A realist evaluation of the learning and practice development strategies in a Clinical Leadership Programme (CLP) to identify what works, in what context, and for whom, to impact on effective workplace cultures and person-centred clinical leadership practice

Abstract

Clinical leadership is pivotal for high quality care and transformation. Despite investment there is little robust evidence of the impact clinical leadership programmes (CLP) have on workplace culture. This thesis identifies the CLP processes that are most useful for understanding the relationships between micro (team) and meso (organisation) system levels, and how specific experiential learning and practice development (PD) strategies impact on micro and meso system culture and clinical leadership practice.

A realist methodology, undertaken between 2016-2020, comprised three foci: a concept analysis of clinical leadership; a realist synthesis of CLP; and a realist evaluation of work-based CLP, underpinned by PD, from an acute NHS hospital case study. Realist focus groups (n=3), realist interviews (n=3), and documentary analysis (n=2), across healthcare professions, roles, and genders, informed initial programme theories about what works in a CLP. Testing with the first integrated multiprofessional CLP participants (n=6); portfolios (n=2); stakeholder (n=5) and external CLP expert (n=4) interviews; and a Patient and Public Involvement representative, refined four resulting programme theories about what works, but also revealed what does not work, and the ‘dark side’ of clinical leadership development.

Four programme theories, illustrated metaphorically using two fairy tales ‘The Frog Prince’ and ‘The Emperor’s New Clothes’, informed a synthesised conceptual framework and impact continuum with enabling/disabling mechanisms impacting on CLP outcomes. Three paradoxes influence outcomes positively or negatively. Individual and team enablers/disablers, together with learning and PD strategies, can explain different outcomes on microsystem level culture. Two key factors, alignment, and psychological safety, are particularly influential on whether CLP impact on the development of flourishing or fractured workplaces and organisations. The insights presented in the Conceptual Framework and Impact Continuum for CLP can inform clinical leadership development for integrated health and social care, but will require further research to understand impact across the macrosystem.

Date of Award	2025
Original language	English