The Problems of Surgical Leadership

Introduction

The presented paper offers a literature review and evidence synthesis for a proposal that targets the problems of surgical leadership (SRL), team performance, and shared leadership (SL) in surgical settings. There is very little information about SRL, even though it is acknowledged as a critical element of providing high-quality surgical services (Barling, Akers, & Beiko, 2017; D’Innocenzo, Mathieu, & Kukenberger, 2016). There are many opportunities for employing leadership to enhance the work of surgical teams (D’Innocenzo et al., 2016). SL has been evidenced to produce multiple positive effects in healthcare teams (Aufegger, Shariq, Bicknell, Ashrafian, & Darzi, 2019; Wu, Cormican, & Chen, 2018), but its use in surgical settings is not covered in recent research. Thus, the discussed problem is the difficulty of establishing a performance-enhancing leadership in surgical settings, which is evidenced by the lack of research on it (Bass, 2019; D’Innocenzo et al., 2016), and the proposed innovation is SL, which is evidenced to have positive effects on team performance (D’Innocenzo et al., 2016; Fausing, Joensson, Lewandowski, & Bligh, 2015), and which is meant to be introduced through SL training.

Based on the presented information, PICOT questions have been established.

  • PICOT 1: in a surgical unit team (P), does an SL training (I) improve critical team performance (O) as compared to pre-training data (C) over four weeks before and after the training (T)?
  • PICOT 2: in a surgical unit team (P), does SL training (I) improve SL score (O) as compared to pre-training outcomes (C) four weeks after the training (T)?

Background/Significance

The primary issue that is being addressed by the present research is that there is little evidence on how to lead surgical teams (Barling et al., 2017; Hu et al., 2016). While multiple studies suggest that SRL can have very diverse and critical outcomes for surgical team performance, including its efficiency and positive behaviors (Barling et al., 2017; Hu et al., 2016; Stone et al., 2017), the research on the matter is scarce, especially when individual types of leadership are considered (Hu et al., 2016). Given that some of the positive outcomes of SL include team performance (D’Innocenzo et al., 2016; Fausing et al., 2015; Sousa & Dierendonck, 2016), it is reasonable to introduce elements of SL into the work of a surgical unit team and evaluate the outcomes as related to the effectiveness of the intervention at improving SL score and advancing team performance.

Search Strategy

Table 1 presents the updated information about the databases and numbers of studies that had been found at every stage.

Database Search Number Search Results
PubMed 1 (shared leadership[Title]) AND surgery[Title] 0
2 (shared leadership[Title]) AND surgery 1
3 (shared leadership) AND (surgery OR surgical) 104
4 (“shared leadership”) AND (surgery OR surgical) + Past five years 4
5 (“shared leadership”) + Past five years 70
6 (“shared leadership”) + (effectiveness OR outcomes) + Past five years 30
7 (“shared leadership”) AND training AND surgery + Past five years 0
8 (“shared leadership”) AND training 22
“surgical leadership” + Past five years 30
PMC 9 (“shared leadership”) AND (surgery OR surgical) + Past five years 81
10 (“shared leadership”) + (effectiveness OR outcomes) + Past five years 319
11 (“shared leadership”) AND training AND surgery + Past five years 75
12 (“shared leadership”) AND training+ Past five years 313
“surgical leadership” + Past five years 53
Google Scholar 13 (“shared leadership”) AND (surgery OR surgical) + Past five years 1,080
14 (“shared leadership”) + (effectiveness OR outcomes) + Past five years 14100
15 (“shared leadership”) + (effectiveness OR outcomes) + Past five years 31
16 allintitle: “shared leadership” training + since 2014 23
17 allintitle: “shared leadership” (outcomes OR effectiveness) + since 2014 44
18 allintitle: “shared leadership” (surgery OR surgical) 0
“surgical leadership” + Past five years 374
Conclusion. One of the articles from search 4 is relevant, and some of the results from other searches are relatively relevant.
Table 1: Search Strategy and Results.

The goal of the search was to collect 15 articles that would cover the problem and intervention. The search was carried out repeatedly as a greater understanding of the project’s goal was being achieved. As a result, two additional articles were added during the final search for a total of 17; the final articles were found after looking for sources that would cover the topic of any SRL. Before that, the keywords included SL, training, effectiveness, outcomes, surgery, and surgical. At first, the keywords were combined to find the most relevant articles, but eventually, due to the lack of very relevant research, adjacent topics were explored. For example, the effectiveness of SL in surgical settings was substituted with the effectiveness of SL in any setting.

