leadership style

Journal of Healthcare Leadership
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Open Access Full Text Article
Leadership communication styles: a descriptive
analysis of health care professionals
This article was published in the following Dove Press journal:
Journal of Healthcare Leadership
25 June 2012
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Rebekah Rogers
School of Communication, East
Carolina University, NC, USA
Introduction
Correspondence: Rebekah Rogers
1640 B Brook Hollow Dr, Greenville,
NC 27834, USA
Tel +1 252 917 7526
Fax +1 252 328 1509
Email rogersr@ecu.edu
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http://dx.doi.org/10.2147/JHL.S30795
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Abstract: The study of leadership in health care is important to examine for many reasons.
Health care leaders will inevitably have an impact on the lives of many people, as individuals
rely on physicians and nurses during some of the most critical moments in their lives. This paper
presents a broad overview of a research study conducted over the past year and highlights its
general conclusions. In this study, I examined the leadership styles of health care administrators
and those of physicians and nurses who chair departments. Thorough analysis yielded three clear
themes: viewpoints on leadership, decision making, and relationships. Physicians’ viewpoints
on leadership varied; however, it was assumed that they knew they were leaders. Nurses seemed
to be in a category of their own, in which it was common for them to use the term “servant
leadership.” Results from the hospital administrators suggested that they were always thinking
“big picture leadership.” Leadership is a working component of every job and it is important
for people to become as educated as possible about their own communication style.
Keywords: leadership, communication, health care
The study of leadership in health care is important to examine for many reasons.
Health care leaders will inevitably have an impact on the lives of many people, as
individuals rely on physicians and nurses during some of the most critical moments
in their lives. This paper presents a broad overview of a research study conducted
over the past year and highlights its general conclusions. In this study, I examined
the leadership styles of health care administrators and those of physicians and nurses
who chair departments. All of the study participants were employees in the health
sciences division of a large Southeastern university in the USA. Before conducting
the study, I determined through research that there are many types of styles that
leaders can embody, including transformational leadership, transactional leadership,
and servant leadership. I will provide more insight into what each of these different
types of leadership entails in the literature review. I will also discuss the relationship
between health care and leadership, as well as the role of physicians as leaders, nurses
as leaders, and hospital administrators as leaders.
This research aimed to elucidate the importance of linking leadership styles to
individual professions, and in this context, specifically investigated the health care
profession. To this end, the following research questions (RQs) were advanced:
RQ1: What are the leadership approaches or philosophies reported by doctors, nurses,
and hospital administrators?
Journal of Healthcare Leadership 2012:4 47–57
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which permits unrestricted noncommercial use, provided the original work is properly cited.
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Rogers
RQ2: Is there a leadership approach that is found to be
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common among health care professionals?
Effective communication and leadership styles are essential in the workforce. Individuals who show superb communication and leadership skills should be able to find success
in their organization at a faster pace than those whose communication and leadership skills are lacking. Additionally,
the study of one’s own leadership style is important in order
for individuals to be able to grow professionally, personally,
and developmentally. Leadership is a working component
of every job, regardless of whether one is employed as a
factory worker, academician, or chief executive officer of
a large corporation. In short, people want to work for and
with people who are skilled in communication and who
have strong professional and personal leadership qualities.
Therefore, the current research is important for many practical reasons. I believe it is critical for individuals to take
this information and apply it to their own working lives.
I was able to gain valuable insights into styles of leadership
through this research, and the research was beneficial to the
participants because they learned about their own leadership
style and were able to draw general conclusions in relation
to their profession, personality, and demeanor. They also
gained valuable insights into the way they work with others.
Individuals are becoming more aware of their leadership
styles and the way they communicate through feedback from
others. In addition to the individual level, this research can
have an impact at a global level. Through the current research,
it is my hope that people will see the value in learning more
about their own leadership styles and ideologies.
Background
Theory
In this study, the style approach was used to guide the
research. In this approach, the focus is on the behavior of
the leader; in fact, it centers exclusively on what leaders do
and how they act. Within the style approach framework,
researchers have suggested that there are two general kinds
of behaviors: task behaviors and relationship behaviors.
Task behaviors assist in goal accomplishment such as helping group members achieve their objectives. Relationship
behaviors help subordinates feel comfortable with each other,
with themselves, and in their specific situation. According to
Northouse, “the central purpose of the style approach is to
explain how leaders combine these two kinds of behaviors
to influence subordinates in their efforts to reach a goal.”1
I used this approach because of the assumption that every
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participant has a different leadership style that affects what
they do and how they act. In addition, the different types of
styles are defined by a combination of exhibited behaviors,
and the easiest way to observe those behaviors is through
an interview. Though the style approach is being used as a
theory, Northouse noted that it is not a perfect indicator of
strong leadership behavior using a structured and organized
approach because it does not have a set rubric for determining
the desired outcome.1 Instead, Northouse stated:
The style approach provides a framework for assessing
leadership in a broad way, as behavior with a task and
relationship dimension. The style approach works not by
telling leaders how to behave, but by describing the major
components of their behavior.1
The style approach is a dynamic approach, because it
looks at the task and relationship behavior of the leader, and
is a reminder that actions result from a combination of the
two. Different situations call for different measures because
in some cases the leader may need to be more task oriented in
their behavior, and in other situations, the leader may need to
be more relationship oriented. Similarly, some subordinates
need to be given specific directions in order to perform their
job well and others may need an environment of support and
praise. Through the leaders knowing how their subordinates
function best, they can perform their jobs better and there will
be a greater sense of job satisfaction overall. Most importantly,
Northouse states that the style approach “reminds leaders that
their impact on others occurs through the tasks they perform
as well as in the relationships they create.”1 Using the style
approach in this study allowed me to be open to obtaining a
wealth of descriptive data that is of a true qualitative nature.
Literature review
Leadership and management
The existing literature on leadership and communication
styles presents a rich overview of this critical phenomenon and
its application to the health care profession. When exploring
leadership communication styles, it is important to carefully
differentiate between the terms “leading” and “managing.”
