Leading from the bottom: The clinical leaders roles in an HIV primary care facility in Eldoret, Kenya

Felishana Cherop; Juddy Wachira; Vincent Bagire; Michael Korir

doi:10.1371/journal.pone.0302066

. 2024 May 31;19(5):e0302066. doi: 10.1371/journal.pone.0302066

Leading from the bottom: The clinical leaders roles in an HIV primary care facility in Eldoret, Kenya

Felishana Cherop ^1,^*,^#, Juddy Wachira ^2,^#, Vincent Bagire ^3,^#, Michael Korir ^1,^#

Editor: Edward Nicol⁴

PMCID: PMC11142606 PMID: 38820443

Abstract

Background

Clinical leaders in health systems play critical roles in making decisions that impact patient care and health system performance. Current literature has focused on the importance of clinical leaders’ roles in healthcare settings and has not addressed the leadership aspect that clinical leaders engage in day-to-day decision-making in HIV facilities while providing HIV patient care. Therefore, identifying the leadership roles that wclinical leaders perform at HIV primary facilities is of critical importance.

Purpose

The study explored the views of healthcare providers working in AMPATH-MTRH HIV facility on what they perceived as the roles of clinical leaders at the HIV primary care facility.

Methods

We conducted a qualitative exploratory study between December 2019 to May 2020, involving in-depth interviews with (n = 22) healthcare providers working in AMPATH-MTRH HIV facility, who were purposively and conveniently sampled to participate in in-depth interviews to explore perceptions regarding the leadership roles of clinical leaders. The collected data were analyzed thematically and Nvivo vs.12 software was used for data management.

Results

The following themes were identified from the analysis regarding perceived clinical leaders’ roles in an HIV primary care facility: 1) Strategic roles: providing direction and guidance, ensuring goals and objectives of the department are achieved within the set timelines, planning, and budgeting for adequate resources to support patient HIV care 2) Interconnecting health systems levels and supervisory oversight roles: a link between management, staff, and patients, solving problems, organizing and attending departmental meetings, facilitate staff training, accountable, collaborating with other departments and leaders, defines and assigns responsibilities, ensure quality patient service, coordination, and management of daily activities 3) Research roles: data collation, analysis, generation, review and reporting to the management.

Conclusion

Clinical leaders in the HIV care system perform leadership roles that are characterized by strategic, middle-level, supervisorial and research which reflects the model of the leadership and management style of the HIV care system. The understanding of these roles contributes valuable insights to HIV leaders and managers to recognize the important contribution of clinical leaders and consider reviewing Standard Operating Procedures to include these leadership roles and strengthen their capacity to maximize clinicians’ contribution to improve HIV care and enhance responsive health systems.

Background

Clinical leadership is recognized as an important element in improving healthcare services and strengthening health systems, however, it has received little attention in low and medium-income countries (LMICs) [1]. Clinical leadership has been defined as one that takes place in any clinical setting whose aim is to enhance care and positive patient outcomes through the provision of quality patient service when leading staff in a dynamic environment that has multifaceted client composition [2]. It has been considered the strongest precondition, and clear leadership that promotes integrative and proactive care through the facilitation of interdisciplinary collaboration [3].

Today, clinical leaders are considered the champions of leading change and improving service in their organizations [4,5]. Their greater involvement in leadership hierarchies such as strategic leadership positions improves the quality of strategic decisions and successful implementation [6,7]. They act as resource persons, preceptors, mentors/coaches and role models in demonstrating critical and reflective thinking as well as establishing and monitoring standards of practice to improve patient care [8]. In Ireland, they were perceived to facilitate evidence-based practice in care delivery, mentor students and co-workers, and, utilize clarity in decision-making [8,9]. However, evidence of mentorship of health personnel to improve the quality of health care in low and middle-income countries remains elusive [10]. From a nursing perspective, clinical leaders influenced care delivery systems through engagement in policy development at all levels of government [1,11], but these perspectives are less documented in the HIV context. Similarly, there is confusion in clinical leadership roles in distinguishing between managerial, resource management, and clinical roles [12].

Additional roles of clinical leaders include setting direction, providing vision and promoting professionalism, promoting interprofessional collaborations, and having the resources to perform tasks effectively [13]. They establish a collaborative atmosphere, structuring work to ensure patients get the best nursing care, customize their presence in the practical work with patients according to standard operating guidelines, and monitor co-workers’ professional practice [14]. However, these roles have not been categorized according to different hierarchies of leadership in most health facilities and unclear whether clinical leaders in similar or different settings such as HIV performed the same leadership roles. In Kenya for instance, the use of distributed leadership to examine clinical leadership in hospitals was useful in analyzing middle-level leadership [1], however, it is unknown if this type of leadership is effective among clinical leaders in HIV primary care. In Sub-Saharan Africa, supportive supervision increased job satisfaction, and health worker motivation and improved and maintained crucial primary healthcare quality standards [15–17]. However, there is mixed evidence on whether it would translate to increased clinical competency and effect on clinical outcomes [16]. In South Sudan, supportive leadership remained a daunting task in the health sector due to a combination of external and health system factors for instance, many supervisors had no formal training on supportive supervision and action plans developed during supervision were inadequately followed up due to insufficient funding [18].

