A variety of organizations, such as graduate-level academic centers, professional societies, and business development companies in concert with healthcare organizations (HCOs), offer leadership development programs (LDPs) to physicians with a wide variety of desired outcomes. The prevailing wisdom is that physicians lack such training in their early clinical development and are disadvantaged in the current healthcare environment.
Leadership is critical in health systems, given that myriad challenges are bringing physicians and HCOs closer together. These challenges include reduced support service budgets, calls for performance standardization, labor shortages, and integration of physicians in the leadership hierarchy.(1) Additionally, the Physicians Advocacy Institute suggests that 74% of physicians in the United States are employed by either hospitals or corporate entities and, in that service, are ill-equipped to align with their partner HCO.(2)
While most HCOs accept that success in healthcare will improve when physicians form collaborative relationships with administrators for the purpose of team-based health delivery outcomes, few organizations address the specific physician leadership and partnering requirements when designing such programs.
Leadership development programs occur in every type of industry, organization, service, and profession. Approaches are typically organization-dependent and focus on developing leadership traits and improving contributions specific to the type of industry and the organizational culture. But Leskiw and Singh suggest the design of any truly effective leadership development program must consider and incorporate six factors: 1) a needs assessment, 2) the combining of the right audiences in the program, 3) infrastructure to support the development, 4) the implementation of a learning system that will drive the individual programs, 5) a means to evaluate the change, and 6) actions that will reward success.(3)
Similarly, Debets, et al., identified five context-mechanism-outcome configurations (CMOs) that describe how LDPs can impact organization-level outcomes:(4) 1) acquiring self-insight and people skills; 2) intentionally building professional networks; 3) supporting quality improvement projects; 4) tailoring content for physician executive/leadership preparation; and 5) valuing physician leaders and organizational commitment.
Previous unpublished work demonstrated that a specific leadership development program produced changes in physician leadership competencies in the areas of leadership behaviors, communication delivery, and information exchange.(5) Given the anecdotal effect of this specific LDP on two cohorts of participants, there is a likelihood that leadership development may also influence organizational attitudes toward the parent HCO, specifically in the area of physician organizational commitment and shared vision.
This study was designed to measure the impact of a specific LDP at one large HCO on organizational commitment and shared vision; results demonstrate a significant increase in both attitudes following the conclusion of the LDP.
Some HCOs address their strategic goals by designing LDPs to improve partnerships among physicians, nurses, administrators, and their employing organization.(4) Hospitals and health systems that offer uniquely designed LDPs to address a lack of leadership education usually attempt to achieve the outcomes of improving individual leader skills, team performance, and organizational outcomes.
While there often is a lack of metrics to clarify how and why LDPs produce specific outcomes, the more effective programs do assess their leader training with specific evaluation tools.(4) These outcome-based training programs, which generate and drive explicit learning objectives, have proven to be an effective method to achieve results.(6)
One often-overlooked but potentially valuable goal of any outcome-based training and development in HCOs is the potential to increase organizational commitment among physicians.
Regardless of the ecosystem, physicians appear to have lower levels of organizational commitment than do other healthcare workers.(1) The prevailing view has been that professional commitment was mutually exclusive from and in conflict with the parent HCO, typified by acknowledgment and acceptance of organizational values, interests, and control.(1) This would imply that the barriers to improved organizational commitment among physicians might not be worth the resources that must be used.
The results of one review found a consistent pattern (albeit only in a few organizations) that higher levels of organizational commitment among physicians were linked to favorable outcomes like improved care quality and productive work behaviors.(4) Further, the authors conclude that organizational commitment looms perhaps as the key element to address to attain improved physicians’ relations with their employers and their organization.(4)
THE INTER-PROFESSIONAL LEADERSHIP DEVELOPMENT PROGRAM
This study was conducted with healthcare professionals serving at a large HCO in the eastern United States. This hospital system consists of four hospitals located within a medium-sized metropolitan area. The executor of the program had conducted two prior physician/provider inter-professional leadership development cohorts that measured change in self-reported and observed leadership behaviors, but the research related to this cohort was designed to measure organizational commitment and shared vision.
