Capturing what and why in healthcare innovation.

Understandings of innovation usually encompass multiple overlapping aspects, putting innovation terminology at risk of vagueness and overuse. However, innovation concepts are expected to remain powerful and useful in healthcare beyond the pandemic and into the future, so clarity will be helpful for effective leadership. To disentangle and disambiguate meanings within innovation, we offer a framework that captures and simplifies foundational substance within innovation concepts. Our method is an overview review of innovation literature from the 5 years preceding COVID-19. 51 sources were sampled and analysed for explicit definitions of healthcare innovation. Drawing on broad themes suggested from previous reviews, and gathering specific themes emergent from this literary dataset, we focused on categorising the nature of innovations (the what) and reasons given for them (the why). We identified 4 categories of what (ideas, artefacts, practice/process and structure) and 10 categories of why (economic value, practical value, experience, resource use, equity/accessibility, sustainability, behaviour change, specific-problem solving, self-justifying renewal and improved health). These categories reflect contrasting priorities and values, but do not substantially interfere or occlude each other. They can freely be additively combined to create composite definitions. This conceptual scheme affords insight and clarity for creating precise meanings, and making critical sense of imprecision, around innovation. Improved communication and clear shared understandings around innovative intentions, policies and practices cannot but improve the chances of enhanced outcomes. The all-inclusive character of this scheme leaves space for considering the limits of innovation, and notwithstanding well-established critiques, provides a basis for clarity in ongoing usage.

Leadership during airway management in the intensive care unit: A video-reflexive ethnography study.

Effective leadership is crucial to team performance within the intensive care unit. This novel study aimed to explore how staff members from an intensive care unit conceptualize leadership and what facilitators and barriers to leadership exist within a simulated workplace. It also aimed to identify factors that intersect with their perceptions of leadership. This study was underpinned by interpretivism, and video-reflexive ethnography was chosen as the methodology for the study. The use of both video recording (to capture the complex interactions occurring in the ICU) and team reflexivity allowed repeated analysis of those interactions by the research team. Purposive sampling was used to recruit participants from an ICU in a large tertiary and private hospital in Australia. Simulation groups were designed to replicate the typical clinical teams involved in airway management within the intensive care unit. Twenty staff participated in the four simulation activities (five staff per simulation group). Each group simulated the intubations of three patients with hypoxia and respiratory distress due to severe COVID-19. All 20 participants who completed the study simulations were invited to attend video-reflexivity sessions with their respective group. Twelve of the 20 participants (60%) from the simulations took part in the reflexive sessions. Video-reflexivity sessions (142 min) were transcribed verbatim. Transcripts were then imported into NVivo software for analysis. The five stages of framework analysis were used to conduct thematic analysis of the video-reflexivity focus group sessions, including the development of a coding framework. All transcripts were coded in NVivo. NVivo queries were conducted to explore patterns in the coding. The following key themes regarding participants' conceptualizations of leadership within the intensive care were identified: (1) leadership is both a group/shared process and individualistic/hierarchical; (2) leadership is communication; and (3) gender is a key leadership dimension. Key facilitators identified were: (1) role allocation; (2) trust, respect and staff familiarity; and (3) the use of checklists. Key barriers identified were: (1) noise and (2) personal protective equipment. The impact of socio-materiality on leadership within the intensive care unit is also identified.

Supporting doctors' well-being and resilience during COVID-19: A framework for rapid and rigorous intervention development.

This paper aims to outline the development of a theoretically informed and evidence-based intervention strategy to underpin interventions to support the well-being of doctors during COVID-19 and beyond; delineate new ways of working were employed to ensure a rapid and rigorous process of intervention development and present the resulting novel framework for intervention development. The research comprised four workstreams: literature review (WS1), qualitative study (WS2), intervention development and implementation (WS3) and evaluation (WS4). Due to time constraints, we employed a parallel design for WS1-3 with the findings of WS1-2 informing WS3 on a continual basis. WS3 was underpinned by the Behaviour Change Wheel. We recruited expert panels to assist with intervention development. We reflected on decisions taken to facilitate the rapid yet rigorous process of intervention development. The empirical output was a theoretically informed and evidence-based intervention strategy to underpin interventions to support doctors' well-being during COVID-19 and beyond. The methodological output was a novel framework that facilitates rapid and rigorous development of interventions. The intervention strategy provides a foundation for development and evaluation of tailored interventions to support doctors' well-being. The novel framework provides guidance for the development of interventions where the situation demands a rapid yet rigorous development process.