Whereas clinical leadership is important at the operational level in making critical clinical decisions daily [19], there is a paucity of clinical leader roles in HIV primary care to steer quality HIV patient care and improve health system performance. Our study explored the perspectives of healthcare providers on the leadership roles of clinical leaders in an HIV primary care facility in Eldoret, Kenya.

Methods

Study design

A qualitative exploratory study was conducted between December 2019 to May 2020 involving in-depth interviews to explore the views of healthcare providers to obtain an in-depth understanding of the perceived leadership roles of clinical leaders that may influence patient outcomes and health system improvements.

Study setting

The study was conducted in the Academic Model Providing Access to Healthcare- Moi Teaching and Referral Hospital (AMPATH-MTRH). AMPATH is a consortium of different institutions that provide comprehensive HIV care to the population in western Kenya. It supports Ministry of Health (MoH) facilities in more than 15 counties in Western Kenya and is organized into cluster clinics that serve adult patients, children, and, adolescents between 8 am to 5 pm from Monday to Friday. The facility has a systematic structure of clinical management that guides patient care (S1 Fig). Each of the clinics in MTRH-AMPATH is headed by a clinical leader who performs both leadership and clinical functions [20,21]. The providers received instructions from the clinical leader and they interacted daily in providing patient care. Therefore, they would be better positioned to provide perspectives on what they think are the leadership roles performed by clinical leaders.

Participant sampling and recruitment

The participants in our study involved frontline healthcare providers (clinicians, nurses, counselors, and a pharmacist). The total population of healthcare providers at MTRH-AMPATH was 50 at the time of the study. We first presented the research permits for conducting the study in AMPATH to the clinical leaders in charge of various clinics to explain the purpose of the study and obtain approval to interview the HCPs. We purposively and conveniently approached 25 HCPs individually and 22 consented to participate in in-depth interviews. Literature suggests that a sample size of 10 is adequate if a homogenous group of people is interviewed, nevertheless, a sample size of 15–30 is considered appropriate for a qualitative study [22].

Data collection procedures

Data collection was done using semi-structured interviews which were conducted in a private room that was identified for the study to protect confidentiality and give ample time for the participant to process information. The interviews lasted between 40–60 minutes upon consent. After interviewing 22 participants, the authors felt that data saturation had been achieved [23,24] A semi-structured interview guide was used to guide the in-depth interviews with a set of questions that sought participants’ insights, particularly to describe the leadership roles of clinical leaders in an HIV primary care facility and included demographic information such as expertise, sex, and age. The views of the study sample reflected the perceptions of the providers in the HIV facility. Also, the audio-recorded data were stored in a safe digital format that was later used for data transcription, interpretation, and analysis.

Data management and analysis

Thematic analysis was used to analyze qualitative data [23,25]. The first author began by transcribing the audio recordings verbatim then the transcripts were read and re-read by all the authors to familiarize themselves with the content of the data and understand its richness and diversity. The transcribed data was imported to NVivo12 for management and coding. Two authors with qualitative backgrounds coded the data, compared, discussed, and examined the codes and categories to identify patterns and themes for interpretation. All the authors then read and discussed the themes and agreed on the final themes to be included in the report. A final codebook (S1 Table) indicating emerging themes was then developed that informed the final write-up of the results and supported by relevant quotes from the data. To ensure validity and reliability, and increase the quality of the data, the codes were counterchecked and appraised by all authors to confirm there was no repeated and conflicting content [26,27]. The data collection procedures and analysis were made clear to help maintain consistency and rigor throughout the study. Team debrief sessions were held during the data collection to enhance the quality of the data. The analysis informed descriptive categories/domains that represent thematic healthcare providers’ perceptions of the clinical leadership roles of clinical leaders in an HIV primary care facility.

Ethical considerations

This study was granted ethical approval by 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) before data collection. Participation in the study was voluntary and the healthcare providers signed written informed consent.

Results

Participant demographic characteristics

Twenty-two (88%) out of twenty-five healthcare providers (HCPs) participated in the in-depth interviews upon data saturation. Most of the participants were clinical officers 14(63.6%), followed by nurses 5(22.8%), a few were counselors 2(9.1%) and a pharmacist (4.5%). There were more males 12(54.5%) than females 10(45.4%), and all 22 (88%) earned a monthly income of (>500$) and 22 (88%) had over 1 year of experience in providing HIV care and had an average age of 41–50 years.

Domains of clinical leader roles

Participants described three themes that characterize clinical leadership roles in an HIV primary care facility: strategic leadership roles, interconnecting health systems levels, and supervisory oversight roles and research roles.

