Research Article - (2020) Volume 8, Issue 6
Background: Clinical leadership is an intense skill leading to safer patient outcomes, while followership is flip side of good leadership. Coronavirus disease-2019 (COVID-19) pandemic has tested both leadership and followership, and as followers’ expectations multiplied, we conducted this single centre survey to assess junior doctors’ perception of leadership.
Materials and Methods: We performed an online cross-sectional survey, among the non-consultant group of doctors in all specialties at The Princess Alexandra Hospital NHS Trust United Kingdom (UK), over two weeks (20 April 2020 – 03 May 2020).
Results: 55 doctors responded to the survey. 32 (58.2%) of the participants had their rota changed during COVID-19 pandemic and 32 (58.2%) felt that changes to their working patterns affected their morale. 22 (40%) participants of the survey believed that they did not have adequate supply of personal protective equipment (PPE). 33 (60%) felt stressed during the pandemic. 16 (29.1%) had to take time off due to illness, of which 9 (52.9%) felt well supported by their colleagues and seniors. 23 (41.8%) of doctors were not satisfied by their departmental leadership, and 51 (92.7%) felt that their leaders were definitely or probably working beyond their competence.
Conclusion: Crisis management during the COVID-19 pandemic was associated with a degree of uncertainty and involved complex and rapid changes in workforce management and clinical protocols. Whilst trust and co-operation between clinical leaders and team members was crucial in maintaining good patient outcomes, the results of our survey highlight the fact that issues faced by the followers in times of crisis do impact their perception of leadership.
Junior doctor; Leadership; Perception; COVID-19
Clinical leadership is an intense non-clinical skill, without standard rules, characterised by effective management of a team, leading to safer patient outcomes in a complex hospital system [1]. Followership, on the other hand, is the ability to take direction well, be part of the team and to deliver on what is expected of you. Effective followership is the flip side of good leadership and is vital for a leader’s success, especially in times of crisis [2,3]. The complexities in the leadership role often involve quick decisions, and if compounded by improper communication between the leaders and followers in the team, can lead to a complicated relationship and lack of trust between them [4].
Coronavirus disease-2019 (COVID-19) pandemic has tested both leadership and followership, especially in the field of medicine. With frequent and ever-changing transformation in work pattern and policies, physical and emotional stress grew among the followers in the teams. This heightened stress increased the risk of burnout and brought changes in behaviour, performance and proficiencies [5,6]. With minimal training for redeployment to high-risk areas, team members also faced shortages in the availability of Personal Protective Equipment (PPE). The sense of security among the team members was also lost as they felt less protected and trained to cope with such a crisis [7]. All these issues compounded the negative perception of leadership among the followers within the team [8,9]. We conducted this single centre survey to understand junior doctors’ perception of leadership during the COVID-19 pandemic.
Questionnaire
A 17-item questionnaire was designed using Google Forms electronic survey. All questions were mandatory. A combination of forced choice questions was used (yes/no or yes/no/maybe). In addition to details of the department and position of the survey responders, the questions focused on their perception of the leadership within their respective departments, changes to their working pattern and psychological aftermath if any. The survey questionnaire can available as supplementary information.
Setting
The questionnaire was distributed by the NHS emails and local trust WhatsApp groups to all the non-consultant doctors at the Princess Alexandra Hospital NHS Trust. The survey was kept open for two weeks from 20 April 2020 – 03 May 2020.
Ethical considerations
Local research ethics committee approval was not required as all the participants agreed to participate voluntarily. The participants were assured that all the information provided will remain confidential and would not be used to identify individual responses.
A total of 55 doctors responded to the survey. Table 1 shows the distribution of grade and specialty amongst the doctors surveyed.
Table 1: Distribution of grade and specialty.
32 (58.2%) of the participants had had their rota changed during the COVID-19 pandemic, of which 28 (84.8%) felt that it had been necessary (Figure 1a and Figure 1b). However, 31 (56.4%) felt that the changed rota had not been well-balanced and 32 (58.2%) felt that changes to their working patterns were affecting their morale.
Figure 1A: Response to Rota change.
Figure 1B: Response to “Was rota change necessary?”.
Only 11 (29.1%) of doctors had been deployed outside their specialty. Whilst 46 (83.6%) claim not to have a background of stress or anxiety, 33 (60%) felt stressed during the pandemic. 16 (29.1%) had to take time off due to illness, of which 9 (52.9%) felt well supported by their colleagues and seniors.
