Towards an Informal Leadership Framework for Interprofessional Primary Care: An Interview Study Among Healthcare Leadership Experts

Towards an Informal Leadership Framework for Interprofessional Primary Care: An Interview Study Among Healthcare Leadership Experts | 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 Research Article Towards an Informal Leadership Framework for Interprofessional Primary Care: An Interview Study Among Healthcare Leadership Experts Loreen Mathilda Hendrikus Merx, Anneke Dijk-de Vries, Marja Y Veenstra, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7085121/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 12 You are reading this latest preprint version Abstract Background The growing number of frail older adults in the Netherlands necessitates robust interprofessional collaboration in primary care to ensure person-centred, high-quality care. In non-managed primary care teams, strong leadership is essential to support team development, coordination, and decision-making. However, there is a lack of clarity about appropriate leadership approaches and the role of the general practitioner (GP) in such teams. This study aims to explore relevant leadership theories and examine the role of the GP in fostering interprofessional collaboration in primary care teams serving frail older adults. Methods A qualitative study was conducted using semi-structured interviews with ten healthcare leadership experts. The data were analysed thematically using an inductive approach to identify key elements of leadership in interprofessional primary care settings. Results The study found that non-managed interprofessional primary care teams require informal leadership, which is captured in the proposed Framework for Informal Leadership in Primary Care (FIL-PC). This framework comprises four key leadership roles—initiator, visionary, tutor, and overseer—that together support effective collaboration, shared responsibility, and ongoing learning. While GPs are well-positioned to take on these leadership roles, they may not yet fully recognize or embrace this potential. Conclusion Informal leadership is crucial for effective interprofessional collaboration in non-managed primary care teams. The FIL-PC offers practical insights into necessary leadership behaviours and can guide teams in improving collaboration. Future research should investigate the framework’s feasibility and explore educational strategies to support its implementation. Interprofessional collaboration leadership primary care older adults qualitative study Figures Figure 1 Background The number of Dutch citizens aged 75 years and older is expected to rise significantly by 2040. In this population, one in five is considered frail, incurring healthcare costs up to five times higher than non-frail peers ( 1 , 2 ). Within this group, delivering person-centred care —defined as integrated, function-oriented care based on patients' personal health priorities— relies on robust interprofessional collaboration among primary care professionals ( 3 , 4 ). Without interprofessional collaboration, older patients with multimorbidity risk conflicting advice, contradictory interactions, and unnecessary treatments ( 5 ). In the Netherlands, non-managed interprofessional teams of primary care professionals collaborate across organizational boundaries at the local community, often relying on informal or loosely defined arrangements. This fragmented structure highlights the need for strong coordination and clear interprofessional agreements to ensure efficient, cohesive care delivery ( 6 ). This article examines team-based collaboration in these interprofessional non-managed primary care teams at the clinical and professional integration levels ( 7 ). At these levels, teams deliver direct patient care and coordinate care for specific groups (e.g., frail older adults) at local communities through team meetings and ad hoc consultations, in both acute and chronic care situations. This article does not address the organizational or system integration, in which networks of different care and social service providers collaborate towards seamless care across regions or communities ( 7 ). Improving effective teamwork and coordination in primary care seems crucial, as it can contribute to a more sustainable healthcare system that delivers high-quality care and is better equipped to cope with the rising demand for care ( 8 – 11 ). Moreover, there is evidence that team functioning is an important predictor of stress levels, and that stressed professionals produce inferior care ( 12 ). Regular interprofessional team meetings support professionals in building relationships and developing joint care plans. While these meetings aim to improve collaboration ( 13 , 14 ), their effectiveness and focus on person-centred care often fall short, with participants overestimating their team’s performance ( 15 , 16 ). Effective teamwork extends beyond meetings focused solely on the day-to-day discussion of patient care (clinical integration). It also encompasses coordinated efforts among various professionals to address community healthcare needs (professional integration). This requires active facilitation of team development over time ( 7 , 17 ). Research highlights leadership as a key factor in effective interprofessional teamwork ( 18 , 19 ). Leaders in the context of interprofessional primary care teams should promote person-centredness, structure and organization, and team development over time ( 20 , 21 ). Team development over time needs interprofessional leadership regarding effective collaboration, decision-making, and team cohesion ( 22 , 23 ). However, Brewer et al. show in a scoping review of 114 studies on leadership in interprofessional education and practice that ‘leadership’ was defined in less than 25% of the studies and required interprofessional leadership competences were often unspecified ( 21 ). Contemporary leadership theories emphasize collective, transformational, and relational approaches in interprofessional primary care teams, rather than traditional hierarchical models ( 24 , 25 ). While strong qualitative evidence highlights the importance of leadership, there is no clear evidence on which type of leadership is most effective for integrated care. ( 23 , 26 ). In addition to questions about the most suitable leadership theory for interprofessional care for older adults, perceptions differ regarding the general practitioner’s (GP’s) leadership role within the interprofessional team ( 27 ). Health and social care professionals view GPs as central figures in developing and implementing joint care plans. They tend to attribute GPs a traditional, hierarchical leadership role due to their ability to see ‘the bigger picture’, their capability of networking strategically and their continuous role in providing care of frail older individuals ( 23 , 27 ). Some studies advocate for GPs to take the lead in reforming primary care ( 28 – 30 ). Grol et al. found that successful non-managed teams often have a GP taking the lead. However, many GPs seem to be unaware of their crucial role in promoting and fostering interprofessional collaboration ( 27 ). Additionally, other professions may also hold leadership roles within interprofessional care ( 31 ), but uncertainties remain about how this manifests in practice and how it aligns with the GP’s responsibilities. To summarize, strengthening leadership is essential for improving effective interprofessional collaboration, reducing stress, and ensuring integrated, high-quality care for vulnerable older patients. However, there is still limited clarity regarding the most suitable leadership approaches in primary care. While GPs are often seen as natural leaders, their role in interprofessional collaboration is not always clearly defined, and leadership responsibilities may also extend to other professionals. Methods This study aims to deepen the theoretical understanding of team leadership in interprofessional collaboration for frail older adults in primary care and clarify the GP's leadership role. Our research question is: 'Which leadership theories are deemed most appropriate by experts in primary care teams, and what role does the GP play?’ A thematic analysis was employed, following the principles of Braun and Clarke ( 32 ), to develop a deeper theoretical understanding of team leadership and the leadership contribution of GPs in interprofessional care for frail older people, based on expert opinions. This method was chosen due to the lack of clarity surrounding existing theories. Data was collected through semi-structured interviews. Participant recruitment In the Netherlands, all patients are registered with a GP, who manages medical issues and refers to secondary care when necessary. The core values of Dutch GP care are personalized, continuous healthcare, a generalist perspective, and collaborative care ( 33 ). To ensure expert input within the Dutch primary healthcare context, we used criterion sampling, selecting experts based on two criteria: 1) having scientific expertise regarding leadership within healthcare and 2) being able to apply their leadership knowledge to Dutch primary healthcare practice. We compiled a list of potential experts by contacting Dutch organizations (e.g. The Dutch College of General Practitioners (NHG) and Erasmus Economics & Business Executive Education) and leveraging researchers’ personal networks. This list was validated by a sounding board group experienced GPs and researchers in interprofessional collaboration. During the iterative process of data collection and analysis, we additionally included targeted experts through purposive sampling. Inclusions ceased upon reaching data saturation. We included experts from various fields, including healthcare business and change management, nursing leadership, leadership in public health, and integrated long-term care. Due to the need to ensure the anonymity of the experts, we do not provide further details regarding their areas of expertise. We approached 12 experts for this study. One declined due to a busy schedule, and another deemed herself unqualified after receiving further clarification and our inclusion criteria. Ultimately, 10 experts participated; 5 of whom were women (50%). As no new information or themes emerged during the eighth interview, we assumed that data saturation had been reached. To ensure the robustness of our findings and avoid premature closure, we conducted the already scheduled ninth and tenth interviews. These interviews further confirmed that no additional insights or variations arose, reinforcing our conclusion that data saturation had been achieved. Data collection Between December 2021 and March 2022, nine interviews were conducted via Zoom, and one by telephone. Due to travel distance, online interviews were chosen. Prior to each interview, participants received an overview of the context of interprofessional teams in Dutch primary healthcare, which was reviewed at the start of the interview to ensure alignment on the leadership discussed. All interviews were audio-recorded and transcribed verbatim with participants’ permission. The semi-structured interviews were conducted by researcher LM, using an interview guide developed from a topic list [see Additional file 1] based on existing literature on healthcare leadership, leadership theories, and interprofessional collaboration in primary care. Data collection and analysis were iterative. After each interview, the transcript was coded and analysed by LM and AvD, and the interview guide was adjusted as needed. All interviews were in Dutch, except for one in English, and lasted between 33 and 65 minutes. Coding and analysis Two researchers (LM and AvD) independently coded the verbatim interview transcripts using a thematic analysis approach. Coding and analysis followed an inductive process, progressing from open coding to the identification of overarching themes and patterns ( 32 ). The researchers discussed their codes iteratively until consensus was reached. During the analysis, memos were written to document emerging insights and analytical reflections. The memos, coding tree, and overarching themes were reviewed with researcher LvB to refine the analysis. For credibility, the overarching themes were shared with all experts for member checking. Experts confirmed the accuracy of these findings without providing significant additional feedback. As the final step of the analysis, the identified themes were abstracted and conceptualized into a framework. Results This results section is organized into three parts: leadership theories identified by experts for interprofessional primary care teams, key domains and roles of informal leadership in primary care (as outlined in the Framework for Informal Leadership in Primary Care - FIL-PC), and the leadership contributions of GPs in these teams. Leadership theories applicable to interprofessional primary care teams All experts emphasized that interprofessional primary care teams in the Netherlands lack a formal leader, as team members work for separate organizations within the country's decentralized primary care system. E4: "They may collaborate around a patient, or they collaborate at community level, because they all have a certain expertise, but they do not collectively form a formal organization with a clearly designated leader." Experts explained that since existing leadership theories in scientific literature have been developed for formal leadership, these theories cannot simply be applied to informal leadership in interprofessional primary care teams. E2: "You work with equal professionals, so anything tending towards hierarchical leadership can be forgotten." E2: "Well, the most important point is, I think... it's all about informal leadership." Nevertheless, experts identified aspects from existing leadership theories that are important to consider, as these are closely linked to the following three key characteristics of informal interprofessional teams delivering primary care for older adults (see also Table 1 ): 1. Dynamic context and Complexity in interprofessional collaboration Primary care for older patients is a dynamic environment where professional involvement constantly shifts, requiring ongoing adaptation of leadership. In each situation, team members should assess the most appropriate leadership style and agree on the team member best suited for the role. This aligns with situational leadership theory. E3: "You don't have the time and the means to endlessly debate things; you have to make decisions and act at times. Someone needs to be admitted to the nursing home tomorrow, so something needs to happen. Some degree of situational direction is needed, so, situational leadership. Knowing when to take charge, when am I in the lead?" Experts also referenced complex adaptive leadership theory, noting that interprofessional collaboration can be seen as a complex system where stakeholders should follow a framework of rules and agreements. This framework should support emergent processes, which depend on the specific case and team dynamics. One expert compared this to a flock of birds, moving together based on implicit rules. E8: "But those few sets of simple rules enable the group to connect with each other. This concept has increasingly been translated into social structures, such as teams, where a few simple agreements are clear agreements. [...] Within that set of rules, all professionals can exercise their autonomy and responsibility, and you can then see how these interaction rules at the group level influence the entire group’s response." E10: "Yes, that’s complexity theory. It’s about how you get large groups of diverse elements to come into and remain in sync with each other, while also allowing for change so that it isn’t something fixed. Complexity theory is, therefore, the ability to anticipate." 