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\begin{document}

\title{LEADS+ Developmental~ Model: Proposing a new model based on an
integrative conceptual review}



\author[1]{Sandra Ramelli}%
\author[1]{Sarrah Lal}%
\author[1]{Jonathan Sherbino}%
\author[2]{Graham Dickson}%
\author[1]{Teresa Chan}%
\affil[1]{McMaster University}%
\affil[2]{Royal Roads}%


\vspace{-1em}



  
  \date{May 19, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
\textbf{Purpose:} Leaders in academic health sciences centres (AHCs)
must navigate multiple roles as an inherent component of their
positions. Changing accountabilities, varying expectations, differing
leadership competencies required of multiple leadership roles can be
exacerbated by health system disruption, such as during the COVID-19
pandemic. We need improved models that support leaders in navigating, so
they can better handle the complexity of multiple leadership roles.

\textbf{Method:} This integrative conceptual review sought to examine
leadership and followership constructs and how they intersect with
current leadership practices in AHCs. The goal was to develop a refined
model of health care leadership development. The authors used iterative
cycles of divergent and convergent thinking to explore and synthesize
various literature and existing leadership frameworks. The authors used
simulated personas and stories to test the model and, finally, the
approach sought feedback from knowledge users (including health care
leaders, medical educators, and leadership developers) to offer
refinements.

\textbf{Results:} After five rounds of discussion and reformulation, the
authors arrived at a refined model: the \emph{LEADS+ Developmental
Model}. The model describes four nested stages, organizing progressive
capabilities, as an individual toggles between followership and
leadership. During the consultation stage, feedback from 29 out of 65
recruited knowledge users (44.6\% response rate) was acquired. More than
a quarter of respondents served as a senior leader in a health care
network or national society (27.5\%, n=8). ~Consulted knowledge users
were invited to indicate their endorsement for the refined model using a
10-point scale (10=highest level of endorsement). There was a high level
of endorsement: 7.93 (SD 1.7) out of 10.

\textbf{Conclusion:} The \emph{LEADS+ Developmental Model} may help
foster development of academic health centre leaders. In addition to
clarifying the synergistic dynamic between leadership and followership,
this model describes the paradigms adopted by leaders within health
systems throughout their development journey.%
\end{abstract}%



\sloppy


\textbf{NOTE ABOUT AUTHORSHIP:} Please note that Sandra Ramelli \&
Sarrah Lal are co-first authors for this paper.

Introduction

Health systems in the 21\textsuperscript{st} century face increasing
complexity. Technological advances, changing patient demographics and
expectations, fiscal pressures, accelerated information flow, and health
human resource challenges, among others, are exacerbating the
complexity.\textsuperscript{1} The pandemic has added a layer of
interconnectedness that leaders in health care have not seen before.
Concomitantly, the pandemic has created `wicked
problems'\textsuperscript{2}, challenges of such intricacy and breadth
that current leadership practice is unprepared for, and therefore has
exposed leadership gaps in academic health centres. We need models to
support emerging and practicing leaders in navigating multiple
professional identities often required to deal with such issues. New
leaders must better understand the emerging complexities of their jobs
across both academia and health care. This will help healthcare leaders
navigate competing priorities, understand the nuances of inter-personal
dynamics and organizational politics, also climb the ranks in both
academic and health care settings.

This paper explores the nuanced roles and career paths of health systems
leaders within academic health centres (AHCs, clinical units that are
affiliated with academic institutions/universities). In matrix
organizations,\textsuperscript{3} such as AHCs, there are at least two
entities at play: a hospital and a university. Matrix organizations are
interdependent organizations with separate cultures and systems that are
connected by individuals who cross between groups, seeking to enact
common outcomes across an organization. Based on its strategic and
operational realities, each entity within an AHC has unique goals,
values, and priorities. Each enterprise also presents different
challenges and knowledge users. The interconnectedness of hospital
systems and academic institutions within AHCs results in individuals
holding multiple roles and, across these, multiple identities. Leaders
working within each entity are often left to navigate competing needs,
goals, values and perspectives.\textsuperscript{4}~ Wicked problems --
demanding a multiplicity of organizational interests and perspectives --
confuse identities further. This is exemplified in different exhibited
behaviors, leadership, and management styles, trade-offs, and ways of
thinking based on context.

As individuals advance in their career, they are often challenged to
develop both personally and professionally. The capacity to do so is
variable between individuals. Leadership roles may include professional
identities as a clinician, administrator, researcher, educator, opinion
leader, among many other professional (and personal) identities.
Regardless of their professional identity, we argue that each person
must engage in both leadership and followership (i.e. a phenomenon in
which individuals support the leader through assuming responsibility for
given objectives, serving the requests made of them,
challenging/debating the leader when appropriate, participating in
organizational transformation, and taking moral action as
needed\textsuperscript{5,6}) with increasing nuance as they advance
their roles. ~