Strategic leadership roles

Clinical leaders in the HIV care system act as team leaders in providing direction and guidance to staff and patients by informing and guiding them in understanding the program, its objectives, strategies, and visions. This is done by informing staff and patients of their expectations and setting targets to be achieved. This would ensure that all the stakeholders are involved in the process to ensure the goals and objectives of providing quality services to patients are prioritized and achieved.

“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. So, you give the way to the people who are under you so that they know their objectives and how to achieve their objectives” (Participant #1, Clinical Officer)

“I believe a leader is someone who takes responsibility for all actions and sets targets that are given by your program and that person shows it by example” (Participant #2, Pharmacist)

Clinical leaders ensure that the objectives of the department are achieved by making sure that all the departments are meeting their targets or the clients are served without complaint so that the clients are satisfied with our services.

“You know, in every organization, you must have what we call objectives or goals. So, as a leader, you must work so that you achieve those goals and objectives. When you want to achieve those goals, you have to make sure that everybody is involved. Like a leader, if you have a task, you identify an individual who can do that task and it can work” (Participant #3, Clinical Officer)

Providers described that clinical leaders carry out planning and budgeting for prioritization and allocation of limited resources particularly in a large care system that has high patient volumes, to ensure a continuous provision of strategic services to patients and strengthening of the health system’s responsiveness. This includes enough supplies of commodities to avoid stockouts when needed, adequate staffing, organizing work shifts to ensure present staff at the facility even during holidays, availability of medical supplies, and finance.

“Another key thing that my leader is doing is the planning and budgeting for the allocation of resources, the allocation of staff such that who is allocated to work where and at what time. When there are emergencies, he assigns who is going to intervene, what are the challenges, and who is going to handle them” (Participant #4Nurse)

Interconnecting health systems and supervisory oversight roles

Participants reported that clinical leaders play an important role in interconnecting different levels of health systems management by facilitating communications, collaboration, and coordination among various stakeholders. Through effective supervisory oversight, the leaders ensure the delivery of high-quality HIV care while fostering professional growth and development within their teams.

(a)Interconnecting health system levels

Participants recognized that a clinical leader acts as a link between different levels of management, patients, and frontline staff. They would coordinate and facilitate communication channels, relay feedback from staff and patients to management, and ensure that the facility goals align with frontline needs such as linking the patients with other care providers including consultants and specialists to ensure that patients receive specialized care

“We have our in charge and most of the time she is the one who connects us with the management level, if we have issues, she is the one to take the issues upwards, and if there is anything that has to be communicated again from the chief of party or the clinical manager, she is the one to relay the information” (Participant #5, Clinical Officer)

“I would say majorly it is coordination; he coordinates the activities and he is the link between the higher management and the client. He coordinates all the activities and the services within the department” (Participant #4, Nurse)

The healthcare providers identified problem-solving as a key role of clinical leaders in addressing technical issues related to patient care, staff conflicts, and challenges in the working environment, such as complaints from the patients, difficult cases that the junior staff would be unable to solve by providing counseling services to the patients, and having a session with the staff to discuss the strategies for addressing the challenges because it helps the clinic run effectively.

“And some patients have complaints; the delays, I was not treated well, somebody is handled badly. A leader should come down to earth to settle down the issues. Sometimes you apologize, one may have said something which is not good and hurts. A leader should come down to be able to apologize on behalf of that staff and clear the matter” (Participant #5, Nurse)

Participants described collaboration within and among the departments in a healthcare system as an important aspect of clinical leadership. Leaders in all departments would not work in isolation but would work in collaboration to borrow information from each other in terms of best practices and services. The leaders would normally interact during inter-departmental meetings and training. The care departments included the nursing, laboratory, clinical, records, nutrition, social work, guidance and counseling, and pharmacy while the support departments could include the finance, accounts, human resource, and legal office department. A client would be referred and receive services from various departments.

“Leadership is not limited to a specific department because in healthcare, it is a system and it is made up of several arms. Because it is made up of several arms, working together is inevitable, they have to reach out to one another “(Participant #8, Nurse)

“The healthcare system is intertwined; the departments being intertwined. And you realize that one department cannot function on its own, you really have to do some coordination and consultations with other departments” (Participant #9, Clinical Officer)

(b) Supervisory Oversight

Providers described the clinical leader’s role as defining and assigning roles and responsibilities to staff in their respective departments, which is a typical function of management where leaders irrespective of their levels must allocate tasks and resources to achieve them. They ensure that each team member understands their tasks and responsibilities and this would foster clarity and accountability.

“Number one is to do supervisory roles like daily supervision and to make sure people are at work and doing the right things and delivering. You know, implementing what they are supposed to be doing” (Participant #9, Clinical Officer)

Other participants described that the clinical leader would be accountable by making monitoring and follow-ups continuously to ensure the staff perform their duties diligently in a conducive work environment that promotes patient-provider relationships, provides timely reports, and represents the unit in all forums.

