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Developing physician trainees leadership skills: an innovation study

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Developing physician trainees leadership skills: an innovation study

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Content Running head: DEVELOPING LEADERSHIP SKILLS IN TRAINEES 1

DEVELOPING PHYSICIAN TRAINEES LEADERSHIP SKILLS:
AN INNOVATION STUDY

by

Nicola Sequeira

A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION

May 2020

Copyright 2020 Nicola Sequeira

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 2

DEDICATION
To my spouse Sandy, for his unwavering support and encouragement from day one. For
staying by my side, and keeping my life together.
My parents, for their unconditional love and support throughout my life. For keeping me
grounded and teaching me what is important in life. For everything they have done to make me
who I am today.
My sister Natasha, although continents apart, for calling me every day to check-in,
believing in me, and pushing me to be better every day. My brother-in-law Rohit, for his
encouragement and immense support. My niece Hannah and nephew Benjamin, for all the joy
and smiles.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 3

ACKNOWLEDGEMENTS
Without the support and guidance of so many individuals in the OCL program, this
dissertation would not have been possible. First, a special thank you to Dr. Ken Yates for his
patience, guidance and dedication throughout the entire process. I am grateful to him for
investing his time (even early mornings) and energy to streamline my many thoughts. Thank
you for encouraging and supporting me all the way to the finish line. Next, Dr. Courtney Malloy
who served as a committee member and faculty member for two of my inquiry classes. Thank
you for guiding me and providing thoughtful feedback on how to approach data collection.
Because of you, analyzing data was actually fun! To Dr. Kim, thank you for years of friendship
and support. I cannot thank you enough for all that you have done for me. I am also extremely
grateful to Dr. Tornetta for encouraging me and believing in my abilities. Lastly, Dr. Maria Ott
and Dr. Mark Pearson, who inspired me throughout this program.
To all the faculty who have taught me in the OCL program- a simple “thank you” is not
enough. Thank you for your enthusiasm, trust, passion, and commitment to my success.
To the OCL program staff, thank you for your hard work and dedication to ensure that we
had the best possible education.
To the participants of this study, thank you for volunteering your time and sharing your
experiences with me.
To cohort 9, thank you for all your support. You have made this journey rewarding and
endlessly entertaining. #FightOn
To my friends, thank you for listening to me, offering advice, and your endless
encouragement. In particular, I am grateful to Christine Wong for her support during my darkest
times of this journey.
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 4

Lastly, to my family and in-laws, thank you for everything. Although continents apart,
you supported me along the way. You sacrificed so much to give me all the opportunities.
Thank you for allowing me to chase my dream! Above all, my heartfelt thanks to my spouse
Sandy. For his patience, encouragement and never-ending support that kept me going
throughout this incredible journey.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 5

TABLE OF CONTENTS
Dedication 2
Acknowledgements 3
List of Tables 7
List of Figures 9
Abstract 10
Chapter One: Introduction 11
Introduction of the Problem of Practice 11
Organizational Context and Mission 12
Organizational Performance Status/Need 13
Related Literature 14
Importance of the Organizational Innovation 15
Organizational Performance Goal 16
Description of Stakeholder Groups 16
Methodological Framework 19
Definitions 20
Organization of the Study 21
Chapter Two: Review of the Literature 22
Influences on the Problem of Practice 22
Residency Training 23
Effectiveness of Resident Leadership Training 24
Leadership Qualities for Medical Practice 25
Communication Skills 26
Team-Building 27
Professionalism 27
Training Residents in Leadership 29
Current Programs 30
Role of Stakeholder Group of Focus 31
Clark and Estes’ (2008) Knowledge, Motivation and Organizational Influences Framework 32
Stakeholder Knowledge, Motivation and Organizational Influences 33
Knowledge and Skills 33
Motivation 37
Organization 41
Conceptual Framework: The Interaction of Stakeholders’ Knowledge and Motivation and
the Organizational Context 47
Conclusion 49
Chapter Three: Methodology 51
Participating Stakeholders 51
Survey Sampling (Recruitment) Criteria and Rationale 52
Interview Sampling Criteria and Rationale 52
Data Collection and Instrumentation 53
Survey Instrumentation and Data Collection 54
Interview Instrument and Data Collection 55
Alignment of the KMO Influences and Data Collection 56
Data Analysis 64
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 6

Credibility and Trustworthiness 65
Validity and Reliability 66
Ethics 66
Limitations and Delimitations 69
Chapter Four: Results and Findings 70
Participating Stakeholders 71
Determination of Assets and Needs 71
Results and Findings for Knowledge Causes 72
Factual Knowledge 72
Conceptual Knowledge 79
Procedural Knowledge 81
Results and Findings for Motivation Causes 82
Value 83
Self-Efficacy 87
Results and Findings for Organization Causes 90
Resources 91
Cultural Settings 95
Summary of Validated Influences 97
Knowledge 97
Chapter Five: Recommendations and Evaluation 100
Purpose of the Project and Questions 100
Recommendations to Address Knowledge, Motivation, and Organization Influences 101
Knowledge Recommendations 101
Motivation Recommendations 105
Organization Recommendations 109
Summary of Knowledge, Motivation and Organization Recommendations 115
Integrated Implementation and Evaluation Plan 116
Organizational Purpose, Need, and Expectations 116
Implementation and Evaluation Framework 116
Level 4: Results and Leading Indicators 117
Level 3: Behavior 119
Level 2: Learning 122
Level 1: Reaction 124
Evaluation Tools 125
Data Analysis and Reporting 127
Summary of the Implementation and Evaluation 128
Limitations and Delimitations 129
Recommendations for Future Research 130
Conclusion 131
References 133
Appendix A: Survey Instrument 144
Appendix B: Interview Protocol 147
Appendix C: Self-Efficacy Results 150
Appendix D: Level 1 and 2 Evaluation Tools 151
Appendix E: Delayed Blended Evaluation Tools 153

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 7

LIST OF TABLES
Table 1: Organizational Mission, Organizational Goal and Stakeholder Performance Goals 17
Table 2: Summary of Core Faculty Member’s Assumed Needs for Knowledge Gap Analysis 37
Table 3: Summary of NPU’s Core Faculty Members Assumed Needs for Motivation Gap
Analysis 41
Table 4: Summary of Core Faculty Member’s Assumed Needs for Knowledge Gap Analysis 46
Table 5: Knowledge, Motivation and Organizational Influences affecting NPU Core
Member’s Ability to Develop a Leadership Curriculum 57
Table 6: Rank of Participants 71
Table 7: Criteria Used to Classify Assumed Knowledge Influence as “Not Validated” 72
Table 8: Survey Results for Factual Knowledge of Leadership 73
Table 9: Survey Results for the Most Important Characteristic of A Good Leader 74
Table 10: Survey Results For Characteristics of Teamwork 76
Table 11: Survey Results For Characteristics of Professionalism 78
Table 12: Survey results for Conceptual knowledge 79
Table 13: Survey Results for Procedural knowledge 81
Table 14: Criteria Used to Classify Assumed Motivation Influences as “Not Validated” 83
Table 15: Survey Results for Value Influence 84
Table 16: Survey Results for Self-Efficacy 88
Table 17: Criteria Used to Classify Assumed Organizational Influences as “Not Validated” 91
Table 18: Survey Results for Resources 92
Table 19: Survey Results for Cultural model 93
Table 20: Survey Results for Cultural Setting 96
Table 21: Knowledge Assets or Needs as Determined by the Data 97
Table 22: Motivation Assets or Needs as Determined by the Data 98
Table 23: Organization Assets or Needs as Determined by the Data 99
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 8

Table 24: Summary of Knowledge Influences and Recommendations 102
Table 25: Summary of Motivation Influences and Recommendations 106
Table 26: Summary of Organization Influences and Recommendations 110
Table 27: The New World Kirkpatrick Model Four Levels of Evaluation 117
Table 28: Outcomes, Metrics, and Methods for External and Internal Outcomes 118
Table 29: Critical Behaviors, Metrics, Methods, and Timing for Evaluation 119
Table 30: Required Drivers to Support Critical Behaviors 120
Table 31: Evaluation of the Components of Learning for the Program 124
Table 32: Components to Measure Reactions to the Program 125

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 9

LIST OF FIGURES
Figure 1: Interactive Conceptual Framework that depicts the core faculty member’s need
analysis. 48
Figure 2: Core faculty members perceptive on leadership skills (Value) 85
Figure 3: Percentage of core faculty members scoring in self-efficay catergories of low,
average and high. 89
Figure 4: Example of the proposed department performance dashboard. 128

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 10

ABSTRACT
In today’s healthcare environment, to be a competent and successful physician, non-
clinical leadership skills are essential. However, many residency training programs in the United
States emphasize technical and clinical skills to be competent while often neglecting non-clinical
skills such as leadership skills. The purpose of this project was to conduct a needs analysis in the
areas of knowledge, motivation, and organizational resources necessary for core faculty
members to develop and teach a leadership curriculum to physician trainees so they can
effectively demonstrate leadership skills in areas of interpersonal communication, team-building
and professionalism during residency training. The study answered three research questions.
First, what are the knowledge and skills, motivation, and organizational constraints and needs
related to NPU’s core faculty member’s goal of developing a leadership program/curriculum by
December 2020 focusing on physician trainee’s leadership skills in team-building,
communication, and professionalism? Second, what is the interaction between organizational
culture and context and core faculty’s knowledge and motivation? Third, what are the
recommended knowledge, motivation, and organizational solutions? The Clark and Estes (2008)
gap analysis was adapted for a needs analysis as the conceptual framework. A mixed-methods
approach, using quantitative and qualitative methods was used for the methodological
framework. Twenty-five core faculty members completed an online survey, and ten participated
in face-to-face interviews. The findings from this study validated two knowledge, one
motivation and three organizational influences that led to recommended solutions. The proposed
recommendations in Chapter Five provide strategies and implementation plans for addressing the
knowledge, motivation and organization needs to achieving the organizational performance goal.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 11

CHAPTER ONE: INTRODUCTION
Introduction of the Problem of Practice
The current medical system is an ever-evolving environment filled with unpredictable,
complex challenges. The need for leadership to navigate through the rough waters has never
been greater. Increasing clinical demands have limited the ability of physicians to be at the
forefront of this journey. Nearly all physicians throughout their career take on significant
leadership responsibilities, however many are not taught leadership skills nor rewarded for good
leadership. According to Stoller (2009), healthcare organizations are still lagging behind in
developing their physicians as leaders. As a result, many physicians are still not prepared when
they take on leadership roles and lack the necessary skills to be effective leaders. In many
teaching hospitals, physician trainees are considered “frontline” leaders, responsible for
providing high-quality patient care and leading daily patient care activities (Blumenthal,
Bernard, Bohnen, & Bohmer, 2012). However, many lack the ability to lead teams effectively.
According to Blumenthal et al. (2012), physicians are thrown into leadership roles every day and
consider themselves to be “accidental leaders,” where they are learning leadership skills on the
job. In the United States, even though few surgical residency programs have begun to
acknowledge the increasing importance of leadership skills “they have tended to see these skills
as valuable only for a limited few on an alternative career path, rather than an integral part of
surgery training for all” (Gawande, 2001, p. 555).
Leadership is about “coping with change” (Blumenthal et al., 2012). Although there is
no universal definition of leadership, effective leaders demonstrate a high degree of emotional
intelligence (Goleman, 1998). According to Goleman (1998), good leaders know who they are
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 12

as individuals, recognize how their actions affect them and others, create a supportive
environment, encourages teamwork, and know how to manage relationships with others.
A review of the literature revealed that leadership skills are an essential component of
residency training, which many programs have yet to embrace. According to Itani et al. (2004),
more than 75% of the surgical residents reported a deficit in specific skills, namely conflict
resolution, leadership theory, compliance, and practice management. In a survey of 23 Baylor
surgical residents, more than 50% of trainees reported they did not feel confident in their
leadership ability (Stoller, 2009). Similarly, in a survey of 177 physician trainees, 85% reported
a need for training in negotiation, practice partnerships, knowledge of health care systems, and
career planning (Blumenthal et al., 2012). Fraser, Blumenthal, Bernard, and Iyasere (2015)
surveyed internal medicine resident physicians that revealed their underlying assessments of
their leadership training. 80% of respondents felt they needed more formal training in
developing their leadership skills and would benefit from developing specific leadership skills,
including coaching, leading a team, resolving interpersonal-conflict, confronting problem
employees, and understanding different leadership styles (Fraser et al., 2015). “Without formal
training in leadership skills, many physicians will not be equipped to lead in this marketplace”
(Chaudry, Jain, McKenzie, & Schwartz, 2008, p. 213) and be effective leaders.
Organizational Context and Mission
Northern Pacific University (NPU)
1
is a large teaching university in the western United
States. NPU has more than 3,300 students enrolled in degree programs, 1,500 clinical residents
or fellows and 1,000 postdoctoral scholars, 3000 faculty, and 22,000 staff (Organization’s

1
A pseudonym was developed in order to mask the identity of the institution.
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 13

website)
2
. The department of orthopaedic surgery at NPU is a sizeable surgical department
within the school of medicine recognized as one of the leading orthopaedic surgery academic
departments in the United States. The department comprises of 69 full-time clinical faculty, 36
physician trainees, nine fellows, and over 100 staff employees. The mission of the department of
orthopaedic surgery is to provide the highest quality of patient care, conduct innovative clinical,
basic science, and translational research, and train the next generation of global leaders in
orthopaedic surgery (Organization’s website)
3
. The training of residents is also one of the
essential missions of the department, and the goal is not only to provide the best orthopaedic
education but also to emphasize leadership, creating a training environment that is the first step
of a career characterized by energy and opportunity (Organization’s website)
4
. The residency
training program comprises 26 males and ten females, all from diverse backgrounds, and trainees
are between the ages of 26 and 32. The training program benefits from a faculty that is dedicated
to teaching and a clinical practice that is both broad in scope and deep in volume and experience.
Organizational Performance Status/Need
To fulfill its mission of developing physician trainees to be global leaders in orthopaedic
surgery, NPU should establish a curriculum or program that focuses not only on developing
clinical skills but also on honing physician trainee’s leadership skills. Our physician trainees are
expected and responsible for providing and leading the day-to-day patient care activities with
other health care providers, although they have received no training and education in leadership
or management during medical school. Patient care is no longer delivered independently but
rather through collaboration with multidisciplinary teams. Their inability to lead teams

2
Actual URL has not been provided because that would reveal the identity of the organization.
3
Actual URL has not been provided because that would reveal the identity of the organization.
4
Actual URL has not been provided because that would reveal the identity of the organization.
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 14

adequately is not discussed explicitly in their curriculum. Failure to develop these critical skills
will prevent physician trainees from providing quality patient care and driving improvement in
the healthcare system. Currently, no leadership program or curriculum exists for physician
trainees in the Department of Orthopaedic Surgery.
Related Literature
Residency programs are burdened with making sure that physician trainees are meeting
their clinical training standards, thus having limited time in developing the non-clinical skills
(e.g., leadership) that is essential for trainees to succeed in their future practices. Currently, there
is no formal curriculum for leadership development that would enable physician trainees to
acquire these leadership skills set and prepare them to be effective leaders (Chaudry et al., 2008).
Even though the Accreditation Council of Graduate Medical Education (ACGME) has included
non-clinical skills in areas of communication, professionalism, and teamwork as a core
competency, these leadership skills are rarely taught and reinforced during residency training.
Evidence suggests that leadership training improved leadership skills of physicians, while also
improving health care quality and organizational performance (Blumenthal et al., 2012; Fraser et
al., 2015; Warren & Carnall, 2011). Researchers identified gaps in leadership skills in physician
trainees across many institutions. According to Blumenthal et al. (2012), residency programs
often fail to inform their clinicians of their day-to-day leadership responsibilities as frontline
leaders. Their research uncovered deficiencies in the following areas: communication, team
building, planning, and priority setting, assessing performance, problem solving, and leading that
leave clinicians unprepared to lead in their healthcare environment effectively (Blumenthal et al.,
2012).

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 15

Importance of the Organizational Innovation
With the numerous challenges facing healthcare systems in access, quality, and cost,
good medical leadership is needed in delivering efficient and effective care (Stoller, 2014). Our
healthcare system needs physicians who are not only clinically competent but also have the skills
to lead, manage, and improve the delivery of patient care. Despite the clear need for leadership
training, there still exists a lack of urgency from residency training programs and institutions to
develop their physician trainee’s leadership skills. In the field of surgery, it is no longer
sufficient for physicians to be just skilled in the operating room. Many of the challenges in
today’s healthcare environment demand leadership skills outside the operating room. In today’s
healthcare environment, to lead inter-professional teams and be successful, a different set of
leadership skills is required. It is crucial for the organization to introduce a leadership
development curriculum or program that focuses on developing non-clinical skills because
physician trainees are responsible for leading teams of medical students, junior residents, and
other healthcare personnel. Yet they do not receive any formal training in leading teams. In
almost all residency training programs, first-year trainees (interns) become second-year trainees,
second-year trainees become third-year trainees, third-year trainees become chief residents, and
chief residents become fellows or attending physicians requiring them to take on more leadership
responsibilities at each level. The span of leadership only increases when physicians enter
independent practice (Rotenstein, Sadun, & Jena, 2018). Evidence shows that beyond clinical
skills and medical knowledge, physicians need to have leadership skills to be prepared to lead
their teams effectively in the administration of high-quality patient care that maximizes health
outcomes. In a 2015 Joint Commission report, “failure of leadership was frequently cited as the
underlying cause of unanticipated adverse events, such as patient mortality” (Randall, Kwong,
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 16

Kuivila, Levine, & Kogan, 2017, p. 6). Additionally, lack of leadership training can negatively
impact physicians as it can lead to loss of confidence when they encounter situations they are not
able to handle, limit career growth, and result in poorly managed health-care systems (Ackerly et
al., 2011). Teaching surgeons not just how to operate, but how to lead effectively will be key to
future surgical progress (Gawande, 2011).
Organizational Performance Goal
By December 2021, 100% of our physician trainees in the department of orthopaedic
surgery at Northern Pacific University (a pseudonym) will be able to effectively demonstrate
leadership skills in team-building, communication, and professionalism. The Program Director
established this goal after receiving feedback from the Clinical Competency Committee (CCC).
The CCC reviews physician trainee’s performance in six different competencies during their
residency training. The six competency areas include medical knowledge, communication skills,
professionalism, systems-based practice, problem-based learning and improvement, and patient
care. To allow our physician trainees to be better clinicians and ensure the highest quality of
patient care, the committee members outlined several key areas in residency training that need
improvement. The achievement of this goal will be measured by surveying physician trainees at
intervals after completing a leadership program, and results received from evaluations and
assessments.
Description of Stakeholder Groups
The three stakeholder groups in the study will be executive leadership, who will establish
the criteria and provide the resources needed to develop the curriculum or program, the core
faculty members who will create and teach the leadership program, and physician trainees who
will participate in the program. Executive leadership includes the Chairman of the department,
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 17

Vice-Chair for Education and Chief of Services for the various specialties in the department.
These stakeholders are primarily concerned with the allocation of resources, facilitating the
necessary changes to reach performance goals and the overall success of the program. Core
faculty members are stakeholders responsible for developing and teaching the curriculum to
physician trainees. These stakeholders are also responsible for providing a positive learning
environment for physician trainees. Physician trainees are stakeholders who are engaged in
graduate training in medicine and serve as a part of a team of providers providing patient care.
These stakeholders participate in various didactic sessions as part of their postgraduate medical
training. Physician trainee satisfaction and learning will be measured to determine if
performance goals are met.
Stakeholder Groups’ Performance Goals
Table 1 shows the goals each stakeholder must achieve to accomplish the mission and
organization’s goal.
Table 1
Organizational Mission, Organizational Goal and Stakeholder Performance Goals
Stakeholder Performance Goals
Organizational Mission
The mission of the department of orthopaedic surgery at NPU is to provide the highest quality of
patient care, conduct innovative clinical, basic science, and translational research, and train the
next generation of global leaders in orthopaedic surgery.
Organizational Performance Goal
By December 2021, 100% of physician trainees will participate in a leadership program at NPU
and will be able to effectively demonstrate leadership skills in team-building, communication, and
professionalism.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 18

Table 1, continued
Stakeholder 1 Goal Stakeholder 2 Goal Stakeholder 3 Goal
Executive Leadership
By June 2020, executive
leadership will provide 8 hours
of dedicated training for core
education faculty to develop
the skills and knowledge
needed to create a leadership
program for trainees.
Faculty- Core Faculty
By December 2020, core
faculty members will develop
a leadership curriculum
focusing on developing
trainees leadership skills in
team-building,
communication, and
professionalism
Physician Trainees
By December 2021, 100% of
our physician trainees will be
able to effectively demonstrate
leadership skills in team-
building, communication, and
professionalism.