Curtis et al suggest that managers administer, maintain,
control, have a short-term view, and initiate.2 Kotterman
further contends that managers tend to “plan and budget,”
as well as focus on narrow objectives in order to “maintain
order, stabilize work, and organize resources.”3 Additionally,
managers often seek to “control and problem solve” as they
“produce standards, consistency, predictability, and order.”3
Curtis et al recognize that leaders innovate, develop, inspire,
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Leadership communication styles of health care professionals
challenge the status quo, and focus on a long-term vision.2
Kotterman “sees management as dealing with procedures,
practices, and complexity and leadership as dealing with
change.”3 The focus of this analysis is on the leadership communication styles of health care professionals; therefore, it
is critical to understand a variety of approaches to effective
leadership. Specifically, this research examines how transformational leadership, transactional leadership, and servant
leadership apply to health care professions. Each of the styles
will be explained in detail within the following review of key
literature concepts that impact this area.
that transactional leaders are different from transformational
leaders in a fundamental sense: they work within the boundaries and the existing standards of the organization.6 Few risks
are taken and the focus of the work is on efficiency, control,
stability, and predictability.6
While transformational and transactional leaders are
different, it is important to know that they are also complementary in nature. Both styles may be associated with the
achievement of desired performance objectives. It is clear
that leaders can function using both styles cooperatively and
can augment each other on the job.6
Transformational leadership
Servant leadership
James McGregor Burns’ Leadership4 is considered to be the
seminal text in the field of leadership studies.5 Transformational
and transactional leadership emerged as the dominant leadership framework in the 1990s, and in 1978, Burns defined
transformational leadership as the following: “wherein one or
more persons engage with others in such a way that leaders and
followers raise one another to higher levels of motivation and
morality.”5 In Burke and Cooper, Avolio and Yammarino state
that transformational leadership consists of the following key
factors: “One, charisma, instills faith, pride, and respect for
the leader. The second, individualized consideration, involves
treating all staff as respected individuals with unique needs.
The third, intellectual stimulation, encourages staff to think in
new ways.”6 According to Burke and Cooper, these types of
leaders closely identify with their subordinates and with the
purpose of the organization.6 Motivation also plays a significant role for transformational leaders, especially since it leads
to success in their position and an optimistic outlook on the
organization.6 Additionally, transformational leaders are not set
in their ways. They are open to change and often appreciate
a creative approach to problem solving and teamwork. While
this approach can be risky at times, transformational leaders
excel using this style of leadership.6
Transactional leadership
Transactional leadership occurs when a person takes the
initiative in making contact with others for the purpose of
an exchange of valued items. The trade could be financial,
social, or emotional in nature: an exchanging of a product
for money; the trading of ideas among businessmen; or even
providing a listening ear to those in need.5 Burke and Cooper
stated that “transactional leadership has two components: the
transactional leader exchanges rewards contingent upon the
exhibition of desired behaviors and results, and intervenes
when performance falls short.”6 Burke and Cooper also noted
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The term “servant leadership” was coined by Robert Greenleaf in his influential 1970 essay “The servant as leader.”5
Greenleaf believes that these types of leaders focus on the
service aspect first, as they have a natural tendency to help
others. Once service is achieved, the individual aims to lead
as a result of this achievement. Greenleaf writes that the best
way to determine whether a person is a servant leader is to
identify whether they grow as a person, become healthier,
and are likely to develop an autonomous and selfless desire to
serve others.5 Servant leadership is a long-term, transformational approach to life and work. It is an ever-changing process
with the goal of creating change throughout society. Spears
believes that the following characteristics are central to the
development of servant leaders: listening, empathy, healing,
awareness, persuasion, conceptualization, foresight, stewardship, commitment to the growth of people, and building community.5 Spears believes that these ten characteristics “serve to
communicate the power and promise that this concept offers
to those who are open to its invitation and challenge.”5
Health care and leadership
The health care industry is constantly advancing. In the past
decade, the health care business has become one of the most
powerful in our society, providing a significant number of
jobs and critical medical services for citizens. The health care
industry is complex and multifaceted.7 Due to the complexity
of the system, changes in health care have left leaders weary
and doubtful of their ability to rebuild trust and provide their
organizations with a sense of direction. Dye gives an example
of a common sentiment among health care leaders:
The stress, the lack of clarity, changing our vision every
two to three years, our constant reengineering and restructuring – all this is taking its toll on our leadership. We are
all physically and mentally exhausted and some of us are
burned out. It’s not fun anymore.8
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Rogers
In order for health care workers to operate efficiently, they
must have effective leadership, and the health care leaders of
today face challenges due to the increasing complexities arising in the industry. These challenges will continue to evolve
for years to come. Twenty-five years ago, hospitals operated
solely to provide care for patients, and their leaders did not
have to deal with multiple business lines. “The more complex the system, the less efficient its operation,” is an adage
that is true of the current health care system.7 Researchers
are realizing that employee commitment and loyalty are at
their lowest, and that health care executives, physicians, and
patients today are generally “dissatisfied with the management in the industry.”7 Leaders are an essential component
of successful health care initiatives. Patients turn to physicians, nurses, and hospital administrators for guidance and
direction. Souba wrote that “Health care today needs … a new
kind of leadership; strong leaders and a new cultural context
in which they can lead.”9 The following paragraphs explain
the importance of leadership among physicians, nurses, and
hospital administrators.
The physician as leader
Physicians are part of an expert culture. An essential element of an expert culture is that the individuals with all the
knowledge make all the decisions, issue by issue, from the
perspective of how decisions will personally affect them.
