Co-Leadership Dyads in Healthcare

Co-Leadership Dyads

Healthcare organizations face the challenge of balancing professional expertise with managerial efficiency, leading to tension between professional and managerial requirements (Gibeau et al., 2020). Co-leadership seeks to address this by pairing individuals with distinct expertise e.g., medical and nursing or medical and administrative, to collaborate and integrate their respective perspectives (Clark and Greenawald, 2013, Kim et al., 2014, Clausen et al., 2017, O'Leary et al., 2017, Saxena et al., 2018).

Research on hospital unit leadership dyads — typically consisting of a nurse manager and a physician leader — has gained increasing attention for its potential to enhance healthcare delivery. Successful unit co-leadership hinges on effective dyad dynamics and achieving a balanced integration of competing demands, personalities, and priorities.

To understand the ways in which co-leadership dyads function, successfully or not, we must first understand how to differentiate their composition. Research has shown that leaders must carefully walk the tightrope of ‘institutional logics’: socially constructed, historical patterns of cultural symbols and material practices, assumptions, values and beliefs that guide individuals in their work and daily activity. Broadly, there are two main logics adhered to in healthcare:

1. The logic of professionalism, in which expertise based on training and professional certification is the source of authority and legitimacy.

2. The logic of managerialism, in which formal hierarchy and a focus on efficiency is king.

The Leadership Types of Co-Leadership Dyads

Recently, research has identified various co-leadership configurations with varying degrees of success in bridging the two logics and achieving shared goals. Gibeau et al. (2020) identified six common healthcare co-leadership configurations:

1. Dyad of One: two dyads in which one co-leader, specifically the administrative co-director, accomplishes the bulk of the work.

2. Professional Consulting: the administrative co-director who accomplishes the biggest portion of the dyads’ work but the medical director provides expertise or leveraging their influence on specific issues when invited, acting as a representative for their peers.

3. Boundary Duo: the two dyads possess roughly the same influence within the shared role space, and were able to function collaboratively.

4. Management Duo: the two dyads coordinate their work but mostly work independently.

5. Management Unit: the two dyads see themselves as almost interchangeable – able to substitute for each other despite their different backgrounds, and in this case both guided by the management principles established within the unit.

6. Mission Unit: similar to the ‘Management Unit’ in that both dyads consider themselves as almost interchangeable, however both are adhere more strongly to the mission principles established within the unit.

 Unit leadership models in which the leadership configuration had one dominating logic, e.g., Dyad of One or Management Duo, showed less effectiveness in bridging the two professionalism and managerialism logics (Gibeau et al., 2020). Where individuals share roles based on expertise and at least one adopts a 'willing hybrid' role, e.g. Boundary Duos, there is the potential for balance. Mission Units that focus on shared values and patient care also demonstrate effective bridging of logics (Gibeau et al., 2020).

Tip: If you are developing co-leadership in your hospital units, or already have them in place, reflect on their current composition and configuration vis-à-vis the types described above. For units functioning as ‘Dyad of One’ or ‘Management Duo’ consider early intervention to optimize for long-term success; try to educate the leaders on their configuration and provide supports to help them self-reflect on their own leadership style and what the organization’s part to play has been.  

Benefits of Co-Leadership

As reported by Steinert et al. (2006), Clark and Greenawald (2013), Kim et al. (2014), Clausen et al. (2017), Saxena et al. (2018), co-leadership models can:

1.      improve communication and cooperation between physicians and nurses,

2.      increase joint problem-solving,

3.      improve conflict resolution,

4.      enhance achievement of goals, and

5.      create greater shared accountability.

When given the organizational support to self-determine, self-govern, and optimize unit-performance coupled with clear accountability, i.e. when performing as clinical microsystems, Nelson et al. (2002), Godfrey et al. (2003), Wallenburg et al. (2019), Côté et al. (2020) and Harbell et al. (2020) have highlighted that unit co-leaders can:

1.      provide a natural context for empowering and engaging frontline staff,

2.      create a shared vision for the unit,

3.      foster teamwork,

4.      support systems improvement,

5.      enable professional development, and

6.      optimize clinical practice through targeted support and resources.