Three databases were searched; the first search was carried out in PubMed, but it failed to produce a sufficient number of articles. Then, PMC was also introduced, and it also failed to offer enough relevant information. Finally, Google was used to search for non-medical literature to complement the medical sources that were not very numerous. Only recent articles were included (from 2014), and the search was geared toward finding original research and systematic reviews or meta-analyses. These criteria were introduced to fit the requirements and improve the quality of collected evidence since the named types of research belong to the highest levels of it (Polit & Beck, 2017).

Literature Review and Synthesis of Evidence

Evidence Matrix contains the modified evidence matrix from the previous task, which can be used to gain some basic knowledge about the articles that will be reviewed in this section (Garrard, 2011). Table 2 includes the new entries in that Evidence Matrix. All of these articles can be divided into two subsections; the articles that consider SRL and the articles that discuss SL. Thus, the literature covers the problem and proposed innovation, which it was meant to reflect.

Author, Year, Title, Journal Purpose Design Sample Level Contribution
Hu, Y. Y., Parker, S. H., Lipsitz, S. R., Arriaga, A. F., Peyre, S. E., Corso, K. A.,… Greenberg, C. C. (2016). Surgeons’ leadership styles and team behavior in the operating room. Journal of the American College of Surgeons, 222(1), 41-51. doi: 10.1016/j.jamcollsurg.2015.09.013 To examine the impact of transactional and transformational leadership in surgical settings Observational study 5 complex operations IV Transformational leadership was associated with more information sharing in teams and more support and less poor behaviors in leaders. Little research on SRL; no mentioning of SL
Stone, J., Aveling, E., Frean, M., Shields, M., Wright, C., & Gino, F. et al. (2017). Effective leadership of surgical teams: A mixed methods study of surgeon behaviors and functions. The Annals of Thoracic Surgery, 104(2), 530-537. doi: 10.1016/j.athoracsur.2017.01.021 To determine the types of leadership that support teamwork in surgical settings Mixed methods (observation, survey, and interviews) 7 surgeons and 116 surgical team members IV Positive perceptions for multiple positive activities, especially facilitating collaboration, consultation, support, inquiry, and politeness; negative perceptions for negative tone setting and criticism
Table 2: New Entries in the Evidence Matrix.

SRL has not been studied very extensively, and it is barely represented in the literature, as is stated by the authors reviewed in this evidence synthesis (Barling et al., 2017; Hu et al., 2016; Stone et al., 2017). During this search, three individual observational and mixed-methods studies have been discovered. One of them had a very small sample size (5 operations) (Hu et al., 2016). That by Barling et al. (2017) had a sample of 150 operations, and Stone et al. (2017) involved individual surgeons (seven people) and team members (116 people). The articles demonstrated that the style and components of leadership (for example, positive and negative leadership behaviors) can have an impact on leadership effectiveness as measured by follower perceptions (Stone et al., 2017), efficiency (Barling et al., 2017), and positive behaviors in teams and leaders (Hu et al., 2016). Thus, the presented literature supports the idea that SRL is important, although the three articles use different approaches to determining its outcomes.

The articles on SL are more numerous, which enables their further classification. First, SL in healthcare settings is noteworthy since it is the closest topic to SL in surgical settings. Two such articles that are not included in the next groups have been identified. In a systematic review of 11 primary research studies, which were not limited to randomized controlled trials, Aufegger et al. (2019) demonstrated that in acute healthcare, SL is correlated with greater satisfaction and performance. Also, Forsyth and Mason (2017) asked 229 clinicians to determine their beliefs about leadership and found that SL was supported by those surveyed and that reported SL was associated with team identification. Thus, SL in healthcare has been represented in the literature, and it was be associated with positive outcomes.

With the lack of literature on healthcare SL that would fit the requirements of this search, non-medical SL literature was also introduced. This area is not underrepresented; ten articles were identified that fit into this section. D’Innocenzo et al. (2016) provided a meta-analysis of 50 studies, some of which were unpublished and unrelated to healthcare. The research showed, using a total sample of over 3,000 teams, that team performance and SL were related in a way that might be affected by task complexity, with simpler tasks demonstrating better correlations. Wang, Waldman, and Zhang (2014) also carried out a meta-analysis, which used a sample of over 3,400 people. It showed that SL was correlated with greater team effectiveness and that the relationship was modified by the type of leadership employed, with more novel types of leadership (not transactional) being more effective. Finally, Wu et al. (2018) offered a meta-analysis of over 3,000 teams, which focused on SL predictors and outcomes, as well as moderators. The findings suggested that SL was associated with heterogeneity and moderated by trust and interdependence; the outcomes included performance and improved attitudes. Overall, the meta-analyses show that SL is correlated, as well as may be the cause of, positive outcomes.