The \emph{LEADS in a Caring Environment framework} (LEADS framework) was
developed in 2006 to articulate and promote core leadership capabilities
in health care.\textsuperscript{7,8} Today, the LEADS framework (or
adapted versions) is one of the most popular leadership frameworks for
health systems in Canada\textsuperscript{9,10} with adoption in
Australia\textsuperscript{11}, Belgium\textsuperscript{12},
India\textsuperscript{13}, Israel\textsuperscript{8,14} and has strongly
influenced the United Kingdom's Faculty of Medical Leadership and
Management's certification standards. Leaders who inhabit multiple roles
may grapple with how to apply the LEADS capabilities across their
multiple roles of varying seniority. For example, while - case in point,
the ``L'' in the LEADS framework refers to \emph{Leading Self} (implying
a singular identity), this poses a challenge when multiple identities
have to be managed and integrated into one's notion of self. However, it
does not explicitly guide leaders navigating multiple roles within
integrated systems, where seniority and complexity vary. Indeed, an
individual may have an executive role in hospital administration, serve
as a clinical supervisor, and be a mid-career faculty member in an
academic department; and the same wicked problem around hospital staff
wellness may be seen differently from each role's vantage point. The
LEADS framework can help an individual to employ their leadership within
a defined system. Without adaptation, it is unlikely that the current
\emph{LEADS framework}, nor any other health care leadership framework,
will explicitly address the context of an AHC leader who has multiple
roles and, more broadly, the fluidity that must exist between leadership
and followership.

Considering the strengths of the LEADS framework and the need to explore
new ways to encapsulate the multiple roles of leader-follower, we set
forth to build upon this prior work. Our new framework (the \emph{LEADS+
Developmental Model}) \emph{} articulates leadership and followership
practice when serving in multiple leadership roles of varying
seniority.\textsuperscript{15,16} Four styles of engagement within an
AHC are described: two followership styles (essential, strategic) and
two leadership styles (role- and complexity-based). We propose that
advanced leadership requires fluid shifts for the \emph{Leading Self}
domain of LEADS, as leaders must reconceptualize themselves from a
leadership/followership perspective as appropriate for given roles,
organizations, and context.

\section*{Methods}

{\label{179336}}

An integrative conceptual review\textsuperscript{17} was conducted to
explore how a leader's development interfaces with a leading health care
leadership framework, the \emph{LEADS in a Caring Environment}
framework. Similar to the process used by Gottlieb and colleagues,
sequential iterative cycles of divergent and convergent thinking were
employed, exploring various vantage points and theories within the
literature.\textsuperscript{18} Ultimately, the perspectives of the
authors coalesced into a singular conceptual framework. Figure 1 depicts
our workflow.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Screenshot-2023-02-17-at-10-21-04-AM/Screenshot-2023-02-17-at-10-21-04-AM}
\caption{{Workflow for our present integrative conceptual review
{\label{698087}}%
}}
\end{center}
\end{figure}

\subsection*{The Team}

{\label{333447}}

Our study team was composed of two clinician-educators with leadership
roles (JS, TMC, both with decanal positions in education leadership),
one health care administrative leader who also holds a faculty
appointment (SR), one leadership and health entrepreneurship educator
who also holds leadership roles within an incubator and several
start-ups (SL), and a PhD professor of leadership studies, who is one of
the originators of the \emph{LEADS} framework and the head of a
non-profit organization (GD).\textsuperscript{7,8} Throughout the
process we empowered members of the team to challenge each other's
personal assumptions and interrogated our selections of theories to
ensure that we remained reflexive about the literature reviewed.

\par\null

\subsection*{Discussions Within the Analysis
Team}

{\label{792063}}

First, we conducted a pilot review of various leadership frameworks and
theories (this was done by SR, SL, TMC). This step formed the basis of
initial discussions. The most salient framework was felt to be the
\emph{LEADS} framework because of its prominence in Canadian
healthcare.\textsuperscript{7,8} Kegan's model of human
development\textsuperscript{19} was selected to augment the LEADS
framework because it seemed to provide the developmental framing that we
felt was absent from the LEADS framework. These two frameworks continued
to inform our discussions, similar to how sensitizing concepts are
incorporated in other qualitative methods.\textsuperscript{20}
Situational leadership \textsuperscript{21} and the
Cynefin\textsuperscript{22} frameworks inspired thinking about the
adaptive nature of leadership and the advanced proficiencies required to
discern among appropriate styles for a given context.

\par\null\selectlanguage{english}
\begin{longtable}[]{@{}l@{}}
\toprule
\textbf{Box 1: What is the~}\emph{\textbf{LEADS in a Caring
Environment}} \textbf{framework?~ ~} The LEADS in a Caring Environment
Capabilities Framework is a framework that identifies the leadership
capabilities needed to effectively lead and manage in the context of
Canadian healthcare. What makes the framework unique from other
competency/capability frameworks is that the LEADS framework is built on
the foundation of CARING -- caring for patients, for staff, for
providers and for the health of the population. The LEADS in a Caring
Environment framework represents the key skills, behaviours, abilities
and knowledge required to lead in all healthcare sectors and in all
levels of the health system. The framework is made of five key domains:
Lead Self, Engage Others, Achieve Results, Develop Coalitions and
Systems Transformation, and within each domain there are four key
capabilities describing what effective leadership looks like. The
framework is designed to show the interplay between leadership and
management as both are equally needed to lead effectively in the
healthcare sector and is designed to be relevant to all roles in
healthcare, be it academic, clinical or administrative. In addition, it
represents a `distributed leadership' approach to defining leadership~ -
that is, it outlines that any~ individual ---regardless of where they
sit in the healthcare system and/or regardless of what~ role/title an
individual may have --- they can lead from where they are. Everyone can
play a role in transforming healthcare and the LEADS framework is a
model that can be leveraged to enable effective leadership in
healthcare. ~\tabularnewline
\bottomrule
\end{longtable}

