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Chapter 3: Training for Leadership image of 2 health care workers examining a child's throat

group of men and women smiling holding notebooks and pens

A major goal of the MCH Training Program is leadership training. This focus is consistent with recommendations of the influential Institute of Medicine (IOM) report The Future of Public Health, which has helped to shape the nation's approach to public health over the last 13 years.

However, despite the IOM report and other documents that attempt to define leadership, the term remains ambiguous. MCHB sponsored two meetings of training directors in the late 1980s to discuss and help define leadership Conference participants struggled with the concept, ultimately concluding that Leadership is an ongoing, dynamic process, not a goal or a definable position one can achieve.” In particular, conference participants resisted the notion that leadership can be defined by an individual’s position within an hierarchical organization.

Conference participants then attempted to define how to measure leadership, and in particular how to assess whether or not MCH graduates actually exhibited leadership. Several indicators were posited as signs of leadership, most of which reflected academic success (e.g., having been published, receipt of funded grants, teaching, participation on grant review panels). However, an important consensus reached by conference participants was that No easy method exists to directly relate a person's contributions to her or his participation in the MCH Training Program. Such a conclusion appears extremely difficult to reach and would require complex experimental designs and extensive resources.

This evaluation did not attempt to assess whether or not particular projects are successful in creating leaders; rather it examined the ways in which the concept of training for leadership is operationalized by grantees. In particular, it explored how projects define leadership, how they train for it, and how they evaluate their success.

DIFFERENCES IN LEADERSHIP TRAINING AMONG PROJECTS

Projects differ in four key ways with respect to leadership training:
(1) the degree to which they explicitly stress training for leadership;
(2) the extent to they emphaswhich ize policy work and academic accomplishment as key to leadership versus more clinical ways of developing leadership;
(3) the methods they use in training for leadership; and
(4) the groups selected to receive leadership training.

The Emphasis on Leadership Training

The administrators of many graduate programs conceive their mission to be that of training self-promotion and pressing national leaders. They expect that their graduates will become university professors, conduct meaningful research, attain high-level positions, and contribute to their professions in myriad ways. The MCH stipend in universities with such a mission becomes primarily an inducement to recruit good students into what is, in reality, an existing leadership training program; with the MCH support, that program becomes more focused on women and children. MCH trainees may receive very little, if anything, that is special with respect to leadership training at such institutions, and there may be little or no explicit emphasis on leadership, even though a strong argument could be made that these trainees are, in fact, being groomed for leadership along with all the other students in the program. On the other hand, project administrators in some programs that attempt to train all students for leadership believe that the MCH program requires them to provide supplemental activities that go beyond what their students already receive. In these projects, a special seminar may be added, policy work more strongly emphasized, or field opportunities developed to allow trainees to practice leadership skills. MCH training project directors in academic departments that do not strive for universal leadership training may develop a special leadership program as a result of the training grant. For example, they may enhance the department’s focus on research for MCH trainees or engage trainees in policy work. A few projects, however, simply redefine leadership to correspond to their existing academic or clinical programs: A leader is someone who does excellent work, whether that is chairing a meeting or treating a patient. In such projects, leadership training consists of the same qualities that define high-caliber graduate training in general.

“Students are trained to be well-educated, to think critically, and build on previous work; they are being trained more to be effective than to be leaders.” —Faculty member, School of Public Health

Policy, Academic, and Clinical Leadership Project directors define leadership as encompassing everything from changing the national system of health delivery for children to providing first-rate clinical care to achieving academic success through teaching and research. Projects that emphasize high-quality clinical care as the most important aspect of leadership often provide little or no content on policy.Other projects stress advocacy and policy work as key components of leadership, and this is reflected in their curricula. Highly academic centers typically equate leadership with success in research endeavors.

“A leader is a capable practitioner who knows how to seek out the services that children need and an agent of change who can affect policy and implement system change.” —Faculty member,LEND

Faculty in one project point out that academic and community leadership require different skill sets which sometimes conflict. Faculty attempt to make the differences explicit in order to promote and help ensure success in both venues.One faculty member commented,“Academic leadership requires self-promotion and pressing your own agenda, while community leadership means letting the community define the agenda.”

"I feel that part of being a leader is conveying the excitement I feel about MCH nutrition."

