Improving leadership in surgery

The NHS is paying increasing attention to leadership within clinical teams. Leadership training can be delivered in different ways, for example, to the team leader alone or to all team members. However, it is not clear which approaches work best. Researchers looked at leadership training for surgeons, and asked what makes training effective.

In this podcast, Helen Saul, Editor in Chief of NIHR Evidence, speaks with Amy Grove, Professor of Implementation Science and NIHR Advanced Fellow, University of Warwick; and Peter Hutchinson, Director of Clinical Research, Royal College of Surgeons of England. They discuss key elements of leadership training: feedback, personal characteristics and atmosphere.

Read a full transcript of the episode here.

The views and opinions expressed in this podcast are those of the host and guests and do not necessarily reflect those of the NIHR or the Department of Health and Social Care.

Transcript

[Music]

Helen Saul: Welcome to this podcast from the National Institute for Health and Care research, the NIHR. This episode is about leadership in surgery. 

The NHS is paying increasing attention to leadership within clinical teams, recognising that good leadership is at the heart of quality and safety within healthcare organisations. Surgical leaders need to develop effective teams; they have to understand the needs of patients, and inspire and manage their team to meet those needs.  

Leadership training can be delivered in different ways and it’s not clear which approaches work best. Today, we're discussing a study that teased out the elements of successful training. My name is Helen Saul and I'm the Editor in Chief of the NIHR Evidence website.

I have two guests with me today and I'll let you introduce yourselves. Welcome first of all to the author of the study, Amy 

Amy Grove: Hello I'm Amy Grove and I'm a professor at Warwick Medical School the University of Warwick so I'm a professor of implementation sciences but also a chartered psychologist. 

Helen Saul: Thank you, and Peter  

Peter Hutchinson: I'm Peter Hutchinson,  I'm director of clinical research at the Royal College of Surgeons of England and professor of neurosurgery at the University of Cambridge.  

Helen Saul: Thank you.  So - to set the scene Peter - why is leadership training important for surgeons?  

Peter Hutchinson: I think it's what important is one word but essential is another word. I think it's something that's absolutely critical in terms of your development as a surgeon throughout your career from becoming a junior surgeon right through to senior consultant level. Why is training important -  I think some people are quite good at it's slightly innate to them they're born with it. But in others, there's no doubt that it's a skill that can be improved with training.  Why do we need to do it? It's about bringing everybody together, leading the team, successful teamwork and everybody being cohesive for the benefit of patients.  

2.31

Helen Saul: Thank you and Amy, What makes a good surgical leader?   

Amy Grove: So from my point of view what makes a good leader in surgery is somebody who is acceptable to the surgical community. And what does that mean, well two things really, it's somebody who has integrity and I mean personal integrity to other surgeons, but also that they have technical surgical skills that are valued by people that work in surgery. So to be a leader, people need to know and see good leadership practice. 

3.06

Helen Saul: What prompted you to conduct your study? What did you want to achieve? 

3.12

Amy Grove: So this study we're talking about today is funded by the NIHR and it's looking at how we can advance leadership within surgery in particular.  So we conducted a realist review which is looking at all the evidence published about surgery, and also about leadership. And I conducted this review because the NHS, our healthcare systems, they give significant investment into leadership and surgical leadership training, and I was interested in seeing if we could understand, can we capture that return on investment? How do we know that what we're doing works? And I was also interested in understanding why we don't treat leadership development like any other intervention in health and social care services where we're examining whether it works, is it clinically effective? and we're also examining is it cost-effective? Does it offer value to the patients that we treat? That was the basis of the study that I undertook. 

4.10 

Helen Saul: Your analysis included 33 studies - from this, what did you find to be the essential elements - the pillars - of successful leadership training? 

Amy Grove: So what we found in performing our review of the published literature were three things that were effective for leadership development. One of them is feedback so how we give and receive feedback effectively. We've also got the characteristics of leadership and how it needs to be tailored to people, to individuals and also the atmosphere in which leadership is delivered. 

4.37

Helen Saul: Okay so if we start with the first pillar then: staff feedback. How can surgeons provide good quality constructive feedback? 

