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Clinical Scholars: Six Core Conclusions for Training Healthcare Professionals as Leaders Impacting Unbounded Systems

2021; Wiley; Volume: 15; Issue: 3 Linguagem: Inglês

10.1002/jls.21785

1935-262X

Claudia S. P. Fernandez, Giselle Corbie,

Health disparities and outcomes

In his work, The Infinite Game, Sinek (2019) described leadership for “unbounded systems”: a model that requires leaders to embrace a “just cause,” show courageous leadership, actively create trust, and work from a flexible playbook as they interact with an often-evolving cast of stakeholders. “Infinite games” themselves are characterized by constantly evolving contexts and a need for continually developing leaders to meet the emerging challenges. For decades, the United States has been playing, and losing at a high-stakes infinite game (Carse, 1986; Sinek, 2019) that has been brought into stark realization by the devastating impacts of the COVID-19 pandemic in historically marginalized communities (Artiga et al., 2020; Centers for Disease Control and Prevention, 2020; Garg, 2020; Gibson, 2020; Walsh, 2020). Health inequities have existed for generations (Institute of Medicine, 2003; Penman-Aguilar et al., 2016). While the players have come and gone, the “game” continued to evolve into systemic structures that formed what are known as the social determinants of health (Allen et al., 2014; Artiga & Hinton, 2018; Carey & Crammond, 2015; Penman-Aguilar et al., 2016). These societally structured factors often create inescapable challenges with no end other than checkmate for those living at the sharp end of the sword of health inequity. Prior to the 2020 pandemic, data about maternal mortality in minority populations (Centers for Medicare and Medicaid Services, 2019; Hoyert & Miniño, 2020; Kassebaum et al., 2015), the differing prevalence of obesity (Hales et al., 2017), and diabetes (Afifi et al., 2020; Gaskin et al., 2014; Selden & Berdahl, 2020; Tai et al., 2020) highlighted the devastating health costs borne by communities of color (Artiga & Hinton, 2018; Heiman & Artiga, 2015; Penman-Aguilar et al., 2016; Smedley et al., 2003). The pandemic served to take an already complex long-standing game and overlay a VUCA lens (Bennett & Lemoine, 2014), in that it brought the elements of Volatility, Uncertainty, Complexity, and Ambiguity (VUCA). As a wider net was cast even broader sets of Americans found their health, livelihoods, housing, and way of life impacted. The confluence of these developments presents a pressing “noble cause,” a just-purpose for a new generation of leaders. All persons should have the ability to lead a healthy life where they live, work, play, and pray (Chandra et al., 2016; Plough, 2019). No group should be systematically left behind or singled out for disease, disability, or premature death (Dwyer-Lindgren et al., 2017). Such disparities aptly fit the term “Wicked Problems” (Churchman, 1967; Rittel & Webber, 1973), coined to describe difficult or impossible to solve issues characterized by incomplete, contradictory, and changing requirements that are often challenging to recognize and are the result of a dynamic interplay between multiple systemic influencers of health and healthcare (Petticrew et al., 2009). Wicked problems (WP) are a canvas upon which the Infinite Game mindset can play out. While the Infinite Game model can be well-applied to WPs, WPs exist as a challenge to any leadership model. In “bounded systems” the health problem of diabetes manifests as a patient with a high hemoglobin A1C, indicating that blood glucose has been too high for too long. That patient works with healthcare providers to learn skills and adjust medications to bring blood glucose into a more acceptable range. In “unbounded systems” diabetes is rampant through a demographic segment of society where systems-level barriers prevent individuals from accessing healthcare professionals, pharmacies, spaces for safe and effective exercise, or a safe and nutritious food supply. In this unbounded example, expert advice from healthcare professionals is easily defeated by the larger system influencers. In 2016, the Clinical Scholars National Leadership Institute (online at ClinicalScholarsNLI.org), more commonly referred to as Clinical Scholars (CSs), aimed to prepare interdisciplinary teams of health professionals with the leadership skills needed to be effective in unbounded systems. CS differs from traditional leadership training in that it employs a validated “Equity Centered Leadership” model developed by team members at the University of North Carolina at Chapel Hill's School of Public Health and School of Medicine. While traditional leadership training programs focus on decisiveness, productivity, efficiency, or maximizing profits, the skills crucial to affecting some of society's most complex health crises are quite different: empathy, humility, creating psychological safety, fostering adaptive