Souba wrote that “today’s medicine structure incents physicians and other leaders to focus on knowing, having (titles,
power) and doing (out-performing) such that personal reward
is often valued above service to others.”9 Bujak, a physician,
says that “when I listen to physicians speak, I notice that
they infrequently speak in the plural. Physicians usually
say “I” and “me,” but rarely “we” and “us.”10 This study
suggests that physicians do not have a collective identity.10
Interestingly, Palmer et al found that “doctors see themselves
as ‘coordinators’, ‘team workers’ and ‘company workers’,
which means that they want to communicate, be organized,
and avoid friction.”11 They also found that physicians “do
not show strong tendencies to be enterprising, creative, or
critical thinkers.”11 Physicians described teamwork as the
following:
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match accrues points for the team, and, at the end of the
day, the team that amasses the most points wins the competition. What, then, must an individual do to contribute to
the likelihood that his team will win the competition? The
answer is to win his individual match. If each member wins
his individual match, the team wins. If the team loses, the
members who have lost their individual matches are blamed.
Teamwork to the physician is a zero-sum game in which the
whole equals the sum of the parts.10
Bujak compares teamwork within the health care organization to volleyball, saying “The roles of the team members
are clear and interdependent. In this case, the whole can
exceed the sum of its individual parts. The functionally
best teams are not always comprised of the best individual
players.”10
When it comes to physicians and decision-making, Bujak
concluded that physicians tend to focus on outcomes.10 If
success was achieved, how it was achieved is irrelevant
because the end justifies the means. This is the essence of
distributive justice. In contrast, the culture of the health care
organization demands a more procedural justice that focuses
on the process rather than the end conclusion. According to
Bujak, the outcomes of the situation are reliant on whether
physicians personally and actively participate in the process
to achieve the desired outcome.10 Individual opinion being
heard in the process is important as well. Solutions are only
appropriate if the right voices are heard from the appropriate
sources.10 According to Bujak, this time-consuming requirement for inclusiveness irritates physicians, whose philosophy
is “if you know the answer, just do it yourself! Stop wasting
time!”10 However, in a health care organization, imposing
a decision without following the appropriate steps or gaining the acceptance of the whole group only ensures that
the measure will be resisted. Bujak recognized that “while
physicians advocate for distributive justice when they are the
ones giving the orders, they too demand procedural justice
when others give orders to them.”10 Bujak also discusses what
motivates physicians:
Experts determine success by outperforming the competition.
Achievement, taking risks, stamina, intense focus, quick decision making, and personal accountability are characteristic.
Physicians’ definition of teamwork is like the game of golf.
Physicians are strongly vision or goal directed. They are
Members of a golf team are seeded in a way that reflects
not usually motivated by mission. Frequently, hospital
their individual competency. The best member of the team
administrators and their governing boards try to leverage
is seeded number one. The next best member is seeded
the medical staff’s behavior by suggesting that they have
number two, and so on. When teams compete, the respective
lost their professional “soul” because they do not support
seeds compete against each other. Winning an individual
the mission of the healthcare organization.10
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Leadership communication styles of health care professionals
However, the health care organization and the physician typically have different missions. Bujak noted that the most important action for creating an effective health care organization is
to link the goals of individual physician practitioners with the
actual needs of the health care setting: if doctors can see a direct
connection between their success and the goals of the organization, then a positive working relationship can occur; if not, then
the vision will fail and self-interest will take over.10
Physicians tend to resist collaboration and teamwork.
They were trained to function under their own self-control,
and partnership is a difficult quality to learn after many years
of operating alone. According to Bujak:
that physicians have a strong need to be able to predict and
thereby control their environment.
Health care organizations recognize the importance of
identifying physician leaders and investing in their leadership
potential, as seen in Bujak:
Healthcare is a culture of personal accountability in which
the mission of the organization must supersede the needs
the attending physicians bear the ultimate responsibility.
of any one individual. As physician leaders begin to acquire
In this context, one can quickly appreciate why physicians
a systems perspective, appreciate the organizational conse-
are taught to trust no one. In addition, physicians are usually
quences, they also begin to apply a vocabulary and share
highly competitive people; obtaining a medical degree is
a perspective that is foreign to the narrow self-interest of
difficult without having been successfully competitive from
their former constituents who, at that point, reject them as
an early age. Highly competitive people are predisposed not
having gone over to “the dark side.”10
to trust. Competitive individuals are prone to see the world
as a zero-sum game. If you win, I might lose. If your slice
of the pie enlarges, mine might become smaller.10
For this reason, health care organizations that seek to
collaborate with physicians form their relationships based
on negotiations. Bujak confirms that one can enter negotiations by adopting one of four postures: competition,
accommodation, compromise, and collaboration.10 Highly
competitive physicians play a win-lose game. Physicians are
typically skeptical of engaging in collaborative behavior, or
win-win negotiations, because collaboration requires trust and
highly competitive physicians are predisposed not to trust.
Palmer et al11 believe that physicians tend to operate under a
transactional leadership style. They noted that the physicians’
favoring of the transactional leadership style “correlates with
the observation that their team preferences are for accepting
and working within the system as it is (mostly transactional),
rather than for making changes and shaping the future (more
transformational).”11 It seems auspiciously evident that physicians are aware of their high intelligence, in most cases, and
often believe they can do anything without ample practice.
According to Bujak, “in physician training, ‘See one, do one,
teach one’ is frequently repeated. This attitude can foster a
sense of arrogance and self-confidence that oversimplifies and
underestimates the contributions of others who contribute to
patient care;”10 as such, physicians are expected to have all
the answers, bear the ultimate legal responsibility, and meet
the expectation of perfection. It is not surprising, therefore,
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Moving from positions of informal leadership to positions
of formal leadership within the organization is a transformative journey. Those who rise to positions of informal
leadership do so because they are eloquent spokespersons
for the shared needs of their constituency. However, when
moving into positions of formal leadership, the individual
can never again be “one of the boys.” For formal leaders,
Souba discussed the importance of physicians understanding their need for “being,” as this understanding could
lead to a greater development and fulfillment of their leadership.9 Souba wrote that the “being of a leader as the basis
for what leaders know, have, and do – is central to restoring
medicine’s long standing ethical underpinnings.”9 In further
comprehension of one’s being, Souba contended that greater
understanding of oneself can be accomplished through “four
ontological pillars – awareness, commitment, integrity, and
authenticity.”9 The leadership potential of a physician should
begin in the early stages of his or her career; in other words,
medical schools should begin teaching this practice. It is clear
that investing in the leadership growth of a physician early
on will allow him or her to acquire the necessary skills to
function as a collaborative, open-minded leader.