“So, being a leader, the major role which our leader plays to the care workers is to check on how we run our activities, whether we perform as healthcare providers, especially giving services to the patient. That is the major role that our group leader does” (Participant #7, Clinical Officer)

“Another thing is a representation of that unit because, in as much as you are working as a team at that place, this leader at some point will have to be accountable for the area in which they are working so that in case of any issues, you don’t always have to fault others. So, this particular leader is the one who will carry the burden of being accountable and being responsible for that particular area” (Participant #9, Clinical Officer)

To ensure quality services to the patient, the clinical leader would create a conducive care environment that promotes quality service delivery and patient-provider relationships. The leader oversees day-to-day operations, intervenes in emergencies, manages data and reporting, and ensures that services are delivered on time and according to established standards. For instance, the laboratory should be equipped and functioning, obtaining feedback from clients for quality improvement of HIV services.

“A leader in a healthcare system ensures that our clients are given quality service. For example, a leader ensures that his team or her team are on duty and are timely with teamwork, so in the long run, we give quality service to our clients” (Participant #10, Clinical Officer)

Participants discussed that a clinical leader would organize and attend regular departmental meetings to discuss the program and departmental activities to provide progress reports. The meetings could range from daily, weekly to monthly and the clinical leader is usually the chair.

“We also have small brief meetings in the course day. We look at anybody who had a problem and what are the successes of the day. We look at all that. So, I think having regular meetings should be one of the things that a leader should inculcate in their team” (Participant #2, Pharmacist)

“He also organizes routine meetings; routine meetings at the clinic level with the staff to evaluate the data, to also check for matters arising, any issues” (Participant #6 #Clinical Officer)

Clinical leaders would serve as mentors to junior staff and guide them in implementing new policies, practice guidelines, and regulations such as the Standard Operating Procedures (SOPs).

“And then secondly, there are government policies like when they are rolling them down, she is the lead person like she mentors us” (Participant #11, Clinical Officer)

The clinical leaders would facilitate staff training and development initiatives through short courses, seminars, and workshops that would enhance skills development and ensure team members remain updated on best practices and emerging trends in healthcare delivery during the monthly Continuous Medical Education (CME).

“It could be we need to have the training and he is the one who arranges. Number three is representing us in activities outside here maybe acquiring some skills outside there and then coming back and training us. I think those are the most important ones that I see in our setup. You understand whereby care providers, all of them, cannot go for training. For example, it is on gender-based violence, he can represent us then at the end of the day, come and brief us on what has been trained” (Participant #7, Clinical Officer)

Research roles

Clinical leaders were described as researchers who would be responsible for the collation of data, analysis of data, generation, review, and submission of progress reports to the high levels of management. These may include, measurements and indicators of services provided to the clients and data review.

“Another role he does is to collect data; to collect specific data about the healthcare system and targets. He also gets the data analyzed and prepares reports. You realize that with HIV, there is so much data; those in care, those who have defaulted, those to follow-up, and all that” (Participant #6, Clinical Officer)

Discussion

In our study, we explored the clinical leadership roles in an HIV primary care facility. To our knowledge, we believe this is the first study to describe these roles in the HIV context in Kenya. The roles of clinical leaders were categorized into three domains: strategic role, interconnecting health systems levels and supervisory oversight, and research role.

A strategic leadership role was identified as key for clinical leaders in an HIV primary facility. Clinical leaders act as team leaders in providing guidance and direction on what is expected of the patients and providers. This suggested that they should understand the structure of the HIV system in terms of its goals, objectives, and strategies to translate them into actionable items and support other stakeholders in realizing them. Consistent with previous literature, a clinical leader was seen as being team-focused while maintaining relationships in and outside the team for effective decision-making and a key player in communication for their local area of practice [28]. Other studies have acknowledged the importance of visionary leadership [29–31], teamwork [32,33], treating team members with respect, and facilitating a conducive work environment [34,35] may enhance teamwork. In addition, the clinical leader in primary care should work strategically and with a vision for better practice across teams [2].

Our study emphasizes the importance of planning and budgeting by clinical leaders by prioritizing available resources highlighting the importance of strategic management knowledge to do forecasting activities of a department. Consistent with our findings, leaders should be strategic planners and, participate in policymaking [36]. However, the findings differ in the type of planning from that of previous literature which required clinical leaders to help patients in developing plans for achieving their treatment goals and setting directions [30,31]. Although clinicians would need to have a broad overview of a budget process, they were not expected to be accountants and should seek help for some financial tasks to manage a budget in a way that will reduce inefficiencies and provide the greatest benefit for patients [37].

Our study also indicates that clinical leaders interconnect different levels of management for example to represent patients’ and providers’ issues to the facility management and link patients with other specialists in the facility. They would do this to address problems that may exist within the health system using clear channels of communication. This aligns with previous literature to solve problems such as patient complaints and other technical challenges [30,35,38–42]. Recent literature echoes similar findings that the role of clinical leaders in workforce development is to be responsive to direct care staff when they communicate their concerns. The leader encourages them to reach out proactively whenever they have concerns to be addressed [43].

