Welcome to Transformational Thinking for Health Leaders. I'm Dr Fiona Day, EMCC Master Practitioner, Coach and Mentor and a registered Chartered Coaching Psychologist with the British Psychological Society. This is a podcast that will help you meet your most complex leadership challenges and transform your perspectives, helping you to become a more effective and creative leader with a deeper understanding of yourself and your own world of work.

I'm committed to transforming health outcomes through my work and to supporting and developing outstanding medical and public health leaders who are able to thrive in complexity and chaos, bring clarity and compassion to those they serve and improve health outcomes whilst also taking care of themselves in order to enable their own best work. I hope you enjoy listening to today's episode. Hello and welcome to Series 2 of my podcast.

I thought I would start this series with a critique of the evidence base for what works in health leadership development. There are two reasons for this. One is that a recent systematic umbrella review by Juliette Philipson et al has just been published in BNJ Leader.

This is a review of reviews and so its conclusions are particularly important. The other reason is that the England National Health Service NHS has set out a new 10-year plan with a specific goal of great leadership in healthcare, one where leaders in the health service are bold, relational and capable of leading system change. A section of the plan is dedicated to this and sets out how this will be achieved.

Proposals include establishing a college of executive and clinical leadership, publishing a new management and leadership framework, enhanced pay for over-performing leaders and giving leaders greater freedom such as empowering them to undertake meaningful performance appraisals. I'll put links to both the umbrella review and the 10-year plan in the show notes. This ambition to focus on developing inspirational and high-performing leaders at all levels in the NHS is of course both desirable and laudable but any plan needs a firm understanding of what really works to achieve this.

We know that competency frameworks and leadership do not directly translate to improved leadership behaviours and I'm concerned that leadership development interventions are often not based on rigorous theoretical models. Too often, as I've been surprised to encounter when working with hundreds of health leaders over the last 10 years, there has been a reliance on un-evidenced or outdated methods to train and nurture health leadership talent in the UK and beyond. Health leaders are doing the best they can but I believe they need much more nuanced support based on rigorous evidence to fully achieve their potential.

So firstly, the systematic umbrella review. I've recently completed a scope and review of coaching for doctors and a systematic review of public health leadership. Like any form of research, these careful evidence reviews are significantly time-consuming.

Both of mine have been major labours of love to complete in line with international standards and to prepare for publication so a big thank you to all the co-authors and peer reviewers for all your help. I'll share them in a newsletter and on my website when they've been officially published. So, you can see that undertaking a systematic umbrella review is a massive undertaking.

The authors state that whilst effective clinical leadership in healthcare has been recognised as a vital component in healthcare efficiency, there is a lack of systematic evidence supporting the clinical and organisational level impact and return on investment and that we still do not yet have consensus on the most effective educational methods or content to support leadership development. The authors also sought to aggregate and synthesise the literature on the effectiveness of healthcare leadership development for a range of staff groups rather than for specific subgroups of participants in order to determine best practises in leadership education and to quantify effects on individual and organisational outcomes. The authors note that leadership is a multifaceted concept with evolving definitions shaped by social dynamics, organisational behaviour and psychology, making its effects difficult to measure uniformly, which has been a challenge in my own systematic and scoping reviews too.

The authors note that leadership in healthcare is often viewed through both individual and distributed perspectives because authority and influence in healthcare is often collective rather than within a single individual. The authors have chosen a specific definition for this review, which is that of Blake, who defines leadership as achieving results with and through others. They also acknowledge that there is a variation in or lack of a standard definition in the synthesised literature.

You can read more in their paper about the methods, including the risk of bias assessments and the evaluation methods, including what level of outcomes have been reported using the Kirkpatrick scales. These are scales that range from individual level outcomes to behavioural outcomes through to organisational and even clinical outcomes, the latter being reported in only a third of the reviews. You can also read more about the quality of individual studies and the learner demographics.

However, almost 70% of the population included in the reviews were doctors, 50% nurses and over 45% healthcare managers or leaders. I notice that they don't mention public health specifically, so I think this means that public health leadership wasn't a lens that they were looking through. In terms of impact, they note that neutral or negative findings were rarely reported in any depth, but that no review concluded that overall impact was negative.

