Journal of Health Care Communications Open Access

Strategic leader attributes for clinical leaders in an HIV healthcare system: Perspectives of healthcare providers in the Academic Model Providing Access to Health at Moi Teaching and Referral Hospital in Eldoret, Kenya

Felishana Cherop^1*, Juddy Wachira², Michael Korir¹ and Vincent Bagire^{3 1}Department of Management Sciences and Entrepreneurship, MOI University, Kenya
²Department of Behavioral Sciences, MOI University, Kenya
³Department of Business Administration, Makerere University Business School (MUBS), Uganda
^*Correspondence: Felishana Cherop, Department of Management Sciences and Entrepreneurship, MOI University, Kenya, Email:

Received: 30-Nov-2022, Manuscript No. IPJHCC-23-15462; Editor assigned: 02-Dec-2022, Pre QC No. IPJHCC-23-15462 (PQ); Reviewed: 16-Dec-2022, QC No. IPJHCC-23-15462; Revised: 21-Dec-2022, Manuscript No. IPJHCC-23-15462 (R); Published: 28-Dec-2022, DOI: 10.36846/2472-1654-7.12.70056

Abbreviations

(AIDS) Acquired Immune Deficiency Syndrome; (AMPATH) Academic Model Providing Access to Healthcare; (CHWs) Community Health Workers; (HCPs) Health Care Providers; (HIV) Human Immunodeficiency Virus; (IREC) Institutional Research Ethics Committee; (MTRH) MOI Teaching and Referral Hospital; (NACOSTI) National Commission for Science, Technology, and Innovation

INTRODUCTION

Strategic leaders in healthcare systems are characterized in terms of possessing organizational abilities and personal characteristics that influence organizational performance [1,2]. However, the strategic leader attributes of clinical leaders are less documented in the HIV and health systems literature. Studies acknowledge that the role of strategic leadership in competitive healthcare services demands personal qualities of top leaders such as working with others to improve healthcare services however; there is a need to rethink the current healthcare leadership due to the contemporary challenging dynamics in Pakistan healthcare [3]. A strategic leadership healthcare systems study in Sub-Saharan African countries established that healthcare systems require clinical leaders with strategic leader competencies to provide vision and inspiration for the organization [4], foster high quality and safety of healthcare [5,6], set realistic goals to meet client needs [7], prepare clinicians to be leaders in both daily clinical and academic practices in a collaborative manner [8] However, these are not known in the HIV care where leaders are confronted with complex situations [9]. A recent strategic leadership study affirmed that leading in the age of more chaotic environments and newly emerging challenges and cases such as the Covid-19 pandemic demands special strategic leadership [10] but the specific strategic leadership attributes were not highlighted. In Uganda, the strategic leadership of clinical leaders, team functionality, patient age, patient sex, and health facility type were significantly associated with HIV viral load suppression [11], but this is not known in the Kenyan context.

Clinical leadership in the healthcare system is critical in enhancing quality patient care and healthy workplaces and if it has to be effective, a greater emphasis should be directed on the aesthetic attributes of leadership rather than the functions [12]. A leader in healthcare should demonstrate specific roles and behaviors to influence others such as being independent, collaborative, trustworthy, multi-faceted, and ambidextrous [13]. In the nursing literature, there is a consensus on the attributes of clinical leaders such as clinical competence, goal setting, coordination, approachability, commitment to patient care, and emotional maturity [12,14-17], however, in an HIV care system, the attributes of clinical leaders are less documented.

Other healthcare studies consent that physician leaders should be effective communicators, collaborators, team leaders, accountable, and trustworthy [18], however, it is important to understand these attributes in the context of HIV. A digital leadership study established key attributes of healthcare leaders such as being visionary and dynamic, innovative, strategic in critical thinking, decisive, and leading by example [19]. Similarly, an integrative review revealed leadership core competencies such as mentoring, and collaboration [20]. However, this is not known in the HIV domain where patient needs, healthcare providers, and healthcare systems are becoming dynamic and unpredictable [9]. This study explored the perceptions of healthcare providers to understand the strategic leader attributes required for clinical leaders in an HIV care system in Western, Kenya.