Heard, valued, supported? Doctors' wellbeing during transitions triggered by COVID-19.

INTRODUCTION: Supporting doctors' wellbeing is crucial for medical education to help minimise negative long-term impacts on medical workforce retention and ultimately patient care. There is limited study of how doctors' transitions experiences impact wellbeing, particularly socially and culturally. Multiple Multidimensional Transitions (MMT) theory views transitions as dynamic, incorporating multiple contexts and multiple domains. Using MMT as our lens, we report a qualitative analysis of how transitions experienced by doctors during the pandemic impacted on social and cultural aspects of wellbeing. METHODS: Longitudinal narrative inquiry was employed, using interviews and audio-diaries. Data were collected over 6 months in three phases: (i) interviews with doctors from across the career spectrum (n = 98); (ii) longitudinal audio-diaries for 2-4 months (n = 71); (iii) second interviews (n = 83). Data were analysed abductively, narrowing focus to factors important to social and cultural wellbeing. RESULTS: Doctors described experiencing multiple interacting transitions triggered by the pandemic in multiple contexts (workplace, role, homelife and education). Patterns identifiable across the dataset allowed us to explore social and cultural wellbeing crosscutting beyond individual experience. Three critical factors contributed to social and cultural wellbeing both positively and negatively: being heard (e.g., by colleagues asking how they are); being valued (e.g., removal of rest spaces by organisations showing lack of value); and being supported (e.g., through regular briefing by education bodies). CONCLUSIONS: This study is the first to longitudinally explore the multiple-multidimensional transitions experienced by doctors during the COVID-19 pandemic. Our data analysis helped us move beyond existing perceptions around wellbeing and articulate multiple factors that contribute to social and cultural wellbeing. It is vital that medical educators consider the learning from these experiences to help pinpoint what aspects of support might be beneficial to trainee doctors and their trainers. This study forms the basis for developing evidenced-based interventions that ensure doctors are heard, valued and supported.

Interventions for the well-being of healthcare workers during a pandemic or other crisis: scoping review.

OBJECTIVES: The aim of this scoping review was to identify pre-existing interventions to support the well-being of healthcare workers during a pandemic or other crisis and to assess the quality of these interventions. DESIGN: Arksey and O'Malley's five-stage scoping review framework was used to identify the types of evidence available in the field of well-being interventions for healthcare workers during a pandemic. PubMed, PsycINFO, Embase, Scopus, Web of Science, CINAHL and ERIC databases were searched to find interventions for the well-being of doctors during pandemics. Owing to a lack of results, this search was expanded to all healthcare workers and to include any crisis. Databases were searched in June 2020 and again in October 2020. INCLUSION/EXCLUSION CRITERIA: Articles were included that studied healthcare workers, reported an intervention design and were specifically designed for use during a pandemic or other crisis. Well-being was defined broadly and could include psychological, physical, social or educational interventions. RESULTS: Searching produced 10 529 total academic references of which 2062 were duplicates. This left 8467 references. Of these, 16 met our inclusion criteria and were included in data extraction. During data extraction, three more papers were excluded. This left 13 papers to summarise and report. Of these 13 papers, 6 were prospective studies and 7 were purely descriptive. None of the interventions were theoretically informed in their development and the quality of the evidence was generally deemed poor. CONCLUSIONS: There are no high-quality, theory-based interventions for the well-being of healthcare workers during a pandemic or other crisis. Given that previous pandemics have been shown to have a negative effect on healthcare workers well-being, it is imperative this shortcoming is addressed. This scoping review highlights the need for high-quality, theory-based and evidence-based interventions for the well-being of healthcare workers during a pandemic.

Change is never easy: How management theories can help operationalise change in medical education.

