The Six Collective Leadership themes that underpin an Organised Stroke Unit: The Outcome of a Scoping Review

The Six Collective Leadership themes that underpin an Organised Stroke Unit: The Outcome of a Scoping Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review The Six Collective Leadership themes that underpin an Organised Stroke Unit: The Outcome of a Scoping Review Paul Bolaji, Adetola Emmanuel Babalola, Simon Fletcher This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7687461/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract There is overwhelming evidence that an organised stroke unit compared with a general ward improves survival, disability, and discharge destination to home after stroke. What is unknown is which component of the organised stroke unit leads to the benefit. Collective leadership, a leadership theory proposed by Peter Gronn, is increasingly influencing the healthcare space, with an emphasis on leadership being more of a collective social process rather than a narrow and centralized one between Individuals. Collective leadership, hypothetically, might be integral to the success of an organised stroke unit. This scoping review, therefore, aims to synthesize existing evidence on ‘collective leadership’ and its related themes, as well as their impact on MDT and patient-related outcomes in the stroke unit. It also seeks to introduce the concept of collective leadership to the stroke community. A systematic search was conducted across seven databases, including PubMed, Google Scholar, and Cochrane Library, with studies screened using Rayyan software. Eleven studies met the inclusion criteria. Thematic synthesis was used to extract and analyse recurring leadership elements and themes relevant to stroke MDTs. While none of the included studies explicitly used the term “collective leadership,” all identified features aligned with its core principles. Six themes emerged: Presence of an adaptive stroke leader, clarity of vision and roles, person-centred and problem-focused MDTs, a warm team culture and climate, protocolised interventions, and succession planning. These elements in the stroke unit and MDT are associated with improved communication, streamlined decision-making, and better patient outcomes. This review highlights that although not overtly labelled, collective leadership principles are inherent in effective stroke MDT practice. This finding shows a gap in explicit leadership research in stroke care, suggesting that structured implementation and evaluation of collective leadership strategies may enhance team performance and patient outcomes. Future studies should incorporate these six leadership themes as a bundle to see if it further enhances the quality of stroke care in an organised stroke unit, especially in developing countries like Africa, where the majority of these collective leadership strategies may be absent. Collective leadership Multidisciplinary team (MDT) Organised stroke unit Stroke care outcomes Team culture Adaptive leadership Person-centred care Healthcare leadership models Figures Figure 1 Figure 2 Background Organized Stroke unit and Outcomes Stroke remains one of the leading causes of disability and mortality worldwide, with the UK experiencing a high burden of stroke-related care needs. [ 1 – 3 ]. Effective management of stroke patients requires the coordinated efforts of multidisciplinary teams (MDTs) in an organised stroke unit. [ 4 ] While Stroke can often be explained using the biomedical and pathophysiological basis of illness, it’s manifestation, the impact and experience by each patient are diverse and personal. This underscores the importance of the biopsychosocial approach and person-centred care [ 5 ]. Patients with stroke are often left with significant disability, a change in their identity, activity limitation and restricted participation. The impaired functioning is not discrete but interwoven together affecting the whole person. [ 6 ]. This myriads of impairments and activity limitations therefore need a biopsychosocial model of medical intervention which a single professional alone cannot achieve [ 5 , 7 , 8 ]. An organised stroke unit consists of multidisciplinary professionals including stroke consultant or neurologist and the medical team, the Nursing staff, the Therapists (Physiotherapist, Occupational therapist, Speech and Language therapist), Psychologists, Dietician, Orthoptist, Dietician), healthcare workers, discharge coordinators and other admin staff. This component may vary based on the resources available. This Multidisciplinary Staff (MDT) also interact with other healthcare professionals who are affiliated with the stroke team, such as radiologist, diabetic nurses, cardiology team, Neurosurgical team and others. [ 4 ] Research has revealed that patient managed in stroke units compared to general ward have better outcomes. [ 9 , 10 ]. A recent systematic review and meta-analysis by Langhorne et al [ 3 ] has shown that patients who were managed in coordinated stroke units compared with general ward were more likely to be alive, at home, and independent in their daily activities of living a year after a stroke. These benefits were seen irrespective of the demography of the people with stroke. The best evidence was seen in a dedicated stroke ward, compared with other stroke units such as a mixed rehabilitation ward and mobile stroke ward. In this review and meta-analysis, the dedicated stroke unit was defined as Acute stroke unit, Stroke rehabilitation ward, or a comprehensive stroke unit that has both acute stroke unit and stroke rehabilitation ward. In a trial conducted in China, Stroke unit care was far more superior to general care [ 9 ]. To get expert evidence about the component of stroke unit care that improved patient outcome, Liao et al.[ 9 ] sent questionnaires containing 107 items in a stroke unit to 83 European stroke experts, although there were disagreement on most of the component, there was a unified consensus that multi-disciplinary care, stroke trained nurses and 24/7 intravenous rt-PA protocols among a few others were very integral to the effectiveness of a stroke unit. Although these were expert opinions with low level evidence, it hints to the possibility that MDT care, protocolized care and empowering nurses to lead stroke call might be crucial in better outcomes seen in an organised stroke unit. Despite the clear benefit of a coordinated and dedicated stroke ward [ 3 , 4 , 10 ], It is still largely unclear what component of stroke unit or even MDT care, contributes to the superiority of stroke unit. [ 10 ] Is it the skill set of professionals, the patient-centered care, improved communication, the regular MDT meeting, shared knowledge among MDT, protocolized care, team spirit or a relatively new concept called Collective Leadership, that makes the difference? Healthcare Leadership Models and the need for Collective Leadership in Stroke Healthcare leadership has traditionally relied on hierarchical models, exemplified by the “great man” theory, where singular leaders hold ultimate responsibility [ 11 ]. However, this model is increasingly unsuitable for addressing the complexities of contemporary healthcare environments, where collaboration and adaptability are essential [ 11 ]. Emerging evidence supports the effectiveness of shared, adaptive, and transformational leadership styles in enhancing team performance, fostering innovation, and improving healthcare delivery outcomes [ 12 , 13 , 14 ]. Collective leadership, a leadership theory proposed by Peter Gronn [ 15 ] is increasingly influencing the healthcare space, with emphasis on leadership being more of a collective social process rather than narrow and centralized between Individuals. There are few theories that underpin the concept of collective leadership which includes the distributed, shared and adaptive leadership theories [ 16 ]. Collective leadership is an approach where all team members share responsibility for decision-making, fostering mutual respect, trust, and accountability [ 17 ]. This style of leadership enhances psychological safety, enabling individuals to voice concerns, contribute ideas, and collaborate effectively [ 18 ]. In MDTs, collective leadership has been linked to improved team dynamics, reduced burnout, and better patient outcomes [ 19 ]. The complexity of stroke care, involving interdependent tasks and high-stakes decision-making, highlights the importance of leadership approaches that promote inclusivity and shared accountability. Evidence from non-stroke healthcare settings indicates that collective leadership can improve communication, enhance decision-making, and foster a culture of continuous improvement [ 17 ]. These benefits are particularly relevant for stroke units, where effective coordination among MDT members is critical for optimizing patient care. The concept of collective leadership among stroke MDTs therefore represents that acme of a highly effective MDT focused on addressing these multifaceted problems in a patient with stroke. Despite the potential advantages, the role of collective leadership within stroke MDTs remains underexplored. Preliminary research reveals limited studies directly addressing this topic, with most research focusing on traditional or general leadership models or using themes related to collective leadership without using the phrase ‘Collective leadership’ [ 20 , 21 ]. This represents a significant gap in literature, as understanding and implementing effective collective leadership strategies might be crucial for the ongoing improvement of stroke care outcomes. Aims and Objectives This scoping review aim was to synthesize existing evidence on ‘collective leadership’ or its related themes and its impact on MDT and patient related outcome in stroke unit. By mapping the current body of knowledge, identifying themes, and highlighting gaps, this review aimed to inform future research on how collective leadership might further enhance the overall outcomes of organised stroke care. It also sought to inform the stroke community on the relatively new concept of collective leadership and its importance in stroke medicine. As Langhorne et al. [ 3 ] put it, the next studies on organized stroke units should focus on the factors in the organized stroke MDT that results in better outcome than a general ward. If we can determine that component, then we might be able to amplify those factors leading possibly to better outcomes in an organized stroke care. This review attempt to give a possible hypothetical answer that collective leadership might be integral to a success of a stroke unit. Methodology Literature Search Seven Databases were searched including PubMed, Google Scholar, ScienceDirect, Directory of Open Access Journals (DOAJ), African Journals Online (AJOL), and Cochrane Library. The Search strategy included the Medical Subject Headings (MeSH) and keywords including “leadership”, “collective leadership”, “multidisciplinary team”, “stroke unit”, “shared leadership”, “adaptive leadership”, “transformational leadership”, and “healthcare teams”. Boolean operators (AND, OR) were applied. The date of search was March 18, 2025, and the studies reviewed were in English only. Inclusion Criteria Studies on MDTs in stroke units Articles on collective, shared, adaptive, transformational leadership in stroke units Peer-reviewed and grey literature Exclusion Criteria Non-hospital stroke care Editorials, opinion pieces, or commentaries Screening Process A two-phase screening process was conducted using Rayyan software for transparency based on the inclusion/exclusion criteria. Phase 1 Title and abstract screening were conducted to exclude irrelevant studies. The initial search yielded 1008 results. 56 Duplicates record were removed. A further 750 articles were excluded based on their titles and then left with 202 articles. 