The majority of reviews reported that included studies had universally or predominantly positive outcomes. The benefits reported included positive participant reactions, improvements in decision making, communication skills, self-awareness, self-reported leadership competence, confidence in leadership roles and conflict resolution, and improvements in self-reflection. Behavioural changes were generally self-reported improvements, such as enhanced collaboration, time management, taking on leadership roles, research, quality improvement initiatives, reflective practises and better management of personal and professional boundaries, with a smaller number of studies including observer evaluations which corroborated with self-reported changes.

Organisational outcomes reported included improved team processes and culture, staff retention and career progression, and some programmes were linked to improved patient outcomes such as patient satisfaction, reduced complaints, and one which reported improvements in morbidity and mortality, and others which reported more broadly on organisational success or in a more vague way reporting organisational or clinical outcomes. The educational content was often not reported in the primary studies, but where it was associated with greater effectiveness, it included interpersonal skills, personal development, self-awareness, leadership theory, emotional intelligence, communication, role clarity in team dynamics, critical thinking and problem solving, a structured curricula and frameworks, as well as learning theory and breadth of content and change management. I'm particularly interested in the Umbrella Review results relating to specific educational methods because the form of coaching that I practise is more than providing a safe listening space for the client to figure things out for themselves.

I do, of course, absolutely provide this safe learning and reflective space. However, as a registered chartered coaching psychologist, I also combine this reflective space with coaching psychology-based interventions, and I also integrate this with mentoring, drawing on my own 20 years in medical and public health leadership roles, and that way I feel that I ensure that I offer the most effective bespoke development programmes for each individual that I work with, which is always based on a thorough understanding of each client's needs, both before and during our work together. Experiential learning and the use of coaching and or mentoring were associated with the greatest leadership outcomes.

Both coaching and mentoring were found to improve performance, enhance self-awareness, and to provide strong support for other developmental activities. One-to-one coaching was frequently highlighted as being particularly effective, with group coaching also offering benefits. One review found that coaching and mentoring were more often linked to achieving organisational level outcomes.

The authors also note that tailoring interventions to suit the specific management and leadership needs of participants and the organisational context was associated with greater outcome effects. The authors created a table of gold standard programme elements, the majority of which are already part of how I work as a coaching psychologist, both in terms of programme design and programme content. I was particularly pleased to see this, and the areas where I didn't meet these gold standards relate to the use of groups or mixed faculty.

However, I believe that a large proportion of the work that I do and the impact that I have can only be achieved on a one-to-one basis, and more to follow later in the podcast around this topic. The authors also note that there is a lack of shared theoretical foundation in leadership training and that few studies explicitly reference underpinning leadership theory. This is particularly interesting to me because this is what I have found over the last 10 years of working with medical and public health leaders across the UK and internationally, that they have not had the opportunity to learn evidence-based, theory-driven approaches to leadership and their own personal and professional development.

In summary, I feel this umbrella review is a very important paper and I've been using it for my own reflective practise. I'm not surprised that experiential learning, coaching and or mentoring have come out as being the most effective methods of developing health leaders, and of course coaching and mentoring are totally grounded in experiential learning. Though I think it would have been helpful if the authors had separated out coaching from mentoring because they are actually very different interventions.

Every mentor should learn how to coach, in my opinion, as workplace coaching has over 10 systematic reviews and meta-analyses behind it. And if you're using a coaching approach, you're actually helping the other person to shape the content of their mind and to help them to learn better which you're not doing when you're mentoring people. These systematic reviews and meta-analyses of workplace coaching have consistently found a positive impact on improved cognitive outcomes such as goal setting, self-awareness, sense of responsibility to one's own learning, goal achievement, goal-directed self-regulation, self-control, adaptability and flexibility, as well as improved meta-cognitive outcomes including the processing and organising of information, the planning, monitoring and revising of goal-orientated behaviours, internal self-regulation and cognition-stimulating, purposeful mental and behavioural changes such as goal attainment through a continuous cognitive process.

Coaching has also been shown by these reviews to have an impact on affective, also known as emotional outcomes, including satisfaction with coaching achievements, satisfaction with work, career and private life, wellbeing improvements, coping mechanisms, personal as well as work attitudes, motivation to apply new knowledge in the work environment, reduced stress, higher commitment to the organisation, greater self-worth, motivation, initiative, self-integration and also core self-evaluations such as self-efficacy and self-confidence. And on top of that, coaching has also been shown by systematic review and meta-analysis to improve skills outcomes such as improved performance and skills at work, including strategic thinking, decision-making, communication, interpersonal skills, improved transformational leadership, improved 360 leadership ratings for self and others and improved resource management such as time. Coaching in the workplace has also been shown to have impacts at team, organisational and system level and coaching psychology has been shown to have additional enhanced benefits on top of those of workplace coaching.