While co-leadership on its own does not guarantee improved clinical, cost or satisfaction outcomes, it does lay the foundation on which to build a new normal, where care delivery can be optimized for the unit’s patient population, cognizant of resource, knowledge, competency and time resources. The Accountable Care Unit (ACU® care model) is a clinical microsystem model, with unit dyad co-leadership as a central pillar, along with patient-centered care processes, e.g. nursing bedside handover and Structured Interdisciplinary Bedside Rounds (SIBR® rounds), which have been widely adopted and shown to improve unit outcomes.

Secrets to success

Challenges of Leadership Dyads

1. Role Ambiguity: One significant challenge is the potential for role ambiguity or overlap, which can lead to conflicts or confusion regarding responsibilities. Clear delineation of roles is essential for effective functioning. Clausen et al. (2017) reported the importance of mutual understanding and acceptance of each other's perspectives between dyad leaders as being fundamental to navigating professional agendas and constructing shared responsibility. This has been reiterated by Gibeau et al. (2020) and Saxena et al. (2018), who identified that clearly defined roles and responsibilities are crucial to avoiding ambiguity and conflict between the leaders.
   "Dyad contention stemmed from differences in physician–nurse professional agendas leading to unclear expectations, ambiguity and apathy." (Clausen et al., 2017)

2. Power Dynamic: Differences in power dynamics between nursing and medical leadership can create tension and be influenced by historical pre-existing hierarchies and professional norms. Physicians, have typically held a higher power status than nurses in organizations and have greater dominance due to their training, professional autonomy, and historical dominance in healthcare decision-making. Where there are differences in preferred institutional logic, there is the potential for one co-leader’s preference to dominate the others, leading to longer-term problems. It has been our experience with clients that you can optimize for success by asking the unit nurses to rank their preferred physician to be co-lead.

3. Cultural and Individual Differences: Nursing and medical cultures often differ significantly, which can lead to misunderstandings or conflicts in decision-making styles. Addressing these cultural differences is crucial for successful dyad functioning.  Keep in mind that individual attributes, such as communication style, assertiveness, and political savvy, can influence a co-leader's ability to exert influence and navigate the power dynamics within the dyad and more broadly within the hospital.
   Saxena et al. highlighted the criticality of establishing shared expectations, goals, and decision-making processes for effective collaboration (Saxena et al., 2018). Supporting collaboration by building trust and fostering respectful communication are crucial for overcoming professional hierarchies and power imbalances that can often exist between the physician and nursing worlds (Clark and Greenawald, 2013, Clausen et al., 2017).

4. Resource Constraints: Limited resources may strain dyad partnerships, as both leaders may struggle to meet competing demands within their respective domains while trying to collaborate effectively. It has been our experience, along with those referenced in the literature that physician co-leads will require between 10-20% of their time dedicated to leadership of the unit. While this may seem extensive initially, the long-term benefits are significantly more. Clark and Greenawald (2013) found that successful dyads prioritize problem-solving rather than achieving specific unit goals.

5. Training and Support Needs: Effective functioning of dyads requires training in collaborative leadership skills. Without proper support and development opportunities, leaders may find it challenging to work together effectively. The role of organizational support in the form of training, resources, and clear communication is essential for successful implementation as many healthcare ‘leaders’ become leaders informally and without the training to support them in their formal leadership role (Mohr et al., 2003, Kim et al., 2014).
   Clearly determining and addressing the "conundrum of accountability" for physician leaders is crucial to balance organizational and professional loyalties (Saxena et al., 2018). In our experience, physician unit-leaders are typically unsure of what unit-level issues they need to address with respect to their peers’ performance or unit outcomes versus what items are the responsibility of the division director or service line leader. We have a curriculum of training that we have found beneficial for unit leaders to complete, which is often seen as a significant benefit of becoming a unit co-lead.