The nurse as leader
Nursing and leadership have been researched extensively.
According to Dirschel, “leadership in nursing is a goal, vision,
and expectation for all professional nurses in any form of
practice.”12 Ultimately, all forms of nursing leadership must
result in excellent patient care and outcomes. Curtis et al highlighted the importance of effective leadership from not only
those individuals who are designated leaders in nursing, but
also the importance of effective leadership from students and
from all levels between: “It seems logical to conclude that the
development of excellence in nursing leadership should, therefore, begin at the earliest stages of basic nursing education
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and training.”2 All forms of nursing leadership must also create
an environment that supports and encourages evidence-based
nursing practice, which is essential for the practice of nursing
at the cutting edge of recognized standards. Dirschel’s views
on nursing are clear in the following:
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The nurse leader in the institution is the force behind clinical
practice in the nursing role. Nurse leaders being the vision
for growth and the power to create the environment needed
to preserve and develop the profession. The nurse leader is
the visionary and the catalyst who brings power to nursing
practice and creates an environment in which innovation and
ideas about nursing practice can flourish. The nurse leader
must create and orchestrate an environment that supports
and encourages excellence in nursing and scholarly, caring
practice. The nurse leader has the interesting challenge of
creating and maintaining openness in a multidimensional,
complex healthcare delivery system and enriching the practice field of nursing for the benefit of the institution.12
Dirschel mentions that nursing leadership at the highest
level occurs primarily in health care delivery systems and in
educational institutions.12
The roles of nurses in these two settings are related, but
differ significantly. It is important to note that nursing leaders in both of these environments have the same challenges
and opportunities to move the profession forward – to move
nursing as it is expressed in their institutions to exceed expectations and to move the standards of practice to a higher level.
According to Dirschel:
the nursing leader also energizes the dynamics of the other
personnel groupings and the vision, mission, structure, and
resources of the broader institution. Doing so creates an
open, more fluid system throughout the healthcare organization where individuals’ resources and roles can work
together with greater understanding and cooperation.12
Curtis et al believe that nurses embody a transformational
style of leadership.2 They stated that “creating a warm, safe,
and supportive organizational culture and work climate is
another initiative that can be used to develop leaders and
improve leadership.”2 Nurses embodying quality communication also leads to a more seamless approach to leadership
in the field of nursing. Finally, when looking at the nurse as
a leader, Dirschel concluded that “the roles, responsibilities,
resources, and information that shape the persona of the nurse
leader and the nurse manager can transport the nurse from
bedside to boardroom easily, accurately, and with support and
enthusiasm from the staff and leadership alike.”12
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The hospital administrator as leader
This study also reviewed the hospital administrator as leader.
One might expect a hospital administrator to be extremely
power- and status-driven. The leadership development of
a hospital administrator must start early in life. Typically,
a person must have a long track record of successes to reach
a hospital administrator position. The root of this research is
embedded in servant leadership: the wanting to give back or
contribute in an effort to help others. This feeling of servant
leadership begins with the first job or first desire to want to
help others. Through the current research, the leadership
styles of hospital administrators could be revealed in an effort
to make them more self-aware.
Methodology
This section provides a brief discussion of the methodology
I used to study the leadership styles of health care professionals within a health sciences division at a large Southeastern
university in the USA. First, I present the interpretive and
critical paradigms. Second, I describe the process of conducting the in-depth interviews that were used in the study.
Third, I describe the participants and the recruitment process.
Finally, I address the methods of data collection, which
included in-depth interviews and document analysis.
Interpretive and critical approach
to research
One purpose of this research was to provide a descriptive
analysis of the leadership styles observed among health care
professionals. I was most interested in learning about the similarities and differences that exist among the leadership styles of
physicians, nurses, and administrators. I was also interested in
determining whether there are certain leadership traits that make
them better suited for their field. In order to achieve these goals,
I drew on the interpretive and critical paradigms of research.
One of the basic goals of the interpretative researcher is to
gain a deeper understanding of the people and practices under
study. Through understanding, I am able to connect to people at a
deeper level regarding their idiosyncrasies and knowledge. Other
fundamental assumptions that underlie interpretive research are
that reality is subjective, researchers seek to gain an understanding through the interpretation of data, knowledge is gained
holistically, and learning occurs through observation.13
As an interpretive researcher in this project, I embraced
subjectivity and realized the necessary uncertainty in field
research.
The participants for this study were recruited from the
health sciences division of a large Southeastern university
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in the USA. Participants consisted of physicians and nurses
who were also department chairs and health care administrators (deans). There were a total of 12 participants, with
four individuals from each group. To begin the recruitment
process, I initially spoke with an administrator who was in a
position that could provide access to the participants I needed.
This administrator helped me by sending emails to prospective participants, introducing me to them at events, and also
by providing me with names and contact information. Hence,
I used a snowball sampling technique; I was able to gain
access and credibility with prospective research participants.
As noted by Lindlof: “snowball sampling uses a person, usually an informant, as a source for locating other persons from
whom a type of data can be generated, who then refer the
research to other persons, and so on.”13 I contacted the prospective participants through email and attached the informed
consent document and institutional review board approval
form. The prospective participants then either emailed me
back with possible dates for the interview or instructed me to
contact their assistant for scheduling purposes. All the twelve
participants I contacted agreed to participate.
The interviews occurred between January and March 2010.