Methods

Study Design

We conducted a qualitative descriptive study between December 2019 to May 2020 about explore healthcare providers’ (HCPs) perceptions of what strategic leader attributes should clinical leaders have at the point of care in an HIV health system.

Study Site

The study was conducted at Academic Model Providing Access to Healthcare (AMPATH) in the MOI Teaching and Referral Hospital (MTRH-AMPATH clinic) Eldoret, Kenya. AMPATH was established in 2001 as an established partnership between MOI Teaching and Referral Hospital and MOI University, College of Health Sciences in Kenya and a consortium of North American academic medical centers [21,22]. AMPATH care model has supported the delivery of HIV care in western Kenya and leads in promoting and fostering a comprehensive approach to HIV/ AIDS control by providing free ART to patients who qualify for therapy and comprehensive services such as nutrition, psychosocial support, economic development and training. AMPATH works with healthcare providers at all government levels in providing effective care that is culturally acceptable [23]. It supports more than 300 Ministry of Health facilities in Western Kenya [24]. In MTRH-AMPATH, there were 50 healthcare providers in all the adult care clinics at the end of July 2019 and each care clinic had an average of 17 providers. The total number of patients in each of the care clinics on average was 8688. Generally, the provider-patient ratio was 1:511 (AMPATH Records, July 2019). In each of the care clinics, there is a clinical leader in charge who provides leadership roles and this formed a healthcare system with all the infrastructural arrangements that provided a basis for studying strategic clinical leader attributes (Figure 1).

Figure 1: AMPATH-MTRH clinical management flow chart

Sample Selection, Recruitment and Data Collection

We purposively interviewed 22 healthcare providers (clinicians, nurses, social workers, counselors, and a pharmacist) at their workplaces who had experience in HIV care service provision and had interaction with a clinical leader [25]. The sample size was reached by saturation. We used an interview guide to explore information on the understanding of the strategic leader attributes, healthcare system, and, strategic leader attributes for clinical leaders. The sessions were audio recorded with permission and each session lasted an average of 40 minutes-60 minutes (Table 1).

Table 1: Healthcare provider’s interview guide

Ethics

Our study protocol and consenting procedures received ethics approval from the Institutional Research Ethics Committee (IREC) in MOI Teaching and Referral Hospital (MTRH); (Approval No:0003485), and a research license from the National Commission for Science, Technology, and Innovation (NACOSTI No NACOSTI/P/20/3253). Written informed consent was sought from the participants before the in-depth interviews which were conducted in private rooms within the facility to ensure the convenience of the providers and confidentiality. Data that were saved on a computer were protected using a password and all methods were carried out under relevant guidelines and regulations.

Data Management and Analysis

A thematic analysis approach was used in analyzing the study findings. First data were transcribed from the audio recorded sessions into transcripts which were imported into Nvivo vs.12 software to manage data ideas, queries, visualization, and reporting [26,27]. The transcripts were then coded to sort and organize the data and similar categories were developed for understanding the data [26,27]. To ensure validation, we conducted independent coding and identified themes from the 22 transcripts, examined the themes to identify duplicate and similar codes that could conflict with each other [26-28], and then we developed a revised and final codebook with consistency that was used in the final write-up.

Results

Respondents Characteristics

We approached 25 healthcare providers (HCPs) from all care clinics (1-3) in the MTRH-AMPATH facility, of whom a sample of 22 (88%) was reached by saturation. Most were clinical officers 14 (63.6%), nurses 5 (22.8%), and the least were counselors (9.1%) and a pharmacist (4.5%). There were more males (54.5%) than females (45.4%) who participated in the study, 22 (88%) earned a monthly income of (>500 $) and 22 (88%) had >1 year of experience in HIV care service provision. Participants were between the ages of 41 years and 50 years.

