, and discriminating measure of team climate among hospital teams (Ouwens,

    2007). However, it is not an efficient scale to assess leadership within health care teams,

    because the leadership function is simply not indicated as an assessment item. The fact that

    leadership and leadership assessment are missing items, has led to new questions within IQ

    healthcare and especially within the integral intern audit team of the UMC St Radboud, that

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    structurally uses the TCI to assess team climate at all clinical wards of the UMC St Radboud.

    This study on leadership in health care teams strives for answering some of these questions IQ

    healthcare and the auditors of the intern audit team are dealing with.

    1.3 Problem statement en research questions

    The following problem statement can be formulated: What are important competences of

    successful clinical team leadership in health care teams and how can these competences be

    assessed in clinical practice? The leading assumption of this study is that clinical leadership

    in health care teams can affect and may improve the quality of care. It aims to define and

    assess clinical team leadership as a tool to improve the quality of care. In relation to this, fourmain questions are defined:

    1) What are competences of successful clinical team leadership in literature on clinical team

    leadership and models of quality improvement?

    2) What are competences of successful clinical team leadership according to professional

    opinions in the UMC St Radboud Nijmegen?

    3) Which existing assessment instruments are useful in measuring clinical team leadership?

    4) Can the competences for successful clinical team leadership found in the literature and by

    professional opinions be assessed by existing instruments?

    1.4 Structure of the thesis

    The next chapters of this thesis will work towards answering the previous research questions.

    Chapter 2 provides the theoretical considerations concerning clinical team leadership in health

    care. Chapter 3 addresses the research methods and strategies that were used. Chapter 4 pays

    attention to the results of the study by answering the formulated research questions. Finally,

    chapter 5 includes the discussion and conclusions in relation to the theoretical considerations,

    and the related recommendations for practice.

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    1 Theoretical framework

    This chapter provides background information about clinical team leadership. Firstly, the

    need for quality improvement in the health care system is described, and a framework to

    improve health care quality is presented. Paragraph two highlights the importance of

    leadership in health care improvement. Paragraph three explains more about leadership at the

    microsystem level. Based on the microsystem level, paragraph four mentioned addition

    improvement models. Finally, paragraph five is focused on the understanding of clinical team

    leadership according to the literature.

    1.5 Quality improvement in the health care system

    Patients should be able to count on receiving care that meets their needs and is based on the

    best scientific knowledge. However, this is frequently not the case. Many patients are harmed

    by medical errors, while the care was supposed to help them (Institute of Medicine, 2001;

    Berwick, 2002). The Institute of Medicine (2001) stated that there is not just a gap, but a

    chasm between the care patients receive and the care they actually should receive. In 1999,

    the institute called for an effort to make health care safe (Institute of Medicine, 1999; Leape

    & Berwick, 2005). Therefore, quality improvement is critical, it should bridge the quality

    chasm (Institute of Medicine, 2001).

    The nature of the health care system is the key concept for effective quality improvement

    (Berwick & Nolan, 1998; Nolan, 1998). In realizing real improvement, the entire system

    should change and individuals at all organizational levels should work together as a team

    (Berwick 1996; Berwick, 2003). An underlying framework for understanding redesign in

    health care systems is The Chain Of Effect (D.M. Berwick, personal communication,

    December 11, 2001). It analyzes the needed changes at four different levels (Figure 1): (1) the

    experience of patients and communities, (2) the functioning of small units of care delivery

    (microsystems), (3) the functioning of the organizations that house or otherwise support

    microsystems (macrosystems), and (4) the environment of policy, payment, regulation,

    accreditation, and other such factors, which shape the behavior, interests, and opportunities of

    the organizations at level 3 (Berwick, 2002).

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    Figure 1.Chain Of Effect in Improving Healthcare QualitySource: Berwick (2001)

    1.6 Leadership and quality improvement in health care

    Leadership is increasingly aimed at leading changes within health care teams. It is needed at

    all levels of the health care system and an essential ingredient of success in the search for

    safety, as it is throughout the enterprise of quality improvement (Berwick, 1996; Leape &

    Berwick, 2000). Leaders have the potential to influence team processes that contribute to

    team innovation. Their role is critical for success in realizing effective team performance. The

    extent to which the leader defines team objectives and organizes the team to ensure progress

    toward achieving these objectives contributes substantially to team innovation (West et al.,

    2003). Leaders also ought to be playing a central role in making the changes in the health care

    system. Especially, clinicians have an opportunity to exercise leadership for the improvement

    of health care (Berwick, 1994).

    1.7 Leadership at the microsystem level

    According to The Chain Of Effect Model, clinical team leadership is focused on leadership at

    the microsystem level. Microsystems are the small units of work that actually give the care

    that the patient experiences (Berwick, 2002). The clinical microsystem concept is originally

    based on an understanding of the systems theory connected with the theory of James Quinn

    (1992), who describes in his theory the significance of small replicable units to build a

    relevant effective system design. Later on, these units were called microsystems.

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    Microsystems are the basic building blocks of the larger meso- and macrosystems. The

    performance of each individual microsystem should be optimized, to ultimately achieve better

    results in the whole macrosystem.

    Batalden et al. (2003) address the importance of leadership as one of the success

    characteristics of high performing clinical microsystems. Firstly, they define the differences

    between the concepts of leader, leadership and leading. Someone who is guiding or

    leading is labelled as a leader, the phenomenon itself is better known as leadership and

    leading refers to the active process. Leading and leadership by leaders exist at all levels and

    between the different microsystems. The role of leadership as success characteristic consists

    of maintaining consistency of purpose, establishing clear goals and expectations, fostering

    positive culture, and advocating for the microsystem in the larger organisation. In this context,

    leaders have to balance setting and reaching collective goals with empowering individual

    autonomy and accountability (Nelson, Batalden, & Godfrey, 2007). In addition a distinction is

    made between three fundamental processes of leading: (1) building knowledge, (2) taking

    action, and (3) reviewing and reflecting. The first process addresses that microsystem leaders

    should build knowledge about the structure, processes and patterns of work within their

    microsystems. The second process requires microsystem leaders to take action with regard to

    the knowledge they have built. Finally, reviewing and reflecting means that leaders should

    take time for the evaluation of the structure, process and patterns of the microsystem

    (Berwick, 1996). As Heifetz (1994) stated: a good leader needs to be both on the dance floor

    in the middle of the action and up in the balcony seeing the larger pattern of what is

    happening and knowing when and how to intervene in a way that promotes progress on

    difficult problems (p. 252) .

    1.8 Improvement models on leadership

    Several quality improvement programmes and models on the microsystem level have their

    vision on leadership in health care teams, and assert to overcome the quality chasm. Some

    prominent models are discussed below.

    The Integrated Care Model

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    The integrated care model, also known as disease management, is described as an

    organizational process of coordination that seeks to achieve seamless and continuous care,

    tailored to the patients needs and based on a holistic view of the patient (Mur-Veeman,

    Hardy, Steenbergen, & Wistow, 2003). The essence of integrated care is divided into five

    principles: patient centeredness, multidisciplinary care, coordination of care, evidence-based

    medicine, and continuous quality improvement. Clinical teams should carry out these

    principles to achieve a higher quality of care (Ouwens, 2007).