182 were then screened out, based on an abstract review with 20 articles remaining. Phase 2 Full-text screening based on inclusion and exclusion preview. Nine full text articles were further excluded based on full text screening, with 11 articles remaining and used for the scoping review. Full-text articles were assessed for final inclusion. (Fig. 1 ) Data Extraction, Analysis and Reporting Data was extracted using a standardized spreadsheet excel capturing: Study details: Author(s), year, country, Perceived leadership model, Study setting, MDT composition, Collective Leadership elements, Impact on MDT Functioning., Outcomes related to MDT effectiveness, Key themes or findings. Thematic synthesis was used to identify recurring themes and concepts. [ 22 , 23 ] Based on our objectives, we extracted the most frequent recurring themes based on collective leadership from the 11 studies using a combination of deductive and inductive approach. Themes related to collective leadership framework were synthesized without having a specific framework in mind. The recurring coded themes of collective leadership were then inductively analysed into 6 recurring themes of collective leadership from the 11 articles included in our study. A narrative summary was used to highlight key findings, trends, and gaps. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used to guide reporting. 2.5 Ethical Considerations No primary data collection occurred therefore, ethical approval was not required. However, this study ensured proper citation of all reviewed materials to maintain academic integrity. Results A total of 11 studies met the inclusion criteria and were included in the final analysis. (Table 1 ) These studies, drawn from five different continents-coincidental, examined multidisciplinary stroke teams in various healthcare settings, including acute stroke units, rehabilitation wards, and general medical wards. Although none explicitly used the term “collective leadership”. Many referenced closely related leadership models such as shared, collaborative, inclusive, or adaptive leadership or used elements related to collective leadership strategies as seen in Table 1 Each study was analysed for Perceived leadership style or model Setting and composition of the MDT. Identifiable elements of collective leadership, Impacts on team functioning and Patient outcomes Emergent themes relevant to stroke care. (Table 1 ) The studies were diverse in design, including qualitative interviews, retrospective observational studies, randomised controlled trials, and systematic reviews. Across the board, they provided insights into leadership practices that promote coordination, communication, and patient-centred care in stroke units. Table 1 Showing Data Extraction Table with the recurring themes) Study ID Abridged Title Authors Year Country Study Objective Study Design Perceived Leadership Model Setting MDT Composition Collective Leadership Elements Impact on MDT Functioning Patient Outcomes Key Themes 1 Stroke Inpatient Rehabilitation Team Conferences Kushner & Strasser 2019 USA Improve team conference structure in stroke rehab Scoping review Shared / Co-leadership Inpatient Stroke Rehab Physicians, nurses, case managers, therapists Equal voice, empathy, structured team meetings Enhanced collaboration, improved structure ↑ FIM scores, ↓ LOS, ↑ Discharge to home Clarity of Vision and Roles Problem Focused MDT 2 Collaborative Interventions Reduce Time to Thrombolysis Zachary et al. 2017 USA Evaluate Intervention to reduce time to thrombolysis Retrospective Observational Not Inferred Acute stroke unit Doctors (Neurology,ED Radiology Nurses Stroke Performance Coordinator Protocol based care Regular collaboratives meeting Improved MDT meeting with Neurointerventional Neurocritical care attendings Vascular Neurosurgeons Reduction in time to thrombolysis Protocolized Interventions Clarity of vision and Roles 3 Implementation of Evidence-Based Stroke Care Purvis et al. 2014 Australia Identify enablers and barriers to implementing evidence-based stroke care Qualitative (interviews) Inclusive / Transformative Leadership Acute + Subacute Stroke Units Stroke Network Facilitator, Neurologist, Nurses, Therapists Non-medical leadership involvement, protocol implementation Improved coordination, protocol adherence Consistent intervention delivery, better continuity Team Climate and Culture Stroke Adaptive Leader. Succession Planning 4 Nursing-led MDT for Stroke Rehab Deng et al. 2024 China Evaluate effectiveness of nursing-led MDT continuous care RCT Collaborative Leadership Stroke Rehab + Home Care Neurologists, Rehab Nurses, Caregivers, Psychologists Nursing department leadership, structured roles Coordinated follow-up, seamless handoff ↑ FMA, ↑ QOL, ↑ MBI scores Patient centered Stroke MDT Stroke Adaptive Leader Clarity of Vision and Roles 5 Swallowing Team Approach in Acute Stroke Aoki et al. 2016 Japan Assess pneumonia reduction from team approach Prospective observational Collective Leadership Acute Stroke Unit Doctors, nurses, PTs, OTs, speech, dieticians Early communication, shared timing Streamlined interventions, faster decisions ↓ Pneumonia incidence Problem focused MDT Care Protocolised Intervention 6 MDT Early Mobilization in SCU Oike et al. N/A Japan Evaluate MDT intervention for early mobilization Retrospective cohort Collective Leadership Acute stroke unit Physicians, SCU therapists, engineers, nurses Facilitator role, protocol-based care Improved timing, cross-role efficiency Earlier mobilization, better safety Stroke Adaptive Leader Problem focused MDT Care Protocolised intervention 7 Perception Towards MDT In Stroke Rehabilitation: Babur et al 2016 Pakistan Determine perception of MDT rehab professionals Qualitative Focus group discussion Collective Leadership Stroke rehab ward Radiologist, PTs,Ots,SALT Nutritionist, vascular surgeon Rehab specialist rehab nurse, Psychology Interdisciplinary Collaboration Communication Understanding of Roles ↑ Physical function and earlydischarge Clarity of vision and Roles Team Climate and Culture 8 Nurse-led Stroke Assessment Guidelines Hamilton et al. 2006 England Evaluate MDT compliance with stroke assessment Quasi-experimental Opinion Leadership Acute Medical Ward Nurses, doctors, AHPs Senior nursing leadership champions Higher compliance in AHPs vs medicine Mixed outcomes, some resistance Stroke Adaptive Leader Protocolised Intervention 9 Organized inpatient (stroke unit) care for stroke Langhorne et al 2020 Scotland Compare Outcomes btw Stroke Inpatient Vs Alternatives Systematic review/ Metanalysis Not Inferred Stroke Unit- Acute and/or Rehab Stroke MDT- Not specified multidisciplinary team care and meetings No specified patient in stroke unit care likely to be alive, independent, and living at home one year Patient Centered Stroke MDT Protocolised Intervention 10 Multi-Disciplinary Stroke Care in Developing Countries Johnson et al 2017 Ghana Outlines the development of a specialist stroke service in Accra, Ghana Prospective Observational Collective leadership Acute stroke unit Doctors, nurses, PTs, OTs, speech, dieticians, pharmacy, and psychology. Open Communication Probity Motivation and reward Increased confidence to share Knowledge and skill And communicate more effectively Consistent and Effective patient centred care Succession Planning Team Climate and Culture 11 Organized stroke MDT in resource limited Adeniji et al 2023 Nigeria Compare stroke outcome before and after stroke MDT retrospective, observational stu.y Stroke MDT in a general medical ward neurologist, Neuro SPR Nurse, OT, PT dietitians, pharmacists, clinical pharmacologists and stroke liaison staff Intrateam communication through whatsapp Shared decision Synergism of professional competencies Improved communication flow More stroke patients discharged alive after intervention Patient centred stroke MDT Team Climate and Culture Succession Planning Six recurring Collective Leadership Themes were identified from our thematic analysis in the 11 articles from Five different Continents that was reviewed The Stroke Adapative Leader Clarity of Vision and Roles Person Centered and Problem Focused MDT A Warm and Open Team Climate Protocolized Intervention Succession Planning and Team Empowerment Each of these collective leadership themes were extracted from at least three of the articles, but averagely five of the articles. Discussion: The Six Collective Leadership Themes A. Stroke Adaptive leader The presence of an experienced, credible, trusted, emotionally intelligent and continually improving staff with clinical experience irrespective of professionalism was critical in the literature reviewed to drive the stroke MDT towards excellent stroke care. In this scoping review, various stroke MDT teams had designated person who demonstrated key leadership principles and steered the rest of the stroke MDT to a team related goal. For example, there was the ‘Opinion leader’ [ 24 ], ‘Dedicated Stroke Performance Improvement Coordinator’ [ 25 ], Stroke Network Facilitator ([ 21 ], and Deputy director of Nursing’ [ 26 ]. There were mostly clinical but non-medical leaders and often from the nursing profession, who made sure that the Stroke MDT maintain a good standard of care by aligning them to the stroke guidelines and group goals in the hospital [ 21 , 26 ]. They were vital in the stroke MDT irrespective of the setting. In China [ 26 ], the adaptive leader was the Deputy Director of Nursing who made sure assessments were adhered in the Stroke Rehab ward. In Australia [ 21 ], A Stroke Network Facilitator ensured the team adhere to evidence-based care in a comprehensive stroke unit(Acute Stroke Unit and Stroke Rehabilitation Ward), whereas a stroke improvement coordinator, an opinion leader and a facilitator nurse demonstrated adaptive leadership in Acute Stroke Unit [24,25,27) These leaders were trusted to facilitate the collective success of the stroke MDT team. For example, the Stroke Network Facilitator in a hospital with limited organization resources played an integral role in establishing and improving stroke unit care at the health services, through translation of policy into evidence-based practice. [ 21 ] One of the theories that underpin collective leadership is the concept of adaptive leadership which emphasizes what attributes a leader within a collective leadership model must possess. [16,28,29) Adaptive leadership gives the framework and quality every leader should possess within the collective leadership space. They categorized the qualities into 4 components. (Fig. 2 ) Emotional Intelligence: Adaptive leaders are self-reflective and recognize their own strength and weaknesses. Character: Being authentic without being harmful. Organization Justice: Adaptive Leaders value considers the group goal first to make sure services are both efficient, cost effective and aligned with long term sustainability of organization. Development: Adaptive leaders engage in personal growth while implementing new strategies and improvement in the organization framework The stroke adaptive leader demonstrates a strong sense of integrity and maintains a sphere of influence over the team members. A stroke adaptive leader must also be obsessed with continual improvement of the stroke team to provide excellent and compassionate patient centred care [ 30 ] There is a tendency to assume that a stroke adaptive leader is akin to ‘the great man’s theory of leadership’ where leadership is a ‘one-man show’ rather than collective leadership.