Stakeholder Group for the Study
While the joint efforts of all stakeholders will contribute to the achievement of the overall
organizational goal of having 100% trainees demonstrate leadership skills in areas of
communication, team-building, and professionalism, it is important to evaluate where NPU
faculty members who will develop and implement a leadership program for our physician
trainees are currently with regard to the organization goal. Therefore, the stakeholders of focus
for this study will be the core faculty members. This stakeholder group was chosen as they have
the most influence in bringing about change in trainee behavior. The stakeholder’s goal,
supported by the Program Director, is that a leadership program will be developed and
implemented by education faculty so trainees can exhibit leadership skills in areas of team-
building, professionalism, and interpersonal communication. Failure to develop these leadership
skills in trainees will prevent them from being effective clinician-leaders in many healthcare
organizations.
Purpose of the Project and Questions
The purpose of this project is to conduct a needs analysis in the areas of knowledge and
skill, motivation, and organizational resources necessary for the faculty members to reach the
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 19

organizational performance goal of having 100% of our trainees effectively demonstrate
leadership skills in areas of communication, team-building and professionalism by December
2021. The analysis will begin by generating a list of possible needs and will then move to
examine these systematically to focus on actual or validated needs. While a complete needs’
analysis would focus on all stakeholders, for practical purposes, the stakeholder to be focused on
in this analysis are core faculty members.
As such, the questions that guide this study are the following:
1. What are the knowledge and skills, motivation, and organizational constraints and needs
related to NPU’s core faculty member’s goal of developing a leadership
program/curriculum by December 2020, focusing on physician trainee’s leadership skills
in team-building, communication, and professionalism?
2. What is the interaction between organizational culture and context and core faculty’s
knowledge and motivation?
3. What are the recommended knowledge, motivation, and organizational solutions?
Methodological Framework
The Clark and Estes (2008) gap analysis, a systematic process that helps to clarify
organizational performance goals and identify the knowledge, motivation, and organizational
influences to achieve those goals, will be adapted as the conceptual framework. This model is
often used as an improvement model. Multiple approaches to gathering and analyzing data will
be used. For this study, an explanatory sequential mixed-methods approach, first using the
quantitative method followed by the qualitative method to understanding the assets and needs of
NPU core faculty members in the areas of knowledge, motivation, and organizational resources,
will be used as the methodological framework. Surveys, face-to-face interviews, observations,
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 20

and literature reviews will be used to validate the needs in the areas of knowledge, motivation
and organizational influences. Evidence-based solutions will be recommended and
implemented, following data analysis.
Definitions
Communication: the ability of physician trainees to effectively exchange information
with patients, their families, and professional associates. It requires the resident to be both an
active listener as well as a clear, articulate speaker (Massachusetts Medical Society, 2020).
Core Faculty members: support the program leadership in developing, implementing, and
assessing curriculum and in assessing physician trainee’s progress toward achievement of
competence in the specialty (ACGME, 2019)
Clinical Competency Committee: A required body comprising three or more members of
the active teaching faculty that is advisory to the program director and reviews the progress of all
Physician trainees in the program (ACGME, 2018)
Physician Trainee: An individual enrolled in an ACGME accredited residency program
(ACGME, 2018)
Professionalism: attitude and behavior of the resident physician. The expectation for all
medical professionals is that each and everyone will treat all people with respect, compassion,
and dignity (Massachusetts Medical Society, 2020)
Program Director: The individual designated with authority and accountability for the
operation of a residency/fellowship program (ACGME, 2018)
Team: consists of two or more individuals who have specific roles, perform
interdependent tasks, are adaptable, and share a common goal (Baker, Salas, King, Battles, &
Barach, 2005)
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 21

Team-Building: is the ability to organize and nurture a collective group of people
effectively in a way that develops synergy between individual performance attributes (Chaudry
et al., 2008, p. 217)
Teamwork: commitment to a shared set of team knowledge, skills and attitudes (KSAs)
rather than permanent assignments that carry over from day-to-day (Baker et al., 2005)
Leadership: is a practice, either organizational or personal, that focuses on achieving
organizational or societal goals (Aguirre & Martinez, 2002, p. 55). Leaders in organizations are
responsible for building organizations where people are continually expanding their capabilities
to shape their future (Senge, 1990, p. 9).
Organization of the Study
Five chapters are used to organize this study. Chapter one provided the reader with the
key concepts and terminology commonly found in a discussion about graduate medical
education, residency training, and stakeholder apprehension. The organization’s mission, goals,
and stakeholders, as well as the initial concepts of gap analysis, adapted to needs analysis were
introduced. Chapter Two provides a review of the current literature surrounding the scope of the
study. This chapter addresses the factors, variables, and causes that influence the development
of a leadership curriculum. Chapter Three details the assumed needs for this study as well as
methodology when it comes to the choice of participants, data collection, and analysis. In
Chapter Four, the data and results from the mixed methods study are assessed and analyzed.
Chapter Five provides solutions, based on data and literature, for addressing the needs and
closing the performance gap as well as recommendations for an implementation and evaluation
plan for the solutions.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 22

CHAPTER TWO: REVIEW OF THE LITERATURE
This study addresses the lack of formal leadership training in many residency programs
across the United States. With the challenges facing the healthcare system in access, quality, and
cost good medical leadership is needed in delivering efficient and effective care. The first
section of this chapter outlines the factors, variables, and causes that influence physician
trainee’s behavior as defined by the literature in this area. The second section identifies the
assumed knowledge, motivation, and organizational influences on core faculty member’s ability
to implement a leadership curriculum. The chapter ends with an analysis of core faculty
member’s participation through the lens of learning and motivation literature utilizing the Clark
and Estes (2008) gap analysis model to examine knowledge, motivation, and organizational
dimensions.
Influences on the Problem of Practice
While Chapter One was more about the impact of developing leadership skills in
physician trainees, Chapter Two addresses the factors, variables, and causes that influence the
development of a leadership program or curriculum as defined by the literature in this area.
Research clearly states that beyond clinical skills and knowledge, physician trainees need to have
formal training in leadership skills such as communication, team-building, professionalism, and
conflict management to be prepared to lead their teams in the administration of high-quality
patient care that maximizes health outcomes. Lack of leadership skills will prevent physician
trainees from effectively leading in today’s healthcare organizations. Blumenthal et al. (2012)
research uncovered deficiencies in the following areas: communication, team-building, planning,
and priority setting, assessing performance, problem solving, and leading that leave clinicians
unprepared to lead in their healthcare environment effectively.
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 23

Residency Training
In the United States, physician practitioners must complete residency training in order to
practice medicine independently. Residency training programs provide the foundation for
physicians to acquire the knowledge and skills required to provide high-quality patient care.
According to the ACGME, there are more than 8,800 medical residency programs in over 130
specialties and subspecialties across the United States and more than 111,000 residents and
fellows training in these programs (ACGME, 2008). In the United States, residency training can
last anywhere from five to seven years, depending on the specialty of training. For physicians,
choosing a career in Orthopaedic surgery, residency training is five years requiring “long-hours,
high-stress levels, and the acquisition of an ever-expanding number of technical skills” (Nemani,
Park, & Nawabi, 2014, p. 164).
Physician trainees are medical doctors who have graduated from medical school but do
not possess the skills and experience to practice medicine independently. In the United States,
there are over 100,000 physician trainees who serve as frontline leaders, responsible for
providing safe care and services to patients (Chen, Kotliar, & Drolet, 2015). The main focus of
many residency training programs, especially surgical programs, is to provide physician trainees
with adequate technical and clinical skills needed to be competent surgeons. Non-clinical skills,
such as leadership skills, have long been neglected during training. According to Markakis,
Beckman, Suchman, and Frankel (2000), “traditional residency programs have given little direct
attention to the processes by which professional and humanistic values, attitudes, and behaviors
are cultivated” in physician trainees (p. 141). Physicians in practice and trainees understand that
training in leadership skills is essential to be a successful physician or surgeon. Based on a
survey of 189 program directors in general surgery, 70% agreed that current trainees were
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 24

inadequately trained in areas of business and practice management (Shirley, Balsamo, &
DeMaio, 2017). Residency training is one of the premier ways that leadership skills can be
introduced to physician trainees. The ACGME has identified six core competencies that
physician trainees must be competent in and charged residency training programs with
developing these skills during training. These six areas include medical knowledge, patient care,
systems-based practice, practice-based learning, interpersonal communication, and
professionalism (Baker et al., 2005). By introducing a significant level of leadership training
into their curriculum, the groundwork can be laid for physician trainees to develop intangible
leadership skills (Nemani et al., 2014).
Effectiveness of Resident Leadership Training
Fernandez, Noble, Jensen, and Chapin (2016) analyzed a leadership training course
completed by a group of 37 physicians selected by the American College of Obstetricians and
Gynecologists (ACOG). Participants completed retrospective evaluations of ten core leadership
competencies before and after the training sessions. Sessions included topics on communication,
leading and empowering teams, process improvement, and general leadership theory. In six
months, participants were asked to provide insight into how their skills were applied. Their
research revealed statistically significant improvement in participant’s understanding of
leadership skills (Fernandez et al., 2016). Based on the 6-month follow-up survey, 62% of
respondents indicated they had “received a promotion, had a change of job, or had taken on new
leadership opportunities” since completion of the leadership course (Fernandez et al., 2016, p.
11). Similarly, Blumenthal et al. (2014) designed, implemented, and evaluated a pilot leadership
development course for second-year trainees in internal medicine. Their research indicated that
sixty-nine percent of participants felt that the course was effective in helping them get a better
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 25

understanding of their strengths and weakness as a leader (Blumenthal et al., 2014). Participants
also indicated that the course prepared them to deal with challenges that may arise while working
with other team members. Leadership training, if provided to physician trainees in addition to
clinical training, provides the foundation for a more rewarding career as a physician, regardless
of specialty. Leadership skills can help and ensure that physicians have the ability and
knowledge of leadership theories to make the proper decisions regarding process improvement
and assessing the overall performance of subordinates or co-workers (Benson, 2014).
Leadership Qualities for Medical Practice
There is a widespread belief that our current medical education system is preparing and
producing clinically competent physicians. However, some experts have argued that physician
education is not fully preparing new practitioners to lead in today’s medical practice (Crosson,
Leu, Roemer, & Ross, 2011). There is only a small percentage of physician trainees that exceed
expectations and exhibit qualities of a great leader (Nemani et al., 2014). There has been
significant research done by trained management professionals regarding the type of skills that
will make a physician successful in their medical practice, as well as how these individuals
should be trained. Traditionally, it has been assumed that physicians are responsible for the care
provided to patients of a hospital or clinic. However, in more recent clinical settings, physicians
are responsible for the development of clinical programs, research projects, and act as leaders for
departments or clinical specialties (Van den Eertwegh, 2013). With this added responsibility,
there is a certain level of leadership that is required to be successful. By including leadership
training in non-clinical skills such as communication, team-building, and professionalism,
physicians will be more likely to identify challenges, build more meaningful relationships with
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 26

their peers and other health care professionals, and succeed in roles of increasing responsibility
as they move forward in their career.
Communication Skills
Arguably the most important skill for medical professionals to master is effective
communication. Good communication is one of the most important attributes for physicians
practicing medicine. Kuo and Robb (2013) suggest that “effective communication is paramount
for reliable surgical team performance” (p. 1795) as it promotes transparent dialogues between
surgical team members and leads to better outcomes for surgical patients. The traditional role of
a surgeon as an authoritative leader needs to be replaced with a leader that is more collaborative
and serves as an effective lead communicator (Kuo & Robb, 2013). According to a study
conducted on preventable surgical harm, the major cause for incorrect surgery and poor patient
care was failure of communication in the Operating Room (Kuo & Robb, 2013). The ability to
communicate with patients, family, staff members, and hospital administration is essential for the
development of a successful clinical practice. Patients want physicians who can diagnose and
treat their illnesses as well as communicate effectively with them (Ha, Anat, & Longnecker,
2010). “Most complaints about doctors are related to issues of communication, not clinical
competency” (Ha, Anat, & Longnecker, 2010, p. 42). The effectiveness of communication skills
training has become increasingly more popular in medical education institutions across the
country. According to Dacre (2004), the Royal College of Physicians has classified
communication skills as a priority in the redevelopment of clinical examinations for physicians
seeking their board recertification. Dacre (2004) also suggests that training in communication
skills within medical education should be done in a format that facilitates active feedback to the
learner, to create a more realistic approach to the education of the individual. Employing a
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 27

method such as this will allow clinicians to acquire effective skills in communication, while they
are attaining their education.
Team-Building
Once a physician has the ability to effectively communicate with and lead the staff of a
medical practice, the next crucial aspect of effective learning would be to facilitate team
building, which is critical to patient safety. Research studies have shown that teamwork in
medicine is linked to patient safety, satisfaction, and improved clinical outcomes (Benson, 2014).
Developing skills and knowledge in teamwork as early as medical school and refining these
skills during residency training can enable physician trainees to work and interact effectively
with team members. Team building is essential to creating a positive and secure work
environment (Baker et al., 2005). Employees that operate within a team-oriented environment
are more likely to stay within their roles and become more productive in their roles. Physician
facilitated team building can produce a more effective and optimized medical practice. To
function effectively as a team, members must know what skills are required, which behaviors are
appropriate, and how to apply the skills in a team setting (Benson, 2014). According to Baker et
al. (2005), “teams make fewer mistakes than do individuals, especially when each team member
knows his or her responsibilities, as well as those of other team members” (p. 187). It is
important to facilitate an atmosphere that is positive; this will increase employee retention and
the overall success and development of the medical practice (Fong, 2010).
Professionalism
In addition to team-building, professionalism is crucial to the success of a medical
practice and the effectiveness of a physician to lead teams of clinical and non-clinical
professionals. According to Gronowski, McGill, and Domen (2016), “unprofessional behavior
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 28

in medical students, residents, and physicians in practice are one of the primary reasons for
disciplinary action in medicine” (p. 1). In a recent study of 431 applicants applying to
orthopaedic surgery residency training programs, data revealed that 16% of applicant’s Facebook
profiles exhibited unprofessional content as defined by the ACGME guidelines (Nemani et al.,
2014). Nagler et al. (2014) reported that Duke University Hospital and Vidant Medical Center/
East Carolina University surveyed 495 entering PGY-1 residents to assess their perception of
professionalism related to training and patient care as well their own participation in
unprofessional behavior. Trainees were surveyed both in 2009 and 2010 on 46 specific
behaviors. 76% of trainees responded to the survey, and based on data analyzed, the majority of
respondents indicated that they had observed or participated in unprofessional behavior (Nagler
et al., 2014). Because of its importance in medical education, the ACGME has included
professionalism as one of the six core competencies by which physician trainees must be
assessed and requires programs to have formal training for physicians in training and those in
practice. Professionalism in the workplace is essential to effective operations in any work
environment; however, physicians must be effective in roles that require leadership, tactfulness,
and the ability to convey a message appropriately. Tactfulness refers to the ability of an
individual to communicate in a manner that is appropriate and understood by all parties but
allows for the utmost understanding from all parties involved (Gillespie, Paik, Ark, Zabar, &
Kalet, 2009). Tactfulness is an attribute of professionalism, and there are others; however,
professionalism in the workforce can be summarized by conducting oneself with understanding
and respect, while upholding the goals and mission of an organization. Burack et al. (1996)
investigated physician trainee’s behavior at a university-affiliated public hospital that uncovered
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 29

disrespectful attitudes and behaviors towards patients, which were ignored by attending
physicians on service.
According to Markakis et al. (2000), a study done by surveying second-year physician
trainees revealed, “both a high incident of perceived mistreatment and that positive learning
experiences and lack of mistreatment enhanced satisfaction during internship” (p.142). The
manner in which physician trainees are treated during residency training and the values and
behaviors exhibited by their attending physicians influence and determine how physician trainees
treat their peers, patients, themselves, and others (Markakis et al., 2000). Developing skills in
professionalism will allow physicians to become respected in their given positions, as well as
throughout their medical practice. Appropriate behavior, leadership skills, and professionalism
will fully equip a physician to be effective in a healthcare environment and be able to facilitate
the best possible outcomes for the patient population of the medical practice (Health Research &
Educational Trust, 2014).
Training Residents in Leadership
In the current healthcare system, physician trainees are leaders of their patient’s care
team. Various administrative support staff, nursing staff, and clinical support staff members look
to physician trainees for leadership and direction when conducting everyday functions. Since
physician trainees are automatically seen in the role of leadership, they must develop these skills,
which will allow them to be successful in leading teams of clinical and non-clinical support staff
(Markakis et al., 2000). The current medical education curriculum does not include training
courses on management and leadership skill sets. Therefore, there is a severe gap in the
leadership skills of physician trainees.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 30

Current Programs
Although there are residency training programs that offer leadership and management
programs and courses to physician trainees, few programs provide formal leadership training to
all residents (Bhatia et al., 2015). Kahn and Gardin (2016) compiled a list of schools and
hospitals with accredited residency programs that include managerial training courses. Their list
consisted of eleven programs offered by nine different universities and schools, and included the
length of program, program type, and program specialties (Kahn & Gardin, 2016). Frich,
Brewster, Cherlin, and Bradley (2015) analyzed several leadership programs for physicians and
revealed that most programs were strongly associated with increases in self-directed knowledge
and expertise. Frich et al. (2015) research also uncovered that few programs addressed self-
awareness and personal growth. Even though thirty-three percent of the programs addressed
self-management, they did not use multi-source feedback tools, and their teaching methods were
limited. Leadership programs focused on “know” and “do” instead of the “be” element, which is
essential in learning how to lead (Frich et al., 2015). Ackerly et al. (2011) investigated the
residency leadership training program offered by Duke Medicine, called the Management and
Leadership Pathway for Residents (MLPR). The MLPR consists of 15 to 18 months of project-
based rotations in which senior leaders guide physicians in a variety of disciplines, including
finance, patient safety, and health system operations (Ackerly et al., 2011). Even though the
program was the first-of-its-kind, it targeted only physician trainees who already had an
advanced degree (e.g., MBA, masters of health administration) or who had experience in
management, thus limiting the benefits to a small subset of physician trainees.
Leadership skills training is essential to physician medical education. Since many
medical education programs are recognizing the efficacy of leadership training when it comes to
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 31

the abilities of a clinician to act as a leader within their organizations, in the future, there should
be less of a knowledge gap between leadership and clinical practice. Various learning programs
can be implemented, such as a residency-based leadership training program, as well as continued
education once a physician is established within a medical practice (Baig, Violato, & Crutcher,
2009). Medical institutions that have chosen to invest in the learning and facilitation of
leadership among its physicians will see better, more continuous outcomes related to patient care
coordination and the ability of the health system to move forward to meet goals and objectives.
Physician leadership can become the foundation on which integrated health systems can develop
into large, effective organizations that can positively impact the lives of patients through careful
implementation of continuing education. In the future, medical education programs will see a
significant increase in the need for physician leadership training to be included in the overall
curriculum. Once this training is made a standard, the nation’s health systems and academic
medical centers will see significant improvements in the manner in which these medical facilities
are operated.
In summary, NPU’s faculty must know and understand the effects of leadership skills in
areas of communication, team-building, and professionalism to create a curriculum or program
for physician trainees.
Role of Stakeholder Group of Focus
The stakeholder group of focus is core faculty members who are responsible for
developing and teaching curriculum to physician trainees. This stakeholder group serves as
clinician-educators, involved in curriculum design and teaching. As clinician-educators, “they
need more than the ability and inclination to teach. They must also possess specific knowledge
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 32

and skills in curriculum design to affect growth and change in individual learners, entire
educational systems, and communities” (Heflin, Pinheiro, Kaminetzky, & McNeill, 2009).
Clark and Estes’ (2008) Knowledge, Motivation and Organizational Influences Framework
The Clark and Estes (2008) gap analysis, which is a systematic process that helps to
clarify organizational performance goals and to identify the knowledge, motivation, and
organizational influences required to achieve those goals, will be adapted as the conceptual
framework. Krathwohl (2002) identified four subclasses of knowledge and skills used to
determine if stakeholders understand how to achieve a performance goal. These four types
include: factual, conceptual, procedural, and metacognitive. Next, motivation influences, which
include mental effort to achieve goals, the willingness to work towards the goal, and persistence
to accomplish the goals will be discussed (Clark & Estes, 2008; Rueda, 2011). Additionally,
motivational principles that will be considered when analyzing stakeholder performance goals
include self-efficacy, competency beliefs, task-value theory, and attributions (Rueda, 2011).
Lastly, some of the assumed organizational influences to consider that impact stakeholder’s from
achieving their performance include alignment of work processes, leadership, resources, and
workplace culture (Clark & Estes, 2008).
Each component of Clark and Estes’ (2008) gap analysis will be addressed below in
terms of NPU’s core faculty’s knowledge, motivation, and organizational needs to meet their
performance goal of developing a program/curriculum in leadership skills in areas of
communication, professionalism, and team-building for physician trainees by December 2020.
The first section will be a consideration of the influences on the stakeholder performance goal in
the context of knowledge and skills. Then, assumed influences that impact the achievement of
the stakeholder’s goal through the lens of motivational indicators will be discussed. Lastly, the
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 33

attainment of the stakeholder’s goal through the perspective of organizational factors to achieve
performance goals will be explored. The methodology used to examine and analyze each of the
knowledge, motivation, and organizational influences on the stakeholder’s performance will be
outlined and discussed in Chapter Three.
Stakeholder Knowledge, Motivation and Organizational Influences
Knowledge and Skills
This section addresses the knowledge influences required for NPU faculty members to
achieve their performance goals. According to Clark and Estes (2008), three factors contribute
to achieving performance goals: knowledge, motivation, and organizational support (p. 43). The
authors assert that “knowledge and motivation systems are the most vital facilitators or inhibitors
of performance goals” (p. 44). Individuals need to possess the required knowledge and skills as
it drives performance and enables them to do their tasks effectively. If individuals have the
knowledge and skills to do the task, they will be able to achieve their performance goals (Clark
& Estes, 2008).
For NPU’s faculty members to achieve their performance goal, examining the various
knowledge types and discussing methods to close gaps is essential. There are four types of
knowledge individuals need to understand in order to achieve their goals (Krathwohl, 2002;
Rueda, 2011). Factual knowledge requires individuals to understand basic facts to solve
problems (Krathwohl, 2002). This type of knowledge focuses on terminology, details, or
elements one must know so they can understand how to solve the problem. The second type of
knowledge is conceptual knowledge, which focuses on concepts individuals must know to solve
problems. This includes “knowledge of categories, classifications, principles, generalizations,
theories, models, or structures (Rueda, 2011, p. 28). The third type of knowledge is procedural
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 34

knowledge, which involves knowing and understanding how to complete a task (Rueda, 2011).
The fourth type is metacognitive knowledge, which emphasizes “awareness and one’s own
cognition” (Krathwohl, 2002, p. 214). This type of knowledge allows an individual to know
when to do something and why things are done (Rueda, 2011). It is important to assess NPU’s
faculty member’s understanding of the various knowledge types to meet performance goals. The
next section will focus on three knowledge influences that NPU’s stakeholders need to know so
they can achieve their performance goal.
Core faculty members need to know and understand the basic elements of
leadership (factual). The first knowledge influence that NPU’s faculty members will need to
achieve in designing and teaching a leadership curriculum is to know and understand the basic
elements of leadership. Medical training primarily focuses on the development of clinical skills.
As a result, a vast majority of physicians do not understand what leadership entails, and “lack the
technical skills needed for major leadership roles that will serve to bring both change and
empower the local culture” (Schwartz & Pogge, 2000, p. 191). Because NPU's faculty members
will be developing and teaching a leadership curriculum, they must understand the basic
concepts of leadership.
Healthcare organizations and physicians know that to provide high-quality patient care,
good leadership is essential. Still, many are unable to define the attributes of leadership other
than recognizing good leadership qualities when they see it (Dine, Kahn, Abella, Asch, & Shea,
2011). A review of the literature reveals that leadership skills are an essential component of
residency training, which many programs have yet to embrace. Understanding the basic
elements of leadership is critical to designing a curriculum for physician trainees. Thus, faculty
members at NPU must possess knowledge of the basic elements of leadership to develop a
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 35

