Effective leadership is essential in health care organisations as in other organisations. It is necessary for driving innovation, effective patient care, patient safety, improving working within clinical teams, sorting out issues within emergency context and other aspects necessary for effective and efficient running of healthcare organisations. Transformational leadership has often been prescribed as the ‘gold standard' of healthcare leadership(Gopee and Galloway 2009).This essay sets out to:
- briefly discuss the concept of leadership;
- highlight why leadership is important in healthcare;
- make a distinction between the closely-related concepts of leadership and management;
- briefly highlight how power relates to leadership;
- describe some leadership approaches applicable within the context of healthcare organisations;
- describe leadership styles visible in healthcare;
- present a case study set in a teaching hospital practice setting in Africa ;
- critically assess the leadership approaches operating within the setting and its effect on organisational performance ;and
- make recommendations on improving leadership practice within the specified setting.
What is leadership?
Leadership can be defined as “the ability of an individual to influence a group of people to achieve a goal(Bryman 1992).It is also noted that ‘leadership can have four possible meanings, namely: the activity of leading; the body of people who lead a group; the status of the leader; and the ability to lead'(Gopee and Galloway 2009).
Kouzes and Posner (2007) suggest some characteristics of an effective leader namely to:
be more effective in meeting job-related demands;
be more successful in representing their units in upper management;
create higher performing teams;
foster renewed loyalty and commitment;
increase motivational levels and willingness to work hard; and
possess high degree of personal integrity.
Why leadership in healthcare?
- Effective leadership and management has been found to contribute to efficiency of health care services, performance (McColl-Kennedy and Anderson 2002) and satisfaction of staff employed within them.(Bradley and Alimo-Metcalfe 2008) researched the causal relationship between leadership behaviours and the performance and productivity of staff and found that ‘engaging leadership' improved employee engagement and performance.
- (Morrison, Jones et al. 1997) studied the relationship between leadership style, empowerment, and job satisfaction on nursing staff at a regional medical centre. They used Bass's Multifactor Leadership Questionnaire to measure leadership style, items from Spreitzer's Psychological Empowerment instrument to measure empowerment, and the Warr, Cook, and Wall's job satisfaction questionnaire to measure job satisfaction. The authors found that both transformational and transactional leadership were positively associated with job satisfaction.
- Some other researchers reported that good leadership skills impacted on patient safety and quality of care (Corrigan, Lickey et al. 2000; Firth-Cozens and Mowbray 2001; Mohr, Abelson et al. 2002).Furthermore, leadership skills are essential in the world of public health policy and leadership is one of the core competencies required of public health trainees(Faculty of Public Health 2010).
Leadership versus management
Relevant to this discourse is making a distinction between leadership and management. They are two similar but distinct concepts. Management is seen as seeking order and maintaining stability while leadership is seen as seeking adaptive and constructive change. Leadership in the healthcare context aims to influence practitioners towards the achievement of the common goal of quality patient care. On the other hand, management as a process coordinates and directs the activities of an organisation to ensure it achieves its set objectives. Management ensures healthcare resources (human such as doctors, nurses and clerical staff and non-human resources like medical devices and consumables) are utilised in an efficient way whilst delivering effective healthcare service(Gopee and Galloway 2009). However, leadership is known to be complementary to management (Kotter 1999; Zaleznik 2004).
Leadership theories and styles in healthcare
A number of theoretical leadership approaches can be applied within healthcare. However, not all aspects fit in perfectly into healthcare, and thus some adaptation may be required.
Transformational leadership is a widely advocated approach for healthcare. Transformational leadership is one of the contemporary leadership approaches that are concerned with how an individual influences others in a group in other to achieve a common goal. Transformational leaders seek to accomplish greater pursuits within an organisation by inspiring other members of the group to share their vision for the organisation. Transformational leaders motivate and raise the morality of their followers and help them reach their fullest potential. Mohandas Gandhi Nelson Mandela have been cited as transformational leaders(Northouse 2007).