After each interview was completed, I transcribed the audio
recording of the session. Meticulous attention was given to
ensure accuracy. Transcribing each interview provided me
with the opportunity to listen again using a more analytical
approach and also allowed me to interpret the data on a greater
level. Kvale emphasizes the importance of the seven stages of
the interviewing process to present credible data within this
qualitative method.14 To follow Kvale’s complete interview
process, each interview was audio recorded, transcribed, and
then re-evaluated to ensure accuracy.14 The in-depth interviews followed an interview schedule with approximately 20
open-ended questions (see Appendix A). In each interview, I
followed the same interview schedule and asked each question in the same pattern so that the order was the same for all
twelve interviews. The duration of each interview varied: one
or two lasted for a little over 30 minutes and one lasted for an
hour and a half; the remainder were somewhere in between.
The interviews yielded 162 pages of transcripts.
Before the formal interview began, I engaged the
interviewee in small talk, not only to get to know them better,
but also to build rapport for the interview that was going to
follow. I wanted the interviewees to feel as comfortable as
possible and embody a sense of ease when they answered the
questions. When the interviewee would give a short answer
to a question, I often asked him or her to provide an example
or to expand. For nearly every question, I would use probe
Journal of Healthcare Leadership 2012:4
Leadership communication styles of health care professionals
questions to provide more of a rich text and understanding,
but I was still able to return the interviewee to the original
question and central concepts. Using this methodology,
the data were collected in order to answer the research
questions.
In the following section, I will provide a general overview
of the data analysis. In this section, I provide rich text on the
central themes that emerged through the in-depth interview
process. Each of these themes provides insight into the leadership styles that are found among physicians, nurses, and
administrators in the health sciences.
Analysis
Through the interview process, I was able to explore twelve
different health care professionals’ perspectives of leadership.
From thoroughly reviewing the transcriptions, it was clear
that there were many themes that were present in all three
groups. The three most evident themes were viewpoints on
leadership, decision making, and relationships. Even though
I could provide rich text about what the data yielded, I will
only present a brief description of what I observed from each
of the three participant groups.
After reviewing the transcriptions from the physicians
regarding their viewpoints on leadership, it seems that they
sent mixed messages about their ideologies. Some of the
physicians I interviewed were extremely reflective on their
beliefs regarding principles of leadership and others seemed
as if they had never given it any thought. One physician said,
“Now am I good at [leadership]? I have no idea.”
Other physicians seemed to have knowledge of what role
leadership can and should play in medicine, but seemed to
not think much of it. For example, “In medicine we talk about
vision and leadership; I think that’s way overrated.”
In contrast, some physicians gave well thought-out answers
about their ideologies of leadership. Here is an example:
Someone once told me that being a department chair is,
especially when the department is made up of doctors who
all feel very accomplished in their own right, um, it’s a little
bit like being the conductor of an orchestra. In other words,
I can’t play the violin, well in this particular case I can play
the violin. But I have certain expectations of the lead violinist and the lead violinist doesn’t want to be told in front
of the whole orchestra that he or she isn’t doing top notch
work um and so even though I have a baton and I wave it,
I expect the whole orchestra to follow me along and they
don’t really have to, I mean they can all decide at any
moment, they all have free will. I mean they can all play the
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notes of their own volition, they can all start playing what-
I’ve always felt that I have tough enough skin to be able to
ever they want, they can just play a different tune! And even
weather someone not liking me or liking my decisions and
collaborate to play a different tune, I can be conducting a
I know that by the end if I stick by them that I’ll probably
tune and they are all playing a different tune. So that author-
get the outcome I wanted and it’s too bad if they didn’t like
ity is a little bit of a delusion I would say. The orchestra’s
the way it was accomplished.
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power, the conductor’s power over the orchestra is a little
bit of an illusion. It requires a lot of um um willingness on
the part of the orchestra members, same deal.
Another physician shared this viewpoint on leadership:
Another thing about leadership is (sigh) I think leadership is
um, is leading, but I think there’s a part of leadership that’s
um, and I try to teach this every day is um, if you really
I try to praise our faculty and staff for their accomplishments.
want to be a great leader and you really care about what
You know, the word “servant leader;” I really feel that that’s
you’re leading, then part of your goal is to build a system
what I am many times. I try not to take the glory myself,
so that when you’re gone, it doesn’t collapse.
but give praise to the people who are doing all the work
Physicians surprised me with their answers with regard
to decision-making. Here is an example:
So at the end, I ask, “geez, was that the right way? Did I,
that makes us such a very fine college of nursing and we’re
really well recognized through the state and throughout the
nation. So I try to plant seeds that actually other people carry
out and we get recognized for those things.
did I make the most impact, did I say what was meaning-
I do think I’m a leader … I care about the students and I
ful, will people remember it without the point that I was
think that that’s important in a leader, especially in nursing;
trying to make, or did I pound my fist in the table too hard
I think we tend to be more of a caring person and I think
or should I have pounded my fist on the table or should I
being in a position, in a leadership position that people see
have been less abstract and more straightforward?” Geez
that as more of a strength but people may not see it more
louise, I have the most difficult time with my administrative
as a strength. I also feel a leader needs to be able to relate
assistant and the administrator for the department and I’m
to the people they work with.
pretty sure I can be pretty direct and get the biggest point
in and somehow I don’t.
I would have thought that physicians would not secondguess themselves on the major decisions that they make on
a daily basis, but it appears that they do. I think it makes
them appear more sincere and caring in their profession,
rather than having a “this is the way we’re going to do it”
mentality. Here is another example of physicians’ viewpoints
on decision-making:
I do try to take the objector’s thoughts and try to factor
them into my decision making. I never feel like I have
to please everyone though. I feel that that is an error that
many leaders make is that they think that at the end of the
day they have to make everyone happy and that’s, I think
it’s almost always impossible unless you have a very small
group and um and nice quote that I can’t tell you who said
it, but it brings true with is that “if everyone likes your
decisions, you’re not taking a tough stand on anything.”
Which means that you don’t stand for anything; you’re so
namby-pamby that everybody likes what you’re doing and
54
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Even though the physicians’ viewpoints on leadership
seemed to vary, it is my overall generalization that they all
know they are leaders.