The study also highlighted that clinical leaders should collaborate with other leaders in different departments to bring collective efforts and expertise in enhancing HIV patient care and health system performance. This emphasizes the need for dialogue and instilling confidence among co-workers. A similar perspective in the literature acknowledges that clinical leaders at the point of service would rely on their communication, collaboration, and coordination skills to motivate others to act because good communication was seen as the foundation for the effective coordination of activities [44]. Similarly, a staff nurse clinical leader who is at the bedside would establish a good atmosphere for collaboration through mutual respect, courage to be honest, and encouraging reflection [14].

In our study, clinical leaders performed supervisory duties by defining and assigning roles and responsibilities to staff in their respective departments which is contrary to a previous finding where departmental heads at the mid-level of management in healthcare institutions in Kenya were expected to tell clinical staff what to do, demonstrating a top-down approach to ensure formal responsibilities were met and accountability done within the departments [45].

The study provides an additional role for a clinical leader to be accountable by managing available resources to ensure quality patient care. Whereas this may be a strategic function of management, there is insufficient literature on the direct accountability of clinical leaders at microsystems given that their roles are clinically oriented. In previous literature, clinical leaders were not only perceived to improve and promote clinical excellence but were also expected to be professionally accountable, enhance multidisciplinary teamwork, and patient safety, and achieve greater value for money [46].

We found a general pattern that clinical leaders ensure quality services to the patient by creating a conducive working environment for the clients and the care providers. The leader would ensure that the patients received all the required services timely, professionally, ethically, and in a satisfactory manner. A related observation from previous studies in nursing leadership established that nurse leaders would consciously structure work to ensure patients’ best possible nursing care [14], while the role of clinical leaders is to enhance quality and transform clinical services for excellence [2,47].

Our study points out that clinical leaders organize and attend regular meetings to discuss departmental performance that may affect patient care and identify areas that would require skills development of staff through training. In contrast, literature found limited opportunities for clinical and nurse leaders that would limit them in executing tasks in the same environment and discussing joint departmental issues even where the standard operating procedures demanded [1].

Clinical leaders were perceived to coordinate activities in the HIV facility to create harmony between and within departments and share knowledge and other resources. This was highlighted by previous literature as important for sharing ideas and best practices for providing quality HIV care [14,36]. However, poor coordination of work across cadres in primary healthcare delivery was highlighted by public health nurses [9], and the inability of some trained nurses to handle the supervision of other people [34].

Participants highlighted that clinical leaders would act as mentors to other healthcare providers and fellow leaders to pursue career development for example through continuous medical education that would enhance health system improvement through implementing new policies and guidelines. The findings concur with previous studies that physician leaders value the role of mentorship because they believe that they are natural mentors, and they would have reached their current position because of someone who mentored them [48]. Also, clinical leaders are role models in leading by example, walking the walk, and not just talking particularly in dealing with day-to-day clinical presentations [49]. On the contrary, a study found that some nurse participants perceived their clinical leader as unwilling to share expertise, knowledge, and skills [28].

Clinical leaders were perceived to perform research roles through the collection of data, analysis, and providing progress reports from their departments. Although the clinical leaders may not be equipped with research scientific knowledge, additional training and involvement in the research process and output relating to HIV care would be necessary. This finding aligns with previous literature that clinical experts/leaders would link theory and practice and would encourage research and dissemination of knowledge [28]. They would initiate, conduct, and disseminate findings of locally based research in specialty and would be involved in larger research studies in Australia [50]. A study acknowledged the attributes of clinical leadership within a framework of quality that a clinical leader should have a vibrant, research-based, evidence-based practice culture [2]. However, a systematic literature review found that the focus on clinical leadership as a research target concerning integrated care appears a new phenomenon [51], demanding further investigation.

Strength and limitation

To our knowledge, there has been little information published on the role of clinical leaders in HIV primary care facilities. Hence, the findings of this study would provide rich views and experiences of providers that shed more light on the varied roles of clinical leaders at the primary care facility level. The findings also provide important aspects for decision-making on quality improvement of service delivery in the HIV primary care setting. While we believe this is a novel study in the HIV context, some limitations are important to acknowledge. First, clinical leaders and patients were not interviewed who could have provided different perspectives on clinical leader roles and this demands a study to obtain their views to gain an understanding of issues surrounding being a clinical leader in an HIV care system. Secondly, the providers who were interviewed included clinical officers, nurses, counselors and a pharmacist, hence little representation of the range of experiences of other providers who were not captured in the study. Third, providers expressed their views and experiences concerning the perceived clinical leader roles in the present HIV facility, hence may have varied degrees of transferability in other settings with varied aspects such as geographical location and service delivery. Fourth, this study only focused on clinical leaders at the lower level of the organization, and may be interesting to obtain views from other leaders in the hierarchy of the organization (meso and strategic levels). Fifth, there is a danger of social desirability bias since most of the statements made by the healthcare providers tended to be positive and this may not reflect a true representation of their views and behaviour because they were evaluating their clinical leader in charge. Also, the set of guiding questions did not focus on relationship dynamics that relate to trust and hierarchies within the care system.