curriculum. They need to know what attributes and skills make a good leader as well as
understand what leadership entails. This knowledge influence is categorized as factual
knowledge because it focuses on understanding the specific details and elements of leadership.
Accordingly, the method to assess whether a factual knowledge gap exists would be through
one-on-one interviews with faculty members. The interview would focus on evaluating the
faculty’s knowledge of basic facts and information on leadership (Krathwohl, 2002).
Core faculty members need to know the relationships between leadership skills and
leadership effectiveness (conceptual). The second knowledge influence that NPU’s faculty
members need to achieve their performance goal is to know how leadership skills such as
communication, team-building, and conflict negotiation skills relate to leadership effectiveness.
According to Stoller et al. (2004), “teamwork and leadership are important components of
effective medical practice” (p. 692). However, developing teamwork skills among physician
trainees has not been emphasized during residency, even though acquiring these skills is critical
to leading healthcare teams. Communication is the “glue that bonds all other leadership skills
together” (Schwartz & Pogge, 2000, p. 190) and is a required skill for physicians to be successful
in the healthcare industry. Surgeons interact with various stakeholders; so it is essential to
communicate effectively to build commitment with these stakeholders and improve productivity
(Schwartz & Pogge, 2000). Blumenthal et al. (2012) affirm that “good clinical leaders possess
team leadership skills, encourage communication and collaboration between team members,
maximize team performance, sets team direction, and encourage purposeful direction” (p. 514).
To effectively design a leadership program focusing on the development of leadership skills,
faculty at NPU need to know concepts of leadership skills. This knowledge influence is
categorized as conceptual knowledge because it focuses on knowledge of skills pertaining to
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 36

leadership. Accordingly, the method to access whether a conceptual gap exists would be through
one-on-one interviews with faculty members. The focus of the interview would be to evaluate
faculty’s knowledge of concepts on leadership skills.
Core faculty members need to know how to develop a leadership program
(procedural). The third knowledge influence that NPU’s faculty need to achieve their
performance goal is to know how to design a leadership program that can affect growth and
change in individual learners. As physician trainees assume leadership responsibilities in their
day-to-day clinical work, they need to know how to manage relationships with nurses, lead
teams, negotiate with patients and colleagues, manage conflict, and make resource allocation
decisions (Blumenthal et al., 2012). Thus NPU’s faculty members need to understand how to
develop and manage each component of the curriculum design to ensure the success of the
program and learners. This knowledge influence is categorized as procedural knowledge
because it focuses on NPU faculty member’s knowledge of the procedures involved with
developing a leadership program. Therefore, the method to assess whether a procedural gap
exists would be through surveying faculty members (Clark & Estes, 2008). The survey would
include questions requiring faculty to demonstrate the ability to design a leadership program
(Krathwohl, 2002). The below table, Table 2, identifies NPU’s core faculty member’s
knowledge influence on developing a leadership curriculum for physician trainees.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 37

Table 2
Summary of Core Faculty Member’s Assumed Needs for Knowledge Gap Analysis
Organizational Mission
The mission of the department of orthopaedic surgery at NPU is to provide the highest quality
of patient care, conduct innovative clinical, basic science, and translational research, and train
the next generation of global leaders in orthopaedic surgery.
Organizational Global Goal
By December 2021, 100% of physician trainees will participate in a leadership program at
NPU and will be able to effectively demonstrate leadership skills in team-building,
communication, and professionalism.
Stakeholder Goal

By December 2020, faculty will develop a leadership program/curriculum focusing on
developing trainee’s leadership skills in team-building, communication, and professionalism.

Knowledge Influence Knowledge Type Knowledge Influence
Assessment
Faculty need to know what
leadership means and the
terminology of the three skills
(communication, professionalism,
and team-building)
Factual Interviews and Survey
Faculty need to know the concepts
of leadership skills and their
relation to leadership effectiveness
Conceptual Interviews and Survey
Faculty need to know how to
develop a curriculum in these three
areas of leadership
Procedural Interviews and Survey

Motivation
This section addresses the motivation influences required for NPU’s faculty members to
achieve their performance goal. According to Grossman and Salas (2011), motivation refers to
the “process that accounts for an individual’s intensity, direction and persistence of effort toward
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 38

attaining a goal” (p. 109). Clark and Estes (2008) explain that motivation is what keeps
individuals interested in tasks and tells us how much effort to put in to accomplish goals. There
are three indicators of motivation that guide employee’s decisions to succeed in the workplace:
active choice, which involves individuals actively making a decision to pursue a goal;
persistence, which involves persevering to accomplish the goal despite distractions; and mental
effort, which involves how much effort one puts forth to seek new knowledge to achieve a goal
(Clark & Estes, 2008). Thus, motivation is the force that allows us to start, continue, or stop
doing a task. By addressing motivational challenges, organizations can help employees achieve
their performance goals.
While there are several motivational influences that enhance performance goals, this
section will focus on two specific motivational influences that impact NPU’s faculty members to
choose to develop a leadership program for physician trainees, task value, and self-efficacy.
According to Clark and Estes (2008), value can be defined as “ways people express their views
about what they expect will make them effective” (p. 95). Self-efficacy is defined as “people’s
judgments of their capabilities to organize and execute the course of action required to attaining
designated levels of performances (Rueda, 2011, p. 39). The sections that follow are organized
by motivation influence.
Faculty see the value in developing a leadership curriculum for physician trainees.
(Expectancy Value Theory). Value is the first motivational influence pertinent to NPU’s
faculty members in achieving their performance goal. Rueda (2011) explains that value refers to
what the individuals perceive as important in a given task. If NPU’s faculty find the task of
developing a leadership program important, then they are more likely to be motivated to do this
task. According to the expectancy-value motivational theory, motivation and performance is
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 39

enhanced if individuals find that they can do the task as well want to do the task (Eccles, 2006).
There are four dimensions of task value: intrinsic value, attainment value, utility value, and cost
value (Eccles, 2006).
Intrinsic value refers to the enjoyment an individual feels when engaged in the task. If
NPU’s faculty members find personal value and enjoy certain aspects of the task, they will be
motivated to do the task. The second value dimension is attainment value, which refers to the
importance an individual gives to a task when done well (Eccles, 2006). The author describes
that if tasks are related to an individual’s self-image, the more likely they are to value doing the
task. If NPU’s faculty members feel that physician trainee’s leadership skills will be enhanced
because of the program, then they will invest time and energy to do the task. The third value
dimension is utility value, which refers to individual’s views of how well the task fits into their
goals. If NPU’s faculty members understand that developing a leadership program for trainees
will enhance their own leadership skills and make them better leaders, then they will be
motivated to do the work (Eccles, 2006). The fourth value dimension is cost value, which refers
to an individual’s interest in the task based on the personal cost associated with achieving the
goal. Eccles (2006) characterizes cost in terms of loss of time and energy to complete other
tasks.
For NPU’s faculty members to be motivated to develop the leadership program, they
must perceive the task to have a low-cost value. Cost value is the most important value
dimension for NPU faculty members. If NPU’s faculty members feel that engaging in
developing a program is taking up the majority of their time and limiting them from providing
care to their patients, which is a top priority, they may choose not to engage in developing the
program even though they enjoy doing the task. Based on the motivation influence, the
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 40

methodology to assess if NPU’s faculty members are motivated to accomplish the goal of
developing a leadership program will be through surveys. According to Rueda (2011), if an
individual has high value for a task, they will choose, persist, and engage in getting the task done
(p.43).
Faculty believe they are capable of effectively developing a curriculum on
leadership skills (Self-Efficacy Theory). The second motivation influence that is pertinent to
NPU’s faculty members achieving their performance goal is self-efficacy. Pajares (2006)
defines self-efficacy as an individual’s beliefs about their own capabilities to learn or to
perform various tasks. According to Rueda (2011), self-efficacy is related to active choice,
persistence, and effort, and is important especially when individuals encounter difficulties
during a task. The author asserts that when individuals have high self-efficacy they are more
likely to be motivated to engage, persist and work hard to accomplish the task (p.41). For
NPU’s faculty to achieve their performance goal, they must feel confident in their capability of
developing a leadership program for physician trainees. Faculty members with a strong sense
of self-efficacy, will have a deeper interest and commitment to achieving the performance goal.
Faculty members with a weak sense of self-efficacy will lose confidence in their ability to
achieve their performance goal and find it hard to focus on the task. Based on the motivational
influence, the methodology to assess whether NPU’s faculty members will be motivated to
achieve their performance goal is through surveys. Table 2 identifies NPU’s core faculty
member’s motivational influences on developing a leadership curriculum for physician trainees.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 41

Table 3
Summary of NPU’s Core Faculty Members Assumed Needs for Motivation Gap Analysis
Organizational Mission

The mission of the department of orthopaedic surgery at NPU is to provide the highest
quality of patient care, conduct innovative clinical, basic science, and translational research,
and train the next generation of global leaders in orthopaedic surgery.
Organizational Global Goal

By December 2021, 100% of physician trainees will participate in a leadership program at
NPU and will be able to effectively demonstrate leadership skills in team-building,
communication, and professionalism.
Stakeholder Goal

By December 2020, faculty will develop a leadership program/curriculum focusing on
developing trainee’s leadership skills in team-building, communication, and professionalism.
Assumed Motivation Influences
(Choose 2)
Motivational Influence Assessment

Value:
Faculty see the value in developing a
leadership curriculum for physician trainees
Survey and Interviews
Self-Efficacy:
Faculty believe they are capable of effectively
developing a curriculum on leadership skills
Survey and Interviews

Organization
This section focuses on organizational related influences that contribute to performance
gaps. Clark and Estes (2008) explain that even if individuals possess the motivation and
knowledge, factors such as resource allocation, internal processes, and organizational culture can
hinder the achievement of performance goals. Aligning organizational related influences with
performance goals is integral and requires an understanding of the cultural models and settings
that define an organization (Clark & Estes, 2008). The purpose of the literature review is to
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 42

understand the organizational influences that promote or hinder NPU’s core faculty members
from effectively achieving the organizational performance goal.
Organizational culture. Clark and Estes (2008) explain that “organizational culture is
the most important work processes in all organizations because it dictates how we work together
to get our job done” (p. 107). Culture comprises of core values, goals, beliefs, emotions, and
processes learned as people develop over time (Clark & Estes, 2008). The authors suggest
further examining culture through various lenses of environment, groups, and individuals.
Within an organization, department, or academic institutions, culture is developed when
individuals share values, beliefs, and assumptions. These shared norms provide a guide to the
organization as well as to individuals within the organization. Clark and Estes (2008) explain
that to determine the culture of an organization, one must develop a profile that includes ways an
organization is unique and different, what people in the organization value most, and who drives
the change and makes important decisions. Understanding the cultural environment of an
organization will allow members to work together and inspire change. According to Schein
(2004), leadership plays a key role in developing a culture of learning within an organization.
Healthcare leaders understand how culture drives performance. Many leaders at various levels in
healthcare organizations have experienced how a fragmented culture can hinder a well-designed
initiative and conversely, how a strong positive culture can develop the foundation for change,
innovation, and success (Cochrane, 2017). Schein (2004) implies that culture is a “stabilizer, a
conservative force, and a way of making things meaningful and predictable” (p.343). The author
further explains that organizations that have a strong culture promote effective and lasting
performance (Schein, 2004).
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 43

Cultural models and cultural settings. According to Schein (2004), artifacts, espoused
beliefs and values, and basic underlying assumptions comprise an organizational culture.
Gallimore and Goldenberg (2001) define cultural models as “shared mental schema or normative
understandings of how the world works, or ought to work” (p.47). These models develop slowly
from collectively transmitted information and shared experiences (Rueda, 2011). According to
Rueda (2011), cultural models in an organizational setting, serve to shape the structure of the
organization, including “values, practices, policies, and reward structures” (p.55). In addition to
cultural models, organizations are also made up of cultural settings, where policies and practices
pertaining to the organization are enacted. Cultural setting is the “who, what, when, why, and
how of the routines which constitute everyday life- in essence, a more concrete version of what
we commonly call a social context (Rueda, 2011, p. 57). The dynamics of cultural settings are
important because it can influence whether stakeholder performance goals are met.
Core faculty members need to have the time, resources, and financial support to
develop a leadership curriculum (Resources). While policies and procedures within an
organization are necessary, having adequate resources is essential to meet performance goals.
Clark and Estes (2008) explain that an organization where knowledge and motivation are
excellent, a lack of resources can impede the achievement of performance goals. In teaching
hospitals, time and resources are major barriers to developing a curriculum. DaRosa et al. (2011)
explain that hospitals “discourage teaching by applying pressure on faculty members to use
facilities efficiently so as to maximize facility-based revenues” (p.3). Based on the literature
reviewed, McCullough, Marton, and Ramnanan (2015) reported that 45% of physicians indicated
that lack of time prevented them from teaching or that students somehow affected their daily
productivity. Other studies identified that academic physicians faced increased pressure from the
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 44

institution and department leaders to generate more of their salary through patient care, hence
resulting in reduced time for research or teaching (McCullough et al., 2015). According to
McCullough et al. (2015), studies reviewed also reported that 26% of physicians indicated that
lack of financial support, such as lack of compensation or potential income loss as a significant
factor preventing them from teaching. Faculty members need appropriate time, resources, and
financial support to develop and teach a curriculum that accommodates differences in learner’s
abilities.
Core faculty members need to believe they are valued and part of an organization that
supports their efforts to develop and teach curriculum (Cultural model). Teaching is an
important commitment for faculty members in an academic institution, and they are tasked with
the critical responsibility of teaching and training students. However, academic institutions and
departments do not always clearly communicate to faculty their teaching expectations and
responsibilities. Also, faculty members do not receive guidance on how to balance and meet
their patient care and teaching responsibilities (DaRosa et al., 2011). There is a belief amongst
faculty members that academic institutions do not see the importance and value of teaching
because “promotion and tenure communities often make decisions demonstrating that
educational scholarship is not as esteemed as traditional form of scholarship” (DaRosa et al.,
2011, p.3). Most academic institutions often place higher merit, recognize and reward clinical
and research achievements, and not teaching excellence. Callcut, Rikkers, Lewis, and Chen
(2004) found that surgical faculty members teaching skills declined with career advancement and
seniority due to increased pressure to put other commitments such as clinical duties over
educational development. According to a survey administered by the Association of Surgical
Education to chairs of 140 surgical departments, only 66% reported that they rewarded faculty
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 45

for teaching excellence (Khan, Khan, Dasgupta, & Ahmed, 2013). It is important and critical to
make faculty members who are education-focused feel valued, to reduce faculty loss as well as
meet standards for excellence (DaRosa et al., 2011).
Core faculty members need to be part of an environment where leaders of the
organization model desired behaviors, practices, and support faculty development (Cultural
setting). Leaders within a healthcare organization play a key role in demonstrating the
constructive behaviors that shape and drive improvement. According to Cochrane (2017), when
faculty members see leaders focusing on modeling and creating an environment where learning
and teaching is a priority, the culture is set. A cultural setting that promotes accountability
policies and practices creates the involvement of faculty members and increases performance
(Schein, 2004). Faculty members also need support to develop themselves as teachers. Most
physicians with teaching appointments in academic institutions have had minimal training on
formal teacher training (Khan et al., 2013). According to a survey administered to 809
physicians, 57% expressed that they needed training in basic teaching skills, and many felt that
attending a teaching training course would greatly benefit them (Khan et al., 2013). To develop
faculty members as educators and increase their engagement, faculty members not only need to
know that leaders value educational excellence but also support their development as educators.
Table 4 identifies NPU’s core faculty member’s organizational influence on developing a
leadership curriculum for physician trainees.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 46

Table 4
Summary of Core Faculty Member’s Assumed Needs for Knowledge Gap Analysis
Organizational Mission

The mission of the department of orthopaedic surgery at NPU is to provide the highest
quality of patient care, conduct innovative clinical, basic science, and translational
research, and train the next generation of global leaders in orthopaedic surgery.
Organizational Global Goal

By December 2021, 100% of physician trainees will participate in a leadership program
at NPU and will be able to effectively demonstrate leadership skills in team-building,
communication, and professionalism.
Stakeholder Goal

By December 2020, faculty will develop a leadership program/curriculum focusing on
developing trainee’s leadership skills in team-building, communication, and
professionalism.
Assumed Organizational Influences Organizational Influence Assessment
Cultural Models. The organization needs to
provide resources, time, and financial
support to core faculty members to develop
a curriculum.
Interviews and Survey
Cultural Models. The organization needs to
make core faculty members feel valued and
support and prioritize their efforts.
Interviews and Survey
Cultural Setting. The organization needs to
make core faculty members feel part of an
organization where leaders demonstrate
behaviors and practices that support faculty
development as educators.
Interviews and Survey

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 47

Conceptual Framework: The Interaction of Stakeholders’ Knowledge and Motivation and
the Organizational Context
The conceptual framework is something that is not solely developed through a review of
literature; instead, it is something that is constructed from information gathered in the form of
existing theories and various other sources (Maxwell, 2013). A conceptual framework attempts
to identify the underlying causes of a problem. This framework “explains, either graphically or in
narrative form, the main things to be studied- the key factors, concepts, or variables- and the
presumed relationships among them” (Maxwell, 2013, p. 39). In other words, the conceptual
framework informs the research design. For this study, assumed influences that hinder core
faculty member’s participation and success in developing a curriculum on leadership skills are
described independently. These assumed influences do not remain in isolation but interact with
each other and co-exist.
According to Clark and Estes (2008), when organizational goals are aligned with the
knowledge, motivation, and organizational influences, performance increases. The purpose of
the interactive conceptual framework below is to graphically describe the alignment between the
organizational goal and the assumed needs and influences underlying the knowledge, motivation,
and organizational context within which core faculty members at NPU (pseudonym) are
collaborating. In this study, the organizational goal is impacted by the interaction between
NPU’s core faculty member’s knowledge, motivation and organizational influences. In order for
core faculty members to achieve success in developing and implementing a leadership
curriculum, underlying knowledge, motivation, and organizational influences need to be
examined and better understood.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 48

Figure 1. Interactive Conceptual Framework that depicts the core faculty member’s need
analysis.