Nurses’ viewpoints on leadership seemed to be in a category by themselves. The term “servant leadership” came up
in dialogue as something to embody. Here is an example:
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The nurses also seemed to want to lead by example. For
instance:
Now leadership is when I say, or people say, we say
together, okay there’s a lot of soldiers coming back with
post-traumatic stress syndrome and we have just terrible
mental health services in this community and we developed
a program of nurse practitioners, they can prescribe drugs,
they can see patients, they can you know, that would be very
useful so what’s it going to take. Well, that’s what a leader
does; a leader sets the direction.
Hospital administrators tended to think “big picture,”
based on the answers they provided. These individuals
were always thinking of the functionalities of the system
as a whole rather than its small components. When asked if
they thought they were a leader, this is a response I received:
“Have to be, yes. I would not be effective if I didn’t think I
was a leader in this job.”
It seemed that their viewpoint was that if the whole
system was operating well, then everything else was too.
Journal of Healthcare Leadership 2012:4
Dovepress
In addition, all the hospital administrators discussed how
they were so consumed by meetings during the day that they
hardly had enough time to respond to their emails. Below
is an example:
I would say a frustrating thing for me is having “think time”
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because I’m constantly involved in meetings after meetings
and I really, to really think visionary you really need blocks
of time to think, where do we need to go, what do we need
to do and sometimes that can only happen at night after you
get home from work and are somewhat exhausted.
This idea of “think time,” I believe, is the perfect way to
describe this problem. One would assume that senior level
administrators would have time in their day to reflect on decisions that were made and to reflect on what reactions they
might have to decisions that were made via group consensus.
Below are an administrator’s thoughts on leadership:
Good leadership is that you have a vision and you successfully achieve it and managing is somebody else having a
vision and you helped them achieve their vision through
your management.
Hospital administrators seemed to have mature viewpoints on decision making. Here is an example:
I’m not a do it all yourself kind of leader. I’m a big time
delegator, which means I try to recruit really capable people
or people with really great aptitude and I give them a lot of
responsibility and I give them guidance when asked but I
try to encourage them to make most of the decisions themselves, so a lot of my decisions that come down are more
global things as opposed to more day to day here’s what
I want you to do today things. And that’s the way I prefer it,
I think that’s the way organizations work best under me.
It appears that the administrators realize that they are not
the single source of power and information; instead, they put
their trust and faith in people who have been highly trained
in their particular field to make the right decisions. Though
some might argue that it is risky to put this level of trust and
faith in another to make a decision that affects the whole
organization, this ability is viewed as strong indicator of true
leadership. True leadership is many times about enabling and
trusting other individuals and providing them with all of the
necessary components to succeed.
Conclusion
The practical implications of this research are important for
all health care professionals. It is evident that physicians,
Journal of Healthcare Leadership 2012:4
Leadership communication styles of health care professionals
nurses, and administrators must have an increased awareness
of self and individual leadership style. Each individual having
a better understanding of him or herself and how they are
perceived from others may help the overall health of the
organization.
In addition, it is important for each of these health care
leaders to be engaged in practices of reflection. Bar-On
defines self-reflection as “a process of exploring and evaluating our thoughts, feelings, and behavior.”15 Through the
process of self-reflection, health care leaders should be able
to better access the needs of their organization on a more
profound level of engagement. As mentioned earlier, Curtis
et al recognized that leaders innovate, develop, inspire, challenge the status quo, and focus on a long-term vision.2 From
this research, the critical need for these health care leaders
to engage in self-reflection to better understand themselves
and have “thinking time” to set the direction for the future of
their organization is evident. The health of each organization
depends upon the health of the leader and his or her greater
understanding of self.
Limitations and future research
suggestions
The key concepts presented in this paper have highlighted
the general knowledge and understanding of basic leadership
ideologies. I have learned a great deal through the course of
this year as I have researched communication and leadership, conducted this study, and found key themes throughout
the long and rich text. Though this paper is not exhaustive,
it provides a general summary and overview of the study
and observations I made after completing the transcriptions. There is still more literature that should be reviewed
and linked to this study. The data might also yield different
results at another university; therefore, the data might not be
a predictable indicator of future leadership and communication expectations and values. Additionally, while this study
matches specific health professions with selected leadership
communication styles, it is important to remember that leaders must be adaptable and flexible. For example, hospital
administrators in this study were most closely aligned with
transformational leadership; however, it is critical for these
leaders to also incorporate other leadership styles based
on situational factors. Future research needs to look at the
core coursework of nurses, physicians, and administrators
in educating them on the principles of leadership and effective communication. Future research could be conducted
looking at the stereotypes applied to nurses, physicians, and
administrators by subordinates or clients.
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Disclosure
The author reports no conflicts of interest in this work.
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For personal use only.
References
1. Northouse PG. Leadership: Theory and Practice, 3rd ed. Thousand Oaks:
Sage Publications; 2004.
2. Curtis AE, Vries JD, Sheerin FK. Developing leadership in nursing:
exploring core factors. Br J Nurs. 2011;20(5):306–309.
3. Kotterman J. Leadership Versus Management: What’s the Difference? J
Qual Participation [serial on the Internet]. 2006;29(2):13–17. Available
from: http://asq.org/pub/jqp/. Accessed March 23, 2012.
4. Burns MJ. Leadership. New York: Harper & Row Publishers; 1978.
5. Spears LC. Insights on Leadership: Service, Stewardship, Spirit, and
Servant-Leadership. New York: John Wiley & Sons, Inc; 1998.
6. Burke RJ, Cooper CL. Inspiring Leaders. New York: Routledge; 2006.
7. Dye CF, Gasrman AN. Exceptional Leadership: 16 Critical ­Competencies
for Healthcare Executives. Chicago: Health Administration Press;
2006.
8. Dye CF. Executive Excellence: Protocols for Healthcare Leaders, 2nd ed.
Chicago: Health Administration Press; 2000.
56
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9. Souba WW. The Being of Leadership. Philos Ethics Humanit Med,
[serial on the Internet]. 2011;6(5):1–11. Available from: http://www.
peh-med.com/content/6/1/5. Accessed March 23, 2012.
