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Abstract
Objectives Leadership knowledge and skills are known to be developed by health professionals during global health experiences overseas. However, volunteers struggle to recognise and use these new skills on return to their workplace. A series of bespoke leadership workshops were designed, delivered and evaluated by leadership experts to help enhance the transferability of leadership skills back to the UK National Health Service.
Design A mixed-methods participatory action research methodology was employed to explore the impact of the workshops. This approach lends itself to a complex, situated project involving multiple partners. Quantitative and qualitative descriptive data were collected via online survey (n=29 participants) and focus groups (n=18 focus groups) and thematically analysed.
Setting The authors delivered the tailored leadership workshops online to globally engaged National Health Service (NHS) healthcare professionals based in England who had all worked overseas within the past 5 years.
Participants 29 participants attended: 11 medical doctors; 6 nurses/midwives; 10 allied health professionals; 1 NHS manager and 1 student nurse (who was also working as a healthcare assistant).
Results Participants were able to network both during the large group discussions and while in smaller breakout groups. Data highlighted the substantial benefits obtained from this networking, with 91% of participants reporting it enriched their learning experience, particularly within a multi-disciplinary context, and by having the time and space for facilitated reflection on leadership. Furthermore, 78% agreed that they learned new skills for influencing change beyond their position and 76% reported they could maximise the impact of this change for themselves and their employer. Participants also reported the development of systems and ethical leadership knowledge that they felt they could transfer to their NHS roles.
Conclusions This study extends explorations of global health experiences by moving beyond the skills gained while working in low-income and middle-income countries. The innovative online leadership workshops gave agency to individuals to recognise and use the skills gained from global health placements on return to the NHS.
- Feasibility Studies
- Health Education
- Health policy
- MEDICAL EDUCATION & TRAINING
- QUALITATIVE RESEARCH
- Surveys and Questionnaires
Data availability statement
Data are available in a public, open access repository. Datasets are available from the PEARL repository.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- Feasibility Studies
- Health Education
- Health policy
- MEDICAL EDUCATION & TRAINING
- QUALITATIVE RESEARCH
- Surveys and Questionnaires
Strengths and limitations of this study
The study used a participatory action research approach, which ensured workshops were tailored to participants’ experiences and needs.
The study employs mixed-data collection methods (surveys and focus groups) for both quantitative and qualitative feedback.
The study includes a diverse sample of healthcare professionals from different seniority levels.
There was limited geographic scope as participants were only recruited from National Health Service Trusts in England.
The study’s self-selected sample may limit the generalisability of the findings.
Introduction
Leadership is championed as one of the major influences on patient safety and the quality of clinical care,1–3 consequently, the impetus to develop leadership for service development has never been greater.3 While single definitions of leadership remain elusive, it is generally accepted that leadership is highly complex, multi-faceted, context-dependent2 and ‘better explained as a process or series of processes of interaction rather than the presumption that it consists of observable and measurable characteristics’.4 It is hard to escape the drive to foster inclusive and ‘distributed’ leadership beyond hierarchical settings in most large complex, systems-based organisations and particularly within the UK National Health Service (NHS)5; yet concepts remain contested, and a coherent and tested academic body of evidence, elusive.2 Themes which reappear again and again, both in political grey literature and academia, point towards the emergence of something altogether more intangible, yet vital, if the ambitious, technical re-shaping of the NHS is to be achieved.3 This paper details an intervention aimed at enhancing the transferability of such new and relevant leadership thinking acquired from participation in global health projects back to the UK workplace, namely the NHS. It may also be relevant to other healthcare sectors globally.