—Current student, Nutrition

Essentially, all the projects strive to motivate trainees by imparting a vision that can sustain them for years to come. A goal of such motivation is to create agents of change who, throughout their lives, will strive to secure a better future for children and their families.

Methods of Leadership Training

Because each project defines the concept of leadership differently, and because the academic settings of the projects are so varied, it is not surprising that the educational programs related to leadership are diverse. For example, some projects provide a weekly or monthly leadership seminar that includes segments on such topics as grant writing, presentation skills, coalition building, and management. Others have no formal course work but may attempt to integrate leadership concepts throughout the curriculum: One project fosters excellence in teaching skills by having trainees orally evaluate faculty lectures immediately after the presentation. Projects that have defined leadership as encompassing research typically assign each trainee a research mentor and require trainees to participate in one or more research methods courses. Some projects are quite innovative: One has developed a formal mentoring program through which faculty work with trainees to develop goals for achieving academic tenure and require trainees to visit other universities to observe a variety of academic administrative systems and styles.

"The leadership concentration focuses on oral and written skills, including presenting at professional meetings, grant writing, and evaluation."

—Faculty member, Nursing

Many projects provide trainees with opportunities to practice leadership by making presentations to community groups or developing policy position papers, and others require trainees to complete a leadership portfolio that describes the variety of leadership activities they have experienced in the program. Internships and field experiences also provide leadership opportunities.

Groups Selected for Leadership Training

Recipients of training include high school students, master's-level students, doctoral candidates, residents and fellows in medicine, residents in pediatric dentistry, certificate students (including bachelor's or master's level individuals currently working in the field), and "mini-fellows" (physicians receiving special training, but not as intensive or as lengthy as that found in traditional fellowships). Moreover, most of the interdisciplinary projects (e.g., LEND, PPC, LEAH) train individuals who spend varying amounts of time in the program, including medical students and residents doing clinical rotations, other short-term trainees (less than 40 hours), intermedi-ate-term trainees (40-300 hours), and long-term trainees (more than 300 hours). In many programs, students from outside the department take MCH courses. Most project directors do not expect that all of these groups of trainees will become leaders; thus, training clearly has other goals besides leadership.

Projects that provide training for high school students hope to influence young people to select a health care-related career. Certificate programs are designed either to encourage practicing professionals to return to school for additional education and/or to provide important information useful in these individuals' current employment. The programs also provide a mechanism to foster ongoing working relationships with local public health agencies. Both high school and certificate programs are used to increase ethnic diversity. One project with a minifellowship program views the program as a way to infuse MCH-related issues and values into the work of midcareer physicians, to enhance the hospital's and university's cultural competency, and to foster institution-wide improvements to children's services through the work of the fellows.

Clinical training programs with different levels of trainees (e.g., short-, intermediate-, and long-term) obviously have a greater impact on those trainees who are in the program the longest, and it is typically these trainees who are expected to become leaders. Other, different advantages accrue from the shorter-term training, such as exposure to the interdisciplinary approach, education about policy issues related to women and children, and improved clinical skills for treating children. One project director, however, questions the value of investing in short-term training; this director commented that although it is possible to teach knowledge in a short time, instilling MCH values takes longer.

Overall, even though leadership is defined in multiple ways, it is clear from the site visits that the goal of preparing long-term trainees for leadership is one that the majority of grantees take quite seriously. Some struggle with defining leadership but most have developed a concept of leadership that is meaningful to them and that they have used in redefining their educational programs in ways that are sometimes innovative and highly creative and that most trainees appear to value.

ASPECTS OF TRAINING FOR LEADERSHIP

Recruitment

Leadership training begins with recruitment. Grantees emphasize that they have the ability to attract excellent trainees, both because of the stipends and the quality of their training programs. One could argue that the individuals who are recruited would likely become leaders in any event, and that a leadership training program is thus somewhat superfluous. It may be true that the trainees selected for many of the projects-often the top graduates in their special-ties-would likely become leaders in their general field, but without the MCH Training Program, the field that they choose might not be MCH-related. Almost all grantees contend that recruitment "captures" young people who are bright and who have already demonstrated great potential, and ensures that their talents are used to benefit children and the broader MCH community. A few projects emphasize their ability to recruit a diverse group of trainees and thus to promote cultural diversity and ethnic visibility in particular fields where these may be lacking.

