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Clinical Leadership Strategies for Large-Scale Service Change in NHS England

This systematic review outlines methodologies and aims to extract, analyze, and synthesize clinical leadership strategies used to implement large-scale service change in NHS England. The research delves into scoping reviews, search strategies, screening processes, and critical appraisal tools employed to gather and assess relevant studies.

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Clinical Leadership Strategies for Large-Scale Service Change in NHS England

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  1. Clinical leadership strategies used to implement large-scale service change in NHS England Olivia Hartrick

  2. Systematic review methodologies • Systematic reviews aim to provide a comprehensive, unbiased synthesis of many relevant studies in a single document using rigorous and transparent methods. • Loads of options. JBI reviewer manual:

  3. Systematic methodology • The Joanna Briggs Institute (JBI) is a renowned international not-for-profit research and development organization within the Faculty of Health Sciences at the University of Adelaide. “We provide you with the best available evidence to inform your clinical decision-making at the point of care.”

  4. Scoping review • Definition • Map the key concepts underpinning a research area, as well as to clarify working definitions, and/or the conceptual boundaries of a topic (Arksey and O’Malley, 2005).  • Scoping reviews are useful for examining emerging evidence when it is still unclear what other questions can be posed. • Type of evidence • Encompasses all the evidence available which would answer the question. • Qualitative, quantitative etc.

  5. My Scoping Review

  6. Stage 1: Introduction and Rationale • Lit review to “find the gap” in the research • Rapid review style with a systematic search approach. • 17 primary research papers. • Systematic review research: little focus on leadership in change, more implementation tools, strategies, one type of change, international etc. • Justification of the methodology chosen • 1. 74% health and social sciences • 2. Range of studies • 3. Map key concepts • 4. Clarify working definitions • 5. Lots of primary research • 6. Rigour

  7. Aims & Objectives • The aim of this proposed study is to synthesise a report of the clinical leadership strategies which have been reported in NHS England to implement large-scale change. • The objectives of this proposed study are: • to examine and map the range of clinical leadership strategies found to be used in large-scale change within NHS England; and • to assess the quality of the relevant research. Research question: What are the clinical leadership strategies reported in large scale change within NHS England?

  8. Stage 2: Search strategy • PCC Framework • Population: NHS England • Concept: Clinical Leadership* • “A social influence process in which a person steers members of a group towards a goal” Bryman’s (1986) • Context: Large-scale Change* • spread across at least one geographical, • must deeply challenge current mental models or ways of thinking so much so there is evidence of resistance to the change, • coordinated change in at least two systems. (Mohrman et al. (1989) and Levy (1986) in Bevan et al., 2013).

  9. Stage 2 (cont’d) Search strategy • Terms • ((“NHS” OR “National Health Service” OR “UK” OR “United kingdom” OR “England” OR “Britain” OR “GB”) AND “Clinical Lead*” AND (“Change*” OR “Improve*”)) • Boolean operators • Search fields used • Thesaurus function • Databases searched • AMED, CINAHL, EMBASE, Medline, PsycINFO, Cochrane Library, Business Source Complete, Web of Science, HMIC and HBE. • Gray literature • Reference list screening • Hand search of journals • Relevant policy documents (King’s Fund)

  10. Stage 3: Screening • Inclusion criteria. • 1. Studies must outline an exploration of change and the clinical leadership strategies used; • 2. The change must impact two or more healthcare teams and have an impact on both clinical environments; • 3. Studies must be based in the healthcare environment in NHS England; • 4. Studies must explore a healthcare professional patient-facing population; • 5. Studies must be published 2005-2018 to reflect the current state of the topic. • Exclusion criteria • 1. Studies not published in English; • 2. Text and opinion literature. • 3. Studies without references.

  11. Rayyan • Duplicate screening • Title/abstract screening • Full-text screening (Long process) (Reference list screening) • Independent secondary reviewer 10% screening and % agreement • Expert opinion (meetings, emails, 5 papers reviewed)

  12. Stage 4: Critical Appraisal process • Although Peters et al. (2017) identified no need to assess quality as a scoping review criterion, quality assessment was employed to permit scope to suggest valid research recommendations. • JBI appraisal tools • Chosen after reviewing the literature on critical appraisal tools (Buccheri & Sharifi, 2017) • Use in evidence-based practice • Checklists for qualitative and systematic review research • The JBI Checklists were chosen over the CASP appraisal tools because these tools are only recommended to be used in an educational setting to develop critical appraisal skills.