NPU Department of
Orthopaedic Surgery
Organizational
Cultural Models: value
for teaching, support for
creativity
Cultural setting:
environment, policies and
practices

Stakeholder group: Core
Faculty members
Knowledge
Motivation
Factual: elements of
leadership
Conceptual: relationships
between leadership skills
and effectiveness
Procedural: how to create
and teach leadership skills

Expectancy-Value
Theory: value in effort
spent
Self-Efficacy: believe in
their capabilities

By December 2021, 100% of physician
trainees will participate in a leadership
course at NPU and will be able to
effectively demonstrate leadership skills in
team-building, communication, and
professionalism

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 49

The conceptual framework presented explains how the knowledge and motivational
influences interact with each other within the organizational context to achieve the broader
organization goal of having 100% physician trainees participate in a leadership course and
effectively demonstrate leadership skills in communication, team-building, and professionalism.
The larger red circle represents NPU (pseudonym) as the organization of study and the cultural
settings and models that exist within the organization. These organizational influences are
important because it helps core faculty members align their teaching responsibilities with the
organizational goals. These organizational influences include organizational culture around
value for teaching, support for creativity, environment, policies, and practices that impact core
faculty member’s commitment to developing a leadership course for physician trainees.
The blue circle represents the knowledge and motivational influences that affect core
faculty member’s engagement with curriculum design. Core faculty member’s need factual
knowledge on basic elements of leadership, conceptual knowledge in relation to concepts of
leadership skills and leadership effectiveness, and procedural knowledge on how to design and
teach a leadership course. The motivational influences can be explained by several motivational
theories, which include expectancy-value in relation to core faculty member’s seeing the value in
developing a leadership course and self-efficacy in relation to believing they are capable of
developing and teaching a curriculum effectively. Because these influences interact with each
other and within the larger organizational context, they are represented in parallel and addressed
simultaneously.
Conclusion
Chapter Two provides a literature review of the problem, lack of leadership training for
physician trainees in many residency programs across the United States. The first section of the
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 50

chapter discussed the background of residency training, leadership qualities required for medical
practice, and leadership training in residency programs. The second section examined the Clark
and Estes’ gap analysis model in relation to knowledge, motivation, and organizational factors,
which impact core faculty members to develop and teach a leadership curriculum to physician
trainees. The third section presented the KMO influences currently hindering or promoting core
faculty members from developing and teaching a leadership curriculum. The knowledge
influences included factual, procedural, conceptual, and meta-cognitive strategies concerning
core faculty member’s ability to develop a leadership curriculum. The motivation influences
included value theory and self-efficacy theory strategies. Finally, the organizational influences
included organization culture and cultural model and settings which contribute to performance
gaps. Chapter Three describes the validation process for these influences.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 51

CHAPTER THREE: METHODOLOGY
The purpose of this study is to conduct a needs analysis in the areas of knowledge,
motivation, and organizational resources necessary for the faculty members to reach the
organizational performance goal of having 100% of trainees effectively demonstrate leadership
skills in the areas of interpersonal communication, team-building and professionalism by
December 2021. As such, the questions that guide this study are the following:
1. What are the knowledge and skills, motivation, and organizational constraints and needs
related to Northern Pacific University (NPU) core faculty member’s goal of developing a
leadership program/curriculum by December 2020, focusing on physician trainee’s
leadership skills in team-building, communication, and professionalism?
2. What is the interaction between organizational culture and context and core faculty’s
knowledge and motivation?
3. What are the recommended knowledge, motivation, and organizational solutions?
Participating Stakeholders
To best understand the interaction of the organizational context with the knowledge and
motivational factors that drive performance, the population of focus for this study is core faculty
members. This population consists of 75 full-time faculty members responsible for supervising
and training physician trainees. This stakeholder group is also responsible for deciding content
to be included in the curriculum and providing a positive learning environment for physician
trainees. For this study, 37 core faculty members who participate in the residency teaching
curriculum and supervise physician trainees were recruited. For the mixed-method approach, the
criteria described below were used to identify the research participants.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 52

Survey Sampling (Recruitment) Criteria and Rationale
For the purpose of this study, an explanatory sequential mixed method approach, first
using the quantitative approach followed by the qualitative approach was used. According to
Creswell (2014), the mixed-methods approach provides a comprehensive understanding of a
research problem than either a quantitative or qualitative approach alone.
The rationale for using surveys is to examine and assess core faculty member’s
knowledge and motivation in developing and teaching a leadership curriculum to physician
trainees. According to Miriam (2009), “survey research describes what is; that is, how variables
are distributed across a population or phenomena” (p. 5). Using the quantitative approach, a
sample of 37 junior and senior faculty members who participate in teaching the resident’s core
curriculum was selected. This allowed for meaningful statistical analysis and provided the
structure for subsequent qualitative data collection.
Criterion 1. Thirty-Seven core faculty members that participate in teaching physician
trainees.
Criterion 2. Core faculty members who are full-time and have an appointment as
assistant professor, associate professor, or professor.
Interview Sampling Criteria and Rationale
Interviews are a method of qualitative data collection used to generate data rich in detail
and embedded in context. According to Creswell (2014), the purpose of using the qualitative
approach is “to explore the general, complex set of factors surrounding the central phenomenon
and present the broad, varied perspectives or meanings that participants hold” (p. 140). For this
study, face-to-face semi-structured interviews with a smaller sample of 10 core faculty members
among the 37 members of the teaching faculty were used. These faculty members are a subset of
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 53

those surveyed and play a larger role in developing curriculum for physician trainees.
Purposefully selected core faculty members were recruited to collect detailed views to help
explain the initial quantitative survey (Creswell, 2014).
Criterion 1. Core faculty members that spend over 40% of their time teaching residents
were interviewed as they are knowledgeable about the problem or issue and can help best
understand the research questions.
Criterion 2. Core faculty members who have participated in developing a curriculum
within the last five years were interviewed as they understand what resources are needed to
develop a leadership curriculum.
Criterion 3. Core faculty members who have been in the organization for more than two
years were interviewed as they can provide valuable insights into the organization’s culture.
Data Collection and Instrumentation
Data collection and instrumentation is an important part of this study. This study will
utilize a mixed-method approach, first using a quantitative approach in the form of a survey
followed by a qualitative approach in the form of interviews to assess the knowledge, motivation,
and organizational constraints and needs of the stakeholder group at Northern Pacific University
(NPU). The data collection methods utilized for this study is well supported by literature on
quantitative and qualitative research. According to Check and Schutt (2012), survey research is
used to collect information from a sample population through their responses to questions. Thus,
using a survey will be helpful in obtaining trends and opinions from the research participants.
Patton (2002) states that interviews are beneficial if a researcher wants to find out things that are
not easily noticeable such as feelings, thoughts, and intentions. Since this study aims to identify
the knowledge, motivation, and organizational barriers affecting core faculty members from
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 54

developing a leadership curriculum for physician trainees, hearing about core faculty member’s
feelings and thoughts through interviews is the right approach.
Survey Instrumentation and Data Collection
A survey was utilized to gain information on the stakeholder’s knowledge, motivation,
and organizational influences.
Survey instrument. In order to assess the knowledge, motivation, and organizational
influences, an online survey using the secure, cloud-based survey tool, Qualtrics was used to
gather and analyze data. A survey is utilized because of the rapid turnaround in data collection
(Creswell, 2014). When developing the questionnaire, the researcher considered specific content
that best informed the research questions. The 11-item questionnaire used a combination of
multiple-choice questions, Likert-style scale questions, continuous scales, categorical scales, and
open-ended to gather information about core faculty member’s perspectives on assumed
knowledge, motivation, and organization influences. Open-ended questions were added to yield
detailed and descriptive data (Merriam & Tisdell, 2016). Since the same open-ended questions
were asked during interviews, data collected from the open-ended questions were not reported
under the survey results and findings section. However, the responses from the open-ended
questions were reported in the interview findings. The purpose of the open-ended questions was
for the researcher to gather additional information.
Survey Procedures. All Thirty-seven core faculty members were sent a personalized
email with a link to complete the online survey. In the email, the researcher described the
background and intent of the research study. Efforts were also made to inform participants how
the results and data gathered would be used. Since the stakeholder group is familiar with online
surveys, it will be completed in the US English language form. The online survey assessed
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 55

knowledge, motivation, and organizational influences of the stakeholder group. An email
reminder was sent a week later after the initial invitation to increase participant’s response rate.
Once participants clicked submit, a thank you page was displayed confirming that they have
completed the survey. The online survey closed after two weeks.
Interview Instrument and Data Collection
Interviews were utilized to gain information on the stakeholder’s knowledge, motivation,
and organizational influences.
Interview protocol. For the purpose of this study, semi-structured interviews were
conducted. This type of approach allowed for questions to be more flexibly worded and the
interview to have a mix of more or less structured questions (Merriam & Tisdell, 2016). This
format was the best approach as it allowed the researcher to respond to “situations at hand, and to
new ideas on the topic” (Merriam & Tisdell, 2016, p. 111).
Research suggests that there are six types of questions to stimulate responses: experience
and behavior, opinion and value, feeling, knowledge, sensory, and background/demographics
(Merriam & Tisdell, 2016). Of these, behavior and experience, opinion and value, and
knowledge questions will be most relevant to assessing the stakeholder’s knowledge, motivation,
and organizational influences in developing a leadership program or curriculum for physician
trainees.
Interview procedures. Once faculty members completed the survey, they received a
message confirming that their responses were recorded. In the same message, they were asked if
they would like to participate in the interview process. If the faculty member responds yes, they
will be directed to another page requesting their contact information, and thus not connected to
the anonymous survey. The interviews will take place within a month of the survey being
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 56

closed. Ten research participants were selected for face-to-face interviews. Of these ten
participants, half were chosen randomly, and the other half were chosen because of their
potential to provide insights to the motivational and organizational factors that interfere with
developing a leadership curriculum or program for physician trainees.
Research participants were sent a personalized email reminding them about their
participation in the hour-long interview process. Participants were provided instructions on how
to schedule their desirable interview time and day. The email also described how interviews
would be conducted, the location of the interviews as well as how data will be maintained. The
researcher selected a location that maintained the participant’s confidentiality.
A reminder email was sent a couple of days prior to the interviews to all confirmed
participants. Interviews began with a standard protocol asking permission from the research
participant to record the interviews. Interviews were conducted in the US English language, done
in an informal manner, and participants were asked 10-12 questions. Interviews were audio-
recorded to ensure that all information provided was preserved for analysis (Merriam & Tisdell,
2016). Notes were also taken during each interview to record the researcher’s reactions to
something informational the research participant said. Audio files were transcribed. During
listening and reading of the audio files, notes were written, and information gathered coded to
identify emerging themes (Maxwell, 2013).
Alignment of the KMO Influences and Data Collection
Table 5 provides a summary of the data collection methods that were used to assess the
assumed knowledge, motivational, and organizational influences affecting Northern Pacific
University’s (NPU) core faculty member’s ability to develop and implement a leadership
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 57

curriculum for physician trainees. This table demonstrates the alignment between the assumed
influences and data collection methods.
Table 5

Knowledge, Motivation and Organizational Influences affecting NPU Core Member’s Ability to
Develop a Leadership Curriculum

Knowledge
Knowledge Influence Knowledge Influence
Assessment
Survey Interviews
Factual. Faculty need
to know what
leadership means and
the terminology of the
five skills
(communication,
professionalism, team-
building)
Surveys and Interviews
with ten core faculty
members
1. Leadership is
a. having an
awareness of both self
and others.
b. A natural ability
that cannot be learned
c. The art of getting a
group to work on a
common goal
d. developing strong
personal and
professional values
e. building a culture
of excellence and
accountability
1. Describe your
understanding of
leadership, what
does it mean to
you?
2. As a physician,
what do these
terms mean to you:
effective
communication,
professionalism,
and teamwork

2. What are the
characteristics of a
good leader? (Check
all that apply
1. Influencing
individuals and
groups to
cooperatively achieve
organizations goals
2. Coaching and
building teams to
effectively achieve
the vision
3. Communicating
effectively the vision
4. Leading by
example
5. Directing people to
do what they will not
otherwise do.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 58

Table 5, continued
Knowledge
Knowledge Influence Knowledge Influence
Assessment
Survey Interviews

3. What is NOT a
characteristic of
teamwork? Check all
that apply
-Open and honest
communication
-Collaboration
-Minimal and formal
knowledge sharing
-Team trust
-Respect for team
members

4. What are the
characteristics of
professionalism?
Check all that apply
-Responsible
-Reliable
-Respectful
-Integrity
-Accountable
-Polite

Conceptual. Faculty
need to know the
concepts of leadership
skills and their relation
to leadership
effectiveness.
Surveys and Interviews 5. Rank the
importance of the
following skills for
leadership
effectiveness.
a. Interpersonal
Communication
b. Teamwork
c. Professionalism
d. Emotional
Intelligence
e. Coaching and
giving feedback
f. Recognizing,
disclosing and
addressing errors
1. If you have to
describe what
leadership skills
are required to be
successful as a
physician, what
would you say?
2. If you had to
explain effective
communication,
professionalism,
and team-building
to physician
trainees, what
would you say?

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 59

Table 5, continued
Knowledge
Knowledge Influence Knowledge Influence
Assessment
Survey Interviews
Procedural. Faculty
need to know how to
develop a curriculum in
these areas of
leadership:
communication, team-
building and
professionalism
Survey and Interviews 6. You have been
asked to create a
leadership program
for physician trainees.
What would be your
first step
a. Look at other
leadership
programs
b. Develop my own
leadership skills
c. Identify the
characteristics of
physician leaders.
d. Decide who is
going to teach the
program
Explain, how would
you develop a
leadership curriculum
for trainees? Please
walk me through the
process.
Motivation
Assumed Motivation
Influences
Motivational
Influence Assessment
Survey Interviews
Expectancy-Value
Theory. Core Faculty
see the value in
developing a leadership
curriculum for
physician trainees.
Survey and Interviews 7. To what extent do
you agree or disagree
with the following
statements:
1. How important do
you feel it is to
have physician
trainees develop
these non-clinical
skills in
communication,
professionalism,
and team-building
during residency
training
2. Some may say,
leadership skills
are not necessary
for physician
trainees. What
would you say?

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 60

Table 5, continued
Motivation
Assumed Motivation
Influences
Motivational
Influence Assessment
Survey Interviews
7a. I believe
leadership skills have
value to strengthen
physician trainee’s
leadership
competencies and
improves
performance

7b. It is important for
me to participate in
leadership
development
programs at my
institution

7c. I believe it is
important to
recognize the need to
develop leadership
skills in physician
trainees

7d. I believe strong
leadership skills is
associated with less
physician burnout and
higher satisfaction

7e. It is important to
develop courses that
enhance physician
trainee’s leadership
skills.
(strongly disagree,
disagree, neither
agree nor disagree,
agree, strongly agree)

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 61

Table 5, continued
Motivation
Assumed Motivation
Influences
Motivational
Influence Assessment
Survey Interviews
Self-Efficacy. Core
Faculty believe they are
capable of effectively
developing a
curriculum on
leadership skills
Survey and Interviews 8. On a scale of 1-10
rate how confident
you are to do the
following right now:
1. Could you describe
how confident you
feel in developing
a leadership
curriculum?
2. Could you describe
how confident you
feel teaching
leadership skills in
areas of
communication,
professionalism
and team-building.
8a. Develop
communication skills
in physician trainees
8b. Develop team-
building skills in
physician trainees
8c. Try something
outside the scope of
what you have
already done
8d. lead physician
trainees by example

8e. design curriculum
for physician trainees

Organizational
Assumed
Organizational
Influences
Organizational
Influence Assessment
Survey Interviews
Resources. The
organization needs to
provide resources, time,
and financial support to
core faculty members
to develop curriculum.
Survey and Interviews 9. To what extent to
do you agree or
disagree with the
following statements
1. To what extent do
you believe the
department
supports your
development as an
educator?
9a. My organization
provides sufficient
resources to develop a
curriculum for the
next generation of
leaders
9b. My organization
provides dedicated
time to focus on
teaching physician
trainees

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 62

Table 5, continued
Organizational
Assumed
Organizational
Influences
Organizational
Influence Assessment
Survey Interviews
9c. My organization
provides financial
support for teaching
and developing the
next generation of
leaders
(strongly disagree,
disagree, neither
agree or disagree,
agree, strongly agree)

Cultural Models. Core
faculty members need
to believe they are
valued and part of an
organization that
supports their efforts to
develop and teach the
curriculum
Survey and Interviews 10. Using the scale
below, please rate the
extent to which you
believe the following:

10a. I feel supported
and valued as a
faculty member.

1. Some faculty
may say that the
culture of the
organization
doesn’t support
education
activities, what
do you say to
that?
2. Imagine I am a
new faculty
member. Tell me
about the culture
of the department
in developing
faculty as
educators?
10b. My peers
welcome opinions
that are different from
their own
10c. The culture of
the organization
supports having a
physician leadership
program.

10d. I am encouraged
to be creative in my
teaching practices
10e. I consider the
environment I work in
to be innovative

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 63

Table 5, continued
Organizational
Assumed
Organizational
Influences
Organizational
Influence Assessment
Survey Interviews
Cultural Setting. Core
faculty members need
to be part of an
environment where
leaders of the
organization model
desired behaviors,
practices, and support
faculty development
Survey and Interviews 10f. The most highly
rewarded faculty are
those oriented
primarily toward
research and clinical
activities
(strongly believe,
somewhat believe,
neutral, somewhat do
not believe, strongly
do not believe)
1. To what extent do
you believe there
are infrastructures
in place to support
faculty’s efforts in
educating
trainees?
11. Please indicate the
level of influence
each of the following
would have on
impacting your ability
to develop curriculum
for physician trainees
(No influence, slight
influence, neutral,
moderate influence,
significant influence)

-Faculty development
workshops

-Financial stipends
-Online professional
development/training

-Dedicated time
-Encouragement from
department leadership
for learning

-Physical workspaces
that promote
collaboration and
innovation

-Online faculty
communities that
promote collaboration
and innovation

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 64

Data Analysis
Because this study used an explanatory sequential mixed method, first quantitative survey
data was analyzed. The results from the survey guided the development of the interview
protocol. Next, qualitative data via face-to-face interviews were collected and analyzed.
For the quantitative data collection, a survey was administered using an online
application, Qualtrics and data was statistically analyzed. Descriptive statistical analysis was
used once all survey results were submitted. When applicable, frequencies, means, and standard
deviations were calculated for each of the survey items. The survey contained a variety of
questions, which determined the type of descriptors for central tendency and measures of
variability (Salkind, 2017). For Ordinal data, mode and medians were reported. Nominal data
were described with a mode. For self-efficacy survey responses, measures of central tendency
were calculated. Value-based survey questions used a Likert-type scale where modes and
frequencies were obtained. For organizational barrier questions, means and standard deviation
were presented to identify the average level of responses. The results of the survey questions
provided information to compare against and identify trends that support assumed knowledge,
motivation, and organizational needs.
For interviews, data analysis began during data collection. Throughout the data analysis
process, the researcher used multiple coding phases, and the coding scheme was based on the
research questions. Data obtained was coded into as many categories as possible. The
researcher’s goal was to identify and describe themes from the perspective of the research
participants. Data was organized categorically, looked at repeatedly, and coded using the
knowledge, motivation, and organization influences (Creswell, 2014). Interviews were audio
recorded, transcribed verbatim, and analytic memos were written after each interview.
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 65

Following the completion of each interview session, the researcher documented thoughts and
concerns in relation to the research questions.
Corbin and Strauss (2008) identified multiple analytic tools to help researchers analyze
datasets. The researcher questioned data, made comparisons, used personal experience, and
scrutinized key concepts to interrogate data. Questioning data and making comparisons during
the analysis phase provided opportunities for the researcher to look for new information as well
as identify similarities and differences. It also forced the researcher to examine their own basic
assumptions, biases, and perspectives (Corbin & Strauss, 2008). The researcher shares a
common culture with the research participants and at times encounters similar experiences so the
researcher drew upon these experiences. In addition, looking for negative cases in datasets
added depth to the analysis.
Credibility and Trustworthiness
Trustworthiness of this study and the data is tied directly to the trustworthiness of the
researcher that designs, collects and analyzes the data (Merriam & Tisdell, 2016). It is extremely
important to the researcher that the approach, design, data collection methods, and analysis all
followed appropriate protocols and guidelines to ensure credibility and trustworthiness of the
study.
To maximize the credibility and trustworthiness during the data collection and analysis
phase four key strategies were employed. First, the confidentiality of the data collected was
maintained throughout the study. All data collected was kept in a secure manner that used strong
alphanumeric passwords. Second, the use of different data sources provided the opportunity for
triangulation, ensuring the credibility of the research study (Creswell, 2014; Merriam & Tisdell,
2016). Third, member checks were utilized to ensure the credibility of the study. The researcher
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 66

took back parts of the semi-polished report and asked up to seven participants to comment on the
major findings. This provided an opportunity for research participants to comment on the
accuracy of the findings. (Creswell, 2014). Member checks are “the single most important way
of ruling out the possibility of misinterpreting the meaning of what the participants say and
identifying your own biases and misunderstandings of what was observed” (p. 246) during
interviews. Lastly, an audit trail in the form of memos, where recording interactions with the
data as it is analyzed and interpreted, was used to ensure the reliability of the study (Merriam &
Tisdell, 2016).
Validity and Reliability
Validity refers to how well research findings match reality, while reliability refers to how
well research findings can be replicated (Merriam & Tisdell, 2016). For this study, the
researcher generated a customized survey based on the knowledge, motivation, and
organizational influences. The survey instrument was pilot-tested for clarity and understanding
with a few faculty members in a different department to ensure that the questions, format, scales,
and scores were valid. The researcher incorporated the comments into the final instrument
revisions (Maxwell, 2013). Finally, the survey instrument and interview protocol went through
an interactive process with dissertation committee members to ensure its validity.
To ensure confidence in the sample, all thirty-seven core faculty members were invited to
participate in the survey and reminders were sent to increase response rates.
Ethics
According to Glesne (2011), ethical guidelines are in place to provide the researcher “a
framework for reflection on fieldwork, sensitizing the researcher to areas that require thoughtful
decisions” (p.165). While conducting research, the author also states that it is imperative that
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 67

research should be conducted in a manner that is understandable to the participant to minimize
the risk or potential harm (Glesne, 2011). As this study involved human subjects, a series of
ethical considerations were considered to ensure the reliability and trustworthiness of the
research as well as eliminate any potential risk. One of the first steps that were required and
completed before participants were enrolled in the research study was submitting the proposal to
the Institutional Review Board (IRB) for review and approval to minimize any risks to the
human subjects. The role of the IRB is to ensure that the research study follows all ethical
guidelines (Rubin & Rubin, 2012).
Informed consent, respect for research participants, minimizing harm, and other ethical
behaviors were followed and guided this research study (Rubin & Rubin, 2012). Informed
consent, which is an important step in the process was properly utilized to ensure that
participants are informed of any aspect of the research that may do them harm, their participation
is voluntary, and they can freely choose to stop at any time (Glesne, 2011). A mixed-methods
design, using both quantitative and qualitative methods was applied to assess the trustworthiness,
answer the research questions, and ensure informed consent (Merriam & Tisdell, 2016).
At the beginning of the interview process for the qualitative group, participants were
provided an information sheet that provided sufficient information so they could make an
informed decision about participating in the study (Glesne, 2011). Because the researcher
understood that interviews carry both risks and benefits, participants were also informed of their
right to privacy. According to Glesne (2011), “participants have a right to expect that when they
give you permission to observe and interview, you will protect their confidence and preserve
their anonymity” (p.172). The researcher gained both verbal and written permission to record
the interviews, and the information obtained was secured and destroyed once transcribed.
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 68

Participants for this study are core faculty members who do not have a direct report to the
primary researcher. Although position of power will not be a factor while conducting this study,
the researcher works with the research participants, so they may feel pressure to participate in the
interviews or answer questions a certain way. To ensure participants do not feel coerced into
participating in the research study, the researcher reminded participants that they could refuse to
be part of this study, and no harm will come to them if they decide not to participate (Rubin &
Rubin, 2012). In addition, the role of the researcher, the purpose of the study, and the risks of
participating in the research study were also described to the research participants. Furthermore,
the researcher informed research participants that they would not receive any incentives for
participating in this study, minimizing any concerns of coercion (Rubin & Rubin, 2012).
One of the potential biases is the fact that the primary researcher works for the
organization. As an employee of the organization, the researcher has maintained friendly
relationships with some of the research participants who are involved in the study and may be
provided with intimate information in the context of friendship instead of their role as a
researcher (Glesne, 2011). To avoid any ethical dilemma, the researcher respected the
confidentiality of the participant and appeared neutral. This is to ensure the trustworthiness of
the data collected (Merriam & Tisdell, 2016). The above actions taken during the research study
minimized risk and tension, protected and built trust with the research participants, and promoted
ethical practices.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 69

Limitations and Delimitations
As with all research studies, there are limitations and delimitations. The first limitation
of this study is the instruments developed specifically for this study. While the instruments were
pilot tested with a small group of faculty from another department before administering it to the
research participants under study, neither instruments were rigorously field tested. The second
limitation was the truthfulness of the research participants. The honesty of the research
participants could have been affected because of the researcher’s position within the
organization. Research participants may have answered questions based on their familiarity with
the interviewer. A third limitation was that the researcher assumed that all the research
participants interpreted the survey items and interview questions as intended. A fourth limitation
is the small sample size and inclusion of only one medical specialty.
In addition to the limitations described above, this study has a few delimitations. The
delimiting factors include the research questions, and the population, the researcher chose to
investigate. Although the data collected will help the researcher understand the problem of
practice, this study will not be generalizable to a larger population.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 70