2. Balancing Equality and Accountability Experts emphasized that providing care for older patients requires contributions from all professionals. To ensure older adults perceive their care as integrated, professionals must collaborate to bridge rigid disciplinary boundaries. This aligns with connecting leadership, which unites individuals around shared goals, values, and visions, and focuses on fostering an environment where individuals can support and inspire each other, enabling effective collaboration. Networking leadership complements this by establishing strategic connections with key stakeholders, such as home care and welfare organizations. Together, these leadership approaches create a foundation for integrated care, ensuring cohesive and well-coordinated experiences for vulnerable older patients. E5: "You need a leader who is highly capable of connecting people, someone who can understand the interests of others and see the bigger picture." Experts also highlighted shared leadership theory, emphasizing that leadership should be distributed among team members. Professionals collaboratively contribute to patient care based on individual needs, with all team members regarded as equals. A shared responsibility is therefore required, even though leadership tasks may vary depending on the situation and timing. E10: "That's how it works. It's not like, "You are the leader, and I'm not." So, it's continuously evolving. And that is the essence of leadership, collectivity, and continuously being aware of yourself and others in the ecosystem and being able to move forward together in that. [...] How do you then switch, you know? And leadership from a nurse, or from a physiotherapist, or from the pharmacy... So, leadership in today's context is inherently shared by definition. It's continuous, but it fluctuates constantly." However, experts also expressed concerns about the challenges of the shared leadership approach. They fear that sharing leadership may compromise both responsibility and accountability. Responsibility refers to the duty to manage or oversee certain tasks, while accountability refers to being answerable for the outcomes or consequences of those tasks. E2: "At some point, someone has to be accountable. And I think that when the physiotherapist takes on the role of 'I am the leader in this plan now', then the physiotherapist must truly be accountable for that and be able to hold others accountable for it. And with shared leadership... Well, shared is halved, right? Literally. It becomes less and less. So then that responsibility fades away." Furthermore, some experts questioned whether all disciplines are adequately prepared for this approach. E8: "I'm not sure that everyone has learned to bear those responsibilities in their basic education. Shared leadership and distributive leadership are things that I am a big fan of, but I'm not sure if this can work already... " 3. Cultivating a Learning Culture Experts stressed the importance of fostering a learning culture within interprofessional primary care teams. To achieve common goals and fully utilize each other’s expertise, team members should inspire and influence one another —a principle rooted in transformational leadership. E8: "This is what is known as transformational leadership, in which the leader […] helps employees rise above themselves." E1: "It’s about thinking beyond boundaries, adapting, and inspiring. That’s where transformational leadership comes into play." Leveraging and allowing everyone’s talent to flourish is also associated with the principles of servant leadership. Experts emphasize that leadership should not only serve the patient, but also the various professionals in the interprofessional team. E4: "That you realize that people all bring their own perspectives into the team and can each have a valuable contribution in ensuring that such a team functions optimally. And when you provide space for those different perspectives, it offers insights that can help the team function as optimally as possible. Essentially, you are leveraging the knowledge that exists throughout the entire team." Table 1 summarizes the aspects of existing leadership theories that experts have identified as important to consider for effective leadership in interprofessional teams in primary care. Table 1 Overview of applicable aspects of existing leadership theories according to experts Leadership theory Description Situational leadership Adaptive, based on the situation, team members’ competences and teams’ maturity. Complex adaptive leadership Guides collaboration through simple rules balancing autonomy and coordination in dynamic situations. Network leadership Builds strategic stakeholder connections to achieve goals and enhance collaboration. Connecting leadership Unites individuals around shared goals, values, and vision, fosters a collaborative environment. Shared leadership Distributes leadership across a team, enabling collective decision-making. Transformational leadership Inspires and motivates team members to achieve higher common goals and fosters a learning culture. Servant leadership Empowers team members by valuing their perspectives and contributions to optimize team performance. Framework for Informal Leadership in Primary Care (FIL-PC) Experts emphasized the importance of informal team leadership for the optimal functioning of interprofessional primary care teams. From the responses provided by experts, we identified four key domains in which effective leadership is deemed crucial to support the continuous development of the team and to achieve high-quality, person-centred care for frail older adults. Through our analysis, we conceptualized these domains into four distinct leadership roles: initiator, visionary, tutor, and overseer. Experts concurred that this leadership in each domain should be assumed by professionals identified as most suitable through mutual agreement within the team and who are committed to a long-term affiliation with the team. Although the four roles must remain consistently assured, they do not need to be addressed in equal measure at all times. Teams must learn to discern which issues and situations require a particular leadership role, resulting in a continuous fluctuation in the expression of these roles. Based on these experts’ insights, we synthesized a Framework for Informal Leadership in Primary Care (FIL-PC), integrating leadership theories and roles crucial for effective interprofessional collaboration for frail older adults in primary care. The framework is presented in Fig. 1 . The proper application and allocation of these leadership roles helps strengthen leadership within an interprofessional team in the essential and challenging domains of interprofessional primary care: the dynamic context and complex collaboration, addressing equality and responsibility, and fostering a learning culture. This is considered to be necessary to pursue sustainable and effective interprofessional collaboration, which is required for high-quality, person-centered care for vulnerable older adults. The four team transcending leadership roles are explained as follows: Initiator Interprofessional teams need an initiator to foster team spirit and encourage a shared responsibility for person-centred care. Experts emphasized the importance of intrinsic motivation and collaboration, with the initiator playing a key role in nurturing these qualities. E4: "That you indeed want a transformation from a care system that is mainly focused on individual healthcare providers doing their job well to recognizing that it is a collective effort. Working interprofessionally as a collective ultimately determines whether a patient experiences adequate care or not. I think that is already a transformative step. It's a whole different awareness, one that not everyone in healthcare has made yet. That we are truly part of a collective." An expert described the following process: Firstly, all distinct team members should recognize that they form a team together. Secondly, they should be aware of their shared responsibility to learn with and from each other and to provide high-quality care. Thirdly, they should give substance to this shared responsibility. Experts stressed that the initiator's role is crucial not only for initiating and facilitating team transformation but also for sustaining it over time. They noted that, based on their experience, the quality of interprofessional collaboration often deteriorates when the initiator's presence is no longer maintained. E7: "It [the quality of collaboration] remains consistently high when the team initiator is present. And the quality of care continues to improve. So, at a certain point, you've reached a certain level of collaboration. [...] And sometimes it suddenly declines. [...] That's when the team initiator is absent. No, you need to keep that person. They don't have to do much. They just need to occasionally ensure that the network comes together every now and then. That's what we've observed." An expert warned that uneven power dynamics could emerge if a single team member consistently takes the initiator role. While shared leadership was encouraged, this type of leadership risks making tasks related to planning, execution, and accountability optional. To avoid this, most experts agreed that significant changes should be led by one or two professionals, who provide ongoing support to motivate and engage the team. E8: " ‘For example, psychologist, (…), you are entrusted with the responsibility to monitor this and, if things go off track, to call a team meeting to discuss the issue before it escalates.’ If no one explicitly gets or takes that responsibility, it will not happen." Visionary The experts discussed the need for interprofessional teams to have a clear vision. Therefore, team leadership includes a visionary role to ensure a joint formulation of a team vision and corresponding SMART goals as well as working rules, values and norms and a plan for evaluation. E4: "And then, you formalize certain responsibilities within the more informal team or the informal organization that you create together. However, this represents a dynamic, negotiated situation within which you operate." Experts stressed the importance of setting up these views together as a team, as this process contributes to team members' intrinsic motivation and sense of shared responsibility. A visionary should also ensure that all professionals experience space to perform their work sufficiently and autonomously. E8: "Uhm, and that provides a certain degree of autonomy through shared responsibility and freedom, which in turn motivates people to participate. It’s not a strictly controlled management approach, where you essentially have a manual for every action. If you don’t have freedom, you are also not motivated to engage when you observe something happening..." Tutor All experts highlighted the crucial role of a tutor within interprofessional teams. The tutor facilitates collaboration and team learning, monitors the achievement of shared goals, and ensures regular evaluation of the partnership. Experts noted that team members often fail to fully utilize each other’s expertise and stressed the importance of learning from one another to better leverage individual strengths. They also emphasized that long-term collaboration frequently occurs without proper evaluation, which is essential for maintaining quality and fostering continuous improvement in teamwork. E4: "So, I think there are teams and constellations of collaborations at the local community level that can satisfactorily perform their work for years without ever getting to reflect on how they can learn from working together. And then, you not only miss the opportunity to learn together to improve, but I think at some point, it even becomes a danger to whether you