leadership skills in healthcare essay

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An integrative review of leadership competencies and attributes in advanced nursing practice

Maud heinen.

1 Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Nijmegen The Netherlands

Catharina van Oostveen

2 Spaarne Gasthuis Hospital, Spaarne Gasthuis Academy, Haarlem The Netherlands

3 Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam The Netherlands

Jeroen Peters

4 Hogeschool van Arnhem en Nijmegen, HAN University of Applied Sciences, Nijmegen The Netherlands

Hester Vermeulen

5 HAN University of Applied Sciences, Nijmegen The Netherlands

Associated Data

To establish what leadership competencies are expected of master level‐educated nurses like the Advanced Practice Nurses and the Clinical Nurse Leaders as described in the international literature.

Developments in health care ask for well‐trained nurse leaders. Advanced Practice Nurses and Clinical Nurse Leaders are ideally positioned to lead healthcare reform in nursing. Nurses should be adequately equipped for this role based on internationally defined leadership competencies. Therefore, identifying leadership competencies and related attributes internationally is needed.

Integrative review.

Embase, Medline and CINAHL databases were searched (January 2005–December 2018). Also, websites of international professional nursing organizations were searched for frameworks on leadership competencies. Study and framework selection, identification of competencies, quality appraisal of included studies and analysis of data were independently conducted by two researchers.

Fifteen studies and seven competency frameworks were included. Synthesis of 150 identified competencies led to a set of 30 core competencies in the clinical, professional, health systems. and health policy leadership domains. Most competencies fitted in one single domain the health policy domain contained the least competencies.

Conclusions

This synthesis of 30 core competencies within four leadership domains can be used for further development of evidence‐based curricula on leadership. Next steps include further refining of competencies, addressing gaps, and the linking of knowledge, skills, and attributes.

These findings contribute to leadership development for Advanced Practice Nurses and Clinical Nurse Leaders while aiming at improved health service delivery and guiding of health policies and reforms.

1. INTRODUCTION

Developments in health care, like a growing number of patients with chronic diseases, an increased complexity of patients, a stronger focus on person‐centred care and a demand for less institutionalized care ask for well‐trained master level‐educated nurses operating as partners in integrated care teams, with leadership qualities at all levels of the healthcare system. Changes in health care are also underlined by a definition of health as proposed by Huber et al. (Huber et al., 2011 ) where health is defined as ‘the ability to adapt and self manage in the face of social, physical and emotional challenges’ as a refinement of the World Health Organization (WHO) definition where health is ‘a state of complete physical, mental and social well being’ (WHO, 1948 ). This stipulates the de‐medicalization of health care and society and emphasizes the need for change in the way health care is organized. Also the Institute of Medicine with their report on ‘The Future of Nursing’ supports the urge for nurses to take their roles to address changes in health care (IOM, 2011 ). However leading change is a complex and not yet well understood process (Nelson‐Brantley & Ford, 2017 ). Therefore, especially master level‐educated nurses have to be trained in leadership based on internationally established leadership competencies. This review investigates what leadership competencies are expected from and can be identified for master educated nurses from an international perspective.

1.1. Background

Clinical nurses who are trained at master's level, for example, Advanced Practice Nurses (APNs) and Clinical Nurse Leaders (CNLs), are in a unique position to take a leadership role, in collaboration with other healthcare professionals, to shape healthcare reform, as they use extended and expanded skills and are trained to focus on improved patient outcomes, the application of evidence‐based practice and assessing cost‐effectiveness of care (Stanley et al., 2008 ). The focus of this review is on APNs and CNLs, where APN is regarded as a general designation for all nurses with an advanced degree in a nursing program, that is, Certified Nurse Practitioner (NP), Certified Registered Nurse Anaesthetist, Certified Nurse Midwife and Clinical Nurse Specialist (CNS) (APRN Joint Dialogue Group, 2008 ) . APNs are prepared with specialized education in a defined clinical area of practice. With APN in this review, we refer to the NP and the CNS. The CNL is educated to improve the quality of care and coordinate care in general through collaboration at the microsystems level in the entire healthcare team (APRN Joint Dialogue Group, 2007 ). Both groups of professionals are trained to integrate science in practice and education, have increased degrees of autonomy in judgments and clinical interventions and are expected to be engaged in collaborative and inter professional practices to achieve the best outcomes for patients, personnel and organization (American Association of Colleges of Nursing, 2011 ). They are also expected to substantially contribute to clinical outcomes through, that is, continuous quality improvement in patient care and creating a supportive environment for their colleagues, and to contribute to the development of their profession, healthcare systems and healthcare policy. (American Association of Colleges of Nursing, 2004 ; Bender, Williams, & Su, 2016 ; Hamric, Hanson, Tracy, & O'Grady, 2014 ). Therefore developing leadership competencies is an essential prerequisite for these master educated nurses, APNs however appear to experience a lot of difficulties in enacting their leadership role (Begley, Murphy, Higgins, & Cooney, 2014 ; Elliott, Begley, Sheaf, & Higgins, 2016a ).

Leadership is subject of many discussions can be regarded from different perspectives and is mostly related to specific contexts. Hence, there is no single definition applicable to all settings and professions. Leadership is mostly regarded in relation to managing a team or organization (Gosling & Mintzberg, 2003 ) but can also be defined as a set of personal skills or traits, or focussing on the relation between leaders and followers (Alimo‐Metcalfe & Alban‐Metcalfe, 2004 ; Bolden, 2004 ). Transformational and situational leadership are also commonly used concepts where transformational leadership is regarded as the process of leading and inspiring a group to achieve a common goal (Northouse, 2014 ) and situational leadership is focusing on the interaction between individual leadership styles and the features of the environment or situation where the leader is operating. (Fiedler, 1967 ; Hamric et al., 2014 ; Lynch, McCormack, & McCance, 2011 ). In this review, leadership is regarded as a process where nurses can develop observable leadership competencies and attributes needed to improve patient outcomes, and personnel and organizational outcomes (Kouzes & Posner, 2012 ). This implies that leadership competencies can be viewed as intended and defined outcomes of learning and that leadership and leadership competencies are not restricted to one single theory. A competency can be defined as ‘an expected level of performance that results from an integration of knowledge, skills, abilities and judgment’ (American Nurses Association, 2013 ).

The lack of an unambiguous definition of leadership in clinical practice, including clearly defined leadership competencies in nursing, is reflected in education. For most training programs and curricula, it is unclear whether the profiles used in education are up‐to‐date and aiming` at internationally accepted leadership competencies with evidence‐based methods to achieve these competencies. To enhance leadership qualities in master educated nurses, it is necessary to explicitly define what leadership competencies are expected from APNs and CNLs (Delamaire & Lafortune, 2010 ). Identifying and establishing internationally agreed on leadership competencies in master educated nurses is a first step to developing evidence‐based curricula on leadership (Falk‐Rafael, 2005 ; Vance & Larson, 2002 ). Such a curriculum facilitates APN and CNL students to not only become competent clinical and professional leaders but also well‐prepared for organizational systems and political leadership (Hamric et al., 2014 ). As such, it enables them to have a positive and significant impact on patient, personnel and organizational level outcomes. Accordingly, this review aims to identify and integrate leadership competencies of the master level‐educated nurse (APN and CNL) from an international perspective.

2. THE REVIEW

Based on the decision flowchart developed by Flemming et al. (Flemming, Booth, Hannes, Cargo, & Noyes, 2018 ), this review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement (Moher, Liberati, Tetzlaff, & Altman, 2009 ) and the Enhancing transparency in reporting the synthesis of qualitative research statement (Tong, Flemming, McInnes, Oliver, & Craig, 2012 ).

To identify and integrate leadership competencies of the master level‐educated nurse (APN and CNL) from an international perspective.

2.2. Design

An integrative review design was used, which allows for the combination of various study designs and data sources to be included. In using this methodology, a rigorous and systematic approach is ensured (Whittemore & Knafl, 2005 ). We followed the five stage methodology by Whittemore and Knafl (Whittemore & Knafl, 2005 ), however for the data synthesis phase, we used the four leadership domains of Hamric et al (Hamric et al., 2014 ; Hamric, Spross, & Hanson, 2009 ) as an a priori framework to integrate the extracted data.

The APN Leadership competency is conceptualized by Hamric et al. (Hamric et al., 2014 ) as occurring in four primary domains; in clinical practice with patients and staff, in professional organizations, in healthcare systems and in health policy‐making arenas. As stated above, this review focuses on the leadership competencies of APNs and CNLs. Additionally, knowledge, skills and attributes (KSA) needed to develop leadership competencies were topic of interest, where knowledge is regarded as being acquired through cognitive learning, skills through practice and attributes as behaviours that are learned over time (Koolen, 2016 ). We would like to add a reference to support this one, the full reference is added to the remark concerning Koolen in the reference list. The reference that needs to be added here is; ​Guillén and Saris ( 2013 )

2.3. Search methods

First, MEDLINE, EMBASE and CINAHL databases were searched from January 2005 ‐ December 2018 to identify articles concerning leadership in APNs and CNLs. To find all literature fitting our scope, we used the words attitude* role* attribute* next to leadership and competenc*. The search strategy was designed and conducted with the help of a clinical librarian (Data S1 ).