    Leadership is not a direct principle of the integrated care model. However, leaders with a

    clear vision of the importance of integrated care are mentioned as essential requirement for

    successful implementation of the model (Ouwens, 2007).

    The Chronic Care Model

    The chronic care model, as its name already suggests, emphasizes the optimization of chronic

    care. It consists of the following elements: community resources and policies, health care

    organisation, self-management support, delivery system design, decision support, and clinical

    information systems. The ultimate goal of the model is to activate patients interaction with a

    prepared, proactive practice team (Bodenheimer, Wagner, & Grumbach, 2002).

    When it comes to leadership, much attention is paid to the previously discussed relation

    between leadership and improvement in health care. Considering the chronic care element

    health care organisation, Wagner et al. (2001) describe that senior leaders should support

    improvement at all levels of the organization. Senior leadership must identify care

    improvement as important work, and translate it into clear improvement goals and policies

    that are addressed through application of effective improvement strategies that encourage

    comprehensive system change.

    Crew Resource Management

    Crew Resource Management (CRM) is a way of team training with an accent on

    communication. It can been seen as a group of strategies in proactive risk management, aimed

    at identifying potential sources of error and initiation of corrective action to prevent unwanted

    outcomes (Taylor, Hepworth, Burhaus, Dittus, & Speroff , 2007). Some of these strategies

    can particularly be relevant to health care, for instance, the standardisation of briefings and

    debriefings, the establishment of team training, and the incorporation of behaviours to

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    monitor other team members on actions that are critical to safety (Musson & Helmreich,

    2004). Figure 2 shows improvements that are accomplished by the introduction of CRM in

    diabetes care.

    For leadership it is important to sustain improvements and integrate CRM into an enduring

    culture through endorsement, role modelling, and booster training.

    Figure 2. Example of changes following the implementation of

    CRM in diabetes careSource: Taylor et al. (2007)

    The Paradigm for Health Care Quality

    The paradigm for health care quality is a monograph that was presented in 2001 as an update

    on quality improvement methodology. It includes the following main principles: client focus,

    understanding of work as processes and systems, testing changes and emphasizing the use ofdata, and teamwork. The paradigm underlines the importance of improvement throughout a

    team approach of problem solving (Massoud et al., 2001).

    In addition, the principle teamwork accentuates the involvement of key people in the

    improvement of a process. This often leads to more clarity and incorporation of insights and

    needs of clients into health care delivery. Moreover it helps reveal the errors that occur during

    hand-offs. Finally, given the opportunity and authority, staff can often identify problems and

    generate more ideas to resolve them (Massoud et al., 2001).

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    Model of Behavior Change

    The model of behaviour change is useful in succeeding the implementation of new

    innovations in health care teams. Self-management training and the related self-efficacy are of

    great importance (Figure 3). A team should manage its own condition to create a kind of

    confidence among the team members. Bourbeau, Nault, and Dang-Tan (2004) summarized

    the following self-efficacy strategies for the patient as useful: (1) practice, (2) feedback, (3)

    reattribution of the perceived causes of failure when there are negative experiences, and (4)

    sharing experience. However, to improve self-management and self-efficacy this strategy can

    also be applied in a broader perspective, at all levels of the chain of effect. In this case,

    especially at the microsystem level.

    Figure 3. Causal model of behaviour change

    Source: Bourbeau et al.(2004)

    1.9 Definition of clinical team leadership

    When looking at the literature, clinical team leadership is not a clearly defined concept.

    Authors that describe clinical leadership talk differently about the phenomenon, which means

    no general agreement can be established. According to Vance and Larson (2002), a single

    definition is not necessary because an appropriate choice of definition depended upon the

    theoretical, methodological and substantive aspects of leadership being considered. Three

    different contexts of clinical leadership can be distinguished in the literature: (1) clinical

    leadership programmes or evaluations, (2) work of managers who work in clinical settings,

    and (3) work of clinicians who practice at an expert level and who have or hold a leadership

    position (Stanley, 2006). In addition, many authors use clinical leadership interchangeably

    with the words nursing leadership or clinical nurse leadership. Therefore it is remarkable

    that clinical leadership is particularly popular in nursing literature. However, Olsen & Neale

    (2005) underline the need for clinical leadership at all levels of the organization.

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    In his paper Clinical leadership: the elephant in the room, Edmonstone (2008) considers a

    vision that is not only focused on nursing leadership, but on clinicians in general: front-line

    health care professionals. His reasoning is in line with Malby (1998), who suggests that

    clinical leadership simply referred to anyone in a clinical role who exercised leadership.

    Health care professionals who perform clinical leadership should competing responsibilities

    as both leaders and clinical providers. Clinical leaders are those who retained some clinical

    role, but at the same time took on a significant part in matters of strategic direction,

    operational resource management, and collaborative working with colleagues in their own and

    other clinical professions, with health care managers, and with other managers and

    professionals in other agencies. More briefly, Cook & Leathard (2004) describe a clinical

    leader as an expert clinician, involved in providing direct clinical care, and influencing others

    to improve the care they provide continuously. Clinicians who became full-time general

    managers in health care organizations are not mentioned as clinical leaders because they are

    not directly involved anymore in care providing. In order to clarify the concept of clinical

    leadership in depth, a distinction can be made with managerial leadership in health care.

    Managerial leadership centralized mainly the overall needs of the organization (macro-view),

    while clinical leadership, by contrast, has a prime focus on the patient, client group or service

    (micro-view) (Edmonstone, 2008).

    Clinical leadership is a topical issue in nursing. Cook (2001) adopted a quotation of the Royal

    College of Nursing (RCN), that describes that clinical nurse leaders are crucial to the success

    of patient care initiatives. Carryer, Gardner, Dunn, & Gardner (2007) highlight the role of the

    nurse practitioner in clinical leadership, that is derived from a strong base of clinical

    experience and education, which develops both extensive and extended clinical skills and

    critical awareness of the place of nursing in health service delivery. Clinical nursing

    leadership reflects all of the complexity of the culture, the organization, the practice settingand situational variables of each clinical nurse leader, the environment in which they operate

    or how and where the impact is felt.

    Although, clinical leadership is often associated with the nursing profession, this study

    emphasizes on front-line health care professionals who exercise leadership, nurses but also

    doctors or allied health professionals. This corresponds to the third context of clinical

    leadership Stanley (2006) talks about, and the definition Malby (1998) suggests.

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    Methods

    Firstly, this chapter addresses information about the research design of the study. The second

    paragraph focuses on the sources that are used to collect the data for the study and the related

    phases of qualitative research. Thirdly, the research population is described more profound.

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    The fourth paragraph reports how the collected data were analysed. Finally, the fifth

    paragraph discusses the psychometric properties of the study.

    1.10 Research design

    Polit and Beck (2005) define research as a systematic inquiry that uses disciplined methods to

    answer questions or solve problems. The ultimate goal of research is to develop, refine, and

    expand a base of knowledge. In accordance with this statement, the study is designed to

    answer the following question: What are important competences of successful clinical team

    leadership in health care teams and how can these competences be assessed in clinical

    practice? The question predicts the research design of the study, qualitative research. Thequestions are focussed on the phenomenon clinical team leadership, as opposed to

    quantitative research, that for instance pays attention to the number of leaders that perform

    successful clinical team leadership (Baarda & de Goede, 2001; Frederiks & te Wierik, 2004).