CHAPTER FOUR: RESULTS AND FINDINGS
The purpose of this study was to evaluate the degree to which core faculty members
Northern Pacific University (NPU) can develop and teach a leadership curriculum to physician
trainees. The questions that guided this study were:
1. What are the knowledge and skills, motivation, and organizational constraints and needs
related to NPU’s core faculty member’s goal of developing a leadership
program/curriculum by December 2020, focusing on physician trainee’s leadership skills
in team-building, interpersonal communication, and professionalism?
2. What is the interaction between organizational culture and context and core faculty’s
knowledge and motivation?
3. What are the recommended knowledge, motivation, and organizational solutions?
As discussed in Chapter Three, quantitative and qualitative data collection methods were
used in this study to validate the assumed needs. Survey and interviews were collected to
understand the knowledge, motivation, and organizational barriers that core faculty members
encounter in developing a leadership curriculum for physician trainees. This chapter will
provide an overview of the results and findings organized by the categories of assumed
knowledge, motivation, and organizational needs.
First, quantitative data was collected via online surveys. The survey focused on assumed
knowledge, motivation, and organizational needs. Then follow-up face-to-face interviews were
conducted with a subset of core faculty members to collect qualitative data. During these
interviews, knowledge, motivation, and organizational needs were discussed. Twenty-five core
faculty members completed the online survey (68% response rate), and ten core faculty members
participated in the interviews.
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 71

Participating Stakeholders
As discussed in previous chapters, the stakeholder group for this study was core faculty
members who are responsible for developing and teaching the curriculum to physician trainees.
These stakeholders are also responsible for providing a positive learning environment for
physician trainees. At the time of this study, 37 individuals were surveyed. Out of the 37
individuals, 25 responded to the survey. Demographics information of the 25 respondents who
completed the survey included 16% females and 84% males from various sub-specialties within
orthopaedic surgery. Respondents of the survey included 32% assistant professor, 40% associate
professor, and 32% professor level. Table 6 summarizes the rank levels of the study population.
Ten core faculty members participated in the interviews.
Table 6
Rank of Participants
Rank level No of Responses Percentage
Assistant Professor 8 32%
Associate Professor 10 49%
Professor 7 28%

Determination of Assets and Needs
Survey and interview questions validated the knowledge, motivation and organizational
influences. The next section focuses on knowledge influences. If core faculty members
demonstrated an overall deficit in the knowledge influences for an assumed need, then that need
was classified as validated. If no deficit in knowledge, motivation, and organizational influence
was identified, then that assumed need was classified as not validated. To determine whether the
KMO influence is a “need” or “asset,” a cut score of 70% was used for both surveys and
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 72

interviews. The criteria used to identify deficits in knowledge influence and classify assumed
knowledge, motivation, and organizational needs as not validated are outlined in Table 7.
Table 7
Criteria Used to Classify Assumed Knowledge Influence as “Not Validated”
Survey Interviews
Knowledge
Factual >70% identifies what is
leadership, characteristics of
a good leader, teamwork and
professionalism
>70% adequately describes
leadership and the
characteristics of leadership
skills
Conceptual >70% understands the
relationship between
leadership skills and
leadership effectiveness
>70% describes leadership
skills to be an effective
leader
Procedural >70% identifies the first step
to developing a leadership
program
>70% describes the first
steps in developing a
leadership program

Results and Findings for Knowledge Causes
The next section focuses on the results and findings of knowledge categories and
assumed causes for each category. Survey and interview questions validated the knowledge
constructs, which were factual, conceptual, and procedural. The survey contained six
knowledge-related questions, and during the interviews, core faculty members were asked a total
of four knowledge-related questions.
Factual Knowledge
Influence 1A. Core faculty members need to know what leadership means.
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 73

Survey results. Twenty-five core faculty members were asked to define leadership. As
seen in Table 8, for the question, “What is leadership?” 68% of those surveyed responded
correctly. With a cut score of 70%, this item is a need.
Table 8
Survey Results for Factual Knowledge of Leadership
# Factual Knowledge Item (n = 25) Percentage Count
What is leadership?
1 Awareness of both self and others 16% 4
2 Natural ability that cannot be
learned
0 0
3 The art of getting and motivating a
group of individuals to work on a
common goal*
68% 17
4 Developing strong personal and
professional values
0 0
5 Building a culture of excellence
and accountability
16% 4
The correct answer is marked by a (*).
Interview findings. Participants were asked to define leadership. Based on the literature
review in Chapter Two, leadership is defined as the art of getting and motivating a group of
individuals to work on a common goal (Northouse, 2010). It was evident that seven out of the
ten participants knew and were able to define leadership, thus making the threshold of 70% as an
asset. Both Participant 1 and 2 described leadership as the “ability to inspire, and influence
others to accomplish a goal.” Participant 3, when defining leadership, stated that “it is the ability
to motivate a group of people to accomplish a specified goal.” Participant 4 and 8, who teach
and supervise trainees stated, “leadership entails having a clear vision for a program or a body of
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 74

individuals and communicating that vision to them such that all of the respective parties feel a
part of that vision and are able to execute their respective roles and achieve the goal.” This
clearly demonstrated that participants understood the meaning of the term leadership.
Observation. No observations were made for this influence.
Document analysis. No document analysis was made for this influence.
Summary. The assumed influence core faculty members need to know what leadership
means, was determined to be a need in the survey results. However, the influence was
determined to be an asset in the interview responses. 68% of surveyed core faculty members
were able to accurately define leadership, which is only 2% below the 70% threshold.
Conversely, 70% of the interview participants knew and were able to define leadership.
Therefore, this influence is determined to be an asset.
Influence 1B. Core faculty members need to understand the basic characteristic of a
good leader.
Survey results. Twenty-five core faculty members were asked to define the most
important characteristic of a good leader. As seen in Table 9, for the question, “What is the most
important characteristic of a good leader?” 28% of those surveyed responded correctly. With a
cut score of 70%, this item is a need.
Table 9
Survey Results for the Most Important Characteristic of A Good Leader
# Factual Knowledge Item (n = 25) Percentage Count
What is the most important
characteristic of a good leader?

1 Influencing individuals and groups
to cooperatively achieve the
organization's goals.*
28% 7
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 75

Table 9, continued
# Factual Knowledge Item (n = 25) Percentage Count
2 Coaching and building teams to
effectively achieve the vision
32% 8
3 Humility 4% 1
4 Communicating effectively the
vision
20% 5
5 Leading by example 12% 3
6 Directing people to do what they
would not otherwise do
4% 1
7 Nurturing team spirit 0% 0
The correct answer is marked by a (*).
Interview findings. No interview questions were asked for this influence
Observation. No observations were made for this influence.
Document analysis. No document analysis was made for this influence.
Summary. This assumed factual knowledge was validated and determined to be a need
based on the survey responses.
Influence 1C. Core faculty members need to know the characteristics of teamwork.
Survey results. Twenty-five core faculty members were asked to identify the
characteristics of teamwork. As seen in Table 10, for the question, “What is not a characteristic
of teamwork?” 96% of those surveyed responded correctly. To be determined an asset,
responses were required to meet the 70% threshold. The threshold score was met. Therefore, this
influence was determined to be an asset.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 76

Table 10
Survey Results For Characteristics of Teamwork
#
Factual Knowledge Item (n = 25) Percentage Count

What is NOT a characteristic of
teamwork

1
Open and honest communication 0% 0
2
Collaboration 0% 0
3
Minimal and formal knowledge
sharing*
96% 24
4
Team trust 4% 1
5
Respect for team members 0% 0
The correct answer is marked by a (*).

Interview findings. Participants were asked to define and identify characteristics of
teamwork. It was evident that all ten participants knew the meaning of teamwork, meeting the
threshold score of 70%. However, to be determined as an asset, participants were required to
meet the 70% threshold of identifying all four characteristics of teamwork. Only three
participants referred to “trust” and “respect” when identifying characteristics of teamwork.
Therefore, this influence was a need.
When asked to define teamwork, Participant 3 stated, “Teamwork is understanding that
what we do is not a single person effort and understanding all people that contribute to the
defined goal and figuring out how you effectively work with others to accomplish that.”
Participant 6 described teamwork as “trying to work as a cohesive group to maximize our
strengths and buffer our other weaknesses.” Participant 7 stated teamwork is “sort of flattening
the hierarchy but still respecting everybody for what their strengths are and what their roles are,
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 77

and to respect people for their roles,” which includes building trusting relationships with
trainees, colleagues, nurses, students, and staff, so everyone is engaged. However, when asked
to identify characteristics of teamwork, open-coding of the interview transcripts revealed
knowledge deficits. This indicated that although participants were able to define teamwork, they
appeared to be lacking basic knowledge about the characteristics of teamwork. Hence it was
determined a need.
Observation. No observations were made for this influence.
Document analysis. No document analysis was made for this influence.
Summary. The assumed influence that participants know the definition and identify the
characteristics of teamwork was determined to be a need. 28% of surveyed participants were
able to identify characteristics of teamwork, which is 42% below the 70% threshold.
Conversely, 100% of participants knew and were able to define teamwork. However, to be
determined as an asset, participants had to meet the 70% threshold for both components, defining
teamwork and identifying the characteristics of teamwork. Since only 30% were able to identify
characteristics of teamwork, this influence was determined to be a need.
Influence 1D. Core faculty members need to know the characteristics of
professionalism.
Survey results. Twenty-five core faculty members were asked to explain the
characteristics of professionalism. The accuracy in identifying the characteristics of
professionalism ranged from 80% to 92%. As seen in Table 10, core faculty members met the
70% threshold for the question, what are the characteristics of professionalism. With a cut score
of 70%, this item is an asset.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 78

Table 11
Survey Results For Characteristics of Professionalism
# Factual Knowledge Item (n = 25) Percentage Count
What are the characteristics of
professionalism?

1 Responsible* 84% 22
2 Reliable* 80% 21
3 Respectful* 92% 24
4 Integrity* 80% 21
5 Accountable* 84% 22
The correct answer is marked by a (*).
Interview findings. It was evident that all ten participants knew and were able to speak
about the characteristics of professionalism. When explaining professionalism, Participant 1
stated, “I believe it is one's behavior that is considered socially acceptable. It means being
respectful of everyone around you. It is also being responsible for your words and actions.” This
explanation demonstrates that the participant understood the characteristics of professionalism.
This response was consistent with those of the other participants. Participant 6 described
professionalism as “it is everything you do. It's the way you carry yourself, the way you interact
with people, the way you treat people, the way you raise yourself to a certain ethical standard.”
Participant 3, when asked stated “professionalism means conducting yourself in a manner fitting
of our field, which I think for a physician it's respecting patients, respecting those around you,
demonstrating the seriousness of what we're doing and conveying that in your language and the
way you present yourself and all of those different spoken and unspoken facets. It is also being
accountable for all your actions, whether it is towards your patients, colleagues, and staff.”
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 79

Observation. No observations were made for this influence.
Document analysis. No document analysis was made for this influence.
Summary. The assumed influence that core faculty members know the characteristics of
professionalism was determined to be an asset in both the survey results and interview responses.
In the survey results, participant’s responses ranged from 80% to 92%, which met the threshold
score of 70%. Conversely, 90% of interview participants knew and were able to identify the
characteristics of professionalism. Therefore, this influence was determined to be an asset.
Conceptual Knowledge
Influence 1. Core faculty members need to know the relationships between
leadership skills and leadership effectiveness.
Survey results. Participants were asked to rank leadership skills that would enable
faculty to be effective leaders. The accuracy in ranking the skills ranged from 8% to 56%. The
participants did not meet the threshold score of 70%. Therefore, this influence was determined to
be a need.
Table 12
Survey results for Conceptual knowledge
# Conceptual Knowledge Item (n=25) Percentage Count
Rank the importance of the following
skills for leadership effectiveness

1 Interpersonal communication 40% 10
2 Teamwork 36% 9
3 Professionalism 24% 6
4 Emotional Intelligence 8% 2

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 80

Table 12, continued
# Conceptual Knowledge Item (n=25) Percentage Count
5 Coaching and giving feedback 16% 4
6 Recognizing, disclosing and addressing
errors
56% 14

Interview findings. Participants were asked to identify the leadership skills required to
be an effective leader. Nine of the ten participants knew and were able to identify leadership
skills that would enable faculty to be effective leaders, making the 70% threshold score, and,
therefore, an asset. Participant 4 stated, “If I had to choose one thing or two things, those would
probably be like professionalism and communication. More important would be effective
communication skills.” Even more, Participant 8 went on to indicate that the skills required to be
an effective leader included “effective communication, professionalism, and teamwork. Those
skills are hugely important. You need to communicate your plan and goals clearly to people you
are working with. You need to respect everyone and most importantly build a team, because you
can't do it alone.”
Observation. No observations were made for this influence.
Document analysis. No document analysis was made for this influence.
Summary. The assumed influence that participants know what leadership skills are
required to be effective leaders was determined to be a need in the survey results. However, the
influence was determined to be an asset in the interview responses. The survey question asked
participants to rank leadership skills for leadership effectiveness. Participants may have found it
difficult to rank the skills, and as a result, did not meet the threshold score of 70%. Conversely,
90% of participants knew and were able to identify leadership skills that would enable faculty to
be effective leaders. Therefore, this influence is determined to be an asset.
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 81

Procedural Knowledge
Influence 1. Core faculty members need to know how to develop a leadership
program.
Survey results. Participants were asked to identify steps in developing a leadership
program. 52% of surveyed participants were able to accurately identify the first step in
developing a leadership program. This was below the threshold score of 70%. Therefore, this
influence was determined in the survey as a need.
Table 13
Survey Results for Procedural knowledge
# Procedural Knowledge Item(n = 25) Percentage Count
You have been asked to create a leadership
program for physician trainees. What would
be your first step:

1 Look at other leadership program 36% 9
2 Develop my own leadership skills 8% 2
3 Identify the characteristics of physician
leaders*
52% 13
4 Decide who is going to teach the program 4% 1

Interview findings. During the interview process, participants were asked to describe the
first step they would take if asked to develop a leadership curriculum for physician trainees.
80% of the participants described an actual process they would take to develop a curriculum.
However, none of the course directors indicated that the first step would be to identify
characteristics of physician leaders. Participant 1 stated, “What I would first do is try to establish
the fundamental goals of the training program.” Participant 5 added, “The first step, I think
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 82

would be describing examples, case examples, to introduce the idea of leadership.” Participant 7
went on to indicate that “in terms of developing curriculum, I think personally, one would be to
get people who are interested and engaged in this. And secondly, you have to make sure that
there is some diversity in all respects in the pool of people that you're training.” To be
determined an asset, participants were required to correctly identify the first step to meet the 70%
threshold. Therefore, this influence is determined to be a need.
Observation. No observations were made for this influence.
Document analysis. No document analysis was made for this influence.
Summary. The assumed influence that participants know the first step in developing a
leadership curriculum was determined to be a need in the survey results and interview responses.
52% of surveyed participants were able to correctly the first step in developing a leadership
curriculum. Even though 80% of interview participants described a process, no one was able to
correctly identify steps to establishing a curriculum for trainees. Therefore, this influence is
determined to be a need.
Results and Findings for Motivation Causes
Survey and interview questions validated the two motivation causes, which were value
and self-efficacy. The survey contained ten motivation-related items, and during the interviews,
core faculty were asked two questions. If core faculty members demonstrated an overall deficit
in motivation for an assumed influence, then it was classified as validated. If no deficit in
motivation emerged, then that assumed need was classified as not validated. The criteria used to
define “asset” in motivation and classify assumed motivation influence as “not validated” are
outlined in Table 14.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 83

Table 14
Criteria Used to Classify Assumed Motivation Influences as “Not Validated”
Survey Interview
Motivation
Value >70% recognize the need to develop a
leadership curriculum
>70% find the importance of
developing a leadership
program
Self-Efficacy >70% indicate they are confident in
developing leadership skills in
physician trainees and a leadership
curriculum
>70% feel confident in
developing a leadership
curriculum

Value
Influence 1. Faculty see the value in developing a leadership curriculum for
physician trainees.
Survey results. Participants were asked about the extent to which they agreed with a
series of statements. A Likert-type scale was used, which recorded a value of strongly disagree
(SD), somewhat disagree (SWD), neither agree nor disagree (NAND), somewhat agree (SWA),
or strongly agree (SA). Table 15 and Figure 3 shows the participant’s responses. For item 1,
72% of core faculty strongly agreed, 20% somewhat disagreed, 4% neither agreed or disagreed,
and 4% strongly disagreed with the statement that leadership skills have value to strengthen
physician trainee’s leadership competencies and improves performance. With respect to item 2,
64% of core faculty members strongly agreed, 28% somewhat agreed, and 8% neither agreed nor
disagreed with the statement that it was important for them to participate in leadership
development programs at their home institution. Next for item 3, 60% of core faculty members
strongly agreed, 32% somewhat agreed, 4% neither agreed nor disagreed, and 4% somewhat
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 84

disagreed with the statement that it is important to recognize the need to develop leadership skills
in physician trainees while 4% somewhat disagreed with this statement. For item 4, 32% of core
faculty members strongly agreed, 40% somewhat agreed, 20% neither agreed nor disagreed, and
8% somewhat disagreed with the belief that strong leadership skills are associated with less
physician burnout and higher satisfaction. Finally, for item 5, 60% of core faculty members
strongly agreed, 28% somewhat agreed, 8% neither agreed nor disagreed, and 4% somewhat
disagreed with the statement that it is important to develop courses that enhance physician
trainee’s leadership skills while 4% somewhat disagreed with this statement. To be considered
an asset participants needed to meet the threshold score of 70% for all five statements. Because
participants met the 70% threshold for only one of the five statements, this influence was
determined to be a need.
Table 15
Survey Results for Value Influence
# Value Influence Item(n = 25) Percentage Count
To what extent do you agree or disagree with the
following statements:

1 I believe leadership skills have value to strengthen
physician trainee’s leadership competencies and
improves performance
72% 18
2 It is important for me to participate in leadership
development programs at my institution
64% 16
3 I believe it is important to recognize the need to
develop leadership skills in physician trainee
60% 15
4 I believe strong leadership skills are associated
with less physician burnout and higher satisfaction
32% 8
5 It is important to develop courses that enhance
physician trainee’s leadership skills
60% 15

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 85

Figure 2. Core faculty members perceptive on leadership skills (Value)
Interview findings. During the interview process, participants were asked how important
they felt it was to develop a curriculum in leadership skills and for physician trainees to develop
these non-clinical skills in communication, professionalism, and team-building during residency
training. The majority of the participants found some degree of value in developing a curriculum
for physician trainees. Nine core faculty members (90%) stated that developing curriculum and
leadership skills during residency training was important, and thus making the threshold of 70%
as an asset. Only one (10%) core faculty mentioned that developing curriculum and leadership
skills during residency training was not important.
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 86

There were several reasons that contributed to value for developing curriculum in
leadership skills and for physician trainees to develop these non-clinical skills during residency
training. Participant 2 asserted, “It’s critical. And the primary reason is, this is the only safe
environment they can do it in.” Participant 3 stated, “Developing those skills is very important.
These skills are what will be essential for somebody to succeed no matter what their practice
setting is when finished.” Participant 5 went on to state that “I think every single person falls
into a position if they practice medicine, of needing to have leadership skills. And I don't think
there's anyone who doesn't benefit from being a better leader. And to that end, I think it's
critical, a critical skill to learn during residency because you're not going to learn it any other
time.” Even more, Participant 7 stated, “I think this is really, really important now. Sometimes
I've witnessed over the years that some residents just based on age, they already have a certain
personality type, and it's very hard to undo some of that. But I think the last thing you want to do
is for trainees to be rewarded for bad behavior.”
Observation. No observations were made for this influence.
Document analysis. No document analysis was made for this influence.
Summary. The assumed influence that core faculty see value in developing a leadership
curriculum was determined to be a need in the survey results. However the influence was
determined an asset in the interview responses. 60% of those surveyed indicated there is value in
developing a leadership curriculum for physician trainees, which is 10% below the threshold
score of 70%. However, 90% of interview participants agreed that it is important to develop a
leadership curriculum for physician trainees. The interview is given more weight because the
number of items in the survey diluted the responses. Therefore, this influence is determined to
be an asset.
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 87

Self-Efficacy
Influence 1. Core Faculty believe they are capable of effectively developing a
curriculum on leadership skills.
Survey results. Participants were asked about their confidence levels with their abilities
to develop non-clinical skills in physician trainees and design a leadership curriculum. An
interactive scale was used, which recorded a value between 1 (lowest confidence score) and ten
(highest confidence score). Participants rated five items. Table 16 and Figure 4 shows the
participant’s responses. If participants selected eight and above on the rating scale, it was
considered a high level of confidence. If participants selected five-seven on the rating scale, it
was considered an average level of confidence. If participants selected two-four on the rating
scale, it was considered a low level of confidence. If participants selected one on the rating
scale, it was considered the lowest level of confidence or no confidence at all. When asked to
rank developing communication skills, 20% of core faculty members indicated a high level of
confidence, while 68% indicated an average level of confidence, and 12% indicated a low-level
of confidence. When asked about developing team-building skills in physician trainees, 24% of
core faculty members indicated a high level of confidence, while 64% indicated an average level
of confidence, and 12% indicated a low level of confidence. When asked to lead physician
trainees by example, 52% of core faculty members indicated a high level of confidence, while
48% indicated an average-level of confidence. None of the core faculty members indicated a
low level of confidence. When asked about developing a curriculum for physician trainees, 24%
of core faculty members indicated a high level of confidence, while 56% indicated an average
level of confidence, and 20% indicated a low level of confidence. This influence did not meet
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 88

the threshold score of 70%. Therefore, this influence is determined in the survey as a need.
Appendix C shows the participants self-efficacy results.
Table 16
Survey Results for Self-Efficacy
# Self-Efficacy Influence Item(n = 25) Percentage Count
On a scale of 1-10 rate how confident are you
to do the following right now b (1- lowest
confidence score, 10- highest confidence
score):

1 Develop communication skills in physician
trainees
20% 5
2 Develop team-building skills in physician
trainees
24% 6
3 Try something outside the scope of what you
have already done
44% 11
4 Lead physician trainees by example 52% 13
5 Design curriculum for physician trainees 24% 6

12%
68%
20%
0%
10%
20%
30%
40%
50%
60%
70%
Low Average High
Develop communication skills in physican
trainees
12%
64%
24%
0%
10%
20%
30%
40%
50%
60%
70%
Low Average High
Develop team-building skills in physician
trainees
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 89

.
Figure 3. Percentage of core faculty members scoring in self-efficacy categories of low, average,
and high.

