Healthcare is facing numerous challenges in the twenty-first century. In Nigeria, in addition to the burden of infectious diseases chronic disease incidence continues to rise and poor quality of service is evident. Effective leadership is essential in health care organisations as in other organisations. It is necessary for effective patient care, patient safety, improving work within clinical teams, sorting out problems in the face of emergencies, driving innovation and other aspects necessary for effective and efficient running of healthcare organisations(Gopee and Galloway 2009). Transformational leadership has often been prescribed as the gold standard of healthcare leadership. 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 theoretical leadership approaches applicable within the context of healthcare organisations;
present a case study set in a teaching hospital setting in Africa ;
critically assess the leadership approach operating within the setting and its effect on organisational performance with a focus on transformational leadership ;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 shared 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 2009b).
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 investigated the causal relationship between leadership behaviours and the performance and productivity of staff and found that 'engaging leadership' improved employee engagement and performance(Bradley and Alimo-Metcalfe 2008).
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A study also looked at the relationship between leadership style, empowerment, and job satisfaction on nursing staff at a regional medical centre(Morrison, Jones et al. 1997). The authors 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 discrete 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 and power
Power is the intrinsic 'potential ability of a person to influence others'(Munduate, Medina et al. 2004) and is thus a component of leadership. Position power is by virtue of formal position or authority within an organisation while personal power is conferred on an individual by subordinates or others members of an organisation(Rigolosi 2005). Physicians and nurses can be viewed as having position power by virtue of their knowledge.
Leadership theories and styles in healthcare
A number of theoretical leadership approaches can be applied within healthcare. However, not all aspects seem to fit in perfectly into healthcare, and thus some adaptation may be required.
Transformational leadership
Transformational leadership is a widely advocated approach for healthcare. It is a contemporary leadership approach that is 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 full potential.
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 in spite of limiting situations (Gopee and Galloway 2009).The transformational approach to 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 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). Bass also suggested that transformational and transactional leadership models where a continuum rather than mutually exclusive entities(Bass and Avolio 1994).
Four qualities or behavioural constructs have been widely cited as the leadership factors which make an integral part to transformational leadership- the 4 I'S(Bass 1985; Avolio, Waldman et al. 1991):
individualised influence-describes the ability of the leader to act as role model. This 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 and what followers will receive if they meet expectations.
Active management by exception- focuses on monitoring tasks and problems as they arise in order 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 principle 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'.
Team leadership
This approach to leadership operates within teams or groups in an organism. In the hospital context, care is usually organised in specialty teams. Teaching hospitals thus have mental health teams, paediatrics team, surgical teams, and even sub-specialty teams. Professional groups also constitute teams in order to carry out their functions for example nursing and physiotherapy teams. Team working is needed in these areas in order to coordinate their unique activities efficiently as leadership enhances team performance(Day, Gronn et al. 2004).
Clinical leadership
This is leadership by physicians which is considered important to overall development in healthcare. It was hinted that the goal of improving health outcomes would be reached if physician acquired leadership skills (Berwick and Nolan 1998; Porter and Teisberg 2007).
Leading change in the University College Hospital Ibadan: a failed effort in transformation?
Case study background
Healthcare in Nigeria is faced with enormous challenges. The University College Hospital Ibadan was established in 1948 as 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 recently established 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 it has now grown to an 850-bed hospital. The current average bed occupancy ranges from 60-70%. The hospital board of management comprises:
-the Chairman
-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.
Vision
'To be the flagship tertiary health care institution in the West Africa sub-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).
Mission Statement
'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. There was also some skill-based assessment of his leadership capabilities based on his career experiences(Mumford, Zaccaro et al. 2000).A highly sociable fellow, he is known to have good communication and decision-making skills which are essential attributes of a leader(Pardey 2007).A trained obstetrician, he participates actively in the care of pregnant women.
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Initially after his appointment, there was increasing satisfaction of healthcare staff and patient satisfaction rates began increase. A new magnetic resonance imaging centre was commissioned and newer facilities for cancer research, diagnosis, treatment was established. Satellite pharmacies were established in order to reduce the time and effort spent by staff in getting patients' medications. He established a day care centre and leased offices to banks in order to facilitate financial transactions by staff that previously had to commute for 30 minutes to get to the banks at the city centre.
After some initial successes following his appointment, mortality rates continued to rise, medical errors are frequent, and post operative patients developed infections frequently. Physicians are verbally and physically abused by patient relatives. Private patients in the newly established private suites get more attention and care from the junior doctors and specialist consultants. Junior doctor on call are frequently away from their duty posts during call hours and medical students practical training is grossly undermined. The hospital is currently failing to meet the needs of the local population.
