Leadership in Healthcare: Transitioning From Clinical Professional to Healthcare Leader : Journal of Healthcare Management

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RESEARCH ARTICLES

Leadership in Healthcare: Transitioning From Clinical Professional to Healthcare Leader

Perez, Jessica DBA, PA-C

Author Information
Journal of Healthcare Management: July-August 2021 - Volume 66 - Issue 4 - p 280-302
doi: 10.1097/JHM-D-20-00057
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Abstract

INTRODUCTION

Often, clinical professionals are promoted or hired into leadership roles without the leadership training that would enable them to succeed (Blanchard, 2017). Instead, they typically are given leadership roles because of accomplishments in their professional careers (Blanchard, 2017). However, the skills needed to be an effective clinical professional differ from the skills needed to be an effective leader. Therefore, having success as a clinical professional is not indicative of having success as a healthcare leader.

The specific problem is that clinical professionals have not been prepared to be effective healthcare leaders (Cheng et al., 2016). Typically, they do not receive management training during their professional training (Veronesi & Sarto, 2016). Moreover, clinical professionals and healthcare leaders fill different roles in healthcare (Gauld, 2017). Consequently, clinical professionals may not have the evidence-based knowledge of the specific leadership styles necessary for success in a leadership role.

In particular, clinical training is focused on medicine, not on management and leadership theories (Mangrulkar et al., 2020). Clinical training addresses problem-solving skills to identify medical diagnoses (Stoller, 2009), whereas management training hones broader thinking to solve organizational problems (Stoller, 2009). Clinical providers should pursue the leadership training not included in their clinical education if they plan to transition to healthcare leadership (Leitman & Nickerson, 2020).

According to Kumar and colleagues (2020), “leadership training has been proposed as a means of managing these changes and ensuring that physicians are able to navigate their changing roles as health providers” (p. 1). Similarly, Hudak and colleagues (2015) state that it is important for healthcare leaders to understand the different types of leadership theories to meet the challenges and dynamics of the system and to “[adapt] to situations that may require firm goals while meeting the personal needs of subordinates” (p. 10). Unfortunately, there is controversy over what styles and skills are necessary for effective leadership (Kumar et al., 2020). The present research was developed to determine the most effective leadership style in healthcare organizations and to provide evidence-based recommendations for healthcare leaders.

Research Question

The standard critically appraised topic question format (Briner et al., 2009) was used to develop a research question specific to the context of the stated problem. The critically appraised topic question format contains four components: (1) context, (2) intervention, (3) mechanism, and (4) outcome (Briner et al., 2009).

Here, the context is healthcare organizations, the intervention is leadership styles (independent variable), and the mechanism is the Path-Goal theory (the theoretical reason that the intervention should have some effect on the context of this research question and cause the outcome). The outcome is the effectiveness of the leadership styles in improving healthcare organizational goals (dependent variables). The organizational goals are increased employee retention, organizational commitment, and job satisfaction.

And so, this is the research question that directed the present systematic literature review: What type of leadership style is most effective for improving healthcare organizational goals?

Leadership Styles

According to Goethals and colleagues (2004), leadership involves three interacting dynamic elements: leader, follower(s), and situation. In addition, Gandolfi and Stone (2017) state that leadership must be action-oriented with goals and objectives. Therefore, leaders influence their employees to meet organizational goals through an interactive process (Goethals et al., 2004).

Healthcare leadership is defined as “the ability to effectively and ethically influence others for the benefit of individual patients and populations” (Hargett et al., 2017, p. 69). A healthcare leader must effectively balance patient outcomes and organizational outcomes to be successful (Hargett et al., 2017). According to Ribeiro and colleagues (2018), the leadership style of a supervisor can influence an employee’s job satisfaction, organizational commitment, and intention to quit.

Numerous leadership styles can be applied to the healthcare field, including laissez-faire, transactional, transformational, and authentic leadership. These different leadership styles can have different effects on healthcare organizational goals. The mechanism component of this research question is the theoretical reason that the leadership style (the intervention component) should have some effect on healthcare organization goals (the context and outcome components).