Two randomized controlled trials were also found for this section. They included the works by Serban and Roberts (2016) (n=120 students) and Xu, Chiu, and Treadway (2019) (team n=63). The former suggested that SL was produced by positive environments, as well as task similarity, and produced task satisfaction. The latter showed that SL and performance were related but faultlines in diversity were having a negative impact on both. In addition, Sun, Jie, Wang, Xue, and Liu (2016) presented the results of a randomized controlled trial and two correlational studies, in which SL was correlated with creativity. Furthermore, multiple correlational and observational studies showed that SL might be associated with improved planning and organization (Choi, Kim, & Kang, 2017), team performance (Fausing et al., 2015; Sousa & Dierendonck, 2016), and team integration. However, the relationships were found to be modified, for example, by team coordination and trust and predicted by empowerment and task interdependence (Fausing et al., 2015; Guenter et al., 2017). To summarize, diverse literature, including some very high-quality meta-analyses with large samples, indicates that SL can yield multiple benefits and provides some evidence on how to develop SL by paying attention to its predicting and moderating variables.

When the question of SL introduction is raised, SL training is a particularly important topic. A pre-post-test non-medical study by Tafvelin, Hasson, Holmström, and Schwarz (2018) showed that shared leadership training could be beneficial in terms of improving leadership skills in formal and informal leaders. Moreover, a healthcare-focused systematic review by Brún, O’Donovan, and McAuliffe (2019) aggregated 21 healthcare studies that considered different approaches to introducing SL. The settings were limited to the global north, subtypes of SL were included in the search, and few of the reviewed articles met all the standards for their respective methodology. Among the team training studies, one reported no effect, and one reported mixed effects, with the rest indicating moderate-to-good advancement of SL in the studied teams. Thus, some research suggests that SL training can be beneficial and should result in SL improvement, but further research could be beneficial.

To summarize, the review of relevant evidence finds multiple gaps in research, especially those that can be covered in part by the proposed study. However, the evidence also suggests that SRL is critical for surgery, and SL can be beneficial in healthcare and other settings. Therefore, the proposed intervention is evidence-based, and the described problem is important enough to address.