  13. Stage 5: Data extraction • (Trial process + Template adjustment) • Refinement process • Tidying up the data extraction • Otherwise very complex to thematically analyse data

  14. Stage 6: Thematic analysis • Process in collaboration with supervisors to increase rigour. • Leadership behaviour • Implicit • Explicit • Characteristics • Strategies for system integration • Working across boundaries • Knowledge • Relationships • Leadership approaches • Where – System Leadership • Who – Distributed Leadership • Achieve what? – Transformational Leadership • Barriers to change • Change fatigue • Operational • Organisational culture • Information for change • Leader knowledge • Good measurements • Feedback

  15. Stage 7: Synthesis of results (write-up) • Numerical Summary • Study characteristics • 2011-2013 and based in the acute and community trust sectors. • Qualitative research methodology was the most common. • 20 studies had good or high methodological quality. • Initiative implementation, integration and reorganisation of services. • Map of Clinical leadership strategies • Narrative Summary • Descriptive and analytical summary of all evidence • This was merged with the discussion chapter of my dissertation

  16. Results

  17. Conclusions • Mapped the research base of clinical leadership reported in Large-scale change. • Close association to key leadership models (NHS Leadership model) • The common themes identified include strategies of explicit and implicit leadership behaviour and leadership characteristics. • Importance of relationships and across-boundary working in service integration. • The system leadership approach, dispersed and transformational leadership styles which facilitate implementation of large-scale change. • Organisational culture, change fatigue, staff resistance etc. which act as a barrier to successful change. • Leader knowledge, feedback, and good measurements of impact which facilitate large-scale change.

  18. Strengths & Limitations • Undefined boundaries of Large-scale change • Subjective nature of clinical leadership • The scoping review methodology has allowed this challenging topic to be explored in a systematically objective, transparent and rigorous manner. • Search terms and inclusion/exclusion criteria used were chosen after an exploration and establishment of a firm conceptual definition for the concepts of “clinical leadership” and “large-scale change”. • Secondary researcher and expert opinion. • Quality appraisal. • Thematic analysis is a systematic but subjective technique. • Research which explored the implementation of change do not routinely explore the effective clinical leadership strategies used in-depth limiting the possibility of new insights into this research field. • Unable to specifically identify when a large-scale change has been “completed”.

  19. Recommendations • More primary research of clinical leadership in large-scale change is suggested, with a focus on the community, mental health and commissioning sectors. • Further exploration into more robust conceptual definitions of “clinical leadership” and “large-scale change” – increase direction and depth. • Higher quality methodological approach • Future research into the specific role of clinicians to facilitate largescale change. • A further exploration into the concept of system leadership will inform clinical leadership decisions for integration. • Exploration into the effectiveness of leadership models and leadership approaches in large-scale change which have been presented in the field is suggested.

  20. Personal Results… • MSc • Lots of knowledge • Lots of evidence-based reviewing skills • Contribution to the research field…

  21. Questions?

  22. References • Bevan, H., Pisek, P., & Winstanley, L. (2013). Part 1: Leading large scale change: A practical guide. NHS Academy for Large Scale Change. NHS Institute for Innovation and Improvement, 17-21. • Bryman, A. (1986). Leadership and Corporate Culture. Management Decision, 24(6), 50-53. • JBI. (2017a). Critical Appraisal Tools. Retrieved 26/05/2018 from: http://joannabriggs.org/research/critical-appraisal-tools.html. JBI. (2017b). About Us. Retrieved 26/05/2018 from: http://joannabriggs.org/about.html. • Kaplan, H. C., Brady, P. W., Dritz, M. C., Hooper, D. K., Linam, W. M., Froehle, C. M., & Margolis, P. (2010). The influence of context on quality improvement success in health care: a systematic review of the literature. The Milbank Quarterly, 88, 500559. • Kelly, N., Blake, S., & Plunkett, A. (2016). Learning from excellence in healthcare: a new approach to incident reporting. Archives of Disease in Childhood, 101, 788791. • Levy, A. (1986). ‘Second-order planned change: definitions and conceptualizations’. Org. Dynamics, 15, 5-20. • Pham, M., Rajić, A., Greig, J., Sargeant, J., Papadopoulos, A., & McEwen, S. (2014). A scoping review of scoping reviews: advancing the approach and enhancing the consistency. Research Synthesis Methods, 5(4), 371-385. • Mohrman, A., Mohrman, S., Ledford Jr., G., Cummings, T., & Lawler III., E. (1989). Large-Scale Organizational Change. San Francisco, Jossey-Bass. • Peters L. D., Johnston, W. J., Pressey, A. D., & Kendrick, T. (2010). Collaboration and collective learning: networks as learning organisations. Journal of Business and Industrial Marketing, 25(6), 478-484. • Peters, M. D. J., Godfrey, C., McInerney, P., Baldini, Soares, C., Khalil, H., & Parker, D. (2017). Chapter 11: Scoping Reviews. In: Aromataris, E., Munn, Z., (Editors). Joanna Briggs Institute Reviewer's Manual. The Joanna Briggs Institute. Retrieved 24/12/2017 from https://reviewersmanual.joannabriggs.org/. • Pham, M., Rajić, A., Greig, J., Sargeant, J., Papadopoulos, A., & McEwen, S. (2014). A scoping review of scoping reviews: advancing the approach and enhancing the consistency. Research Synthesis Methods, 5(4), 371-385.

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