Articles were eligible if they explicitly described leadership competencies or related knowledge, skills or attributes in: (a) studies reporting on theory or theoretical leadership models; (b) developmental studies on leadership programmes (c) studies reporting on the effects of leadership programmes. No restrictions on study designs were applied. Studies were excluded when they concerned managerial leadership, if they did not concern APNs or CNLs (i.e., bachelor nurses and/or undergraduate nurses); or described leadership styles in general. Box gives an overview of in and exclusion criteria.

Inclusion and exclusion criteria.

Secondly, the websites of international professional nursing organizations were searched for documents on leadership competencies in NPs, CNSs, and CNLs. Worldwide, there are more than 100 nursing organizations, usually part of one umbrella association or council. Therefore, this review focused on frameworks of umbrella organizations in Australia, Europe, and North America and international nursing councils. Frameworks had to describe nursing leadership and related competencies in NPs, CNSs, or CNLs.

Eligible articles and frameworks were independently selected by three reviewers (MH, AH, CvO) based on the relevance of their titles and abstracts, as retrieved by the search. If articles met the inclusion criteria, full‐text versions of the articles were obtained and further scrutinized for eligibility by (MH, AH, CvO). HV was involved in any cases of disagreement, where consensus was reached through discussion. The reference lists of included articles were checked to detect any potential additional studies.

2.4. Search outcome

The search strategy in PUBMED, CINAHL, and EMBASE resulted initially in 4,220 records. After removing duplicates, the remaining 2,839 articles were screened on title and abstract. As a result, 168 articles and nine additional articles, added through reference checking, were included for full‐text assessment. Twenty‐four articles were not available in full text. Fifteen articles were eventually included in this review. The flow diagram (Figure ​ (Figure1) 1 ) gives an overview of the inclusion process.

Flow diagram (PRISMA 2009) [Colour figure can be viewed at http://www.wileyonlinelibrary.com/ ]

2.5. Quality appraisal

A quality appraisal (Data S2 ) was conducted by two researchers (MH, AH) on all 15 studies. Quality appraisal of the included studies was conducted using the Mixed methods Appraisal Tool MMAT (Hong, Gonzalez‐Reyes, & Pluye, 2018 ). The MMAT is a critical appraisal tool that is designed for the appraisal stage of systematic mixed studies reviews. It permits to appraise the methodological quality of five categories studies. The MMAT starts with two screening questions to determine whether the study is an empirical study and the tool can be used. For each category, five criteria are defined to rate the quality of the studies. It is advised not to calculate an overall score from the ratings of each criterion and excluding studies with low methodological quality is discouraged. Quality was therefore not used to include or exclude studies from the review, also because of the difficulties in comparing quality of studies using different designs (Whittemore & Knafl, 2005 ). The goal of the quality appraisal was to evaluate the quality of studies and the degree of evidence in an unbiased and transparent way. A quality appraisal of included frameworks was not conducted.

2.6. Data extraction

Data extraction was performed using a pre‐defined, structured data extraction sheet and was double‐checked by three researchers (MH, AH, CvO). The following data were extracted: author, year of publication, title, methodology, country and setting, master's APNs or CNLs. Competencies and KSA were derived from the frameworks and studies, by the same three researchers (MH, AH, CvO). Involvement of three independent researchers was used to ensure rigour of data extraction (Whittemore & Knafl, 2005 ).

2.7. Synthesis

Competencies described in the original studies subsequently were designated to the leadership domains described by Hamric et al. (Hamric et al., 2014 ) by three researchers (MH, AH, CvO). In cases of discrepancy, the selected domains were discussed until consensus was reached. The next step consisted of clustering of overlapping competencies by two researchers (MH, AH), which were checked by a third researcher (CvO). The competency from the overlapping items that best described the content was chosen for the final overview of competencies, sometimes with a minor adaptation to fully grasp the essence of this competency. The same process was followed for the KSA‐items.

3.1. Individual studies

One out of 15 articles concerned both the NP and the CNS, seven were about the NP, three were about the CNS and four articles focused on the CNL. Most articles (9/15) originated from the United States of America (USA), three from Australia and three articles originated from Canada, the UK, and Finland respectively. Two articles published different aspects of the same research (Carryer, Gardner, Dunn, & Gardner, 2007 ; Gardner, Carryer, Gardner, & Dunn, 2006 ) (Table ​ (Table1 1 ).

Overview of included studies (15) and frameworks (7)

Abbreviation: NA, Not Applicable.

Sample sizes were relatively small, ranging from 6‐50 respondents and consisted of nurse leaders (Bahouth et al., 2013 ; Goldberg et al., 2016 ; O'Rourke & Higuchi, 2016 ), experienced nurses (Bender, Williams, Su, & Hites, 2017 ; Carryer et al., 2007 ; Gardner et al., 2006 ; Kalb et al., 2006 ; Leggat, Balding, & Schiftan, 2015 ; Nieminen, Mannevaara, & Fagerström, 2011 ) and APN or CNL students (Ailey, Lamb, Friese, & Christopher, 2015 ; Gerard, Grossman, & Godfrey, 2012 ; Leggat et al., 2015 ; Nieminen et al., 2011 ; Sievers & Wolf, 2006 ).

Multiple research designs were used. These included surveys, interviews, and focus groups to describe experiences on integrating NPs and CNSs into hospitals (Bahouth et al., 2013 ; O'Rourke & Higuchi, 2016 ; Sievers & Wolf, 2006 ) and expressed clinical competences (Nieminen et al., 2011 ), a case study on an education program for CNLs (Ailey et al., 2015 ), exploring the effect of a mentor program of NP students on developing leadership competencies (Leggat et al., 2015 ), piloting an assessment for performance review of NPs and CNSs (Kalb et al., 2006 ) and multi‐method research to develop shared competencies and educational standards for APNs (Bender et al., 2017 ; Carryer et al., 2007 ; Gardner et al., 2006 ; Goldberg et al., 2016 ). Eight were descriptive studies on (experiences with) educational programs for CNLs or CNSs (Ailey et al., 2015 ; Baernholdt & Cottingham, 2011 ; Gerard et al., 2012 ; Goldberg et al., 2016 ; Leggat et al., 2015 ; Maag, Buccheri, Capella, & Jennings, 2006 ; Sievers & Wolf, 2006 ; Thompson & Nelson‐Marten, 2011 ) Baernholdt and Cottingham (Baernholdt & Cottingham, 2011 ) also reported on the development of the CNL role in practice. Six studies explicitly described leadership competencies (Bender et al., 2017 ; Gardner et al., 2006 ; Gerard et al., 2012 ; Goldberg et al., 2016 ; Kalb et al., 2006 ; Nieminen et al., 2011 ). Furthermore, studies focused on knowledge (Ailey et al., 2015 ; Carryer et al., 2007 ), leadership skills (Baernholdt & Cottingham, 2011 ; Maag et al., 2006 ; Thompson & Nelson‐Marten, 2011 ) and leadership attributes (Bahouth et al., 2013 ; Sievers & Wolf, 2006 ).

For eight out of 15 studies, quality could not be determined on the basis of quality appraisal tools for research (Data S2 ), five studies scored positive on all five MMET domains (Bender et al., 2017 ; Carryer et al., 2007 ; Goldberg et al., 2016 ; Nieminen et al., 2011 ; O'Rourke & Higuchi, 2016 ), one study scored positive on four out of five domains (Leggat et al., 2015 ) and one study scored positive on one domain (Bahouth et al., 2013 ).

3.2. Frameworks

Seven competency frameworks, including leadership competencies, were identified. The frameworks were developed between 2006 and 2014 and originated internationally in Europe (1/7) (ICN, 2015 ), the USA (4/7) (American Association of Colleges of Nursing, 2006 , 2013 ; The National Organization of Nurse Practotioner Faculties, 2014 ), Canada (1/7) (The Canadian Nurses Association, 2010 ) and Australia (1/7) (Nursing and Midwifery Board of Australia, 2014 ). All frameworks describe leadership competencies for the NP, CNS, or CNL but the extent to which the four leadership domains (i.e., clinical‐, professional‐, system‐, and health policy leadership) are covered differed (Table ​ (Table1). 1 ). In Australia, leadership is linked to four defined practice standards in the nursing process. Additionally, leadership is defined as the ability to lead care teams where the NP supports other professionals through clinical supervision and mentoring (Nursing and Midwifery Board of Australia, 2014 ). The Canadian Nurse Practitioner Core Competencies Framework identifies leadership as a core competence for the NP that should be reflected in excellent clinical practice and by mentoring colleagues and students. Leadership activities should not be limited to the NPs' own practice or institution but should focus on the entire care continuum, also including the political field of health care (The Canadian Nurses Association, 2010 ). The NONPF‐USA defines nursing leadership as the ability to change care systems, create partnerships, establish adequate communication and to participate in professional organizations (The National Organization of Nurse Practotioner Faculties, 2014 ). The Clinical Nurse Specialist Core Competencies Framework has assigned leadership competencies mainly to the heading ‘System leadership’ and describes specific leadership behaviour and associated sphere of influence and nurse characteristics needed (The National Organization of Clinical Nurse Specialists, 2010 ). The Essentials of Doctoral Education for Advanced Nursing Practice (American Association of Colleges of Nursing, 2006 ) is designed to prepare nurses for the highest level of leadership in practice and scientific inquiry.