Description of Strategic Leadership

The healthcare providers described strategic leadership in terms of the clinical leader’s attributes and their roles in HIV care. “So, according to me leadership is like giving the way forward for the people who are working and you are leading them to where you are supposed to go” (P1). “Leadership is about taking the lead in the healthcare set up whereby we have for instance our chief of party who is now our overall I can say, then we have the human resources, we have the clinical departments, so I think it goes as per the departments, so we have that bureaucracy from the chief of the party, to our clinical manager, then to our clinical in charges. So, I think it depends on the departments you are in” (CO1). “A leader in the healthcare system is a person who coordinates the day-to-day activities of the clinic and oversees the clinical care” (CO2).

Description of Healthcare System

Providers defined a health system as established structures that provide quality healthcare services to HIV patients. This comprised leadership in the care system, health care providers, and patients. “When you talk of a healthcare system, it comprises of staff, it comprises of care providers, it comprises of patients who come here, and the management. When all these are integrated, I see a definition of a healthcare system” (CO3). “Health care system is actually a structure that is put in place or governed by laws and principles in terms of giving health services to the citizen. Actually, structures contain a lot of things, one is the human part of the structures, and there are other resources and there are other support services and also the healthcare structures now. Then there are bodies of other organizations that support now the healthcare structures. For instance, here, we have partners or implementing partners that back up those structures. But the key main structure here is now the ministry of health, that is now our structure” (CO4). It was also defined as an integrated healthcare service provision composed of patients, providers, and other stakeholders. It is also made up of various departments within a facility to help provide health care services in an organized manner.

“The healthcare system has different sectors that I could be doing some part of it. But there are different sectors of it, like the pharmacy part, and the lab, which we try to interlink as much as possible. There is the VITC section where people are tested and given their results. Where they have been registered. If they are having legal issues, there is the legal department. If they have social issues like maybe they need drugs and they cannot afford them the program can waive that because that is what the social worker does. Nutrition is where they need help with their diet and what they need to improve in their management of HIV. So, those sectors are interrelated and interlinked. In the healthcare system, all those should be working in tandem together” (P1).

Strategic Leader Attributes for Clinical Leaders

The primary themes that emerged from the study findings that characterized the strategic leader attributes for clinical leaders in the HIV care system included 4 categories:

• Training and Expertise;

• Inter-professional Traits;

• Interpersonal Skills;

• Managerial Traits.

Training and expertise: The first theme that emerged was clinical competence. The providers noted that clinical leaders who have hands-on experience and expertise in their clinical work were important in the leadership position in a health care system. A competent leader will lead by example by being swift and able to respond to patients’ and health system-changing needs. Moreover, the leader was viewed as an informed and knowledgeable in the field of medicine, which will identify mistakes in service delivery to patients. “In a healthcare system according to me, a leader should be knowledgeable, that is, she should be knowing some at least medicine so that she knows how to treat patients so that when I make a mistake, she can see that I have made a mistake. I wouldn’t like to be led by a person who is lay in medicine” (CO5). Providers also noted that the HIV field is currently dynamic and new guidelines and drugs addressing the HIV pandemic emerge often and must be implemented by health systems. Therefore, the strategic clinical leader should be keen to note new changes, and ready to embrace them and build the capacity of other staff to comprehend the new regulations through training and workshops. “Like now we have issues of pep, prep so, there is a knowledge gap. So, they need to be people who are well trained, maybe trainer of trainers, so that they can pick some of these things and inform management which can then plan and organize training” (CO6).

Inter-professional traits: The providers perceived team leadership as an important inter-professional trait for the leader to embrace teamwork with and among the staff by bringing all and their clinical expertise on board to discuss and consult on various issues within the unit or even the health facility. They noted that the care clinics were composed of different cadres comprising consultants, clinical officers, nurses, retention staff, nutritionists, and social workers, and hence there was a need for them to work as a team and in a coordinated manner to provide quality HIV care. For instance, a patient would come to a nurse or a clinician with multiple problems such as nutritional, psychological, or social issues which they would not be able to solve but refer to a nutritionist and a social worker. Besides, a team leader was viewed to encourage cooperation and harmony in the workplace.