leadership, and power-sharing with communities are vital for those who would successfully lead with an infinite mindset and create system-level impacts on society. For our example above, empathy helps one understand the depth and kind of challenges faced by the patients with uncontrolled blood glucose. Humility helps the provider listen and learn from expertise in other sectors, including other health professionals as well as the patient and the community. Psychological safety creates an environment where individual blind spots can be addressed with compassion and grace and where everyone on the team can learn—again, the patient and the community are seen as team members. Fostering adaptive leadership is crucial because the need to adapt and change traditional approaches to meet emerging conditions or realities can only be successful when all the players are contributing to new solutions, including the healthcare providers, the patient, and the community. Finally, power-sharing with communities embraces the idea of “nothing about me, without me,” giving true voice to those who will live with both the structures of the solutions and the outcomes of those approaches. In the diabetes example, a whole systems approach would address working with the patient and the community to identify needs and implement solutions for places to exercise, locate grocery stores and pharmacies, and improve access to healthcare. The Clinical Scholars Program focuses on robust development experiences that fully braid an equity and a leadership lens, grounded in the five characteristics explored above (i.e., empathy, humility, psychological safety, adaptive leadership, power-sharing) for each of the 44 community-focused projects. The training results in individuals and teams learning the skills needed to deepen their influence and impact as leaders who have the power to transform their workplaces and communities. These leaders both recognize and are effective in unbounded systems. Measuring the outcomes and impacts of leadership training for unbounded systems is in its infancy. In working to understand how to best gather evidence for the efficacy of the approach, CS follows an extensive evaluation model (Dave et al., 2021). This model is designed to assess the return on investment of training along a continuum of (a) engaged learning, (b) measurable gains in learning and development, (c) demonstrated new behaviors, (d) increased spheres of influence, (e) documented changes in communities, (f) establishing meaningful networks, (g) examining network movement and influence, and (h) deeply examining projects that meet our goal “triple S outcome: of Success, Sustainable, and Scalable.” The published data on the program showed that participants highly rated the experience (a), gained both knowledge and skills to a statistically significant degree (b, c) across the 25 program core competencies (see Figure 1) (Dave et al., 2021; Fernandez, Corbie-Smith, et al., 2021). Note. *indicate competencies related to Equity, Diversity and Inclusion Further the evaluation data documented that fellows implemented their skills in new and more effective ways (c, d, e, f) to make tangible impacts in communities (e). Program fellows from Cohort 1 collaborated to create a collective work of their impact (Fernandez & Corbie-Smith, 2021) that effectively serves to document steps (a–e) of this continuum-based approach to leadership development program evaluation. The evaluation approach is ongoing with specific foci on examining network establishment, movement, and influence (f, g), and identifying predictors of implementation science projects which are successful, sustainable, and scalable (h). Through the experience of running the CS program we have drawn six core conclusions for effective leadership development strategies for those who want to make impacts across unbounded systems and complex societal issues. Dedicated leadership training is powerful and important. While we selected highly competitive applicants for CS, we still heard repeatedly that most had never previously been exposed to leadership training of this quality and depth nor had they experienced an equity-centered leadership approach. Leadership training “is a journey” and not a one-and-done proposition. Work by Murphy et al. (2020) suggested a “dose–response” relationship between both (a) leadership experiences and (b) leadership training and more substantial outcomes in leadership self-efficacy and attitudes toward servant leadership. CS provides a high “dose” of learning in that CS is a 3-year program comprised of seven immersive retreats coupled with a multi-component, highly robust distance-based program (see Table 1). As such, the program is uniquely designed to work with enrolled participants on their complex journey of leadership for health equity. Our data indicated that fellows are engaged and immersed in this development, dedicating an average of 541 hours per year to the program and