Interview findings. During the interview process, participants were asked how confident
they felt in developing a leadership curriculum. Eight core faculty members (80%) stated that
they had a low to moderate level of confidence in developing a curriculum for physician trainees.
Participant 5 stated, “I would say I'm moderately competent. I think if I had formal training and
more time to develop that skill set and learn about best practices in leadership, I think I would be
better. And I think if I was better, I'd be more confident in developing it.” Participant 6
indicated, “I don't feel very confident in terms of developing a curriculum that would be able to
address it. It's in these gray areas. I think in terms of where we are in medicine, this area we're
not doing as well as we potentially could.” Even more, participant 9 went on to indicate, “Not
12%
44% 44%
0%
10%
20%
30%
40%
50%
60%
70%
Low Average High
Try something outside the scpoe of what
you haev already done
0%
48%
52%
0%
10%
20%
30%
40%
50%
60%
70%
Low Average High
Lead physician trainees by example
20%
56%
24%
0%
10%
20%
30%
40%
50%
60%
70%
Low Average High
Design curriculum for physician trainees
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 90

particularly confident. I think that I'm still very much developing as a leader, and I feel like I
need a lot more training before I train others.”
Two participants indicated a high level of confidence. Participant 2 stated, “I am very
confident. However, I need to be paired with somebody, one or two people who don't think as I
do.” Participant 10 said, “in terms of my background, I feel that I'd be very confident in terms of
trying to put together, say workshop or a course, regarding communication and professionalism.
But for leadership, I just haven't had as much experience throughout my career.”
Observation. No observations were made for this influence
Document analysis. No document analysis was made for this influence.
Summary. The assumed influence that core faculty members feel confident in
developing a leadership curriculum for physician trainees was determined to be a need. In the
survey responses, when participants were asked to rate their confidence level in developing
leadership skills and designing a curriculum for physician trainees, many indicated an average to
a low level confidence level, thus making the threshold score of 70% a need. In the interview
responses, 80% of the interview participants indicated they were not confident in developing a
leadership curriculum. Therefore, this influence is determined to be a need.
Results and Findings for Organization Causes
Survey and interview questions validated the three organization causes, which were
resources, cultural models, and cultural settings. The survey contained 16 organization-related
items, and during the interviews, core faculty were asked three questions. If core faculty
members demonstrated an overall deficit in organization causes for an assumed influence, then it
was classified as validated. If no deficit in organizational causes was evident, then that assumed
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 91

need was classified as not validated. The criteria used to define “asset” in organizational causes
and classify assumed organizational influence as “not validated” are outlined in Table 17.
Table 17
Criteria Used to Classify Assumed Organizational Influences as “Not Validated”
Survey Interview
Organization
Resources >70% agreed they have sufficient time,
resources and support
N/A
Cultural Model >70% believe they are valued and part of
an organization that supports their efforts
>70% believe the culture of
the organization supports
their education activities
Cultural setting >70% feel there are practices in place that
support faculty development
>70% believe there are
practices in place to support
their efforts as educators

Resources
Influence 1A. Core faculty members need to have the time, resources, and financial
support to develop a leadership curriculum.
Survey results. Resources items. Participants were asked about the extent to which they
had sufficient resources, dedicated time, and financial support to develop a leadership curriculum
for physician trainees. A Likert-type scale was used, which recorded a value of strongly disagree
(SD), somewhat disagree (SWD), neither agree nor disagree (NAND), somewhat agree (SWA),
or strongly agree (SA). When asked about organizational resources, 44% of core faculty
members reported that they had sufficient resources to develop a curriculum. When asked about
dedicated time, 52% indicated that the organization provided dedicated time to focus on teaching
physician trainees. Finally, when asked about financial support, 24% reported they had financial
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 92

support they needed from the organization for teaching and developing the next generation of
leaders. With a cut score of 70%, this influence is determined in the survey as a need.
Table 18
Survey Results for Resources
# Resources Influence Item Percentage Count
To what extent do you agree or disagree with
the following statements:

1 My organization provides sufficient resources
to develop a curriculum for the next
generation of leaders
44% 11
2 My organization provides dedicated time to
focus on teaching physician trainees
52% 13
3 My organization provides financial support
for teaching and developing the next
generation of leaders
24% 6

Interview findings. No interview question was asked for this influence.
Observation. No observations were made for this influence.
Document analysis. No document analysis was made for this influence.
Summary. This influence was determined to be a need in the survey results.
Influence 1B. Core faculty members need to believe they are valued and part of an
organization that supports their efforts to develop and teach the curriculum.
Survey results. Cultural model. Participants were asked a series of statements about the
extent to which they believed they were supported by the organization in developing and
teaching a leadership curriculum. An interactive scale was used, which recorded a value
between one (strongly do not believe) and ten (strongly believe). When core faculty members
were asked if they felt supported and valued as a faculty member, 44% reported they strongly
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 93

believed that the organization supported and valued them as faculty. 20% of core faculty
members indicated they strongly believed that their peers welcomed opinions that were different
from their own. 40% of core faculty members reported that they strongly believed the
organization encouraged them to be creative in their teaching practices. 20% of core faculty
members felt they strongly believed that they are encouraged to be creative in their teaching
practices. Finally, 56% of core faculty members indicated they strongly believed that the most
highly rewarded faculty are those oriented primarily toward research and clinical activities. With
a cut score of 70%, this influence is determined to be a need.
Table 19
Survey Results for Cultural Model
# Cultural Model Influence Item Percentage Count
Using the scale below please rate the extent
to which you believe the following:

1 I feel supported and valued as a faculty
member
44% 11
2 My peers welcome opinions that are different
from their own
20% 5
3 The culture of the organization supports
having a physician leadership program
40% 10
4 I am encouraged to be creative in my teaching
practices
20% 5
5 I consider the environment I work in to be
innovative
32% 8
6 The most highly rewarded faculty are those
oriented primarily toward research and
clinical activities
56% 14

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 94

Interview findings. Participants were asked if the culture of the organization supported
their education activities and developed them as educators. Eight (80%) of the ten participants
felt the organization supported their education activities. However, most mentioned that they did
not feel valued for their education activities. Therefore this influence was determined to be a
need. Participant 4 stated, “I think in medicine in general, what drives this department is just
clinical volume and WRVU's and money and so forth. And so education and activities are not
compensated and some people are much better than others and much more involved. And, is it
fair? I'm not sure. I mean fair is what you think. I mean, if you do it because you love it, then
you don't really care. But it'd be nice to be recognized for that.” Participant 6 indicated, “I say
that the only element that I see that being true is in that those of us who spend our extra time
dedicated to teaching aren't particularly rewarded for those efforts.”
When participants were asked if they felt the department developed them as educators,
60% of participants felt the organizational culture did not develop them as educators. Participant
8 stated, “I really haven't gotten any development as a faculty member. No, I haven't. It's kind of
daunting, in a way, because I really want to become a better educator. Right now, I feel like I'm
just learning through trial and error.” Participant 2 indicated, “There is none. It's sink or swim.
There is not much but some support, the expectation is you navigate it on your own.” These
responses indicate that the department does not take the time to develop their faculty as
educators. Therefore, this assumed influence was determined to be a need.
Observation. No observations were made for this influence.
Document analysis. No document analysis was made for this influence.
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 95

Summary. The assumed influence that core faculty members need to believe they are
valued, and part of an organization that supports their efforts to develop and teach curriculum
was determined to be a need in both the survey results and interview responses.
Cultural Settings
Influence 1. Core faculty members need to be part of an environment where leaders
of the organization model desired behaviors, practices, and support faculty development.
Survey results. Participants were asked to indicate the level of influence each statement
would have on their ability to develop a curriculum for physician trainees. An interactive scale
was used and recorded a value of no influence (one), slight influence (two), neutral (three),
moderate influence (four), and significant influence (five). 36% of core faculty members
indicated faculty development workshops have a moderate to significant influence, 60% of core
faculty indicated financial stipends have a moderate to significant influence, 20% of core faculty
members indicated online professional development/training have a moderate to significant
influence, 76% of core faculty members indicated dedicated time have a moderate to significant
influence, 72% indicated encouragement from department leadership for learning have a
moderate to significant influence, 52% indicated physical workspaces that promote collaboration
and innovation have a moderate to significant influence. Lastly, 36% indicated that online
faculty communities that promote collaboration and innovation have a moderate to significant
influence in impacting their ability to develop curriculum for physician trainees. In order to be
considered an asset, participants had to meet the threshold score of 70% for all responses.
Because all responses did not meet the threshold score of 70%, this influence was determined to
be a need.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 96

Table 20
Survey Results for Cultural Setting
# Cultural Settings Influence Item Percentage Count
Please indicate the level of influence each of
the following would have on impacting your
ability to develop a curriculum for physician
trainees:

1 Faculty development workshops 36% 9
2 Financial stipends 60% 15
3 Online professional development/training 20% 5
4 Dedicated time 76% 19
5 Encouragement from department leadership
for learning
72% 18
6 Physical workspaces that promote
collaboration and innovation
52% 13
7 Online faculty communities that promote
collaboration and innovation
36% 9

Interview findings. Participants were asked to describe the extent to which they believed
there were practices or policies in place to support their efforts as educators. 90% of the
participants indicated they were not aware of any practices or policies that existed which support
faculty as educators. Participant 2 went on to indicate, “I don't think there are any specific
policies in favor of that. I just don't think there are any policies against it.” Participant 5 said,
“We have protected time built into our weeks, during the Wednesday mornings for teaching.
You know, I think we can do better on valuing these efforts. I think we are doing okay in that,
but we can do way better in the value attributed to educating the trainees.” Participant 9,
responded that “I think they're pretty minimal, to be honest. I think that the people who are
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 97

interested in education take efforts in education because they're passionate about it. But it is not
very well reflected in protected time, in kind of financial equivalency. This potential
organizational deficit could serve as a barrier to core faculty members who are interested in
dedicating time towards becoming better educators. Therefore, this influence is determined to be
a need.
Observation. No observations were made for this influence.
Document analysis. No document analysis was made for this influence.
Summary. The assumed influence that faculty members believe there are policies or
practices in place that support their efforts to develop as educators were determined to be a need
in both survey and interview responses.
Summary of Validated Influences
Data analysis provided insight and increased our own understanding of the most
important assumed knowledge, motivation, and organizational influences that need our focus.
Tables 21, 22, and 23 show the knowledge, motivation, and organization influences for this study
and their determination as an asset or a need.
Knowledge
Table 21
Knowledge Assets or Needs as Determined by the Data
Assumed Knowledge Influence Asset or Need?
Factual
Core faculty members need to know what
leadership means
Asset
Core faculty members need to understand the
basic characteristics of a good leader
Need

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 98

Table 21, continued
Assumed Knowledge Influence Asset or Need?
Factual
Core faculty members need to know the
characteristics of teamwork
Need
Core faculty need to know the characteristics
of professionalism
Asset
Conceptual
Core faculty members need to know the
relationship between leadership skills and
effectiveness
Asset
Procedural
Core faculty members need to know how to
develop a leadership program
Need

Motivation
Table 22
Motivation Assets or Needs as Determined by the Data
Assumed Knowledge Influence Asset or Need?
Value
Core faculty see the value in developing a
leadership curriculum for physician trainees
Asset
Self-Efficacy
Core faculty believe they are capable of
effectively developing a curriculum on
leadership skills
Need

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 99

Organization
Table 23
Organization Assets or Needs as Determined by the Data
Assumed Knowledge Influence Asset or Need?
Resources
Core faculty members need to have the time, resources,
and financial support to develop a leadership curriculum
Need
Cultural model
Core faculty members need to believe they are valued
and part of an organization that supports their efforts to
develop and teach the curriculum
Need
Cultural setting
Core faculty members need to be part of an environment
where leaders of the organization model desired
behaviors, practices, and support faculty development
Need

Chapter 4 included a discussion of the results and findings for this study. Based on the
quantitative and qualitative data analysis, the researcher concluded that most of the assumed
knowledge influences were validated. Assumed motivational influences were also validated.
Likewise, all the assumed organizational influences were validated. Chapter 5 will provide
tailored recommendations addressing the identified gaps affecting core faculty ability to develop
and teach a leadership curriculum to physician trainees.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 100

CHAPTER FIVE: RECOMMENDATIONS AND EVALUATION
Purpose of the Project and Questions
The purpose of this project is to conduct a needs analysis in the areas of knowledge and
skills, motivation, and organizational resources necessary for core faculty members to reach the
organizational performance goal of having 100% of our trainees effectively demonstrate
leadership skills in areas of interpersonal communication, team-building and professionalism by
December 2021. The analysis will begin by generating a list of possible needs and will then
move to examine these systematically to focus on actual or validated needs. While a complete
needs’ analysis would focus on all stakeholders, for practical purposes, the stakeholder of focus
in this analysis is core faculty members.
As such, the questions that guide this study are the following:
1. What are the knowledge and skills, motivation, and organizational constraints and needs
related to NPU’s core faculty member’s goal of developing a leadership
program/curriculum by December 2020, focusing on physician trainee’s leadership skills
in team-building, communication, and professionalism?
2. What is the interaction between organizational culture and context and core faculty’s
knowledge and motivation?
3. What are the recommended knowledge, motivation, and organizational solutions?
Chapter Five will address research question 3, what are the recommended knowledge,
motivation, and organizational solutions that can help core faculty members reach their
performance goal. The organization of this chapter will begin by presenting the
recommendations for the knowledge, motivation, and organizational influences. Following the
recommendations, an integrated implementation and evaluation plan will be discussed based on
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 101

the New World Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016). Finally, the limitations
and delimitations of the study and future research will be described.
Recommendations to Address Knowledge, Motivation, and Organization Influences
This section consists of three parts: knowledge, motivation, and organizational specific
recommendations. Each KMO section consists of a brief overview, including a rationale for the
need to prioritize the validated causes, a table with the validated causes, and the priority to
achieve the performance results. Each table includes the KMO cause, the priority given that
particular influence, the evidence-based principles that support the recommendation and
recommendation on applying the principle. Following the table, a detailed discussion is
provided for each cause, the principle, the solution, and support for the solution based on the
literature.
Knowledge Recommendations
The knowledge influences in Table 21 represent the complete list of assumed knowledge
influences and whether or not they were validated based on survey responses and interview
transcripts. It is also supported by the literature review of educational best practices for
developing a leadership curriculum for physician trainees. Clark and Estes (2008), suggest that
declarative knowledge about something is often necessary and important to know before
applying it to classify or identify, as in the case of core faculty members who wish to design a
leadership curriculum for physician trainees. As such, Table 24 lists the knowledge causes,
priority, principle, and recommendations. Following the table, a detailed discussion for each
high priority cause and recommendation, and the literature supporting the recommendation is
provided.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 102

Table 24
Summary of Knowledge Influences and Recommendations
Assumed
Knowledge
Influence
Validated as a
Gap?
Yes, High
Probability or
No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
Core Faculty need
to know what
leadership means
and the
terminology of the
three leadership
skills
(communication,
professionalism,
team-building) (D
V Y Information
learned
meaningfully and
connected with
prior knowledge
is stored more
quickly and
remembered
more accurately
because it is
elaborated with
prior learning
(Schraw &
McCrudden,
2006).

Core faculty will
learn these terms by
connecting what they
currently know about
leadership skills with
the terminology used
in medicine. A job
aid containing a
glossary of terms
used in medicine will
be provided along
with references to the
text.
Core Faculty need
to know the
concepts of
leadership skills
and their relation to
leadership
effectiveness (D)
V N How individuals
organize
knowledge
influences how
they learn and
apply what they
know (Schraw &
McCrudden,
2006).

Segmenting and
simplifying
complex material
enables learning
to be enhanced
(Kirshner,
Kirshner, & Paas,
2006).

Provide a job aid that
clearly organizes the
relationships
between the concepts
of leadership and
leadership
effectiveness

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 103

Table 24, continued
Assumed
Knowledge
Influence
Validated as a
Gap?
Yes, High
Probability or
No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
Core Faculty need
to know how to
develop a
curriculum in these
areas of leadership:
communication,
team-building, and
professionalism (P)
V Y Learning and
performance is
enhanced with
demonstration
and modeled
behavior (Denler,
Wolters, &
Benzon, 2006).

Learning is
highly dependent
on “goal-directed
practice” and
“targeted
feedback”
(Ambrose 2010).

Provide training with
authentic
opportunities to
design curriculum
based on best-
practices, expertise-
based
demonstrations, and
practice by new
reviewers with
feedback from peers
and expert reviewers.

Provide educational
opportunities in the
form of certificate
programs to core
faculty members to
understand how to
use the knowledge
gained to develop
curriculum.

Declarative knowledge solutions. Increase core faculty member’s knowledge of
leadership terminology and basic characteristics of leadership. The findings of the study indicate
that core faculty need more in-depth declarative knowledge about the basic characteristics of
leadership. A recommendation rooted in information processing theory was selected to address
this knowledge gap. Schraw and McCrudden (2006) found that information learned
meaningfully and connected with prior knowledge is stored more quickly and remembered more
accurately because it is elaborated with prior learning. Core faculty will learn leadership
terminology by connecting what they currently know about leadership skills with the
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 104

terminology used in medicine. Clark and Estes (2008) suggest that job-aids provide employees
with self-help information that they can use on the job to perform a task. Rueda (2011) asserts
that one must be familiar with the specific contexts, such as details or terminology, to function
effectively. The recommendation then is to provide core faculty members with a job-aid
containing a glossary of leadership terms used in medicine along with references to the text so
they can facilitate learning and promote changes in behavior.
Learning of fundamental knowledge and skills are essential to critical thinking functions
(Thompson, 2011). Further, when individuals are more proficient in lower-level skills, they will
become more proficient in higher-level skills (Thompson, 2011). Additionally, Campbell (1996)
suggested that job aids guide performance while developing skills and serve as a reference guide
to more experienced learners, while Duncan (1985) suggested the use of job-aids to improve
learning effectiveness. Duncan (1985) examined the use of job-aids in assisting performance in
the military and found that it enhanced learning while saving time and money. Also, job aids
play an essential role in helping learners with their performance, which would likely be forgotten
(Spaulding & Dwyer, 1999). Thus providing a job-aid that highlights concepts and leadership
terminology used in medicine may assist core faculty members in learning about leadership
skills.
Procedural knowledge solutions. Increase core faculty member’s knowledge on how
to develop a leadership curriculum. The results of this study indicated that 48% of core
faculty need more in-depth procedural knowledge on how to develop a curriculum for physician
trainees. A recommendation rooted in social cognitive theory has been selected to close this
procedural knowledge gap. Ambrose (2010) found that learning is highly dependent on “goal-
directed practice” and “targeted feedback.” Additionally, Denler, Wolters, and Benson (2006)
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 105

assert that learning and performance are enhanced with demonstration and modeled behavior.
Therefore, formatting training in a series of in-person sessions where core faculty members will
have the opportunity to design a curriculum based on best practices, and practice could help core
faculty learn how to create a leadership curriculum for physician trainees. Another proposed
recommendation for core faculty members who are interested in developing a curriculum using
the traditional approach could be to provide educational opportunities in the form of certificate
programs where participants understand how to use the knowledge gained to develop curriculum.
Guthrie (1999) posits that for physicians to be effective leaders, they require some hands-
on training and experience. The researcher goes on to state that providing didactic training and
opportunities to practice developing skills is a more systematic and efficient approach to
developing leaders. Wood and Bandura (2014) asserts that to enhance competencies, individuals
require instructive modeling, and guided practice with feedback. Clark and Estes (2008) further
note that educating learners through certificate programs or advanced degrees offer new ways to
understand how to develop new programs and products. It is not enough to instruct core faculty
members what to do; they must know how to do it. Thus, the recommendation of providing
training and educational opportunities in the form of certificate programs to core faculty
members that features authentic opportunities to design curriculum based on best- practices and
practice with feedback from peers and expert reviewers may assist core faculty and contribute to
learning how to develop curriculum for physician trainees.
Motivation Recommendations
Survey and interview questions were used to validate motivation influences, which were
value and self-efficacy. The survey had ten motivation items, and core faculty were asked five
motivation related questions during interviews. The motivation influences in Table 22 represent
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 106

the complete list of assumed motivation influences. The table also indicates whether or not they
were validated based on frequency counts obtained while coding of the survey and interview
transcripts and supported by the literature review of educational best practices for developing a
leadership curriculum for physician trainees. Table 25 lists the motivation causes, priority,
principle, and recommendations. Following the table, a detailed discussion for each high priority
cause and recommendation, and the literature supporting the recommendation is provided.
Table 25
Summary of Motivation Influences and Recommendations
Assumed
Motivation
Influence
Validated
as a Gap
Yes, High
Probability
, No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
Core Faculty
need to see the
value in
developing a
leadership
curriculum for
physician trainees
(Expectancy
Value)
V N Individuals are more
likely to engage in an
activity when it
provides value to
them (Eccles, 2006).

Modeling values and
interests can foster
positive values
(Eccles, 2006).
Provide training
opportunities that are
useful, interesting,
and relevant so core
faculty can see the
value in developing a
leadership
curriculum.

Provide practice-
based educational
programs where core
faculty members can
learn and practice
how to develop
curriculum
generating
enthusiasm and
interest in developing
a leadership
curriculum.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 107

Table 25, continued
Assumed
Motivation
Influence
Validated
as a Gap
Yes, High
Probability
, No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
Core Faculty
need to be
confident that
they are capable
of effectively
developing a
curriculum on
leadership skills
(Self-Efficacy)
V Y Self-efficacy is
increased as
individuals succeed
in a task (Bandura,
1997).

