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Abstract
Background There is growing recognition in the literature of the ‘Herculean’ efforts required to bring about change in healthcare processes and systems. Leadership is recognised as a critical lever for implementation of quality improvement (QI) and other complex team-level interventions; however, the processes by which leaders facilitate change are not well understood. The aim of this study is to examine ‘how’ leadership influences implementation of QI interventions.
Methods We drew on the leadership literature and used secondary data collected as part of a process evaluation of the Safer Care for Older Persons in residential Environments (SCOPE) QI intervention to gain insights regarding the processes by which leadership influences QI implementation. Specifically, using detailed process evaluation data from 31 unit-based nursing home teams we conducted a thematic analysis with a codebook developed a priori based on the existing literature to identify leadership processes.
Results Effective leaders (ie, those who care teams felt supported by and who facilitated SCOPE implementation) successfully developed and reaffirmed teams’ commitment to the SCOPE QI intervention (theme 1), facilitated learning capacity by fostering follower participation in SCOPE and empowering care aides to step into team leadership roles (theme 2) and actively supported team-oriented processes where they developed and nurtured relationships with their followers and supported them as they navigated relationships with other staff (theme 3). Together, these were the mechanisms by which care aides were brought on board with the intervention, stayed on board and, ultimately, transplanted the intervention into the facility. Building learning capacity and creating a culture of improvement are thought to be the overarching processes by which leadership facilitates implementation of complex interventions like SCOPE.
Conclusions Results highlight important, often overlooked, relational and sociocultural aspects of successful QI leadership in nursing homes that can guide the design, implementation and scaling of complex interventions and can guide future research.
- Leadership
- Implementation science
- Qualitative research
Data availability statement
Data may be obtained from a third party and are not publicly available. The data used for this article are housed in the secure and confidential Health Research Data Repository (HRDR) in the Faculty of Nursing at the University of Alberta (https://www.ualberta.ca/nursing/research/supports-and-services/hrdr), in accordance with the health privacy legislation of participating TREC jurisdictions. These health privacy legislations and the ethics approvals covering TREC data do not allow public sharing or removal of completely disaggregated data from the HRDR, even if deidentified. The data were provided under specific data sharing agreements only for approved use by TREC within the HRDR. Where necessary, access to the HRDR to review the original source data may be granted to those who meet prespecified criteria for confidential access, available at request from the TREC data unit manager (https://trecresearch.ca/about/people), with the consent of the original data providers and the required privacy and ethical review bodies.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
It is increasingly recognised in the literature that bringing about change and improvement in healthcare is challenging. Leadership is known to be a critical lever for quality improvement (QI) implementation; however, the processes by which leaders facilitate change are not well understood.
WHAT THIS STUDY ADDS
This study contributes knowledge regarding (1) the longitudinal, highly relational process of ‘how’ leadership influences the implementation of QI and other complex interventions within the context of a QI collaborative, and (2) the limits to looking, in isolation, at the role of leadership in implementation given the complexity of healthcare organisations.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
From a practice standpoint, this study suggests that properly attending to the relational and sociocultural aspects of leadership in QI initiatives may provide the kind of boost struggling healthcare systems need to achieve change and improvement.
Background
Improving healthcare requires complex system changes.1 A recent editorial in this journal acknowledged this, noting that organisations attempting to implement initiatives believed to improve care or outcomes often find these efforts ‘challenging, if not Herculean’.2 High rates of failure3 are therefore not surprising. Much of the literature on healthcare change and improvement interventions focuses on whether change occurs; however, to improve the successful implementation of quality improvement (QI) or complex interventions in healthcare, we need to explore how interventions produce change.4–9
Leadership is critical for implementation of QI and other complex team-level interventions in health settings.10 Its importance is well established—it is an essential determinant in several key research and QI implementation frameworks.11–15 There are also empirical examples of leadership as a facilitator for (or barrier to) implementation of QI and other complex interventions,16–21 and there is a growing literature on the roles that implementation leaders play.22–26 However, the field would benefit from deeper insight, garnered from detailed process evaluations,5 regarding precisely how (ie, the processes by which) leadership influences implementation.2 How do leaders support implementation? What kind of relational approach (transactional, transformational, etc) best fosters implementation and how? How does leadership interact with organisational context to enable successful implementation? Without deeper knowledge of this key implementation lever, organisations will likely continue to struggle with the implementation of QI interventions and changes.