“And above all, you have to embrace teamwork. You see, in a health setup, being a staff or a healthcare provider, you are not the only one who is providing those services. Like I told you before, the module comprises some departments. We have social workers, we have nutrition, and out of all those cadres, a leader has to run all of them. So, if we cannot enhance teamwork, you may end up not giving enough service to the client because you need to incorporate all these cadres. So, working as a team is also very important” (CO6). “I think the main attribute is teamwork and our leader embraces teamwork, yeah so that is what keeps us going because she always brings everybody on board. So, when everybody is on board now, we can discuss within the clinic” (CO7). Providers further perceived a strategic clinical leader as trustworthy. A good relationship goes hand in hand with trustworthiness which enhances good relationships between providers and patients during clinical interactions. The clinical leader should be trusted by other staff and they can feel confident to talk and share their experiences and challenges freely. Good interactions in the healthcare system are informed by respect, fairness, and a good personality.

“She should be trustworthy. Someone that you can trust with your personal issues and you wouldn’t want the next time to see that people are talking about that issue; she should be trustworthy” (NR1). The providers cited honesty and integrity, as important and recurrent strategic clinical leader attributes. They noted that for the leader to gain support from the team, the leader ought to demonstrate discipline, transparency, and predictability. “The main attribute of my leader is integrity. The honesty in the person, and maybe also the transparency between the leadership styles in my leader. This one being a healthcare system, you must be genuine to the patient, you must be honest in the provision of service, and leadership process whereby in other ways you also get supported through the attributes of this particular leader” (CS1). A strategic clinical leader was viewed as a flexible person and quick in responding to work-related issues and the patient’s changing needs and providing possible solutions to unprecedented issues affecting clients. In addition, the organizational dynamics and the changing lifestyle call for flexibility in terms of how a leader addresses the emerging issue. A leader should therefore be ready to learn, accept and accommodate new changes and ideas. This highlights the importance of leader adaptive capacity in the HIV care system. On the contrary, being rigid results in resistance and poor-quality service provision.

“The leader should be kind of flexible and quick in responding to some of the issues and how to address patients changing needs” (CO8). “I think as someone said, change is the only permanent thing. So, when new things come up, that leader should be able to adapt to new situations, to new ideas, to new trends, and should be someone who is probably well read and able to inculcate what is new and be able to put it in part of the team and put it in the work program of that program. So, I think it is someone who should be able to adjust and walk easily in whatever the situation, regardless of if I worked seven years ago and now, we are doing things differently but should be able to adjust to the new regime that is coming up.” (P1) “A leader who is flexible in terms of patient and staff needs, strategically a leader who can learn in the dynamic changes. At any given time, they should be willing to learn because if you don’t learn then you will not move with the trend and what will you give back to your team” (NR2).

In addition, a strategic clinical leader should be impartial and ready to serve the team without any discrimination, hence treating everyone equally. “Then, probably another attribute he should be impartial. Serving without partiality” (CO9). The providers added that a strategic clinical leader should be a mentor to the juniors by being a good role model, motivating and directing others on what they are expected to do in the work environment. For instance, if the leader is punctual and accountable then the other staff is expected to follow suit. In addition, a leader is expected to show respect to others and take lead. “It influences the services because when our leader goes forward and as we see her work, she is not the kind of person who just does for the sake. It influences positively because she is hands-on, definitely if my boss is hands-on, I will definitely work because she is not just speaking it out, and it influences the work positively. For example, I said she is punctual. So that makes even our clients to be served better because we know that if she comes early, tomorrow as a junior if I come late, I will feel guilty because my boss comes early. So, when all of you are punctual, even the clients know that they will get the best because they come, they get served, and they go” (NR2).

Interpersonal skills: It emerged that being approachable was the most occurring attribute for strategic clinical leaders in this domain. The leader should be approachable to the junior staff and patients to discuss diverse issues affecting them with confidence and freely without fear, through good listening and caring. “A leader should be friendly because if you are not friendly, your juniors will not be free to tell you if there are any challenges at work and even giving feedback will be a problem. As I said before, there will be free communication with his or her juniors, and then also we will be free to give feedback and deliver on the duties that he or she gives us” (CO10) “That is basically what a leader is. It should be someone available to the team, someone, who is responsive to their needs, because sometimes some members of the team might have some challenges and therefore you should be willing to listen and hear them out” (P1).