CONTEXT: Medical education is neither simple nor stable, and is highly contextualised. Hence, ways of perceiving multiple connections and complexity are fundamental when seeking to describe, understand and address concerns and questions related to change. PROPOSAL: In response to calls in the literature, we introduce three examples of contemporary organisational theory which can be used to understand and operationalise change within medical education. These theories, institutional logics, paradox theory and complexity leadership theory, respectively, are relatively unknown in medical education. However, they provide a way of making sense of the complexity of change creatively. Specifically, they cross-cut different levels of analysis and allow us to 'zoom in' to micro levels, as well as to 'zoom out' and connect what is happening at the individual level (the micro level) to what happens at a wider institutional and even national or international level (the macro level), thereby providing a means of understanding the interactions among individuals, teams, organisations and systems. We highlight the potential value of these theories, provide a brief discussion of the few studies that have used them in medical education, and then briefly critique each theory. CONCLUSIONS: We hope that by drawing the attention of readers to the potential of these management theories, we can unlock some of the complexity of change in medical education, support new ways of thinking and open new avenues for research.

Leadership in intensive care: A review.

An integrative review of the literature specific to leadership within the intensive care unit was planned to guide future research. Four databases were searched. Study selection was based on predetermined inclusion and exclusion criteria and a quality check was done. Data extraction and synthesis involved developing a preliminary thematic coding framework based on a sample of papers. The coding framework and all selected papers were entered into NVivo software. All papers were then coded to the previously identified themes. Themes were summarised and presented with illustrative quotes highlighting key findings. In total, 1102 relevant quotations were coded across the 28 included papers. Four themes pertaining to leadership were described and analysed: (a) leadership dimensions and discourses; (b) leadership experiences; (c) facilitators and/or barriers to leadership; and (d) leadership outcomes. The literature was found to focus on leader behaviours, as well as the leader dimensions of role allocation, clinical and communication skills and traditional hierarchies. Positive behaviours mentioned included good decision-making, staying calm under pressure and being approachable. Leadership experiences (and outcomes) are typically reported to be positive. Personal individual factors seem the biggest enablers and barriers to leadership within the intensive care unit. Training is considered to be a facilitator of leadership within the intensive care unit. This study highlights the current literature on leadership in intensive care medicine and provides a basis for future research on interventions to improve leadership in the intensive care unit.

Doctors' identity transitions: Choosing to occupy a state of 'betwixt and between'.

CONTEXT: During transitions, doctors engage in identity work to adapt to changes in multiple domains. Accompanied by this are dynamic 'liminal' phases. Definitions of liminality denote a state of being 'betwixt and between' identities. From a social constructionist perspective, being betwixt and between professional identities may either involve a sense of disrupted self, requiring identity work to move through and out of being betwixt and between (ie, temporary liminality), or refer to the experiences of temporary workers (eg, locum doctors) or those in dual roles (eg, clinician-managers) who find themselves perpetually betwixt and between professional identities (ie, perpetual liminality) and use identity work to make themselves contextually relevant. In the health care literature, liminality is conceptualised as a linear process, but this does not align with current notions of transitions that are depicted as multiple, complex and non-linear. METHODS: We undertook a longitudinal narrative inquiry study using audio-diaries to explore how doctors experience liminality during trainee-to-trained transitions. In three phases, we: (a) interviewed 20 doctors about his or her trainee-to-trained transitions; (b) collected longitudinal audio-diaries from 17 doctors for 6-9 months, and (c) undertook exit interviews with these 17 doctors. Data were analysed thematically, both cross-sectionally and longitudinally, using identity work theory as an analytical lens. RESULTS: All participants experienced liminality. Our analysis enabled us to identify temporary and perpetual liminal experiences. Furthermore, fine-grained analysis of participants' identity talk enabled us to identify points in participants' journeys at which he or she rejected identity grants associated with his or her trained status and instead preferred to remain in and thus occupy liminality (ie, neither trainee nor trained doctor). CONCLUSIONS: This paper is the first to explore longitudinally doctors' liminal experiences through trainee-to-trained transitions. Our findings also make conceptual contributions to the health care literature, as well as the wider interdisciplinary liminality literature, by adding further layers to conceptualisations and introducing the notion of occupying liminality.