Using rich data from a mixed-methods process evaluation of a complex, team-level QI intervention, Safer Care for Older Persons in residential Environments (SCOPE), this paper builds on previous work21 27 and draws on leadership literature with the objective of examining ‘how’ leadership influences implementation of QI and other complex interventions.
The SCOPE intervention
SCOPE was a complex 1-year intervention to achieve QI in Western Canadian nursing homes using the Breakthrough Series model.11 SCOPE empowered teams, led by care aides, to use Plan-Do-Study-Act (PDSA) approaches to improve resident care. Teams participated in quarterly workshops (learning congresses, LC) where the PDSA approach and other improvement ideas were taught (LC1) and reinforced (LC2 and LC3). Teams presented on their PDSA implementation progress at LC2–4. Teams were expected to implement PDSA cycles between congresses with QI-specific facilitation from an external quality advisor (QA), and internal facilitation from a unit manager (team sponsor, TS) and facility-level director of care (senior sponsor, SS).
Leadership in SCOPE included both formal unit-level and facility-level leadership (TS and SS, respectively), although some TS were informal leaders such as registered nurses (RNs) who played this role given their place in the professional hierarchy. Enabling care aide leadership was the primary role for TS and SS in SCOPE. (See box 1 for a description and schematic of the SCOPE intervention; proof of principle, pilot, trial and process evaluations are described elsewhere.21 27–29 Of particular relevance to the present study are previously reported moderator effects that highlight the importance of leadership in SCOPE.21 These findings showed that when care aide perceptions of sponsor support were extremely positive, SCOPE teams had high levels of implementation fidelity regardless of how acceptable care aides found the intervention, or how much they felt it improved resident care. The present study deepens our understanding of the processes by which leadership influenced SCOPE implementation.
The Safer Care for Older Persons in residential Environments (SCOPE) intervention with schematic12 52 53
SCOPE is a multicomponent pragmatic trial at the ward care-team level in 31 nursing homes. SCOPE teaches local teams led by healthcare aides (HCAs) to implement improvement initiatives based on current best evidence.
SCOPE is modelled on the Institute for Healthcare Improvement’s Breakthrough Series Collaborative model and was designed to be implementable. Using the Promoting Action on Research Implementation in Health Services (PARiHS) framework,12 30 SCOPE addresses technical aspects of Plan-Do-Study-Act (PDSA) work, provides facilitation and addresses contextual factors necessary to support implementation.
SCOPE trial outcomes included best practice use and improvement in the clinical area that teams chose to work on: pain, responsive behaviours or mobility. Outcomes were measured using Resident Assessment Instrument–Minimum Data Set (RAI-MDS 2.0) indicators.31
The year-long intervention began in June 2018. 31 nursing homes in Western Canada had one ward/unit-based improvement team participate. Teams had five to seven members, including an HCA lead, plus at least two HCAs.
Teams attended quarterly learning congresses (LCs) with other teams in their region to network and participate in plenary sessions and activities on the improvement model, measurement in PDSA cycles and team dynamics. Teams presented on project progress at the 2nd, 3rd and 4th LCs.
Teams received support from a team sponsor (unit manager) and a senior sponsor (facility director). Homes were recruited into SCOPE via the facility’s executive director who, depending on the size and structure of the facility, acted as the senior sponsor or chose another senior person (such as the director of care) to fill the role. Team sponsors were ‘invited’ or ‘voluntold’ by the senior sponsor, depending on the senior sponsor’s style. The current study examined how sponsors implemented their roles.
Teams and sponsors received coaching from an external quality advisor (QA) to support quality improvement (QI) activities and instil a new approach to improvement work at the bedside. Researchers in geriatrics, nursing, implementation science, QI and health services supported the quality team.
A mixed-methods concurrent process evaluation was conducted. Process data collected and intervals are shown on the bottom of the schematic below.
The core components of the SCOPE intervention include:
Care aide-led teams working on a focused clinical area.
Use of QI methods by unit teams (change concepts, measurement, PDSA cycles).
In-person meetings with all teams (quarterly LCs).
Ongoing support from a QA during action periods between LCs.
Supporting leaders (team and senior sponsors) to facilitate and support change, including supporting the care aide-led teams.
