van Diggele et al.

BMC Medical Education 2020, 20(Suppl 2):456

https://doi.org/10.1186/s12909-020-02288-x

REVIEW Open Access

Leadership in healthcare education

Christie van Diggele1,2*, Annette Burgess2,3, Chris Roberts2,3 and Craig Mellis4

Abstract
Effective leadership is a complex and highly valued component of healthcare education, increasingly recognised as
essential to the delivery of high standards of education, research and clinical practice. To meet the needs of
healthcare in the twenty-first century, competent leaders will be increasingly important across all health professions,
including allied health, nursing, pharmacy, dentistry, and medicine. Consequently, incorporation of leadership
training and development should be part of all health professional curricula. A new type of leader is emerging: one
who role models the balance between autonomy and accountability, emphasises teamwork, and focuses on
improving patient outcomes. Healthcare education leaders are required to work effectively and collaboratively
across discipline and organisational boundaries, where titles are not always linked to leadership roles. This paper
briefly considers the current theories of leadership, and explores leadership skills and roles within the context of
healthcare education.
Keywords: Leadership, Leadership theory, Teamwork, Role models, Management, Organisational goals

Background education should not rely on formal positions of author-

Leadership has many interpretations, and has been lik- ity, but instead, utilise their own appropriate leadership
ened to “the abominable snowman whose footprints are qualities irrespective of their level within the organisa-
everywhere but who is nowhere to be seen” [1]. It is an in- tion [3]. A new type of leader is emerging: one who role
fluential process, through which groups of people work models the balance between autonomy and accountabil-
towards the achievement of a common goal [2]. Leaders ity, emphasises teamwork, and focuses on improving
have the ability to shape and influence their followers’ patient outcomes [3]. This paper briefly considers the
values, attitudes and behaviours through a dyadic rela- theories of leadership, and explores leadership skills and
tionship. They are able to gain and enlist the support of roles within the context of healthcare education.
others in order to achieve shared goals [3, 4]. Effective
leadership is a complex and highly valued component of
healthcare education, increasingly recognised as essential Management versus leadership
to the delivery of high standards of education, research Management and leadership are considered just as important
and clinical practice [3]. In order to achieve more effect- as each other in accomplishing organisational goals. How-
ive outcomes, leadership and management skills are now ever, there are differences in the functions of the two roles.
an expectation and requirement in the healthcare educa- Management produces order and consistency, while leader-
tion setting [5]. However, leaders within healthcare ship produces change and movement [2]. Management has
the responsibility of organising all elements within the organ-
isation, so that the leader’s vision and goals are successfully
* Correspondence: Christie.vandiggele@sydney.edu.au
1
The University of Sydney, Faculty of Medicine and Health, The University of achieved. If poor management is in place, then goals cannot
Sydney, Edward Ford Building A27, Sydney, NSW 2006, Australia be achieved; and if poor leadership is in place, then there is
2
The University of Sydney, Faculty of Medicine and Health, Sydney Health no clear goal or vision to work towards. Leadership is seen as
Professional Education Research Network, The University of Sydney, Sydney,
Australia “setting direction, influencing others and managing change:
Full list of author information is available at the end of the article with management concerned with the marshalling and
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van Diggele et al. BMC Medical Education 2020, 20(Suppl 2):456 Page 2 of 6

organisation of resources and maintaining stability” [6]. Transformational leadership