Conclusion

This study explored the roles of clinical leaders in an HIV primary care facility. The leadership roles that were associated with clinical leaders included; strategic, middle-level, supervisory functions, and engagement in research. The understanding of these leadership roles performed by clinical leaders contributes valuable insights to health care leadership discourse, acknowledging the important contribution of clinical leaders to the HIV care systems and providing a basis for enhancing clinical leadership within clinical settings such as HIV. It would be necessary to strengthen the capacities of clinical leaders to maximize their contribution to improve HIV care and enhance responsive health systems.

Supporting information

S1 Fig. AMPATH-MTRH clinical management flow chart.

(DOCX)

pone.0302066.s001.docx^{(42.5KB, docx)}

S1 Table. Codebook with minimal data.

(DOCX)

pone.0302066.s002.docx^{(20.7KB, docx)}

Acknowledgments

We sincerely appreciate the MTRH-AMPATH for allowing this study to be conducted. We also thank the healthcare providers for participating in this study.

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

"This research (or “[FC]”) 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 Center, Norwegian Agency for Development Cooperation (Norad), and by the Wellcome Trust [reference no. 107768/Z/15/Z] and the UK Foreign, Commonwealth & Development Office, with support from the Developing Excellence in Leadership, Training, and Science in Africa (DELTAS Africa) programme. The statements made and views expressed are solely the responsibility of the Fellow. For the purpose of open access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission." The funders had no role in study design, data collection, and analysis, decision to publish or preparation of the manuscript.

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PLoS One. doi: 10.1371/journal.pone.0302066.r001

Decision Letter 0

Edward Nicol

31 May 2023

PONE-D-23-05699Leading from the bottom: The strategic leadership roles of clinical leaders in an HIV primary care facility in Eldoret, KenyaPLOS ONE

Dear Dr. Cherop,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Particularly paying attention to the methodological issues.

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We look forward to receiving your revised manuscript.

Kind regards,

Edward Nicol, PhD

Academic Editor

PLOS ONE

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review this manuscript. I find the manuscript of relevance to the field. However, it requires some major revisions, so as to meet the ideal standard for publication. Details of the required revision are attached.

Reviewer #2: “Strategic” is overused and used in different in contexts. As this is a key term, please be more precise in what is encapsulated in “strategic.” This definition comes out slightly in the results but feels a but tautological to state that theme for perceived clinical leader’s strategic roles was being strategic (lines 19-20)

I am surprised the issue of hierarchy and trust (as well as other social dynamics) did not come more prominently in the findings and themes, and perhaps this reflects also potential social desirability bias or some considerations on reflexivity on what health workers are willing to disclose with regard to their “clinical leaders” Moreover, the findings/themes seem very basic and what you would expect to find on a terms of reference. There should be a re-analysis of themes to identify more profound findings that can add to the literature.

It is also not as clear as how the themes of strategic, managerial and supervisory are distinct themes. The themes should be better fleshed out to describe what strategic means and its facets.

It would also be interesting to overlay the background with literature on “supportive supervision” and “in-service training/mentorship.” This comes out in the discussion, but it’s not clear in the background how this is different and what value strategic leadership means over existing forms support.

In line 76-77, there is not really context for who respondents were acknowledging that it is a grey area.

The strengths and limitations should also include the potential biases, including social desirability bias, especially since most of the quotes and what was stated tended to be positive. Acknowledging that health workers are providing this feedback about their supervisors in the context of their work could put some limitations on the extent of information that would be shared.

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Reviewer #1: No

Reviewer #2: No

**********

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Attachment

Submitted filename: Reviewer comments.docx

pone.0302066.s003.docx^{(14.3KB, docx)}

PLoS One. 2024 May 31;19(5):e0302066. doi: 10.1371/journal.pone.0302066.r002

Author response to Decision Letter 0

9 Jul 2023

I have uploaded a rebuttal letter providing response to reviewers' comments

Attachment

Submitted filename: Response to Reviewers.docx

pone.0302066.s004.docx^{(21.6KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0302066.r003

Decision Letter 1

Edward Nicol

30 Aug 2023

PONE-D-23-05699R1Leading from the Bottom: The Clinical Leaders Roles in an HIV Primary Care Facility in Eldoret, KenyaPLOS ONE

Dear Dr. Cherop,

The authors have not fully addressed comments raised earlier by both reviewers. These are needed to improve the quality of the manuscript. Kindly see below and attached documents for detailed comments.

Please submit your revised manuscript by Oct 14 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Edward Nicol, PhD

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

6. Review Comments to the Author

Reviewer #1: Thank you for the opportunity to review this submission once again.

Unfortunately, the authors have not fully addressed the comments raised earlier; and need to do so, to improve the quality of the manuscript.

Detailed reviewer comments are attached.

Reviewer #2: The abstract background gives a sense of over-using the term "strategic" and if this can be revised to find alternative appropriate wording.