Theoretical grounding for leadership in SCOPE
Sponsor roles in SCOPE emphasised support, facilitation and a participative leadership approach. They were defined by and rooted in the QI learning collaborative literature11 16 and literature on organisational learning and facilitation. According to Stetler30 and others,12 31 facilitation drives change by forming trusting relationships and shared goals between the leader (facilitator) and those engaged in making the change. Facilitation by internal leaders influences implementation by supporting and empowering front-line workers32 and equipping them with the skills and self-efficacy needed to identify and resolve problems, thereby building capacity for higher order learning.31
The sponsor roles in SCOPE are consistent with the concept of transformational leadership in the organisational literature (also referred to as charismatic, visionary, inspirational or adaptive leadership).33–36 Shamir et al offer a self-concept-based motivational theory to explain how leader behaviours can have transformational effects on followers. According to this view, leaders increase the intrinsic value of followers’ efforts by linking efforts to collective values, giving meaning to followers’ accomplishments. They increase followers’ self-efficacy by setting high expectations and expressing confidence in followers’ ability to meet them. Ultimately, this self-concept development process instils faith in a better future and creates strong and lasting commitment (among both leaders and followers) to a common vision.37
Recent organisational literature provides empirical support for self-concept development,38 and suggests transformational leadership predicts important outcomes such as follower task performance, citizenship behaviours, group or organisation performance39 and implementation success.40 The current paper simultaneously considers the organisational learning literature (which offers insights into learning meta-routines but few insights into learning microprocesses)31, aspects of facilitation theory and the transformational leadership literature with the objective of deepening our understanding of ‘how’ leadership influences the implementation of QI and other complex interventions in health settings.
Methods
We performed a secondary analysis of data collected during SCOPE’s concurrent process evaluation21 drawing on data that had originally been analysed using a grounded theory approach.21 Furthermore, we made use of existing open codes to better understand leadership processes. The analysis reported here specifically focused on leadership processes in the SCOPE intervention and used the robust organisational literature on leadership and learning to further develop this understanding. Despite the original grounded theory approach, we applied a thematic analysis with a codebook developed a priori based on existing literature so that we could identify leadership processes rather than develop a model.
Setting and data sources
We analysed data from 31 unit-based teams in four regions in Western Canada that participated in the SCOPE intervention arm: 8 from Edmonton Zone, 6 from Calgary Zone, 6 from Interior Health and 11 from Fraser Health. SCOPE was delivered regionally (each with their own QA), but LCs were delivered collectively.
Qualitative process evaluation data collected from all SCOPE participants (90 care aides, 62 sponsors, 3 QAs, 6 researchers) throughout the 1-year trial (2018–2019) were used for the current analyses. These data include: (1) QA diary entries following every interaction with a team, (2) observations of LC activities, (3) responses to open-ended questions on LC exit surveys and (4) focus group data collected at the final LC. Table 1 provides details about each data collection approach. All data collection tools were published with the SCOPE process evaluation.21
Data collection approaches
Analysis
Using an iterative process and existing theories, we conducted a thematic analysis. One author (AG) constructed initial leadership summaries for each of the 31 teams in SCOPE, by time period, based on a previous analysis of the qualitative data.21 These summaries took all codes pertaining to leadership and compiled them into an Excel file. Based on a deductive thematic approach,41 three authors with knowledge of the health and organisational literatures (LG, WB, LvD) identified two areas of the literature that could be used to help understand the ways in which leadership influences SCOPE implementation: (1) key aspects of transformational leadership37 42 and (2) organisational learning/facilitation theory.31 An initial codebook was created by the first author according to the organisational literature. The second and third authors applied the codebook to the data, suggesting revisions as per their analysis. The revised codes were discussed in meetings and the first three authors reflected on whether and how the codes supported or added to the existing literature. Analysis identified three main themes that reflect multiple concepts/ideas and a thematic map that connects these themes in the form of feedback loops. Final codes were applied to all the SCOPE leadership qualitative data; additional illustrative quotes were added.
We maintained rigour using criteria for good thematic analysis as defined by Braun and Clarke.41 The primary researcher of this study has significant experience studying QI teams, implementation, leadership and culture, which informed reflections on the data. To strengthen trustworthiness, reflexivity and peer debriefing were central to the analysis processes of coding, defining and naming themes, and extracting quotes.
Results
The three main themes describe action-oriented processes and behaviours with which leaders engaged, initially to develop and affirm commitment to SCOPE (theme 1), then to facilitate learning and growth among SCOPE team members (theme 2), and finally to sustain action by supporting team-oriented processes across the unit (theme 3). A dynamic interplay among the themes was also evident from the longitudinal nature of the data.