~\selectlanguage{english}
\begin{longtable}[]{@{}l@{}}
\toprule
\emph{\textbf{Box 2: Kegan's Human Development Model (including the
Orders of Consciousness)}} The Kegan Human Development model is a
framework that reinforced identity formation as a complex phenomenon
that is shaped through experiences. The number and breadth of
experiences enables individuals to have and learn how to objectively use
these perspectives. Challenges bring about changes in the perspectives
that an individual has and their ability to use these in combination to
navigate the world around them. The perspectives are first-order or
second-order (imperial, incorporative, impulsive), third-order
(interpersonal), fourth-order (institutional), and fifth-order
(inter-individual). The first- and second-order stages involve a focus
on self without acknowledgement of the wants or needs of others. The
third-order stage involves an awareness of the needs of self and others.
The fourth-order stage involves an acceptance of aspects of self,
others, and systems that were formerly rejected, due to the development
of self-authorship. The fifth-order stage involves systems-level
thinking and the recognition of multiple selves in self and others. This
framework conceptualizes human development as an incremental progression
through an increasingly complex view of self, others and systems. It is
worth noting that not everyone achieves all orders of consciousness.
~\tabularnewline
\bottomrule
\end{longtable}

We engaged in multiple rounds of discussions via videoconferencing with
memo-generation and collaborative conceptual development using
cloud-based, real-time interactive documents. Each session lasted
approximately one-hour.

\par\null

Literature Review \& Synthesis

{\label{literature-review-synthesis}}

After refining our initial model, we conducted a focused literature
review. We drew from literature within health systems leadership,
followership and organizational development, contrasting our own newly
formulated conceptualization with other existing models. We engaged in
iterative rounds of revisions. Ultimately, we crystalized our thinking
into one conceptual model (see results section), which we refined
through persona-driven testing (i.e. cognitive simulations with various
types of simulated characters that used to elucidate each role in
various scenarios) and knowledge user
consultation.\textsuperscript{23,24}
\protect\hypertarget{_vy7of42x5t3l}{}{}We then developed personas that
were based on exemplars from our collective experiences test and
prototype our model.\textsuperscript{23--25} The vignettes are found in
the online supplemental appendix.

After refining our initial model, we conducted a focused literature
review. We drew from literature within health systems leadership,
followership and organizational development, contrasting our own newly
formulated conceptualization with other existing models. We engaged in
iterative rounds of revisions. Ultimately, we coalesced our thinking
into one conceptual model (see results section), which we refined
through persona-driven testing (i.e. cognitive simulations with various
types of simulated characters that were used to elucidate each role in
various scenarios) and stakeholder consultation.\textsuperscript{22,23}

\par\null

Knowledge user consultations

{\label{stakeholder-consultations}}

Similar to knowledge user consultations endorsed by scoping
reviews\textsuperscript{26} and the \emph{Canadian Institutes of Health
Research} Knowledge Exchange process\textsuperscript{27} and based on a
prior published process\textsuperscript{~}, we sought formative feedback
on our provisional concepts from a range of educators, experts, and
frontline practitioners from across North America via a snowball
sampling technique, starting with nominations from experienced
leadership developers within our team (GD, TC, JS). Our newly proposed
model along with associated persona-driven vignettes were submitted to a
representative sampling of health system knowledge users (clinicians,
administrators, educators and researchers in health care leadership) for
review.

Our inclusion criteria were that the individual would meet one of the
following criteria:

1)~~~~ Personal experience in blended leadership roles across two or
more organizations/units;

2)~~~~ Supervised/lead others who bridge across more than one role; or

3)~~~~ Actively engaged in teaching or scholarship about leadership
training and development.

We excluded those who met the above criteria but had no experience
within the North American health care context. We constructed a simple
survey tool with an embedded video
(\url{https://bit.ly/BridgeLEADsurvey}) and requested that each
knowledge user help us to identify the strengths, weaknesses, and
relevance of the conceptual model to their own leadership-related
practice. The quantitative aspects of the survey were analyzed using
simple descriptive statistics. The qualitative aspects initially
underwent a thematic analysis\textsuperscript{28} by the senior author
(TMC) and was subsequently checked by the first authors (SR, SL). We
subsequently met with each of the leaders for a one-on-one interview led
by our senior author (TMC) to gather feedback from those who volunteered
to engage with us to provide further feedback. A thirty-minute,
one-on-one Zoom interview (Zoom communications, Inc., San Jose, CA) was
completed within a one-month span with any knowledge user who sought to
provide verbal feedback about our model in addition to their survey
responses. Feedback was incorporated into the body of the paper
throughout the writing process.\textbf{}

\section*{Results}

{\label{905664}}

The \emph{LEADS+ Developmental Model} articulates the acquisition of
leadership capabilities, providing tangible milestones for healthcare
professionals embarking on their leadership journeys.