The results tends to provide a lot of quotes back to back and would be good to see if there could be further analysis and quotes used more effectively. It otherwise just feels like excerpts from the transcripts within contextualizing paragraphs in between. This may perhaps mean having additional themes to improve readability as some themes run across several pages and are hard to process all the information. For example, lines 170-249 span several quotes in between them. I also note that within the theme of "managerial duties" it states (line 220) "A strong theme that emerged among the participants was the collaboration within and among the departments in a health care system." Should this therefore be a separate theme or rephrased.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

Attachment

Submitted filename: Reviewer comments PLOS (R1).docx

pone.0302066.s005.docx^{(12.8KB, docx)}

PLoS One. 2024 May 31;19(5):e0302066. doi: 10.1371/journal.pone.0302066.r004

Author response to Decision Letter 1

15 Jan 2024

Dear Reviewer,

Thank you for the valuable comments you have provided in our submitted manuscript. We have responded to the comments provided for by Reviewer (R1), which were sent back to me. We have attached a rebuttal letter outlining the concerns and the response and pasted below this response. Thank you

Rebuttal Letter Addressing Reviewer’s Comments

Reviewer #1

Second Review January 2024

Reviewer’s comments (R1)

1. Comment 2, made during the first review has not been addressed. “The results identified4 themes” is not grammatically right. The phrase therefore needs to be revised.

Response: We have addressed this comment in the abstract and results sections.

In the abstract: “The following themes were identified from the analysis regarding perceived clinical leaders’ roles in an HIV primary care facility: 1) Research roles….

In the results section: “Participants described four themes that characterize clinical leadership roles in an HIV primary care facility: strategic leadership roles, middle-management leadership roles, supervisory leadership roles and research roles”

2. Another comment asked for the purpose of the study/objectives to be included. This hasn’t been addressed. Instead, the authors have added literature, making the background section longer.

Response:

At the end of the background, we have included “Our study explored the perspectives of healthcare providers on the leadership roles of clinical leaders in an HIV primary care facility in Eldoret, Kenya.

We have also included the purpose in the background of the study and summarized text to reflect the gap and the scope of the study.

3. The authors should give a justification for the study design used.

Response: A qualitative exploratory study was conducted between December 2019 to May 2020 involving in-depth interviews to explore the views of healthcare providers to obtain an in-depth understanding of the perceived leadership roles of clinical leaders that may influence patient outcomes and health system improvements.

4. It would be nice to have a detailed description of the study participants and how they were sampled, in the relevant section. This is for the readers, not the reviewer.

Response: We have separated the sections in the methods to highlight: study design, study setting, participant sampling and recruitment, data collection procedures, data management and analysis to provide clarity and coherence in the description

In the ‘participant sampling and recruitment section’ we described as follows;

“The participants in our study involved frontline healthcare providers (clinicians, nurses, counselors, and a pharmacist). The total population of healthcare providers at MTRH-AMPATH was 50 at the time of the study. We first presented the research permits for conducting the study in AMPATH to the clinical leaders in charge of various clinics to explain the purpose of the study and obtain approval to interview the HCPs. We purposively and conveniently approached 25 HCPs individually and 22 consented to participate in in-depth interviews. Literature suggests that a sample size of 10 is adequate if a homogenous group of people is interviewed, nevertheless, a sample size of 15-30 is considered appropriate for a qualitative study (22)”.

5. The data analysis section is unconvincing. First, the authors state that data was managed in Nvivo software. Which version of Nvivo? And what exactly was done using Nvivo? Then what is subsequently stated doesn’t seem to suggest that there was any computer-assisted data analysis. It appears as if the coding and analysis was done manually, but the authors feel obliged to mention Nvivo. The authors need to tell what exactly was done for analysis. Also note that you can’t increase the quality of the data by just counterchecking codes. The quality of the data is determined at the point of data collection.

Response: “Thematic analysis was used to analyze qualitative data (23,25). The first author began by transcribing the audio recordings verbatim then the transcripts were read and re-read by all the authors to familiarize themselves with the content of the data and understand its richness and diversity. The transcribed data was imported to NVivo12 for management and coding. Two authors with qualitative backgrounds coded the data, compared, discussed, and examined the codes and categories to identify patterns and themes for interpretation. All the authors then read and discussed the themes and agreed on the final themes to be included in the report. A final codebook indicating emerging themes was then developed that informed the final write-up of the results and supported by relevant quotes from the data. To ensure validity and reliability, and increase the quality of the data, the codes were counterchecked and appraised by all authors to confirm there was no repeated and conflicting content (26,27). The data collection procedures and analysis were made clear to help maintain consistency and rigor throughout the study. Team debrief sessions were held during the data collection to enhance the quality of the data. The analysis informed descriptive categories/domains that represent thematic healthcare providers' perceptions of the clinical leadership roles of clinical leaders in an HIV primary care facility”.