    In addition, to understand the opinions, experiences, and interpretations of clinical team

    leaders about leadership, it is important to gain more insight from them (A. Krumeich,

    personal communication, March 3, 2009). Qualitative research is a field of inquiry in its own

    right. It crosscuts disciplines, fields, and subject matters. A complex, interconnected family of

    terms, concepts, and assumptions surround the term qualitative research (Denzin & Lincoln,

    2005).

    This qualitative study is performed with the help of two research methods. Research questions

    one and three are answered on the basis of literature. They discuss what is already known

    about clinical team leadership competences and its assessment. The second question is

    answered using opinions of experts obtained through a questionnaire. Finally, the fourth

    research question uses the information gained from the previous three research questions.

    Table 1 gives an overview of the research methods for each research question, the strategies,

    identified keywords and their inclusion criteria.

    Table 1. Properties of the research methods for each research question

    Research questions

    1) What are competencesof successful clinical teamleadership in literature onclinical team leadershipand models of qualityimprovement?

    2) What arecompetences ofsuccessful clinicalteam leadershipaccording toprofessionalopinions in the

    3) Which existingassessment instruments areuseful in measuring clinicalteam leadership?

    4) Can thecompetences forsuccessful clinicalteam leadership foundin the literature and byprofessional opinionsbe assessed by

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    UMC St RadboudNijmegen?

    existing instruments?

    Researchmethods

    Literature study Expert panel Literature study Literature study andprofessional opinions

    Research

    strategies Database: PubMed;

    Snowball strategy.

    Questionnaire. Database: PubMed. Usage of data

    obtained in previousresearch questions.

    Keywords clinical leadership - leadership assessment;leadership questionnaire;leadership performance;

    leadership quality;leadership measurement;leadership measurement

    tool;leadership assessment

    inventory.MeSH terms:

    leadership AND outcome;assessment OR process

    assessment;

    leadership AND inventory;leadership ANDpsychometrics.

    -

    Conditionsforcollectionandinclusioncriteria

    Prominent data on

    quality improvementare provided by expertsof the University ofMaastricht;

    All abstracts areviewed;

    Relevant papers are

    viewed completely;

    Papers published in

    English;

    Papers that describeone or morecompetences of clinicalleaders or clinical teamleadership.

    UMC St

    Radboud expertsthat exerciseclinicalleadership:departmentheads and seniornurses;

    Minimal 10respondents.

    Papers that describe the

    application of a leadershipassessment instrument,are collected;

    Papers that describe

    leadership assessment aspart of a largerinstrument;

    Papers published in

    English;

    Papers published after

    1999.

    Definitions of thesubscales ofinstruments areused in comparingthe with thecompetences.

    1.11 Data collection

    The literature studies on the competences and assessment of clinical team leadership are

    performed with the help of a bibliographic strategy. References are searched by PubMed, a

    free search engine for accessing the Medline database of citations, abstracts and some full text

    articles on life sciences and biomedical topics. In searching for relevant papers different

    search keywords were applied. In addition, Medical Subject Headings (MeSH terms) are

    utilized in finding subject relevant literature. MeSH terminology provides a consistent way to

    retrieve information that may use different terminology for the same concepts (Polit & Beck,

    2005). Both keywords and MeSH terms are defined in Table 1. Apart from computerized

    strategies, the snowball strategy is employed to gather data concerning research question one.

    According to this strategy, the citations from relevant primary papers are used to track down

    http://en.wikipedia.org/wiki/Bibliographic_databasehttp://en.wikipedia.org/wiki/Bibliographic_database
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    earlier research upon which the papers are based (Cooper, 1998). The primary papers are

    provided by two experts in health care science at the University of Maastricht, and comprise a

    selection of the most prominent data on quality improvement.

    In collecting appropriate data for the second research question, the experts are consulted by

    email. This strategy is cost-effective, however, Polit & Beck (2005) express that emails tend

    to yield low response rates. To overcome low response rates, follow-up reminders were also

    send. This procedure involves additional mailings urging nonrespondents to complete and

    return their forms. The follow-up reminders were sent about 14 days after the initial mailing

    (Polit & Beck, 2005). The initial mail that was sent to the experts, included a brief description

    of the content of the study and the problem statement, the request for contributing the study,

    and a questionnaire. The questionnaire consists of the following question: what are, in your

    opinion, the competences of successful clinical team leaders in healthcare? In addition, the

    experts were asked to mention a minimal of five competences. The follow-up reminders

    consist of a request to answer the initial email.

    1.12 Research population

    To obtain data about the competences of successful clinical team leadership in practice, some

    experts in the UMC St Radboud that exercise clinical team leadership participate in the study.

    This is in accordance with the definition of clinical team leadership that was described earlier:

    clinical leadership refers to anyone in a clinical role who exercised leadership (Malby, 1998).

    According to the UMC St Radboud this concerns department heads and senior nurses. The

    department head is a medical professional, who is responsible for the final performance of a

    clinical ward. Senior nurses have an additional responsibility in the coordination, organization

    and planning of daily care. Questionnaires were sent to 17 professionals, 10 department heads

    and 7 senior nurses. A total of 10 follow-up reminders are mailed to 5 department heads and 5

    senior nurses.

    1.13 Data analysis

    The aim of the data analysis was to identify regularities, patterns, and recurrent themes to

    label the categories and subcategories with the help of the theoretical concepts (Polit & Beck,

    2005). In the study the data analysis was based on the competences of successful clinical team

    leadership, determined by the respondents. The following steps were applied in this study to

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    analyse the data: (1) all the mentioned competences are listed in one document; (2) the

    competences are read carefully; (3) the competences are divided into segments; (4) segments

    with similar themes are grouped; (5) all groups receive a code (keyword) that represents a

    certain competence best. Herewith, the grouped segments are linked to the competences of

    clinical team leadership found in the literature; (6) the groups and codes are reviewed once

    again and a second researcher will reflect on the analysis; (7) the segments are translated in

    English.

    1.14 Trustworthiness

    The data that were gathered in this study should be protected against falsification. In researchterms the phenomenon of falsification is also known as bias, an influence that produces a

    distortion or error in the study results. Unfortunately, bias can seldom be avoided totally

    because the potential for its occurrence is so pervasive (Polit & Beck, 2005). In this study, a

    variety of strategies and criteria were adopted to eliminate or minimize bias. Firstly, method

    triangulation was applied to increase the credibility of the study. This means that at least two

    methods are used to address the same research problem (Morse, 1991). In the present study,

    these two methods are qualitative literature search and data collection using questionnaires.

    The results of the study will be presented to the respondents to serve as a check on the

    viability of the interpretation, also known as member check. In addition, the face validity is

    considered by the supervisors of this thesis. Likewise, the transparency and the plausibility

    are achieved through careful description of the research process. Finally, theory development

    involves that the collected research data are compared to the theoretical starting points of the

    study, so that similarities and differences can be found. This increases the objectivity and

    stimulates the development of a new theory.

