Descriptive themes, categories and subcategories identified through the thematic synthesis
| Impeding conditions | Facilitating conditions | |
| Theme 1 | From medical protectionism to management through medicine | |
| Category Subcategory | Medical protectionism | Management through medicine |
| Motivation to lead | Safeguard physicians’ role, identity and influence | Ensure that management decisions have a positive impact on care and clinical outcomes |
| Perception of management | Going over to the ‘dark side’, concerns about losing credibility among clinical peers | A collective decision-making process where expert knowledge is integrated through openness, trust, respect, and cooperation |
| View of oneself as a manager | Heroes ‘working against the odds’ or righteous victims ‘struggling in the face of adversity’ | Knowledge brokers who see the opportunity for management to enhance clinical identities |
| Role of managerial strategies | To protect autonomy and avoid control, that is, modernised professionalism | Productivity as individualised professional duty that builds on physicians’ inner drive to improve care, that is, new professionalism |
| Outcome of managerial strategies | Disengagement from difficult interactions with colleagues and patients | Engagement across professions that mediates status differences and facilitates knowledge-sharing |
| Theme 2 | From ‘command and control’ to participatory leadership practices | |
| Category Subcategory | Command and control | Participatory leadership practices |
| Organisational attributes | Bureaucratic, policy driven and hierarchical; poor communication, lack of support, incompetence | Inclusive, solicit input, participatory decision making, shared vision |
| Performance measurement | Externally imposed performance measures with no authority, staff, budget or time | Codesigned performance measures to align quality and safety agendas |
| Outcome | Lack of ownership and trust, values conflict, sense of powerlessness, focus on compliance | Autonomy, meaning, local improvement, better management of clinician relationships, managerial job engagement and self-efficacy |
| Theme 3 | Organisational practices that form incidental versus willing leaders | |
| Category Subcategory | Practices that form incidental leaders | Practices that form willing leaders |
| Recruitment | Informal networks, ad hoc processes, persuasion, lack of explicit selection criteria or expectations | Formalised, with explicit expectations to match strategic context, early identification of leadership potential, considers demographics and self-efficacy |
| Top management support | Remind of responsibilities by nagging and arguing, crowd agendas with operational matters | Acknowledge and engage medical expertise and academic competence, foster collaborative relationships, effective communication and proactive decision making, remove barriers such as lack of reward and recognition |
| Strategic leadership development | Expected to learn management on their own and on-the-fly. Leader development focused on individuals, divorced from everyday challenges and rarely followed up with opportunities for practice | Starts early, occurs on all levels, benefits patient care and system level challenges not just individuals, and is integral to strategic development |