These differences are summarised in Table 1 [6, 7]. Since the introduction of transformational leadership, the
concept of leadership has undergone a major shift from
representing an authoritative relationship (transactional), to a
Transactional and transformational leadership process of influencing individuals (transformational). Trans-
Leadership is a social construct, and there are many different formational leadership involves leadership through the trans-
leadership models [6]. Two broad types of leadership are formation of individuals or ‘followers’, to work towards a
identifiable: “transactional” and “transformational”. And their common organisational goal [9–11]. This contemporary
respective features are a useful way to think about the many form of leadership is based on inspiring individuals, and
types of leadership. Transactional and transformational lead- forming teams to achieve goals. Transformational leaders de-
ership models are normally amalgamated within organisa- fine organisations through the articulation of a clear vision
tions to “empower others” (transformational) while holding and clear values. The four “I”s of transformational leadership
individuals “accountable” (transactional) for their actions [7– are outlined in Table 2 [9].
9]. While it is clear that both transformational and transac-
tional leadership paradigms are needed for an organisation Team leadership
to be effective, the optimal leader predominantly practices More recently, the focus has shifted towards “team lead-
the transformational aspects of leadership, rather than trans- ership”, with distributed leadership becoming more
actional [10]. prevalent within healthcare education, where different
professions share influence [12, 13]. Increasingly, leader-
ship involves a collaborative role, with an emphasis on
Transactional leadership shared leadership and thoughtful allocation of responsi-
The transactional model is seen as an authoritative rela- bilities. Team-based organisations shift central control
tionship that is transaction based, where exchanges from the one leader, to the team. Teams are comprised
occur between a leader and follower, once specific goals of members who are interdependent, needing to coord-
are identified or decided upon. Transactional leaders inate their activities in order to accomplish their shared
value order and structure, and have formal authority, goals [14, 15]. Personal autonomy, accountability, appro-
with positions of responsibility within organisations. priate recognition, and clarity of roles, are all elements
They achieve organisational goals through a rewards sys- that contribute to optimal team performance. However,
tem and through positive reinforcement. A weakness of to ensure success, the organisational culture needs to
this model is the lack of innovation, as individuals are support the involvement of individuals in these teams,
driven by predetermined outcomes, and there is lack of and encourage leadership qualities [15]. Teams often fail
incentive and motivation to perform beyond what is when they exist in a traditional authority structure,
expected [6]. where organisational culture is not supportive of collab-
orative work, and lower level decision making. Distrib-
Table 1 Leadership versus Management (adapted from
uted leadership entails sharing of influence by team
Swanwick & McKimm, 2011) [6] members, who step forward, or take a step back as
Leadership Management
needed. Leadership is provided by the person who meets
the specific needs of the team at the time, hence provid-
● Establishes direction ● Plan and Budget
ing faster responses to more complex issues in today’s
- Creates a shared vision - Resource allocation
organisations [15–17]. Effective leaders have an
- Identifies the bigger picture - Time management and process
steps Table 2 The four “I”s of transformational leadership (adapted
- Sets goals and strategies in - Establish agendas from Bass & Aviolo, 1994) [9]
place
Idealised influence
● Connecting people ● Employment and organising
Pride, respect and trust is stimulated through the development of a
- Communication of goals - Maintain structure vision
- Team building and networking - Staffing placements Inspirational motivation
- Aims for commitment - Enforce rules and procedures High expectations are created through role modelling
● Motivate and Drive ● Control and Problem solve Individualised consideration
- Inspire and motivate - Reward systems Respect and responsibility is fostered through personal attention to
followers
- Empower followers - Identifies problems
Intellectual stimulation
- Identify and work towards - Solves problems/takes corrective
needs actions New ideas and approaches are used to challenge followers
van Diggele et al. BMC Medical Education 2020, 20(Suppl 2):456 Page 3 of 6

understanding of the conditions needed for teams to Clear

function well. For a team to achieve its potential, the op-  Communicate with clarity of your purpose and the
erational roles of its members should be matched to role of others
their members’ abilities [18]. Belbin (1991) classified
nine roles of team members that contribute to its Stimulating
process and function [19], outlined in Table 3. Import-  Deliver messages in a powerful, inspiring and
antly, within team leadership, no single team role should dramatic way
be regarded as more important than another. Successful
teams thrive on their diversity, drawing from the Congruent
strengths of each member [13].  Lead by example and walk the talk

Effective leadership Include active listening

Leaders need to have good time management and organ-  Acknowledge what has been communicated, and use
isational skills, the ability to network professionally, dis- questioning skills
play political nous and most importantly, they need to  Show that you value others and their contributions
have strong communication skills [4, 20, 21]. Ready ac-
ceptance of feedback and self-awareness are important Challenges for leaders in healthcare education
in development of leadership skills [20, 21]. Behaviour, There are a number of unique challenges in healthcare
habits and biases can be deliberately corrected by utilis- education. Healthcare education is delivered across pro-
ing received feedback. Although there is not one set of fessional disciplines, and notably, across organisational
qualities that apply to being an effective leader, certain boundaries, involving universities, hospitals, and health-
competencies are valued and contribute to the leader- care services. In turn, these organisations are bound by
ship model in different ways [5]. Leadership competen- their own systems, structures, policies, cultures and
cies relevant for all health professional educators are values. At some point, most leaders in healthcare educa-
outlined in Table 4 [3]. tion need to make a decision about their leadership dir-
ection, and whether it lies predominantly in higher
Language of leadership education or the clinical setting; and whether it lies in
Just as education and healthcare organisations have undergraduate education or postgraduate education. It
evolved, so too has the team leader. The role of the can be difficult to merge roles between organisations,
modern leader reinforces the tenets of stepping forward, and McKimm (2004) has identified a number of issues
collaborating and contributing. This role involves en- and challenges specific to health education leaders,
couraging others by practising followership, and lending outlined in Table 5 [22, 23]. Throughout a career, it may
meaningful support to other leaders. As already stated, be necessary to maintain an awareness of available oppor-
when it comes to leadership, excellent communication tunities within organisations, and match these to the
skills are a must. In order for successful communication required experiences and capabilities [22, 23] (see Fig. 1).
to occur, both the sender and receiver must understand
the message. This means that active listening is just as Development of leadership skills
important as active talking [22]. Language used needs to Workforce data indicates that many experienced clini-
be [22]: cians and healthcare educators will retire over the next
Table 3 Roles of team members that contribute to its process and function (adapted from Belbin, 1991) [19]
ROLE DESCRIPTION
Plant: the ‘ideas’ person Thoughtful and creative, but may lack communication skills, and attention to required detail.
Co-ordinator: the ‘chairperson’ Co-ordinates the work, rather than undertaking the work. Involves all team-members, and mediates discussion.
Monitor evaluator: the ‘critic’ Objectively evaluates everything, and may be perceived as negative.
Implementer: the ‘doer’ A reliable worker who puts the ideas into action, although they may lack flexibility.
Completer finisher: the ‘details’ Is conscientious in completing the job, and pays attention to detail.
person
Resource investigator: the Sources information and resources, acts as the group’s ‘ambassador’, although enthusiasm may fade during
‘networker’ the project.
Shaper: the ‘driver’ Keeps the project moving, enjoys the action, but can upset others as they push through the ideas.
Teamworker: the ‘peacemaker’ Assists with diplomacy and helps keep the team working effectively, although they can be indecisive.
Specialist: the ‘expert’ Provides expert knowledge, although their input may be restricted to their own specialised area.
van Diggele et al. BMC Medical Education 2020, 20(Suppl 2):456 Page 4 of 6