Theme 1: Developing and affirming commitment reflects the processes through which team leaders demonstrated commitment to the intervention and their leadership role by inspiring their followers (team members) and tending to more pragmatic aspects of their role.
Leaders influenced follower perceptions of the intervention’s value/benefit. Those who presented SCOPE as an important opportunity to improve resident care, workload and/or staff quality of life inspired their followers and increased engagement. These teams aligned behind a common vision or goal:
The team has chosen the topic of reducing responsive behaviours by more deeply integrating the Eden philosophy techniques [to meaningfully engage residents] … The HCAs [healthcare aides] aim to engage with residents about what they would prefer to do to fill their time. The idea emerged after the Senior Sponsor made a pie diagram that showed how much time an average person spends at sleep, awake, at work, and in leisure and compared it to the day of a resident. This seemed to be a light bulb moment for much of the team and it began a dynamic conversation. (QA Diary, C039)
Leaders who failed to communicate the value of the intervention (or in some cases even the most basic information) saw lower levels of motivation and engagement. These teams often began the intervention late as they did not identify a common goal/purpose until the first LC (where they were in an environment that required them to do so and were provided additional support from the QA and/or research team).
Leaders further demonstrated their commitment by providing followers with the resources needed to enact SCOPE activities (eg, protected time for the team to meet/collaborate). Resource commitment and follow-through were crucial for teams to move forward and develop trust and support between leaders and followers:
(HCA3): They [Senior Sponsor] were investing in us and if we gave them good value, there would be more work to invest in. That’s right so that was in the back of my mind.
(HCA2): I think that was in my mind too, like…they’re investing in me. And they’re
(HCA1): …putting their faith in me and I want to show them that we can like make it [the intervention] permanent—(HCA3) yeah. (Focus Group, C017)
When leaders did not follow through, followers became frustrated and often gave up asking for support, impeding project progress. When asked what they needed the SS to do, participants stated:
(HCA2): Well she just had to approve time if we wanted to come in to work on it…but she didn’t. And she…was very focused on her job and forgot about this…it is extra work for all of us, right? But we all wanted to do it.
(TS1): They [HCAs] were missing out on teleconferences and stuff, because she’d forget to let them know. (Focus Group, D026)
Over the course of the intervention, leaders had to find ways to bridge their role as SCOPE leaders with other work demands. One TS noted that ‘Workload is increasing thus time spent on SCOPE is decreasing. I am trying to juggle it all’ (LC2 Survey, C020). At times work and SCOPE demands were easily bridged, for example, when leaders could draw on facility priorities (eg, previous QI initiatives, recent training) to inspire their team and develop institutional capacity for change. In other instances, competing demands impeded their ability to provide sufficient team support. At the third LC, one QA noted that ‘Falls are a priority for the Senior Sponsor, so she is supportive of the facility’s fall education strategy even if it doesn’t seem to be within the boundaries of SCOPE’ (LC3 QA Survey, A004). This trend continued, and the QA reported at the final LC that ‘the Senior Sponsor was very supportive of the team defaulting to non-SCOPE processes; not supportive of SCOPE processes’ (LC4 QA Survey, A004). Overall, the first theme strongly suggests that leadership commitment to SCOPE led to greater likelihood of continued engagement with the project.
Theme 2: Facilitating learning capacity reflects processes through which leaders fostered follower participation in SCOPE and enabled role change (empowering HCAs to step into leadership) by (a) engaging in strategies to increase participation and promote critical reflection, and (b) identifying opportunities for HCA leadership.
HCAs assumed leadership slowly over the course of the year-long intervention. They first had to actively participate/engage with SCOPE activities. Leaders used many strategies to achieve this—at LCs leaders purposefully called on participants to contribute to team discussions, used guiding questions and provided verbal encouragement. According to one sponsor:
Some things happened that I probably wouldn’t have done that way…but you have to give them [the HCAs] the time and space to fail, so that they can succeed…making sure that they’re coming up with the ideas and asking, ‘How are you going to fix that’? (Focus Group, B004)
Given that factors influencing the participation of each team were different (preferred language other than English (LOE), previous experience with QI, cultural or institutional norms), leaders used different strategies based on the needs of their team and worked to create environments where followers felt safe to actively engage with SCOPE activities. Overtime, some leaders became frustrated by this process and lacked capacity to continue supporting their followers—this was especially true in facilities with high organisational pressure to deliver results and where HCAs required substantial support to engage in SCOPE (eg, LOE HCAs required additional support to read worksheets and encouragement to present team progress during LCs). In these teams, leaders took on more of the work which limited HCA leadership and learning.