    2 Results

    This chapter presents, for every research question individually, the study outcomes that were

    collected with the help of the previous explored research methods. It consists of four

    paragraphs. Successively, paragraph one describes the results of the first research question,

    paragraph two the second research question and so on.

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    1.15 Competences of successful clinical team leadership

    Several prominent competences of clinical team leadership can be distinguished using

    literature on clinical team leadership and models of quality improvement. Some competences

    are mentioned frequently, while other competences are not explicit described. The literature

    sources used different words in defining competences of successful clinical team leadership.

    To avoid ambiguity, the competences are formulated as keywords and presented in Table 2.

    The table shows the competences and the corresponding literature sources. A distinction is

    made between literature on clinical team leadership and the literature concerning models of

    quality improvement. The competences are described with respect to their contents.

    Improvement

    In the literature about both quality improvement models and clinical team leadership, the role

    of leadership in health care improvement is quoted frequently. Concepts like continuous

    quality improvement, change, reform, innovation, evidence based practice, and high

    performance are well known. Effective leadership is mentioned as a requirement that is

    crucial in achieving change in health care practice (Cook, 2001; Institute of Medicine, 2001).

    The involvement of leaders, especially clinical team leaders, in striving for excellent

    performance in health care delivery includes various tasks.

    Batalden et al. (2003) describe that leaders should build knowledge on, for instance, the

    methods that are associated with better practice. Clinical leaders are supposed to create a

    culture and provide an environment for continuous improvement (Institute of Medicine,

    2001). They are responsible for the introduction of new and more effective ways of delivering

    services based on evidence-based practice (Cook, 2001; Edmonstone, 2008). In realizing

    improvements, leaders work through and with their team members, whereas engagement,

    help, support, and influence are of substantial importance (Cook & Leathard, 2004; Davidson,

    Elliott & Daly, 2006; Ham, 2003; Holleman, Poot, Mintjes, & Achterberg, 2009; Nelson et

    al., 2008). Leaders negotiate in the process of change and pave a way for their teams in

    continuous development (Davidson et al., 2006). Finally, leaders have a significant task to

    enhance the durability of improvements. They should foster development, sustain

    improvement and promote continuous improvement by coaching and supporting the front-

    lines (Holleman et al., 2009; Nelson et al., 2007; Nelson et al., 2008; Taylor et al., 2007).

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    Goal & vision

    Nelson et al. (2007) determine leadership in the microsystem concept as one of the success

    characteristics of high-performing microsystems. As success characteristic, the leadership role

    is to maintain constancy of purpose and establish clear goals and expectations. The leader, the

    person who is leading, should reach collective goals together with the whole professional

    team (Barach & Johnson, 2006; Foster, Johnson, Nelson & Batalden, 2007; Nelson et al.,

    2007). The task of leaders in goal setting is also highlighted in the integrated care model.

    Ouwens (2007) state that leaders with a clear vision are of great importance. In the scope of

    health care improvement, Wagner et al. (2001) explain that leadership should translate

    improvement into clear goals and policies. Leaders should be capable of defining and

    communicating the purpose of the organization clearly. They are responsible for the creation

    and articulation of the vision and goals and, in addition, provide clear and visible values, and

    high expectations. Learning organizations need leadership at many levels that can provide

    clear strategic and sustained direction and a coherent set of values and incentives to guide

    group and individual actions (Institute of Medicine, 2001).

    Apart from quality improvement programs, papers about clinical team leadership also

    promote goal setting and goal establishing as essential tasks in leadership. Davidson et al.

    (2006) for instance, define leadership as follows: A multifaceted process of identifying a goal

    or target, motivating other people to act, and providing support and motivation to achieve

    mutually negotiated goals. Leaders are often described as being visionary, equipped with

    strategies, a plan, and a desire to direct their teams and services to a future goal. Moreover,

    Johns (2003) clarifies that vision gives meaning and direction to practice. Finally, clinical

    team leaders should develop a clear view of themselves as leaders, of themselves as part of

    the team, in their relation to other team members, and of themselves as clinical leaders withinthe organization (Dierckx de Casterl, Willemse, Verschueren & Milisen, 2008).

    Table 2. Competences of successful clinical team leadership and corresponding literature

    Literature on qualityimprovement models

    Literature on clinical teamleadership

    Improvement Batalden et al., 2003Bodenheimer et al., 2002Institute of Medicine, 2001Nelson et al., 2007Taylor et al., 2007Wagner et al., 2000Wagner et al., 2001

    Carryer et al., 2007Cook, 2001Cook & Leathard, 2004Davidson et al., 2006Edmonstone, 2008Ham, 2003Holleman et al., 2009

    Johns, 2003Stanley, 2008

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    Goal & vision Barach & Johnson, 2006Batalden et al., 2003Foster et al., 2007Institute of Medicine, 2001Nelson et al., 2007Nelson et al., 2008

    Ouwens, 2007Wagner et al., 2001

    Davidson et al., 2006Dierckx de Casterl et al., 2008Edmonstone, 2008Johns, 2003Stanley, 2008

    Collaboration Batalden et al., 2003Institute of Medicine, 2001Nelson et al., 2007Nelson et al., 2008

    Cook & Leathard, 2004Davidson et al., 2006Dierckx de Casterl et al., 2008Edmonstone, 2008Johns, 2003

    Reviewing &

    reflecting

    Batalden et al., 2003Barach & Johnson, 2006Bourbeau et al., 2004Foster et al., 2007Nelson et al., 2007

    Dierckx de Casterl et al., 2008Edmonstone, 2008

    Patient-centerness Batalden et al., 2003Institute of Medicine, 2001Nelson et al., 2007

    Dierckx de Casterl et al., 2008Edmonstone, 2008

    Communication Institute of Medicine, 2001 Dierckx de Casterl et al., 2008

    Johns, 2003Stanley, 2008

    Support & coaching Batalden et al., 2003Barach & Johnson, 2006Foster et al., 2007Institute of Medicine, 2001Massoud et al., 2001Nelson et al., 2007Nelson et al., 2008Wagner et al., 2001

    Cook, 2001Cook & Leathard, 2004Davidson et al., 2006Dierckx de Casterl et al., 2008Holleman et al., 2009Johns, 2003Olsen & Neale, 2005

    Role models Bourbeau et al., 2004Taylor et al., 2007

    Davidson et al., 2006Stanley, 2008

    Respect Batalden et al., 2003Foster et al., 2007

    Cook & Leathard, 2004

    KnowledgeBarach & Johnson, 2006

    Batalden et al., 2003Bourbeau et al., 2004Foster et al., 2007Nelson et al., 2008

    Carryer et al., 2007

    Cook & Leathard, 2004Dierckx de Casterl et al., 2008Hyrks & Dende, 2008Johns, 2003Stanley, 2008

    Creativity Batalden et al., 2003Institute of Medicine, 2001

    Cook & Leathard, 2004Holleman et al., 2009

    Influencing Bourbeau et al., 2004 Cook, 2001Cook & Leathard, 2004

    Responsibility Institute of Medicine, 2001 Carryer et al., 2007Davidson et al., 2006Dierckx de Casterl et al., 2008Edmonstone, 2008Johns, 2003

    Collaboration

    Collaboration, or cooperation, within health care teams contributes significantly to achieving

    transformation (Cook & Leathard, 2004). Therefore, collaboration is also an important theme

    for leaders in the health care sector. In daily work, clinical leaders make time and space to

    operate through and with people to improve care (Edmonstone, 2008). This includes the

    cooperation through and with patients and fellow colleagues, and it involves multi-

    disciplinary and interdisciplinary working relationships as well (Davidson et al., 2006;

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    Dierckx de Casterl et al., 2008; Johns, 2003; Institute of Medicine, 2001). The clinical team

    leader has an additional task in establishing and maintaining working relationships, in order to

    realize optimal collaboration which the patient will benefit from. Nelson et al. (2008) go one

    step further by addressing collaboration across systems. Clinical team leaders should

    understand system thinking, that is the way of how units relate to each other. Then leaders can

    invest in the collaboration between the micro-, meso-, and macro-organization.

