Characterizing the leadership of family medicine registrars of Kamuzu University of Health Sciences: Perspectives of healthcare workers engaged in bedside teaching

This qualitative study of family medicine registrars at Kamuzu University of Health Sciences reveals that while they demonstrate strong clinical leadership and interpersonal skills, their effectiveness is hindered by unclear role boundaries, insufficient mentorship, and limited involvement in decision-making, highlighting the need for targeted improvements in their leadership training.

The Gist

Imagine a busy hospital ward as a kitchen in a bustling restaurant. In this kitchen, you have the Head Chefs (the senior doctors/consultants), the Line Cooks (nurses and junior doctors), and the Culinary Students (medical students and interns).

Now, imagine a new group of Apprentice Chefs (the Family Medicine Registrars) arrives. They have just finished a special "Leadership & Management" cooking class at a fancy culinary school (Kamuzu University of Health Sciences). Their job is to step in, guide the students, help the line cooks, and make sure the food (patient care) is delicious and safe, all while learning how to run the kitchen themselves.

This paper is like a review from the kitchen staff about how well these Apprentice Chefs are doing their job.

The Big Picture: Why This Matters

The world has agreed that primary healthcare (the "front door" of the medical system) needs strong leaders to work well. Malawi, like many places, is trying to build better leaders. This study asked the people working under these new leaders: "How are you doing? Are you leading us well?"

What Went Well (The "Secret Sauce")

The kitchen staff gave the Apprentice Chefs a lot of praise for their attitude and teamwork:

• The "Family" Vibe: The staff felt the registrars were friendly and supportive. One staff member described the relationship as a "father and son" dynamic. It wasn't scary or strict; it felt like a team working together to help patients.
• Resourcefulness: The kitchen is often short on ingredients (money, medicine, equipment). The registrars were praised for being careful not to waste anything. They made sure the medicine went straight to the patient and wasn't lost or stolen.
• Ethical Heart: When things got tough—like a patient refusing a life-saving blood transfusion due to religious beliefs—the registrars showed they could handle difficult moral choices with respect and care. They knew when to listen to the patient and when to advocate for them.
• Flexibility: They could adapt to the chaos of a busy ward, shifting gears quickly to help where they were needed.

What Was Confusing (The "Missing Recipe")

Despite the good vibes, the kitchen staff pointed out some major glitches that made the job harder for everyone:

• The "Who's the Boss?" Confusion: This was the biggest issue. The staff didn't always know what the Apprentice Chefs were actually supposed to do.
  • The Analogy: Imagine a new manager walks in and just starts cooking without telling anyone, "I am in charge of the grill today." The line cooks don't know if they should take orders from the new guy or the Head Chef. Sometimes the Head Chef steps in and does all the work, making the new manager look invisible. Other times, the new manager is too scared to speak up because the Head Chef is watching.
  • The Result: The registrars felt unsure of their own power, and the staff felt confused about who to ask for help.
• No "Innovation" Menu: The kitchen staff felt that while the environment was okay, no one was really encouraging new ideas. If a junior cook had a great idea for a new dish, it was hard to get it approved unless it was backed by a senior chef. The "innovation culture" was more of a theory than a reality.
• Missing Feedback: While the staff got some nice "good job" comments, there wasn't a formal system for performance reviews. It was like getting a thumbs-up from a friend but never getting a written report card on how to actually get better.

The Takeaway: How to Fix the Kitchen

The study suggests that the Apprentice Chefs have a great heart and good skills, but they need better tools and a clearer map.

1. Clear Job Descriptions: Before the registrars start, everyone needs a clear "menu" of what they are supposed to do. They need to be introduced properly so the staff knows, "This is our new leader for the week."
2. Confidence Building: The senior chefs need to step back a little and let the registrars shine. If the senior chef does everything, the registrar never learns how to lead.
3. Formal Mentorship: Instead of just "winging it," there should be a structured system where the registrars get regular feedback and coaching.
4. Encouraging New Ideas: The kitchen needs to be a place where junior staff feel safe to say, "Hey, what if we tried this?" without fear of being shut down.

The Bottom Line

The Family Medicine registrars in Malawi are promising leaders with a lot of potential. They are kind, ethical, and good at teamwork. However, to become the Head Chefs the healthcare system needs, they need clearer roles, more confidence, and a system that actively supports their growth. If the hospital fixes these "kitchen" issues, the whole restaurant will run smoother, and the patients will get better care.

Technical Summary

1. Problem Statement

The study addresses a critical gap in the Malawian healthcare system: the lack of empirical data regarding the leadership capabilities of Family Medicine (FM) registrars, who are emerging leaders in Primary Health Care (PHC).

• Context: Despite global and national commitments (e.g., Astana Declaration, Malawi's Health Sector Strategic Plan III) to strengthen PHC through effective leadership, there is a recognized deficit in leadership capacity at district and facility levels in Malawi.
• Specific Issue: Since the introduction of the Master of Medicine (MMed) in Family Medicine program at Kamuzu University of Health Sciences (KUHeS) in 2020, which includes a specific leadership training module, no study has characterized the actual leadership performance of these registrars during their clinical rotations.
• Research Gap: There is a need to understand how these registrars function as bedside supervisors and whether their training translates into effective leadership behaviors as perceived by their supervisees (healthcare workers).