Once HCAs were active participants in the intervention, sponsors identified opportunities for HCA leadership (eg, in-service education to stakeholder groups, documenting and measuring SCOPE processes and outcomes, onboarding new staff). In these teams, HCA self-efficacy increased, they gained respect from their peers and real role change was evident, ‘(HCA2) We had to introduce our project to _____in their [management] meeting. At first, we were nervous (HCA1: It was okay) (HCA4: Yeah) and they [the Sponsors] kept saying, ‘You girls can do it.’ And we did’ (Focus Group, C023).
However, other leaders were unable to identify these opportunities, or did not believe that HCAs could take on leadership, which lessened the likelihood of HCA role change. According to one QA:
This team overall has excellent capacity for implementing this work, however the leadership style and the limited interactions that I was able to have with the team (due to never being able to contact the Team Sponsor) mean that leadership came from Sponsors rather than the…HCAs (as much as I could tell). The presentation and ideas for measurement were always put together and directed by the Team Sponsor. (QA Diary, B015)
Theme 3: Supporting team-oriented processes reflects how leaders acted within their teams to (a) develop and nurture relationships with their followers and (b) support followers to navigate other staff relationships during intervention dissemination.
Mutual trust between leaders and followers developed over time as leaders expressed confidence in and respect for their followers’ abilities. Observing one team meeting, a QA noted it was ‘a really warm, positive, and supportive dynamic to observe. The Team Sponsor did not speak during the call, although they joked with her. She continues to demonstrate that she is engaged in the project but that events are firmly in the hands of the team members’ (QA Diary, C012). When trust developed, followers felt respected, valued and could ask for help without fear of repercussions. However, when HCAs felt they were a burden to their leaders, they were more reluctant to ask for help and were less likely to receive adequate leadership support to advance the intervention.
In addition to fostering interpersonal relationships among SCOPE team members, leaders also helped followers navigate relationships with other staff who were not part of the SCOPE team. They used their position of authority to address tensions resulting from a lack of buy-in from non-SCOPE staff which helped teams move forward and, ultimately, fostered a culture of improvement. This is illustrated well by an SS comment:
(SS1): Well, I would say the challenge at the beginning was getting the staff to buy-in. And also, getting past when the HCA would email the team saying, ‘Can you guys do this, this, and this?’ and the RN coming to me saying: ‘Why isn’t that email coming from you? Why is it coming from her?’ and me explaining to them what the process was and what we’re doing, and then they were all like, ‘Oh, okay.’ And then about a month later, the whole change around in that person’s attitude. It was really neat to see. (Focus Group, D025)
Addressing these tensions early allowed teams to focus on the intervention tasks rather than spending time engaging reluctant staff. When leaders did not address these tensions, teams faced challenges spreading the intervention and individual-level changes in perceptions of QI were detected, though these did not extend across the unit. Ultimately, team-oriented processes led to recognition of QI benefits and a shift towards increased QI collaboration within the unit.
Interestingly, our results indicate that engaging both front-line and senior leaders as sponsors created much needed redundancy in leadership support (ie, SCOPE teams each had two different leaders they could turn to). We rarely saw teams receiving significant support from both the TS and SS; instead, teams that successfully implemented SCOPE had either the TS or SS engaged in the three processes/themes outlined.
Dynamic interplay among the themes. Our analysis suggests that the themes above describe a dynamic process by which leaders engaged people with SCOPE, helped maintain commitment and ultimately ‘transplanted’ SCOPE within the facility. Fostering a culture of improvement may be the overarching process by which leadership can facilitate the implementation of a complex intervention like SCOPE (see figure 1). Longitudinal reflections provided by one QA illustrate some of these feedback loops:
The team leader transformed from what seemed to me to be a resentful assuming of the leadership role, to one who wore the mantle well, and brought team members along with her in the development journey. HCAs appeared to be the most empowered of region A teams to lead the work, and all described their growth. Their senior sponsor deserves credit for embracing the SCOPE approach and enabling/empowering the team—though directive at times—to keep working. In the last meeting, it was delightful to see the critical thinking evolving by HCAs as they questioned each other about how to interpret measurement information. (QA Diary, A017)
Fostering sustainability, adapting leadership and creating a collective identity around Safer Care for Older Persons in residential Environments (SCOPE; themes 1–3) are related in a dynamic way and describe the mechanisms by which leaders help bring people on board with SCOPE, help them stay on board and ultimately ‘transplant’ SCOPE within a facility. Fostering a culture of improvement may be the overarching process by which leadership facilitates implementation of a complex intervention like SCOPE.