Current SWOT analysis of the University College Hospital Ibadan
Strengths
Weaknesses
Fairly well-equipped operating theatres
Newly renovated and well-built hospital blocks
Excellent medical microbiology services, including HIV testing
Residential accommodation for house officers and other specialist trainees
Strong alliance with international organisations for infectious diseases research
Expensive laboratory services
Relative shortage of medical staff
Politicisation of board of management appointments
Weak administrative set-up
Expensive pharmacy services
Inadequate funding
Delay in staff remuneration
Few opportunities for exchange programmes for students and residents
Expensive nursing school
Inadequate supply of electricity
Opportunities
Threats
Federal Government's commitment to the development of tertiary care
More research funding
Competition from existing private and missionary hospitals
Incessant industrial actions embarked upon by nursing staff, physicians and support staff
As a theoretical model, the main strengths of this approach are its moral appeal and its prolificacy in research literature. Transformational leadership has also been shown to be a positive factor in driving innovation. It is also known to be an important factor in driving innovations in an organisation (Jung, Chow et al. 2003; Jung, Wu et al. 2008).It is also important in enhancing the effectiveness of specialty teams within the hospital(Dionne, Yammarino et al. 2004).Even with its own merits, the view that transformational leadership is the solution for healthcare leadership has been subject to criticisms by leadership scholars. While there are advantages of using the transformational approach, it is not a universal panacea.
It is widely recognised that transformational leadership has some positive benefits, it is noted that it is particularly difficult to act out within public services organizations (Frederickson (1996) cited in (Currie 2005). Transformational leadership, while focusing on change, may not be in consonance with performance management needed for accountability in healthcare(Firth-Cozens and Mowbray 2001).
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 mediator 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 changing organisational culture on hand-washing practice (Larson, Early et al. 2000)and policy(Sharek, Benitz et al. 2002) recorded fewer hospital acquired infections.
The contextual(Pawar and Eastman 1997) and situational factors (Thomas 1988) in which a leadership style operates has a role in determining outcome irrespective of leadership approach. It is suggested 'to have leadership approaches that are sensitive to a context in which there are significant professional and moral concerns'(Currie 2007).Leadership scholars have also cited environmental risk, leader hierarchical level and leader follower gender as contextual variables affecting leadership effectiveness(Antonakis, Avolio et al. 2003).
On one hand, there is some evidence that transformational leadership is linked to improved employee psychological well-being(Nielsen, Randall et al. 2008). However, studies have also 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-related 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. His appointment was also thought to be politically influenced and hence commissioning of projects may be influenced by politics.
Transformational leadership places the leader in focus and assumes that the leader takes credit for and is responsible for motivating followers to success. This `heroic leadership bias'(Yukl 1999) does not seem to give credit to other members of the organisation. Indeed, when the hospital was thriving well the CMD received numerous awards and in the typical African style, he also traditional chieftaincy titles and knighthood were conferred on him at his village and church respectively.
Conclusion
A number of leadership theories, skills, and style in healthcare have been discussed. Several approaches may operate simultaneously. Context, political environment, and social factors also affect leadership styles and approach therefore clarifying the situation of a practice and flexibility is very important. 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 workforce will be the key to meeting the numerous challenges facing healthcare organisations in Nigeria. However, 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 focus on adopting an eclectic blend of theories and styles in practice in order to improve its performance.
Recommendations
Educational interventions have been proposed to improve healthcare leadership(Butler 2008).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).Developing leadership skills of all healthcare practitioners would be desirable.
Fostering connective leadership by establishing more relationship with specialist hospitals abroad and more opportunities for exchange programme would help in increasing the clinical knowledge and practice. Understaffing increases stress levels and makes knowledge ineffective and it is thought that higher nursing staff level may help reduce the spread of infections(Duffin 2008).Encouraging nursing leadership may also help in achieving the organisation's objectives.
Adding more transactional dimensions to the leadership role may help in improving the organisational performance. Though, a systematic review found transformational leadership is more effective(Lowe, Kroeck et al. 1996),it has also been argued that both transactional and transformational roles are needed for the successful running of an organisation. Efforts should be made to recognise well-performing staff and junior doctors committed to repeated errors and absence at call duty posts should have their training duration extended.
A distributed model of leadership has been suggested for organisations in which leadership is shared rather than focusing on an individual (Gronn 2002).It may be considered as healthcare involves working with teams and there are complexities involved in the delivery of care.
Acknowledgements
The author wishes to acknowledge some ideas in this work arose from reflections after a class group presentation and lecture on healthcare leadership by Professor Graeme Currie at the Department of Epidemiology and Public Health, University of Nottingham.
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