It also emerged that a strategic clinical leader was viewed as an understanding and a good listener, particularly in paying attention to the staff and patients’ challenges. This also allows the junior staff and patients to be ready and always willing to sit, listen and discuss with the leader. As a leader, one is always dealing with a dynamic team as well as clients with different characters hence the leader should be accommodative. “Maybe I can just mention a few that one, as a leader you should be understanding, you should be able to understand your staff and listen to their challenges, sometimes when patients come, they have a lot of issues, then you should be able to be at their shoes “(CO11). “A good listener, to be a leader you are supposed to be a good listener so that you can get to know what is going on to be able to understand any eventualities” (CO12). Providers noted that a strategic clinical leader should possess good communication skills during clinical interactions which can be useful in identifying work environment challenges and providing suggestions for improvement to provide patient quality service. The strategic clinical leader should provide timely communication to the team on new developments such as training and pass new information from the management to the juniors.

“The main attribute that I can talk about is there is what we call open communication, especially in our set up here, so we usually deal with patients, so the major thing we usually talk about is patient care, then the challenges we are facing, then, any other thing that we need to improve pertaining care and services towards the patients” (CO4). “If I start with my leader, it is that he is a person that always makes sure that all information that comes he passes to me and I make sure that I pass that information to the team. So that if there is something new that has to be done, that information reaches me. It has to be the biggest attribute that someone who gets information and passes to the team” (P1). A good relationship, interaction, and respect for other staff were noted as attributes of a strategic leader. The clinical leader should have a strong personality since they are dealing with different people. “Being a leader also apart from understanding, dedication, you have to have a good interaction with your staff” (CO6). “So, I think reliability and respect for your juniors. It is very important because when you respect your juniors, they will respect you in return and your job becomes simpler” (P1).

Managerial traits: A strategic leader was perceived as a good planner, an important component of strategic management in scheduling daily activities and the utility of resources. For instance, developing flexible work schedules to enable providers to work on shifts to ensure continuous patient services. “You know the resources will never be enough. So planning is the backbone of all the activities that go on in the program for the best services in terms of prioritization. And if the planning doesn’t go well then you will not be able to do what is expected of you. He should be swift as well, in terms of changing what is not working” (NR3). Accountability was a key recurrent theme. The providers emphasized that an accountable leader promotes responsibility by attending to clients and upholding good values like transparency and time management in financial expenditure. “You also have to be very accountable because sometimes we handle money for our clients, so you need to be transparent and make sure when you are given something, you can account for it to the boss” (CO13).

In addition, a strategic clinical leader is expected to be disciplined, dedicated, and hard-working to ensure that the objectives and goals of the health facility are achieved. This includes report writing and submissions on time. “Sometimes you go home very late, not like any other person or like any other staff because you have to make sure that the duties of that day, the reports are submitted on time, and all that” (CO13). The providers described the strategic clinical leader as an innovative leader who makes suggestions and provides solutions to a working team in unforeseen situations by being visionary and dynamic to provide solutions to unforeseen challenges. Innovativeness leads to positive change and healthcare system development through new ideas and strategies. “For her, she normally analyses what happens on the ground. After analyzing what happens on the ground, based on her knowledge and her leadership, she takes it higher. Introducing something new and giving it time to work. If it doesn’t work, she drops it. If it works, she rolls it down” (NR4).

“I think being visionary and probably dynamic as per need, is just the motive to improve the healthcare system because if a strategy is not working at that time, you might be forced to either leave it or modify it in such a way that you think it might give a positive impact to the healthcare system. And when I talk about the system, it does not just mean the whole system from top to bottom. You know even in that small area of jurisdiction; you can have a best practice that can influence the whole system” (CO12). “A leader who can learn in the dynamic changes at any given time, they should be willing to learn because if you don’t learn then you will not move with the trend and what will you give back to your team” (NR3). Having problem-solving attributes enables clinical leaders to provide solutions to healthcare system challenges. For instance, reviewing customer feedback forms to document compliments, and identify complaints, and conflicts to provide objective feedback. This will aid the leader in making strategic decisions on behalf of the junior staff and the health facility. However, there can also be instances when some issues are beyond the capacity of the leader and will require help from the facility management. It was noted that problem-solving skills create harmony, avoid the blame game, foster unity, and, provide a good role model to the patients on how to relate well. It also leads to efficiency in service delivery in the workplace.