In one focus group, comments by a sponsor demonstrated how this dynamic culture change process takes place:
(TS1): As a team it’s been a journey…we had to go through that process of learning how to work as a team—how are we going to communicate? How are we going to work together? How are we going to collaborate? We lost a member, we gained a member, we lost another member. We… you know, we went through a lot of transitions together. And then I would say build trust. We kind of listened and supported each other and depended on each other. Like, for me, it takes a big trust for me to just not manage them—micromanage them and then, just say, ‘okay’. You know, like I trust that you’re doing your safety—or whatever it is that you are implementing. (Focus Group, C017)
Overall, the dynamic interplay among the themes highlights some of the inherent challenges associated with complex system change. As HCAs engaged with SCOPE and were supported to step into leadership opportunities, their relationships with one another and to their work transformed, ultimately fostering a broader cultural shift towards embracing QI and HCA leadership. Importantly, this shift occurred gradually throughout the year-long intervention.
Discussion
Our results deepen understanding about what is meant by ‘leadership support’ when it is shown, quantitatively,21 to be an important variable for facilitating implementation in QI collaboratives like SCOPE. Our findings align with the self-concept-based motivational theory of transformational leadership in which leaders give meaning to work by infusing it with moral purpose and commitment42 and then engage followers’ concept of self through goal achievement. SCOPE leaders who successfully carried out their sponsorship role went beyond transactional behaviours and the removal of implementation barriers. Instead, they used social/relational processes to build a common vision and engage in two-way relationship building and interactive problem solving, characteristic of higher order learning.30 31 43
Our findings mirror and extend work in the transformational leadership literature on the importance of understanding follower growth and change, in addition to examining leadership behaviours.37 We showed here and in our previous work21 that leaders and followers both experience growth, developing a new and genuine respect for one another’s capabilities and building trust during the implementation process. Lastly, our suggestions that processes to build learning capacity and create a culture of improvement may facilitate implementation of a complex intervention fit with Schein’s idea that leadership (what leaders attend to, how they allocate resources, coaching, etc) is a key culture embedding mechanism.44
Empirically, our findings are consistent with a small but emerging body of work emphasising the importance of relational aspects of ‘how’ leadership influences implementation of QI and other complex interventions in health settings, including: (1) a study of a series of integrated care initiatives45 that showed a key mechanism of implementation involved leaders at different levels who built trust and strong relationships among stakeholders, as well as a compelling shared vision and narrative regarding the importance of the initiative; and (2) results of the Leadership Saves Lives intervention9 46 47 that demonstrated the importance of creating psychological safety, which emerges when trust is built across the hierarchy. These two studies, along with a recent study of the successful implementation of the I-PASS handover system,48 also highlight the importance of more tangible forms of leadership assistance, such as staff support (time and resources) and direct engagement in the implementation process.
While many studies24 26 45 48 49 suggest that leader roles in the implementation process are predominantly communication based, we found they used a primarily transformational (ie, deeply motivational and relational) process, where they achieved implementation using a goal-oriented process infused with meaning, moral purpose and commitment. It is possible that these observed approaches may be more relevant for complex, team-level interventions (like SCOPE) than for interventions targeting individual-level practice change (such as use of practice guidelines).
Finally, as noted, teams that successfully implemented SCOPE were those where either the TS or SS engaged in the three processes outlined in our results—engagement by both sponsors was not required. However, QI implementation frameworks often identify leadership at the unit and organisation levels as key implementation determinants.14 Pragmatically, how to make the most judicious use of leaders’ time as they support implementation should be the subject of future research.
Practice implications
The leadership process in SCOPE and other QI initiatives can be understood using both organisational learning/facilitation theory and the self-concept development process in transformational leadership. The former speaks to the provision of supportive context, capacity building and opportunity, and the latter relates to the development of worker self-efficacy and latent capacity. Our work highlights the cruciality of the interpersonal and relational aspects of implementation leadership.