\subsection*{Contrasting to Prior Leadership Frameworks and
Models}

{\label{567068}}

In our review of the prior literature (both from within and outside of
health care), we noted that there was a paucity of frameworks that
mapped the developmental journey of leaders. There were many papers that
told the story of individual leaders'\textsuperscript{29--32}, how
senior individuals might mentor junior leaders\textsuperscript{33}, or
health care systems' developmental pathways journeys throughout a
career.\textsuperscript{34--36} However, most of these frameworks do not
explicitly articulate the asymmetric growth of a leader across multiple
roles nor stratify their progression via acquisition of more complex
leadership capabilities (e.g., within themselves, in relation to small
teams, with regards to other organisations and groups, and finally in
achieving systems changes or results). For instance, Heifetz's adaptive
leadership approach suggests that a given leader should change and adapt
to their context\textsuperscript{37}, but assumes that a leader is at a
specific stage within variable contexts and does not provide the insight
about how a leader's roles change over time.

Meanwhile, the meta-leadership framework (developed by McNulty, Marcus
and their other colleagues from Harvard)\textsuperscript{38--40}~ speaks
to the need for leaders who can bridge multiple worlds and work
together, especially in times of crisis. The meta-leadership framework
was first developed from studying various emergency situations (e.g.,
Boston Marathon Bombing) and is highly resonant with our
complexity-based leadership phenotype. However, meta-leadership does not
speak to the versatility of an individual to switch between various
types of engagement or leadership and followership in varying contexts,
nor does it compare meta-leadership with other stages of development
that a leader might encounter on their professional development journey.

Numerous other leadership frameworks have multiple levels (e.g. Collins'
Good to Great five leaders levels\textsuperscript{41}) or loosely
describe various stages a leader may experience though their lives (e.g.
Joiner \& Joseph's Leadership Agility\textsuperscript{42}), but few
models tend to pull together the various aspects of development into a
model that expects a health care leader to variably manifest
capabilities in different contexts.

\subsection*{Selecting the Frameworks for
Integration}

{\label{203810}}

The LEADS framework is well known across the Canadian health care
landscape and is used as the basis for numerous leadership development
programs; it has more specificity than the Leader Role identified in the
2015 CanMEDS Physician Competency Framework.\textsuperscript{43,44}
After review of existing models, we felt that although the \emph{LEADS}
framework mapped the capabilities of health care leaders, it was not
clearly adaptable to situation in which a leader has multiple
organizational roles. The \emph{LEADS} framework does not explicitly
account for the context nor experience of an AHC leader who has multiple
synchronous roles of mixed-seniority.~ Similar to other
outcome-frameworks in health care, the \emph{LEADS} framework describes
the capabilities of the ideal leader.~ Complimentary to the \emph{LEADS}
framework, Kegan's adult development model focuses on an individual's
cognitive development without any specific attention leadership
capabilities. Prior work by Kegan and colleagues has described various
ways in which individuals develop and assume various orders of
consciousness, engage in constructive-development (despite an innate
resistance to change), and create cultures that support all members of
an organization.\textsuperscript{19,45,46} As such, we felt that a
``remix'' of these two frameworks might be most informative for AHC
leaders.

\subsection*{\texorpdfstring{Synthesis of Selected Frameworks:
\emph{LEADS} meets
Kegan}{Synthesis of Selected Frameworks: LEADS meets Kegan}}