Participants in this research were members of this cohort in the third year of the program’s existence in this healthcare system. All three programs were the same, albeit with different participants in each cohort.
The program objective is to equip the graduates with leadership attributes, competencies, and influence methods that contribute to the building of trust with followers and to achieving stated organizational objectives. Additionally, the graduates are taught to model shared behaviors that foster improved inter-professional communication and contribute to organizational goals and overall culture.
Research with four previous cohorts at other healthcare organizations showed that the program demonstrated measurable changes in physician leadership competencies in the areas of leadership behaviors, communication delivery, and information exchange.(5)
As in past programs, the healthcare professionals in the cohort participated in six leadership development seminars and one field trip. Before the start of the program, each participant received a pamphlet outlining the entire program, including the subject matter and objectives for every seminar, the anticipated focus of discussions for the seminars, and the participant’s responsibilities, along with the books required for each seminar.
Each seminar consisted of a five-hour program taught by the same instructor one afternoon per month. Before each seminar, the instructor outlined the teaching material, methods of instruction, session objectives, required assignments, and items for discussion for that session. During each seminar, the instructor engaged participants in discussion and dialogue and assigned teams within the group to provide information briefings regarding their observation of seminar topics observed in their work environment.
After each seminar, participants were tasked to further explore the topic discussed during the seminar, observing tasks within their own work environment and reporting their observations in a shared briefing with the class in the following month’s session.
The seminar objectives were:
Describe/Discuss Elements of Leadership
Describe/Discuss Leader Attributes & Competencies
Review Influence Methods
Review Communications Techniques
Demonstrate Effective Information Exchange
Ability to Contribute to Organizational Culture
Ability to Lead Organizational Change
The desired outcomes were:
Awareness of Role in the Medical Profession
Awareness of Individual Role in the Organization
Understanding of Various Leadership Models
Understanding of Leadership Responsibilities
Effective Execution of Role in Team Leadership
Effective Execution of Role in Organizational Leadership
Additionally, the program had the objective of ensuring participants understood how leadership excellence in healthcare is primarily focused on effective patient outcomes, meeting the challenges outlined in the triple aim (plus one), and organizational, cultural, and strategic effectiveness.
The first two seminar sessions required participants to explore the profession of healthcare, the definition of leadership, the attributes and competencies required of leaders, and familiarity with how leaders and followers interact in high-performing organizations. These first two sessions focused on developing the attributes of a leader, introducing participants to leader self-awareness, strengths and weaknesses of leaders, leadership styles, and a leader’s character, values, and presence.
The third and fourth seminars explored the various dynamics of dyadic leadership, one-on-one engagements and interactions with patients, and the leadership dynamics needed to build healthcare teams. These two seminars focused on helping those in leadership positions understand various influence methods, know the motivations of each team member, and achieve the desired result with members who contribute diverse skills to their respective teams.
Seminars five and six focused on understanding the role of the leader in building and leading small and large teams and in contributing to the strategies and objectives of the organization and of healthcare at large. Participants discussed the various methods and dynamics necessary to lead high-performing teams in various environments and were introduced to the elements of situational leadership, strategic framing, models of team development, and the understanding of how leadership, communication, and information exchange contribute to effective teams.
As part of the final seminar, participants attended briefings regarding the strategies of the organization and participated in an extended panel discussion with key C-suite leaders regarding the physician’s role in leading healthcare teams.
The field trip, or what business sector research describes as a type of “extraordinary experience,” was scheduled between lessons five and six as an optional event. The activity provided the opportunity for the members of the cohort to observe leadership dynamics in a large non-healthcare organization that focuses on science, engineering, quality, and life safety, discussions on how the lessons in that organization compare to what is found in healthcare.
METHODS
A pre-/post-survey design was used to assess the extent to which shared vision and affective commitment increased in response to participation in the inter-professional leadership development program. Using Qualtrics, both the pre- and post-surveys were designed to be identical and included the focal study measures along with key demographic information. The Institutional Research Board at the Florida Institute of Technology reviewed the study, granted exempt status, and provided a certificate of clearance for human participant research.