“He should also be good at solving conflicts. Sometimes you find some roles that are almost the same between a nurse and a clinical officer so the nurse says this is not within my job description and the other one is like that. At the end of the day, you find that patients are not seen or somebody is overworked” (CO7). “You know the health system is broad. We have the service deliveries; you have to have some supplies. So, all these pillars they interact, and when there is a weakness somewhere, then the leadership comes in and works out solutions” (CO12). “When a patient comes in and they see staff, they see how they relate with one another, beyond being a member of staff who attends to these clients, we are human beings. So, the way we relate, with my colleagues, with my staff, might affect the way the client perceives me and the way the services are being offered” (P1). In addition, a strategic clinical leader should be organized in terms of time management in reporting to work and also submitting reports. “Punctuality; you have to keep time by coming in very early and again staying until the program’s time is over, until five. You have to be here until five so that you make sure that the clinic is running smoothly.

Punctuality in terms of reports; you have to submit reports on time, even in attending meetings, and even when you call for meetings you should be punctual. If you call for a meeting and you are late, that is not leading by example. So, in every aspect, you have to be punctual and you lead by example” (CO12). Another attribute was noted as someone vocal and ready to fight for the right of the junior staff by being understanding and ready to present the issues arising from the team to the management for solutions. “And then, he should be able to represent us well; because sometimes you can give your grievances and then he goes there and he doesn’t say anything and yet down here you are like your issues were addressed” (CO7).

Discussion

In this study, understanding the structures of a healthcare system and the role of clinical leadership is important in achieving HIV patient care. The definition of a health system by the healthcare providers corresponds to the elements of a health system defined by the World Health Organization (WHO) that brings multiple elements together such as healthcare workforce, healthcare financing, and governance, medical products and technologies, health service delivery, to provide service delivery [29]. Studies argue that the leadership competencies in the health systems domain are shifting from direct patient care to the strategic level which requires an understanding of the healthcare systems to create and share an organizational vision for quality improvement of patient care [30].

In the training and expertise domain, the attributes focus on clinical service provision to HIV patients by addressing their problems. This suggests that strategic clinical leaders should have clinical competence to identify technical problems affecting patients and provide technical solutions promptly. This highlights the importance of being informed and knowledgeable in HIV clinical care. Also, there is a need for capacity building in leadership in the academic training for clinicians and physicians in HIV healthcare. Prior research report similar findings that a clinical leader demonstrates clinical expertise in organizing the healthcare system and using the expertise to meet patient needs [15,17,31]. In addition, apart from strategic decision-making, strategic leaders address conflicting strategic issues [32], which demand technical expertise. Importantly, training and capacity building and continuing education or graduate education for health workers improve health outcomes [33,34], and transforming rural health systems through clinical academic leadership improved quality of care and rural health outcomes [35].

In the inter-professional traits, our findings found that a strategic clinical leader in an HIV system is a team leader who provides direction and guidance, suggesting the need for collaboration with other leaders and team members in providing HIV care. Consistent with this finding, successful strategic leaders depend on teams because it brings collective expertise and enhances patient care [36-39]. In addition, clinical leaders direct and help people [15,40]. Similarly, we found that good relationships in a healthcare system are built on the trustworthiness of the clinical leader to engage with the providers and patients and provide confidence during clinical interactions. Also, treating everyone equally with respect and without discrimination suggests the importance of upholding the principle of fairness to promote good interaction and harmony in the health system. Consistently, a model of youth leadership in HIV prevention in Canada established that a leader should be confident, trustworthy, willing to listen, humble ad patient [41]. Similarly, clinical leaders should demonstrate characteristics such as trustworthiness that influence the attitudes and behaviors of others [15].