are still doing well together." For evaluation, a safe learning climate is necessary. A tutor should be responsible for creating this safe learning climate in which every team member feels comfortable contributing actively and proposing initiatives. Overseer Experts unanimously agreed that every interprofessional primary care team requires an overseer to maintain an overview of potential team challenges, particularly those involving tasks with unclear responsibilities. E3: "The oversight role. [...] There are many tasks for which it's not very clear whose responsibility it is, but it's more about ensuring that it gets done. And that you know from each other who does what. So, delegating might not be entirely the right word, but I think structuring is more appropriate in primary care." Overseers are responsible for managing both case-specific and team-level issues, taking on necessary responsibilities as needed. As the main point of contact when a case becomes (too) complex, they should also be empowered to make treatment decisions. Experts noted that overseers use their knowledge, experience, and network to either support or take over the coordination of the case. In some instances, they may grant mandates and help other professionals assume responsibility. With a broad perspective on the team’s work, overseers understand each member’s expertise and play a central role in the professional network within the community. Leadership contribution of GPs Experts underlined that the four leadership roles should be assigned to the most appropriate team member or members, depending on profession, competencies, personality, context and situation. E6: "It is about recognizing that there are different moments when certain people take the lead, while others step back. But it is also about moving away from the idea of having the leader, the heroic leader, as the solution to problems." While the focus should be less on 'who' assumes these roles, experts advised to perform the leadership roles by team members who are committed long-term. They highlighted the central role of GPs, who hold a key position in the Dutch healthcare system, provide generalist care, are accessible 24/7 for patients and caregivers, and are accustomed to bearing final responsibility for patient care. Given these attributes, GPs are deemed indispensable within interprofessional teams, ensuring coordinated and comprehensive care. In terms of the four leadership roles, the experts noted that GPs may be best suited for both the initiator and overseer leadership roles. The designation of GPs as initiators can be explained by power dynamics between GPs and other healthcare professionals, which have evolved over time but continue to exert influence today. E10: "The role of the physician can be crucial to the success or failure of such regional multidisciplinary rule systems. If the physician doesn’t participate, it simply won’t happen." Experts highlighted GPs as the most convenient team members to influence other professionals. Therefore, experts advised leveraging this unique position effectively. However, according to some experts, GPs themselves may not always be aware of their distinct role, emphasizing the need for increased awareness. E7: "And this is really important for GPs to realize, as they are often at the top of the hierarchy among primary care professionals. Everyone still looks up to the GP, even though the GP may not be aware of this. So, when a GP asks you to do something, everyone is inclined to join in. For example, community nurses […] are very eager to collaborate with GPs, but often struggle to gain access to them. So, if a GP asks you to join their network, I can guarantee that not a single community nurse would say, 'No, I won’t do that." GPs are also likely to assume the role of overseer, given their comprehensive medical knowledge, generalist approach, habitual assumption of responsibility, and experience in conferring authority. E3: "It’s not necessarily the case that the physician has to be the leader, but often they are the one where knowledge converges, and they likely have the most comprehensive understanding. (...) This is because the GP has such a broad perspective and can take diversity into account, considering medical, social, spiritual, and participation aspects. I think GPs are well-suited to assess these different dimensions. So it’s logical for them to take a leading role." Furthermore, experts emphasized the increasing need for GPs to empower other professionals to take on leadership responsibilities. Some other professionals may hesitate to step into leadership roles due to traditional hierarchies, ingrained attitudes, or a lack of confidence in their abilities. E8: "Take, for example, nurses (…). They graduate with a wide range of competencies, yet still often have an attitude of waiting for the physician’s direction. So, considering the direction of healthcare and the shift towards shared responsibility, I believe it is the role of the physician, as a leader within a team, to teach others to take on that responsibility." It is possible that GPs, alongside their possible roles as overseers and initiators, could also contribute to other leadership roles. However, experts unanimously agreed that a leader's personality and competencies must align with the specific requirements of the role to ensure effectiveness. Other team members may be better suited for certain roles. For instance, not every GP may be suitable for the tutor role, as illustrated by the following quote: E7: "A physician is still somewhat trained with the mindset of, ‘I’ll figure it out. I know best. I’ll tell the others how it should be done.’ We noticed this in those networks as well. Connecting leadership is much more about asking questions, like, ‘Oh, what would you prefer? What are you doing? What challenges are you facing in patient care, and how can we solve that together?’ [...] GPs can actually learn this quite well, as they are intelligent people. So, they can certainly develop connecting leadership skills." Discussion This study explored theories of team leadership in interprofessional collaboration for frail older adults in primary care and the leadership role of GPs as perceived by experts. We argue that improved team leadership fosters better interprofessional collaboration, which is crucial for providing optimal care to frail older adults. In this study, experts highlighted the critical need for informal leadership in interprofessional primary care for frail older adults, where professionals from diverse, equally important organizations collaborate to deliver high-quality care. Existing leadership theories, mainly developed for formal hierarchical structures, were deemed insufficiently applicable to this context. The complexity of interprofessional primary care necessitates adaptable leadership styles tailored to situational demands. Given the need for a combination of team leadership theories at different key domains, we conceptualized four key roles essential for sustainable, high-quality care for frail older adults. These findings have been synthesized into a Framework for Informal Leadership in Primary Care (FIL-PC). This framework is grounded in the idea that team members recognize their shared responsibility to learn from each other and contribute to high-quality care. The FIL-PC identifies four leadership roles: initiator, visionary, tutor, and overseer. Experts recommended that teams collectively determine which role suits each professional, but also emphasized that GPs, due to their broad perspective and central role in Dutch healthcare, are best suited for the initiator and overseer roles. Comparison with the existing literature: Framework for Informal Leadership in Primary Care (FIL-PC) In our FIL-PC, aspects of various leadership theories are integrated, reflecting the understanding that the use of a specific leadership theory should be guided by the context within the interprofessional team ( 21 ). The recommendation by experts to develop a new framework aligns with Sims et al.'s recent observation that existing frameworks, designed for less complex settings, cannot simply be applied to interprofessional primary care ( 33 ). The FIL-PC is unique in its emphasis on informal leadership within a decentralized care system without a formal leader. Leadership tasks are distributed across four team-transcending roles—initiator, visionary, tutor, and overseer—which are applied flexibly and adaptively based on the situation and the team's needs. The focus is on shared responsibility, collective decision-making, and fostering a learning culture in informal settings, distinguishing it from formal leadership models. This approach enables teams to navigate the complexities of a dynamic care environment, balance equality and accountability, and cultivate a learning culture—essential for providing effective, person-centered care for frail older adults. The initiator is essential for transforming the team into a cohesive and effectively collaborating unit by fostering involvement and a sense of ownership among team members ( 34 ). Key characteristics of such ‘inspiring’ leaders, corresponding to this role, were identified in the literature; visibility ( 35 , 36 ), earning trust and respect ( 17 , 35 , 37 , 38 ), building strong interpersonal relationships ( 37 – 39 ) and cultivating a culture of interdependence, reciprocity and collaboration ( 40 , 41 ). The visionary facilitates the joint development of a team vision and corresponding goals. While Sims et al. emphasize the importance of leaders having and passionately articulating a clear vision for collaboration ( 33 , 35 , 39 , 40 , 42 , 43 ), experts in our study argued against a leader-defined vision, as this limits team ownership. Instead, they advocated for a visionary role that enables the team to collectively and adaptively shape its vision. The tutor facilitates collaboration and team learning evaluation. Key skills include fostering appreciation for others’ expertise, bridging diverse cultures, managing difficult conversations and removing obstacles to change ( 38 , 41 , 44 – 48 ). This aligns with the experts’ views on the tutor role. The overseer maintains an overview of various issues at both the case and team levels. Leaders must be able to adjust their leadership style, driving an agenda forward when necessary and stepping back when appropriate ( 42 ). Experts agree that the overseer should demonstrate situational leadership, make decisive decisions, and empower others to take on more responsibility. A requisite level of power, including influence, credibility, and responsibility, is crucial for overseers to support interprofessional collaboration ( 36 , 49 ). While experts emphasized that it is not crucial who fulfills a leadership role within a team, they stressed the importance of clearly defined roles and ensuring they are carried out. Literature supports this, showing that team processes improve when there is no confusion or conflict over leadership ( 21 ). Additionally, a standardized approach is recommended to structure interprofessional collaboration ( 50 ). Our framework provides this structure, guiding collaboration within teams. Comparison with the existing literature: the team leadership role of the GP In our study, experts advocated for distributing leadership across the team, rather than assigning it to a single individual, as previously suggested by Malik et al. (2018) ( 51 ). This contrasts with most literature, in which interprofessional leadership often is assigned to one (or two) individual(s). The problem with a single leader is the negative impact on team functioning when they leave ( 52 ), as well as the focus on hierarchy and individual authority ( 33 ). Our findings suggest that interprofessional leadership in primary care should focus on fostering collaboration and shared responsibility among all team members, rather than hierarchy of power. Leaders succeed by engaging with the team, promoting collective responsibility and ownership ( 34 ). While experts emphasized that GPs should not be the sole leader, they acknowledged their unique role due to their competencies and central position in Dutch healthcare. Although GPs are often seen as the most likely leaders in many studies ( 23 , 27 ), experts emphasized their significant influence and the crucial role their participation plays in initiating action. This is consistent with Oostra et al. ( 52 ) and Goldman et al. ( 53 ), who linked GP involvement and their role modeling with innovation and change in primary care teams. However, experts also pointed out that GPs are often unaware of their leadership role, aligning with Grol et al. ( 27 ). Strengths and limitations A strength of this study is the diverse perspectives in our sample, providing a comprehensive representation of views across various professional backgrounds and resulting in rich and valuable data. We also engaged with experts whose work we referenced when comparing our results with existing literature. While this enhanced credibility and depth, it introduced potential bias. By stating that our findings align well with the existing literature —partly authored by the same experts— there is a risk that their established viewpoints may have influenced both our data and its interpretation. Nevertheless, consulting leading figures enriched our study and provided a more comprehensive understanding of the topic. The process of recruiting suitable participants proved more challenging than initially anticipated. Many potential participants had gained expertise through practical experience, while we aimed to include experts with a scientific understanding of leadership. This may raise questions about the comprehensiveness of our representation. Nieuwboer et al. ( 22 ) attributed this to the relatively recent focus on leadership as a research topic in the