10. Bujak JS. Inside the Physician Mind: Finding Common Ground with
Doctors. Chicago: Health Administration Press; 2008.
11. Palmer R, Cragg R, Wall D, Wilkie V. Team and leadership styles
of junior doctors. The International Journal of Clinical Leadership,
[online]. 2008;16:131–135. Available from: http://www.radcliffe-oxford.
com/journals/J24_The_International_Journal_of_Clinical_Leadership/
default.htm. Accessed March 23, 2012.
12. Dirschel KM, Klainberg M. Today’s Nursing Leader: Managing,
Succeeding, Excelling. Sudbury: Jones and Bartlett Publishers; 2010.
13. Lindlof T. Qualitative Communication Research Methods. Thousand
Oaks: Sage; 1995.
14. Kvale S. Interviews: An Introduction to Qualitative Research
Interviewing. Thousand Oaks: Sage; 1996.
15. Bar-On T. A meeting with clay: individual narratives, self-reflection,
and action. In: Smith JK, Smith LF, Kaufman JC, editors. Psychology
of Aesthetics, Creativity, and the Arts [serial on the Internet]. 2007;
1(4):225–236. Available from: http://www.apa.org/pubs/journals/aca/
index.aspx. Accessed March 15, 2012.
Journal of Healthcare Leadership 2012:4
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Appendix
Interview questions
Leadership communication styles of health care professionals
accomplish your goal? Do the strategies differ according to
who is resisting?
Thank you for agreeing to participate in this study. Since our
interview will be recorded, I want to be sure some information is correct. Will you please tell me your name and the
current position you hold here at ECU?
Can you recall a particularly challenging event or interaction
at work and how you dealt with it?
*Everything is confidential, your identity, your name.
Would you consider it to have had a good or bad outcome?
What issues most affect your daily work life?
Are there situations where you make decisions that others
have to follow?
Are there any issues that seem to require more negotiation
than others?
Can you think of any instances where you needed to exercise
your authority in order to get something done? How did you
handle it?
What happens if someone disagrees with your decisions?
I know doctors (nurses, administrators) are often thought of
by the public as “leaders;” would you characterize yourself
as a leader? If so, what do you think makes you a good
leader?
When you encounter conflict over or resistance to a goal you
are pursuing do you have any set strategies you employ to
How do you inform others about the decision? How do you
enforce it?
How are you informed about others’ decisions that affect
you?
Do you ever have to do collaborative work in teams or
groups? Can you provide an example of how you were particularly valuable to the outcome?
Is there anything else that you want to address about what
we have discussed, eg, your position, your role?
If I have any follow-up questions, can I email you?
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Oman Medical Journal (2013) Vol. 28, No. 4:285-287
DOI 10. 5001/omj.2013.79
Brief Communication
Leadership of Healthcare Professionals: Where Do We Stand?
Abdulaziz Al-Sawai
Received: 23 May 2013 / Accepted: 10 Jun 2013
© OMSB, 2013
L
eadership has been described as the behavior of an individual
when directing the activities of a group toward a shared goal.
The key aspects of the leadership role involves influencing group
activities and coping with change. A difficulty when considering
leadership of healthcare professionals is that most theories were not
developed within a healthcare context but were usually developed
for the business setting and then applied to healthcare. Published
researches provide little evidence that such leadership initiatives
are associated with improvements in patient care or organizational
outcomes when applied in the healthcare setting.
Leadership theory is dynamic and continues to change over
time. The early Great Man theory assumed that certain people have
characteristics that make them better leaders. Various behavioral
theories were developed between 1940 and 1980 describing
common leadership styles such as authoritarian, democratic and
laissez-fair. Situational and contingency theories between 1950 and
1980 recognized the importance of considering the needs of the
worker, the task to be performed, and the situation or environment.
Interactional leadership theories (1970 to the present) focus on
influence within the specific organizational environment and
the interactive relationship of the ‘leader’ with the ‘follower’. An
emerging theory involves supportive leadership, which states that
supporting and building relationships with employees will increase
the likelihood that they will be positively influenced and motivated
to work towards goals. The theory is founded on organizational
behavior studies that suggest that people are happier and more
satisfied in their work when they have supportive leaders who
empathize at a personal level.1,2
Healthcare systems are composed of numerous professional
groups, departments, and specialties with intricate, nonlinear
interactions between them; the complexity of such systems is often
unparalleled as a result of constraints relating to different disease
areas, multidirectional goals, and multidisciplinary staff. Within
large organizations such as healthcare systems, the numerous groups
with associated subcultures might support or be in conflict with
each other. Leadership needs to capitalize on the diversity within
the organization as a whole and efficiently utilize resources when
designing management processes, while encouraging personnel to
Abdulaziz Al-Sawai
Senior Specialist Dental, Sultanate of Oman, Ministry of Health, Muscat,
Sultanate of Oman.
E-mail: ibtaisam@hotmail.com
Oman Medical Specialty Board
work towards common goals. A number of leadership approaches
can be adapted to the healthcare setting to optimize management in
this highly complex environment.3
Transformational Leadership
The transformational theory goes beyond the more traditional
style of transactional leadership (which focuses on supervision,
organization and group performance) and emphasizes that
people work more effectively if they have a sense of mission. The
transformational theory requires leaders to communicate their
vision in a manner that is meaningful, exciting, and creates unity and
collective purpose; the manager who is committed, has vision, and
is able to empower others can be described as a transformational
leader. Transformational leaders are able to motivate performance
beyond expectations through their ability to influence attitudes.4
Collaborative Leadership
Collaboration is an assertive and cooperative process that occurs
when individuals work together towards mutual benefit, in
a form of organizational symbiosis. Collaborative leadership
involves communicating information to coworkers and associated
organizations, to allow them to make their own informed
decisions.5,6 Such collaborative communication strategies enhance
healthcare management by: encouraging dialogue between
multiple stakeholders; sharing knowledge and experiences; and
reducing the level of complexity within healthcare organizations.