Table 4 Leadership competencies for health professional nurtured and supported by the organisations in which
educators (adapted from Oates, 2012) [3] they are educated, train and work [6]. As a learned skill,
Knowledge of leadership concepts the topic of leadership is gathering momentum as a key
• This includes theoretical background, organisational structure, and curriculum area. Leadership development, assessment
leadership development of others. and feedback are necessary throughout the education
Motivator, mentor and facilitator and training of health professionals. Aspiring and
• Integrity should be shown in motivating and encouraging others current leaders can be identified, trained and assessed
instead of controlling situations. through formal leadership development programs, and
• Through excellence in role modelling, and careful delegation, future through supportive organisational cultures. This requires
leaders are developed, and succession planning can occur. embedding leadership training programs, opportunities
Communicator for leadership practice, and promotion of professional
• Good communication entails consistent messages through various networks within and beyond the organisation. The im-
methods over time. portance of mentorship within healthcare education is
• Communication by leaders is required at all levels: to senior well recognised, offering a means to further enhance
management, administrators, team members, and to patients. leadership and engagement within the workforce [28].
• Communication should always be respectful, and acknowledge the While many are assigned as leaders through their job
input and achievements of others. title, it is important to identify, support and develop
• Networking, facilitating groups, effective listening and feedback skills. emerging leaders [2]. Leadership consists of a learnable
Ability to set direction and lead change set of practices and skills that can be developed by read-
• Understand the environment, set goals, change management, decision ing literature and attending leadership courses [29].
making. Additionally, investment in the social capital of organisa-
Leadership presence tions, fostering interprofessional learning and communi-
cation in the work setting, and collaboration across
• The ability to assume a leadership role in various settings, share your
opinion with confidence, and communicate and engage with others. organisations assists in leadership development. Devel-
Team leader, team player, team-building oping leadership skills is a life-long process [21]. Re-
sources and opportunities should be considered to assist
• A good leader is not only a team leader, but also a team player, who
values and seeks the opinions of others. in the development of leadership skills. Some examples
• Leaders are involved in teaching, coaching and mentoring, holding
include:
team members accountable, and undertaking performance appraisals.
• Conflict resolution skills are needed in leadership roles. The views and  Reading about leadership e.g. theories on leadership
abilities of all parties should be respected. styles
• Group problem-solving, conflict management, contributions to team  Attending leadership training workshops
processes and development.
Healthcare education research skills
• Although time may not permit involvement in educational research, a Table 5 Issues and challenges of health education leaders
good leader will have the ability to critically appraise research, and an (adapted from McKimm, 2004) [22, 23]
understanding of the value of research. Personal issues
Business skills • It can be difficult to maintain an appropriate work-life balance, particu-
• Human Resource management, work flow, budgeting, effectiveness larly for those with family responsibilities.
evaluation, business plan development. • Managing both clinical and academic careers is difficult.
• Reduction of waste and inefficiencies. Organisational and cultural issues
• Financial management skills, including resource allocation, reduction in • In order to succeed, leaders need to understand the culture of their
variation of clinical practice to reduce costs, and increase provisions for own organisation.
clinical care.
• Some healthcare disciplines may better facilitate the demands of both
Self-management clinical and academic life.
• Time management, work-life balance. Balancing competing agendas
Ability to develop others • Dual demands of the higher education sector, which is highly
• Coaching, motivating, interpersonal effectiveness. accountable, and healthcare systems, with rapid change, may be
stressful for healthcare education leaders.
The wider agenda
ten years [24, 25]. The need for effective succession • Education leaders need to have an awareness of the wider healthcare
planning and leadership training is well recognised [25– and education agendas, and help drive new issues, such as
27], with a current shortage of emerging leaders moving interprofessional learning and collaboration. They need to help
promote diversity and innovation in leadership.
into leadership roles. Effective leaders need to be
van Diggele et al. BMC Medical Education 2020, 20(Suppl 2):456 Page 5 of 6