Leadership competencies mainly refer to the category ‘Organizational and system leadership for quality improvement and systems thinking’. Leadership competencies are applied in clinical practice, as well in the entire field of health care. The ‘Master's Essentials and Clinical Nurse Leader Competencies’ outlined in the ‘Competencies and Curricular Expectations for Clinical Nurse Leader Education and Practice’ (American Association of Colleges of Nursing, 2013 ) describes the CNL as ‘a leader in the healthcare delivery system in all settings where healthcare is delivered’ (American Association of Colleges of Nursing, 2013 , p. 4). The leader competencies are embedded in nine categories, with the core leadership competencies mainly described in ‘Essential 2: Organisational and Systems Leadership’. Finally, the International Council of Nurses Leadership for Change™ (LFC) program is developed to prepare nurses to take a leadership role during health sector change and reform and enhance their contribution to health services (ICN, 2015 ). Leadership competencies are mainly focused on a system‐ and health policy leadership. Four frameworks provide suggestions for curriculum development concerning required KSA or performance indicators (ICN, 2015 ).

3.3. Data synthesis

The 150 competencies derived from the literature are displayed in Data S3 . Table ​ Table2 2 shows the final synthesis of the extracted competencies which resulted in the identification of 30 core leadership competencies, assigned to the four leadership domains of Hamric et al. (Hamric et al., 2014 ). The highest number of competencies ( n  = 8) was designated to the clinical and to the systems leadership domains, six to the professional and two to the health policy leadership domains. Six competencies fitted more than one domain, of which one competency related to three domains, the clinical, the health systems, and the health policy domains and four competencies were linked to the clinical, and to the health systems leadership domains. One competency was designated to the professional and the health systems leadership domains. The model in Figure ​ Figure2 2 presents this synthesis of competencies.

Final 30 leadership Core competencies within (four) leadership domains

Model competencies [Colour figure can be viewed at http://www.wileyonlinelibrary.com/ ]

Seven studies and two frameworks reported on knowledge (Ailey et al., 2015 ; Bahouth et al., 2013 ; Carryer et al., 2007 ; The National Organization of Nurse Practotioner Faculties, 2014 ), skills (Ailey et al., 2015 ; Baernholdt & Cottingham, 2011 ; Maag et al., 2006 ; The National Organization of Clinical Nurse Specialists, 2010 ; The National Organization of Nurse Practotioner Faculties, 2014 ; Thompson & Nelson‐Marten, 2011 ) and attributes (Ailey et al., 2015 ; Bahouth et al., 2013 ). Both Ailey et al. (Ailey et al., 2015 ; Sievers & Wolf, 2006 ) and the NONPF (The National Organization of Nurse Practotioner Faculties, 2014 ) described skills and knowledge in terms of explicit curricula content for APNs. Other studies reported broadly formulated KSA. Eleven knowledge items, 21 skills and 21 attributes were identified (Table ​ (Table3) 3 ) and assigned to a leadership domain.

Overview of identified needs for knowledge, skills, and attributes

Abbreviations: CL, clinical; PR, professional; HS, health systems; HP, health policy.

4. DISCUSSION

The results of this integrative review lead to the synthesis of 30 leadership competencies for APNs and CNLs derived from international literature and official documents of international nursing organizations. Competencies were furthermore designated to the clinical, professional, health systems or the health policy leadership domains, according to Hamric et al. (Hamric et al., 2014 ). Six competencies were linked to more than one domain. The clinical, professional and the health systems domains dominated regarding the number of competencies.

In the clinical leadership domain, core competencies are focused on delivering excellent patient care and concern items like collaboration with professionals and other health agencies, implementation of innovations, and enhancing EBP. Although EBP is often viewed as a stand‐alone competency (Hamric et al., 2014 ), leadership and EBP are strongly connected (Sastre‐Fullana et al., 2017 ). Stetler et al. (Stetler, Ritchie, Rycroft‐Malone, & Charns, 2014 ) assume supportive leadership as a key driver for the successful institutionalization of EBP in an organization (Stetler et al., 2014 ).

Competencies on the professional leadership domain appear to be clearly formulated and provide for sufficient direction to further develop the nursing profession. This is important because hospital decision makers need to learn from professionals about their roles and a collaborative evidence‐based vision on APN (Carter et al., 2013 ) (Kilpatrick et al., 2014 ; Kleinpell, 2013 ).

The leadership competencies in the Health Systems domain are shifting from direct patient care to the strategic level. Influencing at the strategic level requires an in‐depth understanding of healthcare systems to create and share an organizational vision on quality improvement, leading to the implementation of changes and to evaluate their results. (Thompson & Nelson‐Marten, 2011 ; Walker, Cooke, Henderson, & Creedy, 2011 ). Health system leadership also means that APNs and CNLs articulate the nursing perspective by joining or chairing interdisciplinary committees and raise their voice in the boardroom. However, formal positions for APNs and CNLs at strategic level are not self‐evident. System leadership can therefore only be reinforced when supported by managers and administrators of the organization (Hanson, 2015 ; Higgins et al., 2014 ).

Competencies related to the health policy domain were minimally present. Identified core competencies in the health policy domain were the guiding and initiating of leadership in policy‐related activities, to practice influence in health care and the articulation of the value of nursing to key stakeholders and policymakers on the (inter)national level. These rather abstract competencies do not allow for a clear understanding of the content and nature of health policy leadership. Further specification and operationalization are needed to guide nurses to the political arena. For example, health policy competences should be focussing on in‐depth understanding of global trends in relevant health issues and the profession's involvement in healthcare policy decisions (Rains & Barton‐Kriese, 2001 ). Additionally, information technology including e‐health applications and ‘Big Data’ analytics are important issues on the health policy agenda and the nursing perspective should be part of decision‐making processes in this area.

Half of the studies and two frameworks reported on KSA (table ​ (table3) 3 ) needed for the development of leadership competencies. The distinction between KSA however, appeared somewhat unclear. Being knowledgeable about legal rules was described as an attribute in one study (Bahouth et al., 2013 ) and as knowledge in others (Ailey et al., 2015 ; Carryer et al., 2007 ). Although KSA are closely related to each other, a distinction is helpful to specify what is needed to achieve defined leadership competencies.

Acquiring leadership competencies and related KSA occurs over time and is comparable with Benner's continuum ‘from novice to expert’ (Benner, 1982 ). Both APNs and CNLs curricula and clinical learning programs should train and empower their students to become leaders. Evidenced‐based training programs for clinical, professional, and systems leadership are scarce (Elliott, Farnum, & Beauchesne, 2016b ). Training programs for political leadership are even scarcer, which is in line with the identified competency gap in the health policy domain. The model laid out in this paper could provide a useful base for evidence‐based curriculum development, although identified competencies need to be further refined and discussed and completed with KSA related to each competency. Educational programs which integrate course work and clinical learning seem promising in developing and improving leadership competencies in especially the clinical and systems domains (Ailey et al., 2015 ; Sievers & Wolf, 2006 ; Thompson & Nelson‐Marten, 2011 ). Ainslie (Ainslie, 2017 ) advocates that organizations should map leadership competences to observable milestones so that progress can be clearly determined. This competence‐based learning has similarities with the concept of Entrustable Professional Activity (EPA). EPAs are elements of professional practice, that is, tasks or responsibilities that are observable and measurable in their process and outcome (Ten Cate, 2013 ) and may also be useful in developing leadership in APNs and CNLs. An assessment determines the entry competency levels and point out a personalized leadership development path. An APN, for example, may test at the expert level for ‘promoting and performing EBP’ but test at the novice level for ‘leading inter professional healthcare teams’. Additionally, situated coaching and mentoring is considered an essential element in educational and clinical learning programs (Ailey et al., 2015 ; Elliott, 2017 ).

Positive results are found for the effects of hierarchical leadership in nursing on quality of care and, more specifically, on nursing‐sensitive patient outcomes (Vaismoradi, Griffiths, Turunen, & Jordan, 2016 ; Wong, Cummings, & Ducharme, 2013 ). However, further research is needed to establish the relationship between leadership practices of APNs and CNLs and nursing‐sensitive patient outcomes (Dubois et al., 2017 ; Kapu & Kleinpell, 2013 ).

A limitation of this review is the fact that 24 of the 177 literature articles included based on title and abstract were not available in full text and the final selection of only 15 studies consisted of varying study designs and quality. Furthermore, most studies originated from the United States and Australia which might be challenging the representativeness of this review from an international perspective. Nonetheless, this review represents an integrative overview including a gap analysis of leadership competencies for APNs and CNLs in the current literature and as established by international nursing organizations.

5. CONCLUSION

This review identified 30 core leadership competencies for APNs and CNLs in the clinical, professional, health systems, and health policy leadership domains. The next steps include: (a) discussing gaps in this overview of competencies with master level‐educated nurses and educational institutes and linking KSA to each of the established leadership core competencies; (b) translating these competencies and aligned KSA to curricula and clinical learning programs; and (c) evaluating the effect of leadership competencies on nurse sensitive outcomes. These steps should be part of a continuous process needed for continuous quality improvement, healthcare reform, and high‐reliability health care.