If you'd like to know more about this, then please see the links in the show notes to my website and to my three publications in BMJ Leader to this effect. So coming back to the England 10-year plan and its recommendations for health leadership, it's useful to remind ourselves that a growing body of research and studies show that leadership is a complex construct underpinned by values such as compassion. Whilst leaders can cognitively know the science of great leadership, ultimately we need them to consciously choose behaviours in the workplace on a moment-by-moment basis.

Before choosing how to respond, the leader must know themselves, their colleagues and stakeholders in minute, nuanced ways, their own internal thought processes and responses, also known as metacognition, noticing the details of their own and others' language and perceiving tiny changes in others' non-verbal communication. This demands that every health leader knows and consciously works to expand their psychological growth edge, the state of emotional discomfort which is uncomfortable yet tolerable, and this is highly personal, dynamic and expands as the leader develops and increases their comfort zone. Health leaders also need to understand the complexities of other humans and their own selves from a perspective of psychological trauma to gain insight into how this shows up every day in the workplace.

Processing complex information whilst actively listening to others, managing emotions and controlling impulses to communicate non-violently, being skilful in conflict situations and creating participatory environments for shared decision-making, problem-solving and effective collective action requires more than just leadership training. For most leaders, achieving this level of psychological sophistication requires a fundamental rewiring of their neural networks as the leader gradually progresses through various stages of adult development and sense-making, and I feel that this is really only achievable in one-to-one coaching relationships. To increase their psychological flexibility, leaders need to know and understand their own growth edge and then learn how to hone their reflections, insights, personal and professional development on an ongoing basis.

They need bespoke professional development, highly nuanced to their unique needs in one-to-one contexts. Leaders need safe professional relationships outside of their workplace where they can examine and be totally vulnerable to their own internal psychological processes and how these manifest as behaviours in the workplace. To achieve world-class leadership in the NHS in England and in a wide range of other contexts globally, we need experts who are able to expand leaders' development using a wide range of psychologically sound approaches to behaviour change and the achievement of potential.

Coaching psychology is a discipline within psychology which focusses on potential and wellbeing in the workplace. I believe it is the most evidence-based way to enable leaders to develop the psychological flexibility, metacognitive skills and emotional regulation needed to fulfil their potential and also to stay well in their roles. Registered Chartered Coaching Psychologists are experts in the field of leadership development.

They are uniquely able to use their training to identify on a moment-by-moment basis with each individual client what core biopsychosocial processes, i.e. an individual's biological and psychological processes plus effecting change within the wider system, should be targeted with this specific leader given this goal in this situation and how can they be most effectively and efficiently changed to best impact the desired outcomes. The new planned England College of Executive and Clinical Leadership must provide evidence-based programmes for those in clinical and managerial leadership roles. However, without the ability to also provide robust individual coaching psychology-based interventions, we are unlikely to achieve the scale of leadership development which is required.

If we want outstanding health leaders, we need to go further than the recommendations in the plan. There is no upper limit of adult development, but without continuously and consciously cultivating exceptional psychological flexibility, clinicians and managers cannot become world-class leaders. Only through the widespread integration of the science of coaching psychology into leadership development, including personalised individual support, in the context of helpful organisational structures and cultures, do we have any hope of achieving this vision and positively impacting health outcomes in England and beyond.

Thank you for listening to my podcast and please do check out the show notes for links to the documents that I've talked about in the show and please do pass this podcast on to anybody that you think would enjoy listening to it. Thank you ever so much for listening. If you've enjoyed this podcast and would like to find out more, head over to www.fionadayconsulting.co.uk and you can receive 3 hours of free CPD through my Health Career Success programme and there's loads of other resources to support you as a medical or public health leader on my website too.

I greatly value any feedback and to know what you would like more of, so please don't hesitate to get in touch with me at fiona at fionadayconsulting.co.uk to help me to better meet your needs. Thank you for listening and for your commitment to transforming health outcomes.