Our study also found that strategic clinical leaders who led with honesty and integrity gained support from team members and maintained good discipline in the management of resources suggesting that healthcare leaders should act in good faith and demonstrate responsibility in managing resources. These findings concur with previous literature which highlights the importance of a leader having integrity in their work [14-16,37,39,42] by behaving in an open, honest, and trustworthy manner [43]. Moreover, our study found that strategic clinical leaders are flexible to learn and adapt to new situations as well as responsive to dynamics however, the focus is different. Previous studies argue that clinical leaders should be flexible [12], to transition from a clinical role to executive policy decision-making and are responsive to the needs of diverse stakeholders such as the chief executive officer, chief financial officer, chief medical officer, and chief nursing officer [44]. Our findings highlight the importance of mentorship to junior staff in taking lead in all tasks in the HIV facility particularly in motivating the staff to achieve their goals and tasks. This suggests the need for strong personal values to lead a group of people in a health system. This finding is consistent with previous findings which established that clinical leaders act as role models/mentors [15,45], and they lead by example, a necessary leadership quality in healthcare [46].

On the interpersonal traits, the attributes of strategic clinical leaders appear to direct focus on the personality of the clinical leader and patient care. This is important because clinical leaders interact with patients, providers, facility management, and other stakeholders in the care system. In this study, our findings concur with previous literature that clinical leaders should be approachable, friendly, and listen to everyone [8,17,20]. This finding is important in creating an enabling environment with less tension for patients and providers to interact. The importance of simplicity enables clinicians to be accessible to the patient and staff needs, however, a lack of approachable and effective leadership led to low staff morale, frustration, lack of commitment, and persistence of other confining and restrictive factors [47]. Moreover, clinical leaders are approachable to all medical and nursing staff and are consultative [15,17,44]. Our findings emphasize the importance of active listening and understanding by the clinical leaders to address patient and staff needs which concur with previous literature [45] because clinical leaders are situational driven [48]. Similarly, A leader should have the ability to listen and communicate effectively with staff, residents, and their families in an aged care facility [49], hence they should have good communication skills important during consultation rooms and providing feedback [15,40,43,45]. Similarly, building and maintaining relationships with the leader through listening to and supporting others helps the leader to gain trust and show a sense of understanding [43]. However, the adaptive leadership framework provides evidence of how communication approaches were often mismatched with the needs of the patients in the hospital [50].

The managerial traits identified in the study shifted focus from direct patient care to strategic leadership. In our study, strategic clinical leaders should have good planning skills to schedule tasks and in utilizing available resources suggesting the need for technical aspects in finance and management. Although this finding is not directly related to previous findings, studies in nursing found that the professional core competencies of nurse leaders were associated with good planning and implementation of training and providing technical assistance to other staff [20]. Additionally, clinicians helped patients to develop plans for achieving their treatment goals and setting directions [37,42]. Furthermore, a leader should be a strategic planner, and, participative in executive policy [8]. In our study, the providers perceived the strategic clinical leaders to demonstrate responsibility in terms of patient care and management of financial resources by being accountable highlighting important values such as transparency and honesty. Previous studies found that leaders in an acute care hospital should be honest, resilient, consistent, participatory, and accountable [51]. Similarly, clinical leaders manage services including performance, people, resources, and planning [52].

Furthermore, strategic clinical leaders were expected to be innovative in providing suggestions and innovative solutions to a working team and patients’ problems in unforeseen situations, suggesting the importance of a leader’s vision, creativity, and adaptivity in dynamic situations to create change in the healthcare system. This is also important for adaptive healthcare systems because of changing patient needs and dynamic health systems that may require innovative approaches. This is a novel finding that encourages healthcare managers to direct more focus on innovative leadership to scale up patient care and health system performance. Some aspects of innovative leadership reported in leadership studies highlight the importance of proactiveness, being dynamic, and leading the organization to another level [15,46]. It is important to note that these studies were not specific to innovative leadership approaches as strategic leadership aspects but generally the attributes of a clinical leader.