Modeling and
Feedback
increases self-
efficacy
(Pajares, 2006).

Provide instructional
support early on, and
build on multiple
opportunities for
practice that allow
the learner to master
the task and
experience success.

Provide training
opportunities
coupled with
demonstration,
frequent, credible,
and targeted
feedback on progress
in learning and
performance.

Value solutions. Increase the need for core faculty to see value in developing a
leadership curriculum. The survey data from this study showed that 60% of core faculty
members saw the value in developing a curriculum addressing leadership skills in physician
trainees. A recommendation rooted in expectancy-value theory was selected to address this
motivation influence. Eccles (2006) found that individuals are more likely to engage in an
activity when it provides value to them. Furthermore, modeling values and interests can foster
positive values (Eccles, 2006). Thus the proposed recommendation is to provide training
opportunities that are useful, interesting, and relevant so core faculty members can see the value
in developing a leadership curriculum to trainees. In addition, providing educational-based
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 108

practice programs where core faculty members can learn and practice how to develop a
curriculum can generate enthusiasm and interest in developing a leadership curriculum.
Rueda (2011) states that values are the importance individuals place on various tasks,
suggesting that if an individual values a task, they are more likely to engage in it. Conrad,
Ghosh, and Isaacson (2015) surveyed a total of 114 physicians and 24 physician leaders to
identify what motivators are important to them. The authors found that some of the most crucial
motivation elements included interesting work, and appreciation of the work done which suggest
that physicians are driven by an interest in the work itself, rather than external pressures or
reward (Conrad et al., 2015). Clark and Estes (2008) assert that individuals are more likely to
easily choose what interests them the most. Therefore, the recommendation of providing
training opportunities that are useful, interesting, and relevant as well as practice-based
educational programs where core faculty can practice developing curriculum, so enthusiasm and
interest are generated is expected to increase core faculty member’s value for developing a
leadership curriculum for physician trainees.
Self-efficacy solutions. Increase the self-efficacy of core faculty members. The
findings of this study showed that approximately 64% of core faculty members are not confident
in their ability to design curriculum for physician trainees. A recommendation rooted in the self-
efficacy theory has been selected to close this declarative knowledge gap. Bandura (1997) found
that self-efficacy increased as individuals succeeded in a task. Furthermore, Pajares (2006)
suggested that modeling and feedback increase self-efficacy. Therefore, the proposed
recommendation is to provide instructional support early on to learners and build on multiple
opportunities for practice, which allows the learner to master the task and experience success.
Also, designing courses that provide information on how to succeed in developing a curriculum
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 109

and specify not only challenging goals but are achievable will build self-confidence.
Furthermore, providing training opportunities coupled with demonstration, frequent, credible,
and targeted feedback on progress in learning and performance will increase self-efficacy.
Clark and Estes (2008) state that one’s belief in their own capabilities is the most critical
factor for individuals to succeed. The author further states that when individuals have positive
beliefs about their ability to do a certain task, they are committed to investing in the task and to
pursuing the goal. Wood and Bandura (1989) suggest that the stronger one’s beliefs in their
capabilities, the greater and more persistent are their efforts. The authors further note that one of
the ways to increase and strengthen one’s self-belief is through modeling. When learners who
have had no prior experience observe their peers performing and succeeding at a task, it allows
them to judge their own capabilities and builds their confidence that they too can succeed
(Druckman & Bjork, 1994). de Paor (2014) surveyed teachers, coaches, and interviewed with
key stakeholders to examine the use of demonstration lessons as a support for teacher’s
curriculum implementation. The author highlighted that teachers found that modeled lessons
were highly useful and enhanced their confidence to try out an idea they observed (de Paor,
2014). Providing effective feedback on performance is also key to building self-confidence.
Giving constructive feedback to learners improves performance as it allows them to assess their
own performance and goals and make changes to behavior, increasing their self-efficacy (Kelly
& Richards, 2020). Thus it would appear that increasing core faculty member’s self-efficacy
would enable them to develop curriculum for physician trainees.
Organization Recommendations
The organization influences in Table 23 represent the complete list of assumed
organizational influences and whether or not they were validated based on survey responses and
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 110

while coding of the interview transcripts. It is also supported by the literature review of
educational best practices for developing a leadership curriculum for physician trainees. Clark
and Estes (2008) suggested that even if individuals have the knowledge and motivation, lack of
organizational support can prevent individuals from achieving their performance goal. The
assumed organizational influences are resources, cultural models, and cultural settings. Table 26
lists the organization’s causes, priority, principle, and recommendations. Following the table, a
detailed discussion for each cause and recommendation and the literature supporting the
recommendation is provided.
Table 26
Summary of Organization Influences and Recommendations
Assumed Organization
Influence
Validated
as a Gap
Yes, High
Probability
, No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and
Citation

Context-
Specific
Recommendat
ion
Core faculty members need to
have the time, resources, and
financial support to develop a
leadership curriculum
(Resources)
V Y Organizational
performance
increases when
leaders ensure
that employees
have the
resources and
time needed to
achieve the
organization’s
goals (Waters,
Marzano, &
McNulty,
2003).
Leadership
Toolkit-
Principle #10

Conduct
monthly
meetings with
core faculty
members in
education and
leadership to
establish goals
for faculty
interested in
teaching and
regularly
monitor the use
of resources to
ensure that
faculty are able
to achieve the
organization’s
goal.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 111

Table 26, continued
Assumed Organization
Influence

Validated
as a Gap
Yes, High
Probability,
No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and
Citation

Context-
Specific
Recommendat
ion
Core faculty members need to
believe they are valued as
educators and part of an
organization that supports their
efforts to develop and teach
curriculum (Cultural model)
V Y Organizational
performance
increases when
messages,
rewards,
policies, and
procedures that
govern the work
of the
organization are
aligned with or
are supportive
of stakeholder
goals and
values (Clark &
Estes, 2008).
Toolkit for
Organizational
change-
Principle #2
Conduct
quarterly
meetings with
core faculty
members and
leadership to
gather feedback
on department
education
practices and
communicate
the
organization’s
strategic plan
for education.

Develop
systems that
recognize and
reward
excellence in
teaching.
Core faculty members need to
be part of an environment
where leaders of the
organization model desired
behaviors, practices, and
support faculty development
(Cultural setting)
V Y Organizational
performance
increases when
leaders identify,
articulate, focus
the
organization’s
efforts on, and
reinforce the
organization’s
vision (Clark &
Estes, 2008).
Leadership
Toolkit-
Principle #1
Conduct
quarterly
meetings with
core faculty to
reinforce the
department’s
practices and
vision in the
development of
faculty as
educators.
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 112

Cultural model solutions. Increase core faculty member’s belief that they are
valued as educators (Cultural models). The findings of this study found that 56% of core
faculty members did not strongly feel the department values them as educators. Clark and Estes
(2008) state that organizational performance increases when messages, rewards, policies, and
procedures that govern the work of the organization are aligned with or are supportive of
stakeholder goals and values. The proposed recommendation is for the organization to conduct
quarterly meetings with core faculty members and leadership to gather feedback on department
education practices and communicate the organization’s strategic plan for education. In addition,
developing systems that recognize and reward excellence in teaching may increase core
member’s belief that the department values and supports them as educators.
Leaders play an essential role in developing the culture they believe will enhance
organizational performance and functioning (Packard, 2009). There is a belief amongst faculty
members that academic institutions do not see the importance and value of teaching because
candidates for promotion are judged based on their research and clinical achievements and not
teaching excellence (DaRosa et al., 2011). DaRosa et al. (2011) state that providing support to
faculty members carrying out the organization’s mission is fundamental. Leaders should include
clear criteria for advancement based on educational contributions (DaRosa et al., 2011) so
faculty can feel supported as educators. A survey administered by Harris Interactive on behalf of
the American Psychological Association (APA) to 1,714 adults revealed that employees who felt
valued by their employer were more likely to report higher levels of job motivation (Spears,
2012). According to Morrison and Milliken (2000), research has shown that when employees
are able to express their viewpoint on procedures, they view them positively because it indicates
that they are valued members of the organization. If employees feel less valued by their
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 113

organization, it leads to diminished commitment and trust (Morrison & Milliken, 2000).
Gunderman et al. (2008) state that leaders need to know and show their employees that they care
about them. By recognizing and valuing their contributions, leaders can inspire their colleagues
to seize opportunities, and reach their full potential (Gunderman, Weinreb, Hillman, VanMoore
& Neiman, 2008). As such, it appears that the recommendation to conduct quarterly meetings
with core faculty members and leadership to gather feedback on department education practices
and develop systems that recognize and reward excellence in teaching would benefit both core
faculty members and the organization.
Cultural settings solutions. Increase core faculty member’s belief that they are part
of an environment where leaders model desired behaviors, practices, and support faculty
development (Cultural setting). The findings of the study showed that the majority of core
faculty members do not strongly believe that the department supports their teaching practices and
development as educators. Clark and Estes (2008) state that organizational performance
increases when leaders identify, articulate, focus the organization’s efforts on, and reinforce the
organization’s vision. Thus the proposed recommendation is to conduct quarterly meetings with
core faculty members to reinforce the department’s practices in the area of education and vision
in the development of faculty as educators.
The most powerful mechanism that leaders have available for communicating what they
believe in is what they pay attention to, measure, and control on a regular basis (Schein, 2004).
Kotter (1995) states that a vision is critical as it guides and directs the efforts of an organization.
The author also further notes that leaders should use every possible channel to communicate the
organization’s mission (Kotter, 1995). If employees are not clear or confused by the
organization’s vision, they will not be motivated to carry out the mission of the organization.
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 114

Communicating the vision will help employees see their desires and concerns being heard and
allow them to take ownership of the vision (Calegari, Sibley, & Turner, 2015). Gunderman
(2006) notes that when leaders make visible investments in the development of their colleagues,
they are more likely to contribute to the success of the organization. As such, the
recommendation to conduct quarterly meetings with core faculty to reinforce the department’s
practices in the area of education and vision in the development of faculty as educators will
benefit both core faculty members and the organization.
Resources solutions. Increase core faculty member’s time and resources to develop
a curriculum (Resources). The findings of this study showed that approximately 40% of core
faculty members do not have time to develop a curriculum for trainees. Waters, Marzano, and
McNulty (2003) suggested that organizational performance increases when leaders ensure that
employees have the resources and time needed to achieve the organization’s goals. Therefore,
the proposed recommendation is to conduct monthly meetings with core faculty members in
education and leadership to establish goals and regularly monitor the use of resources to ensure
that faculty are able to achieve the organization’s goal.
Clark and Estes (2008) suggested that when structures, processes, and resources are
aligned with organizational goals, individual performance increases. The majority of faculty
members want to teach and be effective educators. However, several factors are impeding their
efforts. DaRosa et al. (2011) indicated that time was one of the major barriers to effective
teaching for clinical faculty. McCullough et al. (2015) reported that, based on the literature
reviewed, 45% of physicians indicated that lack of time prevented them from teaching. Another
26% indicated that a lack of financial support was a significant barrier to teaching (McCullough
et al., 2015). Clinical faculty do not necessarily get financial support for time spent teaching in
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 115

the clinical curriculum (DaRosa et al., 2011). Distribution of time and resources is essential for
individuals to achieve goals and is also necessary for the success of the organization (Lim &
Seers, 1993). Thus, the recommendation of conducting monthly meetings with core faculty
members in education and leadership to establish goals for faculty interested in teaching and
regularly monitoring the use of resources to ensure that faculty are able to achieve the
organization’s goal will benefit faculty in developing curriculum for physician trainees.
Summary of Knowledge, Motivation and Organization Recommendations
The survey and interviews identified gaps in knowledge, motivation, and organizational
influences. Based on the results, recommendations to bridge the gap for knowledge influences
include, providing a job-aid containing a glossary of leadership terms used in medicine along
with reference to the text, and providing educational opportunities in the form of certificate
programs to develop optimal leadership qualities and understand how to apply the knowledge
gained to shape the next generation of leaders. The recommendation to bridge the motivation
gap includes, providing instructional and training support early on to core faculty members, and
building on opportunities for practice so they can master the task and experience success. Lastly,
recommendations to bridge the organizational gap include conducting monthly meetings with
core faculty members to establish goals for faculty interested in teaching and monitoring the use
of resources to ensure they can meet the organization's goal. Another recommendation includes
conducting quarterly meetings to gather feedback and reinforce the department’s vision in the
development of faculty as educators.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 116

Integrated Implementation and Evaluation Plan
Organizational Purpose, Need, and Expectations
The mission of the department of orthopaedic surgery at Northern Pacific University is to
provide the highest quality of patient care, conduct innovative clinical, basic science, and
translational research, and train the next generation of global leaders in orthopaedic surgery. The
stakeholder’s goal, supported by the Program Director, is that a leadership curriculum will be
developed and implemented by education faculty so trainees can exhibit leadership skills in areas
of team-building, professionalism, and interpersonal communication. Failure to develop these
leadership skills in trainees will prevent them from being effective clinician-leaders in many
healthcare organizations. This project examined the knowledge and skills, motivational, and
organizational barriers that prevent core faculty from developing a leadership curriculum for
physician trainees. The proposed solutions, which include resources, training opportunities,
improved communication strategies, and support should yield the desired outcome- 100% of
physician trainees will complete a leadership course at NPU and will be able to effectively
demonstrate leadership skills in team-building, communication, and professionalism.
Implementation and Evaluation Framework
The New World Kirkpatrick Model informed this implementation and evaluation plan
(Kirkpatrick & Kirkpatrick, 2016), which is based on the original Kirkpatrick Four-Level Model
of Evaluation (Kirkpatrick & Kirkpatrick, 2006). While the original Four-Level Model of
Evaluation followed the sequence of reaction, learning, behavior, and results, the new model
promotes working in reverse order (Kirkpatrick & Kirkpatrick, 2016). This begins with
identifying the organizational goals and working backwards, keeping the focus on what is most
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 117

important, which is the project outcome. The four levels that have been adapted based on the
study’s recommendation are described below in Table 27.
Table 27
The New World Kirkpatrick Model Four Levels of Evaluation
Evaluation Level Description
Level 4 Measures the results of the faculty leadership development
program in the context of the organizational goals
Level 3 Measures the critical behaviors that core faculty members
will demonstrate after completing the faculty leadership
development program
Level 2 Measures the learning goals established for the program
Level 1 Measures core faculty member’s reaction -How engaged are
they during the program? How relevant is the program to
their interest in developing leadership skills? How satisfied
are they with the program?

The starting point for the New Kirkpatrick Model is Level 4, which begins with
identifying the organizational goals and the leading indicators. Next, Level 3, which is focused
on solution outcomes that have a focus on assessing work behavior, followed by Level 2, which
is the identification of indicators that demonstrate learning transpired during implementation.
Lastly, Level 1, which is determining the satisfaction of organizational stakeholders with the
implementation strategies. Designing the implementation and evaluation plan in this manner
ensures that immediate solutions align with the larger goal and solicits buy-in that will contribute
to the successful change of the initiative (Kirkpatrick and Kirkpatrick, 2016).
Level 4: Results and Leading Indicators
The below table shows the proposed Level 4: Results and leading indicators in the form
of outcomes, metrics and methods for both external and internal outcomes for developing a
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 118

leadership curriculum at NPU. If internal outcomes are achieved following the training and
organizational support for core faculty members at NPU, then the external outcomes can also be
reached.
Table 28
Outcomes, Metrics, and Methods for External and Internal Outcomes
Outcome Metric(s) Method(s)
External Outcomes
Increased patient satisfaction The number of positive reviews
received from patients
Data obtained from patient surveys
at discharge
Increased physician
engagement
The number of positive comments
and scores received from patients

Positive and negative comments
and scores received from the
Provider engagement survey
Quarterly data obtained from
patient surveys

Yearly data obtained from the net
promoter score survey
Increased department
reputation
Reports received from net promoter
score survey
Quarterly data obtained from the
patient satisfaction survey

Yearly data obtained from the net
promoter score survey

Tracking US News Report of best
hospitals
Internal Outcomes
Increased faculty confidence
in teaching
Positive/negative feedback from
medical students, trainees, nurses
and staff
Reports received from completed
evaluations in MedHub
Increased knowledge of
leadership skills
Positive/negative comments
received from medical students,
trainees, and nursing staff
Reports received from completed
evaluations in MedHub
Increased faculty
participation in education
programs
Number of faculty who participate
in institution and department-wide
education initiatives.
Track the number of faculty who
participate in education initiatives
Improved relationships with
peers, nurses, trainees, and
other health professionals
Number of complaints Reports obtained from the office of
Academic affairs

Feedback received from nurses and
trainees

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 119

Level 3: Behavior
Critical behaviors. The stakeholder group of focus is core faculty members who are
responsible for developing and teaching a leadership curriculum to physician trainees. These
stakeholders are also responsible for providing a positive learning environment for physician
trainees. The first critical behavior is that core faculty must review existing leadership programs
for physician trainees and document progress. The second critical behavior is that core faculty
need to understand and develop their own leadership skills. The third critical behavior is that
core faculty need to identify characteristics of physician leaders. The fourth critical behavior is
that core faculty need to identify the faculty in teaching a leadership curriculum. The specific
metrics, methods, and timing for each of these outcome behaviors appear in the below table.
Table 29
Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical Behavior Metric(s)
Method(s)
Timing
1. Core faculty
members
conduct
monthly team
meetings to
review existing
leadership
programs for
physician
trainees and
document
progress
Number of team
meetings
Team lead and staff will
document if monthly
meetings were
conducted
Ongoing-monthly
2. Core faculty
must complete
specific
leadership
training
modules or
courses
Number of
training courses
attended

Number of
training modules
completed
Staff tracks the number
of modules or courses
completed
Ongoing- weekly

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 120

Table 29, continued
Critical Behavior Metric(s)
Method(s)
Timing
3. Core faculty
members need
to identify
characteristics
of physician
leaders
Number of
characteristics
core faculty are
identifying to
include in the
curriculum
Faculty team leader and
staff tracks progress
Ongoing- weekly
4. Core faculty
members must
identify who
will teach the
leadership
curriculum
Number of core
faculty members
identified
Staff tracks the number
of core faculty identified
Ongoing- weekly

Required drivers. Core faculty require support from executive leadership to reinforce
what they learn during this process and encourage them to apply what they learned to achieve
organizational goals. Executive leadership members play a vital role in reinforcing,
encouraging, rewarding, and monitoring the progress of core faculty members. To enhance the
organizational support of core faculty members, recognition programs, and reward systems
should be established to highlight the achievement of performance goals. Table 30 shows the
recommended drivers to support the critical behaviors of core faculty.
Table 30
Required Drivers to Support Critical Behaviors
Method(s) Timing
Critical Behaviors Supported
1, 2, 3 Etc.
Reinforcing
Job aid containing a glossary of
terms used in medicine will be
provided along with references to
the text.
Ongoing 1, 3
Team meetings with the Vice-Chair
of education to establish goals.
Weekly 1
Providing training opportunities to
core faculty members
Ongoing 2,3

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 121

Table 30, continued
Method(s) Timing
Critical Behaviors Supported
1, 2, 3 Etc.
Reinforcing
Checklists for monitoring progress Initial session 1,2,3,4
Feedback received during the
training session
Ongoing 2,3
Encouraging
Peer modeling and targeted
feedback received during the
training sessions.
Ongoing 1,2,3,4
Coaching from the Center for
Faculty Educators
Monthly 2,3
Education workshops and training
opportunities
Yearly 1,2,3,4
Rewarding
Performance incentive when
curriculum improves trainee
knowledge and behavior
Yearly 1,2,3,4
Recognition during faculty meetings
to celebrate success
Monthly 1,2,3,4
Monitoring
Staff and Vice-Chair of Education
check-in with faculty on progress
Monthly 1,2,3,4
Faculty evaluations Bi-yearly 1,2,3,4

Organizational support. For core faculty members to successfully develop and teach a
leadership curriculum to physician trainees, the organization will need to implement and support
the required drivers described in Table 30. To ensure core faculty members success, the
organization will be actively involved in supporting them. First, executive leadership will
conduct monthly meetings with core faculty members in education to establish goals for faculty
interested in teaching. Resources will also be monitored to ensure that core faculty are able to
achieve the organization’s goal. Second, quarterly meetings will be conducted with leadership
and core faculty to gather feedback on current department education practices. Simultaneously,
an action plan to communicate the department’s strategic plan for educators will be generated.
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 122

Finally, quarterly meetings with core faculty members will be conducted to reinforce the
department practices and vision in the development of faculty as educators.
Level 2: Learning
Learning goals. Following the completion of the recommended solutions, core faculty
will be able to do the following:
1. Understand and describe leadership and its terminology (Declarative)
2. Explain leadership concepts and its relation to leadership effectiveness (Declarative)
3. Describe the process of developing a leadership curriculum (Procedural)
4. Value their efforts, commitment, and direct involvement in designing a leadership
curriculum (Expectancy Value)
5. Believe that they can successfully implement a leadership curriculum (Self-Efficacy)
Program. The learning goals listed in the previous section will be achieved through a
faculty leadership development program that explores in-depth curriculum design in education
leadership. The learners, core faculty members involved in teaching physician trainees will
study specific topics pertaining to leadership and discuss principles of course design. These
topics were identified based on the learning goals to ensure core faculty members succeed in
developing and teaching a leadership curriculum. The program is blended, consisting of one e-
learning module, psychometric assessments, and three half-day in-person learning sessions. The
estimated total time for completion is 14 hours.
During the asynchronous e-learning modules, learners will be provided a job aid of key
terms and references to the text pertaining to leadership. The video will pause from time to time
to allow learners to process the information on leadership terminology and concepts. Following
the modules, the learners will be required to answer multiple-choice questions to self-gauge their
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 123

own understanding of leadership. Learners will also be asked to complete the Myers Briggs
Type Indicator assessment (MBTI) to gain an understanding of one's own leadership styles
before the in-person learning session.
During the synchronous in-person learning sessions, core faculty members will be able to
apply what they learned from the asynchronous content through interactive discussions, peer-to-
peer dialogue, and team-based activities. These sessions will be taught by faculty from the
Health Force Center with decades of healthcare and leadership experience. This will allow the
instructors to discuss and emphasize the value and benefits of developing leadership skills in
physicians.
Evaluation of the components of learning. To ensure that learning is taking place, it is
important to have approaches that verify desired learning outcomes. Demonstrating an
understanding of declarative knowledge is often necessary as a prerequisite to applying the new
knowledge learned into practice. Therefore, it is critical to evaluate learning for both declarative
and procedural knowledge being taught. Kirkpatrick and Kirkpatrick (2016), outlined five
essential components of level 2 learning to include in evaluation- knowledge, skills, attitude,
confidence, and commitment. Therefore, it is essential that learners value the training as it
increases motivation and a desire to learn and apply the new knowledge and skills on the job.
They must also be confident with their abilities to succeed in applying the newly obtained
knowledge and skills and show commitment to using them on the job. As such, Table 31 lists
the evaluation methods and timing for these components of learning.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 124