AUTHOR CONTRIBUTIONS

MH, CvO, JP, HV, AH: made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; MH, CvO, JP, HV, AH: Involved in drafting the manuscript or revising it critically for important intellectual content; MH, CvO, JP, HV, AH: Given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content; MH, CvO, JP, HV, AH: Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Supporting information

Heinen M, van Oostveen C, Peters J, Vermeulen H, Huis A. An integrative review of leadership competencies and attributes in advanced nursing practice . J Adv Nurs . 2019; 75 :2378–2392. 10.1111/jan.14092 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Contributor Information

Maud Heinen, Email: [email protected] , https://twitter.com/MaudHeinen .

Catharina van Oostveen, https://twitter.com/CatharinavanOOstveen .

Jeroen Peters, https://twitter.com/jeroenpeters6 .

Hester Vermeulen, https://twitter.com/hvermeulen67 .

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• Volume 7, Issue 3
• Attributes, skills and actions of clinical leadership in nursing as reported by hospital nurses: a cross-sectional study
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• http://orcid.org/0000-0001-8401-4976 Majd T Mrayyan 1 ,
• http://orcid.org/0000-0002-6393-3022 Abdullah Algunmeeyn 2 ,
• http://orcid.org/0000-0002-2639-9991 Hamzeh Y Abunab 3 ,
• Ola A Kutah 2 ,
• Imad Alfayoumi 3 ,
• Abdallah Abu Khait 1
• 1 Department of Community and Mental Health Nursing, Faculty of Nursing , The Hashemite University , Zarqa , Jordan
• 2 Advanced Nursing Department, Faculty of Nursing , Isra University , Amman , Jordan
• 3 Basic Nursing Department, Faculty of Nursing , Isra University , Amman , Jordan
• Correspondence to Dr Majd T Mrayyan, Department of Community and Mental Health Nursing, Faculty of Nursing, The Hashemite University, Zarqa 13133, Jordan; mmrayyan{at}hu.edu.jo

Background Research shows a significant growth in clinical leadership from a nursing perspective; however, clinical leadership is still misunderstood in all clinical environments. Until now, clinical leaders were rarely seen in hospitals’ top management and leadership roles.

Purpose This study surveyed the attributes and skills of clinical nursing leadership and the actions that effective clinical nursing leaders can do.

Methods In 2020, a cross-sectional design was used in the current study using an online survey, with a non-random purposive sample of 296 registered nurses from teaching, public and private hospitals and areas of work in Jordan, yielding a 66% response rate. Data were analysed using descriptive analysis of frequency and central tendency measures, and comparisons were performed using independent t-tests.

Results The sample consists mostly of junior nurses. The ‘most common’ attributes associated with clinical nursing leadership were effective communication, clinical competence, approachability, role model and support. The ‘least common’ attribute associated with clinical nursing leadership was ‘controlling’. The top-rated skills of clinical leaders were having a strong moral character, knowing right and wrong and acting appropriately. Leading change and service improvement were clinical leaders’ top-rated actions. An independent t-test on key variables revealed substantial differences between male and female nurses regarding the actions and skills of effective clinical nursing leadership.

Conclusions The current study looked at clinical leadership in Jordan’s healthcare system, focusing on the role of gender in clinical nursing leadership. The findings advocate for clinical leadership by nurses as an essential element of value-based practice, and they influence innovation and change. As clinical leaders in various hospitals and healthcare settings, more empirical work is needed to build on clinical nursing in general and the attributes, skills and actions of clinical nursing leadership of nursing leaders and nurses.

• clinical leadership
• health system
• leadership assessment

Data availability statement

Data are available on request due to privacy/ethical restrictions. https://authorservices.taylorandfrancis.com/data-sharing/share-your-data/data-availability-statements/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/leader-2022-000672

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Clinical leadership was limited to service managers; however, currently, all clinicians are invited to participate in leadership practices. Clinical leaders are needed in various healthcare settings to produce positive outcomes.

WHAT THIS STUDY ADDS

This study outlined clinical leadership attributes, skills and actions to understand clinical nursing leadership better. The current study highlighted the role of gender in clinical nursing leadership, and it asserts that effective clinical nursing leadership is warranted to improve the efficiency and effectiveness of care. The results call for nurses’ clinical leadership as essential in today’s turbulent work environment.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Nurses and clinical leaders need additional attributes, skills and actions. Clinical nursing leaders should use innovative interventions and have skills or actions to manage current work environments. Further work is needed to build on clinical nursing in general and the attributes, skills and actions of clinical nursing leadership. Clinical leadership programmes must be integrated into the nursing curricula.

Introduction

Clinical leadership is a matter of global importance. Currently, all clinicians are invited to participate in leadership practices. 1 This invitation is based on the fact that people deliver healthcare within complex systems. Effective clinicians must understand systems of care to function effectively. 1 2 Engaging in clinical leadership is an obligation, not a choice, for all clinicians at all levels. This obligation is more critical in nursing with many e merging global health issues , 2 such as the COVID-19 pandemic.

The systematic literature review of Cummings et al 3 shows the differences in leadership literature. In early 2000, clinical leadership emerged in scientific literature. 4 It is about having the knowledge, skills and competencies needed to effectively balance the needs of patients and team members within resource constraints. 4 Clinical leadership is vital in nursing as nurses face complex challenges in clinical settings, especially in acute care settings. 4 Although developed from the management domain, leadership and management are two concepts used interchangeably, 5–9 leading to further misunderstanding of the relationship between clinical leadership and management. While different types of leadership have been evident in nursing and health industry literature, clinical leadership is still misunderstood in clinical environments. 8 Clinical leadership is not fully understood among health professionals trained to care for patients, as clinical leadership is a management concept, leaving the concept open to different interpretations. 10 For example, Gauld 10 reported that clinical leaders might be professionals (such as doctors and nurses) who are no longer clinically active, mandating that clinical leaders should also be involved in delivering care. 10

There is no clear definition of ‘clinical leadership’. However, effective clinical leadership involves individuals with the appropriate clinical leadership skills and attributes at different levels of an organisation, focusing on multidisciplinary and interdisciplinary work. 10 The main skills associated with clinical leadership were having values and beliefs consistent with their actions and interventions, being supportive of colleagues, communicating effectively, serving as a role model and engaging in reflective practice. 4–9 The main attributes associated with clinical leadership were using effective communication, clinical competence, being a role model, supportive and approachability. 4–9 Stanley and colleagues reported that clinical leaders are found across health organisations and are presented in all clinical environments. Clinical leaders are often found at the highest level for clinical interaction but not commonly found at the highest management level in wards or units. 4–9

With the increasing urgency to improve the efficiency and effectiveness of care, effective nursing leadership is warranted. 4 11–17 Clinical leaders can be found in various healthcare settings, 4 most often at the highest clinical level, but they are uncommon at the top executive level. 6–9 18–24 In the UK, the National Health Service (NHS) 25 empowers clinicians and front-line staff to build their decision-making capabilities, which is required for clinical leadership. This empowerment encourages a broader practice of clinical leadership without being limited to top executives alone. 25 26

Purpose and significance

This study assesses clinical nursing leadership in Jordan. More specifically, it answers the following research questions: (1) What attributes are associated with clinical nursing leadership in Jordanian hospitals? (2) What skills are important for effective clinical nursing leadership? (3) What actions are important for effective clinical nursing leadership? (4) What are the differences in skills critical to effective clinical nursing leadership based on the sample’s characteristics? (5) What are the differences in effective clinical nursing leaders’ actions based on the sample’s characteristics?

Nursing leadership studies are abundant; however, clinical leadership research is not well established. 8 27 Until fairly recently, clinical leadership in nursing has tended to focus on nursing leaders in senior leadership positions, ignoring nurse managers in clinical positions. 8 There has been significant growth in research exploring clinical leadership from a nursing perspective. 4 8 9 14–17 24 26–32 A new leadership theory, ‘congruent leadership’, has emerged, claiming that clinical leaders acted on their values and beliefs about care and thus were followed. 6–9 20 This study is the first in Jordan’s nursing and health-related research about clinical leadership. Clarifying this concept from nurses’ perspectives will support greater healthcare delivery efficiencies.

Search methods

The initial search was done using ‘clinical nursing leadership’ at the Clarivate database and Google Scholar database from 2017 to 2021, yielded 35 studies, of which, after abstracting, 14 studies were selected. However, Stanley’s work (12 studies), including those before 2017, was included because we followed the researcher’s passion and methodology of studying clinical leadership; also, some classical models of clinical leadership because they were essential for the conceptualisation of the study as well as the discussion, such as the NHS Leadership Academy (three studies; ref 25 33 34 ).

Another search was run using the words ‘attributes’, ‘skills’ or ‘actions’ using the same time frame; most of the yielded studies were not relevant, this search year was expanded to 2013–2021 because the years 2013–2015 were the glorious time of studying these concepts. Using ‘clinical leadership’ rather than ‘leadership studies’, 15 studies were yielded; however, Stanley’s above work was excluded to avoid repetition, resulting in using three studies (ref 29 30 35 ). A relevant reference of 2022 similar to our study (ref 36 ) was added at the stages of revisions. The remaining 16 of 49 references were related to the methodology and explanation of some results, such as those related to gender differences in leadership. The following limits were set: the language was English; and the year of publication was basically the last 5 years to ensure that the search was current.