[ 31 ] However, this stroke adaptive leader is not in the spotlight, might not be the most knowledgeable or most experienced, but rather has credibility in driving the stroke MDT collectively toward continual improvement with a combination of humility and fierce resolve. [ 32 ]. B. Clarity of Vision and Roles Team related vision and roles delineation shared lucidly with all members of Stroke MDT, are important features of an effective Stroke MDT. In the qualitative focus group discussion by [ 33 ] clarity of vision was among the attributes in a highly effective stroke team. A Stroke Adaptive Leader [ 21 ] might be crucial in communicating the vision clearly for the stroke MDT. This fosters a sense of collective purpose among the wider MDT. In Kotter’s change management framework,[ 34 ] communicating vision with clarity is crucial to team members embracing a new change in an organization. The vision goals need to be discussed frequently and embedded in activities of the stroke MDT team. Beyond the clarity of vision is, the clarity of roles, In Kushner and Strasser’s [ 20 ] work on stroke inpatient rehabilitation conferences, the concept of teamness and Team effectiveness was introduced. Teamness is ‘how well the team works together. To build ‘teamness’ and team effectiveness, clarity and understanding of each other’s roles is needed for accountability and avoid confusion. It is worthy of note that some roles may not be discrete and might overlap especially when a transdisciplinary approach is used in MDT based care. [ 25 , 35 ] Nevertheless, clarity must be maintained where there is an overlap and where there is overlap or distinction of roles to avoid conflict and confusion among Stroke MDT. C. Person-centered and problem-focused Stroke MDT A Stroke MDT focused on delivering excellent and relevant stroke care in the best interest of the patient leads to improved functional outcome in a stroke unit.[ 20 ] This is called the person-centred care as explained by Coulter and Oldham [ 36 ]. Collective focus towards excellent patient care leads to better outcomes in an MDT irrespective of the stroke setting either in general ward with stroke MDT or a stroke unit. [ 37 ] A person-centred stroke MDT in the randomized controlled trial by Deng et al [ 26 ] improved the quality of life and motor outcomes of patients. The stroke adaptive leader is important to ensure a person-centred approach by the stroke MDT. [ 21 ] There is an equally sound argument about the need to make staff well-being a priority while delivering person-centred care.[ 38 ] as there is some evidence of a clear link between staff wellbeing and good outcome with person-centred care. [ 38 ] A person-centred MDT focused on addressing different activity limitations of patients or focused on improving systemic problems, might be beneficial in healthcare. [ 39 ] For example, the collaborative and MDT based Swallowing team in this review improved dysphagia in stroke patient in Japan. [ 35 ] The problem-based MDT conference tool called Manchester Multidisciplinary Meeting Model used in the scoping review on stroke rehabilitation inpatient conferences was shown to be more effective in-patient outcome compared to the standard MDT approach. Patient related benefits were seen in increased function independence measure (FIM) scores of patients at discharge. More patients were also discharged back to their homes in the community and length of stay were shorter. [ 20 ] Different sub-MDT, created from a larger MDT working with an Holacratic ideology [ 40 ] might deliver interventions in diverse activity limitations in stroke patients such as communication, mobility, swallowing, continence, cognition, spasticity or mood of patients. Within a Stroke MDT, there might sub-teams created to tackle this activity limitations for example the MDT swallowing team from Japan who reduced complications of dysphagia in people with stroke. Problems identified might be system or process based rather than activity limitation. For example, a sub-team within the MDT might be created to improve Door to Needle time [ 25 ] or improve early discharges. D. A Warm and Open Team Climate and Culture A culture that is warm, with open communication in a flat hierarchical structure removes barriers within the stroke MDT, resulting in good and positive outcomes for the team and patient [ 35 ] A culture that emphasizes equal voice with empathy led to a positive social climate as demonstrated in the scoping review on stroke rehabilitation team conferences by Kushner and Strasser [ 20 ]. A great teamwork culture was perceived enabler to evidence-based stroke service in a comprehensive stroke Centre in Australia. [ 21 ] There is some evidence that a positive approach to safety and errors called safety 2, reduce error and fosters team bonding with resultant effect on improved patient care. [ 41 ] while hierarchical communication in a healthcare team can affect training of doctors and hamper patient’s care. [ 42 ] E. Protocolized Interventions Standardized and organized stroke protocol and guidelines in this review were integral to the Stroke MDT. In the retrospective observational study conducted by Zachari et al. [ 25 ] Eleven structured interventions were done to reduce to time to thrombolysis in an acute stroke unit. A clear stroke protocol in the acute stroke unit and stroke rehab improve the outcome of patients. [ 20 , 21 ] Clear pathways and protocol will foster collective leadership and improve the efficiency of the stroke MDT. Protocolised interventions in stroke help standardise care. It also reduces overt dependence on few experts. It can be helpful in teams with junior or new staff. For example, a TIA Clinic template developed in my local unit has helped boost the confidence of our resident doctors to run an often-difficult TIA Clinic Service which was initially overtly dependent on Senior Doctors. [ 43 ] While protocols, local guidelines and standard operating procedures are useful, it must be clear, simple and accessible. Protocols must also be swiftly generated without the delay from bureaucratic processes. [ 44 ] F. Succession Planning and Team Empowerment Another key theme of collective leadership in a Stroke MDT is sustainability of an effective Stroke MDT through mentorship, training of stroke adaptive leaders [ 4 , 21 ]. A key strategy in the development of stroke unit in Ghana, West Africa [ 4 ], was appointment of deputies within the leadership of the Stroke unit. This was very important to maintain longevity and continuity of optimal patients care in the stroke unit as demonstrated in Nigeria. [ 37 ] Succession Planning is imperative in the healthcare setting including the stroke MDT who seeks to maintain high quality care over a period. [ 45 ] This might be enhanced through diverse styles through mentorship, coaching, training or supervision in a structured format called the mentoring umbrella. [ 46 ] Empowering Teams with knowledge and continual training ensures that the long-term vision of the team is perpetuated when the early drivers of the vision are no longer there. [ 21 ] A stroke team culture focused on team building, continual improvement, and succession planning is critical in reducing barriers towards sustained delivery of evidence-based care. [ 21 ] Conclusion Collective Leadership in Stroke MDT incorporate the concepts that “every mind” is utilized to the best of their ability [ 47 ]. A stroke MDT with collective leadership is problem-focused and patient-centred [ 35 ]. Conflicts are resolved within a collective framework, diversity of opinion and perspective are encouraged, the patient and staff feel valued leading to good outcome in patient care. [ 48 ] These six collective leadership themes drawn from rigorous review of literature with in-depth review of 11 articles from 5 different continents appear to the consistent across board. Although the phrase “collective leadership” was not directly used in any of the reviewed studies, the presence of its core attributes was consistently present most of the articles reviewed. Stroke MDTs exhibiting these principles had improved communication, cohesion, and patient outcomes from our review. It is worthy of note that there was a paucity of literature that addressed leadership in stroke MDT. Also, none of the full report literature reviewed used ‘Collective leadership’ as a phrase. However, other synonyms and the concept and themes surrounding collective leadership were extrapolated. This scoping review therefore highlights a gap in leadership-specific research in stroke care and suggests the need for in-depth studies in collective leadership in the stroke MDT. There are potentials limitation to this work. This was a scoping review where qualities of studies reviewed was not analysed as there were even few relevant literatures on collective leadership in stroke. Also, our search could have potentially left out some publications as different terms could have been used for leadership or stroke MDT. In-depth Snowballing could have helped to identify other relevant articles. [ 49 ] However, as stated by Doyle [ 50 ], a systematic review of qualitative studies should aim for interpretative explanation rather than predictions, therefore, it does not always have to be exhaustive but rather purposive. Our final selected eleven article from 5 different continents (a surprising coincidence) with six recurring themes might potentially validate the generalisability and replicability of these themes in the wider stroke population. The way forward from here will be to validate the six collective leadership recurring themes either through quality Improvement framework, prospective studies, or a well-designed step wedged randomised controlled trial. Future studies should determine whether these six collective leadership elements, when implemented as a bundle, can further improve outcomes compared with usual practice in stroke units. Abbreviations • BMC BioMed Central • DOAJ Directory of Open Access Journals • ED Emergency Department • FIM Functional Independence Measure • LOS Length of Stay • MDT Multidisciplinary Team • MeSH Medical Subject Headings • OT Occupational Therapist/Therapy • PT Physiotherapist/Physical Therapy • QOL Quality of Life • RCT Randomized Controlled Trial • SCU Stroke Care Unit • SALT Speech and Language Therapist/Therapy • TIA Transient Ischemic Attack Declarations Ethics approval and consent to participate Not applicable. This study is a scoping review of published literature and did not involve human participants, human data, or animal subjects. Consent for publication Not applicable. This manuscript does not contain data from any individual person. Competing interests The authors declare that they have no competing interests. Authors’ information Dr. Paul Bolaji is a consultant physician in stroke medicine with a focus on service development and multidisciplinary care. He has a master’s in healthcare leadership from the University of Warwick, and this manuscript was an outcome of his master’s thesis. He is currently an executive member of the African Stroke Organisation, and he is keen on stroke units’ capabilities and improvement in Africa and beyond. Funding The authors received no financial support for the research, authorship, or publication of this article. Author Contribution P.B (Paul Bolaji) conceived and designed the study. P.B and A.B conducted the literature search, data screening, and extraction. P.B drafted the manuscript. S.F critically reviewed and revised the manuscript. All Authors read and approved the final version of the manuscript. Acknowledgements The authors would like to thank the institutions and libraries that provided access to the databases used for this scoping review. Data Availability All data generated or analysed during this study are included in this published article and its supplementary information files. 