the Wicked Problem Impact Projects that served as an action learning project for each team. The long-term support in CS enables the kind of personal and team transformation seen in this program. CS supports these participants in seeing themselves as leaders and in nurturing the skills to help them engage and navigate the complexities of addressing entrenched health disparities. Much as Sinek (2019) remarked, these leaders are not engaging in their own Infinite Game to be popular or even to play a game. They are engaged in the CS model of leadership development because it produces real and lasting outcomes. These kind of outcomes can evolve with the changing circumstances and the successive players that both emerge and retreat to the background. While our previous work has shown that individuals can gain substantial benefits even with “short burst” approaches to training (Fernandez, Noble, Jensen, & Chapin, 2016), the results of longer-term training have been associated with significant learning both within the given program (Fernandez et al., 2014), in multi-year sustained results (Fernandez, Noble, Jensen, Martin, & Stewart, 2016), and career trajectory of participants (Fernandez, Esbenshade, et al., 2021). While work experience is important, leadership training itself is crucial and irreplaceable, particularly when the issues revolve around structural racism and other causes of inequity that lead to health disparities. “Equity Centered Leadership” is a powerful model for developing infinite-minded leaders (Brandert et al., 2021). Equity-centered leadership is about braiding more traditional concepts in leadership with equity, diversity, and inclusion values, skills, perspectives, and tools. We believe that equity-centered leadership is crucial for developing leaders who want to work in unbounded systems, with diverse stakeholders, and on the most pressing issues of our time. The concepts of inclusion and shared power are essential frameworks for “infinite minded” leaders. CS weaves our equity-centered leadership model into all leadership sessions, including those based on the 11 different psychological assessments employed in the program, “braiding” in the concepts of thought diversity and how to use leadership to promote equity. The equity, diversity, and inclusion-focused sessions similarly “braid” content with leadership tools and theories. We believe that equity-centered leadership forcefully supports the development of a new kind of leader who can practice in unbounded systems. Supporting diverse leadership creates a cadre of colleagues stratified throughout the system, many of whom do not typically see themselves reflected in healthcare leadership for reasons of race, gender, or profession. Professions such as dietitians, social workers, pharmacists, speech language pathologists, physical therapists, and others join their physician and nursing colleagues in the training and on the teams. In fact, 15 different disciplines across 26 states and territories are represented in the CS fellow family. CS supports these individuals in seeing themselves as leaders and in nurturing the skills to help them engage and navigate the complexities of addressing entrenched community-based health disparities. The program prepares participants to understand that effectiveness, persuasiveness, and inclusivity are going to be powerful measures of how a leader can emerge into the existing power structures that determine resource allocation, to build their self-efficacy as leaders and their dedication to serving their communities. The program helps prepare these diverse fellows for the nuances of outcomes that evolve with changing circumstances and the successive players that both emerge and retreat to the background. In short, they are prepared to lead in unbounded systems. Teams learn differently than individuals. CS fellows apply as and matriculate through the program as interprofessional teams representing multiple clinical disciplines. These teams partner with local communities on their projects. These teams deal with developing relationships and team dynamics over time that both challenge and grow their skills and mirror larger, real-world challenges. We strongly believe in the interprofessional team-based model for deep learning about leadership/followership in unbounded systems. One diversity area that we could not address through CS was equal inclusion of community-based partners as program fellows, so that built-in structures aligned learning and power sharing with the communities involved. In CS, this was implemented at the team level rather than the program level. We recommend other programs working in unbounded systems consider the importance of full inclusion of stakeholders. Implementation science/action learning projects are crucial for applied focus of nuanced and sophisticated skills fostered in the leadership development program. In CS, all interprofessional teams applied with a concept Wicked Problem Impact