Clinical leadership

Clinical leadership ensures quality patient care by providing safe and efficient care and creating a healthy clinical work environment. 4 10–17 27 31 32 It also decreases the high costs of clinical litigation settlements and improves the safety of service delivery to consumers. 4 11–17 32 For these reasons, healthcare organisations should initiate interventions to develop clinical leadership among front-line clinicians, including nurses. 8 9

Literature was scarce on clinical leadership in nursing. 4 8–10 14–17 27 28 31 Stanley and Stanley 8 defined clinical leadership as developing a culture and leading a set of tasks to improve the quality and safety of service delivery to consumers.

Clinical leadership is about focusing on direct patient care, delivering high-quality direct patient care, motivating members of the team to provide effective, safe and satisfying care, promoting staff retention, providing organisational support and improving patient outcomes. 31 Clinical leadership roles include providing the vision, setting the direction, promoting professionalism, teamwork, interprofessional collaborations, good practice and continued medical education, contributing to patient care and performing tasks effectively. 31 Moreover, the researchers added that clinical leadership is having the approachability and the ability to communicate effectively, the ability to gain support and influence others, role modelling, visibility and availability to support, the ability to promote change, advise and guide. 31 Clinical leadership competencies include demonstrating clinical expertise, remaining clinically focused and engaged and comprehending clinical leadership roles and decision-making. In addition, clinical leadership was not associated with a position within the management and organisational structure, unlike health service management. 31 33

Clinical leadership is hindered by many barriers that include the lack of time and the high clinical/client demand on their time. 8 9 Clinical leadership is limited because of the deficit in intrapersonal and interpersonal capabilities among team members and interdisciplinary and organisational factors, such as a lack of influence in interdisciplinary care planning and policy. 37 Other barriers include limited organisational leadership opportunities, the perceived need for leadership development before serving in leadership roles and a lack of funding for advancement. 38

This paper aligns with the theory of congruent leadership proposed by Stanley. 19 This theory is best suited for understanding clinical leadership because it defines leadership as a congruence between the activities and actions of the leader and the leader’s values, beliefs and principles, and those of the organisation and team.

Attributes of clinical leadership

The clinical leadership attributes needed for nurses 8 28 to perform their roles effectively are: (1) personal attributes: nurses are confident in their abilities to provide best practice, communicate effectively and have emotional intelligence; (2) team attributes: encouraging trust and commitment to others, team focus and valuing others’ skills and expertise; and (3) capabilities: encouraging contribution from others, building and maintaining relationships, creating clear direction and being a role model. 8 28 Clinical leadership attributes are linked to communicating effectively, role modelling, promoting change, providing advice and guidance, gaining support and influencing others. 28–30 Other attributes to include are clinical leaders’ engagement in reflective practice, 29 provision of the vision; setting direction, having the resources to perform tasks effectively and promoting professionalism, teamwork, interprofessional collaborations, effective practice and continued education. 27 28 31

Skills of clinical leadership

Clinical leadership skills include (1) a ‘clinical focus’: being expert knowledge, providing evidence-based rationale and systematic thinking, understanding clinical leadership, understanding clinical decision-making, being clinically focused, remaining clinically engaged and demonstrating clinical expertise; (2) a ‘follower/team focus’: being supportive of colleagues, effectively communicating communication skills, serving as a role model and empowering the team; and (3) a ‘personal qualities focus’: engaging in reflective practice, initiating change and challenging the status quo. 17 30 32 Clinical leaders have advocacy skills, facilitate and maintain healthier workplaces by driving changes in cultural issues among all health professionals. 17 29 Moreover, the overlap between the attributes and skills of clinical leaders includes being credible to colleagues because of clinical competence and the skills and capacity to support multidisciplinary teams effectively. 17 29 32

Actions of clinical leadership

A clinical leader is anyone in a clinical position exercising leadership. 26 The clinical leader’s role is to continuously instil in clinicians the capability to improve healthcare on small and large scales. 26 Furthermore, Stanley et al 9 demonstrated that clinical leaders are not always managers or higher-ups in organisations. Clinical leaders act following their values and beliefs, are approachable and provide superior service to their clients. 9 Clinical leaders define and delegate safety and quality responsibilities and roles. 14 32 39 They also ensure safety and quality of care, manage the operation of the clinical governance system, implement strategic plans and implement the organisation’s safety culture. 14 32 39 The Australian Commission on Safety and Quality in Health Care 39 also reported that clinical leaders might support other clinicians by reviewing safety and quality performance data, supervising the clinical workforce, conducting performance appraisals and ensuring that the team understands the clinical governance system.

In summary, clinical leadership attributes, skills and actions were outlined to understand clinical nursing leadership. The literature shows limited nursing research on clinical leadership, calling for clinical leadership that paves the road for nurses in the current turbulent work environment.

Study design

A descriptive quantitative analysis was developed to collect data about the attributes and skills of clinical nursing leadership and the actions that effective nursing clinical leaders can take. A cross-sectional design was employed to measure clinical leadership using an online survey in 2020. This design was appropriate for such a study as it allows the researchers to measure the outcome and the exposures of the study participants at the same time. 40

Sample and settings

The general population was registered nurses in medical centres in Jordan. The target population was registered nurses in teaching, public and private hospitals. Most nurses in Jordan are females working at different shifts on a full-time basis in different types of healthcare services. The baccalaureate degree is the minimum entry into the clinical practice of registered nurses. As previous nurses, we would like to attest that nurses in Jordanian hospitals commonly use team nursing care delivery models with different decision-making styles. The size of the sample was calculated by using Thorndike’s rule as follows: N≥10(k)+50 (where N was the sample size, k is the number of independent variables) (attributes, skills, actions), the minimum sample size should be 80 participants. 40 From experience, the researcher considers the sample’s demographics and subscales as independent variables (k=17); the overall sample should not be less than 220.

Research participants were recruited through a ‘direct recruitment strategy’ from the hospitals where the nursing students were trained. A survey was used to collect data using non-random purposive sampling; of possible 450 Jordanian nurses, 296 were recruited from different types of hospitals: teaching (51 of possible 120 nurses), public (180 of possible 210 nurses) and private (65 of possible 120 nurses), with a response rate of 66%, which is adequate for an online survey. The inclusion criteria were that nurses should work in hospital settings, and any nurses who work in non-hospital settings were excluded. No incentives were applied.

Using a direct measurement method, Stanley’s Clinical Leadership Scale ( online supplemental file 1 ) was used to collect the data using the English version of the scale because English is the official education language of nursing in Jordan. 8 9 The original questionnaire consists of 24 questions: 12 quantitative and qualitative questions relevant to clinical leadership, and 12 related to the sample’s demographics. Several studies about clinical leadership among nurses and paramedics in the UK and Australia used modified versions of a survey tool 5 8 9 18–24 ; construct validity was ensured using exploratory factor analysis or triangulation of validation. Cronbach’s alpha measures the homogeneity in the survey, and it was reported to be 0.87 8 9 and 0.88 in the current study.

Supplemental material

Several questions were measured on a 5-point Likert scale in the original scale, and others were qualitative. The survey for the current study consists of 12 quantitative and qualitative questions related to clinical leadership and 14 questions related to the sample’s demographics. However, the qualitative data obtained were scattered and incomplete; thus, only the quantitative questions were analysed and reported, and another qualitative study about clinical leadership was planned. For the current study, three quantitative questions only focused on clinical leadership, leadership skills and the actions of clinical leaders, and 14 questions focused on the sample’s characteristics relevant to the Jordanian healthcare system developed by the first author. The sample characteristics were gender, marital status, shift worked, time commitment, level of education, age, years of experience in nursing, years of experience in leadership and the number of employees directly supervised. Other characteristics include the type of unit/ward, model of nursing care, ward/unit’s decision-making style, formal leadership-related education (yes/no) and formal management-related education (yes/no). Before data collection, permission to use the tool was granted.

Ethical considerations

Nurses were invited to answer the survey while assuring the voluntary nature of their participation. The participants were told that their participation in the survey was their consent form. Participants’ anonymity and confidentiality of information were assured; all questionnaires were numerically coded, and the overall results were shared with nursing and hospital administrators. 40

Patient and public involvement

There was no patient or public involvement in this research’s design, conduct, reporting or dissemination.

Data collection procedures

After a pilot study on 12 December 2020, which checked for the suitability of the questionnaire for the Jordanian healthcare settings, data were collected over a month on 23 December 2020. Data were collected through Google Forms; the survey was posted on various WhatsApp groups and Facebook pages. Using purposive snowball sampling, nurses were asked to invite their contacts and to submit the survey once. To assure one submission, the Google Forms was designed to allow for one submission only.

No problem was encountered during data collection. The two attrition prevention techniques used were effective communication and asserting to the participants that the study was relevant to them.

The researchers controlled for all possible extraneous and confounding variables by including them in the study. A possible non-accounted extraneous variable is the organisational structure; a centralised organisational structure may hinder the use of clinical nursing leadership.

Data analyses

After data cleaning and checking wild codes and outliers, all coded variables were entered into the Statistical Package for Social Sciences (SPSS) (V.25), 35 which was used to generate statistics according to the level of measurement. A descriptive analysis focused on frequency and central tendency measures. 40 Part 1 of the scale comprises 54 qualities or characteristics to answer the first research question. Responses related to skills were measured on a 1–5 Likert scale; thus, means and SDs were reported to answer the second research question. Eight actions were rated on a 1–5 Likert scale; thus, means and SDs were reported to answer the third research question. Independent t-tests using all sample characteristics were performed to answer the fourth and fifth research questions.