Informed consent was obtained via the first item in the survey; participants completed the survey only if they selected “I consent.” Participants were informed that the survey was anonymous and that they had the right to exit at any time. The pre-survey link was sent to all participants in the Physician’s Leadership Development Course before the start of the course, and the post-survey link was sent on the last day of the course.
Shared vision, defined as the extent to which the participants understood and shared the vision of the organization, was measured using five items adapted from Chai, Hwang, and Joo.(7) An example item is “I fully understand the meaning of [organization name]’s vision and mission and can fully explain it in detail.” All items were rated on a 5-point scale ranging from 1 strongly disagree to 5 strongly agree, such that higher scores reflect a higher level of shared vision.
Affective commitment, defined as the sense of emotional attachment to the organization, was measured using three items adapted from McGee and Ford.(8) These items assessed the extent to which the participants are attached and committed to the organization. An example item is “I do not feel a strong sense of belonging to [organization name]” (reverse coded). All items were rated on a 5-point scale ranging from 1 strongly disagree to 5 strongly agree, such that higher scores reflect a higher level of affective commitment.
The scales demonstrated adequate reliability with Cronbach’s alphas for shared vision of .83 (pre-survey) and .77 (post-survey) and for affective commitment, .78 (pre-survey) and .81 (post-survey). All analyses were performed using SPSS Statistics Version 28.0.1.1.
RESULTS
Thirty-two individuals completed the pre-survey, 25 individuals completed the post-survey, and 18 individuals completed both the pre-survey and the post-survey and were included in the focal analyses. Descriptives and intercorrelations for all study variables can be found in Table 1.
The 18 participants used in the focal analyses included 10 clinical providers and eight nurse or non-nurse directors /administrators. Organizational tenure ranged from one to 32 years, with an average tenure of 9.6 years. Seven participants identified as men, and 11 participants identified as women. Fourteen individuals identified as White, two as Asian, and two preferred not to say. Fifteen identified as Not Hispanic, one as Hispanic, and two preferred not to say.
Before testing the primary study hypotheses, we compared pre-survey scores for individuals who completed both surveys to individuals who completed only the pre-survey. We found no significant differences in pre-survey shared vision for the 13 participants who completed the pre-survey only (M = 4.06; SD = .71) compared to the 18 participants who completed both surveys (M = 4.13; SD = .70), t(29) = −.28, p = .78.
We also found no significant differences in pre-survey affective commitment scores for the 14 participants who completed only the pre-survey (M = 4.00; SD = .76) compared to the 18 participants who completed both surveys (M = 4.26; SD = .75), t(30) = −.96, p = .35. This suggests study attrition was not related to pre-existing differences in the study variables.
Because the hypotheses were directional, one-tailed paired sample t-tests were conducted to determine the effect of the Physician’s Leadership Development Program on shared vision and affective commitment. The results indicate a significant difference between shared vision scores before the program (M = 4.26; SD = .75) and shared vision scores after the program (M = 4.56; SD = .59), t(17) = −1.76, p = .048.
The results also indicate a significant difference between affective commitment scores before the program (M = 4.09; SD = .70) and commitment scores after the program (M = 4.69; SD = .32), t(16) = −3.96, p < .001. Figure 1 illustrates the increase in shared vision and affective commitment in response to the program.
DISCUSSION
Following a six-month inter-professional leadership development program, survey scores measuring shared vision and affective commitment increased significantly. A change of .6 (shared vision) and .3 (affective commitment) of a point on a 5-point scale demonstrates that this single, one-time LDP moved participants from endorsing on average “agree” toward “strongly agree” in terms of their feelings of shared vision and affective commitment.
A recent systematic review of organizational commitment in physicians showed mean levels of commitment for U.S. samples varying between 2.5 and 4.(1) Very low scores, and therefore larger potential changes, are not common when measuring most organizational attitudes. In fact, this suggests that our sample reflects an organization that was doing better than most in terms of initial levels of commitment, thus suggesting that the statistically significant findings may be a conservative estimate of the potential benefit of LDPs.