The practice of healthcare professionals volunteering overseas has long been supported by UK government policy6 as part of the UK’s global health contribution. Global health experiences in low/middle-income countries (LMICs) have been shown to develop a range of attributes and skills, including leadership skills7–11 and potentially provide a rich landscape for leadership development. The leadership skills acquired align with those required by the NHS workforce of the future, such as the ability to empathise and influence within diverse cultures, to work across systems and to be self-critical in the ethics of their decision-making.5 7 12
Global health engagement in low resource or humanitarian settings is extremely diverse, varying from online training to in-country projects, lasting from a few hours to several years.7 Despite this diversity in work, all global health projects typically involve working across communities, building trust and creating shared goals to enhance health service provision. Volunteers are often provided greater levels of responsibility away from the bureaucracy of the large NHS, and are required to adapt to very different, culturally sensitive, complex situations, frequently with limited support, what Streeton et al refer to as the ‘heat experience’.10
One programme that does provide leadership support to global health volunteers is Health Education England’s Improving Global Health (IGH) fellowship: a 6 to 12-month system strengthening secondment in an LMIC. Streeton et al demonstrate the horizontal and vertical leadership skills developed by participation in IGH fellowships, including increasing adaptability, collaborative working, and changes to the participants’ way of thinking, with a shift towards strategic and ‘big picture’ thinking.10 The well-defined system of support for IGH fellows includes: an intensive 4-day induction programme, placement with a well-versed overseas partner, and an allocated mentor throughout the project. The professional development package is extensive incorporating ‘concepts of leadership; project planning, implementation and evaluation; quality improvement methods; peer learning and support; concepts of public health and the wider determinants of health; the UN Sustainable Development Goals … and cultural preparation’.10 Qualitative analysis of reflective leadership development summaries provides multiple examples of personal development on return to the NHS.10
While the benefits to IGH fellows of the leadership training is evident, in 7 years (2008–2015), just 111 NHS employees completed this route as a pathway to engage in global health projects,13 in part due to the requirement to dedicate a minimum period of 6 months. There are also specific eligibility requirements for IGH fellowships. Consequently, while the leadership development acquired via this route is clear, unless the programme can be scaled up, the impact to the wider NHS is likely to be minimal.
Alternatively, more accessible routes for overseas global health experiences include securing international aid grants, attracting charitable funding or self-funding. Published figures from the Tropical Health Education Trust (THET), who oversee international aid grants, indicate that between 2011 and 2019 there were 210 projects, managed by 103 different UK-based health institutions, with more than 2000 NHS professionals contributing over 60 000 days of time.9 Additionally, there are large numbers of UK healthcare workers who travel independently to engage in global health work. Local NHS Trusts may provide some support to employees volunteering overseas, however, beyond the IGH programme, except for masters level study, there are no courses that aim to develop leadership skills linked to global health experiences, presenting a missed opportunity for the healthcare sector.
An external evaluation of the Health Partnership Scheme, a £32.3 million Department for International Development (now the Foreign, Commonwealth and Development Office) funded programme linking UK health institutions to LMIC health institutions, managed by THET between July 2011 and February 2019, recommended that more support is needed for volunteers to maximise the application of improved competencies and skills on return to the UK.9 Without appropriate and contextualised professional development, individuals struggle to recognise and draw on the skills gained on their return to the NHS.14 Returned volunteers have also identified this gap, calling for opportunities for supported reflection.15 Development in volunteer preparation, in addition to guided reflection on return, is likely to positively influence the application of newly acquired learning.16 17
Methods
This project employed a participatory action research (AR) methodology18 (figure 1) to design, deliver and evaluate a series of bespoke virtual leadership workshops targeted at healthcare professionals previously engaged in global health projects overseas. Reflection on action is a key component of AR19 and a crucial component underpinning the development of expertise.20
Action research cycle.38
Three unique and inter-related online leadership workshops were designed following consultation with those leading global health (GH) initiatives (table 1). Topics were derived specifically from the needs outlined in the current NHS workforce and people plans, and from the skills which those who have served abroad clearly bring to the UK. They also align with sources which detail concepts increasingly seen as relevant to leadership in a 21st century world.21 22 The success of today’s leader depends on their ability to bring positive change, clarity and purpose to an increasingly complex and information-swamped world. They must be able to reach beyond the now-contested tropes of position power, hierarchies and outdated notions of ‘leader knows best’.23 An emergent paradigm shift in how to lead effectively is under consideration around the world.24 Therefore, newer leadership thinking around relevant topics such as systems, influence and how to remain ethically conscious within the desire to lead change were considered as the guiding principles of the workshops. Our key concern was to draw on the participants’ global health experiences to facilitate them to transfer their leadership learning to the vastly complex NHS. Distributed leadership is required to facilitate change beyond visible control structures25 and the workshops were necessarily highly discursive and employed a variety of active learning techniques,26 including incorporating multiple opportunities for deep reflection on practice in breakout groups.27
Workshop titles and overview of learning outcomes
Patient and public involvement
Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Participants
Participants were recruited via: emails to global health networks; Twitter; HEE global health distribution contacts; and the THET pulse platform. Eligibility criteria included: NHS employees; engagement in a global health experience within the last 5 years to an LMIC (as defined by the Organisation for Economic Cooperation and Development), and a commitment to attend all three workshops.