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In an organisational context, a transformational leader is one who attempts to change the organisations values in order to portray a standard of fairness and justice while in the process emerging with a better set of moral values. Transformational leadership is about the collective good of an organisation; it is expected to bring about organisational change. It aims to inspire commitment to the organisation's vision and ideals. In healthcare, teams of health care professionals are inspired to achieve the highest quality of patient care irrespective of limiting situations (Gopee and Galloway 2009).
The concept of transformational approach of leadership was popularised by the political sociologist, leadership expert, and presidential biographer- James Macgregor Burns in his seminal work Leadership written in 1978. In this book, he described the leadership styles of some political leaders. Bernard Bass widely cited in leadership literature built on the work of Burns and argued that leadership is an influence process which motivates followers to perform above their expected output by ‘raising the follower's level of consciousness about the importance and values of the shared goals, operating beyond their self-interests and addressing higher level needs'(Bass 1985). He also suggested that transformational and transactional leadership models where a continuum rather than mutually exclusive entities.
Four qualities or behavioural have been widely cited as the leadership factors which are an integral part of transformational leadership- the 4 I'S(Bass 1985; Avolio, Waldman et al. 1991) namely:
- idealised influence-describes the ability of the leader to act as role model s whose followers emulate. This factor is sometimes mentioned as being the same as charisma;
- inspirational motivation-the ability to inspire the members of the group to become integrated with the vision of the organisation while transcending their own self-interest ;
- intellectual stimulation-the stimulation of creativity and innovation in the followers so that they are able to discover and develop new ways of sorting out issues within the organisation as they arise; and
- individualised consideration-portrays the need for leaders to recognise the strength and weakness of each member of the group foster on the development of followers and help each in the achievement of goals through personal development.
Transactional leadership, on the other hand, is one based on reward for performance. A transactional leader is described by (Bass 1985)as one who prefers a leader-member exchange relationship, in which the leader meets the needs of the followers in exchange for meeting basic expectations. In essence, a transactional leader has a penchant for avoiding risks and is able to build confidence in subordinates to allow them to achieve goals. The transactional leadership construct has three components:
Contingent reward -clarifies what is expected from followers and what they will receive if they meet expectations.
Active management by exception- focuses on monitoring tasks and arising problems and correcting these to maintain current performance.
Passive -Avoidant Leadership-reacts only after problems become serious and often avoids decision-making(Avolio, Bass et al. 1999).
Connective leadership is a theory based on the premise that establishing alliance with other organisations via networking is essential to the success of an organisation. Collaboration between different clinical teams within a hospital and with other health care organisations and service industry exemplifies this.(Klakovich 1994) suggests that ‘empowering staff at all levels facilitates the collaboration and synergism needed in the reformed health care environment of the future'.
Leading change in the University College Hospital Ibadan: a failed effort in transformation?
Healthcare in Nigeria is faced with enormous challenges. The University College Hospital Ibadan was established in 1948 is the foremost tertiary hospital in Nigeria. It is basically organised as a public sector organisation whose primary goal is to provide the best available healthcare service in the western region and the country as a whole. Funding is from the Federal Government and its activities are regulated by the Federal Ministry of Health which is also responsible for the implementing healthcare policies. However, a private section of the hospital was established recently modelling the prevalence of internal markets currently prevailing within healthcare. Currently, the University College Hospital produces 1 in every 5 physician in the nation. It was initially commissioned with 500 bed spaces but has now grown to a 850 bed hospital. The current average bed occupancy ranges from 60-70%. The hospital board of management comprises:
the Chief Medical Director;
the Chairman, Medical Advisory Committee;
the Secretary of the Board;
representatives of public interest;
representative of the Nigerian Medical Association;
representative of the State Government;
representative of the University of Ibadan Senate;
representative of the Vice Chancellor of the University of Ibadan; and
the Provost of the College of Medicine.
The organisation has three principal officers but the day -to -day running of the hospital falls on the Chief Medical Director who demonstrates some attributes of transformational leadership in order to bring about change.
‘To be the flagship tertiary health care institution in theWest Africasub-region, offering world-class training, research and services, and the first choice for seeking specialist health care in a conducive atmosphere, renowned for a culture of continuing and compassionate care'(University College Hospital Ibadan 2009).