Amy Grove: So we found evidence to suggest that surgeons can provide constructive and good quality feedback to support leadership in a few different ways. 

So the first one is that it's timely. So feedback needs to be given, very close to an event and that might be a technical event or a leadership event. As long as the feedback is aligned to when that event happens, it's more effective. Feedback needs to be given on multiple occasions. So we're repeating the message consistently to people we’re feeding back to.  For feedback to be effective it needs to be given by a trusted and respected source: the person giving the feedback and receiving the feedback needs to view the other person as a credible person who has integrity within the field. 

Interestingly, we found that negative feedback, when somebody's done something wrong, this needs to be delivered in private, and I think that often doesn't happen in the NHS. When we think about things like trauma meetings, negative feedback takes place in an open forum. And also the seniority is important, giving and receiving feedback. So if you're giving feedback from a senior to a junior, or peer-to-peer so you imagine two consultants, that feedback can be given openly and directly. But when we're talking from a junior to a senior, it's more effective to give feedback anonymously which is interesting and I think talks to the hierarchy that we have within surgical training.

6.24

Helen Saul: Thank you Amy. Peter how much of what Amy has outlined happens in surgical practice and where would you see that we could make improvements?

6.34

Peter Hutchinson: Yeah that's a really good question. So I think the answer to that is, it's variable. If you look at feedback, I guess we can divide that into two types in practice. The first would be what we would call formal feedback and there are ways by which surgical trainees and consultants are assessed. So the trainees have their multisource feedback, procedure-based assessments, clinical-based assessments, 360 degree appraisals. 

But I thought what Amy said was really important about the timeliness of this. And often perhaps more informal feedback immediately after an event is probably more valuable and that's probably something we could do more of. Perhaps you could argue it should be done at the end of every operation, or every clinic interaction, and I think what's going to be helpful about progressing training is the way we do that. 

7.30

Peter Hutchinson: So how important is feedback in a constructive manner? That's how we give feedback and that can be taught. It's no good being very critical of people saying that was rubbish, that was poor, particularly in a public forum, and I absolutely appreciate Amy's finding that these things are best done in private. But there are good ways and bad ways to give feedback. And a good way to give feedback is to start by asking the other person what they thought was good. So that's something that we're trying to introduce: ‘What went well about that?’ and then ‘What would you do differently next time?’ 

I think they're very positive ways of doing that and that is beginning to be taught. It's taught through mentoring courses; it's very much part of the ATLS ethos of feedback. So we need to consider both the timing. I agree it should be done soon after an event. We need to look at the environment - it is best done in an open forum but there will be times when it's better done confidentially. But I think the way that you phrase feedback can be really really important in making it a positive experience, not just for the person receiving the feedback but also the person giving the feedback. 

8.44 

Helen Saul: Amy, there was also something about that feedback needed to be repeated?

Amy Grove: I think that the importance of repeating feedback it's that you are repeating a consistent message. When as Peter mentioned, trainees for example, when they're assessed it may be that it's a long period of time between assessment or they may have even rotated through different hospitals, and they get inconsistent messaging and inconsistent approaches to feedback. So having feedback that happens timely but also repeated across training, is more effective in terms of when we're thinking about leadership development. 

9.19

Helen Saul: Peter, I'm wondering whether you have any examples from your own career of constructive feedback either that you've given or received?

9.32

Peter Hutchinson: We've had a recent example of an operation that could have been done slightly differently. And I think that was a recent example where the operation could be performed in different ways. I had a personal view that it should be performed one way; the trainee thought it could be performed the other. I mean both were acceptable but you know I had my views, the trainee had their views, but I think by adopting this approach if you know ‘What are the options?’ That's the first thing to say. And then ‘Why did you go with that option? Have you considered this option?’ It's the way you phrase it but it's really important to respect their views and not make people feel belittled in any way, because I think that can knock confidence.

You know what we do is tough. It's a privilege to be able to operate on patients. It's not always easy, we need to get it right but when people are learning, you need to nurture them and look after them. We all have complications but help them deal with them and move on.

10.32

Helen Saul: OK - The second pillar of good leadership training came down to the personal characteristics of surgical leads, their mindset and their approach to training. So Amy, what did you find makes someone amenable to leadership training?

10.52

Amy Grove: So when we think about personal characteristics, we were exploring the aspects that are amenable. You know people are different and we can't expect different personalities to behave the same. And I don't think we should expect that of leadership training either. We should embrace the difference between different types of surgeons.

So what would be effective for me in terms of my leadership development and what would be effective for Peter for his, they will be different. So in our review we found that leadership interventions were shown to be more effective when they could be tailored and customised to different types of surgeons. So here we're talking about different specialties but also generational differences: what works for more senior surgeons, what works for more junior surgeons. And it's also important to conceptualise leadership like Peter talked about right up front as an essential component of surgery and that's quite important when we're talking about personal characteristics. It's having an understanding of confidence in technical surgical skills, that then you need to go on then and develop some leadership development and develop your approaches to leadership. 

What was interesting in the review is that leadership was more effective when somebody recognised or perceived that they had a deficit and that deficit-based model maybe because they believed themselves they had deficits in their leadership practice. But also when they received feedback from colleagues who maybe suggested this is an area where they could go and show more improvement.

12.30

Helen Saul: That's interesting that it's almost they had to be quite humble perhaps to get the most out of the training. Peter, what advice would you give to other surgeons about when to embark on training and how to approach it?

12.45

Peter Hutchinson: So my advice as to when to embark on leadership training should be as soon as possible. We talk about surgeons but there's no reason why this should not begin much earlier in your career, and for me, I think medical students should be taught leadership training. It's not something that's really on the curriculum that's addressed. So I think that would be well worth considering and a positive benefit for everyone. Perhaps you could argue that the earlier you start it, in some ways it may be easier, because you can as a medical student discuss it amongst your peers. But fundamentally starting early and continuing throughout your career is going to benefit you, your juniors and and probably also your seniors as well. We need to get across a culture of leadership and leadership training and it's not on the radar as much as it should be.

13.37

Helen Saul: Thank you. So Amy, you found that the final pillar of high quality surgical leadership training was the atmosphere in the training environment and the context in which the surgeon goes on to apply their learning. Could you say a little about why atmosphere and context are so important?

13.55

Amy Grove: So I think atmosphere was fundamental to effective leadership training really, it sort of underpinned the other two elements. It was important for both how leadership training is delivered, but also when we think about the receptive context of that training. So you can imagine if somebody goes under a period of leadership development, if they cannot then go and do what they have learned in practice, there's a disconnect between that. So the atmosphere in which leadership is taught and delivered needs to be supportive of that. 

But, I think touching on what Peter just said, when we think about atmosphere it brings in a bigger discussion about organisational culture, and we touched on that briefly in the review is that you know people need to be able to speak up, to be heard, to be listened to and that within training like I mentioned earlier one size doesn't fit all so ensuring that you create an atmosphere where differences are accepted is important to making these types of development programmes effective. 

15.06

Helen Saul: Thank you Amy - and Peter how can a surgical lead foster a speak up culture and a positive atmosphere?

15.14

Peter Hutchinson: So let's take an example of an operating theatre which is teamwork. There's a consultant surgeon there, but there's any members of the team and it's about making everybody feel part of that team and everybody having an important contribution to the success of that operation.

Let's look at some examples so when we're operating on the head as I do and the tumours on the left side or the right side we look at the scan. And we have to be absolutely sure that we're operating on the correct side and it's often very valuable to ask junior members of that team to look at the scan with you, confirm we're on the right side because then they feel really important part of that decision making process. Another example: the WHO checklist when we check the patient, the procedure, at the beginning of the operation, that everybody is happy and everybody feels able to speak up at that moment about what we're going to do. And fundamentally for me it's making everybody feel that they have an equal contribution.

When JFK went to visit NASA, he asked the cleaner what is her job was. The cleaner said ‘My job is to put a man on the moon’. At Old Trafford, the cleaner when Alex Ferguson said my job as the cleaner is to win the Premier League. So it's the job of everybody at whatever level they are in that room, to deliver a successful operation. It's not just about the surgery, it's about the surgeon and the team and that's where the leadership comes in. This operation would not happen without everybody so I think that if you can get that across, then it really does encourage this speak up culture because if people feel they're part of a team they'll be prepared to speak up. And I've been very grateful on many occasions where relatively junior people have said something and it's really important to give them the space and the time to speak up.

17:28

Helen Saul: Thank you. Amy, a lot of previous work has been on individual leadership rather than team leadership. I just wondered if you could outline what the difference is and why training as a team might be an effective way of improving leadership?

17.44

Amy Grove: You are right nearly all the investment we have at the minute in leadership within the health service within training surgeons is looking at training that individual person. And there's a real distinction that needs to be made about leaders being that heroic person at the top, and the process of leadership which, as Peter just hinted to, is a collective, a collaborative and a distributed activity across a surgical team.

So we need to move away from thinking about investing in the person, and instead we're investing in when we talk about leadership development, in a group of people who are delivering surgery for patients. It is really important to state again that surgery is not conducted in isolation so why do we train leadership in isolation? I think that's a really fundamental point that when we're commissioning these types of activities that we think about who is really benefiting from them 

18.44

Helen Saul: So Peter in practice would team training bring particular benefits if you have experience of it, or would you see it posing challenges practically?

18.50

Peter Hutchinson: No I think that pendulum is very heavily in favour of team training because it'll help us understand each other and the challenges that both the leader and people who are being led have to face. So for me team training will help in terms of more clearly defining roles and responsibilities, setting objectives, fundamentally streamlining care but also I think it'll help with managing conflict. I think if we're all learning together and we can see the challenges that each of us face, it's probably more valuable than doing it individually. 

19.30 

Helen Saul: Fantastic thank you well we can move on to our take-home messages. I'm wondering Peter first of all what advice would you give to somebody entering surgical training to make sure they get the most benefit from it?

19.46

Peter Hutchinson: So my advice would be for us all to lobby to get more leadership training but it doesn't need to be formal. Look at role models, look at people who are good at it and learn from them. You may well be learning and having leadership training without realising it. That may sound a bit crazy but there are good leaders out there and they can be really good role models so I would certainly advocate that.

The formal methods of feedback are important but why don't we at the end of every operation just say to one another: What went well? What could we do differently next time? Maybe that should be a formal part of the operation where we actually talk to each other about that as a formal step and that's not something that.. it's done but if there's some way that we could really encourage people to do that for every interaction, that would be really helpful. 

Helen Saul: Thank you. Amy, if you could change one thing about leadership training in the UK for surgeons, what would it be?

Amy Grove: It would fundamentally be what we're doing at the moment is to try and move it down the pipeline of surgical training. So people right from the beginning recognize that leadership and responsibility for leadership across a group, is essential to becoming both a good surgeon but also a surgical leader. I think you can be an outstanding surgeon and you can achieve excellent outcomes for patients, but that doesn't necessarily mean you're an excellent surgical leader or an excellent surgical educator. So these are discrete development activities that need to be honed and practised within services - that’d be one thing I'd love to change.

21.33

Helen Saul: Any final thoughts Peter?

Peter Hutchinson: I think what Amy said is really important: there are some amazing surgeons and very good surgery is done, but nobody lasts forever. So as critical as performing your individual practice to the highest of standard is, we have a duty to train the next generation of surgeons both in terms of their clinical practice, but also helping them develop their leadership skills to pass on to others.

Helen Saul: That’s a strong message to end this podcast, thank you Peter. 

We have discussed the essential elements of effective training. Feedback that is timely, repeated, consistent and constructive. Training that is tailored to the personal characteristics of the surgeon, according to their specialty and stage in their career. And a positive atmosphere for training, with opportunities afterwards for the surgical leader to apply their learning within a supportive working environment. 

Innovations to look out for, are training for the whole team - not just for the individual - and training that starts earlier, even at medical school.

This is an episode of the NIHR podcast. Huge thanks to Amy Grove and Peter Hutchinson for joining me today. I'm Helen Saul and thank you for listening. 

If you have any thoughts or comments on this or any other episodes, please contact us at evidence@NIHR.ac.uk or via our Channel on X - @NIHR Evidence. And do visit our website which is evidence.NIHR.ac.uk