{\label{976404}}

The \emph{LEADS+ Developmental Model} highlights stages of leadership in
matrix organizations and promotes self-reflection to help leaders manage
multiple leadership identities. See Table 1.~ The Supplemental Digital
Content (Appendix 1) provides worked examples for each of the phenotypes
within this model. The model may support teams in understanding roles
played by their leaders in various contexts. Talent \& leadership
developers, such as educators in university-affiliated faculty
development teams or hospital-related organizational development units,
seeking to add more theoretical underpinnings to their courses or
programs can use it to scaffold their curricular design. Coaches and
mentors seeking to provide one-on-one support for AHC leaders may also
find the \emph{LEADS+ Developmental Model} helpful as a reflective tool.\selectlanguage{english}
\begin{table}[H]
\centering
\normalsize\begin{tabulary}{1.0\textwidth}{CCCCCCCCC}
Domain of Behaviour &  & Kegan's model of Human Development & LEADS framework domains &  &  &  &  &  \\
 &  &  &  &  &  &  &  & Versatility \\
 &  &  & Leading Self & Engage Others & Achieve Results & Develop coalitions & Systems Transformation & (Shifting between Domains of behaviour) \\
A leader would... &  &  &  &  &  &  &  &  \\
 Engaging & Essential Followership & Imperial, Incorporative, Impulsive & Explore and define self in context & Explore and define how to engage with others & Working towards tasks as prescribed by context/others in the team but are not intentionally mission- aligned. & N/A & N/A & N/A \\
 &  & (First or Second Order) &  &  &  &  &  &  \\
 & Domain 1 &  &  &  &  &  &  &  \\
 &  & Represents a stage when first forming and perceiving the world around oneself. Usually refers to stages within childhood, but can apply to those new to roles or organizations. &  &  &  &  &  &  \\
 & Strategic Followership & Interpersonal & Recognizing yourself as interdependent with others & Aligning with team or organizational values. Orientated towards affiliating well within group & Achieves goals articulated by context/others in team (cultural imperative) & Work with individuals who have commonalities including goals and attributes (group think) & N/A & Ability to shift between Strategic Followership and Essential Followership. \\
 &  & (Third Order) &  & ("Fitting in") &  &  &  &  \\
 & Domain 2 &  &  &  &  &  &  &  \\
 &  & Individuals see their role in society or an organization. &  &  &  &  &  &  \\
 Leading & Role-based Leadership & Institutional & Gives themselves permission to see themselves as a leader & Understanding individuals are interdependent and need mutual exchange/support & Achievement orientation - & Articulate and pursue opportunities for transactional relationships with mutual benefit  & Design functional systems or navigate change from their zone of control; singular perspective & Ability to shift between Role-based Leadership to Strategic Followership. \\
 &  & (Fourth Order) &  &  & winning for own team &  &  &  \\
 & Domain 3 &  &  &  &  &  &  &  \\
 &  & Individuals see themselves as actors within systems. &  &  &  &  &  &  \\
 & Complexity & Inter-Individual  & Define and articulate multiple identities  & Help others to engage in self-authorship & Non-competitive win-win condition (complexity and polarity theory - "AND") & Recognize multiple and common citizenship amongst traditionally disparate groups, break down silos and build bridges & Facilitate convergence and synergy among multiple groups via empowerment, and alignment  & Ability to shift between Complexity-based Leadership to Role-based Leadership to Strategic Followership. \\
 & -based Leadership & (Fifth Order) &  &  &  &  &  &  \\
 &  &  &  &  &  &  &  &  \\
 & Domain 4 & Individuals see themselves as highly connected within a complex world across various systems. Seeking to connect and transform systems that should link. &  &  &  &  &  &  \\
\end{tabulary}
\caption{{A table that describes the \emph{LEADS+ developmental model} which has
been developed by overlaying Kegan's model of human development and the
LEADS framework.
{\label{420436}}%
}}
\end{table}\par\null

\textbf{}Importantly, this model highlights opportunities for
individuals to enhance their leadership effectiveness within an AHC.
Simultaneously, it can serve as a guide for health leadership
development programs.\textsuperscript{1} \textbf{}

\subsection*{Followership within the LEADS+ Developmental
Model}

{\label{551530}}

The base of the \emph{LEADS+ Developmental Model} is formed by our
conceptions of what we call \emph{essential followership} and
\emph{strategic followership}. Often individuals in AHCs engage with the
work and mission but may not be specifically displaying (or feeling
ready to act upon) their leadership capabilities. Aligned with the
concepts of distributed leadership, Dickson et al. have noted that that
anyone can exude informal leadership skills and that learning to lead
means that you must also learn to follow.\textsuperscript{47} That is to
say, that while anyone can be a leader, not everyone must lead in all
circumstances, on all teams, and in all contexts. When individuals
cannot be \emph{the} leader ---i.e., when there is a more appropriate
individual to lead, or the individual's energy or capacity is
depleted---they must become effective followers. There is an emerging
literature on the concept of followership - the capabilities to support
the leader and team. While some scholars criticize the term as being
outdated due to increasingly flattened hierarchies in specific cultural
contexts\textsuperscript{48,49}, there are distinct situations when team
members deliberately choose to follow the lead of another to implement a
strategic direction, rather than be the first to exercise the power or
influence needed to achieve a strategic goal.

\textbf{Essential Followership.} At this stage an individual is
discovering their place within the organization and requires guidance to
effectively engage in necessary day to day activities. An example is a
newly graduated clinician (e.g., physician, nurse practitioner) who has
completed their onboarding and orientation to their first clinical job
in a cardiac rehabilitation unit. This clinician will looks to others
within the team to lead meetings, set the clinical schedule, present,
and prioritize new quality improvement projects, develop new processes
etc. In this context essential followership is expected and necessary.
This individual needs to acquire tacit information about the team, build
relationships with team members, develop social capital, avail
themselves of opportunities to complete work valued by the team, and
eventually discern leadership gaps they might fill. However, at the
beginning of their journey, the individual may simply need to be given a
particular mandate (e.g., their initial job description).