Table 31
Evaluation of the Components of Learning for the Program
Method(s) or Activity(ies) Timing
Declarative Knowledge “I know it.”
Knowledge checks using multiple choice In the asynchronous portions of the course
after video demonstrations
Knowledge checks through discussions and other
individual/group activities
Periodically during the in-person learning
session and documented via observation
notes
Procedural Skills “I can do it right now.”
Scenario-based knowledge checks using
multiple-choice items
In the asynchronous portions of the course
at the end of each module/lesson/unit
Quality of feedback from peers during group
activities report out
During the training session
Pre and post-survey asking core faculty members
to rate their level of proficiency
Before and after each training session
Attitude “I believe this is worthwhile.”
Instructor’s observation of participants’
comments, expressions, and actions
demonstrating that they see the benefit of what
they are being asked to do on the job
During the training session
Discussions on the value of what they are
learning and how it can help physician trainees
and the organization
During the training session
Reflection pre and post-survey One week after the program ends
Confidence “I think I can do it on the job.”
Survey items using scaled items Pre and Post-program survey

Discussion following modeling, practice, and
feedback
Throughout the course
Commitment “I will do it on the job.”
Discussions following practice and feedback During each in-person workshop session
Creating an Individual action plan and discussing
with Vice-Chair of education
Following each in-person workshop
session

Level 1: Reaction
Level 1 is the most basic and necessary level of evaluation. It consists of engagement,
relevance, and customer satisfaction (Kirkpatrick & Kirkpatrick, 2016). These three components
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 125

are essential when evaluating and making necessary changes in the delivery of the program
content. Hence formative evaluations will be used to measure Level 1. Table 32 describes the
methods and timing used to measure learner’s reactions.
Table 32
Components to Measure Reactions to the Program
Method(s) or Tool(s) Timing
Engagement
Observation by the instructor teaching the
course
During the workshop
Timely completion of online modules Ongoing during the asynchronous portion of
the course
Attendance During the workshop
Program evaluation One week after completion of the course
Discussions During the workshop
Relevance
Brief pulse-check with participants via a
survey (online) and discussion (ongoing)
After the online module and during in person
workshop sessions
Program evaluation One week after course completion
Post-survey After each workshop
Customer Satisfaction
Brief pulse-check with participants via a
survey (online) and discussion (ongoing)
After the online module and during in-person
workshop sessions
Program evaluation One week after course completion

Evaluation Tools
Immediately following the program implementation. Continuous assessment of the
training program will be integrated into the learning and development process (Kirkpatrick &
Kirkpatrick, 2016). During the asynchronous portion of the program where learners engage in
online modules, progress will be managed through the learning management system (LMS).
Data on the frequency of assessing the course, time spent on sections, rate of progress through
the course, and completion of modules by learners will be collected, which will indicate
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 126

engagement with the online course material. Level 2 learning will be assessed through scenario-
based quizzes, in addition to post-training surveys. Upon completion of the online module, a
brief survey will be administered via the LMS to measure knowledge and skills, learner’s
attitudes, their beliefs of proficiency attained, and their overall confidence and commitment to
applying what they learned back on the job.
During the synchronous in-person learning sessions, for level 1, the instructor will
monitor attendance, observe engagement of the learners, conduct brief pulse checks by asking
learners their level of satisfaction with the course, and whether the content is relevant to their
teaching activities. Level 2 will include checks for understanding declarative and procedural
skills during the learning activities, and group discussions. Also, an online survey will be
administered to learners after the learning session to understand attitudes, confidence in applying
what they have learned, and commitment to transferring their new knowledge into practice on
the job. Appendix C contains the proposed instrument for this evaluation.
Delayed for a period after the program implementation. Summarize the instrument
here and attach it as an appendix. Create an evaluation instrument consisting of one or two items
per category for Level 1, 2, 3, and 4 that you outlined above using the appropriate rating scale.
Four weeks and then 12 weeks following the completion of the program, a survey will be
administered to faculty members with oversight from the Vice-Chair of Education. The survey
will contain scaled questions following Kirkpatrick’s blended evaluation approach (Kirkpatrick
& Kirkpatrick, 2016). The survey will measure satisfaction and relevance of the program
material (Level 1), confidence in applying new knowledge learned, value, and commitment to
applying their training (Level 2), application of the content to their teaching practices (Level 3),
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 127

and the extent to which what they have learned during the training has influenced targeted
outcomes. Appendix D contains the proposed instrument for this evaluation.
Data Analysis and Reporting
The external outcomes, as previously discussed in Table 28, are to increase patient
satisfaction, increase physician engagement, and increase department reputation. The internal
outcomes are to demonstrate increased confidence in teaching, to have increased knowledge in
leadership skills, increased participation in education programs, and promote positive
relationships with peers, students, trainees, and other healthcare professionals. These goals will
be measured and tracked immediately after the launch of the faculty development program and
throughout the academic year. The Director of Educational programs will monitor, compile, and
report the level 4 outcomes data by using a Department performance dashboard to provide
relevant metrics to executive leadership. The dashboard below will be used as a monitoring and
accountability tool that tracks progress, accomplishments, and highlights opportunities for
growth. Similar dashboards will be created to monitor levels 1, 2, and 3.

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 128

Figure 4. Example of the proposed department performance dashboard.

Summary of the Implementation and Evaluation
The implementation strategies, recommended solutions, and evaluation plan for this
research study utilized the New World Kirkpatrick Model framework (Kirkpatrick &
Kirkpatrick, 2016). According to this model, by focusing on the results (Level 4), efforts are
automatically directed to what is important. Following the New World Kirkpatrick Model, the
faculty development program begins with establishing outcomes, metrics, and methods for
measuring results. Next, critical behaviors are assessed to ensure that core faculty members are
able to transfer what they learned during training to their teaching activities. Required drivers
are added and supported by the organization. The organization is also actively involved in
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 129

supporting core faculty members to ensure their success. Then evaluation tools were designed to
measure level participant knowledge and skills, attitude, confidence, and commitment as well as
satisfaction and engagement with the faculty development program.
To ensure that the faculty development program has a positive impact on core faculty
members, continuous evaluation methods are being used and also integrated into the program
design. This creates an opportunity to get real-time input and make the necessary changes to the
training to adapt to the participants needs. The Kirkpatrick model provided a useful tool to
evaluate this programs innovation.
Limitations and Delimitations
As with all research, there are limitations to the study. Limitations are the influences that
are usually beyond the control of the researcher. Some aspects of the study are susceptible to the
risk of producing inaccurate data (Merriam & Tisdell, 2016) that cannot be controlled. The first
limitation of this study was the selected sample size, which was small. Only 25 core faculty
members responded to the survey, which made it difficult to find significant relationships from
the data. The second limitation to highlight is that the survey and interview protocol was
developed specifically for this study. Even though both measurement tools were pilot tested
with a small group of faculty before administering it to the same population, neither the survey
or interview protocol was thoroughly tested. The third limitation to clarify is that the researcher
works with the sample population, and participants could have withheld information during
interviews.
In addition to the limitations, this research study also has a few delimitations.
Delimitations are factors that affect the study which the researcher can control. Considering this
is a sub-specialty group within medicine, generalizability to other groups within medicine may
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 130

not be achievable. Future studies in a similar manner could be conducted within the same sub-
specialty at other teaching institutions, and results can be compared. Another delimitation is that
to assure the data collected was manageable, the survey instrument used multiple-choice items
and only two open-ended response items. Additionally, while this study could have included
multiple stakeholders, this study focused on core faculty members only. So results may not be
generalizable to other stakeholder groups.
Recommendations for Future Research
Leadership development for physicians has long been studied. There is no one approach
or method that has resulted in answering this problem of practice. From the surveys and
interviews, several themes emerged during this study. There are four possible options for future
research that may provide useful insight into the practice of developing leadership skills in
physician trainees. One area of focus to better understand how to support faculty members in
developing a leadership curriculum is to examine the role of motivation factors. For example, do
incentives, job security, and opportunities for promotion motivate faculty to participate in and
develop leadership skills. Another area of focus is to examine what additional barriers core
faculty members encounter in developing a curriculum for physician trainees. Understanding
clearly the barriers will be critical in supporting the faculty member’s goal of developing a
leadership curriculum and training physician trainees in leadership skills. Another area of focus
is to examine what leadership competencies are most important for surgeons in an academic
institution. Lastly, further research on how formal leadership programs have improved physician
performance, productivity, and enhanced relationships with other health care professionals will
highlight the importance of developing a curriculum for trainees during the early years of their
career in order for them to be successful.
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 131

Conclusion
Leadership skills are essential to address many of the current healthcare challenges and
systems around the world (Blumenthal et al., 2014). However, many residency training
programs across the United States have failed to prioritize leadership training for physician
trainees. The purpose of the study was to understand the knowledge, motivation, and
organizational influences that prevent core faculty members from effectively developing and
teaching a leadership curriculum to physician trainees. The study centered on providing
direction for achieving the organization’s performance goal of having 100% of physician trainees
completing a leadership program and effectively demonstrating leadership skills in team-
building, communication, and professionalism by December 2021. The stakeholder of focus for
this study was core faculty members. This stakeholder group was chosen as they have the most
influence in bringing about change in trainee behavior. Core faculty members spend the
majority of their time supervising and teaching physician trainees.
The Clark and Estes (2008) Gap Analytic Framework was essential as it structured the
review of literature, which identified eight influences, three knowledge, two motivation, and
three organizational influences. Each influence, validated through survey and interviews,
identified gaps in core faculty member’s knowledge and motivation as well as organizational
barriers to developing a leadership curriculum for physician trainees. The New World
Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016) was used to generate an integrated
implementation and evaluation plan.
In this study, our research showed that core faculty members understood the meaning of
leadership. However, they fell short in identifying the characteristics of a good leader.
Therefore, efforts should be made to provide core faculty members with job-aids containing the
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 132

glossary of terms to understand how to improve a gap that is being identified. The study also
showed that core faculty members valued developing leadership skills in physician trainees and
described it as an important skill for their success. However, there is room for improvement in
how confident they felt in their own leadership skills and their ability to develop and teach a
leadership curriculum to physician trainees. Core faculty members can benefit from receiving
support and training opportunities that allow them to master the task, building their confidence.
Thus preparing them to develop physician trainee’s leadership skills. Lastly, the study found that
department leaders need to place a greater focus on providing resources, improving core faculty
member’s feelings of being appreciated and valuable, and building an environment that supports
core faculty member’s efforts in developing themselves as leaders and educators. Efforts should
be made to gather feedback on current education practices and reinforce the department’s
mission and vision in the development of faculty as educators.
The study was intended as the first step toward understanding what is needed for core
faculty members to develop and teach a curriculum in leadership skills for physician trainees.
However, the study also provided a basis for further research on how other factors can influence
core faculty member’s success. Some specific areas of research include examining motivation
factors, understanding leadership competencies that are important to surgeons in an academic
institution, barriers to developing a curriculum, and the role leadership programs play in
establishing life-long career success. In conclusion, the research participants in this study clearly
articulated the influences that support and hinder the achievement of the organization’s goal.
The healthcare industry is experiencing significant changes, with more changes to come in the
next few years. In order to keep up with this rapid change, it is essential for health care
organizations to develop their physician’s leadership capabilities for continued success.
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 133

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https://doi.org/10.5465/amr.1989.4279067

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 144

APPENDIX A
Survey Instrument
Knowledge
Factual
1. Leadership is

a. having an awareness of both self and others.
b. a natural ability that cannot be learned
c. the art of getting and motivating a group of individuals to work on a common goal
d. developing strong personal and professional values
e. building a culture of excellence and accountability
2. What are characteristics of a good leader? (Check all that apply
a. Influencing individuals and groups to cooperatively achieve organizations goals
b. Coaching and building teams to effectively achieve the vision
c. Communicating effectively the vision
d. Leading by example
e. Directing people to do what they will not otherwise do.
3. What is NOT a characteristic of teamwork? Check all that apply
a. Open and honest communication
b. Collaboration
c. Minimal and formal knowledge sharing
d. Team trust
e. Respect for team members
4. What are characteristics of professionalism? Check all that apply
a. Responsible
b. Reliable
c. Respectful
d. Integrity
e. Accountable
f. Polite
Conceptual
5. Rank the importance of the following skills for leadership effectiveness.
a. Interpersonal Communication
b. Teamwork
c. Professionalism
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 145

d. Emotional Intelligence
e. Coaching and giving feedback
f. Recognizing, disclosing and addressing errors

Procedural

6. You have been asked to create a leadership program for physician trainees. What would be
your first step?
1. Look at other leadership programs
2. Develop my own leadership skills
3. Identify the characteristics of physician leaders.
4. Decide who is going to teach the program
Motivation
Value
7. To what extent do you agree or disagree with the following statements:
(1. Strongly agree 2. Agree 3. Neutral 4. Disagree 5. Strongly disagree)

7a. I believe leadership skills have value to strengthen physician trainee’s leadership
competencies and improves performance
7b. It is important for me to participate in leadership development programs at my institution
7c. I believe it is important to recognize the need to develop leadership skills in physician
trainees
7d. I believe strong leadership skills is associated with less physician burnout and higher
satisfaction
7e. It is important to develop courses that enhance physician trainee’s leadership skills.
Self-Efficacy
8. On a scale of 1-10 rate how confident you are to do the following right now:
8a. Develop communication skills in physician trainees
8b. Develop team-building skills in physician trainees
8c. Try something outside the scope of what you have already done
8d. Lead physician trainees by example
8e. Design curriculum for physician trainees

Organization
Resources
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 146

9. To what extent to do you agree or disagree with the following statements
(1. strongly disagree, 2. disagree, 3. neither agree or disagree, 4. agree, 5. strongly agree)

9a. My organization provides sufficient resources to develop a curriculum for the next generation
of leaders
9b. My organization provides dedicated time to focus on teaching physician trainees
9c. My organization provides financial support for teaching and developing the next generation
of leaders

Cultural Models
10. Using the scale below, please rate the extent to which you believe the following:
(1. strongly believe, 2. somewhat believe, 3. neutral, 4. somewhat do not believe, 5. strongly do
not believe)

10a. I feel supported and valued as a faculty member.
10b. My peers welcome opinions that are different from their own
10c. The culture of the organization supports having a physician leadership program.
10d. I am encouraged to be creative in my teaching practices
10e. I consider the environment I work in to be innovative
10f. The most highly rewarded faculty are those oriented primarily toward research and clinical
activities

11. Please indicate the level of influence each of the following would have on impacting your
ability to develop curriculum for physician trainees
(No influence, slight influence, neutral, moderate influence, significant influence)

a. Faculty development workshops
b. Financial stipends
c. Online professional development/training
d. Dedicated time
e. Encouragement from department leadership for learning
f. Physical workspaces that promote collaboration and innovation
g. Online faculty communities that promote collaboration and innovation

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 147

APPENDIX B
Interview Protocol
Introduction:

Before we begin the interview process, I want to thank you for taking the time to meet
and speak with me today. I am conducting this interview as part of my dissertation research with
my doctoral program at USC, exploring the need for developing leadership skills among
physician trainees. The purpose of this interview is to understand faculty member’s views on
leadership and to conduct a needs analysis in the areas of knowledge motivation, and
organizational resources so faculty can be successful in developing and teaching a leadership
curriculum.
Your participation is completely voluntary. Any information shared during this interview
will remain confidential. Any comments made, will not be identified in any way. You can
choose to not answer any question and can withdraw from the interview at any time. The
interview is scheduled for an hour and I have 12 questions for your consideration.
Lastly, I am requesting permission to record this interview. By doing so, I can focus my
attention on you and your responses. I have also prepared a consent form that requires your
signature permitting me to record this conversation. All recordings are only for the purpose of
this study and will be destroyed after transcribed. Are you comfortable with me recording this
interview?
Do you have any questions for me? May we please begin?

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 148

Interview Questions
Knowledge

Factual

1. Describe your understanding of leadership, what does it mean to you?
2. As a physician, what do these terms mean to you: effective communication, professionalism,
and teamwork
Conceptual
3. In your opinion what leadership skills are required to be an effective and successful physician
and leader?
Procedural
4. Explain, how you would develop a leadership curriculum for trainees? Please walk me
through the process.

Motivation

Value theory

5. How important do you feel it is for physician trainees to develop these non-clinical skills in
communication, professionalism and team-building during residency training?
6. How important do you feel it is to develop a curriculum that addresses leadership skills in
areas of communication, team-building and professionalism for trainees?
7. Some faculty may say, physician trainees can develop their leadership skills through
observing their attending and self-learning. They do not need training in leadership skills. What
would you say?

Self-efficacy

8. Could you describe how confident you feel in developing a leadership curriculum?
9. Describe how confident you feel teaching leadership skills in areas of communication,
professionalism and team-building?

Organization

Resources
10. To what extent do you believe the department encourages and supports your development as
an educator?

Cultural Models

11. Some people say that the culture of the organization doesn’t support education activities,
what do you say to that?
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 149

12. Imagine I am a new faculty member. Tell me about the culture of the department in
developing faculty as educators?
Cultural Setting

13. To what extent do you believe there are infrastructures in place to support faculty’s efforts in
educating trainees?

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 150

Appendix C
SELF-EFFICACY RESULTS

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 151

APPENDIX D
Level 1 and 2 Evaluation Tools
Strongly disagree Strongly Agree
1 2 3 4 5 6 7 8 9 10
Engagement
1. The workshop added to my learning experience
2. The instructors had a thorough knowledge of the topic being discussed
3. The instructor encouraged participation during each workshop session
Relevance
1. I found value in this workshop
2. I believe my knowledge in this subject matter has increased by taking this training
3. The activities aided me in learning leadership concepts
4. The workshop was relevant to my needs
Open-ended question
1. What course material did you find to be the most relevant?
Customer Satisfaction
1. I feel the e-learning modules will allow me to apply what I learned to my teaching
activities
2. I feel satisfied with the educational tools employed
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 152

3. I feel satisfied with the pace of instruction and would recommend this workshop to a
colleague
Open-ended question
1. Any suggestions to improve this course?
Strongly disagree Strongly Agree
1 2 3 4 5 6 7 8 9 10
Knowledge:
1. I can successfully apply the knowledge learned in this course to my teaching activities
2. On a scale of 1-10, rate your knowledge on leadership concepts
Attitude:
1. I believe it is worthwhile for me to apply what I learned to my job
Confidence:
1. I am confident in my abilities to design a leadership curriculum
2. I am confident about applying what I learned in the course to my teaching activities
Open-ended question
1. What barriers do you anticipate that could limit your success?
Commitment:
1. I am committed to applying what I learned from the course to my teaching activities
DEVELOPING LEADERSHIP SKILLS IN TRAINEES 153

APPENDIX E
Delayed Blended Evaluation Tools
Level 1
Strongly disagree Strongly Agree
1 2 3 4 5 6 7 8 9 10
Relevance
1. The information provided during the course is applicable to my teaching activities and
job
2. The course materials were easy to follow
Open-ended question:
1. What information from this workshop was most relevant to you
2. What information from this workshop was least relevant to you
Customer satisfaction
1. Looking back, the faculty development program was a good use of my time
2. Looking back, this course was helpful to my learning
Open-ended question:
1. Looking back, what would you change about this program?
2. Looking back, would you choose to participate in this program again?

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 154

Level 2
Confidence
Strongly disagree Strongly Agree
1 2 3 4 5 6 7 8 9 10
1. I feel confident in my abilities to effectively teach leadership topics to physician trainees
2. I feel confident in my abilities to effectively design a leadership curriculum for physician
trainees
Commitment
1. I am committed to applying what I learned to my teaching activities
2. I am committed to designing a leadership curriculum for physician trainees
Open-ended question
1. Explain any obstacles you are experiencing that limit your commitment?
Level 3
Behavior
1. I have successfully applied what I have learned during the faculty development training
program?
2. I have noticed that my own leadership styles are changing after the leadership training
Open-ended question
1. How have you used what you learned in training on the job?

DEVELOPING LEADERSHIP SKILLS IN TRAINEES 155

Level 4
Results
1. I am making progress and already seeing positive results from this training
2. This program has positively impacted my trainee’s leadership skills.
Open-ended question
1. How has your participation in this program benefited the department?
2. What early signs of success have you noticed from your efforts?

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Asset Metadata

Creator Sequeira, Nicola V. (author)

Core Title Developing physician trainees leadership skills: an innovation study

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 04/27/2020

Defense Date 03/04/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag communication skills,leadership,leadership curriculum,leadership qualities,OAI-PMH Harvest,physician leadership,physician trainees,professionalism,residency training,resident leadership training,resident trainees,team-building

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Yates, Kenneth (committee chair), Kim, Hubert (committee member), Malloy, Courtney L. (committee member)

Creator Email nicolasequeira@gmail.com,nvsequei@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-293532

Unique identifier UC11666063

Identifier etd-SequeiraNi-8362.pdf (filename),usctheses-c89-293532 (legacy record id)

Legacy Identifier etd-SequeiraNi-8362.pdf

Dmrecord 293532

Document Type Dissertation

Rights Sequeira, Nicola V.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA