Introduction

Health systems in the 21st century face increasing complexity. Technological advances, changing patient demographics and expectations, fiscal pressures, accelerated information flow, and health human resource challenges, among others, are increasing system complexity.1 Complex health systems require leaders who are agile and adaptive to dynamic environments. This paper explores the nuanced roles and career paths of health systems leaders within academic health centres (AHCs, clinical units that are affiliated with academic institutions/universities), where leaders typically have multiple identities. These may include professional identities as a clinician, administrator, researcher, educator, opinion leader, among many other professional (and personal) identities. Regardless of their professional identity, each person must engage in both leadership and followership (i.e. a phenomenon in which individuals support the leader through assuming responsibility for given objectives, serving the requests made of them, challenging the leader when appropriate, participating in organizational transformation, and taking moral action as needed2,3) in ever increasing complexity as they develop professionally. The LEADS in a Caring Environment framework (LEADS) was developed in 2006 to articulate and promote core leadership capabilities in healthcare.4,5 Today, the LEADS framework (or adapted versions) is one of the most popular leadership frameworks for health systems in Canada6,7with adoption in Australia8, Belgium9, India10, Israel5,11 and has strongly influenced the United Kingdom’s Faculty of Medical Leadership and Management’s certification standards.
In the complexities of AHCs, leaders who inhabit multiple roles may grapple with how to apply the LEADS capabilities across multiple roles. For example, an individual may have an executive role in hospital administration, serve as a clinical supervisor, and be a junior faculty member in an academic department. The LEADS framework helps leaders to understand the capabilities of leadership required within a defined system. It does not guide leaders navigating multiple roles, where seniority and complexity vary.
In matrix organizations,12 such as AHCs, there are at least two entities at play: a hospital and a university. Matrix organizations are interdependent organizations with separate cultures and systems that are connected by individuals who cross between groups, seeking to enact common outcomes across an organization. Based on its strategic and operational realities, each entity within an AHC has unique goals, values and priorities. Each enterprise also brings about different challenges and stakeholders. The interconnectedness of hospital systems and academic institutions within AHCs results in individuals holding multiple roles and, across these, multiple identities. Leaders working within each entity are often left to navigate competing needs, goals, values and perspectives.13 This is exemplified in different exhibited behaviors, leadership and management styles, trade-offs, and ways of thinking based on context. As individuals advance in their career, they are often challenged to develop both personally and professionally within leadership roles. The capacity to do so is variable between individuals. Prior work by Kegan and colleagues has described various ways in which individuals develop and assume various orders of consciousness, engage in constructive-development (despite an innate resistance to change), and create cultures that support all members of an organization.14–16 As such, academic health system leaders require flexible leadership models that address multiple identities across varying levels of seniority. This paper addresses this need by integrating LEADS with Kegan’s five levels of development.
The LEADS+ Development Model articulates leadership and followership practice when occupying multiple leadership roles. We highlight both the dynamics of leadership and followership. Afterall, without followership, leadership cannot exist.17,18 Four styles of engagement within an AHC are described: two followership styles (essential, strategic) and two leadership styles (role- and complexity-based). We propose that advanced leadership requires fluid shifts among leadership styles as appropriate for the given role, organization, time, and context.

Methods

A conceptual review19 was conducted to explore how a leader’s development interfaces with a leading healthcare leadership framework, the LEADS in a Caring Environment framework. Similar to the process used by Gottlieb and colleagues, sequential iterative cycles of divergent and convergent thinking were employed, exploring various vantage points and theories within the literature.20Ultimately, the perspectives of the authors coalesced into a singular conceptual framework.
The Team
Our study team was composed of two clinicians (JS, TMC, both with decanal positions in education leadership), one healthcare administrative leader (SR), one leadership and health entrepreneurship educator (SL), and a PhD scientist, who is one of the originators of theLEADS framework (GD).4,5 Throughout the process we empowered members of the team to challenge each other’s personal assumptions and interrogated our selections of theories to ensure that we remained reflexive about the literature reviewed.
Discussions Within the Analysis Team
A pilot review of various leadership frameworks and theories was conducted (by SR, SL, TMC). This formed the basis of initial discussions. The two most prominent frameworks were felt to be Kegan’s model of human development14 and the LEADS framework.4,5 These frameworks continued to inform our discussions, similar to how sensitizing concepts are incorporated in other qualitative methods.21
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We engaged in multiple rounds of discussions via videoconferencing with memo-generation and collaborative conceptual development using cloud-based, real-time interactive documents, each session lasting approximately one-hour in length.
Literature Review & Synthesis
After refining our initial model, we conducted a focused literature review. We drew from literature within health systems leadership, followership and organizational development, contrasting our own newly formulated conceptualization with other existing models. We engaged in iterative rounds of revisions. Ultimately, we coalesced our thinking into one conceptual model (see results section), which we refined through persona-driven testing (i.e. cognitive simulations with various types of simulated characters that were used to elucidate each role in various scenarios) and stakeholder consultation.22,23
Prototype and Persona-based testing of the model
Next, we simulated personas and stories to test and prototype our model.22–24 The resulting model with associated persona-driven vignettes were submitted to a representative sampling of health system stakeholders (clinicians, administrators, educators and researchers in healthcare leadership) for review. Feedback from stakeholder consultation was used to refine the model.
Stakeholder consultations
Similar to stakeholder consultations endorsed by scoping reviews25 and the Canadian Institutes of Health Research Knowledge Exchange process26, we sought formative feedback on our provisional concepts from a range of educators, experts, and frontline practitioners. This process has been used previously20. Our inclusion criteria were that the individual would meet one of the following criteria:
  1. Personal experience in blended leadership roles across two or more organizations/units;
  2. Supervised/led others who bridge across more than one role; or
  3. Actively engaged in teaching or scholarship about leadership training and development.
We excluded those who met the above criteria but had no experience within the North American leadership context. We constructed a simple survey tool with an embedded video (https://bit.ly/BridgeLEADsurvey) and requested that each stakeholder help us to identify the strengths, weaknesses, and relevance of the conceptual model to their own leadership-related practice. We subsequently met with each of the leaders for a one-on-one interview led by our senior author (TC) to gather feedback from those who volunteered to engage with us to provide further feedback. A thirty-minute, one-on-one Zoom interview (Zoom communications, Inc., San Jose, CA) was completed within a one-month span with any stakeholder who sought to provide verbal feedback about our model in addition to their survey responses.