Together, these two meaningful measurements suggest that after taking part in a well-defined leadership program, participants of the program developed an increase in organizational commitment to the parent organization, the sponsor of the program.
As suggested in a recent study, organizational commitment is potentially a key factor in driving organizational outcomes and, therefore, might be considered a priority outcome of any leadership development program.(4)
The U.S. healthcare system has been undergoing a significant transformation in the past two decades, with acceleration during and following the COVID-19 pandemic. One of the features of this transformation is the ever-tighter fusion of physicians and their organizations. This is most notable with a growing number of vertical integration and physician employment/alignment strategies that health systems are deploying to reach their organizational goals and succeed in their missions.
The structure alone, however, may not be enough to reach the desired outcomes. Organizations seek to utilize leadership development programs (LDPs) to equip physicians with the necessary skills to lead in these new structures.(6) The LDPs may serve an additional function by improving the partnership and integration between physicians and organizations through increasing organizational commitment.
This study sought to measure two specific changes in the attitudes of participants following a defined inter-professional leadership program: shared vision and affective commitment.
Physicians, as primary stakeholders in healthcare organizations, are most likely to be key agents of change, and while leadership development is critical to the growth of change agents, organizational success may also depend on those physicians forming collaborative relationships with administrators for the purpose of team-based health delivery outcomes.(9)
The results of this study suggest that in addition to equipping physicians with the necessary skills, behaviors, and techniques of leadership, LDPs may also improve the partnership between physicians and their employing organization through increased organizational commitment.
An extensive evidentiary review by Spurgeon, et al., contends that medical leadership is a mechanism or process to achieve greater medical engagement in the running of the organization and that it is this engagement that has an impact on organizational performance.(10)
The researchers make a clear distinction between engagement and leadership, further elaborating: “The view adopted here is that engagement is a…… level of commitment that exists within the individual.” Further, “....an individual’s reservoir of motivation/commitment can increase and, if this is extended to a collective workforce, then one can see why an organization, by increasing its overall level of engagement, has effectively increased its potential ‘power’ to perform.”(10)
This research suggests that leadership development increases commitment, which, in turn, improves the organization, once again highlighting the potential value of increasing commitment in healthcare, where the stakes are so high.
There are two other elements to consider regarding increasing organizational commitment through leadership development. The first element is the problem of professional trust within the healthcare space.
Research has shown, and executives and physicians in healthcare likely would agree, that there is a lack of trust between administrators and physicians in the healthcare industry. One data set suggests that one-third of physicians do not trust their own organizational leadership, and about half of physicians do not trust health leaders/executives en masse.(11) Another survey, taken after the start of COVID-19, suggests up to two-thirds of physicians have a negative/neutral view toward health systems.(12)
According to McLeod’s assessment, trust is a foundational element that begins even before any action is taken toward a desired outcome in healthcare organizations.(13) When trust is achieved, even in small parts, individual physicians are more likely to move along the spectrum toward action that best serves the organization:
Trust → Motivation → Engagement → Alignment → Integration.
The second element regarding increasing commitment through leadership development is that despite many physicians’ distrust of HCOs, there are physicians, in fact, who want defined leadership development programs specifically to close the gaps in key areas of interpersonal literacy and systems literacy.(14) As a result of delivering training and skill development, national physician companies have shown improved engagement.(15)
By granting doctors an opportunity to close their leadership gaps (e.g., to learn how to manage themselves and others, to learn the generic business of healthcare, and to understand their organizational strategic objectives and decision-making), systems can expect to see improved attitudes toward the sponsoring organization.
When education and training are delivered to physicians who also seek to improve their leadership skills, the activity may improve attitudes and aid in closing the gap(s) in trust among physicians. All of these, in turn, serve to foster momentum toward organizational success.
LIMITATIONS
The research described herein was borne out of anecdotal comments program attendees made upon course graduation using the words “more trusting” to describe how they felt about the organization. Comments like that, among others, led to the concept of assessing the attitudes of participants before and after the program, particularly with an eye to moving the attendees toward greater roles, responsibilities, and outcomes within the organization.