context of integrated care. However, by combining criterion and purposive sampling, we are confident that we engaged the most relevant experts, leading to the conclusion that leadership in interprofessional primary care was an underexplored field. This study was conducted in the Netherlands, with a focus on national experts. This approach was deliberately chosen to provide an in-depth examination of Dutch primary care. However, this decision inherently limited the transferability of our findings. Nevertheless, our findings are likely to have international relevance, suggesting that aspects of the FIL-PC could be applied in diverse healthcare environments (e.g. the social welfare and mental health sectors) beyond the Dutch primary care context. Future research Further investigation is recommended to assess the robustness of the FIL-PC in different countries and settings. Investigating its applicability in various healthcare systems will provide valuable insights into its adaptability and effectiveness. Its applicability in interprofessional primary care is currently under investigation in an ongoing study (2024–2026). Additionally, further research is needed to explore how primary care professionals perceive their leadership roles in interprofessional care for frail older adults. Given the experts’ emphasis on equality within teams, studies should prioritize the perspectives of both GPs and other interprofessional stakeholders. Engaging with these professionals will deepen our understanding of their challenges, leadership needs, and training requirements. These insights are crucial for implementing the FIL-PC within interprofessional teams. Conclusion In conclusion, interprofessional primary care teams operate without a formal leader, and existing leadership theories cannot be directly applied. Our Framework for Informal Leadership in Primary Care distributes leadership across four key roles -initiator, visionary, tutor, and overseer- incorporating relevant aspects of leadership theories. We believe this framework can guide teams in their interprofessional collaboration. Future research should assess its robustness and feasibility, including role assignment, relevance at different stages of team development, and adaptability to evolving team dynamics. Additionally, research should explore the training needs of professionals to equip them with the skills to apply these leadership theories, ensuring their ability to foster collaboration and provide high-quality, person-centred care. Abbreviations GP General practitioner FIL-PC Framework for Informal Leadership in Primary Care Declarations Ethics approval and consent to participate This study was conducted in accordance with the principles of the Declaration of Helsinki and the Netherlands Code of Conduct for Research Integrity. It did not require approval under Dutch law but was reviewed by the Research Ethics Committee of Maastricht University (FHML-REC/2021/107) and found to comply with the university’s scientific code of conduct. All participants were informed about the study’s purpose, procedures, and potential risks, and they provided written or audio-recorded informed consent prior to participation in the interview. Consent for publication Not applicable Availability of data and materials Data may be available from the corresponding author on reasonable request, subject to ethical approval and data sharing agreements. Competing interests The authors declare that they have no competing interests. Funding This study was funded by ZonMW. Authors’ contributions LM conducted the interviews, analysed and interpreted the data, and was the primary author of the manuscript. AvD contributed to the analysis and was closely involved in drafting the manuscript. LvB supervised the interpretation process and provided critical feedback throughout the writing. MV, AM, EvR, and HS reviewed several drafts and the final manuscript and gave constructive comments. All authors read and approved the final manuscript. Acknowledgements We gratefully acknowledge ZonMw for funding this study. We also thank the experts who participated in the interviews for their time and valuable insights, which were essential to this research. References Vektis. Factsheet Kwetsbare Ouderen. [Factsheet Vulnerable Older Adults]. Zeist: Vektis; 2020. Stoeldraijer L, Van Duin C, Nicolaas H, Huisman C. Kernprognose 2022–2070. [Core prognosis: 2022–2070]. Centraal Bureau voor Statistiek (CBS); 2022. Kaljouw M, Van Vliet K. 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Nieuwboer MS, Van Der Sande R, Van Der Marck MA, Olde Rikkert MGM, Perry M. Clinical leadership and integrated primary care: A systematic literature review. Eur J Gen Pract. 2019;25(1):7–18. Weiss D, Tilin F, Morgan MJ. The Interprofessional Health Care Team: Leadership and Development. Jones & Bartlett Learning; 2016. George AE, Frush K, Michener JL. Developing Physicians as Catalysts for Change. Acad Med. 2013;88(11):1603–5. Wranik WD, Price S, Haydt SM, Edwards J, Hatfield K, Weir J, Doria N. Implications of interprofessional primary care team characteristics for health services and patient health outcomes: A systematic review with narrative synthesis. Health Policy. 2019;123(6):550–63. Grol SM, Molleman GRM, Kuijpers A, Van Der Sande R, Fransen GAJ, Assendelft WJJ, Schers HJ. The role of the general practitioner in multidisciplinary teams: a qualitative study in elderly care. BMC Fam Pract. 2018;19(1). Plochg T, Van Den Broeke JR, Kringos DS, Stronks K. Integrating Primary Care and Public Health. Am J Public Health. 2012;102(10):e1–e. Mostashari F, Sanghavi D, McClellan M. Health Reform and Physician-Led Accountable Care. JAMA. 2014;311(18):1855. Goodwin N, Dixon A, Poole T, Raleigh V. Improving the quality of care in general practice. London: The King’s Fund; 2011. Wind A, Te Velde B, Neumann R, Zwart H, Blom A. Kwetsbare ouderen thuis. Handreiking voor integrale zorg en ondersteuning in de wijk. [Vulnerable elderly at home: Guidelines for integrated care and support in the community]. In: Ministerie van Volksgezondheid Welzijn en Sport, editor.; 2021. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101. Sims S, Fletcher S, Brearley S, Ross F, Manthorpe J, Harris R. What does Success Look Like for Leaders of Integrated Health and Social Care Systems? a Realist Review. Int J Integr Care. 2021;21(4). Davy C, Bleasel J, Liu H, Tchan M, Ponniah S, Brown A. Factors influencing the implementation of chronic care models: A systematic literature review. BMC Fam Pract. 2015;16(1). Rosen R, Mountford J, Lewis G, Lewis R, Shand J, Shaw S. Integration in action: Four international case studies. Nuffied Trust; 2011. Best S. Facilitating integrated delivery of services across organisational boundaries: Essential enablers to integration. Br J Occup Therapy. 2017;80(5):302–9. Lunts P. Change management in integrated care: what helps and hinders middle managers – a case study. J Integr Care. 2012;20(4):246–56. Chreim S, Williams BE, Janz L, Dastmalchian A. Change agency in a primary health care context: the case of distributed leadership. Health Care Manage Rev. 2010;35(2):187–99. Shaw S, Levenson R. Towards integrated care in Trafford. The Nuffield Trust; 2011. Aitken K, Von Treuer K. Organisational and leadership competencies for successful service integration. Leadersh Health Serv. 2014;27:150–80. Williams P. The role of leadership in learning and knowledge for integration. J Integr Care. 2012;20:164–74. Atkinson M, Wilkin A, Stott A, Doherty P, Kinder K. Multi-Agency Working: A Detailed Study. The Mere, Upton Park, Slough, Berkshire SL1 2DQ. National Foundation for Educational Research; 2002. Alexander JA, Comfort ME, Weiner BJ, Bogue R. Leadership in Collaborative Community Health Partnerships. Nonprofit Manage Leadersh. 2001;12(2):159–75. Cramm JM, Nieboer AP. Disease-management partnership functioning, synergy and effectiveness in delivering chronic-illness care. Int J Qual Health Care. 2012;24(3):279–85. Nicholson C, Hepworth J, Burridge L, Marley J, Jackson C. Translating the Elements of Health Governance for Integrated Care from Theory to Practice: A Case Study Approach. Int J Integr Care. 2018;18(1). Karam M, Tricas-Sauras S, Darras E, Macq J. Interprofessional Collaboration between General Physicians and Emergency Department Teams in Belgium: A Qualitative Study. Int J Integr Care. 2017;17(4):9. Williams PM. Integration of health and social care: a case of learning and knowledge management. Health Soc Care Community. 2012;20(5):550–60. Benzer JK, Cramer IE, Burgess JF, Mohr DC, Sullivan JL, Charns MP. How personal and standardized coordination impact implementation of integrated care. BMC Health Serv Res. 2015;15(1). Cohen JR, Dowling M, Gallagher JS. The trials, tribulations, and relative success of the ongoing clinical merger of two large academic hospital systems. Acad Med. 2001;76(7):675–83. Grol S, Molleman G, van Heumen N, Muijsenbergh MVD, Scherpbier-de Haan N, Schers H. General practitioners' views on the influence of long-term care reforms on integrated elderly care in the Netherlands: a qualitative interview study. Health Policy. 2021;125(7):930–40. Malik RF, Hilders CGJM, Scheele F. Do ‘physicians in the lead’ support a holistic healthcare delivery approach? A qualitative analysis of stakeholders’ perspectives. BMJ Open. 2018;8(7):e020739. Oostra DL, Harmsen A, Nieuwboer MS, Rikkert M, Perry M. Care Integration in Primary Dementia Care Networks: A Longitudinal Mixed-Methods Study. Int J Integr Care. 2021;21(4):29. Goldman J, Meuser J, Rogers J, Lawrie L, Reeves S. Interprofessional collaboration in family health teams: An Ontario-based study. Can Fam Physician. 2010;56(10):e368–74. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1TopicListAndInterviewGuide.docx Additional file 1: Topic List and Interview Guide. 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Care","correspondingAuthor":false,"prefix":"","firstName":"Erik","middleName":"","lastName":"Rossum","suffix":""},{"id":495566412,"identity":"5f70c14d-0142-4d71-ae0b-eb27d47fd13c","order_by":5,"name":"Henk J Schers","email":"","orcid":"","institution":"Radboud University Nijmegen Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Henk","middleName":"J","lastName":"Schers","suffix":""},{"id":495566413,"identity":"94ec26b9-7bc6-47ae-806b-b2c70e0f0545","order_by":6,"name":"Marloes A Bokhoven","email":"","orcid":"","institution":"Maastricht University","correspondingAuthor":false,"prefix":"","firstName":"Marloes","middleName":"A","lastName":"Bokhoven","suffix":""}],"badges":[],"createdAt":"2025-07-09 15:08:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7085121/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7085121/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88421910,"identity":"e3e1129d-18cf-49c6-a145-226631669050","added_by":"auto","created_at":"2025-08-06 09:32:51","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":364176,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFramework for Informal Leadership in Primary Care (FIL-PC)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7085121/v1/24e54d7257e01ad2fe37d717.jpeg"},{"id":88424627,"identity":"ed4975e9-3cb8-4ca8-81e1-64dc8c42258f","added_by":"auto","created_at":"2025-08-06 09:48:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":858115,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7085121/v1/f3e270d2-a773-4b1d-89f9-7fb3284cd0b7.pdf"},{"id":88421913,"identity":"8248700d-d0e4-49bb-ba6f-af08100f56a0","added_by":"auto","created_at":"2025-08-06 09:32:51","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":24176,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 1: Topic List and Interview Guide.\u003c/p\u003e","description":"","filename":"Additionalfile1TopicListAndInterviewGuide.docx","url":"https://assets-eu.researchsquare.com/files/rs-7085121/v1/5213c6c689f042ac9074ccdf.