    Reviewing & reflecting

    One of the fundamental processes of leading that can be recognized by leaders at work is

    reviewing and reflecting, which contains the creation of a structure for reflection (Barach &

    Johnson, 2006; Batalden et al., 2003; Foster et al., 2007; Nelson et al., 2007). Clinical leaders

    should take the time and space to review established clinical practice with their colleagues,

    because this can lead to the implementation of new and more effective ways of delivering

    services (Edmonstone, 2008). Part of the structure of review and reflection is also an

    awareness of the temporal limits of the members participation in the work of the

    microsystem and the ability to anticipate the future time when the current leaders turns are

    over. Eventually, review and reflection about the actions of the leader himself, the individual

    team members, and the reflection of the care team as a whole can increase professional

    growth and development in the entire organization (Batalden et al., 2003).

    Patient-centerness

    Patient-centredness comprises care organized around the physical, social and emotional needs

    and preferences of patients, and explicitly involves patients in their own care (Ouwens, 2007).

    Clinical team leadership has always had a prime focus on the patient, client group or service

    (Edmonstone, 2008). Special attention should be paid to the responsibility of leaders inproviding a patient focus and optimizing patient-centredness (Institute of Medicine, 2001).

    Communication

    Effective communication skills are required in the realization of successful clinical leadership

    and seeking reciprocal respect within the clinical team. Leaders should demonstrate openness,

    and a great willingness to discuss positive as well as negative issues. Clinical leaders are

    supposed to promote direct communication by stimulating conversations between team

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    members and by keeping all team members informed about each other (Dierckx de Casterl et

    al., 2008; Johns, 2003; Stanley, 2008).

    Listening is a component of communication that is mentioned by the Institute of Medicine

    (2001). In particular, the leader is supposed to listen to the needs and aspirations of those

    working on the front-line.

    Support & coaching

    In the context of clinical team leadership, support and coaching cover the ability of a leader to

    motivate team members to change (Cook & Leathard, 2004; Davidson et al., 2006). Leaders

    should create a supportive environment for their team members, that encourages and enables

    success (Institute of medicine, 2001). Team members receive also support and coaching by

    their clinical leaders when it comes to the stimulation of professional autonomy and

    accountability. Leaders are obliged to give coworkers the chance to develop both personally

    and professionally, and enable them to develop into leaders themselves. Leaders can support

    their team members by giving them added responsibilities and motivate them in reaching the

    organizational goals (Dierckx de Casterl et al., 2008; Nelson et al., 2007).

    Role models

    Role modeling is often associated with quality improvement. It means that team members can

    observe in their leader the successful behavior (Grol, Wensing & Eccles, 2005). Clinical

    leaders operate as exemplary role models, for instance in case of implementing an innovation.

    They are an inspiration to others in functioning as positive clinical role models for their team

    members in demonstrating a particular behavior (Bourbeau et al., 2004; Davidson et al., 2006;

    Stanley, 2008; Taylor et al., 2007).

    RespectCook & Leathard (2004) determine respecting as one of the five attributes of the work of

    effective clinical nurse leaders. It involves having a regard for the signals that emanate from

    individuals, both patients and team members, and the wider organizational arena. Respecting

    these signals enables people to position themselves appropriately to respond to both

    individual and organizational needs. Effective clinical leaders have well-developed perceptual

    ability and, therefore, respect signals from individuals with whom they work.

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    Knowledge

    Clinical leaders are required to have a double package of knowledge, skills and expertise,

    because they have to fulfill the roles of both clinician and leader (Malby, 1998). Firstly, the

    clinical team leader should be clinically competent and maintains expert clinical credibility

    (Johns, 2003; Stanley, 2008). A strong base of clinical experience, understanding and

    education of clinical practice is required (Carryer et al., 2007; Hyrks & Dende, 2008).

    Secondly, as Batalden et al. (2003) describe, the role of leadership involves building

    knowledge about the structure, processes, and patterns of work in the clinical microsystems.

    Finally, apart from the two roles, clinical leaders should have a dose of self-knowledge and

    self-awareness to continuously improve their personal development in leadership (Dierckx de

    Casterl et al., 2008).

    Creativity

    Creativity in practicing clinical team leadership is directly connected to improvement in

    health care. It has to do with the ability of clinical leaders to generate new ways of working

    and the way in which team members are stimulated by their leaders to demonstrate creativity

    (Holleman et al., 2009). Creativity results from engaging actively with the surroundings to

    seek new possiblities. The successful clinical leader takes time to understand a situation

    within its wider context (Cook & Leathard, 2004).

    Influencing

    Cook (2001) reports about the key abilities of clinical leadership in nursing, providing

    direction, influencing change, and empowering others. Clinical leaders are defined as nurses

    who are directly involved in providing clinical care that continuously improve care through

    influencing others. For instance, leaders can influence their team members through theprovision of meaningful information or by helping them to see and understand a situation

    from different perspectives (Cook & Leathard, 2004).

    Responsibility

    The Institute of Medicine (2001) describes various responsibilities for leaders in managing

    change in health care. The content of these responsibilities are, for the greater part, equal to

    the competences earlier described. The institute claims, for instance, the responsibility for

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    creating and articulating the organizations vision and goals, listening to the needs and

    aspirations of people working on the front line, providing direction, creating incentives for

    change, aligning and integrating improvement efforts, and creating a supportive environment,

    and a culture of continuous improvement that encourage and enable success. Clinical team

    leaders should prove their responsibilities, on several facets in care delivery, to other team

    members and the public. Thereby, they are trained to think in quite a specific way, with a

    strong emphasis on individual responsibility (Edmonstone, 2008).

    1.16 Competences of successful clinical team leadership according to professionals

    Seventeen experts in the UMC St Radboud were invited to give their opinion on thecompetences of successful clinical team leadership, 10 department heads and 7 senior nurses.