For optimal co-leadership, evaluation and feedback mechanisms between the dyad and external to the dyad are required to assess effectiveness and identify opportunities for improvement (O'Leary et al., 2017).

Conclusion

Co-leadership offers a promising approach to bridge competing demands in healthcare. However, successful implementation requires careful attention to dyad dynamics, role clarity, communication, organizational support, and ongoing evaluation. Further research is needed to understand the long-term impact of different co-leadership configurations on patient outcomes, staff satisfaction, and organizational performance.

References

Clark, R.C. & Greenawald, M., 2013. Nurse-Physician Leadership: Insights Into Interprofessional Collaboration. JONA: The Journal of Nursing Administration, 43, 653-659.

Clausen, C., Lavoie-Tremblay, M., Purden, M., Lamothe, L., Ezer, H. & Mcvey, L., 2017. Intentional partnering: a grounded theory study on developing effective partnerships among nurse and physician managers as they co-lead in an evolving healthcare system. Journal of Advanced Nursing, 73, 2156-2166.

Côté, A., Beogo, I., Abasse, K.S., Laberge, M., Dogba, M.J. & Dallaire, C., 2020. The clinical microsystems approach: Does it really work? A systematic review of organizational theories of health care practices. Journal of the American Pharmacists Association, 60, e388-e410.

Gibeau, É., Langley, A., Denis, J.-L. & Van Schendel, N., 2020. Bridging competing demands through co-leadership? Potential and limitations. Human Relations, 73, 464-489.

Godfrey, M.M., Nelson, E.C., Wasson, J.H., Mohr, J.J. & Batalden, P.B., 2003. Microsystems in health care: Part 3. Planning patient-centered services. The Joint Commission Journal on Quality and Safety, 29, 159-170.

Harbell, M.W., Li, D., Boscardin, C., Pierluissi, E. & Hauer, K.E., 2020. Teaching systems improvement to early medical students: Strategies and lessons learned. Academic Medicine, 95, 136-144.

Kim, C.S., King, E., Stein, J., Robinson, E., Salameh, M. & O'leary, K.J., 2014. Unit‐based interprofessional leadership models in six US hospitals. Journal of hospital medicine, 9, 545-550.

Mohr, J.J., Barach, P., Cravero, J.P., Blike, G.T., Godfrey, M.M., Batalden, P.B. & Nelson, E.C., 2003. Microsystems in health care: Part 6. Designing patient safety into the microsystem. The Joint Commission Journal on Quality and Safety, 29, 401-408.

Nelson, E.C., Batalden, P.B., Huber, T.P., Mohr, J.J., Godfrey, M.M., Headrick, L.A. & Wasson, J.H., 2002. Microsystems in health care: Part 1. Learning from high-performing front-line clinical units. The Joint Commission journal on quality improvement, 28, 472-493.

O'leary, K.J., Johnson, J.K., Manojlovich, M., Astik, G.J. & Williams, M.V., 2017. Use of unit-based interventions to improve the quality of care for hospitalized medical patients: a national survey. The Joint Commission Journal on Quality and Patient Safety, 43, 573-579.

Saxena, A., Davies, M. & Philippon, D., 2018. Structure of health-care dyad leadership: an organization’s experience. Leadership in Health Services, 31, 238-253.

Steinert, T., Goebel, R. & Rieger, W., 2006. A nurse–physician co-leadership model in psychiatric hospitals: Results of a survey among leading staff members in three sites. International Journal of Mental Health Nursing, 15, 251-257.

Wallenburg, I., Weggelaar, A.M. & Bal, R., 2019. Walking the tightrope: how rebels “do” quality of care in healthcare organizations. Journal of health organization and management, 33, 869-883.