Realist Review of Leadership Development in Healthcare

Context: Leadership development (LD) is often cited as a method for improving the performance of healthcare teams and organizations, but the available evidence on LD programs remains inconsistent and sparse.

Objective: We conducted a systematic realist review of literature on LD in healthcare to better inform policy and practice.

Dataset/Study Design/Analysis: We used an iterative, theory-driven search strategy to review 311 publications and identified 40 sources that examined definitions of healthcare leadership, the need for LD in healthcare settings, specific components within LD interventions, and contexts and mechanisms that lead to positive outcomes. Using a realist framework, our analysis consisted of qualitative case comparison; identification of context, mechanism, and outcome configurations; and development of a common program theory.

Results: We found that healthcare entities widely view improved leadership as a mechanism to address low morale and suboptimal quality of care. In early intervention development, entities assessed existing leadership theory, attempted to define leadership empirically, and performed local needs assessments. Successful interventions often consisted of cohorts of engaged learners and provided protected “time out” for reflection in psychologically safe environments. Interventions often included relationship building, learning application, and a longitudinal component to reinforce skills and maintain connections.

Interventions typically targeted individuals to promote career advancement but also sought to improve organizational efficacy and change culture. Institutions prioritized LD programs by embedding them in the organization’s structure. Quantitative participant surveys typically showed positive perceptions of programs and skill development, but rarely detected broader effects, while qualitative evaluations detected individual, team, and systems impacts. Outcomes developed over time, and nonlinear impacts were noted in longitudinal evaluations.

Conclusions: Leadership is a contextual skill expressed by individuals, teams, and systems. Successful LD interventions can be characterized by specific context, mechanism, and outcome configurations, have nonlinear impacts, and can transform work culture. As interventions attempt to shift the culture and, ultimately, the structure of healthcare delivery and practice, future evaluations should consider longitudinal holistic evaluation methods.