Previous studies have reported that the attributes of clinical leaders in contemporary nursing include problem-solving as a clinical focus aspect [53]. Although the finding explored the views of the nurses, our study found that strategic clinical leaders solve conflicts among staff relating to work roles by identifying areas of weaknesses and ensuring positive patient perception towards HIV care. To promote the effectiveness of service delivery in the HIV care system, strategic clinical leaders should have organizational skills in managing time, organizing work to run smoothly in the clinic, scheduling and attending meetings, and providing timely reports. Previous studies have highlighted the clinical attributes that shape a clinical leader including organization of care to support the well-being of patients [54,55], and clinicians to develop a greater understanding of the structure of the healthcare services [56,57]. Vocal clinical leaders are necessary to represent the issues of patients and staff to the relevant leadership and management of the HIV facility. This suggests the need for enthusiastic leaders to take up the issues on their own and provide total support. Whereas there is limited literature on this, previous studies acknowledge that clinical leaders are supportive [14,15,58], and have interpersonal understanding [59]. A study suggests that clinical leaders should be enthusiastic, caring, and empathetic [60].

Implications for Policy, Theory and Practice

Our study found that clinical leaders perform strategic leadership roles at the HIV primary care level in providing HIV care. A clinical leader who is equipped with strategic leadership attributes influences health system performance and patient care. There is a need for the AMPATH leadership and management to develop clinical leaders’ capacity to equip them with strategic leader attributes to back up their clinical expertise. In addition, AMPATH leadership and management should cascade down the strategic leadership roles to engage the clinical officers in decision-making as this will help them to be confident, responsive, and adaptive to the dynamics of the HIV care environment and inform excellent performance and quality HIV care. Our findings also provide a basis for the hospital to partner with relevant government and academic institutions to develop a leadership curriculum for clinical leaders in healthcare service. This will make HIV care strategic in the global platform.

Strengths and Limitations

The strength of this study lies in its qualitative nature exploring perceptions from the healthcare providers through in-depth interviews in the HIV context. To our knowledge, this is a novel qualitative study exploring strategic leader attributes for clinical leaders in an HIV healthcare system in Kenya. However, our study had some limitations that we wish to acknowledge. First, the study had a narrow lens of obtaining information from providers’ perspectives, lacking the perspectives of the patients on important aspects of care like patient experience, effectiveness, and quality of care. Similarly, we did not interview the clinical leaders in charge who could shade more light on their leadership attributes and experiences in HIV care, providing a basis for further investigations. Thirdly, there is a danger of response bias because the healthcare providers assessed the attributes of their clinical leader.

Conclusion

Clinical leaders require strategic leader attributes to lead HIV health systems, manage patient dynamics and provide excellent HIV care. The leadership and management of the HIV facility should develop the capacities of the clinical leaders to a more strategic leadership approach so that they become dynamic and responsive in their leadership and clinical roles.

Acknowledgement

The authors wish to appreciate the MTRH-AMPATH facility for allowing this study to be conducted. We acknowledge the contribution of healthcare providers in providing data regarding their clinical leaders. Besides, we sincerely recognize the efforts of Dr. Josephat Cheboi for providing personal direct support in establishing information from the HIV facility for this study. Also, we thank Dr. Patrick Limo and Dr. Andrew Kimwolo for their intellectual and moral support while developing the study protocol and during data collection. Most importantly, Dr. Sunday Adenini, Prof. Sharon Fonn, Dr. Oluwafemi Akinyele Popoola, Dr. Martha Makwero, and Lebogang Maseko for their comments during the CARTA Joint Advanced Seminar (JAS 3) and mostly Dr. Henry Zakumumpa for valuable comments during the CARTA JAS4 conference presentation.

Funding

This research was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant No:G-19-57145), Sida (Grant No:54100113), Uppsala Monitoring Centre, and the DELTAS Africa Initiative (Grant No: 107768/Z/15/Z). The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)’s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust (UK) and the UK government. The statements made and views expressed are solely the responsibility of the Fellow.

Availability of Data and Materials

The data sets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Competing Interests

The authors declare that they have no competing interests

Consent for Publication

Not Applicable.

Author’s Contribution

All authors participated in the design and review of the study. FC conceptualized the study and produced the first manuscript draft. JW, VB, and MK participated in the conceptualization, design, and review of the manuscript. All authors read and approved the final manuscript draft.

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