An international study of trainee-trained transitions: Introducing the transition-to-trained-doctor (T3D) model.

Background: Throughout their careers, doctors and other healthcare professionals experience numerous transitions. When supporting transitions, opportunities for development and learning should be maximized, while stressors having negative impacts on well-being should be minimized. Building on our international data, this study aimed to develop a conceptual model of the trainee-trained transition (i.e. the significant transitions experienced by doctors as they complete postgraduate training moving from trainee/resident status to medical specialist roles).Methods: Employing Multiple and Multidimensional Transitions (MMT) theory and current conceptualizations of clinical context, this study undertook secondary analysis of 55 interviews with doctors from three countries (Netherlands, Cananda and the UK) undergoing trainee-trained transitions.Results: Through this analysis, the Transition-To-Trained-Doctor (T3D) conceptual model has been developed. This model takes into consideration the multiple contexts and multiple domains in which transitions take place.Discussion: This model is significant in that it has several uses and is applicable across countries: to remind doctors, managers and medical educators of the complexity of transitions; to frame and facilitate supportive conversations; and as a basis to teach about transitions.

Preparing for leadership in General Practice: a qualitative exploration of how GP trainees learn about leadership.

The recent rise to prominence of healthcare leadership worldwide has prompted those involved in medical education to consider how to facilitate learning to lead effectively. Research has focused on formal curriculum activities. Curricular theory suggests that trainee doctors may also learn through the informal curriculum but there is a lack of medical education literature on this. We aimed to explore how GP trainees learn about leadership in their GP training practices. Epistemologically grounded in social constructionism, this research involved 15 semi-structured interviews with GP trainees about to complete their training. Interviews were conducted using an online video conferencing method, audio-taped, transcribed and analysed using thematic framework analysis. We identified three learning processes contributing to leadership development; evaluating leadership, formulating views on leadership and constructing a personal leadership identity. Other factors operating within the informal curriculum included leadership terminology, and the quality of relationships and networks. Paradoxically, a role model's fallibility could positively influence leadership learning. Based on our findings, we present a model for the informal leadership learning process. This may enhance the facilitation of leadership learning by trainers and the wider clinical team, and positively influence the delivery and content of formal leadership courses.

Multiple and multidimensional transitions from trainee to trained doctor: a qualitative longitudinal study in the UK.

OBJECTIVES: To explore trainee doctors' experiences of the transition to trained doctor, we answer three questions: (1) What multiple and multidimensional transitions (MMTs) are experienced as participants move from trainee to trained doctor? (2) What facilitates and hinders doctors' successful transition experiences? (3) What is the impact of MMTs on trained doctors? DESIGN: A qualitative longitudinal study underpinned by MMT theory. SETTING: Four training areas (health boards) in the UK. PARTICIPANTS: 20 doctors, 19 higher-stage trainees within 6 months of completing their postgraduate training and 1 staff grade, associate specialist or specialty doctor, were recruited to the 9-month longitudinal audio-diary (LAD) study. All completed an entrance interview, 18 completed LADs and 18 completed exit interviews. METHODS: Data were analysed cross-sectionally and longitudinally using thematic Framework Analysis. RESULTS: Participants experienced a multiplicity of expected and unexpected, positive and negative work-related transitions (eg, new roles) and home-related transitions (eg, moving home) during their trainee-trained doctor transition. Factors facilitating or inhibiting successful transitions were identified at various levels: individual (eg, living arrangements), interpersonal (eg, presence of supportive relationships), systemic (eg, mentoring opportunities) and macro (eg, the curriculum provided by Medical Royal Colleges). Various impacts of transitions were also identified at each of these four levels: individual (eg, stress), interpersonal (eg, trainees' children spending more time in childcare), systemic (eg, spending less time with patients) and macro (eg, delayed start in trainees' new roles). CONCLUSIONS: Priority should be given to developing supportive relationships (both formal and informal) to help trainees transition into their trained doctor roles, as well as providing more opportunities for learning. Further longitudinal qualitative research is now needed with a longer study duration to explore transition journeys for several years into the trained doctor role.