29 globally engaged NHS healthcare professionals participated in the project (figure 2). A range of seniority levels were represented, from pre-registration to consultant (figure 2B). Participants enrolled from NHS trusts across England (figure 2C). The location of global health experiences varied (figure 2D) as did the duration, with the most common responses being less than 3 months (n=11), or greater than 1 year (n=8).
Demographic information. NHS, National Health Service.
Data collection
The first workshop series was delivered in Spring 2022 followed by a second in Autumn 2022. Quantitative and qualitative evaluation data was collected via two Jisc online surveys distributed at the beginning and end of each series.28 In brief, the surveys sought to gain insights into participants’ prior global health experiences, perceived skills development (pre-workshop), and newly acquired leadership skills following the workshops.
To conclude each online workshop, participants were divided into reflective focus groups. The focus groups ran for approximately 20 min, were moderated by a member of the research team, and asked participants to reflect on what leadership skills they learned from the workshop and how they would apply these newly acquired skills in their profession. Across all workshops, there were 18 focus groups in total; these were recorded with Zoom software and subsequently transcribed verbatim.
Data analysis
Descriptive statistics were applied to the quantitative data, and thematic analysis was conducted on the open, qualitative responses from the survey. Two project team members performed the initial coding of the focus groups. The coding matrix was then further refined with input from the wider team and data was stored and sorted in an Excel spreadsheet (table 2).
Emergent themes from survey and focus groups
Results
22 participants (76%) completed the post-workshop evaluation survey, and all 29 participants engaged in two or more focus groups.
Developing agency to enact change
Skills of influence
81% of participants felt that this tailored series of leadership interventions helped them to identify new, previously unrecognised skills gained from global health volunteering. These skills included: adaptability, leadership, non-judgemental approaches, how to effect change, understanding that there are many ways of doing things, thinking differently, strategising, prioritising what is important and ethics.
The new skill I gained was being able to articulate and see the ‘big picture’ of the other skills I have gained […]. I had thought a lot in the abstract about what global health work brings to individuals but funnily enough I hadn’t been able to see the way that my own skills and career had developed. These workshops helped me ‘join the dots’ about my own personal development and articulate that to others. (Survey 2)
Both the online survey data and the focus groups highlighted the shift in individual agency due to the focus on personal power (workshop 1) with 78% reporting that they now knew how to use personal power to influence change beyond their position, and 73% reporting that they now felt empowered to enact change (figure 3). As one participant explained:
[…] It’s both confirmed some of the things that I’ve thought and known about leadership and influence, but it’s also bought in new principles as well […] and, recognising in myself that I do use some of these techniques, but not all of them in my leadership roles …. and reflecting back on some of the interactions that I’ve had, that perhaps, they’re not as successful as I might have liked them to be and thinking, have I utilized the full spectrum of what I might have at my disposal? […] and just thinking about how I will conduct myself maybe differently in difficult situations, to try and bring people with me in difficult times. (FG12)
Developing agency to enact and influence change.
Learning from others
While the facilitators played an important role in building confidence within the group, skillfully eliciting real-life examples and carefully using probing questions to include the voices of all group members, the benefits of the diverse experiences of the participants cannot be understated. Across both survey and focus group data the opportunity to discuss leadership challenges with like-minded, and diversely experienced healthcare professionals was referred to 51 times. 91% of survey respondents indicated that they had learned a lot from others, and the focus groups provided further detail as to the importance of this:
Sometimes I find more of a culture shock when I come home than when I go away. And when I come back into the NHS setting, I find it quite frustrating. And I have been going to and from Africa for … maybe sort of 11-12 years. And I don’t think I’ve found a very good technique for doing this yet. I suppose that’s maybe why I’m on this course. It’s quite nice to be in a group where you can talk about these things and reflect on it with other people who have had similar experiences. (FG10)
Confidence and motivation
Personal confidence and peer support
Related to the shift in individual agency, increasing personal confidence was mentioned nine times in the final survey and emerged as a key theme throughout the focus groups. Leaders who exhibit confidence inspire trust and credibility among their followers who perceive them as competent, decisive and capable of navigating complexity.29 30 Such leaders are more likely to motivate their teams, encourage innovation and drive organisational change. Moreover, peer support played an important role in bolstering this personal confidence. Within the context of these workshops, peer support contributed to participants feeling validated and empowered.