The preanalysis phase of data analysis was performed; data were eligible and complete as few missing data were found; thus, they were left without intervention. The assumption of normality was met; both samples are approximately normally distributed, and there were no extreme differences in the sample’s SDs.

Characteristics of the sample

There were 296 nurses in the current study from different types of hospitals: teaching (51 nurses), public (180 nurses) and private (65 nurses), with a response rate of 66%. Most nurses were females (209, 70.6%), single (87, 29.4%), working a day shift (143, 48.3%) or rotating shifts (92, 31.1%), on a full-time basis (218, 73.6%), with a baccalaureate degree (236, 79.7%), aged less than 25 years (229, 77.4%) and 25–34 years (45, 15.2%), respectively. Also, 65.1% (166) of nurses reported having less than 1 year of experience in nursing; thus, they have few nurses under them to supervise (145, 49% supervise one to two nurses), and 23.3% (69) of nurses reported having 1–9 years of experience in leadership. Nurses reported that their unit or ward has a primary (81, 27.4%) or team nursing care delivery model (162, 54.7%), with a mixed (94, 31.8%) or participatory decision-making style (113, 38.2%), and had formal leadership-related education (191, 64.5%), and had no formal management-related education (210, 70.9%) ( table 1 ).

• View inline

Sample’s characteristics (N=296*)

Attributes of clinical nursing leadership

Nurses were asked to think about the attributes and features of clinical leadership. Based on Stanley’s Clinical Leadership Scale, 8 9 nurses were given a list of 54 qualities and characteristics and asked to select the most strongly associated with clinical leadership, followed by those least strongly associated with clinical leadership. Table 2 shows the respondents’ ‘top ten’ selected qualities in ranked order.

'Most’ and ‘Least’ important attributes associated with clinical nursing leadership (N=296)

Skills of effective clinical nursing leaders

On a Likert scale of 1–5, respondents were asked to rank the skills of effective clinical leaders from ‘not relevant’ or ‘not important’ to 5=‘very relevant’ or ‘very important’. The top skills were having a strong moral character, knowing right and wrong and acting appropriately which received a high rating, with a mean of 4.17 out of 5 (0.92). Being in a management position to be effective was ranked as the least skill of an effective leader, with a mean value of 3.78 out of 5 (1.00). As indicated by respondents, other skills of effective clinical leaders are shown in table 3 .

Skills of effective clinical nursing leaders (N=296)

Actions of effective clinical nursing leaders

On a Likert scale of 1–5, respondents were asked to rank the actions of effective clinical leaders. Leading change and service management achieved a high rating of 4.07 out of 5 points (0.90). Influencing organisational policy was rated last, with a mean score of 3.95 out of 5 (1.01), which may reflect the very junior nature of the majority of the sample. As described by respondents, some of the other actions of effective leaders are shown in table 4 .

Actions effective clinical nursing leaders can do (N=296)

Significant differences in skills of effective clinical nursing leaders based on gender

Independent t-tests using all sample’s characteristics were performed to answer the fourth research question. Gender was the only characteristic variable that differentiated clinical leadership skills. An independent t-test demonstrates that males and females have distinct perspectives on 3 out of 10 items measuring clinical leadership skills. Female participants outperform male participants in terms of ‘working within the team (p value=0.021)’, ‘being visible in the clinical environment (p value=0.004)’ and ‘recognizing optimal performance and expressing appreciation promptly (p value=0.042) ( table 5 )’.

Significant differences in skills and actions of effective clinical nursing leaders based on gender (n=296)

Significant differences in actions of effective clinical nursing leaders based on gender

Independent t-tests using all sample’s characteristics were performed to answer the fifth research question. Gender was the only characteristic variable that differentiated clinical leadership actions, and it was discovered that five of the eight propositions varied in their actions: the way clinical care is administered (p=0.010); participating in staff development education (p=0.006); providing valuable staff support (p=0.033); leading change and service improvement (p=0.014); and encouraging and leading service management (p=0.019). The independent t-test results revealed that female participants scored higher in those acts, corresponding to effective leaders’ competencies. The mean values of participants’ responses to the actions of effective clinical leaders are shown in table 5 .

The characteristics of the current sample are similar to those of the structure of the task force in Jordan. The remaining question is how men in Jordan be supported in nursing to develop clinical leadership skills on par with females. Al-Motlaq et al 41 proposed using a part-time nurses policy to address nurses’ gender imbalances. Although this is necessary for both genders, we propose to develop a clinical leadership training package to promote working male nurses’ clinical leadership. In Jordan, we apply the modern trend of using leadership in nursing rather than management. About 65% of the nurses reported having formal leadership-related education, while around 71% reported no formal management-related education.

The findings clearly showed what nurses seek in a clinical leader. They appear to refer to a good communicator who values relationships and encouragement, is flexible, approachable and compassionate, can set goals and plans, resource allocation, is clinically competent and visible and has integrity. They necessitate clinical nursing leaders who can be role models for others in practice and deal with change. They should be supportive decision-makers, mentors and motivators. They should be emphatic; otherwise, they should not be in a position of control. These findings align with other research on clinical leadership. 7–9 21 Clinical leaders should be visible and participate in team activities. They should be highly skilled clinicians who instil trust and set an example, and their values should guide them in providing excellent patient care. 8 9

Participants chose other terms or functions associated with leadership roles less frequently or perceived as unrelated to clinical leadership functions. Management, creativity and vision were among the terms and functions mentioned. The absence of the word ‘visionary’ from the list of the most important characteristics suggests that traditional leadership theories, as transformational leadership and situational leadership, do not provide a solid foundation for understanding clinical leadership approaches in the clinical setting. This result can also be influenced by the junior level of the majority of the sample.

Skills of clinical nursing leadership

Numerous studies have documented the characteristics and skills of clinical leaders. 27 29 31 Clinical leaders’ skills include advocacy, facilitation and healthier workplaces. 27 29 31 Our participants were rated as having high morals (similar to other studies) 27 29 31 and worked within teams. 29 In turn, they were flexible and expressed appreciation promptly. 7–9 21 They were clinically competent; thus, they improvised and responded to various situations with appropriate skills and interventions. They recognised optimal performance, initiated interventions, led actions and procedures and had the skills and resources necessary to perform their tasks.

The lowest mean was ‘ being in a management position to be effective ’. This lowest meaning ‘ somehow ’ makes sense; all nurses can be effective leaders rather than managers, assuming effective clinical leadership roles without having management positions. 28 42

Actions of clinical nursing leadership

Influential nursing leaders are clinically competent and can initiate interventions and lead actions; these skills translate to actions. Clinical leaders are qualified to lead and manage the service improvement change (similar to Major). 42 This role will not suddenly happen; it requires clinical nursing leaders who encourage and participate in staff development education (consistent with Major). 42 This is an essential milestone and an example of providing valuable staff support. As these were the lowest reported actions, clinical nursing leaders should initiate and lead improvement initiatives in their clinical settings, 42 resulting in service improvement. They also have to influence evidence-based policies to improve work–life integration 43 and enhance patients, nurses and organisational outcomes. These outcomes include quality of care, nurses’ empowerment, job satisfaction, quality of life and work engagement. 4 11–17 32

Female nurses had more clinical leadership skills. Because the findings of this study have never been reported in the previous clinical leadership research literature, they are considered novel. This finding indicates that one possible explanation is that the overwhelming majority of respondents were females, with the proportion of females in favour (70.6%) exceeding that of males (29.4%). Furthermore, the current findings could be explained because the study was conducted in Jordan, a traditionally female-dominated gender nursing career.

This study discovered that there are gender differences in the characteristics of nurses and their clinical leadership skills, with female clinical nursing leaders scoring higher on the t-test than male clinical nursing leaders in the following areas: this is contrary to Masanotti et al , 43 who reported that male nurses have a greater sense of coherence and, in turn, more teamwork than female nurses, who commonly have job dissatisfaction and less teamwork. These could apply to female clinical nursing leaders. These female nurses had more ‘visibility in the clinical environment’, as expected in female-dominated gender nursing careers. As they were commonly dissatisfied as nurses, 43 clinical nursing leaders would be competent in caring for their nurses’ psychological status. These leaders know that even ‘thank you’ is the simplest way to show appreciation and recognition; however, this should be given promptly.

In Arab and developing countries, the perception that females have more skills with effective clinical leadership characteristics than males is consistent with Alghamdi et al 44 and Yaseen. 45 They found that females outperform males on leadership scales, which may also apply to clinical leadership. This study shows consistency between female and male clinical nursing leaders’ general perceptions of clinical leadership skills in female-dominated gender nursing careers but not in male-dominated, gender-segregated countries, including Jordan.

Female nurses had more clinical leadership actions, which differed in five out of eight actions. Female clinical nursing leaders were better at impacting clinical care delivery, participating in staff development education, providing valuable staff support, leading change and improving service.

