The growing demand for leadership skills among healthcare professionals is widely recognized (1, 2). Adequate leadership skills among healthcare professionals were found to be an important determinant of healthcare quality and patient safety (3–5) and are regarded as essential in shaping tomorrow’s healthcare (1, 2, 6). Improvement of leadership skills may also add to well-being of healthcare professionals themselves and help tackle the relatively high occurrence of burnout (7, 8). For this reason, it has been emphasised to include leadership development in medical education (1, 6).
However, leadership is difficult to define and so are the related competences that should be developed. The definition of leadership is influenced by time and context (9, 10) and depends on whether it is regarded as, for instance, a role, a behaviour, a process or a set of skills (9, 11). In contemporary medical education, leadership often refers to the social process that creates change and to the skills needed to be effectively engaged in this social process (1, 2, 6). In this light, leadership development requires a deep understanding and awareness of the organisational and social context of the medical system, and how this context influences individual and group functioning (1, 3, 11). People’s understanding of the social context is largely based on tacit knowledge (12). Tacit knowledge is the collective, implicit knowledge, that consists of habits, beliefs, values, informal social structures, and ‘how we do things here’, also called ’embedded knowledge’ (13, 14). Tacit knowledge is regarded as an essential source of knowledge for the healthcare professional, but is not easy to transfer (12). In contrast to explicit knowledge, which can be learned through lectures and books, acquiring tacit knowledge is experiential and requires social interaction (13).
A promising method to develop this awareness for the surrounding social system and to become able to tap into this embedded knowledge and make it explicit, is the systemic training approach. Previous practical experience and research in various organisational settings shows that the systemic training approach could be very useful in developing awareness of the surrounding social system (in short, systemic awareness) (15–18). This approach is already widely used in business settings for organisational development, team building, and consultancy and for leadership training in non-medical workplace settings (15–18). The basis of this approach is to zoom out from the individual level to the larger social system level and make the system visible and explicit. ‘Social system’ refers to any group of people (e.g. colleagues, team members). The systemic approach aims to aid people in developing skills to identify complex, often informal or implicit, patterns and inter-dependencies within an organisation and to deal with these patterns. The systemic approach can be characterised as a method of experiential learning for the individual and the group. It enables cognitive and affective learning and has been shown to support transformative learning (19). In transformative learning, students are offered an experience that stimulates a critical reflection of current beliefs that may lead to a change in perspective on the situation and change in behaviour (20).
In 2017, we piloted a systemic awareness training using the systemic training approach in the medical curriculum of the University of Groningen, the Netherlands, as part of the educational line on leadership development (21). We repeated the training in 2018 and 2019, after the pilot showed that the training could be practical implemented in this setting and time frame. The theoretical underpinning of the educational line lies in transformative and experiential learning, which fit well with the systemic training method.
The systemic training approach
The systemic training approach invites people to take another perspective than their own on organisations, teams or any group of people and thereby making them more aware of their social context (e.g. the perspective of an external observer or of someone else in the team). The method was originally developed for psychotherapy (focused on the family system) by Hellinger and was further developed and applied to other systems such as organisations (15, 18, 22). The basic idea behind this approach is that individuals are part of many different social systems at the same time, in line with the concept of habitus from Bourdieu (23). Organisations can then be seen as complex networks of, often informal, relations, dependencies, and patterns which are interwoven with each other in many ways. When you zoom out from the individual level to the system level, often a different or richer picture emerges.
Systemic constellation method
The systemic training approach makes use of the intuitive, tacit knowledge people have about the inter-dependencies, structures and patterns in teams and organisations and makes this implicit knowledge explicit. It aims to display the structures of a system and the inter-dependencies between different elements of this system. To this end, systemic constellations may be used. Systemic constellations are a visualization of a system, using a spatial arrangement of elements (using people or objects) relevant to the organisation and its context (Figure 1). Elements can be a function or role in the organisation (e.g. nurse), stakeholders (e.g. patients), and concepts or societal aspects (e.g. insurance). By externalising the elements of a system, systemic constellations render the inner image someone has of a system in a visible and tangible way.
Systemic constellation process
A constellation is performed with a group of people led by a trained facilitator. The facilitator interviews a focal person regarding a team or organisational issue. Together they identify elements that are relevant in this case and create a visualization of the system. The other people who are present actively participate as representatives of one of the elements or as observers. The facilitator examines the constellation together with the focal person by interviewing the focal person or the elements and invites the person to literally try different perspectives. Important is that the facilitator keeps an open, non-judgemental attitude at all times, and does not aim for solutions, to allow for other perspectives or ideas to develop. At a point of saturation, the constellation process is closed with a short reflection.
To our knowledge, leadership training using the systemic approach has currently not yet been included in undergraduate or graduate medical curricula. Because of the novelty of the approach for the medical learning setting, reaction of the students on the training needs to be explored before further implementation can take place. In this study, we describe how we applied the systemic training approach in the medical learning setting in a large group of undergraduate students. We evaluate the first reaction (liking and perceived usefulness) of the students, and, because of the important role of the facilitator in the constellation process, we compare two different types of trainers, i.e. experienced systemic trainers versus trainers newly trained in the systemic method, but experienced with working in the medical teaching setting.