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.
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
Appendix A 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 Appendix. 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.
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.
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