"I discovered that the MCH program was the best program at the school. I like the structure and the curriculum. Initially, I was thinking of going into hospital administra-tion/management. But when I took a few courses in MCH and met the professors, I realized that I was interested in MCH."

-Former student, School of Public Health

image of smiling girl

Policy and Community Action

Great variation exists among training projects in the extent to which they foster and encourage policy and community work, and in the manner in which they do so. Some projects instruct trainees on how to be effective in working in collaboration with professional associations, legislative bodies, and local organizations. As a result, grantees have successfully improved health care services for children, both locally and nationally. For example, trainees have advocated for new community services, many of which have become institutionalized. Many projects consciously emphasize a dual mission: to teach young people while engaging them in activities that effect important system and/or policy changes to benefit women and children.

Without the grant, fellows would not have the time to engage in community advocacy. All their time would have to be devoted to clinical work.

Project director, Behavioral Pediatrics

We are helping people to recognize that it is possible to provide services in the community, that it doesn't have to be done in a hospital. We are trying to see how to link the medical center with the medical home; that is in practice here.

Faculty member, LEND

Skills-Based Training

Clinical projects teach trainees the skills needed to practice effectively. But MCH training projects also seek to teach other skills. Certain skills are required for effective advocacy (e.g., how to communicate effectively or how to work with the media). Other skills are for leadership (e.g., how to lead a group, manage a budget, or raise money). Some skills are competencies, such as those developed by the Association of Teachers of Maternal and Child Health and by individual projects, or the ones for nutrition training developed by the Association of Graduate Programs in Public Health Nutrition and which are now used nationally. And finally, some skills are designed to facilitate success in a career (e.g., how to work within an academic setting or make a PowerPoint presentation).

"The program takes a 'see-do-teach' mode of learning. You aren't just studying from a textbook. You are physically doing things. Then, when you can explain it to others, you really understand the material."

-Current student, Historically Black Colleges and Universities

Providing a Mentor

Essentially all projects claim that faculty act as mentors to trainees. However, the term mentor is as elastic as that of leadership. In some projects, a faculty mentor becomes so close to a trainee that he or she knows the trainee very well and is able to tailor the educational program to the special needs of the trainee. In other cases, the term mentor is used to define a role that is closer to that of guidance counselor-that is, the mentor is someone who ensures that a student takes appropriate courses. In most MCH projects, the role of a mentor lies somewhere in between. Due to the variability across projects in the way in which mentoring is defined and provided, it is difficult to generalize about its impact on the program as a whole. However, trainees almost always appreciate any mentoring that they receive, and they believe that mentoring relationships greatly enhance their learning. Moreover, the extent to which trainees are satisfied with their educational program appears to be related to the depth of the mentoring they receive.

"My mentor appreciates the experience that I had before I came [to the program]. We work as partners in planning my experience here, including what I can bring [to the program]."

-Current student, LEND

ASSESSING PROJECT SUCCESS IN TRAINING LEADERS

Several project directors stated that an evaluation of the MCH Training Program would require an assessment of the success of the various projects in actually creating leaders. That is, because leadership training is the primary goal of the program, leaders are the outcome of interest. However, given the varied definitions of leadership and the subjective nature of most of those definitions, measuring attainment of leadership by former trainees presents great difficulties.

A further challenge is that trainees do not emerge as leaders immediately upon completion of the training; rather, according to faculty, it takes most trainees about 10 years to actually accomplish those activities that define someone as a leader in a field. However, tracking former students for 10 years is extremely difficult for projects. Moreover, projects are constantly changing and evolving, and assessing leadership in a cohort of persons who completed a training program 10 years earlier may say nothing about a current program. And finally, there are undoubtedly many intervening variables over a 10-year period, and crediting (or blaming) the training projects for success (or failure) would seem a dubious proposition at best.

For these and other reasons, not all projects attempt to assess the accomplishments of their graduates. Some do, however, typically through administration of a survey of their graduates, either annually or every 5 years. Many of the projects report low response rates, some as low as 8 percent, citing the difficulty in maintaining current contact information for trainees who may have moved several times over the course of the years. Some projects have been slightly more successful in tracking their alumni.