It is aware that the nursing profession has a difficult context in some Arab and developing countries. For example, a study conducted in Saudi Arabia could explain the current findings that male nurses face various challenges, including a lack of respect and discrimination, resulting in fewer opportunities for professional growth and development. 46 The researchers reported that female clinical nursing leaders are preferred over male nurses because nursing is a nurturing and caring profession; it has been dubbed a ‘female profession’. 46 Additionally, this study corroborates a study that found many males avoid the nursing profession entirely due to its negative connotations 47 ; the profession is geared towards females. These and other stereotypes have influenced male nurses to pursue masculine nursing roles.

The study’s findings are unique because they have never been published in the previous clinical leadership research literature. However, these results can be explained indirectly based on non-clinical leadership literature. Consistent with Khammar et al , 48 as it is a female-dominated profession, it is apparent that female clinical nursing leaders are better at delivering clinical care. This result could also be related to female clinical nursing leaders having a better attitude towards clinical conditions and managing different conditions. 48 Female clinical nursing leaders, in turn, are better at influencing patient care and improving patient safety 36 and overall care and services. This improvement will not happen suddenly; it should be accompanied by paying more attention to providing continuous support, especially during induced change.

The current study reported that female clinical nursing leaders supported staff development and education because it is a female-oriented sample. Yet, Khammar et al 48 reported that men had more opportunities to educate themselves in nursing; this is true in a male-dominated country like Jordan. They also noted that males could communicate better during nursing duties. Regardless of gender, all of us should pay attention to our staff’s working environment and related issues, including promoting open communication, providing support, encouraging continuing education, managing change and improving the overall outcomes.

Limitations

Even though the study’s findings are intriguing, further investigation is needed to comprehend them. Because of the cross-sectional design used in the current study, we cannot establish causality. For this reason, the results should be interpreted with caution. Also, the purposive sample limits the generalisability; thus, this research should be carried out again with a broader selection of nursing candidates and clinical settings. Moreover, the sample consists mostly of nurses with minimal experience compared with nurses in other international countries such as Canada, the UK and the USA. 5 The current study also included nurses in their 40s and above, with male nurses less represented, and this causes misunderstanding of the true clinical leadership in nursing.

Implications

For practice, our sample consists of nurses with minimal experience compared with nurses in other developed counties. Our sample reported ‘influencing organizational policy’ as the last clinical leadership skill, which reflects the very junior nature of the sample. Unlike our study, in their systematic review, Guibert-Lacasa and Vázquez-Calatayud 36 reported that the profiles of the care clinical nurses’ experience usually varied, ranging from recent graduates to senior nurses. If our nurses were more experienced, it might lead to different results. More nurses’ clinical experience would increase nurses’ abilities at the bedside, especially in areas related to reasoning and problem solving. 36 More experienced nurses tend to work collaboratively within the team with greater competency and autonomy. 36 More experienced nurses would provide high-quality care, 36 resulting in patient satisfaction. To generate positive outcomes of clinical nursing leadership, such early-career nurses should be qualified. Guibert-Lacasa and Vázquez-Calatayud 36 suggested using the nursing clinical leadership programme based on the American Organization for Nursing Leadership 34 competency model, pending the presence of organisational support for such an initiative. 36

‘Most’ important clinical nursing leadership attributes should be promoted at all organisational and clinical levels. Clinical nursing leadership’s ‘least’ important attributes should be defeated to achieve better outcomes. Clinical nursing leaders should use innovative interventions and have skills or actions conducive to a healthy work environment. These interventions include being approachable to enable their staff to cope with change, 28 using open and consistent communication, 28–30 being visible and consistently available as role models and mentors and taking risks. 28 Hospital administrators must help their clinical leaders, including nursing leaders, to effectively use their authority, responsibility and accountability; clinical leadership is not only about complying with the job description. A good intervention to start with to promote the culture of clinical leadership is setting an award for the ‘ideal nursing leaders’. This award will bring innovative attributes, skills and actions.

Moreover, as they are in the front line of communication, nurses and clinical nursing leaders should be involved in policy-related matters and committees. 49 An interventional programme that gives nurses more autonomy in making decisions is warranted. In turn, various patient, nurse and organisational outcomes will be improved. 13–17 32

The study’s findings revealed statistically significant differences in the skills and actions of effective clinical leaders, with female nurses scoring higher in many skills and actions. Hence, healthcare organisations must re-evaluate current leadership and staff development policies and prioritise professional development for nurses while also introducing new modes of evaluation and assessment that are explicitly geared at improving clinical leadership among nurses, particularly males.

For education, this study outlined clinical leadership attributes, skills and actions to understand clinical nursing leadership in Jordan better. Nevertheless, nurses and clinical leaders need additional attributes, skills and actions. Consequently, undergraduate nursing students might benefit from clinical leadership programmes integrated into the academic curriculum to teach them the fundamentals of clinical leadership. A master’s degree programme in ‘Clinical Nursing Leadership’ would prepare nurses for this pioneering role and today and tomorrow’s clinical nursing leaders. However, all nurses are clinical leaders regardless of their degrees and experience. Conducting presentations, convening meetings, overseeing organisational transformation and settling disagreements are common ways to hone these abilities.

For research purposes, it is worth exploring the concept of clinical leadership from a practice nurse’s perspective to provide insight into practice nurses’ feelings and perceptions. Thus, a longitudinal quantitative design or a phenomenological qualitative design might be adopted to assess the subjective experience of the nurses involved. It is better in future research to focus on both young and veteran clinical leaders; some of our nurses were aged 45 years and above, and those nurses may not be clinically focused.

Summary and conclusion

The current study put clinical leadership into the context of the healthcare system in Jordan. This study highlighted the role of gender in clinical nursing leadership. Nurses’ clinical leadership is a milestone for influencing innovation and change. The current study identified the ‘most’ and ‘least’ important attributes, skills and actions associated with clinical leadership. However, the male and female nurses found substantial differences in effective clinical nursing leadership skills and actions. This study is unique; little is known about the collective concepts of attributes, skills and actions necessary for clinical nursing leadership.

Nurses need leadership attributes, skills and actions to influence policy development and change in their work environments. Leadership attributes can help develop programmes that give nurses more autonomy in making decisions. As a result, nurses will be more active as clinical leaders.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by The Hashemite University, Jordan (IRB number: 1/1/2020/2021) on 18 October 2020. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The researchers thank the subjects who participated in the study, and Mrs Othman and Mr Sayaheen who collected the data.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1

Contributors MTM developed the study conception, abstract, introduction, literature review and methods; collected the data and wrote the first draft of this research paper and the final proofreading. HAN analysed the data and wrote the results. AA wrote the discussion and updated the literature review. OK wrote the limitations, implications, and summary and conclusion. IAF and AAK did the critical revisions and the final proofreading. All authors contributed to the current work.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Volume 20 Supplement 2

Peer Teacher Training in health professional education

• Open access
• Published: 03 December 2020

Leadership in healthcare education

• Christie van Diggele 1 , 2 ,
• Annette Burgess 2 , 3 ,
• Chris Roberts 2 , 3 &
• Craig Mellis 4  

BMC Medical Education volume  20 , Article number:  456 ( 2020 ) Cite this article

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Effective leadership is a complex and highly valued component of healthcare education, increasingly recognised as essential to the delivery of high standards of education, research and clinical practice. To meet the needs of healthcare in the twenty-first century, competent leaders will be increasingly important across all health professions, including allied health, nursing, pharmacy, dentistry, and medicine. Consequently, incorporation of leadership training and development should be part of all health professional curricula. A new type of leader is emerging: one who role models the balance between autonomy and accountability, emphasises teamwork, and focuses on improving patient outcomes. Healthcare education leaders are required to work effectively and collaboratively across discipline and organisational boundaries, where titles are not always linked to leadership roles. This paper briefly considers the current theories of leadership, and explores leadership skills and roles within the context of healthcare education.

Leadership has many interpretations, and has been likened to “ the abominable snowman whose footprints are everywhere but who is nowhere to be seen” [ 1 ]. It is an influential process, through which groups of people work towards the achievement of a common goal [ 2 ]. Leaders have the ability to shape and influence their followers’ values, attitudes and behaviours through a dyadic relationship. They are able to gain and enlist the support of others in order to achieve shared goals [ 3 , 4 ]. Effective leadership is a complex and highly valued component of healthcare education, increasingly recognised as essential to the delivery of high standards of education, research and clinical practice [ 3 ]. In order to achieve more effective outcomes, leadership and management skills are now an expectation and requirement in the healthcare education setting [ 5 ]. However, leaders within healthcare education should not rely on formal positions of authority, but instead, utilise their own appropriate leadership qualities irrespective of their level within the organisation [ 3 ]. A new type of leader is emerging: one who role models the balance between autonomy and accountability, emphasises teamwork, and focuses on improving patient outcomes [ 3 ]. This paper briefly considers the theories of leadership, and explores leadership skills and roles within the context of healthcare education.

Management versus leadership

Management and leadership are considered just as important as each other in accomplishing organisational goals. However, there are differences in the functions of the two roles. Management produces order and consistency, while leadership produces change and movement [ 2 ]. Management has the responsibility of organising all elements within the organisation, so that the leader’s vision and goals are successfully achieved. If poor management is in place, then goals cannot be achieved; and if poor leadership is in place, then there is no clear goal or vision to work towards. Leadership is seen as “setting direction, influencing others and managing change: with management concerned with the marshalling and organisation of resources and maintaining stability” [ 6 ]. These differences are summarised in Table  1 [ 6 , 7 ]. 