Laissez-Faire Leadership

Laissez-faire leadership is a subtype of the passive-avoidant leadership style. Laissez-faire leaders have a hands-off approach and allow employees the freedom to work with minimal interference or direction (Asiri et al., 2016; Sfantou et al., 2017).

Transactional Leadership

The transactional (achievement-oriented) leadership style is task-focused. These leaders believe that their employees are motivated by rewards and punishments (Cummings et al., 2018). In addition, transactional leaders provide clear roles, goals, and task requirements for their employees (Baysak & Yener, 2015).

Transformational Leadership

The transformational leadership style is focused on the relationships between the leaders and subordinates and improving their work-related experiences (Gabel, 2013). The four components of transformational leadership are (1) idealized influence, (2) inspirational motivation, (3) intellectual stimulation, and (4) individualized consideration (Gabel, 2013). Transformational leaders see idealized influence as a model for employees, apply inspirational motivation to communicate vision and mission, and use intellectual stimulation to support and challenge employees (Gabel, 2013). They also apply individualized consideration to understand the strengths and weaknesses of their employees and recommend opportunities for development (Gabel, 2013).

Authentic Leadership

The authentic leadership style is centered on being a role model to employees and leading with authenticity and integrity (Wulffers, 2017). Authenticity is defined as “the degree to which we are true to ourselves, despite external pressures, bearing in mind that we are in a material world where we encounter external forces and influences that might be very different from our own, our beliefs and values” (Wulffers, 2017, p. 13). Employees view authentic leaders as transparent, ethical, and trustworthy (Wulffers, 2017).

Theoretical Framework

This systematic literature review used the Path-Goal theory developed by Robert House as the theoretical lens because it considers the effects of leader behavior on subordinate satisfaction, motivation, and performance (House, 1971). In addition, this theory proposes that the leader is responsible for defining goals and clarifying the path to attain these goals by removing obstacles and providing support (Yukl, 1989).

The Path-Goal theory also “[focuses] on subordinate motivation as the explanatory process for the effects of leadership, and the theory ignores other explanatory processes such as leader’s influence on task organization, resource levels, and skill levels” (Yukl, 1989, p. 264). Figure 1 demonstrates the conceptual framework diagram for this theory and how it applies to the problem.

F1
FIGURE 1:
Conceptual Framework Diagram

The following methodology section describes the search method used to obtain evidence-based articles that could answer the research question with this theoretical framework in mind.

METHODS

According to Tranfield and colleagues (2003), systematic reviews have “[improved] the quality of the review process by synthesizing research in a systematic, transparent and reproducible manner to inform policy and decision-making” (p. 209). Harden and Thomas (2005) identified seven stages of a systematic review: (1) develop a user-driven review question, (2) develop a review protocol, (3) perform a comprehensive search for evidence, (4) apply the inclusion and exclusion criteria, (5) perform a quality assessment, (6) perform the data extraction, and (7) synthesize the findings.

The first stage of this systematic review was completed when the research question was developed. The second and third stages included the review protocol and search for evidence, respectively.

Identification of Evidence

The second stage of the systematic literature review process is developing a protocol and reviewing it (Harden & Thomas, 2005). For this review, the third stage of the systematic review (the search for evidence) was performed parallel to the fourth stage (inclusion and exclusion criteria). Three databases were searched using keywords and Boolean phrases (Cronin et al., 2008). Table 1 identifies the databases and search strings.

TABLE 1 - Quantity of Articles From the Electronic Databases and Search Strings
Electronic Databases
Search Strings UMGC OneSearch ABI/INFORM Healthcare Administration Database Total Articles From Search Strings
(leader* OR manage*) n5 (style* OR trait* OR characteristic*) n10 effective AND (healthcare OR “health care” OR medic* OR clinic*) 137 9 7 153
(leader*) AND (style OR trait) AND effect* AND (healthcare OR “health care”) 743 38 25 806
Total articles from databases 880 47 32 959

Inclusion and Exclusion Criteria

The study selection was a continuance of the third and fourth stages of the systematic review. To delimit the search, articles that met the inclusion criteria were selected for review, and the articles that did not meet the inclusion criteria were excluded (George et al., 2014; Table 2).