Of course, leaders’ efforts to influence implementation of QI and other complex changes do not occur/cannot succeed in isolation. There are broader processes that affect how teams implement complex interventions such as being part of a larger network or collaborative engaged in the work, using a model for change with prescribed activities and having external facilitation (education and support) for teams and leaders.21 50 These supports and resources may fulfil the transactional and communication roles identified in other implementation leadership models and studies. However, organisations should remain cognisant that the most effective levers available for internal implementation leaders may be their capacity for transformational leadership. Cultivating this capacity can help organisations navigate aspects of context and team characteristics known to pose non-trivial implementation challenges. Indeed, the QI collaborative context in which we examined leadership (an increasingly prevalent way to engage in healthcare improvement) may itself provide a valuable mechanism for cultivating this kind of transformational leadership within organisations.
Study limitations and future research
We acknowledge limitations associated with the active nature of the researchers in the analysis process—as described, we engaged in reflexivity and peer debriefing throughout the study. Other potential threats to trustworthiness associated with qualitative inquiry were reduced by triangulation of data collected from a range of stakeholders using multiple methods of data collection.
It is useful to briefly consider transferability of our findings to other care settings. Our study took place in 31 Canadian nursing homes. In these severely resource-constrained environments, the ways in which leaders influence complex QI intervention implementation may differ from better resourced, professionalised care settings. That said, empirical support exists regarding the benefits of transformational leadership in acute settings (for promoting positive work culture and improved patient outcomes).46 51 Ultimately, given anticipated growth in demand for nursing home care and human resource shortages in these settings, strengthening our understanding of how to successfully implement QI in nursing homes is itself an important phenomenon.
Future research might explore when transformational approaches may be particularly important—such as whether they are more advantageous in lower skilled settings or for change initiatives with any degree of complexity. Studies might also explore whether transformational leadership styles face unique challenges or are particularly well suited to settings with higher rates of cultural or linguistic diversity among staff. The field would also benefit from research on how to develop robust transformational leadership capacity—as noted above, there may be value in exploring whether and how QI collaboratives can help build such capacity.
Conclusions
There is growing recognition in the literature of the ‘Herculean’2 efforts required to bring about change in healthcare processes and systems. Leadership is recognised as a critical lever for the implementation of QI and other complex team-level interventions, although the processes by which leaders facilitate change are poorly understood. This study contributes knowledge regarding (1) the longitudinal, highly interpersonal and relational process of ‘how’ leadership influences the implementation of QI and other complex interventions, and (2) the limits to looking, in isolation, at the role of leadership in implementation given the complexity of healthcare organisations. Properly attending to the relational and sociocultural aspects of leadership may provide the kind of boost struggling healthcare systems need to achieve meaningful change and improvement.
Data availability statement
Data may be obtained from a third party and are not publicly available. The data used for this article are housed in the secure and confidential Health Research Data Repository (HRDR) in the Faculty of Nursing at the University of Alberta (https://www.ualberta.ca/nursing/research/supports-and-services/hrdr), in accordance with the health privacy legislation of participating TREC jurisdictions. These health privacy legislations and the ethics approvals covering TREC data do not allow public sharing or removal of completely disaggregated data from the HRDR, even if deidentified. The data were provided under specific data sharing agreements only for approved use by TREC within the HRDR. Where necessary, access to the HRDR to review the original source data may be granted to those who meet prespecified criteria for confidential access, available at request from the TREC data unit manager (https://trecresearch.ca/about/people), with the consent of the original data providers and the required privacy and ethical review bodies.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the Research Ethics Boards of the University of Alberta (Pro00000012517) and University of British Columbia (H14-03286). Operational approval was obtained from all included facilities as required. SCOPE sponsors and team members were asked for informed consent prior to taking part in the study. Participants gave informed consent to participate in the study before taking part.
References
Footnotes
X @adrianwagg
Contributors LG led the SCOPE leadership study. LG, LvD and WB defined the theoretical work to guide the deductive thematic analysis. LG, AE and AG developed the data analysis plan, conducted the analysis and interpreted the results. LG wrote the first draft of the manuscript and drafted all the figures and tables. LG, AE, AW, PGN and CAE developed the SCOPE process evaluation plan and materials and oversaw the data collections. CAE and AW were lead investigators of the SCOPE study. All authors reviewed, edited and approved the manuscript. LG is responsible for the overall content as the guarantor.
Funding Canadian Institutes of Health Research (PS 148582).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.