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Towards an Informal Leadership Framework for Interprofessional Primary Care: An Interview Study Among Healthcare Leadership Experts","fulltext":[{"header":"Background","content":"\u003cp\u003eThe number of Dutch citizens aged 75 years and older is expected to rise significantly by 2040. In this population, one in five is considered frail, incurring healthcare costs up to five times higher than non-frail peers (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Within this group, delivering person-centred care \u0026mdash;defined as integrated, function-oriented care based on patients' personal health priorities\u0026mdash; relies on robust interprofessional collaboration among primary care professionals (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Without interprofessional collaboration, older patients with multimorbidity risk conflicting advice, contradictory interactions, and unnecessary treatments (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn the Netherlands, non-managed interprofessional teams of primary care professionals collaborate across organizational boundaries at the local community, often relying on informal or loosely defined arrangements. This fragmented structure highlights the need for strong coordination and clear interprofessional agreements to ensure efficient, cohesive care delivery (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis article examines team-based collaboration in these interprofessional non-managed primary care teams at the clinical and professional integration levels (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). At these levels, teams deliver direct patient care and coordinate care for specific groups (e.g., frail older adults) at local communities through team meetings and ad hoc consultations, in both acute and chronic care situations. This article does not address the organizational or system integration, in which networks of different care and social service providers collaborate towards seamless care across regions or communities (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eImproving effective teamwork and coordination in primary care seems crucial, as it can contribute to a more sustainable healthcare system that delivers high-quality care and is better equipped to cope with the rising demand for care (\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Moreover, there is evidence that team functioning is an important predictor of stress levels, and that stressed professionals produce inferior care (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Regular interprofessional team meetings support professionals in building relationships and developing joint care plans. While these meetings aim to improve collaboration (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), their effectiveness and focus on person-centred care often fall short, with participants overestimating their team\u0026rsquo;s performance (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Effective teamwork extends beyond meetings focused solely on the day-to-day discussion of patient care (clinical integration). It also encompasses coordinated efforts among various professionals to address community healthcare needs (professional integration). This requires active facilitation of team development over time (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eResearch highlights leadership as a key factor in effective interprofessional teamwork (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Leaders in the context of interprofessional primary care teams should promote person-centredness, structure and organization, and team development over time (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Team development over time needs interprofessional leadership regarding effective collaboration, decision-making, and team cohesion (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). However, Brewer et al. show in a scoping review of 114 studies on leadership in interprofessional education and practice that \u0026lsquo;leadership\u0026rsquo; was defined in less than 25% of the studies and required interprofessional leadership competences were often unspecified (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Contemporary leadership theories emphasize collective, transformational, and relational approaches in interprofessional primary care teams, rather than traditional hierarchical models (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). While strong qualitative evidence highlights the importance of leadership, there is no clear evidence on which type of leadership is most effective for integrated care. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn addition to questions about the most suitable leadership theory for interprofessional care for older adults, perceptions differ regarding the general practitioner\u0026rsquo;s (GP\u0026rsquo;s) leadership role within the interprofessional team (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Health and social care professionals view GPs as central figures in developing and implementing joint care plans. They tend to attribute GPs a traditional, hierarchical leadership role due to their ability to see \u0026lsquo;the bigger picture\u0026rsquo;, their capability of networking strategically and their continuous role in providing care of frail older individuals (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Some studies advocate for GPs to take the lead in reforming primary care (\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Grol et al. found that successful non-managed teams often have a GP taking the lead. However, many GPs seem to be unaware of their crucial role in promoting and fostering interprofessional collaboration (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Additionally, other professions may also hold leadership roles within interprofessional care (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), but uncertainties remain about how this manifests in practice and how it aligns with the GP\u0026rsquo;s responsibilities.\u003c/p\u003e\u003cp\u003eTo summarize, strengthening leadership is essential for improving effective interprofessional collaboration, reducing stress, and ensuring integrated, high-quality care for vulnerable older patients. However, there is still limited clarity regarding the most suitable leadership approaches in primary care. While GPs are often seen as natural leaders, their role in interprofessional collaboration is not always clearly defined, and leadership responsibilities may also extend to other professionals.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study aims to deepen the theoretical understanding of team leadership in interprofessional collaboration for frail older adults in primary care and clarify the GP's leadership role. Our research question is: 'Which leadership theories are deemed most appropriate by experts in primary care teams, and what role does the GP play?\u0026rsquo;\u003c/p\u003e\u003cp\u003eA thematic analysis was employed, following the principles of Braun and Clarke (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), to develop a deeper theoretical understanding of team leadership and the leadership contribution of GPs in interprofessional care for frail older people, based on expert opinions. This method was chosen due to the lack of clarity surrounding existing theories. Data was collected through semi-structured interviews.\u003c/p\u003e\u003cp\u003e\u003cem\u003eParticipant recruitment\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn the Netherlands, all patients are registered with a GP, who manages medical issues and refers to secondary care when necessary. The core values of Dutch GP care are personalized, continuous healthcare, a generalist perspective, and collaborative care (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). To ensure expert input within the Dutch primary healthcare context, we used criterion sampling, selecting experts based on two criteria: 1) having scientific expertise regarding leadership within healthcare and 2) being able to apply their leadership knowledge to Dutch primary healthcare practice.\u003c/p\u003e\u003cp\u003eWe compiled a list of potential experts by contacting Dutch organizations (e.g. The Dutch College of General Practitioners (NHG) and Erasmus Economics \u0026amp; Business Executive Education) and leveraging researchers\u0026rsquo; personal networks. This list was validated by a sounding board group experienced GPs and researchers in interprofessional collaboration. During the iterative process of data collection and analysis, we additionally included targeted experts through purposive sampling. Inclusions ceased upon reaching data saturation.\u003c/p\u003e\u003cp\u003eWe included experts from various fields, including healthcare business and change management, nursing leadership, leadership in public health, and integrated long-term care. Due to the need to ensure the anonymity of the experts, we do not provide further details regarding their areas of expertise. We approached 12 experts for this study. One declined due to a busy schedule, and another deemed herself unqualified after receiving further clarification and our inclusion criteria. Ultimately, 10 experts participated; 5 of whom were women (50%). As no new information or themes emerged during the eighth interview, we assumed that data saturation had been reached. To ensure the robustness of our findings and avoid premature closure, we conducted the already scheduled ninth and tenth interviews. These interviews further confirmed that no additional insights or variations arose, reinforcing our conclusion that data saturation had been achieved.\u003c/p\u003e\u003cp\u003e\u003cem\u003eData collection\u003c/em\u003e\u003c/p\u003e\u003cp\u003eBetween December 2021 and March 2022, nine interviews were conducted via Zoom, and one by telephone. Due to travel distance, online interviews were chosen. Prior to each interview, participants received an overview of the context of interprofessional teams in Dutch primary healthcare, which was reviewed at the start of the interview to ensure alignment on the leadership discussed. All interviews were audio-recorded and transcribed verbatim with participants\u0026rsquo; permission. The semi-structured interviews were conducted by researcher LM, using an interview guide developed from a topic list [see Additional file 1] based on existing literature on healthcare leadership, leadership theories, and interprofessional collaboration in primary care. Data collection and analysis were iterative. After each interview, the transcript was coded and analysed by LM and AvD, and the interview guide was adjusted as needed. All interviews were in Dutch, except for one in English, and lasted between 33 and 65 minutes.\u003c/p\u003e\u003cp\u003e\u003cem\u003eCoding and analysis\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTwo researchers (LM and AvD) independently coded the verbatim interview transcripts using a thematic analysis approach. Coding and analysis followed an inductive process, progressing from open coding to the identification of overarching themes and patterns (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The researchers discussed their codes iteratively until consensus was reached. During the analysis, memos were written to document emerging insights and analytical reflections. The memos, coding tree, and overarching themes were reviewed with researcher LvB to refine the analysis. For credibility, the overarching themes were shared with all experts for member checking. Experts confirmed the accuracy of these findings without providing significant additional feedback. As the final step of the analysis, the identified themes were abstracted and conceptualized into a framework.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThis results section is organized into three parts: leadership theories identified by experts for interprofessional primary care teams, key domains and roles of informal leadership in primary care (as outlined in the Framework for Informal Leadership in Primary Care - FIL-PC), and the leadership contributions of GPs in these teams.\u003c/p\u003e\u003cp\u003e\u003cem\u003eLeadership theories applicable to interprofessional primary care teams\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAll experts emphasized that interprofessional primary care teams in the Netherlands lack a formal leader, as team members work for separate organizations within the country's decentralized primary care system.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE4: \"They may collaborate around a patient, or they collaborate at community level, because they all have a certain expertise, but they do not collectively form a formal organization with a clearly designated leader.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eExperts explained that since existing leadership theories in scientific literature have been developed for formal leadership, these theories cannot simply be applied to informal leadership in interprofessional primary care teams.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE2: \"You work with equal professionals, so anything tending towards hierarchical leadership can be forgotten.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eE2: \"Well, the most important point is, I think... it's all about informal leadership.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eNevertheless, experts identified aspects from existing leadership theories that are important to consider, as these are closely linked to the following three key characteristics of informal interprofessional teams delivering primary care for older adults (see also Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e):\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e1. Dynamic context and Complexity in interprofessional collaboration\u003c/p\u003e\u003cp\u003ePrimary care for older patients is a dynamic environment where professional involvement constantly shifts, requiring ongoing adaptation of leadership. In each situation, team members should assess the most appropriate leadership style and agree on the team member best suited for the role. This aligns with situational leadership theory.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE3: \"You don't have the time and the means to endlessly debate things; you have to make decisions and act at times. Someone needs to be admitted to the nursing home tomorrow, so something needs to happen. Some degree of situational direction is needed, so, situational leadership. Knowing when to take charge, when am I in the lead?\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eExperts also referenced complex adaptive leadership theory, noting that interprofessional collaboration can be seen as a complex system where stakeholders should follow a framework of rules and agreements. This framework should support emergent processes, which depend on the specific case and team dynamics. One expert compared this to a flock of birds, moving together based on implicit rules.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE8: \"But those few sets of simple rules enable the group to connect with each other. This concept has increasingly been translated into social structures, such as teams, where a few simple agreements are clear agreements. [...] Within that set of rules, all professionals can exercise their autonomy and responsibility, and you can then see how these interaction rules at the group level influence the entire group\u0026rsquo;s response.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eE10: \"Yes, that\u0026rsquo;s complexity theory. It\u0026rsquo;s about how you get large groups of diverse elements to come into and remain in sync with each other, while also allowing for change so that it isn\u0026rsquo;t something fixed. Complexity theory is, therefore, the ability to anticipate.