\textbf{Strategic Followership.} Many individuals may find themselves
evolving beyond essential followership as they seek to enhance their
position within an AHC team. While a sense of belonging can certainly be
affected by cultural drivers and inclusionary best practices, alignment
with an organization's strategy (aims and goals) may help individuals to
advance in their leadership aspirations. An example of strategic
followership is a finance manager within a unit that reports directly to
a head of a large academic department who seeks to integrate their
actions with the ethos of the organizational culture around them, taking
cues from senior leaders, and acts with more creativity and less
oversight. Depending on an organization's goals and culture, this leader
will morph their actions accordingly to strategic alignment. For
instance, the finance manager in our example may seek to find ways to
reduce costs in one sector to reallocate those costs to another area of
strategic importance for the department. In some settings this has been
described as leading from any seat and a manifestation of distributed
leadership principles.\textsuperscript{50}

\par\null

\subsection*{Leadership within the LEADS+ Developmental
Model}

{\label{102538}}

As individuals advance within an AHC, they may often head into a phase
where they begin taking on both formally identified leadership roles.
This leads to two types of formal leadership: \emph{role-based
leadership} and \emph{complexity-based leadership}.

\textbf{Role-Based Leadership.} This category of leaders work within the
boundaries and mandate of their title. Role-based leaders, sometimes
described as formal leadership, often define themselves in relation to
other groups via their role. One example is a department chair. This
type of leader displays high interpersonal mutuality, a term coined by
Kegan to explain how an individual engages with others on a
transactional level due to their perceptions of themselves. As a
role-based leader identifies with their position they begin to see how
to engage with other groups in a mutually beneficial manner. For
example, the department chair may be protective of colleagues within the
department, preventing another service unit from making unreasonable
demands on their time. Those who see themselves exclusively as
role-based leaders have an achievement orientation for their team to
stand out, defining their own success via the team.~ However, this
stance may result in challenges when interactions with other groups
necessitate coalitions that diminish the leader's profile. Organizations
that force linear and hierarchical accounting or reporting structures
may inherently force individuals into role-based leadership stances.
Role-based leadership structures confine the role, influence, and
accountability of the leader. As well, the creativity and responsiveness
of a leader may be stifled by the hierarchical processes of role-based
leadership within the complex environment of AHCs.

\textbf{Complexity-Based Leadership.} In the \emph{LEADS+} framework,
complexity-based leaders look beyond a singular identity to wrestle with
and reconcile their multiple roles. Complexity-based leadership
acknowledges that people can be ``leading from every
seat,''\textsuperscript{47} but also that collective and distributed
leadership can be far more advantageous in complex
environments.\textsuperscript{51} These individuals self-author their
leadership roles by engaging others across the AHC, identifying issues
that cross programs and departments and achieve results via
non-competitive wins for multiple groups (including their own). For
example, a vice-president of innovation and research integrates their
role as a clinician, hospital administrator and university professor to
identify an opportunity for the AHC to compete for new governmental
funding.~ Developing a proposal requires a coalition of various
knowledge users that the complexity-based leader connects via their
diverse professional network. This leader implements a strategy to
pursue innovation funding that leverages common and intersecting needs
across the programs and institutions within the AHC

Complexity-based leaders leverage shared commonalities and alignment of
values to break down silos and build effective coalitions between
traditionally disparate groups. Typically, this type of leader emerges
from previously held formal role-based leadership positions. However,
complexity-based leaders may also be outside of formal hierarchical
structures; they are not limited by titles. Knowledge of organizational
structures and processes allows complexity-based leaders to identify
non-linear systems outside of regular reporting structures or AHC
divisions. Complexity-based leaders tackle big goals beyond the
immediate accountability of any one unit, helping the AHC to become less
fragile.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/5---Figure-2/5---Figure-2}
\caption{{This graphic depicts the elements of the LEADS+ Development Model.
{\label{291186}}%
}}
\end{center}
\end{figure}

\subsection*{Versatility: Integrating followership and
leadership}

{\label{844037}}

Leaders that exhibit versatility will adjust their leadership or
followership traits to fit the situation or need. Their capabilities may
exist but waiting for the right context to exhibit them is important.
For example, when dealing with a global pandemic that disrupts both
clinical and academic missions of an AHC\textsuperscript{27-29}, an
academic department chair may be engaging with multiple departments
across the AHC, dynamically toggling between leading (as the lead of
their academic department) and following (as a member of a clinical
group). Having this versatility to transition between roles allows an
individual to align with others and fill the necessary function of
serving the larger process or goal. Similar to the way that individuals
might move through various milestones throughout their development and
not lose their previously attained skills, we imagine versatility
functioning in this way. Once the capabilities of followership and
leadership are acquired, individuals would be free to enact these skills
in the situations that suit it best (aligned with the theories of
situational leadership\textsuperscript{21}).