As described, trust appears to contribute to the foundational element that is required to move individuals and teams toward the desired organizational behavior.
Organizational commitment, as modeled by Meyer and Allen, consists of three factors: normative commitment (obligatory attachment based on alignment and values/beliefs with the employer), continuance commitment (attachment based on the costs of leaving), and affective commitment (attachment based on emotions).(16)
By selecting the affective component, we are attempting to observe a change in the subjects’ perception that is directionally related to the organization and influenced by the experience of the program rather than to external motivations that drive continuance commitment or inherent values that drive normative commitment. Likewise, without a specific tool for measuring trust, any conclusions relative to that concept in our discussion are speculative.
The size of the LDP was limited to about 50 participants, so even if we achieved higher response rates, the absolute amount of information is limited to this single cohort. Additionally, the cohort was the final one to participate in the LDP, and we did not have any “control” group or prior cohorts to measure and compare results across time or across different demographics.
The first cohort was hand-picked by a small committee of leaders in the healthcare organization who were driving the leadership development initiative. Once selected, the first cohort received a “by special invitation” only to participate, allowing the members to opt-out, but volunteers were not requested.
The chosen physician invitees for the first cohort were all in specified leadership roles, either as medical directors or in medical staff positions or similar roles. This was essentially true for the second cohort, but with more informal leaders and a small number of volunteers allowed. The third cohort, surveyed in this research project, were almost all volunteers. This third cohort represented a more unbiased group than the first two; the mere notion that the participants all volunteered may have self-selected a group (of participants) more aligned to the organization at baseline.
Similarly, at the very beginning of the six-month course, but after the selection of the cohort, there was a major change of executive leadership in the C-suite, which may have “artificially” deflated the pre-survey levels of shared vision and affective commitment if participants felt any uncertainty about the direction of the organization given the leadership change.
The program had discrete curriculum elements that may have influenced the participant results on the survey. The program had a clear set of deliverables related to learning how to lead selves, lead others, and lead organizations, and it was designed to impart those abilities, at least at a competent beginner level.
The program was not intended or designed to increase notions of shared vision or affective commitment, much less an increased level of trust. As such, the program might have delivered an unintended change in attitudes by the specific nature of the teacher and participants rather than through any rational design that could be replicated.
The use of an “extraordinary experience” or field trip to a non-healthcare organization that also focuses on quality, safety, and high reliability, along with the participation of C-suite members in a panel discussion about the health system during the final class may be unusual for traditional physician leadership programs, and the influence of these two curriculum elements is unknown, nor is it clear if they could be replicated and/or produce similar results.
Lastly, we cannot definitively rule out the possibility that the increase in scores over time may be because of participant reactivity or social desirability, but given the seventh-month temporal separation between the pre-survey and post-survey measurements and the anonymous nature of the data collection, it is unlikely that the changes in the scores were because of reactivity of the participants.
Reactivity would require that the participants remember their prior scores such that they could purposefully increase post-test scores in reference to the pre-test, and that type of reactivity, such as social desirability, is less likely to occur in anonymous data collection settings. It is just as likely to inflate pre-survey scores as post-survey scores.(17,18) Future research using a control group (i.e., pre-survey and post-survey only with no intervention) would be necessary to explore those possibilities.
POTENTIAL FOR FURTHER RESEARCH
The current outlook of U.S. healthcare and its limited resources, along with concomitant disruptors in this space, means that the conditions of the landscape will require more of our physicians to participate in leadership development. The participation can close gaps relative to organizational literacy, to personal attitudes such as trust and shared vision toward organizations, and ultimately to meaningful commitment to solve organizational dilemmas and achieve organizational success.
Sponsors of other inter-professional (or physicians-only) leadership programs should consider using similar validated surveys and outcomes-based objectives to add to this research, comparing the metrics and results to improve understanding of these contributions to healthcare. With more data in hand, collectively, there may be a better understanding of what happens and why as it relates to shaping physician attitudes, engagement, and commitment as outcomes of physician leadership development.
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