I feel that these workshops gave me a sense of confidence that I do bring a lot back to the NHS from my global health experiences and being able to speak about that to more senior people, advocate for global health opportunities and feel part of a community of like-minded interprofessional people within the NHS—I definitely now feel more confident in interprofessional and inter-seniority conversations. (Survey 2)
New understandings of leadership
Emerging from the focus group data was a consistent reporting of a lack of opportunities to discuss leadership within their NHS roles. While many held leadership responsibilities this focused intervention, with relevant, and current leadership content related to participant experiences, was conveyed as much needed and highly informative.
I personally loved it. […] At my level you don’t get opportunities to talk about what makes a good leader? Are you a leader? Do you do any leading? No one talks to you about it, just get on—lead your small team. I’m not high enough to get any specific leadership training. To be invited to this and given ways to think about it and to be told it’s something anybody can do, for me is really nice. (FG5)
Systems leadership
Systems leadership recognises the interconnectedness of various components within the healthcare system1 and emphasises the importance of collaboration. Fostering relationships, promoting interdisciplinary teamwork, and facilitating communication are all fundamental to successful leadership when working across organisational boundaries. By understanding the system, leaders can identify opportunities for synergy, streamline processes and address systemic challenges more effectively.31 Participants found the leadership frameworks useful for contextualising the complexities and significance of leadership in the NHS.
Having a sort of framework and some words and some theory to put around it, I think will help me in my future leadership roles, because I have a tendency towards one style […] being aware of that and being aware of other people’s preferences, it will help me to have greater influence I think, and, or to produce ideas in a way that maybe open up a greater range of options for different stakeholders. (FG15)
Participants were particularly keen to learn about the system when they engaged in global health projects.
When I’ve worked abroad […], if I’ve done some theory around global health and health systems, and I’ve been forced to think about […] where does the funding come for from for this particular service? […] And where is the training for the staff coming from? And how has that been sustained? And, you know, you’re, you’ve got a natural curiosity, because you want to understand the context. […] (FG7)
Conversely, the NHS had not been perceived in this way, in part due to its complexity, and the aforementioned lack of training, meaning individuals felt powerless to effect change. After the workshop, one participant reflected:
I’ve never really thought about [a problem] in a systems way. I’ve thought when approaching an issue about the people involved, but I’ve not thought about the influence of those people and at what level. And I think that’s quite a nice way of mapping it, to think about, not just that individual, but that individual within a system. (FG6)
Research has shown that individuals who engage in global health volunteering are often exposed to greater levels of responsibility when they volunteer in LMICs.11 Several participants reflected that they had not necessarily considered how decisions were made within the NHS or whether they even had a decision-making role to play.
Yeah, I think, certainly in [named LMIC] the system is a lot simpler. And therefore, it’s sometimes easier to see what is actually going on and how things work. And then you come back and you go, yeah, I can sort of slightly see things differently. And we don’t have to do them things the way we currently do it, just because that’s the way we’ve always done it. [In the NHS] we’ve grown layers of complexity. And understanding that those are just layers of complexity. They’re not, you know, written down in tablets of stone, or determined by God or whatever […] you CAN change them. (FG8)
Ethical leadership
Ethical leadership emphasises the importance of moral values, integrity and responsible decision-making. Ethical leaders set positive examples for their followers, by demonstrating transparency, honesty and fairness, promoting a culture of ethical conduct22 and these aspects generated powerful discussions within each focus group.
I’ve realised if I approach [the problem] from an ethical point of view rather than ’shit that’s going to be a difficult conversation’, I have tools in my bag now. I can view it as an ethical problem. […]. I probably need to soften my opinion in the outcome […] to get the right people on board … and plan my strategy. (FG5)
Brown et al32 and Mayer et al33 highlight the significance of ethical leadership in promoting ethical behaviour, enhancing organisational effectiveness and maintaining stakeholder trust. During the focus groups participants reflected on the complexity and nuanced nature of ethical leadership and the importance of building trust.
It’s not paint by numbers, it’s not a case of ticking these boxes and change will happen. It’s something very subtle, nebulous, hard to pin down very much about personality and human factors. […] And, you know, I don’t think we can get away from the fact that some of it is just about the people. (FG12)
Simultaneously, there was a recognition that you need to consider the individuals in each scenario.
