Abstract
The use of a dyad leadership model involving a physician co-leader and a co-leader with a different background, the dyad co-leader, is gradually increasing in Healthcare Organizations (HCOs). There is a paucity of empirical studies on various aspects of this model. This study’s aim was to identify challenges and strategies for success in the dyad leadership model in healthcare. Through a mixed-methods approach utilizing focus groups, surveys, and semi-structured interviews, perceptions of 37 leaders in one HCO at different hierarchical levels were analysed based on their lived experiences. The challenges and success strategies spanned personal, interpersonal, and organizational domains. The areas requiring attention included mindsets, competencies, interpersonal relationship, support, time, communication, and collaboration. In addition, the importance of organizational context addressing its structure, strategy, operations, and culture was highlighted. The findings from this study may be used for praxis, development, and implementation of dyad leadership.
Introduction
Dyad leadership in healthcare refers to a Physician Leader (PL) and another leader—Dyad Co-Leader (DCL) with a different background (business, administration, nursing, technical, or other)—sharing responsibilities for leading an organization or its components. It has been defined as, “dyads are mini-teams of two people who work together as co-leaders of a specific system, division, clinical service line or project.” 1
This model is based on the belief that leading organizations and its knowledge workers in a complex environment in the information age would benefit from harnessing talent in more than one individual. 2 It is particularly relevant to the complex adaptive system of Healthcare Organizations (HCOs) 3 with the coexistence of professional and bureaucratic cultures, 4 which can also be viewed as professional and management logics, 5 and there is a need to integrate these two arms of governance. 6 Increasing calls for leadership by physicians 7,8 rooted in studies linking effective physician leadership with better outcomes, 9 further asserting the need for this model. This model draws from theories that espouse sharing of leadership among multiple individuals such as shared, 10 connective, 11 distributed, 12 and collaborative 13 leadership perspectives.
Although this model has been in place in some organizations for a significant period of time, for example, Mayo Clinic, Cleveland Clinic, 14 its increasing utilization worldwide is relatively recent. 15 –25 Despite its increasing adoption, there is a paucity of empirical studies in peer-reviewed literature, and this topic is more widely discussed in the grey literature. The peer-reviewed literature contains a large number of editorials and commentaries.
Whether the proposed benefits of the dyad model have been realized widely is not completely resolved. The grey literature contains reports of reduced infections, lowered costs, improved communication and patient satisfaction, 26 and standardization of care. 27 In the peer-reviewed literature, commentaries point to improved communication, collaboration, culture, and patient care. 17,28 A few empirical studies that exist have highlighted improvements in communication and collaboration, staff turnover and patient satisfaction, 19,24 joint problem solving and goal achievement, 20,24 standardization of care, 19,20 successful policy implementation and culture change, 29 and improved physician engagement and culture. 30
The practice of leadership has its challenges, and co-leading with another individual adds to dimensions to be considered. The literature is even more limited in describing the challenges and strategies for the success of this model. The advice in grey literature includes common values, shared vision, respect, trust, and transparent communication. 23,31 The peer-reviewed literature has highlighted relationships and effective interactions between dyad partners, 24,32 role clarity, 22 and organizational support. 19
Building upon our earlier findings on the structural aspects of the dyad leadership model, 22 this empirical study describes the challenges faced and the strategies used for success by dyad leaders. Our findings are also unique in that these reflect perceptions of multiple stakeholders (dyad leaders at different hierarchical levels reflecting on their lived experiences and senior institutional leaders involved in the decisions and early implementation of the dyad model). Implications for practice and development of dyad leadership are discussed.
Methods
Perceptions of key leaders in a healthcare setting in Canada and extant leadership literature review were utilized to achieve the aim of identifying challenges and strategies for success in a dyad leadership model in healthcare. To explore contextual richness and complexity of leadership, the qualitative component (focus group and semi-structured interviews and open-ended components in surveys) 33 heavily outweighed the quantitative component in surveys in this mixed-methods study. Ethics approval for this study was obtained from the University of Saskatchewan Ethics Committee’s Behavioural Board of Ethics and from the Saskatoon Health Region (SHR).
Organization
The research was conducted at SHR, a regional health authority and an academic HCO in the province of Saskatchewan in Canada, which has since December 04, 2017, been incorporated in the province-wide Saskatchewan Health Authority. Key facts about the research setting are shown in Table 1. The departments and programs had a mix of the traditional single-person leadership structure along with the then relatively recently implemented dyad leadership model (average: approximately 3 years; range: 2-5 years) in many areas.