Evidence Matrix

Author, Year, Title, Journal Purpose Design Sample Level Contribution
Aufegger, L., Shariq, O., Bicknell, C., Ashrafian, H., & Darzi, A. (2019). Can shared leadership enhance clinical team management? A systematic review. Leadership in Health Services. To explore SL in acute healthcare and evaluate its benefits Systematic review Primary research of SL in acute care; 11 studies III Association of SL with increased satisfaction and performance; negatively associated with seniority
Barling, J., Akers, A., & Beiko, D. (2018). The impact of positive and negative intraoperative surgeons’ leadership behaviors on surgical team performance. The American Journal of Surgery. To examine the effects of surgeon leadership Observational 150 random operations IV Negative relationships between abusive leadership and psychological safety and efficiency. Over-controlling leadership associated with reduced efficiency. No direct SL focus, but the article covers SRL
Brún, A., O’Donovan, R., & McAuliffe, E. (2019). Interventions to develop collectivistic leadership in healthcare settings: A systematic review. BMC Health Services Research. To review existing literature on how to achieve SL Systematic review (observation and experiment) 21 healthcare studies III Mostly discusses the effectiveness of team training (11 studies). Suggests that interventions are likely to be successful but might fail; very heterogeneous in terms of methodology
Choi, S., Kim, K., & Kang, S. (2017). Effects of transformational and shared leadership styles on employees’ perception of team effectiveness. Social Behavior and Personality: An International Journal. To review the perceived effectiveness of SL and transformational leadership Correlational 424 Korean employees IV Different effectiveness outcomes correlate with different leadership styles. SL improves organizing and planning
D’Innocenzo, L., Mathieu, J., & Kukenberger, M. (2016). A meta-analysis of different forms of shared leadership–team performance relations. Journal of Management. To search for relationships between SL and performance Meta-analysis 50 published and unpublished studies (n=3,198) III Evidence of a relationship between team performance and SL; evidence of task complexity affecting the relationship. The article discusses SL in terms of surgery
Fausing, M., Joensson, T., Lewandowski, J., & Bligh, M. (2015). Antecedents of shared leadership: Empowering leadership and interdependence. Leadership & Organization Development Journal. To test a hypothesis about the predictors of SL Correlational 81 teams (Danish; manufacturing and knowledge) IV Empowering leadership are task interdependence were evidenced to predict SL; SL is correlated with team performance
Forsyth, C., & Mason, B. (2017). Shared leadership and group identification in healthcare: The leadership beliefs of clinicians working in interprofessional teams. Journal of Interprofessional Care. To explore leadership beliefs in healthcare professionals Survey and correlational 229 healthcare workers IV Support for SL among healthcare professionals; professional and team identification associated with SL
Guenter, H., Gardner, W., Davis McCauley, K., Randolph-Seng, B., & Prabhu, V. (2017). Shared authentic leadership in research teams: Testing a multiple mediation model. Small Group Research, 48(6). To determine mediators in the relationship between SL and various outcomes in research teams Survey-based correlational study 142 research teams IV Team coordination mediates the relationship between SL and effectiveness; also, trust and shared mentality improve satisfaction but not publication success. Different aspects of SL and mediating variables can modify SL effects. Specific setting and type of SL, which is not surgery
Serban, A., & Roberts, A. (2016). Exploring antecedents and outcomes of shared leadership in a creative context: A mixed-methods approach. The Leadership Quarterly. To explore antecedents and outcomes of SL in creative task-based teams Mixed methods with experimental data 120 students II Indicates that SL causes task satisfaction and is caused by positive team environment and task cohesion. Small sample and specific task (creative teams), which is not surgery
Sousa, M., & Dierendonck, D. (2016). Introducing a short measure of shared servant leadership impacting team performance through team behavioral integration. Frontiers in Psychology. To study the impact of SL on team performance; to validate an SL measure 2 validation studies (round-robin); correlational methods 244 and 288 students (61 and 72 teams) IV The tool is validated; SL predicted team integration and, therefore, performance
Sun, X., Jie, Y., Wang, Y., Xue, G., & Liu, Y. (2016). Shared leadership improves team novelty: The mechanism and its boundary condition. Frontiers in Psychology. To examine the mechanism of SL affecting creativity 3 studies; correlational and experimental designs Chinese students (55 in 17 groups, 62 in 21 groups, 108 in 36 teams) II and IV The role of constructive controversy in enhancing creativity is indicated; SL relationship with creativity is supported
Tafvelin, S., Hasson, H., Holmström, S., & Schwarz, U. (2018). Are formal leaders the only ones benefitting from leadership training? A shared leadership perspective. Journal of Leadership & Organizational Studies. To determine effects of shared transformational leadership training Pre- and post-test study 20-day training for 74 Swedish pulp factory formal (47) and informal (27) leaders IV Improved leadership in both groups of leaders; formal leaders associated with improved well-being in employees, and informal – with efficiency
Wang, D., Waldman, D., & Zhang, Z. (2014). A meta-analysis of shared leadership and team effectiveness. Journal of Applied Psychology. To examine relationships between SL and team effectiveness. Correlational meta-analysis 42 samples (work and student teams; 3,439 people) III SL is associated with improved effectiveness; the relationship is stronger for novel (e.g., transformational) and all-team SL. The source is rather old (2014) and not healthcare-focused
Wu, Q., Cormican, K., & Chen, G. (2018). A meta-analysis of shared leadership: Antecedents, consequences, and moderators. Journal of Leadership & Organizational Studies. To explore the variables that are in a relationship with SL Meta-analysis (correlational) 40 studies of teams (over 3,000 teams) III Demonstrates SL predictors (heterogeneity, environment), outcomes (performance, attitudes), and moderators (trust, task interdependence). Very diverse teams
Xu, N., Chiu, C., & Treadway, D. (2019). Tensions between diversity and shared leadership: The role of team political skill. Small Group Research. To study relationships between SL, performance, and diversity Experiment 63 student teams II Diversity faultlines had negative effects on SL and performance; further provides evidence to the connection between SL and performance

References

Bass, B. (2019). Surgical leadership in changing times: The American College of Surgeons perspective. Innovative Surgical Sciences, 4(2), 75-83.

Garrard, J. (2011). Health sciences literature review made easy: The matrix method (3rd ed.). Sudbury, MA: Jones & Bartlett.

Polit, D.F., & Beck, C.T. (2017). Nursing research: Generating and assessing evidence for nursing practice (10th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.

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