Project that served as their focus throughout the 3-year experience. Regular accountability-grounding expectations were built into the progression of learning. The teams enrolled during the COVID-19 pandemic had to adjust to VUCA conditions and bring an adaptive leadership lens to pivoting their work given the limitations imposed by the crisis. They broadened their stakeholder base and refocused their partnerships, experiencing the reality of adaptive leadership and implementation science in real time as they engaged in action learning. We believe that leadership development programs are best served when participants apply their learning to tangible and reported impacts in both organizations (bounded systems) and in communities (unbounded systems). Funded support for dedicated learning and project application is crucial. CS provides $35,000 per fellow per year (range $210,000–$525,000 for teams of 2–5 respectively across the 3-year program) for teams to use to support both their learning (buy-out of time) and their community-based projects. Sharing of financial resources with community partners, as a measure of shared power, is strongly encouraged. While highly motivated learners can dedicate their time to learning new skills, healthcare professionals shoulder significant responsibilities, particularly during the COVID-19 pandemic, increasing their burden and limiting time and energy for learning beyond maintaining their clinical expertise. “Slack-time” at work to use in critical reflection and skill acquisition is rarely part of the picture in the VUCA healthcare world. As such, the funding that enabled these fellows to deeply engage in learning and to empower them to collaborate with communities to address WPs was a core asset toward promoting the impressive outcomes seen in the program across a wide-range of issues (Fernandez & Corbie-Smith, 2021). Our country needs leaders who understand the evolving and adaptive context for leadership, they need to understand that they are playing an infinite game and that these problems will persist after the headlines have moved on to focus elsewhere. Traditional clinical training does not provide the leadership skills to help clinicians advance health equity in their communities, yet, healthcare professionals are uniquely suited to become players in an infinite game that addresses the devastating impact of health disparities. The CS program provides a real-time, community-based application to test Sinek's (2019) model of The Infinite Game when applied to the contemporary WP of health disparities. The Infinite Game provides a cogent theory to guide the leadership development of these healthcare professionals so that they can harness their passion to effectively address the WPs of health inequities in their own organizations and communities. Through understanding the complexities of a “game” where players come and go, issues rise in prominence and then fall from public concern, and many players with vastly different perspectives and motives need to be engaged, health professionals can become eloquent and effective players and collaborative leaders in addressing such complex problems. CS employs an effective equity-centered leadership development approach that embraces Infinite Game theory as it develops a new cadre of leaders for health equity. The experience of CS illustrates the value of offering a funded, dedicated team-based equity-centered leadership training program that braids leadership equally with equity, diversity and inclusion principles, in which diverse participants focus on real-world issues through implementation science-based projects. The Clinical Scholars program is generously funded by the Robert Wood Johnson Foundation (Award #78005). G. Corbie: no conflicts; C. S. P. Fernandez: Ruben Fernandez, JD, serves as a faculty member in the CS program, is a co-author of a text used in the CS program (It-FACTOR Leadership: Become a Better Leaders in 13 Steps) authored with Dr. Claudia Fernandez, and provides the FastTrack Leadership Library used in the program; and is related to the author. Claudia Fernandez, DrPH, MS, RD, LDN is an Associate Professor in Maternal and Child Health at the UNC Gillings School of Global Public Health. She is an executive coach, teaches in several national and global leadership development programs, and is the co-author of It-FACTOR Leadership: Become a Better Leader in 13-Steps. Dr. Fernandez is Co-PI of the Clinical Scholars National Leadership Institute and serves as a faculty in the program. Communications can be directed to claudia_fernandez@unc.edu. Giselle Corbie, MD, MSc, is Kenan Distinguished Professor, Departments of Social Medicine and Medicine, Director of the UNC Center for Health Equity Research at the University of North Carolina at Chapel Hill, and Associate Provost for UNC Rural. Dr. Corbie is Co-PI of the Clinical Scholars National Leadership Institute and serves as a faculty in the program. Email gcorbie@med.unc.edu.