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003e2. Balancing Equality and Accountability\u003c/p\u003e\u003cp\u003eExperts emphasized that providing care for older patients requires contributions from all professionals. To ensure older adults perceive their care as integrated, professionals must collaborate to bridge rigid disciplinary boundaries. This aligns with connecting leadership, which unites individuals around shared goals, values, and visions, and focuses on fostering an environment where individuals can support and inspire each other, enabling effective collaboration. Networking leadership complements this by establishing strategic connections with key stakeholders, such as home care and welfare organizations. Together, these leadership approaches create a foundation for integrated care, ensuring cohesive and well-coordinated experiences for vulnerable older patients.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE5: \"You need a leader who is highly capable of connecting people, someone who can understand the interests of others and see the bigger picture.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eExperts also highlighted shared leadership theory, emphasizing that leadership should be distributed among team members. Professionals collaboratively contribute to patient care based on individual needs, with all team members regarded as equals. A shared responsibility is therefore required, even though leadership tasks may vary depending on the situation and timing.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE10: \"That's how it works. It's not like, \"You are the leader, and I'm not.\" So, it's continuously evolving. And that is the essence of leadership, collectivity, and continuously being aware of yourself and others in the ecosystem and being able to move forward together in that. [...] How do you then switch, you know? And leadership from a nurse, or from a physiotherapist, or from the pharmacy... So, leadership in today's context is inherently shared by definition. It's continuous, but it fluctuates constantly.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHowever, experts also expressed concerns about the challenges of the shared leadership approach. They fear that sharing leadership may compromise both responsibility and accountability. Responsibility refers to the duty to manage or oversee certain tasks, while accountability refers to being answerable for the outcomes or consequences of those tasks.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE2: \"At some point, someone has to be accountable. And I think that when the physiotherapist takes on the role of 'I am the leader in this plan now', then the physiotherapist must truly be accountable for that and be able to hold others accountable for it. And with shared leadership... Well, shared is halved, right? Literally. It becomes less and less. So then that responsibility fades away.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFurthermore, some experts questioned whether all disciplines are adequately prepared for this approach.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE8: \"I'm not sure that everyone has learned to bear those responsibilities in their basic education. Shared leadership and distributive leadership are things that I am a big fan of, but I'm not sure if this can work already... \"\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e3. Cultivating a Learning Culture\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eExperts stressed the importance of fostering a learning culture within interprofessional primary care teams. To achieve common goals and fully utilize each other\u0026rsquo;s expertise, team members should inspire and influence one another \u0026mdash;a principle rooted in transformational leadership.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE8: \"This is what is known as transformational leadership, in which the leader [\u0026hellip;] helps employees rise above themselves.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eE1: \"It\u0026rsquo;s about thinking beyond boundaries, adapting, and inspiring. That\u0026rsquo;s where transformational leadership comes into play.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eLeveraging and allowing everyone\u0026rsquo;s talent to flourish is also associated with the principles of servant leadership. Experts emphasize that leadership should not only serve the patient, but also the various professionals in the interprofessional team.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE4: \"That you realize that people all bring their own perspectives into the team and can each have a valuable contribution in ensuring that such a team functions optimally. And when you provide space for those different perspectives, it offers insights that can help the team function as optimally as possible. Essentially, you are leveraging the knowledge that exists throughout the entire team.\"\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the aspects of existing leadership theories that experts have identified as important to consider for effective leadership in interprofessional teams in primary care.\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\u003eOverview of applicable aspects of existing leadership theories according to experts\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeadership theory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDescription\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSituational leadership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdaptive, based on the situation, team members\u0026rsquo; competences and teams\u0026rsquo; maturity.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplex adaptive leadership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGuides collaboration through simple rules balancing autonomy and coordination in dynamic situations.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNetwork leadership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBuilds strategic stakeholder connections to achieve goals and enhance collaboration.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConnecting leadership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnites individuals around shared goals, values, and vision, fosters a collaborative environment.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eShared leadership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDistributes leadership across a team, enabling collective decision-making.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTransformational leadership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInspires and motivates team members to achieve higher common goals and fosters a learning culture.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eServant leadership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmpowers team members by valuing their perspectives and contributions to optimize team performance.\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\u003e\u003cem\u003eFramework for Informal Leadership in Primary Care (FIL-PC)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eExperts emphasized the importance of informal team leadership for the optimal functioning of interprofessional primary care teams. From the responses provided by experts, we identified four key domains in which effective leadership is deemed crucial to support the continuous development of the team and to achieve high-quality, person-centred care for frail older adults. Through our analysis, we conceptualized these domains into four distinct leadership roles: initiator, visionary, tutor, and overseer. Experts concurred that this leadership in each domain should be assumed by professionals identified as most suitable through mutual agreement within the team and who are committed to a long-term affiliation with the team. Although the four roles must remain consistently assured, they do not need to be addressed in equal measure at all times. Teams must learn to discern which issues and situations require a particular leadership role, resulting in a continuous fluctuation in the expression of these roles.\u003c/p\u003e\u003cp\u003eBased on these experts\u0026rsquo; insights, we synthesized a Framework for Informal Leadership in Primary Care (FIL-PC), integrating leadership theories and roles crucial for effective interprofessional collaboration for frail older adults in primary care. The framework is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The proper application and allocation of these leadership roles helps strengthen leadership within an interprofessional team in the essential and challenging domains of interprofessional primary care: the dynamic context and complex collaboration, addressing equality and responsibility, and fostering a learning culture. This is considered to be necessary to pursue sustainable and effective interprofessional collaboration, which is required for high-quality, person-centered care for vulnerable older adults.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe four team transcending leadership roles are explained as follows:\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eInitiator\u003c/span\u003e\u003c/p\u003e\u003cp\u003eInterprofessional teams need an initiator to foster team spirit and encourage a shared responsibility for person-centred care. Experts emphasized the importance of intrinsic motivation and collaboration, with the initiator playing a key role in nurturing these qualities.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE4: \"That you indeed want a transformation from a care system that is mainly focused on individual healthcare providers doing their job well to recognizing that it is a collective effort. Working interprofessionally as a collective ultimately determines whether a patient experiences adequate care or not. I think that is already a transformative step. It's a whole different awareness, one that not everyone in healthcare has made yet. That we are truly part of a collective.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAn expert described the following process: Firstly, all distinct team members should recognize that they form a team together. Secondly, they should be aware of their shared responsibility to learn with and from each other and to provide high-quality care. Thirdly, they should give substance to this shared responsibility.\u003c/p\u003e\u003cp\u003eExperts stressed that the initiator's role is crucial not only for initiating and facilitating team transformation but also for sustaining it over time. They noted that, based on their experience, the quality of interprofessional collaboration often deteriorates when the initiator's presence is no longer maintained.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE7: \"It [the quality of collaboration] remains consistently high when the team initiator is present. And the quality of care continues to improve. So, at a certain point, you've reached a certain level of collaboration. [...] And sometimes it suddenly declines. [...] That's when the team initiator is absent. No, you need to keep that person. They don't have to do much. They just need to occasionally ensure that the network comes together every now and then. That's what we've observed.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAn expert warned that uneven power dynamics could emerge if a single team member consistently takes the initiator role. While shared leadership was encouraged, this type of leadership risks making tasks related to planning, execution, and accountability optional. To avoid this, most experts agreed that significant changes should be led by one or two professionals, who provide ongoing support to motivate and engage the team.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE8: \" \u0026lsquo;For example, psychologist, (\u0026hellip;), you are entrusted with the responsibility to monitor this and, if things go off track, to call a team meeting to discuss the issue before it escalates.\u0026rsquo; If no one explicitly gets or takes that responsibility, it will not happen.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eVisionary\u003c/span\u003e\u003c/p\u003e\u003cp\u003eThe experts discussed the need for interprofessional teams to have a clear vision. Therefore, team leadership includes a visionary role to ensure a joint formulation of a team vision and corresponding SMART goals as well as working rules, values and norms and a plan for evaluation.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE4: \"And then, you formalize certain responsibilities within the more informal team or the informal organization that you create together. However, this represents a dynamic, negotiated situation within which you operate.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eExperts stressed the importance of setting up these views together as a team, as this process contributes to team members' intrinsic motivation and sense of shared responsibility. A visionary should also ensure that all professionals experience space to perform their work sufficiently and autonomously.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE8: \"Uhm, and that provides a certain degree of autonomy through shared responsibility and freedom, which in turn motivates people to participate. It\u0026rsquo;s not a strictly controlled management approach, where you essentially have a manual for every action. If you don\u0026rsquo;t have freedom, you are also not motivated to engage when you observe something happening...