Individuals with different levels of responsibility need to engage
with the leadership process, so that they are actively involved in
validating and communicating needs and identifying modifications
in practices that may be required to address changing demands.
Collaborative healthcare leadership requires a synergistic work
environment, wherein multiple parties are encouraged to work
together toward the implementation of effective practices and
processes. Such collaborations promote understanding of different
cultures and facilitate integration and interdependency among
multiple stakeholders,7,8 individuals are unified by shared visions
and values,7 and the resulting synergistic working practices can
achieve outcomes that are greater than the sum of individual efforts.
Leaders need to be the first to model collaborative behaviors, to raise
levels of motivation, and nurture interdependency between different
healthcare practitioners.9
Oman Medical Journal (2013) Vol. 28, No. 4:285-287
Conflict Management
Distributed Leadership
Despite the recognized importance of collaborative working
practices, only a small proportion of time is spent in true collaboration.
Conflict can be a pervasive force within healthcare organizations
and, as gaps in communication develop and are potentiated, failure
in working practices can occur.10 The most common sources of
conflict are recognized as the following: individualistic behavior
within the organization, poor communication, organizational
structures, and inter-individual or inter-group conflicts. Conflict
usually develops from underlying latent issues (which implies the
existence of antecedent conditions) and can progress to perceived
conflict (where the issue becomes apparent) and subsequently to
manifest conflict (the behavioral/action phase), with the last stage
being conflict aftermath. The healthcare leader must adopt a suitable
approach for handling conflict at all stages with the aim of creating
a positive outcome for all involved. A leader can employ strategies
such as competition, avoidance, compromise, accommodation,
collaboration, bargaining/negotiation, mediation, facilitating
communication, seeking consensus, and engendering vision to aid
resolution of conflict.
Globalization necessitates that responsibility and initiative be more
widely distributed and many large corporations have recognized
this by becoming less hierarchical and more collaborative in their
leadership approach. This distributed leadership approach requires
4 key characteristics:19 sense making – the ability to understand
the constantly changing business environment and interpret the
ramifications of changes within an organization; relating – the
ability to build trusting relationships, balance advocacy with inquiry,
and cultivate networks of supportive confidants; visioning – creating
credible and compelling images of a desired future that those in the
organization can work towards; and inventing – creating new ways
of approaching tasks or overcoming seemingly insurmountable
problems. All four characteristics are interdependent and leaders
need to identify their own capabilities, strengths, and weakness. The
leader’s goal is to create an ethos whereby individuals can complement
one another’s strengths and offset one another’s weakness, with
leadership distributed throughout the organization.18,19
Shared Leadership
Numerous studies have shown that autonomous healthcare
workers with direct responsibility for their patients do not respond
well to authoritarian leadership to lead highly qualified healthcare
professionals.1,5,10,11 Leadership needs to focus on the development
of effective collaborative relationships through support and task
delegation, and this could be the basis for widespread implementation
of the shared leadership model within the healthcare setting, as it
encourages shared governance, continuous workplace learning and
development of effective working relationships.12,13
Shared leadership is a system of team-level management/
leadership that empowers staff within the decision-making
processes.14 It offers the opportunity for individuals to both manage
and develop within a team and is effective at improving the work
environment and job satisfaction.15,16 Effective teamwork is key
to the shared-leadership approach, with a focus on identifying
team values and optimizing team efficiency to improve practices.
Shared leadership ideally results in individual staff members
adopting leadership behaviors, greater autonomy, and improved
patient care outcomes. Barriers to developing shared leadership
can include a poor team ethos, high workload and staff turnover
rates, uninteresting work, lack of responsibility, and insufficient
goal setting. Shared leadership is an ongoing and fluid process that
requires continuous evaluation to be responsive to ever-changing
healthcare challenges,5 and presumes a good working relationship
between managers and staff.17 When organizational and group
inter-relationships are developed and fostered to achieve defined
goals, they can influence the practices of groups and individuals
outside of the core team and also increase the standing of the group
within the organizational hierarchy.18,19
Ethical Leadership
Practicing effective leadership can have a substantial impact on the
working lives of healthcare staff, patient outcomes, and the fate of
an organization. In some instances, the leader will need to influence
group members by: (1) creating enthusiasm for risky strategies,
(2) requiring a change in underlying beliefs and values, and (3)
influencing decisions that favor some at the expense of others.
However, by practicing such behaviors, in some instances, the
leader can influence others to engage in crimes of obedience,11,20,21
which has led to declining public trust. A good leader must have
intentions, values, and behaviors that intend no harm and respect
the rights of all parties.
Functional Results Oriented Healthcare Leadership
The types of challenges that clinicians face when leading within the
complex setting of a modern healthcare services include: diverse
and changing needs, increasing patient expectations, and the high
cost of new interventions and treatments. This requires clinicians
to: consider the needs of the wider patient population; to take
decisions that not only make the best of resources but also deliver
clinical quality; and implement clinically-led service improvements
that are likely to suceed.
The functional results-oriented leadership style focuses on the
process of an organization implying leadership as having the specific
role and skills necessary to deliver the desired results of the group
based on and meeting the needs of three areas, namely; individuals,
team, and tasks.22,23 It emphasizes in establishing the leadership
role that facilitates effective and efficient healthcare provision. As
indeed, results take a crucial center stage at this type model.22, 23
Oman Medical Specialty Board
Oman Medical Journal (2013) Vol. 28, No. 4:285-287
Conclusion
Many theories, cases, and models have influenced the current
leadership strategies that can be applied to the healthcare setting.
Guidance for effective leadership should focus on the dynamic
relationships between leadership values, culture, capabilities and the
organizational context. The leader’s developmental journey must
operate within this dynamic, supported by a high level of self, team
and organizational awareness. Leadership development has clearly
reached a critical crossroad, and the most important role of the
leader could be described as ensuring a ready supply of replacement
leaders to maintain organizational progress in the ever-changing
healthcare environment.
Acknowledgements
Author reported no conflict of interest and no funding was received
for this work.
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