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(2001) Level 5 leadership: The triumph of humility and fierce resolve, Harvard Business Review. Available at: https://hbr.org/2001/01/level-5-leadership-the-triumph-of-humility-and-fierce-resolve-2 (Accessed: 22 June 2025). Babur MN, Habibullah S, Farooq N. Perception towards multidisciplinary team approach in stroke rehabilitation: a qualitative study. Pak Armed Forces Med J. 2017;67(1):171–5. Kotter JP. Leading change. Boston (MA): Harvard Business School Press; 1996. Aoki N, Sasaki N, Satoh M, Yano T, Ishikawa H. Team approach for preventing aspiration pneumonia in acute stroke patients. J Stroke Cerebrovasc Dis. 2016;25(9):2238–44. Coulter A, Oldham J. Person-centred care: what is it and how do we get there? Future Healthc J. 2016;3(2):114–6. 10.7861/futurehosp.3-2-114 . Adeniji O, Ogunyemi A, Ojelabi O. Organized stroke MDT in a resource-limited setting: a Nigerian experience. Nigerian Med J. 2023;64(1):33–9. Kirk K. 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Improving local healthcare policies and practices. Nursing standard (Royal College of Nursing (Great Britain): 1987), 25(7), 39–48. Beauchemin M, Cohn E, Shelton RC. Implementation of Clinical Practice Guidelines in the Health Care Setting: A Concept Analysis. ANS Adv Nurs Sci. 2019;42(4):307–24. https://doi.org/10.1097/ANS.0000000000000263 . Yudianto K, et al. Succession planning leadership model for Nurse Managers in Hospitals: A narrative review. Healthcare. 2023;11(4):454. 10.3390/healthcare11040454 . Toh RQ, et al. The role of mentoring, supervision, coaching, teaching and instruction on Professional Identity Formation: A Systematic Scoping Review. BMC Med Educ. 2022;22(1). 10.1186/s12909-022-03589-z . Pearce CL, Conger JA. Shared leadership: reframing the hows and whys of leadership. Thousand Oaks, CA: Sage; 2003. De Brún A, McAuliffe E. when there’s collective leadership, there’s the power to make changes: A realist evaluation of a collective leadership intervention (co-lead) in healthcare teams. J Leadersh Organizational Stud. 2022;30(2):155–72. 10.1177/15480518221144895 . Wohlin C. (2014) ‘Guidelines for snowballing in systematic literature studies and a replication in software engineering’, Proceedings of the 18th International Conference on Evaluation and Assessment in Software Engineering, pp. 1–10. 10.1145/2601248.2601268 Doyle LH. Synthesis through meta-ethnography: paradoxes, enhancements, and possibilities. Qualitative Res. 2003;3(3):321–44. 10.1177/1468794103033003 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 09 Jan, 2026 Reviewers agreed at journal 04 Jan, 2026 Reviews received at journal 29 Dec, 2025 Reviewers agreed at journal 23 Dec, 2025 Reviewers invited by journal 04 Oct, 2025 Editor assigned by journal 25 Sep, 2025 Submission checks completed at journal 25 Sep, 2025 First submitted to journal 22 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7687461","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":591845090,"identity":"0fe397c2-ef5d-495d-9823-3a35931a4196","order_by":0,"name":"Paul Bolaji","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYBACxgYwZcEgz8x+8AEDwwFitDCDKAkGw/aeZAOitDAwQLUwnDlgJkGUFub2/mMPfrZJyDHOSEir5qm5I8fPwPzw0Q18Dus5zG7Y2yZhzC6ReOw2z7FnxpINbMbGOfi0zEhmk+Btk0hsBNpym4ftcOKGAzxs0ni1zH/MJvkXqKXhRoJZMc8/YrTMYGaTBtnSAPQ+M28bMVp6ks2NZc5JGIMCWXJu32FjyWYCfjFsP/js4ZsyGzlQVH548+2wHD9788PHeLU0MLDBOUw8IJIZj3IQkGdA0sL4g4DqUTAKRsEoGJkAAEcETFuPL0+iAAAAAElFTkSuQmCC","orcid":"","institution":"African Stroke Organization","correspondingAuthor":true,"prefix":"","firstName":"Paul","middleName":"","lastName":"Bolaji","suffix":""},{"id":591845091,"identity":"30fff9a7-5894-40b3-b40b-a8d2fef49699","order_by":1,"name":"Adetola Emmanuel Babalola","email":"","orcid":"","institution":"Temple University","correspondingAuthor":false,"prefix":"","firstName":"Adetola","middleName":"Emmanuel","lastName":"Babalola","suffix":""},{"id":591845092,"identity":"bb938cac-fb39-4cc6-bc7d-02f7dffc5a56","order_by":2,"name":"Simon Fletcher","email":"","orcid":"","institution":"University of Kent","correspondingAuthor":false,"prefix":"","firstName":"Simon","middleName":"","lastName":"Fletcher","suffix":""}],"badges":[],"createdAt":"2025-09-23 01:53:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7687461/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7687461/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104582424,"identity":"6d964840-c564-425e-a35a-ff13c89c25ee","added_by":"auto","created_at":"2026-03-13 15:12:28","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":503057,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA FLOW CHART\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7687461/v1/231bb26d84f4b28cbeba84ed.jpeg"},{"id":104582255,"identity":"287ed670-2a9b-40ca-9ffe-37f3a7f5a2ff","added_by":"auto","created_at":"2026-03-13 15:12:15","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":142178,"visible":true,"origin":"","legend":"\u003cp\u003eShowing the key features of Adaptive Leadership [16]\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7687461/v1/3bf400af328c26205aecf887.png"},{"id":104582462,"identity":"ceab598f-cf0f-4337-bea8-450645b4b976","added_by":"auto","created_at":"2026-03-13 15:12:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1532719,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7687461/v1/c82677da-52fc-470b-81d8-c64c1cd984c2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Six Collective Leadership themes that underpin an Organised Stroke Unit: The Outcome of a Scoping Review","fulltext":[{"header":"Background","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eOrganized Stroke unit and Outcomes\u003c/h2\u003e \u003cp\u003eStroke remains one of the leading causes of disability and mortality worldwide, with the UK experiencing a high burden of stroke-related care needs. [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Effective management of stroke patients requires the coordinated efforts of multidisciplinary teams (MDTs) in an organised stroke unit. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eWhile Stroke can often be explained using the biomedical and pathophysiological basis of illness, it\u0026rsquo;s manifestation, the impact and experience by each patient are diverse and personal. This underscores the importance of the biopsychosocial approach and person-centred care [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatients with stroke are often left with significant disability, a change in their identity, activity limitation and restricted participation. The impaired functioning is not discrete but interwoven together affecting the whole person. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This myriads of impairments and activity limitations therefore need a biopsychosocial model of medical intervention which a single professional alone cannot achieve [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAn organised stroke unit consists of multidisciplinary professionals including stroke consultant or neurologist and the medical team, the Nursing staff, the Therapists (Physiotherapist, Occupational therapist, Speech and Language therapist), Psychologists, Dietician, Orthoptist, Dietician), healthcare workers, discharge coordinators and other admin staff. This component may vary based on the resources available. This Multidisciplinary Staff (MDT) also interact with other healthcare professionals who are affiliated with the stroke team, such as radiologist, diabetic nurses, cardiology team, Neurosurgical team and others. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eResearch has revealed that patient managed in stroke units compared to general ward have better outcomes. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. A recent systematic review and meta-analysis by Langhorne et al [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] has shown that patients who were managed in coordinated stroke units compared with general ward were more likely to be alive, at home, and independent in their daily activities of living a year after a stroke. These benefits were seen irrespective of the demography of the people with stroke. The best evidence was seen in a dedicated stroke ward, compared with other stroke units such as a mixed rehabilitation ward and mobile stroke ward. In this review and meta-analysis, the dedicated stroke unit was defined as Acute stroke unit, Stroke rehabilitation ward, or a comprehensive stroke unit that has both acute stroke unit and stroke rehabilitation ward. In a trial conducted in China, Stroke unit care was far more superior to general care [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo get expert evidence about the component of stroke unit care that improved patient outcome, Liao et al.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] sent questionnaires containing 107 items in a stroke unit to 83 European stroke experts, although there were disagreement on most of the component, there was a unified consensus that multi-disciplinary care, stroke trained nurses and 24/7 intravenous rt-PA protocols among a few others were very integral to the effectiveness of a stroke unit. Although these were expert opinions with low level evidence, it hints to the possibility that MDT care, protocolized care and empowering nurses to lead stroke call might be crucial in better outcomes seen in an organised stroke unit.\u003c/p\u003e \u003cp\u003eDespite the clear benefit of a coordinated and dedicated stroke ward [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], It is still largely unclear what component of stroke unit or even MDT care, contributes to the superiority of stroke unit. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Is it the skill set of professionals, the patient-centered care, improved communication, the regular MDT meeting, shared knowledge among MDT, protocolized care, team spirit or a relatively new concept called Collective Leadership, that makes the difference?\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eHealthcare Leadership Models and the need for Collective Leadership in Stroke\u003c/h2\u003e \u003cp\u003eHealthcare leadership has traditionally relied on hierarchical models, exemplified by the \u0026ldquo;great man\u0026rdquo; theory, where singular leaders hold ultimate responsibility [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, this model is increasingly unsuitable for addressing the complexities of contemporary healthcare environments, where collaboration and adaptability are essential [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEmerging evidence supports the effectiveness of shared, adaptive, and transformational leadership styles in enhancing team performance, fostering innovation, and improving healthcare delivery outcomes [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCollective leadership, a leadership theory proposed by Peter Gronn [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] is increasingly influencing the healthcare space, with emphasis on leadership being more of a collective social process rather than narrow and centralized between Individuals. There are few theories that underpin the concept of collective leadership which includes the distributed, shared and adaptive leadership theories [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCollective leadership is an approach where all team members share responsibility for decision-making, fostering mutual respect, trust, and accountability [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis style of leadership enhances psychological safety, enabling individuals to voice concerns, contribute ideas, and collaborate effectively [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In MDTs, collective leadership has been linked to improved team dynamics, reduced burnout, and better patient outcomes [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e The complexity of stroke care, involving interdependent tasks and high-stakes decision-making, highlights the importance of leadership approaches that promote inclusivity and shared accountability. Evidence from non-stroke healthcare settings indicates that collective leadership can improve communication, enhance decision-making, and foster a culture of continuous improvement [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. These benefits are particularly relevant for stroke units, where effective coordination among MDT members is critical for optimizing patient care.