TABLE 2 - Inclusion and Exclusion Criteria
Inclusion Exclusion
2015–2020 Before 2014
English language Non-English language
Qualitative, quantitative, or mixed methods studies None
Articles in peer-reviewed, scholarly journals Commentaries, letters, editorials, case descriptions, clinical and policy decisions, unpublished studies (dissertation and theses), duplicates
Articles related to healthcare and leadership styles Articles not related to healthcare and leadership styles

Study Selection

The literature search identified 381 unique articles from three databases after the duplicates were removed. The titles and abstracts of these articles were reviewed, and 332 were excluded because they could not answer the research question. The remaining 49 articles were reviewed, and another 29 were excluded because they could not answer the research question. This methodology left 20 articles for thematic synthesis. Figure 2 illustrates the preferred reporting items for systematic reviews and meta-analysis diagram, which represents the review process for this study (Shamseer et al., 2015).

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FIGURE 2:
PRISMA Diagram

After completing the search for evidence and inclusion and exclusion criteria, the selected articles underwent the fifth stage of the review (quality assessment).

Quality Assessment

The Mixed Methods Appraisal Tool (MMAT) tool was used to critically appraise the quality of the studies in this review because some studies used both qualitative and quantitative methods (Pace et al., 2012).

The MMAT requires that each article satisfy two screening questions prior to answering the quality appraisal questions (Pace et al., 2012). The screening questions determined whether the studies presented a clear research question and whether the data collected in the study addressed the research question (Pace et al., 2012). If the studies passed the screening, then quality appraisal questions were added based on whether the studies were qualitative (section 1), quantitative (section 2, 3, or 4), or mixed methods (section 5; Pace et al., 2012). The quality for each study was determined by calculating the number of criteria met within the study’s respective section and then dividing this number by the total number of criteria in that section (Pluye et al., 2011). For example, there are four criteria in the qualitative section (section 1), and if a study met three of these criteria, it received a score of 75%. A study with a quality score of 100% was rated as excellent, a score between 75% and 99% was rated as good, a score between 50% and 74% was rated as fair, and a score of less than 50% was rated as poor.

After completing the fifth stage of the systematic review, the sixth stage was performed (data extraction).

Data Extraction

The data extracted from these articles included the name(s) of the author(s), year of publication, sector/population, design and sample size, main findings, and limitations of the studies. The data were used to determine if the studies were relevant to their research questions and the research question of this systematic review. Also, the data were used to determine if the main findings could be generalized to the healthcare field. The main findings of the articles were also coded to identify their themes (Table 3).