Research setting and participant characteristicsa
Abbreviations: DCL, dyad co-leader; PL, physician leader.
a The PL:DCL ratio was 15:17 (47%:53%).
b Values may not add up to 100% due to rounding.
c Experience in dyad leadership positions ranged from 2 to 5 years (mean: approximately 3 years).
d Dyad leadership model was least implemented at this level at the time of this study.
e Dyad leadership was not implemented at the senior leadership team, CEO, and board level.
Participants
The participants (n = 37) included PLs and DCLs representing three different hierarchical levels delineated by the scope of the positional authority 34 : (1) a limited scope first-level, for example, divisional heads and managers, (2) a wider scope middle-level, for example, department heads and directors of cross-departmental programs, and (3) an institution-wide scope senior-level, for example, board and senior leadership team members. All first-, middle-, and senior-level leaders were invited for the event study portion (described below), and purposive non-probability sampling of senior leaders at the SHR was used to select the participants for the interviews. Participant characteristics are depicted in Table 1.
Event studies
In the half-day long sessions, called event studies, that included components of focus groups and surveys, small groups of four to five participants were asked to reflect, discuss, and summarize their thoughts, feelings, and experiences in seven broad areas (two relevant to this study). These sessions of approximately 30 minutes duration each were on (1) challenges faced and (2) strategies they used for success in the dyad leadership model (the latter undergirded by an appreciative inquiry approach, eg, people were asked to recall success and think of what contributed to success). The data were collected in the form of flipchart writings, summarized reports, and short surveys (pilot tested earlier).
Interviews
The semi-structured interviews were based upon a set of general questions, 35 and the main interview questions (pilot tested to establish trustworthiness and credibility by two leaders) drew from grounded theory’s social constructionist orientation and informed by the research questions. The data were collected by note taking and transcribed tape recordings.
Data analysis
The structured response data, for example, participant characteristics in the surveys, and Likert scale data were interpreted through descriptive statistics using SPSS. Themes extracted from the open-ended and write-in responses from the surveys, session notes from the “event study,” and interview data were analysed by content analysis (coding and categorization). Data were imported into QSR’s NVivo 11 Pro for analysis. Demographic factors were analysed by conducting coding queries to parse out responses based on node (ie, survey question) and case attribute (ie, specific factors such as PLs vs DCLs). These subgroup investigations provided the basis for any perceived differences or lack thereof in the qualitative (open-ended) responses by demographic.
Results
The findings are presented in the summaries below and in joint display tables (Tables 2 and 3). The percentages in the quantitative section point to the number of times that topic was identified; “es” refers to transcribed recordings of focus group sessions, session notes, and survey questions (numerical data and open-ended comments), and “i” refers to semi-structured interviews. Both the challenges and success strategies are described in personal, interpersonal, and organizational categories and subthemes in each category. Any emphases and variations due to demographic factors are described at the end of each section.
Challenges faced by dyad leadersa
Abbreviations: DCL, dyad co-leader; PL, physician leader.
a The percentages in the quantitative section point to the number of times that topic was identified; “es” refers to transcribed recordings of focus group sessions, session notes, survey questions (numerical data and open-ended comments), and “i” refers to semi-structured interviews. Representative comments by participants are given in inverted commas.
Strategies utilized for success by dyad leadersa
Abbreviations: DCL, dyad co-leader; PL, physician leader.
a The percentages in the quantitative section point to the number of times that topic was identified; “es” refers to transcribed recordings of focus group sessions, session notes, survey questions (numerical data and open-ended comments), and “i” refers to semi-structured interviews. Representative comments by participants are given in inverted commas.
Summary of challenges
Although some challenges were unique to DCLs and PLs, most were common to both partners. The organizational factors (eg, “lack of clear understanding of the roles/relationship of dyad” and “lack of formal support [staffing and resources”]) accentuated personal (eg, “a lack of dependability and follow-through” and “time pressures on both leaders” due to “competing pressures”) and interpersonal challenges (eg, “lack of a common vision” and “insufficient information sharing”), making these even more difficult to navigate.
Demographic factors
Professional development was highlighted as a major theme by women leaders, DCLs, and mid-level leaders, while having different visions as cited more by male leaders and early- and mid-level leaders. First-level leaders highlighted relationship, first- and middle-level leaders highlighted negative attitudes, and mid- and senior-level leaders highlighted poor communication.
Summary of strategies for effectiveness
There were no appreciable differences between DCLs and PLs regarding commonly deployed strategies. There were limited areas where the model was successful and the perceptions of those are reported. These included personal (eg, “Setting out a very clear work plan…with key milestones, key targets…and then stick to it”) and interpersonal (eg, “Be a team—like a pilot and co-pilot; know when to lead and when to follow”) strategies. The senior leadership was highly cognizant of contextual relevance and creating conditions for the success of this leadership model (eg, “clearly defined roles and responsibilities,” “providing administrative support,” and “creating a learning organization’).