\textbf{Knowledge User Consultation Findings}

During our knowledge user consultation stage, we were able to receive
feedback on the conceptual model from 29 out of 65 recruited individuals
(44.6\% response rate). Roughly one third of individuals (10/29; 34\%)
offered to provide verbal feedback via one-on-one interview sessions
with our senior author. Most of the participants held multiple
leadership roles across academia and health care (48.3\%, n=14). More
than a quarter of participants were senior leaders in a health care
network or national society (27.5\%, n=8) See Table 2 for demographic
details about the knowledge users.~ During the knowledge user
consultation stage, participants indicated their endorsement for the
LEADS+ Development Model using a 10-point scale.~ There was a high level
of endorsement: 7.93 (SD 1.7) out of 10 (1=Hated this new model,
10=Loved this new model). Most of the knowledge users surveyed felt that
the framework resonated with them. One wrote that they felt the model
was: ``comprehensive, developmental, aspirational.'' See Table 3 which
details themes and exemplar quotes from our survey of the knowledge
users). All the interviewees thought that the framework was highly
useful to them as leadership developers or relevant to them as
practicing leaders. ~No substantial changes were suggested however, many
gave contributions suggesting next steps on how they might apply the
framework in their leadership programs or practice.\selectlanguage{english}
\begin{table}[H]
\centering
\normalsize\begin{tabulary}{1.0\textwidth}{CCC}
Knowledge User Population & Number of Respondents (n) & Percentage of respondents \\
Practicing Clinician & 10 & 0.44 \\
Leadership Researcher & 3 & 0.13 \\
Leadership Educator & 10 & 0.44 \\
Academic Leader & 12 & 0.52 \\
Senior Executive at Hospital & 5 & 0.22 \\
National Organizational Lead & 2 & 0.09 \\
NB: Since we purposefully sought the input of those who might bridge more than one role and exist as practitioners of leadership within complex environments, the \% total is greater than 100\%, since many stakeholders held more than one role simultaneously. &  &  \\
\end{tabulary}
\caption{{Demographics of Knowledge User Consultants
{\label{765362}}%
}}
\end{table}\selectlanguage{english}
\begin{table}[H]
\centering
\normalsize\begin{tabulary}{1.0\textwidth}{CC}
Themes from the Knowledge User Survey & Exemplar Quotes \\
Affirming Themes &  \\
Appreciation for the merging of the two other conceptual frameworks to bring more complexity to the original LEADS framework. & "I do like the additional complexity and clarity that it provides to the standard LEADS framework. It has more 'depth.'" \\
 &  \\
 & "It has been well thought through and is articulated well. I also like how it integrates leads with other concepts and might help practitioners think about LEADS more dynamically." \\
 &  \\
 & "[Speaks to] the evolution of one's leadership skills and approaches resonates - also the complexity of the situation in which one is leading - the case examples were bang on and helpful in understanding the nuances between the levels." \\
Feeling that the model resonated with their observations and experience. & "I particularly like the code-switching for different roles. This is of particular importance for those moving from intense clinical environments to decanal or government roles." \\
 &  \\
 & "I like the concept of the evolution as a leader over time as well as the need / ability to transition between the different behaviours based on what is called for at the time." \\
Explained the complexity of multiple roles in the academic healthcare sector. & "Fits very well with the model of academic medicine in which we have roles at the University and the Hospitals and in our communities, which intersect with so many other leaders." \\
 &  \\
 & "It did resonate with me. Addressing leadership in a complex world, creating conditions to build internal capacity by leading at times and encouraging others to lead at others, recognizing that we live in a dynamic world where the demands from us change (even within the same role)." \\
Useful for their work as knowledge users. & "It can help define expectations for different roles in an organization and then help assessment individual; against those roles instead of thinking everyone needs to get to a certain point and are suboptimal if they do not. By defining leadership expectations, it also helps define a more tangible development path for mid and senior level leaders." \\
 &  \\
 & "I keep thinking how this model will be used for leader development. Would be very helpful in leader self-assessments (360s) and coaching/mentoring over time. Emphasizes that leadership is a journey as one progresses in their career especially agility and complexity. Building leadership capabilities must begin in university/college and continue throughout one's career pathway." \\
Connects to other models & "It connects nicely the concepts of individual development and leadership development, within different contexts. It connects many existing models. ... What is nice is to see the increase in connectivity of the agent within increasing awareness of the existence of the system." \\
 &  \\
 & "It describes a continuum and reminds me of Maslow 's work and inner control by Rotter." \\
 &  \\
 & "Like that it links to well-known and used evidence based (health) leadership frameworks."  \\
Concerns from Knowledge Users &  \\
The model was felt to be very complex. & "It looks to me as a meta model, that goes beyond the usual scope of leadership models. It fits well with the reality I evolve within, which is complex and multidimensionnal (university, hospital, sitting on different boards, etc.)." \\
 &  \\
 & "I am personally not one who easily buys into complex models. I think it needs to be simplified." \\
 &  \\
 & "With greater depth it may be harder to understand, however, I think any motivated person who is interested in learning about both Kegan's work and LEADS will quickly see the synergies." \\
Disconnect with their experience. & "The model did not resonate with me particularly at the lower levels of Kegan's stages of development." \\
 &  \\
 & "[Y]es, although the example re: academic and clinical mostly applies to MDs only in my experience." \\
 &  \\
 & "It is static rather than dynamic.  Seems to be missing a third dimension...taking one leader through the lifecycle of leadership.  Perhaps through a reflective lens...a level 4/5 leader reflecting on his/her leadership journey?" \\
Hesitations about the implicit hierarchy within the model. & "A real concern I have is that proposed model hints that reaching the highest level is the ultimate goal. That is only part, while it is ONE element, the most important element is too be able to move fluently (be agile) between these 4 levels, back and forward, or even look at the levels at the same time on occasion...." \\
 &  \\
 & "I also am concerned a bit about folks assessing themselves and feeling negative to be on the lower end of the framework - whereas LEADS currently does not have that hierarchical feel." \\
 &  \\
 & "You are making assumptions that the leadership mindsets/Kegan mindset of people is more defined by the place in the organization than how they function in that place, the opportunities given and the culture of organization which has tremendous influence. ... I also think that the initial formal leadership level that you describe is a disservice to assume that all their interactions are transactional in nature. For example having to deal with performance issues of colleagues is highly complex and requires both and ways of thinking." \\
\end{tabulary}
\caption{{\textbf{} Themes from the Knowledge User Survey \textbf{}
{\label{796614}}%
}}
\end{table}\section*{Discussion}