\u003c/p\u003e \u003cp\u003eThe concept of collective leadership among stroke MDTs therefore represents that acme of a highly effective MDT focused on addressing these multifaceted problems in a patient with stroke. Despite the potential advantages, the role of collective leadership within stroke MDTs remains underexplored. Preliminary research reveals limited studies directly addressing this topic, with most research focusing on traditional or general leadership models or using themes related to collective leadership without using the phrase \u0026lsquo;Collective leadership\u0026rsquo; [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis represents a significant gap in literature, as understanding and implementing effective collective leadership strategies might be crucial for the ongoing improvement of stroke care outcomes.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAims and Objectives\u003c/h3\u003e\n\u003cp\u003e This scoping review aim was to synthesize existing evidence on \u0026lsquo;collective leadership\u0026rsquo; or its related themes and its impact on MDT and patient related outcome in stroke unit. By mapping the current body of knowledge, identifying themes, and highlighting gaps, this review aimed to inform future research on how collective leadership might further enhance the overall outcomes of organised stroke care. It also sought to inform the stroke community on the relatively new concept of collective leadership and its importance in stroke medicine.\u003c/p\u003e \u003cp\u003eAs Langhorne et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] put it, the next studies on organized stroke units should focus on the factors in the organized stroke MDT that results in better outcome than a general ward. If we can determine that component, then we might be able to amplify those factors leading possibly to better outcomes in an organized stroke care.\u003c/p\u003e \u003cp\u003eThis review attempt to give a possible hypothetical answer that collective leadership might be integral to a success of a stroke unit.\u003c/p\u003e "},{"header":"Methodology","content":"\u003ch3\u003eLiterature Search\u003c/h3\u003e\n\u003cp\u003eSeven Databases were searched including PubMed, Google Scholar, ScienceDirect, Directory of Open Access Journals (DOAJ), African Journals Online (AJOL), and Cochrane Library. The Search strategy included the Medical Subject Headings (MeSH) and keywords including \u0026ldquo;leadership\u0026rdquo;, \u0026ldquo;collective leadership\u0026rdquo;, \u0026ldquo;multidisciplinary team\u0026rdquo;, \u0026ldquo;stroke unit\u0026rdquo;, \u0026ldquo;shared leadership\u0026rdquo;, \u0026ldquo;adaptive leadership\u0026rdquo;, \u0026ldquo;transformational leadership\u0026rdquo;, and \u0026ldquo;healthcare teams\u0026rdquo;. Boolean operators (AND, OR) were applied. The date of search was March 18, 2025, and the studies reviewed were in English only.\u003c/p\u003e\n\u003ch3\u003eInclusion Criteria\u003c/h3\u003e\n\u003cp\u003eStudies on MDTs in stroke units\u003c/p\u003e \u003cp\u003eArticles on collective, shared, adaptive, transformational leadership in stroke units\u003c/p\u003e \u003cp\u003ePeer-reviewed and grey literature\u003c/p\u003e\n\u003ch3\u003eExclusion Criteria\u003c/h3\u003e\n\u003cp\u003eNon-hospital stroke care\u003c/p\u003e \u003cp\u003eEditorials, opinion pieces, or commentaries\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eScreening Process\u003c/h2\u003e \u003cp\u003eA two-phase screening process was conducted using Rayyan software for transparency based on the inclusion/exclusion criteria.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePhase 1\u003c/h3\u003e\n\u003cp\u003eTitle and abstract screening were conducted to exclude irrelevant studies. The initial search yielded 1008 results. 56 Duplicates record were removed. A further 750 articles were excluded based on their titles and then left with 202 articles. 182 were then screened out, based on an abstract review with 20 articles remaining.\u003c/p\u003e\n\u003ch3\u003ePhase 2\u003c/h3\u003e\n\u003cp\u003eFull-text screening based on inclusion and exclusion preview. Nine full text articles were further excluded based on full text screening, with 11 articles remaining and used for the scoping review. Full-text articles were assessed for final inclusion. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData Extraction, Analysis and Reporting\u003c/h2\u003e \u003cp\u003eData was extracted using a standardized spreadsheet excel capturing:\u003c/p\u003e \u003cp\u003eStudy details: Author(s), year, country, Perceived leadership model, Study setting, MDT composition, Collective Leadership elements, Impact on MDT Functioning., Outcomes related to MDT effectiveness, Key themes or findings.\u003c/p\u003e \u003cp\u003eThematic synthesis was used to identify recurring themes and concepts. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] Based on our objectives, we extracted the most frequent recurring themes based on collective leadership from the 11 studies using a combination of deductive and inductive approach. Themes related to collective leadership framework were synthesized without having a specific framework in mind. The recurring coded themes of collective leadership were then inductively analysed into 6 recurring themes of collective leadership from the 11 articles included in our study. A narrative summary was used to highlight key findings, trends, and gaps.\u003c/p\u003e \u003cp\u003e The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used to guide reporting.\u003c/p\u003e \u003cp\u003e \u003cb\u003e2.5 Ethical Considerations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eNo primary data collection occurred therefore, ethical approval was not required. However, this study ensured proper citation of all reviewed materials to maintain academic integrity.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 11 studies met the inclusion criteria and were included in the final analysis. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThese studies, drawn from five different continents-coincidental, examined multidisciplinary stroke teams in various healthcare settings, including acute stroke units, rehabilitation wards, and general medical wards.\u003c/p\u003e \u003cp\u003eAlthough none explicitly used the term \u0026ldquo;collective leadership\u0026rdquo;. Many referenced closely related leadership models such as shared, collaborative, inclusive, or adaptive leadership or used elements related to collective leadership strategies as seen in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/p\u003e \u003cp\u003eEach study was analysed for\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePerceived leadership style or model\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSetting and composition of the MDT.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIdentifiable elements of collective leadership,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eImpacts on team functioning and\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePatient outcomes\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEmergent themes relevant to stroke care. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e The studies were diverse in design, including qualitative interviews, retrospective observational studies, randomised controlled trials, and systematic reviews.\u003c/p\u003e \u003cp\u003e Across the board, they provided insights into leadership practices that promote coordination, communication, and patient-centred care in stroke units.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eShowing Data Extraction Table with the recurring themes)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"14\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy ID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbridged Title\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAuthors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStudy Objective\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStudy Design\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePerceived Leadership Model\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSetting\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eMDT Composition\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eCollective Leadership Elements\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eImpact on MDT Functioning\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003ePatient Outcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c14\"\u003e \u003cp\u003eKey Themes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStroke Inpatient Rehabilitation Team Conferences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKushner \u0026amp; Strasser\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImprove team conference structure in stroke rehab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eScoping review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eShared / Co-leadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eInpatient Stroke Rehab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePhysicians, nurses, case managers, therapists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eEqual voice, empathy, structured team meetings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eEnhanced collaboration, improved structure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u0026uarr; FIM scores, \u0026darr; LOS, \u0026uarr; Discharge to home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eClarity of Vision and Roles\u003c/p\u003e \u003cp\u003eProblem Focused MDT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollaborative Interventions Reduce Time to Thrombolysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eZachary\u003c/p\u003e \u003cp\u003eet al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEvaluate Intervention to reduce time to thrombolysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRetrospective Observational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNot Inferred\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAcute stroke unit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eDoctors\u003c/p\u003e \u003cp\u003e(Neurology,ED\u003c/p\u003e \u003cp\u003eRadiology\u003c/p\u003e \u003cp\u003eNurses\u003c/p\u003e \u003cp\u003eStroke Performance Coordinator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eProtocol based care\u003c/p\u003e \u003cp\u003eRegular collaboratives\u003c/p\u003e \u003cp\u003emeeting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eImproved MDT meeting with Neurointerventional\u003c/p\u003e \u003cp\u003eNeurocritical care attendings\u003c/p\u003e \u003cp\u003eVascular Neurosurgeons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eReduction in time to thrombolysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eProtocolized Interventions\u003c/p\u003e \u003cp\u003eClarity of vision and Roles\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImplementation of Evidence-Based Stroke Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePurvis et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIdentify enablers and barriers to implementing evidence-based stroke care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eQualitative (interviews)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInclusive / Transformative Leadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAcute\u0026thinsp;+\u0026thinsp;Subacute Stroke Units\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eStroke Network Facilitator, Neurologist, Nurses, Therapists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNon-medical leadership involvement, protocol implementation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eImproved coordination, protocol adherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eConsistent intervention delivery, better continuity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eTeam Climate and Culture\u003c/p\u003e \u003cp\u003eStroke Adaptive Leader. Succession Planning\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNursing-led MDT for Stroke Rehab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDeng et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEvaluate effectiveness of nursing-led MDT continuous care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCollaborative Leadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eStroke Rehab\u0026thinsp;+\u0026thinsp;Home Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNeurologists, Rehab Nurses, Caregivers, Psychologists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNursing department leadership, structured roles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eCoordinated follow-up, seamless handoff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u0026uarr; FMA, \u0026uarr; QOL, \u0026uarr; MBI scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003ePatient centered Stroke MDT\u003c/p\u003e \u003cp\u003eStroke Adaptive Leader\u003c/p\u003e \u003cp\u003eClarity of Vision and Roles\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSwallowing Team Approach in Acute Stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAoki et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eJapan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAssess pneumonia reduction from team approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eProspective observational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCollective Leadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAcute Stroke Unit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eDoctors, nurses, PTs, OTs, speech, dieticians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eEarly communication, shared timing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eStreamlined interventions, faster decisions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u0026darr; Pneumonia incidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eProblem focused MDT Care\u003c/p\u003e \u003cp\u003eProtocolised Intervention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMDT Early Mobilization in SCU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOike et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eJapan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEvaluate MDT intervention for early mobilization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCollective Leadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAcute stroke unit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePhysicians, SCU therapists, engineers, nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eFacilitator role, protocol-based care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eImproved timing, cross-role efficiency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eEarlier mobilization, better safety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eStroke Adaptive Leader\u003c/p\u003e \u003cp\u003eProblem focused MDT Care\u003c/p\u003e \u003cp\u003eProtocolised intervention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerception Towards MDT In Stroke Rehabilitation:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBabur et al\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePakistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDetermine perception of MDT rehab professionals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eQualitative Focus group discussion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCollective Leadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eStroke rehab ward\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eRadiologist,\u003c/p\u003e \u003cp\u003ePTs,Ots,SALT\u003c/p\u003e \u003cp\u003eNutritionist, vascular surgeon\u003c/p\u003e \u003cp\u003eRehab specialist\u003c/p\u003e \u003cp\u003erehab nurse, Psychology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eInterdisciplinary Collaboration\u003c/p\u003e \u003cp\u003eCommunication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eUnderstanding of Roles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u0026uarr; Physical function and earlydischarge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eClarity of vision and Roles\u003c/p\u003e \u003cp\u003eTeam Climate and Culture\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse-led Stroke Assessment Guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHamilton et al.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEngland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEvaluate MDT compliance with stroke assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eQuasi-experimental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eOpinion Leadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAcute Medical Ward\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNurses, doctors, AHPs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSenior nursing leadership champions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigher compliance in AHPs vs medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eMixed outcomes, some resistance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eStroke Adaptive Leader\u003c/p\u003e \u003cp\u003eProtocolised Intervention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrganized inpatient (stroke unit) care for stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLanghorne et al\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eScotland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCompare Outcomes btw Stroke Inpatient Vs Alternatives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSystematic review/ Metanalysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNot Inferred\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eStroke Unit- Acute and/or Rehab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eStroke MDT- Not specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003emultidisciplinary team care and meetings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNo specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003epatient in stroke unit care likely to be alive,\u003c/p\u003e \u003cp\u003eindependent, and living at home one year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003ePatient Centered Stroke MDT\u003c/p\u003e \u003cp\u003eProtocolised Intervention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMulti-Disciplinary Stroke Care in Developing Countries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eJohnson et al\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGhana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOutlines the development of a specialist stroke service in Accra, Ghana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eProspective\u003c/p\u003e \u003cp\u003eObservational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCollective leadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAcute stroke unit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eDoctors, nurses, PTs, OTs, speech, dieticians, pharmacy, and psychology.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eOpen Communication\u003c/p\u003e \u003cp\u003eProbity\u003c/p\u003e \u003cp\u003eMotivation and reward\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eIncreased confidence to share Knowledge and skill\u003c/p\u003e \u003cp\u003eAnd communicate more effectively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eConsistent and Effective patient centred care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eSuccession Planning\u003c/p\u003e \u003cp\u003eTeam Climate and Culture\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrganized stroke MDT in resource limited\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdeniji et al\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCompare stroke outcome before and after stroke MDT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eretrospective, observational stu.y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eStroke MDT in a general medical ward\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eneurologist,\u003c/p\u003e \u003cp\u003eNeuro SPR Nurse,\u003c/p\u003e \u003cp\u003eOT, PT dietitians,\u003c/p\u003e \u003cp\u003epharmacists, clinical pharmacologists and stroke liaison staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eIntrateam communication through whatsapp\u003c/p\u003e \u003cp\u003eShared decision\u003c/p\u003e \u003cp\u003eSynergism of professional competencies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eImproved communication flow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eMore stroke patients discharged alive after intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003ePatient centred stroke MDT\u003c/p\u003e \u003cp\u003eTeam Climate and Culture\u003c/p\u003e \u003cp\u003eSuccession Planning\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSix recurring Collective Leadership Themes were identified from our thematic analysis in the 11 articles from Five different Continents that was reviewed\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe Stroke Adapative Leader\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eClarity of Vision and Roles\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePerson Centered and Problem Focused MDT\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eA Warm and Open Team Climate\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eProtocolized Intervention\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSuccession Planning and Team Empowerment\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eEach of these collective leadership themes were extracted from at least three of the articles, but averagely five of the articles.\u003c/p\u003e \u003cp\u003e \u003cb\u003eDiscussion: The Six Collective Leadership Themes\u003c/b\u003e \u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eA. Stroke Adaptive leader\u003c/h2\u003e \u003cp\u003eThe presence of an experienced, credible, trusted, emotionally intelligent and continually improving staff with clinical experience irrespective of professionalism was critical in the literature reviewed to drive the stroke MDT towards excellent stroke care. In this scoping review, various stroke MDT teams had designated person who demonstrated key leadership principles and steered the rest of the stroke MDT to a team related goal. For example, there was the \u0026lsquo;Opinion leader\u0026rsquo; [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], \u0026lsquo;Dedicated Stroke Performance Improvement Coordinator\u0026rsquo; [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], Stroke Network Facilitator ([\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], and Deputy director of Nursing\u0026rsquo; [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. There were mostly clinical but non-medical leaders and often from the nursing profession, who made sure that the Stroke MDT maintain a good standard of care by aligning them to the stroke guidelines and group goals in the hospital [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. They were vital in the stroke MDT irrespective of the setting. In China [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], the adaptive leader was the Deputy Director of Nursing who made sure assessments were adhered in the Stroke Rehab ward. In Australia [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], A Stroke Network Facilitator ensured the team adhere to evidence-based care in a comprehensive stroke unit(Acute Stroke Unit and Stroke Rehabilitation Ward), whereas a stroke improvement coordinator, an opinion leader and a facilitator nurse demonstrated adaptive leadership in Acute Stroke Unit [24,25,27)\u003c/p\u003e \u003cp\u003eThese leaders were trusted to facilitate the collective success of the stroke MDT team. For example, the Stroke Network Facilitator in a hospital with limited organization resources played an integral role in establishing and improving stroke unit care at the health services, through translation of policy into evidence-based practice. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eOne of the theories that underpin collective leadership is the concept of adaptive leadership which emphasizes what attributes a leader within a collective leadership model must possess. [16,28,29)\u003c/p\u003e \u003cp\u003eAdaptive leadership gives the framework and quality every leader should possess within the collective leadership space. They categorized the qualities into 4 components. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eEmotional Intelligence: Adaptive leaders are self-reflective and recognize their own strength and weaknesses.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCharacter: Being authentic without being harmful.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eOrganization Justice: Adaptive Leaders value considers the group goal first to make sure services are both efficient, cost effective and aligned with long term sustainability of organization.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDevelopment: Adaptive leaders engage in personal growth while implementing new strategies and improvement in the organization framework\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe stroke adaptive leader demonstrates a strong sense of integrity and maintains a sphere of influence over the team members. A stroke adaptive leader must also be obsessed with continual improvement of the stroke team to provide excellent and compassionate patient centred care [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThere is a tendency to assume that a stroke adaptive leader is akin to \u0026lsquo;the great man\u0026rsquo;s theory of leadership\u0026rsquo; where leadership is a \u0026lsquo;one-man show\u0026rsquo; rather than collective leadership.[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] However, this stroke adaptive leader is not in the spotlight, might not be the most knowledgeable or most experienced, but rather has credibility in driving the stroke MDT collectively toward continual improvement with a combination of humility and fierce resolve. [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eB. Clarity of Vision and Roles\u003c/h2\u003e \u003cp\u003eTeam related vision and roles delineation shared lucidly with all members of Stroke MDT, are important features of an effective Stroke MDT. In the qualitative focus group discussion by [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] clarity of vision was among the attributes in a highly effective stroke team.\u003c/p\u003e \u003cp\u003eA Stroke Adaptive Leader [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] might be crucial in communicating the vision clearly for the stroke MDT. This fosters a sense of collective purpose among the wider MDT. In Kotter\u0026rsquo;s change management framework,[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] communicating vision with clarity is crucial to team members embracing a new change in an organization. The vision goals need to be discussed frequently and embedded in activities of the stroke MDT team.\u003c/p\u003e \u003cp\u003eBeyond the clarity of vision is, the clarity of roles, In Kushner and Strasser\u0026rsquo;s [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] work on stroke inpatient rehabilitation conferences, the concept of teamness and Team effectiveness was introduced. Teamness is \u0026lsquo;how well the team works together. To build \u0026lsquo;teamness\u0026rsquo; and team effectiveness, clarity and understanding of each other\u0026rsquo;s roles is needed for accountability and avoid confusion.\u003c/p\u003e \u003cp\u003eIt is worthy of note that some roles may not be discrete and might overlap especially when a transdisciplinary approach is used in MDT based care. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] Nevertheless, clarity must be maintained where there is an overlap and where there is overlap or distinction of roles to avoid conflict and confusion among Stroke MDT.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eC. Person-centered and problem-focused Stroke MDT\u003c/h2\u003e \u003cp\u003eA Stroke MDT focused on delivering excellent and relevant stroke care in the best interest of the patient leads to improved functional outcome in a stroke unit.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] This is called the person-centred care as explained by Coulter and Oldham [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCollective focus towards excellent patient care leads to better outcomes in an MDT irrespective of the stroke setting either in general ward with stroke MDT or a stroke unit. [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] A person-centred stroke MDT in the randomized controlled trial by Deng et al [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] improved the quality of life and motor outcomes of patients.\u003c/p\u003e \u003cp\u003eThe stroke adaptive leader is important to ensure a person-centred approach by the stroke MDT. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] There is an equally sound argument about the need to make staff well-being a priority while delivering person-centred care.[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] as there is some evidence of a clear link between staff wellbeing and good outcome with person-centred care. [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eA person-centred MDT focused on addressing different activity limitations of patients or focused on improving systemic problems, might be beneficial in healthcare. [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] For example, the collaborative and MDT based Swallowing team in this review improved dysphagia in stroke patient in Japan. [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] The problem-based MDT conference tool called Manchester Multidisciplinary Meeting Model used in the scoping review on stroke rehabilitation inpatient conferences was shown to be more effective in-patient outcome compared to the standard MDT approach. Patient related benefits were seen in increased function independence measure (FIM) scores of patients at discharge. More patients were also discharged back to their homes in the community and length of stay were shorter. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eDifferent sub-MDT, created from a larger MDT working with an Holacratic ideology [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] might deliver interventions in diverse activity limitations in stroke patients such as communication, mobility, swallowing, continence, cognition, spasticity or mood of patients. Within a Stroke MDT, there might sub-teams created to tackle this activity limitations for example the MDT swallowing team from Japan who reduced complications of dysphagia in people with stroke. Problems identified might be system or process based rather than activity limitation. For example, a sub-team within the MDT might be created to improve Door to Needle time [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] or improve early discharges.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eD. A Warm and Open Team Climate and Culture\u003c/h2\u003e \u003cp\u003eA culture that is warm, with open communication in a flat hierarchical structure removes barriers within the stroke MDT, resulting in good and positive outcomes for the team and patient [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eA culture that emphasizes equal voice with empathy led to a positive social climate as demonstrated in the scoping review on stroke rehabilitation team conferences by Kushner and Strasser [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A great teamwork culture was perceived enabler to evidence-based stroke service in a comprehensive stroke Centre in Australia. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThere is some evidence that a positive approach to safety and errors called safety 2, reduce error and fosters team bonding with resultant effect on improved patient care. [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] while hierarchical communication in a healthcare team can affect training of doctors and hamper patient\u0026rsquo;s care. [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eE. Protocolized Interventions\u003c/h2\u003e \u003cp\u003e Standardized and organized stroke protocol and guidelines in this review were integral to the Stroke MDT. In the retrospective observational study conducted by Zachari et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] Eleven structured interventions were done to reduce to time to thrombolysis in an acute stroke unit. A clear stroke protocol in the acute stroke unit and stroke rehab improve the outcome of patients. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] Clear pathways and protocol will foster collective leadership and improve the efficiency of the stroke MDT.\u003c/p\u003e \u003cp\u003eProtocolised interventions in stroke help standardise care. It also reduces overt dependence on few experts. It can be helpful in teams with junior or new staff. For example, a TIA Clinic template developed in my local unit has helped boost the confidence of our resident doctors to run an often-difficult TIA Clinic Service which was initially overtly dependent on Senior Doctors. [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e While protocols, local guidelines and standard operating procedures are useful, it must be clear, simple and accessible. Protocols must also be swiftly generated without the delay from bureaucratic processes. [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eF. Succession Planning and Team Empowerment\u003c/h2\u003e \u003cp\u003eAnother key theme of collective leadership in a Stroke MDT is sustainability of an effective Stroke MDT through mentorship, training of stroke adaptive leaders [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. A key strategy in the development of stroke unit in Ghana, West Africa [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], was appointment of deputies within the leadership of the Stroke unit. This was very important to maintain longevity and continuity of optimal patients care in the stroke unit as demonstrated in Nigeria. [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eSuccession Planning is imperative in the healthcare setting including the stroke MDT who seeks to maintain high quality care over a period. [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] This might be enhanced through diverse styles through mentorship, coaching, training or supervision in a structured format called the mentoring umbrella. [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eEmpowering Teams with knowledge and continual training ensures that the long-term vision of the team is perpetuated when the early drivers of the vision are no longer there. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e A stroke team culture focused on team building, continual improvement, and succession planning is critical in reducing barriers towards sustained delivery of evidence-based care. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCollective Leadership in Stroke MDT incorporate the concepts that \u0026ldquo;every mind\u0026rdquo; is utilized to the best of their ability [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. A stroke MDT with collective leadership is problem-focused and patient-centred [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Conflicts are resolved within a collective framework, diversity of opinion and perspective are encouraged, the patient and staff feel valued leading to good outcome in patient care. [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThese six collective leadership themes drawn from rigorous review of literature with in-depth review of 11 articles from 5 different continents appear to the consistent across board. Although the phrase \u0026ldquo;collective leadership\u0026rdquo; was not directly used in any of the reviewed studies, the presence of its core attributes was consistently present most of the articles reviewed. Stroke MDTs exhibiting these principles had improved communication, cohesion, and patient outcomes from our review.\u003c/p\u003e \u003cp\u003eIt is worthy of note that there was a paucity of literature that addressed leadership in stroke MDT. Also, none of the full report literature reviewed used \u0026lsquo;Collective leadership\u0026rsquo; as a phrase. However, other synonyms and the concept and themes surrounding collective leadership were extrapolated. This scoping review therefore highlights a gap in leadership-specific research in stroke care and suggests the need for in-depth studies in collective leadership in the stroke MDT.\u003c/p\u003e \u003cp\u003eThere are potentials limitation to this work. This was a scoping review where qualities of studies reviewed was not analysed as there were even few relevant literatures on collective leadership in stroke. Also, our search could have potentially left out some publications as different terms could have been used for leadership or stroke MDT. In-depth Snowballing could have helped to identify other relevant articles. [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] However, as stated by Doyle [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], a systematic review of qualitative studies should aim for interpretative explanation rather than predictions, therefore, it does not always have to be exhaustive but rather purposive. Our final selected eleven article from 5 different continents (a surprising coincidence) with six recurring themes might potentially validate the generalisability and replicability of these themes in the wider stroke population.\u003c/p\u003e \u003cp\u003eThe way forward from here will be to validate the six collective leadership recurring themes either through quality Improvement framework, prospective studies, or a well-designed step wedged randomised controlled trial. Future studies should determine whether these six collective leadership elements, when implemented as a bundle, can further improve outcomes compared with usual practice in stroke units.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; BMC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBioMed Central\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; DOAJ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDirectory of Open Access Journals\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; ED\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmergency Department\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; FIM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFunctional Independence Measure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; LOS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLength of Stay\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; MDT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMultidisciplinary Team\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; MeSH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMedical Subject Headings\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; OT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOccupational Therapist/Therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; PT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePhysiotherapist/Physical Therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; QOL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eQuality of Life\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; RCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRandomized Controlled Trial\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; SCU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStroke Care Unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; SALT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSpeech and Language Therapist/Therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; TIA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTransient Ischemic Attack\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eNot applicable. This study is a scoping review of published literature and did not involve human participants, human data, or animal subjects.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable. This manuscript does not contain data from any individual person.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eAuthors\u0026rsquo; information\u003c/h2\u003e \u003cp\u003eDr. Paul Bolaji is a consultant physician in stroke medicine with a focus on service development and multidisciplinary care. He has a master\u0026rsquo;s in healthcare leadership from the University of Warwick, and this manuscript was an outcome of his master\u0026rsquo;s thesis. He is currently an executive member of the African Stroke Organisation, and he is keen on stroke units\u0026rsquo; capabilities and improvement in Africa and beyond.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors received no financial support for the research, authorship, or publication of this article.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eP.B (Paul Bolaji) conceived and designed the study. P.B and A.B conducted the literature search, data screening, and extraction. P.B drafted the manuscript. S.F critically reviewed and revised the manuscript. All Authors read and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThe authors would like to thank the institutions and libraries that provided access to the databases used for this scoping review.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data generated or analysed during this study are included in this published article and its supplementary information files.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMurphy SJ, Werring DJ. Stroke: causes and clinical features. Med (Abingdon). 2020;48(9):561\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharma R, Lee K. Stroke therapies: what\u0026rsquo;s new in 2025? BMJ. 2025;389:e076161.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLanghorne P, Ramachandra S, and Stroke Unit Trialists\u0026rsquo; Collaboration. 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Synthesis through meta-ethnography: paradoxes, enhancements, and possibilities. Qualitative Res. 2003;3(3):321\u0026ndash;44. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1468794103033003\u003c/span\u003e\u003cspan address=\"10.1177/1468794103033003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Collective leadership, Multidisciplinary team (MDT), Organised stroke unit, Stroke care outcomes, Team culture, Adaptive leadership, Person-centred care, Healthcare leadership models","lastPublishedDoi":"10.21203/rs.3.rs-7687461/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7687461/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThere is overwhelming evidence that an organised stroke unit compared with a general ward improves survival, disability, and discharge destination to home after stroke. What is unknown is which component of the organised stroke unit leads to the benefit. Collective leadership, a leadership theory proposed by Peter Gronn, is increasingly influencing the healthcare space, with an emphasis on leadership being more of a collective social process rather than a narrow and centralized one between Individuals. Collective leadership, hypothetically, might be integral to the success of an organised stroke unit.\u003c/p\u003e \u003cp\u003e This scoping review, therefore, aims to synthesize existing evidence on \u0026lsquo;collective leadership\u0026rsquo; and its related themes, as well as their impact on MDT and patient-related outcomes in the stroke unit. It also seeks to introduce the concept of collective leadership to the stroke community.\u003c/p\u003e \u003cp\u003eA systematic search was conducted across seven databases, including PubMed, Google Scholar, and Cochrane Library, with studies screened using Rayyan software. Eleven studies met the inclusion criteria. Thematic synthesis was used to extract and analyse recurring leadership elements and themes relevant to stroke MDTs.\u003c/p\u003e \u003cp\u003eWhile none of the included studies explicitly used the term \u0026ldquo;collective leadership,\u0026rdquo; all identified features aligned with its core principles. Six themes emerged: Presence of an adaptive stroke leader, clarity of vision and roles, person-centred and problem-focused MDTs, a warm team culture and climate, protocolised interventions, and succession planning. These elements in the stroke unit and MDT are associated with improved communication, streamlined decision-making, and better patient outcomes.\u003c/p\u003e \u003cp\u003e This review highlights that although not overtly labelled, collective leadership principles are inherent in effective stroke MDT practice. This finding shows a gap in explicit leadership research in stroke care, suggesting that structured implementation and evaluation of collective leadership strategies may enhance team performance and patient outcomes.\u003c/p\u003e \u003cp\u003eFuture studies should incorporate these six leadership themes as a bundle to see if it further enhances the quality of stroke care in an organised stroke unit, especially in developing countries like Africa, where the majority of these collective leadership strategies may be absent.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e","manuscriptTitle":"The Six Collective Leadership themes that underpin an Organised Stroke Unit: The Outcome of a Scoping Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-13 15:11:40","doi":"10.21203/rs.3.rs-7687461/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-01-09T21:34:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8999785111016896762549634138238849159","date":"2026-01-04T23:56:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-29T15:17:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"268371168818227059369677594955355351316","date":"2025-12-23T17:40:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-04T19:27:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-25T05:51:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-25T05:51:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-09-22T19:26:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ed0a96c7-d6db-48f0-8e73-412c8e3eaeb0","owner":[],"postedDate":"March 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-13T15:11:40+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-13 15:11:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7687461","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7687461","identity":"rs-7687461","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}