TABLE 3 - Summary of Articles in the Systematic Review
Author(s) and Year Title Sector/Population Design and Sample Size Main Findings Limitations
Ahmed et al. (2018) Roles of leadership styles and relationship-based employee governance in open-service innovation: Evidence from Malaysian service sector Healthcare/medical doctors from 10 hospitals in Malaysia Quantitative cross-sectional; 422 questionnaire respondents (93.7% response rate) Paternalistic, democratic, and authentic leadership styles are positively related to open service innovation. All leadership styles are also positively related to relationship-based employee governance. A longitudinal study would be better than this cross-sectional study to provide causality. Generalizability of Malaysian findings is limited.
Alshahrani & Baig (2016) Effect of leadership styles on job satisfaction among critical care nurses in Aseer, Saudi Arabia Healthcare/critical care nurses from two hospitals in Aseer, Saudi Arabia Quantitative cross-sectional; 98 respondents to multifactor leadership questionnaire (MLQ-5X rater form) and job satisfaction survey (58.8% response rate) Nurses with transformational leaders have higher job satisfaction than nurses with transactional leaders. Nurses with transformational leaders have better organizational outcomes (efforts to achieve organizational goals, effectiveness, satisfaction). Evaluated the leadership style of only eight head nurses in one hospital in Saudi Arabia.
Al-Yami et al. (2018) Leadership style and organisational commitment among nursing staff in Saudi Arabia Healthcare/nurses and nurse managers from two hospitals in Saudi Arabia Quantitative; 219 respondents to MLQ and organizational commitment questionnaire (84.2% response rate) Transformational leadership is positively related to organizational commitment (value commitment, commitment to stay). Transactional leadership contingent reward is positively related to commitment (more than transformational leadership). Passive-avoidant leadership is negatively related to commitment. There is self-selection bias in the data.
Arnold et al. (2019) Medical leaders identify personal characteristics and experiences that contribute to leadership success in medicine Healthcare/medical doctors who graduated from the University of Missouri-Kansas City, 1976–1999 Qualitative; 48 e-mail or phone interviews (67.6% response rate) Most leaders (≥80%) are open to new ideas and opportunities and intelligent risk-taking; are also motivated, actively involved, committed, passionate; people-oriented, capable, competent, prepared, and intelligent. Many (60%–79%) are self-aware and service-oriented. Medical leaders view service orientation as more important than does general literature on leadership. Retrospective study evaluated formal leaders at one institution with a unique 6-year curriculum. Informal leaders were not studied.
Asamani et al. (2016) Leadership styles in nursing management: Implications for staff outcomes Healthcare/nurses from five hospitals in Ghana Quantitative cross-sectional; 273 respondents to path-goal leadership questionnaire, job satisfaction scale, and intention to stay scale (99.3% response rate) Nurse managers show more supportive (transformational) leadership behavior. Supportive, participative, and achievement-oriented leadership styles are positively related to job satisfaction and intention to stay. Achievement-oriented leadership style is positively related to perceived productivity levels. Not stated
Asiabar et al. (2019) Leadership effectiveness of hospital managers in Iran: A qualitative study Healthcare/managers of public, private, or social security hospitals in Tehran, Iran Qualitative; 30 face-to-face interviews (100.0% response rate) Managers with charismatic personalities, knowledge, positive attitude, and skills in intra-organizational relations, teamwork, stakeholder engagement, participative decision-making, conflict management, time management, human resource management, and planning are good leaders. Socioeconomic factors influence leadership.
Asiri et al. (2016) The association of leadership styles and empowerment with nurses’ organizational commitment in an acute health care setting: A cross-sectional study Healthcare/acute care nurses from one hospital in Saudi Arabia Quantitative cross-sectional; 322 respondents to MLQ, psychological empowerment scale, and 3-component model of employee commitment (94.9% response rate) Transformational leadership is negatively correlated with commitment and perceived psychological empowerment. Transactional leadership is positively correlated with commitment. Study was limited to acute-care nurses in a single hospital in Saudi Arabia.
Azar & Asiabar (2015) Does leadership effectiveness correlate with leadership styles in healthcare executives of Iran University of Medical Sciences Healthcare/internal managers (executive leaders) from 16 hospitals of Iran University of Medical Sciences Quantitative cross-sectional; 96 respondents to MLQ and two other questionnaires that assessed readiness and effectiveness of leadership (100.0% response rate) Transformational leadership is positively related to healthcare executive readiness and effectiveness. Transactional leaders exhibit better preparation than leaders with other leadership styles. Not stated
Baysak and Yener (2015) The relationship between perceived leadership style and perceived stress on hospital employees Healthcare/employees from five hospitals in Istanbul, Turkey Quantitative; 312 respondents to MLQ and perceived stress scale (62.4% response rate) Transformational leadership is negatively related to stress. Passive-avoidant leadership is positively related to stress. Small sample size did not include outsource employees.
Cheng et al. (2016) Transformational leadership and social identity as predictors of team climate, perceived quality of care, burnout, and turnover intention among nurses Healthcare/nurses in Victoria, Australia Quantitative; cross-sectional 201 respondents to MLQ-5X, social identity, team climate, burnout, quality of care, and turnover intention questionnaire (23.4% response rate) Social identity is strengthened by a transformational leader. Transformational leadership is positively related to team climate and quality of care and negatively related to burnout and turnover intention. Self-report questionnaires may cause artifacts due to a distortion of the responses to make them more favorable toward the respondent. Common method variance was evident.