Demographic factors
Systems approach, quality assurance, and evidence-based decisions were identified more by male participants and PLs (this group had more men), those older than 45 and those with over 10 years of experience in their healthcare leadership position. Women leaders and DCLs (this group had more women) emphasized collaboration strategies. Mid-level leaders emphasized interpersonal relationships. One senior leader raised the issue that selecting the right kind of people is crucial since the basic values and attitudes are hard to change.
Discussion
Based upon our findings and extant literature, a model is developed (Figure 1) that identifies specific areas requiring attention and specific strategies in personal/interpersonal and organizational categories and overall organizational contextual factors for success.
The proposed model for dyad leadership success concepts from the extant literature not specifically identified by the participants in our study is identified by numbers identifying the specific reference cited in the text. The key terms referred to include partnering intelligence (accomplishment of mutually beneficial objectives through trust, interdependence, self-disclosure and feedback, mutuality, comfort with change, and future orientation), 36 intentional partnering (taking a broader perspective, taking risk together, and actively developing shared responsibilities), 24 professional and management logics (the former referring to expertise and certification-based authority and the latter to former hierarchical positions), 5 and moral imagination (considering a situation’s context, nuances, and reimagining the framework to expand one’s conceptualization of the problem and its solution). 37
Mindset and attitudes
The effectiveness of the model is likely based on each dyad partner’s contribution. The incongruence between the mental models of DCLs and PLs (financial prudence vs clinical care) needs to evolve into a more expansive and inclusive mindset. Our earlier work had highlighted a dialectic approach to reconcile dualities and simultaneously uphold multiple truths for effective healthcare leadership. 38 However, shared leadership requires the incorporation of new information into the existing mental framework 39 and changing mental models takes time. 40 Although not specifically highlighted in our study, the importance of a “growth mindset” 41 appears intuitively integral as it focuses on continuous learning. Both physicians and leaders are considered knowledge workers, 42 and managing oneself is essential to provide effective leadership 43 and create an interdependent and effective dyad.
Competencies
Concerns by some participants regarding inadequate experience and training are in keeping with the key role of formal education in healthcare administration 4,44 and the need for ongoing professional development. 19,20 Interpersonal skills have been identified to be the most important attribute in the dyad leadership model. 15 This is consistent with multiple leadership styles, for example, democratic and coaching, utilized by the dyad partners in our study. Individual and joint leadership development, in addition to being informed by relevant theoretical perspectives, needs to take into account demographic variations (eg, gender and leadership level) and systemic issues. As in our study, more women are in DCL roles 45 and face different challenges and utilize different strategies for success—partially attributable to physician power structures in healthcare 46,47 and the hierarchical relationship between physicians and nurses. 48 It is important the organizations be deliberate in identifying the appropriate talent suitable for dyad leadership based upon underlying motivations and aptitudes.
Interpersonal relationships
Building productive relationships rooted in possessing shared values 49 between the two leaders and sharing vision is important to success. 50 Both partners will need to perceive the relationship as “mutually valued” as that sets the foundation for working together effectively and addressing disagreements constructively. The centrality of trust, respect, and authenticity is obvious but may be difficult to achieve in real-life settings if the mindsets, agendas, and goals are different. One of the tenets of a mutually valued relationship is the presence of a safe space where the partners can express freely. This “psychological safety” 51 is critical to creating a fertile ground for sharing knowledge, 52 offering suggestions for improvements, 53 and developing innovations. 54 The concept of “intentional partnering” includes taking a broader perspective, taking risk together, and actively developing shared responsibilities. 24 Similarly, “partnering intelligence” that refers to accomplishment of mutually beneficial objectives involving trust, interdependence, self-disclosure and feedback, mutuality, comfort with change, and future orientation 36 is believed to be integral for achieving synergy in a dyad model. 32 With these in place, the tactical approaches such as frequent meetings and active listening would be relatively easy to emerge.
Support
The starting point for support is role clarity. A few studies have described roles in separate and overlapping domains. 22,55 The importance of organizational support has been highlighted in other studies. 19,20,56 The implementation of the dyad model does have implications for additional remuneration and leadership development activities. 18 Lack of or inconsistent organizational support 57 will undermine dyad leaders’ efforts, and it may be difficult to implement the dyad model in resource-constrained environments. 21
Time
As identified in our study, designated (protected) time is crucial for both dyad partners 20 –22,24 and is usually estimated to be 10% to 20% of their effort. 19,58 Providing protected time is even more important for the PLs as their counterparts may not have additional clinical responsibilities. In addition to attending to tasks, designated time is required for “margin”—time for thinking about complex issues and strategies. In addition to widely available time and attention management strategies, a mutually agreed-upon meeting schedule that is honoured would be essential.