2. Methodology

• Study Design: An exploratory descriptive qualitative study.
• Setting: Two teaching sites in Malawi: Mangochi District Hospital and Nkhoma Mission Hospital. These sites host six-week bedside teaching rotations for FM registrars.
• Participants:
  • Sample: 12 healthcare workers (HCWs) acting as supervisees.
  • Composition: Student nurses, student medical officers, qualified nurses, qualified clinical officers, and interns. (MBBS students were excluded due to unavailability).
  • Selection: Purposive sampling based on the "information power" principle, ensuring participants were in their 5th or 6th week of rotation to ensure sufficient experience.
• Data Collection:
  • Tool: Semi-structured Focus Group Discussions (FGDs).
  • Framework: The study utilized the Six-Part Model for Adapting and Thriving during Transformational Change (Browning et al., 2016) as the theoretical framework. This guided the development of interview guides and data analysis.
  • Procedure: Two trained research assistants conducted FGDs lasting ~80 minutes. Sessions were audio-recorded, transcribed, and analyzed.
• Data Analysis:
  • Approach: A hybrid approach combining deductive analysis (guided by the Six-Part Model themes) and inductive analysis (allowing emergent themes from the data).
  • Framework: Followed Braun and Clarke's six-step thematic analysis process.
• Trustworthiness: Established through peer debriefing with an independent qualitative researcher and member checking with participants.
• Ethics: Approved by the College of Medicine Research and Ethics Committee (COMREC) and District Health Offices.

3. Key Contributions

• Empirical Evidence: This is the first study to characterize the leadership of FM registrars in Malawi from the perspective of their supervisees.
• Theoretical Application: It successfully applies the "Six-Part Model" to a low-resource, sub-Saharan African clinical teaching context, validating its relevance for analyzing leadership in transformational change.
• Curriculum Feedback: Provides direct, evidence-based recommendations for improving the KUHeS Master of Family Medicine leadership curriculum.
• Systemic Insight: Highlights the tension between individual leadership potential and systemic barriers (hierarchy, role ambiguity) in Malawian hospitals.

4. Key Results

The findings were categorized into strengths (positive leadership behaviors) and limitations (systemic and behavioral barriers).

A. Strengths (Positive Leadership Attributes)

• Collaboration & Relationship Building: Registrars demonstrated strong interpersonal skills, fostering a supportive, "father-son" dynamic with supervisees. They were viewed as approachable, fostering trust and open communication.
• Resource Stewardship: Registrars were effective in managing existing resources (medications, equipment) through careful allocation, tracking, and accountability, minimizing wastage.
• Ethical Leadership: Registrars navigated complex ethical dilemmas (e.g., patient refusal of blood transfusion due to religious beliefs, inability to afford medication) with sensitivity, balancing clinical needs with patient autonomy and cultural values.
• Adaptability: They managed busy ward conditions and adapted to varying learning needs of diverse supervisee groups.

B. Limitations & Challenges

• Role Ambiguity: A major finding was the lack of clarity regarding the registrars' specific roles. Supervisees often did not understand the registrars' leadership duties, leading to confusion about reporting lines (Registrar vs. Senior Consultant).
• Overshadowing by Supervisors: Senior consultants often "overshadowed" registrars, inadvertently undermining the registrars' authority and confidence. Registrars were observed to step back in the presence of seniors, failing to lead.
• Lack of System-Level Involvement: Registrars were effective at the ward level but had minimal participation in hospital-wide decision-making or strategic planning.
• Stagnant Innovation Culture: While the environment was theoretically open to innovation, there was a lack of practical mechanisms to foster it. Junior staff ideas were rarely implemented without robust evidence, and there was no formal recognition for innovation.
• Informal Mentorship: Feedback and mentorship were inconsistent, relying on the registrar's personal style rather than a structured system. There was no formal performance appraisal framework for supervisees.

5. Significance and Recommendations

• Significance: The study confirms that while FM registrars possess high potential and strong foundational leadership skills (collaboration, ethics, resource management), their effectiveness is severely constrained by organizational culture and structural ambiguity. Without clear role definitions and systemic support, their leadership potential remains underutilized.
• Recommendations for Practice & Policy:
  1. Structured Orientation: Implement a formal orientation process where registrars clearly define their roles and expectations to the ward team upon arrival.
  2. Role Clarity: Hospitals and universities must delineate the boundaries between registrars and senior consultants to prevent "overshadowing" and empower registrars to lead.
  3. Formalized Mentorship: Integrate structured mentorship and feedback loops into the rotation, moving away from ad-hoc interactions.
  4. Curriculum Enhancement: The KUHeus leadership training should be updated to include modules on system-level leadership, innovation management, navigating hierarchy, and structured performance appraisal.
  5. Innovation Ecosystem: Create organizational strategies (e.g., psychological safety, dedicated time for innovation) to encourage and reward creative problem-solving among junior staff.

Conclusion: The study concludes that Family Medicine registrars are vital assets for PHC leadership in Malawi. However, maximizing their impact requires a shift from viewing them solely as clinical trainees to recognizing them as emerging leaders who need structural support, clear mandates, and a culture that values their input in system-wide improvements.