Cummings et al. (2018) Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review Healthcare Qualitative systematic review; 129 articles Relational leadership styles are positively associated with nurse job satisfaction, empowerment, engagement, and job autonomy. Task-focused leadership styles are negatively associated with nurse job satisfaction. Supportive and considerate leadership styles are positively associated with nurse intention to stay. Study limited by variability in conceptualizations and measurements of leadership. Only quantitative designs were included, leading to potential publication bias.
Lavoie-Tremblay et al., (2016) Transformational and abusive leadership practices: Impacts on novice nurses, quality of care, and intention to leave Healthcare/Nurses (less than 5 years’ experience) in Quebec, Canada Quantitative; 727 respondents to global transformational leadership scale, abusive leadership, quality of care, and intentions to quit questionnaire (20.8% response rate) In novice nurses, transformational leadership is positively associated with the quality of care that their patients receive and their intentions to stay. Abusive leadership is negatively associated with the quality of care that patients receive, intentions to stay, and intentions to stay in the profession. Common method bias was evident. Instead of this cross-sectional study, a longitudinal study could provide causality.
Lorber et al. (2016) The examination of factors relating to the leadership styles of nursing leaders in hospitals Healthcare/nursing leaders and nursing employees in eight Slovene hospitals Quantitative cross-sectional; 640 questionnaire respondents (75 nursing leaders, 565 other nursing employees; 58.2% response rate) Transactional is the most common leadership style for nursing leaders, but their employees view their leadership style as laissez-faire (difference in leaders and employee perception). Transformational leadership is positively associated with communication and team building. Emotional intelligence, communication, and personal characteristics (decisiveness, communicativeness, honesty, self-confidence, reliability, responsibility, objectivity, cooperation, organization, ambition) are important for successful leadership. Research was based on theoretical findings that discussed the influence of some predictors on leadership style. Not all participants had help with understanding items in the questionnaire.
Malik (2018) Authentic leadership— An antecedent for contextual performance of Indian nurses Healthcare/nurses and supervisors in 41 small and medium-sized hospitals in Uttarakhand, India Quantitative; 530 questionnaire dyad respondents (530 nurses and 146 supervisors; 70.4% response rate from nurses, 72.0% response rate from supervisors) Authentic leadership is positively associated with contextual performance of nurses. Psychological capital of the nurses (hope, optimism, self-efficacy, resiliency) is positively associated with contextual performance (due to authentic leadership). Autonomy of nurses is positively associated with contextual performance (due to psychological capital). Research was limited to healthcare and mainly a female population. Small and medium-sized hospital results cannot be generalized to large hospitals. There was a reverse causal relationship between nurses (psychological capital, contextual performance) and leaders (authentic leadership).
Quinn (2015) The affect of vision and compassion upon role factors in physician leadership Healthcare/members of the American College of Physician Executives (ACPE) in 46 countries Quantitative; 677 online survey respondents (7.5% response rate) Shared vision and compassion are positively associated with an increased level of participation in leadership activities. Positive affect is a mediating factor for physician leaders. Participants had self-selected to join ACPE. Common methods bias was evident.
Ribeiro et al. (2018) How transformational leadership predicts employees’ affective commitment and performance Healthcare/Professionals at one hospital in Turkey Quantitative; 476 questionnaire respondents (56.0% response rate) Transformational leadership is positively associated with commitment and individual performance. Transformational leadership, affective commitment, and individual performance were measured from the same individual using the same questionnaire (common method variance).
Sfantou et al. (2017) Importance of leadership style towards quality of care measures in healthcare settings: A systematic review Healthcare Qualitative systematic review; 18 articles Consensus manager leadership style has improved the quality of healthcare services (regarding pain, restraint use, ulcers, catheters). The resonant leadership style has improved the quality of safety climate (drops in medication errors, 30-day mortality). Task-oriented leadership style improves the quality of care (patient satisfaction). Not stated
Smith et al. (2018) Leadership in interprofessional health and social care teams: A literature review Healthcare Qualitative literature review; 28 articles Effective interprofessional leadership themes include focus on shared leadership, transformation and change, personal qualities, goal alignment, creativity and innovation, communication, team building, leadership clarity, direction setting, external liaison abilities, skills mix, diversity, and clinical and contextual expertise. Not stated
Stuber et al. (2019) Investigating the role of stress-preventive leadership in the workplace hospital: The cross-sectional determination of relational quality by transformational Healthcare/leaders and staff of different professions at one hospital in Germany Quantitative cross-sectional; 1,137 online survey respondents (315 leaders, 822 staff members) to integrative leadership and leader–member relationship questionnaires (11.3% response rate) Leaders give themselves a higher self-rating of transformational leadership behavior and relationship quality than their staff members give them. Transformational leaders have higher job satisfaction. Transformational leadership behavior (individuality-focus, being a role model, fostering innovations, providing vision) is positively associated with the relationship quality between leader and team member. The improved relationship quality is positively associated with stress prevention in employees. Ratings between the leaders and staff members cannot be associated directly with each other. Only one measurement method was used. Response rate was low.
Yang et al. (2019) Humble leadership and innovative behavior among Chinese nurses: The mediating role of work engagement Healthcare/nurses in China Quantitative cross-sectional; 377 respondents to humble engagement, innovative behavior, and work engagement scale questionnaire (83.8% response rate) Humble leadership is positively related to nurses’ innovative behavior and work engagement. Work engagement mediates the relationship between innovative behavior and work engagement. A longitudinal study would be better than this cross-sectional study to provide causality.