\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTutor\u003c/span\u003e\u003c/p\u003e\u003cp\u003eAll experts highlighted the crucial role of a tutor within interprofessional teams. The tutor facilitates collaboration and team learning, monitors the achievement of shared goals, and ensures regular evaluation of the partnership. Experts noted that team members often fail to fully utilize each other\u0026rsquo;s expertise and stressed the importance of learning from one another to better leverage individual strengths. They also emphasized that long-term collaboration frequently occurs without proper evaluation, which is essential for maintaining quality and fostering continuous improvement in teamwork.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE4: \"So, I think there are teams and constellations of collaborations at the local community level that can satisfactorily perform their work for years without ever getting to reflect on how they can learn from working together. And then, you not only miss the opportunity to learn together to improve, but I think at some point, it even becomes a danger to whether you are still doing well together.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFor evaluation, a safe learning climate is necessary. A tutor should be responsible for creating this safe learning climate in which every team member feels comfortable contributing actively and proposing initiatives.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eOverseer\u003c/span\u003e\u003c/p\u003e\u003cp\u003eExperts unanimously agreed that every interprofessional primary care team requires an overseer to maintain an overview of potential team challenges, particularly those involving tasks with unclear responsibilities.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE3: \"The oversight role. [...] There are many tasks for which it's not very clear whose responsibility it is, but it's more about ensuring that it gets done. And that you know from each other who does what. So, delegating might not be entirely the right word, but I think structuring is more appropriate in primary care.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOverseers are responsible for managing both case-specific and team-level issues, taking on necessary responsibilities as needed. As the main point of contact when a case becomes (too) complex, they should also be empowered to make treatment decisions. Experts noted that overseers use their knowledge, experience, and network to either support or take over the coordination of the case. In some instances, they may grant mandates and help other professionals assume responsibility. With a broad perspective on the team\u0026rsquo;s work, overseers understand each member\u0026rsquo;s expertise and play a central role in the professional network within the community.\u003c/p\u003e\u003cp\u003e\u003cem\u003eLeadership contribution of GPs\u003c/em\u003e\u003c/p\u003e\u003cp\u003eExperts underlined that the four leadership roles should be assigned to the most appropriate team member or members, depending on profession, competencies, personality, context and situation.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE6: \"It is about recognizing that there are different moments when certain people take the lead, while others step back. But it is also about moving away from the idea of having the leader, the heroic leader, as the solution to problems.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWhile the focus should be less on 'who' assumes these roles, experts advised to perform the leadership roles by team members who are committed long-term. They highlighted the central role of GPs, who hold a key position in the Dutch healthcare system, provide generalist care, are accessible 24/7 for patients and caregivers, and are accustomed to bearing final responsibility for patient care. Given these attributes, GPs are deemed indispensable within interprofessional teams, ensuring coordinated and comprehensive care.\u003c/p\u003e\u003cp\u003eIn terms of the four leadership roles, the experts noted that GPs may be best suited for both the initiator and overseer leadership roles. The designation of GPs as initiators can be explained by power dynamics between GPs and other healthcare professionals, which have evolved over time but continue to exert influence today.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE10: \"The role of the physician can be crucial to the success or failure of such regional multidisciplinary rule systems. If the physician doesn\u0026rsquo;t participate, it simply won\u0026rsquo;t happen.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eExperts highlighted GPs as the most convenient team members to influence other professionals. Therefore, experts advised leveraging this unique position effectively. However, according to some experts, GPs themselves may not always be aware of their distinct role, emphasizing the need for increased awareness.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE7: \"And this is really important for GPs to realize, as they are often at the top of the hierarchy among primary care professionals. Everyone still looks up to the GP, even though the GP may not be aware of this. So, when a GP asks you to do something, everyone is inclined to join in. For example, community nurses [\u0026hellip;] are very eager to collaborate with GPs, but often struggle to gain access to them. So, if a GP asks you to join their network, I can guarantee that not a single community nurse would say, 'No, I won\u0026rsquo;t do that.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eGPs are also likely to assume the role of overseer, given their comprehensive medical knowledge, generalist approach, habitual assumption of responsibility, and experience in conferring authority.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE3: \"It\u0026rsquo;s not necessarily the case that the physician has to be the leader, but often they are the one where knowledge converges, and they likely have the most comprehensive understanding. (...) This is because the GP has such a broad perspective and can take diversity into account, considering medical, social, spiritual, and participation aspects. I think GPs are well-suited to assess these different dimensions. So it\u0026rsquo;s logical for them to take a leading role.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFurthermore, experts emphasized the increasing need for GPs to empower other professionals to take on leadership responsibilities. Some other professionals may hesitate to step into leadership roles due to traditional hierarchies, ingrained attitudes, or a lack of confidence in their abilities.\u003c/p\u003e\u003cp\u003e\u003cem\u003eE8: \"Take, for example, nurses (\u0026hellip;). They graduate with a wide range of competencies, yet still often have an attitude of waiting for the physician\u0026rsquo;s direction. So, considering the direction of healthcare and the shift towards shared responsibility, I believe it is the role of the physician, as a leader within a team, to teach others to take on that responsibility.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIt is possible that GPs, alongside their possible roles as overseers and initiators, could also contribute to other leadership roles. However, experts unanimously agreed that a leader's personality and competencies must align with the specific requirements of the role to ensure effectiveness. Other team members may be better suited for certain roles. For instance, not every GP may be suitable for the tutor role, as illustrated by the following quote:\u003c/p\u003e\u003cp\u003e\u003cem\u003eE7: \"A physician is still somewhat trained with the mindset of, \u0026lsquo;I\u0026rsquo;ll figure it out. I know best. I\u0026rsquo;ll tell the others how it should be done.\u0026rsquo; We noticed this in those networks as well. Connecting leadership is much more about asking questions, like, \u0026lsquo;Oh, what would you prefer? What are you doing? What challenges are you facing in patient care, and how can we solve that together?\u0026rsquo; [...] GPs can actually learn this quite well, as they are intelligent people. So, they can certainly develop connecting leadership skills.\"\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored theories of team leadership in interprofessional collaboration for frail older adults in primary care and the leadership role of GPs as perceived by experts. We argue that improved team leadership fosters better interprofessional collaboration, which is crucial for providing optimal care to frail older adults.\u003c/p\u003e\u003cp\u003eIn this study, experts highlighted the critical need for informal leadership in interprofessional primary care for frail older adults, where professionals from diverse, equally important organizations collaborate to deliver high-quality care. Existing leadership theories, mainly developed for formal hierarchical structures, were deemed insufficiently applicable to this context. The complexity of interprofessional primary care necessitates adaptable leadership styles tailored to situational demands. Given the need for a combination of team leadership theories at different key domains, we conceptualized four key roles essential for sustainable, high-quality care for frail older adults. These findings have been synthesized into a Framework for Informal Leadership in Primary Care (FIL-PC). This framework is grounded in the idea that team members recognize their shared responsibility to learn from each other and contribute to high-quality care. The FIL-PC identifies four leadership roles: initiator, visionary, tutor, and overseer. Experts recommended that teams collectively determine which role suits each professional, but also emphasized that GPs, due to their broad perspective and central role in Dutch healthcare, are best suited for the initiator and overseer roles.\u003c/p\u003e\u003cp\u003e\u003cem\u003eComparison with the existing literature: Framework for Informal Leadership in Primary Care (FIL-PC)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn our FIL-PC, aspects of various leadership theories are integrated, reflecting the understanding that the use of a specific leadership theory should be guided by the context within the interprofessional team (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The recommendation by experts to develop a new framework aligns with Sims et al.'s recent observation that existing frameworks, designed for less complex settings, cannot simply be applied to interprofessional primary care (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe FIL-PC is unique in its emphasis on informal leadership within a decentralized care system without a formal leader. Leadership tasks are distributed across four team-transcending roles\u0026mdash;initiator, visionary, tutor, and overseer\u0026mdash;which are applied flexibly and adaptively based on the situation and the team's needs. The focus is on shared responsibility, collective decision-making, and fostering a learning culture in informal settings, distinguishing it from formal leadership models. This approach enables teams to navigate the complexities of a dynamic care environment, balance equality and accountability, and cultivate a learning culture\u0026mdash;essential for providing effective, person-centered care for frail older adults.\u003c/p\u003e\u003cp\u003eThe initiator is essential for transforming the team into a cohesive and effectively collaborating unit by fostering involvement and a sense of ownership among team members (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Key characteristics of such \u0026lsquo;inspiring\u0026rsquo; leaders, corresponding to this role, were identified in the literature; visibility (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), earning trust and respect (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), building strong interpersonal relationships (\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) and cultivating a culture of interdependence, reciprocity and collaboration (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe visionary facilitates the joint development of a team vision and corresponding goals. While Sims et al. emphasize the importance of leaders having and passionately articulating a clear vision for collaboration (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), experts in our study argued against a leader-defined vision, as this limits team ownership. Instead, they advocated for a visionary role that enables the team to collectively and adaptively shape its vision.\u003c/p\u003e\u003cp\u003eThe tutor facilitates collaboration and team learning evaluation. Key skills include fostering appreciation for others\u0026rsquo; expertise, bridging diverse cultures, managing difficult conversations and removing obstacles to change (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan additionalcitationids=\"CR45 CR46 CR47\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). This aligns with the experts\u0026rsquo; views on the tutor role.\u003c/p\u003e\u003cp\u003eThe overseer maintains an overview of various issues at both the case and team levels. Leaders must be able to adjust their leadership style, driving an agenda forward when necessary and stepping back when appropriate (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Experts agree that the overseer should demonstrate situational leadership, make decisive decisions, and empower others to take on more responsibility. A requisite level of power, including influence, credibility, and responsibility, is crucial for overseers to support interprofessional collaboration (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhile experts emphasized that it is not crucial who fulfills a leadership role within a team, they stressed the importance of clearly defined roles and ensuring they are carried out. Literature supports this, showing that team processes improve when there is no confusion or conflict over leadership (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Additionally, a standardized approach is recommended to structure interprofessional collaboration (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Our framework provides this structure, guiding collaboration within teams.