Communication
The importance of communication, generating goodwill and developing a small group of confidants, was recently identified as essential for healthcare leadership success. 59 Communication and interpersonal relationship appear to be a mutually enforcing loop; honest and timely communication both require and build trust, credibility, and respect. 24 Under these conditions, communication leads to generative conversations and development of creative ideas for meeting organizational goals.
Collaboration
Finding a balance in the shared governance model is difficult. 57 A wide salary difference between PLs and DCLS may also be a contributory factor for friction between the partners. Therefore, there is a potential for disputes and disagreements. Further, improving access, quality, and safety for patients is likely to be in conflict with the DCL’s fiduciary responsibilities. 60 Leaders from different backgrounds may retain their professional and management logics and often one leader assimilates the other partner’s perspectives instead of reconciling and integrating demands that are often oppositional. 5 There are multiple ways to effectively work together. The “mission unit” is proposed as the way forward, where the partners focus on the patient care mission and work for it through a foundation of shared values. 5 As discussed earlier by us and others, a clear distinction between the responsibilities in shared and individual domains that span leadership and management functions and administrative and clinical realms 22,55 with clear authority and accountability would help in working together. Considering a situation’s context, nuances, and reimagining the framework to expand one’s conceptualization of the problem and its solution has been referred to as “moral imagination” 37 has been suggested for successful collaboration. 32
Operationalizing processes and acting with accountability for goals and outcomes were highlighted in a study. 20 One proposed approach included aggressive agendas with set goals, 59 although addressing the issues instead of focusing on achieving set goals was found in another study to be more effective. 20 It would be helpful if the partners are interdependent and leverage each other’s complementary skills, especially with appropriate emotional orientation, 61 as tapping into the PL’s understanding of the clinical processes can be a unique advantage. 62 Decision-making by leaders focusing on mutually exclusive goals creates conflict. 63 Since shared governance improves clinical effectiveness, 64 it is better when decision-making processes are inclusive 65 and consider both data and values. However, the decision-making may become slower due to two persons being involved in decision-making with different approaches, 18,23 but a robust decision is more likely to be made. 18
Since the dyad leaders are jointly leading constituents from diverse backgrounds that often cross organizational boundaries, it is important to be adept at leading across boundaries. Simultaneous application of two fundamental principles remains central: enhancing allophilia (promoting feelings of kinship and engagement) and decreasing intergroup conflict (reducing prejudice and conflict), which require an artful practice of simultaneously bringing people under a superordinate identity umbrella while honouring their group and other identities. 66 –68 Joint accountability calls for a joint front; it is underscored by the advice, “to never speak ill of the partner.” 69 Having joint accountability along with a joint reporting structure, where the dyad partners report to higher hierarchical levels jointly (the modified quadrat structure), 22 strengthens the collaborative mechanisms, helps resolve disagreements, and it becomes natural to convey a joint front to all internal and external stakeholders.
Additional organizational factors conducive to success
These are broader overarching contextual strategies that significantly affect all areas. The organizations need to be clear about the model’s rationale not only to the dyad partners 17,19 but also all internal stakeholders, so its link to the overall goal(s) is well-understood. 17,25 The organizations can support this by ensuring that the strategy and operations are linked to the values of patient-first and resource stewardship as two truths that need to be upheld simultaneously. There is a need for a supportive culture for the dyad model’s success. 70 Simply assigning roles to dyad leaders is not enough; there needs to be ongoing monitoring of the accountabilities and outcomes. Building incentives to achieve leadership performance of a jointly led unit 19 and wide sharing of this model’s success are likely to further enhance its perception among the internal stakeholders and sustain the momentum for its continuation. 71 Sharing of information and learnings among different dyad partners across the organization would also assist with developing a learning organization. 19
Limitations and future research
Limitations include findings from only one organization affecting generalizability, smaller sample size, studying the model at an early stage of its implementation, and absence of objective data on the performance of the model and participants. Future research would benefit from studying the impact of this model and implementation efforts and the impact of this model using robust “social network” approaches.
Conclusion
The key areas that require attention in personal, interpersonal, and organizational domains are intertwined and overlap; however, there is some value in a reductionist approach so that specific strategies can be applied to these smaller components with the aim of integrating these for an artful practice of co-leading. The findings would benefit the dyad leaders in enhancing their own practice by adapting success strategies to their own environments. The success of the dyad model in an HCO would require organizational commitment in its strategy and operations, managing culture, assigning organizational resources for development and support of the dyad partners, and measuring its impact. Leadership development work would be improved by considering the findings in this study.