Thematic Coding

QSR International NVivo software (Release 12.6.0) was used to perform two cycles of coding to find common themes among the 20 studies. The first cycle included deductive coding because a research question was known (Saldaña, 2009). The first cycle also used inductive coding to reveal additional themes during the review and thematic coding to identify thematic elements in the studies (Saldaña, 2009). The second cycle of coding was used to reexamine parts of the text to edit and group the codes identified in the first cycle of coding (Saldaña, 2009). The main findings and themes were applied to the research question: What type of leadership style is most effective for improving healthcare organizational goals?

RESULTS

This systematic review is composed of 5 qualitative studies (25% of the studies) and 15 quantitative studies (75%). Twelve (60%) had a quality score of 100%, an excellent quality rating, and eight (40%) had a quality score of 75%, a good quality rating.

Sector/populations consisted of nurses in nine studies (45% of the studies), nonclinical healthcare leaders (managers, supervisors, healthcare administrators, CEOs, chief financial officers, and chief operating officers) in six studies (30%), physicians in three studies (15%), and unspecified healthcare employees in three studies (15%). Four studies (20%) surveyed both the nurse/healthcare employee and their leaders. Four were systematic reviews that consisted of several sectors/populations and locations.

Fourteen studies (70%) discussed transformational (supportive) leadership, 10 studies (50%) discussed transactional (achievement-oriented) leadership, 8 studies (40%) discussed laissez-faire (a subtype of passive-avoidant) leadership, 5 studies (25%) discussed authentic leadership, 2 studies (10%) discussed democratic (participative) leadership, 2 studies (10%) discussed abusive leadership, 1 study (5%) discussed humble leadership, 1 study (5%) discussed autocratic leadership, 1 study (5%) discussed paternalistic leadership, and 1 study (5%) discussed shared leadership.

Several themes emerged during the thematic coding of the studies:

  • Transformational leadership was associated with higher levels of employee retention, organizational commitment, and job satisfaction.
  • Transactional leadership was associated with higher levels of organizational commitment.
  • Laissez-faire leadership was associated with lower levels of employee retention and organizational commitment.
  • Authentic leadership was associated with higher levels of organizational commitment and job satisfaction.

Table 3 summarizes the articles in this systematic review.

DISCUSSION

Synthesis of Findings

The following sections describe in detail the leadership styles identified in the review: transformational, transactional, laissez-faire, and authentic.

Transformational Leadership

Transformational leaders encourage employees “to transcend their self-interests and accomplish extraordinary goals by exhibiting idealized influence or charisma, inspirational motivation, intellectual stimulation, and individualized consideration” (Cheng et al., 2016, p. 1202). Transformational leadership has been positively associated with retention (Al-Yami et al., 2018; Asiri et al., 2016; Cheng et al., 2016; Cummings et al., 2018; Lavoie-Tremblay et al., 2016). Employees appreciate the intellectual stimulation from this type of leadership style (Al-Yami et al., 2018) and feel more committed to the organization (Al-Yami et al., 2018; Ribeiro et al., 2018). This increased commitment results from the loyalty and respect that they have for their leader (Al-Yami et al., 2018; Ribeiro et al., 2018). The organization benefits from transformational leaders because its employees are motivated to contribute more to the success of the organization.