\u003c/p\u003e\u003cp\u003e\u003cem\u003eComparison with the existing literature: the team leadership role of the GP\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn our study, experts advocated for distributing leadership across the team, rather than assigning it to a single individual, as previously suggested by Malik et al. (2018) (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). This contrasts with most literature, in which interprofessional leadership often is assigned to one (or two) individual(s). The problem with a single leader is the negative impact on team functioning when they leave (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e), as well as the focus on hierarchy and individual authority (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Our findings suggest that interprofessional leadership in primary care should focus on fostering collaboration and shared responsibility among all team members, rather than hierarchy of power. Leaders succeed by engaging with the team, promoting collective responsibility and ownership (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhile experts emphasized that GPs should not be the sole leader, they acknowledged their unique role due to their competencies and central position in Dutch healthcare. Although GPs are often seen as the most likely leaders in many studies (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), experts emphasized their significant influence and the crucial role their participation plays in initiating action. This is consistent with Oostra et al. (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e) and Goldman et al. (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e), who linked GP involvement and their role modeling with innovation and change in primary care teams. However, experts also pointed out that GPs are often unaware of their leadership role, aligning with Grol et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cem\u003eStrengths and limitations\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA strength of this study is the diverse perspectives in our sample, providing a comprehensive representation of views across various professional backgrounds and resulting in rich and valuable data. We also engaged with experts whose work we referenced when comparing our results with existing literature. While this enhanced credibility and depth, it introduced potential bias. By stating that our findings align well with the existing literature \u0026mdash;partly authored by the same experts\u0026mdash; there is a risk that their established viewpoints may have influenced both our data and its interpretation. Nevertheless, consulting leading figures enriched our study and provided a more comprehensive understanding of the topic.\u003c/p\u003e\u003cp\u003eThe process of recruiting suitable participants proved more challenging than initially anticipated. Many potential participants had gained expertise through practical experience, while we aimed to include experts with a scientific understanding of leadership. This may raise questions about the comprehensiveness of our representation. Nieuwboer et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) attributed this to the relatively recent focus on leadership as a research topic in the context of integrated care. However, by combining criterion and purposive sampling, we are confident that we engaged the most relevant experts, leading to the conclusion that leadership in interprofessional primary care was an underexplored field.\u003c/p\u003e\u003cp\u003eThis study was conducted in the Netherlands, with a focus on national experts. This approach was deliberately chosen to provide an in-depth examination of Dutch primary care. However, this decision inherently limited the transferability of our findings. Nevertheless, our findings are likely to have international relevance, suggesting that aspects of the FIL-PC could be applied in diverse healthcare environments (e.g. the social welfare and mental health sectors) beyond the Dutch primary care context.\u003c/p\u003e\u003cp\u003e\u003cem\u003eFuture research\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFurther investigation is recommended to assess the robustness of the FIL-PC in different countries and settings. Investigating its applicability in various healthcare systems will provide valuable insights into its adaptability and effectiveness. Its applicability in interprofessional primary care is currently under investigation in an ongoing study (2024\u0026ndash;2026).\u003c/p\u003e\u003cp\u003eAdditionally, further research is needed to explore how primary care professionals perceive their leadership roles in interprofessional care for frail older adults. Given the experts\u0026rsquo; emphasis on equality within teams, studies should prioritize the perspectives of both GPs and other interprofessional stakeholders. Engaging with these professionals will deepen our understanding of their challenges, leadership needs, and training requirements. These insights are crucial for implementing the FIL-PC within interprofessional teams.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, interprofessional primary care teams operate without a formal leader, and existing leadership theories cannot be directly applied. Our Framework for Informal Leadership in Primary Care distributes leadership across four key roles -initiator, visionary, tutor, and overseer- incorporating relevant aspects of leadership theories.\u003c/p\u003e\u003cp\u003eWe believe this framework can guide teams in their interprofessional collaboration. Future research should assess its robustness and feasibility, including role assignment, relevance at different stages of team development, and adaptability to evolving team dynamics. Additionally, research should explore the training needs of professionals to equip them with the skills to apply these leadership theories, ensuring their ability to foster collaboration and provide high-quality, person-centred care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGeneral practitioner\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFIL-PC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFramework for Informal Leadership in Primary Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki and the Netherlands Code of Conduct for Research Integrity. It did not require approval under Dutch law but was reviewed by the Research Ethics Committee of Maastricht University (FHML-REC/2021/107) and found to comply with the university\u0026rsquo;s scientific code of conduct. All participants were informed about the study\u0026rsquo;s purpose, procedures, and potential risks, and they provided written or audio-recorded informed consent prior to participation in the interview.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eData may be available from the corresponding author on reasonable request, subject to ethical approval and data sharing agreements.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study was funded by ZonMW.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u003c/p\u003e\n\u003cp\u003eLM conducted the interviews, analysed and interpreted the data, and was the primary author of the manuscript. AvD contributed to the analysis and was closely involved in drafting the manuscript. LvB supervised the interpretation process and provided critical feedback throughout the writing. MV, AM, EvR, and HS reviewed several drafts and the final manuscript and gave constructive comments. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe gratefully acknowledge ZonMw for funding this study. We also thank the experts who participated in the interviews for their time and valuable insights, which were essential to this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eVektis. Factsheet Kwetsbare Ouderen. [Factsheet Vulnerable Older Adults]. Zeist: Vektis; 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStoeldraijer L, Van Duin C, Nicolaas H, Huisman C. Kernprognose 2022\u0026ndash;2070. [Core prognosis: 2022\u0026ndash;2070]. 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The role of the general practitioner in multidisciplinary teams: a qualitative study in elderly care. BMC Fam Pract. 2018;19(1).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePlochg T, Van Den Broeke JR, Kringos DS, Stronks K. Integrating Primary Care and Public Health. Am J Public Health. 2012;102(10):e1\u0026ndash;e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMostashari F, Sanghavi D, McClellan M. Health Reform and Physician-Led Accountable Care. JAMA. 2014;311(18):1855.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGoodwin N, Dixon A, Poole T, Raleigh V. Improving the quality of care in general practice. London: The King\u0026rsquo;s Fund; 2011.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWind A, Te Velde B, Neumann R, Zwart H, Blom A. Kwetsbare ouderen thuis. Handreiking voor integrale zorg en ondersteuning in de wijk. [Vulnerable elderly at home: Guidelines for integrated care and support in the community]. 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BMJ Open. 2018;8(7):e020739.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOostra DL, Harmsen A, Nieuwboer MS, Rikkert M, Perry M. Care Integration in Primary Dementia Care Networks: A Longitudinal Mixed-Methods Study. Int J Integr Care. 2021;21(4):29.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGoldman J, Meuser J, Rogers J, Lawrie L, Reeves S. Interprofessional collaboration in family health teams: An Ontario-based study. Can Fam Physician. 2010;56(10):e368\u0026ndash;74.\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-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Interprofessional collaboration, leadership, primary care, older adults, qualitative study","lastPublishedDoi":"10.21203/rs.3.rs-7085121/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7085121/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe growing number of frail older adults in the Netherlands necessitates robust interprofessional collaboration in primary care to ensure person-centred, high-quality care. In non-managed primary care teams, strong leadership is essential to support team development, coordination, and decision-making. However, there is a lack of clarity about appropriate leadership approaches and the role of the general practitioner (GP) in such teams. This study aims to explore relevant leadership theories and examine the role of the GP in fostering interprofessional collaboration in primary care teams serving frail older adults.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA qualitative study was conducted using semi-structured interviews with ten healthcare leadership experts. The data were analysed thematically using an inductive approach to identify key elements of leadership in interprofessional primary care settings.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe study found that non-managed interprofessional primary care teams require informal leadership, which is captured in the proposed Framework for Informal Leadership in Primary Care (FIL-PC). This framework comprises four key leadership roles\u0026mdash;initiator, visionary, tutor, and overseer\u0026mdash;that together support effective collaboration, shared responsibility, and ongoing learning. While GPs are well-positioned to take on these leadership roles, they may not yet fully recognize or embrace this potential.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eInformal leadership is crucial for effective interprofessional collaboration in non-managed primary care teams. The FIL-PC offers practical insights into necessary leadership behaviours and can guide teams in improving collaboration. Future research should investigate the framework\u0026rsquo;s feasibility and explore educational strategies to support its implementation.\u003c/p\u003e","manuscriptTitle":"Towards an Informal Leadership Framework for Interprofessional Primary Care: An Interview Study Among Healthcare Leadership Experts","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-06 09:32:46","doi":"10.21203/rs.3.rs-7085121/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-20T14:47:48+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-03T06:18:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-24T22:39:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"324239192434221664653662369121011311660","date":"2025-08-19T13:36:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"199078572140171196781283335227164781822","date":"2025-08-18T23:08:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"251551173627732144305015316221330431464","date":"2025-08-18T15:28:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"239220955946364551633205565402208157761","date":"2025-08-17T06:20:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-04T11:20:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-11T20:53:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-11T13:25:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-11T13:21:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2025-07-09T15:03:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"93cf3205-e14d-4090-ac36-cb1a294b22bd","owner":[],"postedDate":"August 6th, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-20T14:47:48+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-20T14:55:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-06 09:32:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7085121","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7085121","identity":"rs-7085121","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}