    Ten experts, 4 department heads and 6 senior nurses send a response email. This corresponds

    to a total response rate of 59%. Table 3 shows, in random order, the most prominent

    competences of clinical team leadership according to the professional opinions of the

    respondents in the UMC St Radboud. The competences were divided into 83 segments, the

    segments were classified in 16 groups that were coded with a keyword. A total of 11

    competences (69%) was already identified in literature on clinical team leadership and models

    of quality improvement (Paragraph 4.1). Interconnecting Leadership, Steering at Result,

    Research & Education, Decisively, and Planning & Organization are underlined in the table

    because these competences were not recognized previously. Interconnecting Leadership and

    Steering at Result refer to the prominent behavior competences on leadership, formulated by

    the UMC St Radboud. Interconnecting Leadership gives direction, steering, and support to a

    group of people, working- or project team, by setting goals, accomplishing, and maintaining

    of effective liaisons. The competence steering at result formulates qualitative and quantitative

    results in Result Drive Agreements (RDAs), aims at actions and decisions to realize and

    evaluate results (UMC St Radboud, 2004).

    Table 3. Competences of clinical team leadership by the respondents

    Knowledge Excellent specialistAll-round clinician with specificexpertiseSpecialised expertiseSkillsKnowledge

    Reviewing &Reflecting

    Reflect on and with your fellowsSkills for (self) reflectionBe able to handle reverseStress resistantProgress control

    Support &Be able to motivateStimulate Planning &

    EnterprisePlanning

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    Coaching StimulateCoachingCoachingRole of coachEnthusiasm to reach the goalInvolve employees/colleagues

    and pay attention to theirprocessAffinity with human resourcemanagementBe able to put employees in theright positionCreate basis for support

    Organization OrganizingAbility to organizeManagementProject planDelegate

    Respect IntegrityIntegrityHonestyIntegritySensitivityTransparencyInvolvementInvolvementHart of the matter

    Patient-centerness

    Customer focusIndividual orientedIndividual oriented leadershipAffinity for patint care

    Communication Optimal communicationCommunicate clearly andconsistentlyAdequate communicative skillsAdequate communicative skillslistening; interrogating;summarizingCommunicationListeningListeningListening

    Goal & vision Vision on the professionVisionVision developmentVisionStrategy developmentStrategyStrategyReaching goalsConceptual thinking

    InterconnectingLeadership

    Interconnecting leadershipInterconnecting leadership

    Steering at Result Steering at resultSteering at result

    Research &Education

    Leading researcherResearch

    EducationEducationTraining

    Creativity Be proactiveInitiative

    FlexibilityFlexibilityFlexibility

    Improvement InnovativeInnovative

    Collaboration Share whenever possiblePartnership

    Decisively DecisivelyDecisivelyResolute

    Role models Being an example

    * Non underlined competences of clinical team leadership: comptences that were also identified in literature on clincal team

    leaderhsip an models of quality improvement (paragrapth 4.1)

    * Underlined competences of clinical team leadership: competences that were not recognized previously

    1.17 Existing assessment instruments useful for measuring clinical team leadership?

    A total of 1596 references were found, applying the keywords described in Table 1. Some of

    these references were recognized twice or more. Eventually, 35 studies were adopted because

    they described the application of a leadership assessment instrument. Table 4 gives an

    overview of the included studies. It shows for each keyword the corresponding literature and

    the coherent assessment instruments.

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    The following 13 assessment instruments were identified: Transformational Leadership

    Assessment Tool (3%), Scale Leadership Assessment and Team Evaluation (SLATE) (3%),

    Multifactor Leadership Questionnaire (MLQ) (49%), Baruto-Wheeler Servant Leadership

    Questionnaire (3%), Clinical Nursing Leadership Learning and Action Process Model

    (CLINLAP) (3%), Global Transformational Leadership Scale (3%), Leadership Practices

    Inventory (LPI) (14%), CPE Questionnaire (3%), Malcolm Baldrige National Quality Award

    criteria for organizational performance (MBNQA) (5%), Quality Work Competence

    Questionnaire (3%), Microsystem Assessment Tool (MAT) (5%), The Integrated Leadership

    Practice Model (5%) and the Human Capital Competencies Inventory (3%). The percentages

    indicate the quantity of an assessment instrument over the 35 studies that were adopted. Only

    the four most common assessment instruments on leadership in the literature, are discussed in

    this study: the MLQ, the LPI, the MBNQA, and the MAT.

    Multifactor Leadership Questionnaire (MLQ)

    The Multifactor Leadership Questionnaire proposed by Bass and Avolio (1994), is a self-

    report measure based on the multifactor leadership theory. It includes 78 items designed to

    measure nine subscales of leadership. The subscales are divided over three behavioral

    domains that range from non-leadership, termed laissez-faire, to transactional leadership,

    based upon rewards and punishments, to transformational leadership, based upon attributed

    and behavioral charisma (Kanste, Mietunen & Kyngs, 2007) .

    Table 4. Search in assessment instruments for measuring clinical team leadership

    Literature Assessment instruments

    Leadership assessment Drenkard, 2001 Transformational Leadership Assessment Tool

    Fichtner et al., 2001* Scale Leadership Assessment and TeamEvaluation (SLATE)

    Leadership questionnaire Barbuto et al., 2000*Dunham-Taylor, 2000Gunther et al., 2007*Hendel et al., 2005Horwitz et al., 2008Jeff et al., 2008

    Johnson et al., 2004Kleinman, 2004

    Multifactor Leadership Questionnaire (MLQ)

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    Menaker & Bahn, 2008Raup, 2008Snodgrass & Shachar, 2008Stordeur et al., 2001Turner, et al., 2002Wylie & Gallagher, 2009

    Xirasagar, 2008Xirasagar et al., 2006Xirasagar et al., 2005

    Garber et al., 2009 Baruto-Wheeler Servant LeadershipQuestionnaire

    Leadership performance Phillips, 2005 Clinical Nursing Leadership Learning and ActionProcess Model (CLINLAP)

    Leadership quality -

    Leadership assessmentinstrument

    Fichtner et al., 2001* SLATE

    Psychometric assessmentleadership

    -

    Leadership inventory Munir et al., 2009 Global Transformational Leadership Scale

    Adams, 2007Bowles & Bowles, 2000Krugman & Smith, 2003Laurent et al., 2007Strack et al., 2008

    Leadership Practices Inventory (LPI)

    Donaher et al., 2007* The Human Capital Competencies Inventory

    Barbuto et al., 2000*Gunther et al., 2007*

    MLQ

    Kornr & Nordvik, 2004 CPE Questionnaire

    Leadership measurement Foster & Pitts, 2009 Malcolm Baldrige National Quality Award criteriafor organizational performance (MBNQA)

    Wallin et al., 2006 The Quality Work Competence Questionnaire

    Fichtner et al., 2001* SLATE

    Leadership measurementtool

    -

    MeSH Leadership andOutcome assessment orProcess assessment

    Godfrey et al., 2003Nelson et al., 2002

    Microsystem Assessment Tool (MAT)

    Weeks et al., 2000 Malcolm Baldrige Criteria for OrganizationalPerformance

    Perra, 2000 The Integrated leadership Practice Model

    * The paper is mentioned twice or more, using different keywords The table is continued on the next page

    Table 4. Continuation

    Literature Assessment instruments

    MeSH Leadership andInventory

    Donaher et al., 2007* The Human Capital Competencies Inventory

    Barbuto et al., 2000*Gunther et al., 2007*

    MLQ

    MeSH Leadership andPsychometrics

    -

    * The paper is mentioned twice or more, using different keywords

    Leadership Practice Inventory (LPI)

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    The Leadership Practices Inventory is a 30-item leadership behavior measurement instrument

    that has been used extensively across organizational sectors. It was developed and revised by

    Kouzes and Posner (1988). The LPI is based on a leadership framework, which incorporates

    five fundamental practices of exemplary leadership that are consistent with transformational

    leadership style: (1) challenging the process, (2) inspiring a shared vision, (3) enabling others

    to act, (4) modeling the way, and (5) encouraging the heart (Bowles & Bowles, 2000;

    Krugman & Smith, 2003; Tourangeau & McGilton, 2004).