It’s nice to go back to the basics. And consider, what does that actually mean to people? And how do we put that into everyday aspects of things that we do? And how do we embed that into the systems? How do we embed that into how we interact with people? (FG15)
Discussion
Building on the seminal work of Wenger who highlighted ‘communities of practice’ and their associated shared values, goals and cultural markers, Wenger-Trayner and Wenger-Trayner emphasise the complexity of professional communities.34 This complexity is something that volunteers undertaking global health projects must navigate with sensitivity and purpose. As they do so, global health volunteers develop leadership skills.8 10 However, these leadership skills are not always used on return to the NHS, despite persuasive evidence of their increasing relevance.3 5 In undertaking three context specific leadership workshops with experienced mentors and facilitators, healthcare workers, of varying levels of seniority, and from a range of disciplines, were able to make sense of the leadership skills they had gained while working overseas and make explicit connections to their roles within the NHS.
Three overarching themes (table 2) were identified from both the survey and the focus groups. Broadly, participants reported that the workshops helped them (1) develop agency to enact change, (2) build confidence and motivation and (3) develop new understandings of leadership. Together, these highlight the value of the online leadership development intervention. Our findings show important parallels with earlier studies that highlight the need for focused reflection to enable those engaged in global health volunteering to transfer their newly acquired skills back to the UK NHS.14–17 Small numbers of IGH fellows receive appropriate support to scaffold their learning13 but most GH volunteers do not. In our intervention we also found evidence that people learn new skills to influence change because of a GH placement, and that they benefitted from an intervention to help them realise those skills and think about leadership more holistically. Leadership frameworks were found to be particularly useful.
Our experience has shown us that by bringing global health volunteers together, with focused activities and careful facilitation, an extensive professional network can be developed via online communities with enormous transformative potential for individuals, and therefore for the organisation at large. A particular strength of this research is the workshops’ online format which has advantages in terms of cost and accessibility for busy healthcare workers, lending itself to attracting a diversity of participants, both in terms of seniority and discipline.
Zamora et al35 show that international volunteering increases productivity for the NHS by up 37% for doctors and up to 62% for nurses. If these economic modelling figures are accurate, then providing this opportunity to returning volunteers is a cost-effective way to facilitate reflection and positive institutional change. By exerting their influence, effective leaders navigate the complexity of healthcare systems by developing strategic partnerships, managing change and leveraging resources effectively.36 37
One limitation of the study is that it relies on self-reported data collected at the end of each workshop. Further longitudinal follow-up is required to capture the ongoing impact. Participants commented on the rarity of professional development opportunities such as this. Wider provision of leadership training connected to global health experiences, and the evaluation and capture of impact from a larger number of subjects would strengthen any hypothesis of causation.
Conclusion
The disorientating ‘heat experiences’10 of global health engagement gives colliding perspectives (eg, cultural, clinical, communicative) which, with mentorship and guidance, can lead to elevated sense-making. The majority of participants in this study indicated that participating in leadership workshops helped them realise new competencies from their global health volunteering. Specifically, 81% of participants felt that the workshops helped them identify new skills from their global health volunteering experience, with 78% feeling they had gained an understanding of how to leverage personal power to influence change regardless of role, and 73% expressing a sense of empowerment to enact change. Additionally, 91% of participants reported an enhancement of their learning through engaging with each other’s experiences. Together, these suggest that the benefits of Global health volunteering could be maximised with further small-group workshop training. As the workforce of the health and care sector becomes an ever-more precious resource, it will be increasingly required to flex and respond to new challenges and opportunities.3 5 The skills required to respond to these complexities include the development of systems leadership to achieve positive change and personal mastery of influence within multifaceted environments.
Data availability statement
Data are available in a public, open access repository. Datasets are available from the PEARL repository.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and ethical approval for the study was granted by the University of Plymouth Faculty of Health Ethics Committee (Ref. 2021-2828-2177). Participants gave informed consent to participate in the study before taking part.
Footnotes
Contributors LS was a workshop facilitator, researcher and lead author for this paper. ACI was the principal investigator and analysed and coded the data. LJH designed and led the workshops. MJD was a workshop facilitator, analysed and coded the data, and is the guarantor. All authors were involved in the writing of this paper.
Funding This work was supported by Health Education England. The funding body had no role in the design of the study, the collection of data, the analysis and interpretation of data, nor in writing the manuscript (grant no: NA).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.