Transformational leadership has also been demonstrated to be positively associated with job satisfaction (Alshahrani & Baig, 2016; Asamani et al., 2016; Asiri et al., 2016; Cummings et al., 2018) because of the two-way communication that this type of leadership style enables (Alshahrani & Baig, 2016). In addition, employee satisfaction results from the individualized consideration that leaders give to their employees (Al-Yami et al., 2018). Furthermore, employees experience increased engagement, empowerment, and team innovation/creativity (Cummings et al., 2018; Smith et al., 2018).

Transactional Leadership

Transactional leaders make a transaction with followers by providing rewards in exchange for completed tasks (Cummings et al., 2018). This type of leadership style has been positively associated with organizational commitment. The positive association between organizational commitment and transactional leadership is stronger than the association between organizational commitment and transformational leadership (Al-Yami et al., 2018; Asiri et al., 2016). This strength in transactional leadership arises from the relationship between the leaders’ contingent rewards and the employees’ commitment to the organization (Al-Yami et al., 2018; Asiri et al., 2016). Organizations gain increased productivity from their employees with the contingent reward system.

Laissez-Faire Leadership

Laissez-faire, a subtype of the passive-avoidant leadership style (Al-Yami et al., 2018), is defined as “avoiding responsibility” (Azar & Asiabar, 2015, p. 2). This leadership style has been negatively associated with retention, organizational commitment, and job satisfaction (Al-Yami et al., 2018; Alshahrani & Baig, 2016; Asiri et al., 2016). Laissez-faire leadership has negative outcomes because the leaders are not actively engaged with their employees.

Authentic Leadership

Authentic leadership “emphasizes leader insight, transparency, and congruence in their actions and personal or expressed beliefs” (Cummings et al., 2018, p. 20). Authentic leaders’ benevolent features include tolerance and respect of others and going the extra mile to support the team’s best interests (Ahmed et al., 2018). Authentic leadership has also been positively associated with employee retention, organizational commitment, and job satisfaction. According to Cummings and colleagues (2018), authentic leadership is more strongly linked to improved behavioral and attitudinal staff outcomes than transformational leadership, which it closely resembles.

Study Limitations

This systematic literature review has limitations. First, it was conducted by one researcher, indicating possible selection bias. Second, only one researcher conducted the quality review with the MMAT. An additional researcher would have helped confirm or refute the quality ratings. Third, only 20 articles were assessed. More research could add depth to the findings. Fourth, many of the articles represented nursing leadership, so it would be difficult to generalize the recommendations. Subsequent research should include more studies that examine the relationship between transformational leadership and other clinical professionals such as physicians, physician assistants, and nurse practitioners. Finally, the review was limited to English language. Additional criteria could broaden the findings to include clinical leaders in other countries.

CONCLUSION

Clinical professionals who are promoted or hired into leadership roles will have a better likelihood of succeeding if they learn and adopt the transformational leadership style. This leadership style is associated with greater employee retention, organizational commitment, and job satisfaction— factors that are important in leading a successful healthcare organization.

This systematic literature review found that higher levels of employee retention were associated with transformational and authentic leadership styles in healthcare. Organizational commitment was also positively associated with transformational, transactional, and authentic leadership styles. And finally, job satisfaction was positively associated with transformational and authentic leadership styles.

These findings suggest that clinical professionals should apply the transformational leadership style in their efforts to become effective healthcare leaders because it is more strongly associated with employee retention and job satisfaction than the transactional leadership style. Authentic leadership could possibly be better suited for leadership in healthcare, but there is not yet enough evidence in the literature to recommend it. Cummings and colleagues (2018) recommend additional research to differentiate those two styles and their effects on employee retention, organizational commitment, and job satisfaction.

The implications of leadership style in practice are considerable. Employees may have a stronger intention to leave their organizations if they are not committed to it or are dissatisfied with their jobs. According to Hall (2019), turnover can cost an employer approximately 33% of an employee’s annual salary to hire, interview, and train a comparable replacement. There is also the incalculable cost of losing institutional and cultural knowledge when an employee leaves (Shufutinsky & Cox, 2019). Clinical professionals who can apply the transformational leadership style can retain their invaluable, skilled staff and thus serve the best interests of their organizations, their employees, and themselves as healthcare leaders.

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