"We use an annual survey. The response rate varies, but it is about 65 percent for first-year graduates." -Project director, School of Public Health

In their continuation applications, grantees are asked to provide short descriptions of several former trainees. These vignettes provide anecdotal evidence for the success of the projects, but they obviously are insufficient to document the overall success of a project in creating leaders.

The MCHB-sponsored PPCs developed and conducted a Pediatric Pulmonary Leadership Training Outcomes Survey during 1996-98. Surveys were sent to 418 graduates from all seven programs, including physicians, nurses, nutritionists, social workers, respiratory care practitioners, and physical therapists; 274 (66 percent) of those surveyed responded. Survey results indicated that most PPC graduates have served MCH populations (82 percent) and are members of an interdisciplinary health care team (82 percent). Almost all (92 percent) have provided training to professional and lay audiences about the special needs of the MCH population. Leadership activities included developing guidelines (68 percent), conducting strategic planning (46 percent), and participating in program evaluation (48 percent). Graduates have been officers or committee chairpersons in 7 national, 18 state, and 27 local professional associa-tions.These findings suggest that the PPCs have been quite successful in training national leaders in MCH.

Findings from Interviews with Current Trainees

As a part of this study, each training project that was site visited invited its current trainees to meet as a group with the evaluation team to discuss the academic program. The vast majority of those interviewed were extremely positive about their training experiences. A few provided candid critiques, with suggestions for improvement.

"The stipend provides external validation that you have the potential to be a leader."

-Current student, Social Work

An interesting finding was the impact of these projects on self-efficacy. For some students, being selected to participate in a leadership training program in and of itself was enough to initiate changes in self-perception. Moreover, for some, the honor of being selected brings with it an expectation of high-level accomplishment. Explicit statements by faculty that trainees are expected to be leaders, perhaps paired with specific course work focused on leadership (however it is defined), reinforce the message of the selection process and appear to lead to a stronger sense of self-confidence and to higher aspirations among a large number of trainees.

"As part of the LEAH program, we had several training opportunities specifically designed to encourage our leadership potential. More importantly than these individual instructions, I felt that the program and specifically the faculty worked hard to instill confidence in our abilities as professionals, which often translates into more productive leadership skills."

-Current student, LEAH

The impact of the projects on self-efficacy is apparent when comparing the responses of students who are new to a training project with those of students who have been in the training project for 2 or 3 years; the students with more time in the project are much more likely to say that they can envision themselves as future leaders than are the new students. Many continuing students also say that they did not have a perception of themselves as potential leaders in their field upon entry into the program. In other words, many bright trainees enter these traineeships with no personal goals of leadership but, as a result of their training, come to view themselves as having both the responsibility and the capability to lead. They appear to transform their ideas of themselves, to develop a belief that they can make a difference in the lives of women and children. The strong sense of self-efficacy that many trainees develop through the MCH Training Program may well be one of the major factors that permit some program graduates to become national leaders in their fields.Trainees clearly value the training they have received in the interdisciplinary approach to care provision. The opportunity to work with professionals from a wide variety of disciplines has helped trainees to understand the role of other professionals and to see a perspective other than their own.

"My career goals have changed due to the program. I want a community leadership role when I leave the program."

-Current student, Pediatric Pulmonary Center

One LEAH trainee described the impact of interdisciplinary training on his career in this way: "The advantage I have over my colleagues is a knowledge and comfort level with medicine, social work, and other disciplines that I will have to work with in my professional career. Specific treatments have been defined for me that many of my colleagues do not utilize, such as the necessity of involving physicians and dieticians in psychological treatment of eating disorder cases."

"I have had the opportunity to give a lecture, which I had not done before. I appreciated the confidence that others had in my skills."

-Current student, Occupational Therapy

MCH trainees also expand their visions of leadership. For example, many who enter a program with the goal of university-level teaching-and who may view that as a form of leadership-come to incorporate research and advocacy into their definitions of leadership and into their personal ambitions. Others state that their training has helped them to view leadership as incorporating aspects of their daily work, such as successfully leading a treatment team.

image of students sitting around a table studying

"Pediatric dentistry is relatively new to the LEND training program at the University of Washington. I've learned about the role of developmental pediatrics. I've added assessment skills since participating in the program."