‘Rendering excellent, prompt, affordable, and accessible health care in an environment that promotes hope and dignity, irrespective of status, and developing high quality health personnel in an atmosphere that stimulates excellent and relevant research'. (University College Hospital Ibadan 2009).
The Chief Medical Director is an assigned leader-one whose leadership is based on formal position and legitimate authority. His appointment by the Federal Government in 2003 was proposed to be vital contribute to the improvement of the hospital. A trained obstetrician, he participates actively in the care of pregnant women.
With increasing satisfaction of healthcare staff, patient satisfaction rates began increase. A new magnetic resonance imaging, centre, cancer treatment and research centre....new innovations...the bank to collect..Satellite pharmacies were established in order to reduce the time and effort spent by staff in getting patient medications....staff development through exchange programmes, establishment of day care centres....shows his entrepreneurial qualities.
Despite it all, mortality rates remain high, medical errors are frequent, post operative patients developed infections frequently and physicians were verbally and physically abused by patient relatives. Private patients get more attention from the junior doctors and other specialist consultants. It has now been found wanting in serving the needs of the local population. Repeated nurses strike, junior workers strike.....
Despite recognition that transformational leadership has some positive benefits, it is particularly difficult to act out within public services organizations Frederickson 1996 cited in (Currie 2005).Though with its own merits, the view that transformational leadership is the solution for healthcare leadership has been criticised. While there are advantages of using the transformational approach, it is not a universal panacea.
Transformational leadership alone cannot account for effective outcomes in this health care organisation. Other aspects like of organisational behaviour such as management practices, knowledge management, and organisational culture are also key determinants. A US study of 370 hospitals explored the relationship between leadership, quality and knowledge management and found that transformational leadership is fully mediated by knowledge responsiveness in its effect on organisational performance (Gowen, Henagan et al. 2009). Effective knowledge management is thus strong confounder in the relationship between leadership and organisational performance. In relation to organisational culture, there is also a link between hospital and ward culture with patient outcomes. Research has shown that hospitals with a strong hand-washing policy and practice recorded fewer infections.
Transformational leadership, while focusing on change, may not be in consonance with performance management needed for accountability in healthcare(Firth-Cozens and Mowbray 2001).
The context in which a leadership style operates is also a key determinant on outcome irrespective of leadership style. Studies have shown the relationship physician working hours, stress, and burnout on quality of care and patient outcomes (Firth-Cozens and Cording 2004; Landrigan, Rothschild et al. 2004).Tackling job stress is thus a key avenue for improving quality of care. The Chief Medical Director needs to understand the complexity within which healthcare is delivered and translate it to his practice setting rather than trying to adopt a prescribed process.
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This essay has highlighted a number of leadership theories, skills, style leadership in healthcare has been assessed. There is no perfect style or approach to leadership and healthcare organisations pose a complex setting. Several approaches may operate simultaneously. Context, political environment and social factors will affect leadership styles and approach. Clarifying the situation of a practise and flexibility is very important.
Numerous challenges face healthcare organisations in Nigeria. The ability to deliver safe, effective, high quality care within organisations with the right cultures, the best systems, and the most highly skilled and motivated work forces will be the key to meeting this challenge. Conflicts still exist as to what constitutes good practice in leadership and there is no perfect set of prescriptions for effective leadership. All the existing theories merely provide a framework for which practise can be based. Healthcare organisations are a complex setting and to achieve efficiency and effectiveness, healthcare leaders need to be very flexible in their leadership. The University College Hospital should adopt an blend of different theories and styles in practice.
Leadership can be taught (Parks 2005)and improved through organising leadership development programme. It is also noted that leadership development programmes improved efficiency and quality in healthcare(McAlearney 2008). Top management and clinical staff can take these.(Kotter 1990) suggests that organisations can nurture and ‘grow' their own leaders while adapting to constant changes(Parks 2005)
There appears a need for leadership approaches that are sensitive to a context in which there are significant professional and moral concerns graeme.
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