    Malcolm Baldrige National Quality Award criteria for organizational performance

    (MBNQA)

    The Malcolm Baldrige National Quality Award was established to improve organizations

    performance practices and capabilities, to facilitate communication and sharing of best

    practices information, and to serve as a working tool for understanding and managing

    performance and guiding planning and training (Shirks, Weeks, & Stein, 2002). It provides a

    set of criteria and subdivided dimensions for organizational quality assessment and

    improvement in several sectors including health care. Leadership is one of the seven criteria

    can be used as a tool for self-evaluation, and widely recognized as a robust framework for

    design and evaluation of health care systems (Foster., 2007; Nelson et al., 2007).

    Microsystem Assessment Tool (MAT)

    The microsystem concept, explained by Nelson et al. (2007) forms the basis of the

    Microsystem Assessment Tool (MAT). This concept is an organizational framework for

    providing and improving care, by focusing on clinical microsystems. In creating the MAT

    self-assessment tool, the 10 characteristics of high performing microsystems where used.

    With the MAT individuals can assess the functioning of their microsystem and identify

    potential areas to focus improvements (Mohr & Batalden, 2002; Mohr, Batalden, & Barach,

    2004). Moreover, it addresses the nature of the interaction between the microsystem and the

    parent organization, and offers considerable insight into the functioning of a microsystem.

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    1.18 Assessment of successful clinical team leadership competences by existing

    instruments

    Table 5 gives an overview of the accessibility of the competences of clinical team leadership

    in relation to the MLQ, LPI, MBNQA, and the MAT. In addition, it describes the

    corresponding items of the existing instruments that can assess these competences

    Eighteen competences of clinical team leadership were identified using the literature and

    professional opinions in the UMC St Radboud. A percentage of 22% of the competences

    (improvement, goal & vision, reviewing & reflecting, and support & coaching) can be

    measured by each of the four selected assessment instruments. Three assessment instruments

    are able to measure the competence respect (6%). Communication and role models are

    competences that can be assessed by two instruments (11%). 7 competences, collaboration,

    patient-centredness, knowledge, creativity, responsibility, planning & organisation, and

    research & education, are just assessable by one assessment instrument (39%). 22% of the

    competences (influencing, decisively, steering at result and interconnecting leadership) cannot

    be assessed by any of the instruments..

    Multifactor Leadership Questionnaire

    The MLQ evaluates different leadership styles: transformational leadership, transactionalleadership and passive-avoidant behaviors. The leadership styles are divided into several

    subscales that are used to assess the extent to which a leader exhibits a certain leadership style

    (Tejeda, Scandura, & Pillai, 2001). The subscales include idealized influence attributed (IIA),

    idealized influence behavior (IIB), inspirational motivation (IM), intellectual stimulation (IS),

    individualized consideration (IC), contingent reward (CR), management-by-exception active

    (MBEA), management-by-exception passive (MBEP), and laissez-faire leadership (LP).

    Table 5 shows which subscales of the MLQ correspond to which competences of clinical

    team leadership, found in the literature and by professional opinions. Herewith, the definitions

    of the subscales were used to compare the content of the subscales with the competences. The

    definitions of the subscales are described in the Appendix. The MLQ comprises in total 7

    competences of clinical team leadership (39%): improvement, goal & vision, reviewing &

    reflecting, support & coaching, respect, creativity, and research & education. Some subscales

    (33,3%), MBEA, MBEP and LP do not correspond to the competences. Both, IIA and IS

    contain two competences of clinical team leadership.

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    Leadership Practices Inventory

    The definitions of the five practices of the LPI (challenging the process, inspiring shared

    vision, enabling other to act, modelling the way, and encouraging the heart), are employed to

    consider if the LPI assesses the competences of clinical team leadership (Appendix). Table 5

    gives an overview of which practices correspond to which competences. The five practices

    represent 8 competences, which is equal to 44% of all the competences of clinical team

    leadership. The practices involve the competences, improvement, goal & vision,

    collaboration, reviewing & reflecting, communication, support & coaching, role models, and

    respect. The practices challenging the process, inspiring a shared vision, modelling they way,

    and enabling others to act, are similar to more competences.

    Malcolm Baldrige National Quality Award criteria for organizational performance

    The leadership category of the Malcolm Baldrige criteria for organizational performance

    examines how senior executives guide personal actions and sustain the organization. In

    addition, it examined the organizations governance system and how the organization fulfils

    its legal, ethical, and societal responsibilities and support its communities (Baldrige National

    Quality Program, 2009). Leadership is the first criterion of organizational performance and

    consists of two assessment items: 1) senior leadership, and 2) governance and societal

    responsibilities. Senior leadership is divided into a) vision, values, and mission, and b)

    communication and organizational performance. Governance and societal responsibilities is

    subdivided into a) organizational governance, b) legal and ethical behaviour, and c) societal

    responsibilities, support of key communities, and community health. The items and their

    subdivisions are used to perceive if the MBNQA assesses the competences of clinical team

    leadership. In Table 5, the items are demonstrated as a number, the sub-items as a letter. Theitems contain 9 competences of clinical team leadership (50%): improvement, goal & vision,

    reviewing & reflecting, patient-centredness, communication, support & coaching, role

    models, responsibility, and planning & organisation. Whereas, 6 competences are encouraged

    by more than one (sub-)item.

    Table 5. The competences of successful clinical team leadership found in the literature and by professional

    opinions in the UMC St Radboud, and the corresponding items of existing instruments that can assess thesecompetences

    MLQ LPI MBCOP MAT

    ImprovementIntellectual

    stimulation

    Challenging the

    process

    1A: vision, values, and mission.

    1B: communication and

    X

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    organizational performance.

    2A: organizational governance.

    2C: societal responsibilties,

    support of key communities, and

    community health.Goal & Vision Idealized influence

    attributed;

    Contigent reward.

    Inspiring a shared

    vision;

    Modelling the way.

    1A: vision, values, and mission.

    1B: communication and

    organizational performance.

    2B: legal and ethical behaviour.

    X

    Collaboration Enabling others to act

    Reviewing &

    Reflecting

    Idealized influence

    attributed

    Challenging the

    process;

    Encouraging the heart.

    1A: vision, values, and mission.

    2A: organizational governance

    X

    Patient-centerness 1A: vision, values, and mission.

    1B: communication and

    organizational performance.

    2B: legal and ethical behaviour

    Communication Enabling others to act 1B: communication and

    organizational performance.

    Support & Coaching Inspirational

    motivation;

    Individualized

    consideration.