-Current student, LEND

Not surprisingly, students highly value the financial support that they receive. Some would be unable to participate in a training program at all without such support. Others believe that the impact of the training would be diminished if they did not have funding, because of the time they would need to devote to paid work as opposed to learning. Some projects support students with assistantships rather than grants, and these assistantships enable trainees to work closely with professors on real-world projects, providing valuable experience.

"The stipend increased my ability to take risks and challenges and be involved in things that I otherwise couldn't because I don't have to work."

-Current student, School of Public Health

Many projects include field work as a part of the curriculum, and trainees find these for the most part to be an extremely valuable aspect of their training. Many trainees state that these experiences reinforce their views of themselves as future leaders.

"Seminars and field experiences complement one another nicely and expand our knowledge in different ways."

-Current student, Nutrition

Findings from Interviews with Former Trainees

Of the 110 former trainees who completed the interview, 65 percent (n=72) graduated in 1995 and 35 percent (n=38) in 1990. Information detailing additional characteristics of the respondents is provided in Appendix C.

"Faculty in the program believed in what they were doing; they weren't just providing a service. They involved students in every aspect. I never felt like a student I always felt like a member of the team."

-Former student, Pediatric Pulmonary Center

As shown in Figure 6, 78 percent (n=86) of the former trainees who were interviewed are still practicing in the MCH field. Most respondents reported significant changes in their careers as a result of the training, including new jobs or new responsibilities; only 6 percent (n=7) reported no significant change in their jobs following the training (see Figure 7). The great majority (80 percent) of former trainees attributed job changes to the training they obtained (see Figure 8).

Former trainees stated that the faculty in their respective programs were highly knowledgeable, and respondents considered this a major strength of the training projects. Faculty expertise in the field of public health in general, and maternal and child health specifically, was cited as particularly valuable. A large majority of respondents (83 percent; n=91) reported that they had had a faculty mentor (see Figure 9), and they perceived the mentoring to be quite important to their careers and education (see Figure 10). Trainees appreciated the easy access to faculty and the personal encouragement they received from faculty. Sixty-eight percent of former trainees who received mentoring stated that the mentoring continued after they left the training program (see Figure 11).

"Without the mentoring, my most significant achievement to date—an article published in a peer-reviewed journal would not have been possible."

-Former student, School of Public Health

Survey respondents were provided with a list of possible strengths and asked to indicate which of these strengths applied to their respective training projects. A majority of former trainees indicated that the curriculum was quite strong (60 percent; n=66). In addition, those in programs with a clinical training component rated that aspect as a strength (60 percent; n=46). Those who trained in an interdisciplinary model particularly appreciated their training, and many spoke eloquently about the benefits of learning how to treat a child holistically and how to incorporate a multiplicity of per-spectives—those of various health professionals as well as the family—into treatment, leading to a higher quality of services provided. These trainees not only gained skills, but experienced attitudinal changes as well, learning to understand the complex and multifaceted needs of children and the roles of the various other disciplines also providing care to children.

"In traditional classroom settings, you don't have the whole team communicating with you. You read about it but don't really experience it. It was one of the greatest things to have this experience. I don't think I could have gotten it any place else."

-Former student, Nutrition

In addition to identifying the strengths of their projects, former trainees also identified areas in which the projects could have met their needs better. Nearly one quarter of the respondents (n=26) said they would have benefited from more administrative training, such as managing staff, developing budgets, and dealing with workplace issues. Although many touted the research component as a program strength, others (18 percent; n=20) felt that research training could have been stronger. Similarly, although the majority of the former trainees interviewed were pleased with the mentoring they received, a small percent (15 percent; n=16) stated they would have benefited from additional one-on-one time with faculty. A few former trainees (16 percent; n=18) would have preferred more attention to policy; suggestions for strengthening this aspect of the project included having guest lecturers and developing joint courses with a school of public policy.

Former trainees were provided with a list of topics and asked if the Training Program had enhanced their knowledge in any of the topic areas. Some of the topics in which trainees most consistently reported increased knowledge are those that MCHB is especially interested in promoting: knowledge of MCH programs and policies (82 percent; n=90); interdisciplinary services (78 percent; n=90); com-munity-based programs (70 percent; n=77); advocacy (66 percent; n=73); population-based public health practice (65 percent; n=72); and family-cen-tered health practice (56 percent; n=62). Although cultural competence was not included as one of the potential checkbox responses, two former trainees stated that the program had enhanced their knowledge in the area of cultural competence.