{\label{942769}}

We present a conceptual leadership model that is suited for the
complexities of AHCs and integrates a dominant leadership framework
(LEADS) \emph{and} a theory of psychological development (Kegan's Theory
of Development: The \emph{LEADS+ Developmental Model}.

The LEADS+ Developmental Model lays bare some of the codes and cultural
expectations that many organizations may have of their members, but
never articulate fully. As evidenced by our knowledge user consultation,
many felt that this new model resonated with them and would be useful in
guiding or coaching others throughout their leadership pathway. Indeed,
it has been reflected upon that by bolstering leadership development and
training it is possible to enhance the visibility and leadership
attainment of underrepresented groups.\textsuperscript{52--54}

\subsection*{Implications for the
Field}

{\label{403758}}

As a guide for educational programming or as a diagnostic tool, the
\emph{LEADS+ Developmental Model} provides a tailored description of the
capabilities at each stage of leadership development. We also anticipate
that the human resource implications in that AHCs may undertake mapping
exercises to identify the necessary follower and leader phenotypes
required across units or programs. Rather than assuming a singular
leader construct for a team with team members rounding out the team
based on technical expertise, organizations can attend to the specific
capabilities required of each time of leadership role.

\subsection*{Limitations}

{\label{837722}}

This is an integrative conceptual review.~ The \emph{LEADS+
Developmental Model} will evolve with additional research and
development work. While informed by knowledge users, it lacks empirical
evidence to support the many underlying assumptions. Further research is
required to validate the \emph{LEADS+ Developmental Model} in a range of
settings While the consultation process purposely sampled from a broad
range of experienced leaders and leadership educators, our analysis did
not determine if theoretical sufficiency (e.g., a fulsome contribution
of opinions to ensure balance and completeness) was achieved and only
sampled opinions based on North American AHC leadership contexts (i.e.
more egalitarian and hierarchical).~ Consultations with health care
leaders and eduators identitifed limitations of the model, specifically:
1) the high complexity of the conceptual model, 2) similarity to other
leadership models, 3) the lack of assessment tools to support this
model, 4) the implied trajectory of the model may not align with an
individual's intended leadership capabilities, 5) the absence of
capacity-building in the model, and 6) the perceived physician-centric
nature of the model. \textbf{}

\textbf{Conclusion}

The \emph{LEADS+ Developmental model} integrates a dominant leadership
model (LEADS) with the psychological development stages described by
Kegan. Based on knowledge user consultation, this model effectively
describes and aids the diagnosis of followership and leadership
abilities necessary for leaders in complex academic health systems.~~

\par\null

\textbf{Conflict of Interest:~} GD is a creator of the \emph{LEADS in a
Caring Environment framework}. SR, SL, JS, and TMC have received
honoraria for teaching in leadership \textbf{Ethics:} This is an
integrative conceptual review paper and we received an exemption from
our institutional review board confirming that we did not engage in
human subjects research requiring ethical approval.
\textbf{Acknowledgements:} We would like to thank the following
individuals who acted as knowledge user consultants for our paper: Peter
Angood, Felix Ankel, Lily I. Bale-Feldman, Sheila Betker, Stevie Colvin,
Ming-Ka Chan, Kelly Grimes, Antoine Groulx, Gillian Hawker, Constance
LeBlanc, Susan Lieff, Anne Matlow, Susan Dianne Moffatt-Bruce, Mike
Nader, Howard Ovens, Julien Poitras, Karen Schmaltz, Ivan Silver,
Jennifer Spencer, Bill Tholl, Brent Thoma, John Van Aerde, and Sarita
Verma. We would also like to thank participants in the McMaster Bridging
Leaders Program for being the inspiration for this paper. We would also
like to thank all the participants in our knowledge user consultations.

\textbf{Funding:~}There was no funding for this paper.~

\textbf{Author Contributions (based on ICMJE criteria):~}SR, SL, JS, and
TC contributed to the concept of the paper, based upon previous work by
GD. All members of the team contributed to the authoring of this paper.
TC gathered the consultation data and conducted the 1:1 interviews with
our knowledge users. All authors contributed to writing and editing the
paper for submission.

\par\null

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\par\null

APPENDIX 1: LEADS+ Development Model Handout PDF below

\par\null

\selectlanguage{english}
\FloatBarrier
\end{document}