22 (40%) participants of the survey believe that they did not have adequate supply of PPE, while 13 (23.6%) were not sure about adequacy of it. However, 20 (36.4%) stated that they had adequate availability of PPE.
23 (41.8%) of doctors were not satisfied by their departmental leadership, and 51 (92.7%) felt that their leaders were definitely or probably working beyond their capacity (Table 2). Out of 23 respondents of this survey who were not satisfied, 17 felt stressed during the current pandemic crisis, while 15 thought that their morale was low. However, 32 (58.2%) did acknowledge that their leaders were following government guidelines.
Table 2: Departmental leadership responses (n, %).
Our hospital is a District General Hospital in the United Kingdom (UK) serving a population of 500,000. During the peak of the pandemic, our critical care/Intensive Therapeutic Unit (ITU) capacity was overwhelmed by 660%. Significant redeployment occurred between specialties. In the initial phase of the pandemic, junior doctors were regularly challenged if they wore PPE to examine patients. The majority of infections in healthcare workers happened in this initial phase, before the PHE guidelines caught up with the reality in the frontline.
Our survey results showed that whilst the majority of our participants felt that rota changes had been necessary, more than half felt that the changed rota had not been well balanced. The majority of our participants felt stressed while working during COVID-19 pandemic and such incidence of higher stress has been witnessed during different periods of crisis [10,11]. Lack of availability of adequate PPE was an important issue for 40% of the responders and this has been shown to directly affect satisfaction with the leadership [12,13]. Not surprisingly, approximately half of the participants were not satisfied by their departmental leadership.
Clinical leadership is a hybrid role for a doctor, as in addition to clinical responsibilities they have the administrative responsibilities that come with the task of being a manager. These extra responsibilities are not always visible to those on the frontline [14]. In fact, junior team members as followers always have greater expectations from the leader in terms of support and wellbeing especially during times of crisis [15].
An imbalance between expectations and perceived lack of support can lead to reduced morale amongst the followers. Changes to work-pattern are also another factor for reduction in morale as witnessed in most of our responders. Building trust among team members is essential in a crisis and leaders however busy they may be, have to make time for regular meetings with followers. Constructive feedback is essential to acknowledge and reflect upon intra-departmental performance and to initiate new and innovative ways of providing patient care and utilising the depleted work force effectively [16].
Followers, however, also need to understand that in this pandemic, the whole world continues to learn, with no clear cut evidence for managing a multitude of situations – is full PPE required if you have an air filtration device; is COVID-19 transmitted via faeces; is colonoscopy safe; is laparoscopy safe; is regular testing of staff without isolation and social distancing at home sufficient to prevent staff to patient spread of the virus? [17-19]. The leader may need to take bold steps in thelarger interests of public health which may not seem favourable or straight-forward. Team members need to understand this process of divergent thinking and the amount of energy spent by the leaders in achieving overall organizational satisfaction. They also need to come forwards to join hands to become future leads of each emergency operation plan, to bring long-term changes under COVID-19 guidance. Loyalty, trust and support from the followers during a crisis goes a long way in encouraging resilience in the leader in making these difficult decisions [20]. As this was the first episode of the pandemic in 100 years, and as we have now learned different experiences around the world, teams should be better prepared for the second wave.
While everybody understands that there exists an uncertainty associated with the complex and rapid changes involved in the COVID-19 crisis management, never before has trust and cooperation between a leader and team members been more crucial, both to provide a sense of security for the team members and to deliver the best possible patient outcomes. Whilst what a leader does has not changed much in this pandemic, our survey highlights the importance of followership. In times of crisis, we believe that the profile of followership should match, if not supersede that of leadership.
Disclaimers
The authors alone are responsible for the content and writing of the paper, and are not an official position of the institution.
Funding
This article does not receive any funding from any institution or organization.
The authors declare that they have no conflict of interest.
Author’s Contributions
• Adeel Abbas Dhahri: Study design, data collection, data analysis, Writing and editing.
• Muhammad Rafaih Iqbal: Data analysis, Writing and editing.
• Nourelhuda Darwish: Data collection.
• Vardhini Vijay: Study design, Writing and editing.
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