6. The manuscript still requires some language editing.

Response: We have reviewed the entire manuscript and made necessary edits to ensure coherence in language and general flow

Attachment

Submitted filename: Response to Reviewers_second review_Jan 2024.docx

pone.0302066.s006.docx^{(20.4KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0302066.r005

Decision Letter 2

Edward Nicol

20 Feb 2024

PONE-D-23-05699R2Leading from the Bottom: The Clinical Leaders Roles in an HIV Primary Care Facility in Eldoret, KenyaPLOS ONE

Dear Dr. Cherop,

Please submit your revised manuscript by Apr 05 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #2: Yes

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6. Review Comments to the Author

Reviewer #1: No further comments. The authors have fully addressed all concerns earlier raised; and i am happy with the submission.

Reviewer #2: The distinctions in the categories between Middle- Level Leadership and Supervisory roles is not always clear. Perhaps it would be better to organize the themes around functions, such as "establishing linkages between health system levels," supervision, etc.

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pone.0302066.s007.docx^{(11.1KB, docx)}

PLoS One. 2024 May 31;19(5):e0302066. doi: 10.1371/journal.pone.0302066.r006

Author response to Decision Letter 2

3 Mar 2024

Journal Requirements:

Response: The reference list has been reviewed to ensure it is updated. 1 journal article article of “Oates K. The new clinical leader. Vol. 48, Journal of Paediatrics and Child Health. 2012. p. 472–5.: / which was initially cited in APA format has now been cited in the current citation format and included as citation No.37 in the body document and reflected in the reference list. Retracted papers are not applicable in the references used in this document.

6. Review Comments to the Author

Reviewer #1: No further comments. The authors have fully addressed all concerns earlier raised; and i am happy with the submission.

Reviewer #2: The distinctions in the categories between Middle- Level Leadership and Supervisory roles are not always clear. Perhaps it would be better to organize the themes around functions, such as "establishing linkages between health system levels," supervision, etc.

• I have reorganized this section to provide a sub-title “ Interconnecting health systems and supervisory oversight roles” that would describe the themes around the different leadership levels of the health systems. I have provided a brief introduction of the section to reflect the interconnectedness and the supervisory oversight roles of the clinical leader in the health system.

• This is the brief introduction “Participants reported that clinical leaders play an important role in interconnecting different levels of health systems management by facilitating communications, collaboration, and coordination among various stakeholders. Through effective supervisory oversight, the leaders ensure the delivery of high-quality HIV care while fostering professional growth and development within their teams.

• The emerging themes and quotes around interconnectedness and supervisory oversight have been reorganized to fit the 2 sub-themes.

• The reorganization of the themes has been reflected in the results section, the discussion section to enhance a good flow of the themes, and the sub-title revised in the abstract to reflect 3 roles of a clinical leader.

Attachment

Submitted filename: Rebuttal Letter Addressing Reviewer and editors comments.docx

pone.0302066.s008.docx^{(18.2KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0302066.r007

Decision Letter 3

Edward Nicol

27 Mar 2024

Leading from the Bottom: The Clinical Leaders Roles in an HIV Primary Care Facility in Eldoret, Kenya

PONE-D-23-05699R3

Dear Dr. Cherop,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Edward Nicol, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Fig. AMPATH-MTRH clinical management flow chart.

(DOCX)

pone.0302066.s001.docx^{(42.5KB, docx)}

S1 Table. Codebook with minimal data.

(DOCX)

pone.0302066.s002.docx^{(20.7KB, docx)}

Attachment

Submitted filename: Reviewer comments.docx

pone.0302066.s003.docx^{(14.3KB, docx)}

Attachment

Submitted filename: Response to Reviewers.docx

pone.0302066.s004.docx^{(21.6KB, docx)}

Attachment

Submitted filename: Reviewer comments PLOS (R1).docx

pone.0302066.s005.docx^{(12.8KB, docx)}

Attachment

Submitted filename: Response to Reviewers_second review_Jan 2024.docx

pone.0302066.s006.docx^{(20.4KB, docx)}

Attachment

Submitted filename: Reviewer comments.docx

pone.0302066.s007.docx^{(11.1KB, docx)}

Attachment

Submitted filename: Rebuttal Letter Addressing Reviewer and editors comments.docx

pone.0302066.s008.docx^{(18.2KB, docx)}

Data Availability Statement

All relevant data are within the paper and its Supporting Information files.

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PERMALINK

Leading from the bottom: The clinical leaders roles in an HIV primary care facility in Eldoret, Kenya

Felishana Cherop

Juddy Wachira

Vincent Bagire

Michael Korir

Roles

Abstract

Background

Purpose

Methods

Results

Conclusion

Background

Methods

Study design

Study setting

Participant sampling and recruitment

Data collection procedures

Data management and analysis

Ethical considerations

Results

Participant demographic characteristics

Domains of clinical leader roles

Strategic leadership roles

Interconnecting health systems and supervisory oversight roles

Research roles

Discussion

Strength and limitation

Conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Edward Nicol

Roles

Author response to Decision Letter 0

Decision Letter 1

Edward Nicol

Roles

Author response to Decision Letter 1

Decision Letter 2

Edward Nicol

Roles

Author response to Decision Letter 2

Decision Letter 3

Edward Nicol

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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