Fig. 1 Reflection task

 Participating in mentorship programs either as organisational boundaries, where titles are not always
mentee or mentor linked to leadership roles, but may occur in everyday
 Joining small group seminars on leadership work. Good leadership also means knowing when,
development and how to support others in their endeavours.
 Accepting more responsibilities when required, or Provision of opportunities for leadership development
when opportunities arise. is crucial in improving education sectors and health
services, and effecting change. The future belongs to
Process for effective leadership healthcare education leaders who demonstrate excel-
A title is not required to enable effective leadership. lence in teamwork, clinical skills, patient centred care
Leadership may occur in everyday work, and occurs in [3], and responsibly balance accountability with
collaboration with other professionals within the educa- autonomy.
tion and healthcare systems. For example, leadership in
teaching, administration, research, and/or excellence in Take-home message
clinical practice.
Leadership roles include the important concept of • Titles are not always linked to leadership roles.
management of both personal and professional practice. • The role of today’s leader requires stepping forward, collaborating and
contributing.
Priorities need to be set and time managed to integrate • A good leader is a good team player who values and seeks the
work and personal life. Tools can be used to stay orga- opinions of others.
nised, and deliberately manage busy schedules. Effective • Leadership requires clear, respectful communication that
acknowledges the input and achievements of others.
delegation may be used to share the work of new
projects:
Abbreviation
HR: Human Resources
 Organisation to ensure an understanding of tasks,
priorities and deadlines Acknowledgements
 Establish steps and a sequence to achieve the desired Not applicable.

outcomes About this supplement

 List required resources, considering the This article has been published as part of BMC Medical Education Volume 20
competencies of individual team members, and Supplement 2, 2020: Peer Teacher Training in health professional education.
The full contents of the supplement are available online at URL. https://
match tasks appropriately (also consider skill bmcmedicaleducation.biomedcentral.com/articles/supplements/volume-20-
development needs) supplement-2.
 Communicate with team members, monitor
Authors’ contributions
progress in activities and provide guidance to team CVD, AB and CM contributed to the drafting, and critical review of the
members. manuscript. CR contributed to the critical review of the manuscript. All
authors read and reviewed the final version of the manuscript.

Conclusion Funding
Leadership competencies, and the incorporation of No funding was received.
leadership development as part of curricula, are iden-
Availability of data and materials
tified as important across all health professions, in- Not applicable.
cluding allied health, nursing, pharmacy, dentistry,
and medicine, in meeting the needs of healthcare in Ethics approval and consent to participate
Not applicable.
the twenty-first century [30]. With an increase in in-
terprofessional teams and an emphasis on collabor- Consent for publication
ation, more effective outcomes are achieved [5]. Not applicable.

Healthcare education leaders are required to work ef- Competing interests

fectively and collaboratively across discipline and The authors have no competing interests to declare.
van Diggele et al. BMC Medical Education 2020, 20(Suppl 2):456 Page 6 of 6

Author details 27. Matthews JH, Morley GL, Crossley E, Bhanderi S. Teaching leadership: the
1
The University of Sydney, Faculty of Medicine and Health, The University of medical student society model. Clin Teach. 2017;15:2.
Sydney, Edward Ford Building A27, Sydney, NSW 2006, Australia. 2The 28. Burgess A, van Diggele C, Mellis C. Mentorship in the health professions: a
University of Sydney, Faculty of Medicine and Health, Sydney Health review. Clin Teach. 2018;14:1–6.
Professional Education Research Network, The University of Sydney, Sydney, 29. Burgess A, Dornan T, Clarke A, Menezes A, Mellis C. Peer tutoring in a
Australia. 3The University of Sydney, Faculty of Medicine and Health, Sydney medical school: perceptions of tutors and tutees. BMC Medical Education.
Medical School – Education Office, The University of Sydney, Sydney, 2016;16:85.
Australia. 4The University of Sydney, Faculty of Medicine and Health, Sydney 30. Druker PF. What makes an effective executive? Harv Bus Rev. 2004;82(6):58–
Medical School – Central Clinical School, The University of Sydney, Sydney, 63 136.
Australia.

Published: 3 December 2020 Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in
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