Former trainees were also asked about new skills that they had learned as a result of the Training Program. The most frequently mentioned skill was critical thinking (78 percent; n=84), whereas 71 percent (n=78) stated that the program had improved their research skills, and 63 percent (n=69) stated that the program had enhanced their policy and advocacy skills. Without prompting from the interviewer, four trainees stated that the program had in general improved their leadership skills.

"This training program accurately reflected the complexity that exists in the field. And I had resources to draw on when I left the program. I especially appreciate this now that I am working with new therapists who haven’t had this background. I realize how much I learned in a very short period of time."
-Former student, Occupational Therapy

A strong majority of former trainees (64 percent; n=71) considered themselves leaders in their field (see Figure 12). Many of the respondents who did not consider themselves leaders cited current familial obligations as the reason. As shown in Figure 13, a higher percentage of trainees who graduated in 1990 (76 percent; n=29) viewed themselves as leaders than those who graduated in 1995 (58 percent; n=42). This is consistent with the common-sense notion that achieving leadership takes time. In fact, several trainees noted that they had not been in the field long enough and did not yet have the experience to be considered a leader, but several commented that they see themselves as being on a “leadership trajectory.”

Figure 11: Graph showing former trainees who received continued mentoring after training.

"The way the whole thing comes together creates a context where trainees and fellows really get to become leaders in MCH with a lot of mentorship and guidance— everything from developmental screening skills to researching policies and guidelines to working on an interdisciplinary team."

-Former student, LEND

Those trainees who saw themselves as leaders cited as evidence activities such as teaching, program development and administration, and policy work and advocacy through service on state advisory committees, on task forces, and with professional associations. These activities mirror the goals of the Training Program. Figure 14 provides examples of leadership activities mentioned by former trainees.

Consistent with the findings of interviews with current trainees, former trainees stated that the Training Program altered their thinking about leadership and what they, as individuals, could and should accomplish. One former LEND trainee noted,“I consider myself a leader primarily because my notion of what a leader is has changed, from that of ‘positional’ leadership to understanding that leadership is an experience that comes from within oneself. The Training Program fostered this kind of thinking.”

Figure 12, Graph showing former trainees who consider themselves leaders in the field. Figure 13: Graph showing leadership by Cohort

Figure 14: Examples of Leadership Activities of Former Trainees

Publications

• Authoring book chapters

Teaching/Curriculum Development

Developing a training program for dietitians in MCH
Teaching continuing education courses in neonatal resuscitation
Conducting training workshops for health education
Teaching continuing medical education courses nationwide
Designing and establishing a curriculum for pediatric residents
Establishing a fellowship in developmental and behavioral pediatrics
Supervising psychiatry trainees
Serving on the local medical school curriculum committee

Involvement with Professional Associations

Participating on an American Physical Therapy Association task force
Serving as a delegate to the Alabama Nurses Association
Serving 8 years on the state perinatal board
Holding a leadership position in the Massachusetts Nurses Association
Developing the specialty board exam for the American Dietetic Association

Policy/Advocacy

Serving on numerous community action groups
Developing an interdisciplinary child abuse and neglect team
Serving on an advisory group to the state Medicaid program to initiate funding for aug-mentative/alternative communication devices
Participating in a group reviewing proposed regulations on the Individuals with Disabilities Education Act
Working as part of a state team to design and implement training for special education professionals
Serving as chair of the Surgeon General’s Conference on Children and Oral Health
Developing a new program and related office in oral health at the University of Washington

In sum, these interviews suggest that the training projects are quite successful in creating leaders (as defined by the former trainees themselves and exemplified in the activities they are pursuing); that most individuals trained through the program remain in the field; and that former trainees believe their mentoring experiences were quite helpful in directing their careers.

SUMMARY

One Training Program project director commented somewhat plaintively that “it would help to have a definition of leadership.” An elusive concept, training for leadership nevertheless has real benefits: It provides helpful skills to many trainees, enhancing their ability to become effective more quickly; it provides some trainees with a positive sense of self-efficacy that may well contribute to success; and it includes fairly intensive guidance to many trainees through mentoring relationships that foster success. Most projects have intelligently operationalized the term leadership in ways that have tended to enhance trainees’ learning and to foster qualities that define leadership.

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