    Inspiring a shared

    vision;

    Enabling others to act;

    Modelling the way.

    2C: societal responsibilties,

    support of key communities, and

    community health.

    X

    Role models Modelling the way 1A: vision, values, and mission.

    Respect Idealized influence

    behavior

    Enabling others to act X

    Knowledge X

    Creativity Intellectual

    stimulation

    Influencing

    Responsibility 2B: legal and ethical behaviour.

    2C: societal responsibilties,

    support of key communities, and

    community health.

    Planning &

    Organisation

    1A: vision, values, and mission.

    1B: communication and

    organizational performance.

    The table is continued on the next page

    Table 5. Continuation

    MLQ LPI MBCOP MAT

    Research &

    Education

    Individualized

    consideration

    Decisively

    Steering at result

    Interconnecting

    leadership

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    Microsystem Assessment Tool

    Leadership is one of the success characteristics of high performing microsystems, that is

    utilized to assess the functioning of microsystems and identify potential areas to focus

    improvements. The definition of leadership described in the microsystem concept, is used to

    find out if the MAT assesses the competences of clinical team leadership. Six competences

    (33%) can be measured using the MAT: improvement, goal & vision, reviewing & reflecting,

    support & coaching, respect, and knowledge. Because the MAT does not define (sub-) items,

    the included competences are ticked off in Table 5.

    Discussion

    This final chapter discusses the study outcomes that were presented in the previous chapter.Based on the discussion, the conclusions and recommendations are set up. Finally, the chapter

    describes the limitations of the study that should be taken into account.

    1.19 Discussion

    Based on the literature and the opinions of clinical team leaders in the UMC St Radboud, 18

    competences on clinical team leadership were identified as most important for successful

    clinical team leadership (Table 5). Slightly more than two third of the competencies (69%),

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    were mentioned both in the literature and by clinical team leaders in the UMC St Radboud.

    The competences improvement, goal & vision, reviewing & reflecting, and support &

    coaching are prominent, in particular. These competences are determined in the literature and

    by clinical team leaders, as well as in all four selected assessment instruments that measure

    leadership. To be successful, a clinical team leader should master skills that are conguent with

    the 18 major competencies of clinical team leadership. In measuring clinical team leadership,

    the existing assessment instruments, MLQ, LPI, MBNQA, and MAT are useful in greater or

    lesser extent.

    None of the existing assessment instruments is able to measure all the 18 competences of

    clinical team leadership found in this study. Only some competences can be measured by the

    selected instruments on leadership. The MBNQA is most obvious, since the Malcolm

    Baldrige criteria examine most of the competences of clinical team leadership (50%). An

    additional advantage is that the organizational performance criteria of the Malcolm Baldrige

    show many parallels with the European Foundation for Quality Management (EFQM)

    Excellence model, that has also a Dutch application: the management model by the Dutch

    Quality Institute, the Instituut Nederlandse Kwaliteit (INK). This Dutch translation might be

    suitable in assessing clinical team leadership in the UMC St Radboud. Self-assessment is

    emphasized in the teaching programs of the INK (Minkman et al., 2007; Nabitz et al., 2000).

    Inter alia, the institute developed a self-assessment questionnaire for measuring leadership

    styles, that is part of the publication Leiderschap als kunst by Van Loon and Roozendaal

    (2006). Machteld Dronkers, expert in leadership and responsible for the management

    development program on leadership in the UMC St Radboud, also recommended a

    publication of Van Loon: Het geheim van de leider (M. Dronkers, personal communication,

    June 15, 2009; Van Loon, 2006). However, it should be noted that the MBNQA as well as his

    derivatives, the EFQM Excellence model and the INK-management model, are designed tofocus more at the entire organization while clinical team leaders, who are highlighted in this

    study, are part of the microsystems. Following the Baldrige Malcolm criteria, leadership is

    defined as how senior leaders guide the organization (Foster et al., 2007). Instead of clinical

    team leadership, senior leadership or managerial leadership is focused on the macrosystem,

    concerning the chain of effect on improving healthcare quality (Berwick, 2001).

    Discrepancies between these different organizational levels may cause problems in measuring

    clinical team leadership. However, Foster et al. (2007) refute this partly by stating:

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    microsystems that operate within the context of a larger organization face many challenges.

    In the ideal world, organizational alignment would be clear and consistent at all levels, though

    the outstanding performers do not live in such a world. While the Malcolm Baldrige

    assessment can make those gaps clear, organizational leadership must be committed to

    closing them (p.341). Despite its organizational basis, the Malcolm Baldrige is especially

    focused on the health care sector, by using criteria developed for health care organizations

    (Goldstein & Schweikhart, 2002). This is in contrast with the EFQM Excellence model and

    the INK-management model, that do not go into specific standards and norms for health care.

    Anyway, the EFQM Excellence model is general and aligns conceptually with the ideas of

    Donabedian (1982), who looked at health care services. The dimensions of Donabedian,

    structure, process, and outcome, fit well with the EFQM Excellence model (Nabitz et al.,

    2000).

    The Leadership Practice Inventory is able to measure 44% of the competences on clinical

    team leadership indicated in this study. The LPI is not explicitly based on team leadership in

    health care, but centralized transformational leadership that is commended as highly effective

    and suitable for nursing (Bowles & Bowles, 2000). In a study of Huber et al. (2000) about

    nursing administration instruments, the LPI was best on criteria related to psychometric

    properties and ease of use. In case of nursing, the LPI is used in practice at the microsystem

    level, to measure leadership practices of nurses working in the larger marcosystem

    (Tourangeau & McGilton, 2004). Nevertheless, clinical team leadership focuses on front-line

    health care professionals in general, and not only on nursing leadership (Edmonstone, 2008).

    The LPI is considered as an assessement instrument that measures leadership behaviors

    (Tourangeau & McGilton, 2004). Similarly, the UMC St Radboud places value on behavioral

    competences that a successful leader should show: interconnecting leadership and result

    orientation. Perhaps the Leadership Practices Inventory can play a role by assessing thebehavioral competences in clinical team leaders in the UMC St Radboud. Still, a disadvantage

    is the lack of a Dutch LPI version.

    The Multifactor Leadership Questionnaire comprises 39% of the competences on clinical

    team leadership found in this study. It is remarkable that the questionnaire is employed in

    almost half of the studies adopted to analyze existing assessment instruments useful in

    measuring clinical team leadership (Table 4). Psychometric properties of the MLQ are

    discussed in various articles (Antonakis, Avolio, & Sivasubramaniam, 2003; Avolio, Bass, &

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    Unfortunately, the study shows that none of the existing assessment instruments is

    specifically aimed to measure leadership within the clinical microsystems. In parallel, the

    instruments are either not able to measure all the 18 competences of clinical team leadership

    found in this study. Thus, as Foster et al. (2007) already conclude, a different tool might be

    needed, which recognizes leadership in the clinical microsystem context. However, to

    improve health care quality, clinical team leaders should keep their eye on the whole chain of

    effect by improving the relations with the parent organisation and not just focusing on their

    own microsystem. Building on this reasoning, existing assessment instruments that stress the

    organizational perspective provide as well suitable opportunities in measuring