Using video-reflexive ethnography to capture the complexity of leadership enactment in the healthcare workplace.

Current theoretical thinking asserts that leadership should be distributed across many levels of healthcare organisations to improve the patient experience and staff morale. However, much healthcare leadership education focusses on the training and competence of individuals and little attention is paid to the interprofessional workplace and how its inherent complexities might contribute to the emergence of leadership. Underpinned by complexity theory, this research aimed to explore how interprofessional healthcare teams enact leadership at a micro-level through influential acts of organising. A whole (interprofessional) team workplace-based study utilising video-reflexive ethnography occurred in two UK clinical sites. Thematic framework analyses of the video data (video-observation and video-reflexivity sessions) were undertaken, followed by in-depth analyses of human-human and human-material interactions. Data analysis revealed a complex interprofessional environment where leadership is a dynamic process, negotiated and renegotiated in various ways throughout interactions (both formal and informal). Being able to "see" themselves at work gave participants the opportunity to discuss and analyse their everyday leadership practices and challenge some of their sometimes deeply entrenched values, beliefs, practices and assumptions about healthcare leadership. These study findings therefore indicate a need to redefine the way that medical and healthcare educators facilitate leadership development and argue for new approaches to research which shifts the focus from leaders to leadership.

Leadership and followership in the healthcare workplace: exploring medical trainees' experiences through narrative inquiry.

OBJECTIVES: To explore medical trainees' experiences of leadership and followership in the interprofessional healthcare workplace. DESIGN: A qualitative approach using narrative interviewing techniques in 11 group and 19 individual interviews with UK medical trainees. SETTING: Multisite study across four UK health boards. PARTICIPANTS: Through maximum variation sampling, 65 medical trainees were recruited from a range of specialties and at various stages of training. Participants shared stories about their experiences of leadership and followership in the healthcare workplace. METHODS: Data were analysed using thematic and narrative analysis. RESULTS: We identified 171 personal incident narratives about leadership and followership. Participants most often narrated experiences from the position of follower. Their narratives illustrated many factors that facilitate or inhibit developing leadership identities; that traditional medical and interprofessional hierarchies persist within the healthcare workplace; and that wider healthcare systems can act as barriers to distributed leadership practices. CONCLUSIONS: This paper provides new understandings of the multiple ways in which leadership and followership is experienced in the healthcare workplace and sets out recommendations for future leadership educational practices and research.

Dimensions, discourses and differences: trainees conceptualising health care leadership and followership.

CONTEXT: As doctors in all specialties are expected to undertake leadership within health care organisations, leadership development has become an inherent part of medical education. Whereas the leadership literature within medical education remains mostly focused on individual, hierarchical leadership, contemporary theory posits leadership as a group process, which should be distributed across all levels of health care organisation. This gap between theory and practice indicates that there is a need to understand what leadership and followership mean to medical trainees working in today's interprofessional health care workplace. METHODS: Epistemologically grounded in social constructionism, this research involved 19 individual and 11 group interviews with 65 UK medical trainees across all stages of training and a range of specialties. Semi-structured interviewing techniques were employed to capture medical trainees' conceptualisations of leadership and followership. Interviews were audiotaped, transcribed verbatim and analysed using thematic framework analysis to identify leadership and followership dimensions which were subsequently mapped onto leadership discourses found in the literature. RESULTS: Although diversity existed in terms of medical trainees' understandings of leadership and followership, unsophisticated conceptualisations focusing on individual behaviours, hierarchy and personality were commonplace in trainees' understandings. This indicated the dominance of an individualist discourse. Patterns in understandings across all stages of training and specialties, and whether definitions were solicited or unsolicited, illustrated that context heavily influenced trainees' conceptualisations of leadership and followership. CONCLUSIONS: Our findings suggest that UK trainees typically hold traditional understandings of leadership and followership, which are clearly influenced by the organisational structures in which they work. Although education may change these understandings to some extent, changes in leadership practices to reflect contemporary theory are unlikely to be sustained if leadership experiences in the workplace continue to be based on individualist models.