Transactional and transformational leadership

Leadership is a social construct, and there are many different leadership models [ 6 ]. Two broad types of leadership are identifiable: “transactional” and “transformational”. And their respective features are a useful way to think about the many types of leadership. Transactional and transformational leadership models are normally amalgamated within organisations to “empower others” (transformational) while holding individuals “accountable” (transactional) for their actions [ 7 , 8 , 9 ]. While it is clear that both transformational and transactional leadership paradigms are needed for an organisation to be effective, the optimal leader predominantly practices the transformational aspects of leadership, rather than transactional [ 10 ].

Transactional leadership

The transactional model is seen as an authoritative relationship that is transaction based, where exchanges occur between a leader and follower, once specific goals are identified or decided upon. Transactional leaders value order and structure, and have formal authority, with positions of responsibility within organisations. They achieve organisational goals through a rewards system and through positive reinforcement. A weakness of this model is the lack of innovation, as individuals are driven by predetermined outcomes, and there is lack of incentive and motivation to perform beyond what is expected [ 6 ].

Transformational leadership

Since the introduction of transformational leadership, the concept of leadership has undergone a major shift from representing an authoritative relationship (transactional), to a process of influencing individuals (transformational). Transformational leadership involves leadership through the transformation of individuals or ‘followers’, to work towards a common organisational goal [ 9 , 10 , 11 ]. This contemporary form of leadership is based on inspiring individuals, and forming teams to achieve goals. Transformational leaders define organisations through the articulation of a clear vision and clear values. The four “I”s of transformational leadership are outlined in Table  2 [ 9 ].

Team leadership

More recently, the focus has shifted towards “team leadership” , with distributed leadership becoming more prevalent within healthcare education, where different professions share influence [ 12 , 13 ]. Increasingly, leadership involves a collaborative role, with an emphasis on shared leadership and thoughtful allocation of responsibilities. Team-based organisations shift central control from the one leader, to the team. Teams are comprised of members who are interdependent, needing to coordinate their activities in order to accomplish their shared goals [ 14 , 15 ]. Personal autonomy, accountability, appropriate recognition, and clarity of roles, are all elements that contribute to optimal team performance. However, to ensure success, the organisational culture needs to support the involvement of individuals in these teams, and encourage leadership qualities [ 15 ]. Teams often fail when they exist in a traditional authority structure, where organisational culture is not supportive of collaborative work, and lower level decision making. Distributed leadership entails sharing of influence by team members, who step forward, or take a step back as needed. Leadership is provided by the person who meets the specific needs of the team at the time, hence providing faster responses to more complex issues in today’s organisations [ 15 , 16 , 17 ]. Effective leaders have an understanding of the conditions needed for teams to function well. For a team to achieve its potential, the operational roles of its members should be matched to their members’ abilities [ 18 ]. Belbin (1991) classified nine roles of team members that contribute to its process and function [ 19 ], outlined in Table  3 . Importantly, within team leadership, no single team role should be regarded as more important than another. Successful teams thrive on their diversity, drawing from the strengths of each member [ 13 ].

Effective leadership

Leaders need to have good time management and organisational skills, the ability to network professionally, display political nous and most importantly, they need to have strong communication skills [ 4 , 20 , 21 ]. Ready acceptance of feedback and self-awareness are important in development of leadership skills [ 20 , 21 ]. Behaviour, habits and biases can be deliberately corrected by utilising received feedback. Although there is not one set of qualities that apply to being an effective leader, certain competencies are valued and contribute to the leadership model in different ways [ 5 ]. Leadership competencies relevant for all health professional educators are outlined in Table  4 [ 3 ].

Language of leadership

Just as education and healthcare organisations have evolved, so too has the team leader. The role of the modern leader reinforces the tenets of stepping forward, collaborating and contributing. This role involves encouraging others by practising followership, and lending meaningful support to other leaders. As already stated, when it comes to leadership, excellent communication skills are a must. In order for successful communication to occur, both the sender and receiver must understand the message. This means that active listening is just as important as active talking [ 22 ]. Language used needs to be [ 22 ]:

Communicate with clarity of your purpose and the role of others

Stimulating

Deliver messages in a powerful, inspiring and dramatic way

Lead by example and walk the talk

Include active listening

Acknowledge what has been communicated, and use questioning skills

Show that you value others and their contributions

Challenges for leaders in healthcare education

There are a number of unique challenges in healthcare education. Healthcare education is delivered across professional disciplines, and notably, across organisational boundaries, involving universities, hospitals, and healthcare services. In turn, these organisations are bound by their own systems, structures, policies, cultures and values. At some point, most leaders in healthcare education need to make a decision about their leadership direction, and whether it lies predominantly in higher education or the clinical setting; and whether it lies in undergraduate education or postgraduate education. It can be difficult to merge roles between organisations, and McKimm (2004) has identified a number of issues and challenges specific to health education leaders, outlined in Table  5 [ 22 , 23 ]. Throughout a career, it may be necessary to maintain an awareness of available opportunities within organisations, and match these to the required experiences and capabilities [ 22 , 23 ] (see Fig. 1 ).

Reflection task

Development of leadership skills

Workforce data indicates that many experienced clinicians and healthcare educators will retire over the next ten years [ 24 , 25 ]. The need for effective succession planning and leadership training is well recognised [ 25 , 26 , 27 ], with a current shortage of emerging leaders moving into leadership roles. Effective leaders need to be nurtured and supported by the organisations in which they are educated, train and work [ 6 ]. As a learned skill, the topic of leadership is gathering momentum as a key curriculum area. Leadership development, assessment and feedback are necessary throughout the education and training of health professionals. Aspiring and current leaders can be identified, trained and assessed through formal leadership development programs, and through supportive organisational cultures. This requires embedding leadership training programs, opportunities for leadership practice, and promotion of professional networks within and beyond the organisation. The importance of mentorship within healthcare education is well recognised, offering a means to further enhance leadership and engagement within the workforce [ 28 ].

While many are assigned as leaders through their job title, it is important to identify, support and develop emerging leaders [ 2 ]. Leadership consists of a learnable set of practices and skills that can be developed by reading literature and attending leadership courses [ 29 ]. Additionally, investment in the social capital of organisations, fostering interprofessional learning and communication in the work setting, and collaboration across organisations assists in leadership development. Developing leadership skills is a life-long process [ 21 ]. Resources and opportunities should be considered to assist in the development of leadership skills. Some examples include:

Reading about leadership e.g. theories on leadership styles

Attending leadership training workshops

Participating in mentorship programs either as mentee or mentor

Joining small group seminars on leadership development

Accepting more responsibilities when required, or when opportunities arise.

Process for effective leadership

A title is not required to enable effective leadership. Leadership may occur in everyday work, and occurs in collaboration with other professionals within the education and healthcare systems. For example, leadership in teaching, administration, research, and/or excellence in clinical practice.

Leadership roles include the important concept of management of both personal and professional practice. Priorities need to be set and time managed to integrate work and personal life. Tools can be used to stay organised, and deliberately manage busy schedules. Effective delegation may be used to share the work of new projects:

Organisation to ensure an understanding of tasks, priorities and deadlines

Establish steps and a sequence to achieve the desired outcomes

List required resources, considering the competencies of individual team members, and match tasks appropriately (also consider skill development needs)

Communicate with team members, monitor progress in activities and provide guidance to team members.

Leadership competencies, and the incorporation of leadership development as part of curricula, are identified as important across all health professions, including allied health, nursing, pharmacy, dentistry, and medicine, in meeting the needs of healthcare in the twenty-first century [ 30 ]. With an increase in interprofessional teams and an emphasis on collaboration, more effective outcomes are achieved [ 5 ]. Healthcare education leaders are required to work effectively and collaboratively across discipline and organisational boundaries, where titles are not always linked to leadership roles, but may occur in everyday work. Good leadership also means knowing when, and how to support others in their endeavours. Provision of opportunities for leadership development is crucial in improving education sectors and health services, and effecting change. The future belongs to healthcare education leaders who demonstrate excellence in teamwork, clinical skills, patient centred care [ 3 ], and responsibly balance accountability with autonomy.

Take-home message

Availability of data and materials

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Effective leadership of healthcare professionals is critical for creating supportive work environments but also for strengthening quality of care. Based on current evidence, the aim of this chapter is to synthesize how different approaches to leadership are associated with healthy and unhealthy employee and patient outcomes. Further the chapter points to promising Healthy Healthcare approaches and discusses potential strengths and weaknesses. The increasing research interest in the links between leadership and quality of care is also outlined.

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The Need for Healthy Leadership in the Health Care Sector: Consideration of Specific Conditions for Implementation

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An analysis of student essays on medical leadership and its educational implications in South Korea

• I Re Lee 1   na1 ,
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• Jae Il Shin 3 &
• Shinki An 1 , 4  

Scientific Reports volume  12 , Article number:  5788 ( 2022 ) Cite this article

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To examine medical students’ perceptions of leadership and explore their implications for medical leadership education. We conducted a qualitative analysis of the essays submitted by students in the medical leadership course from 2015 to 2019. We categorised the essays by the characteristics of the selected model leaders (N = 563) and types of leadership (N = 605). A statistically significant proportion of students selected leaders who were of the same gender as themselves (P < 0.001), graduate track students chose leaders in science (P = 0.005), while; military track students chose leaders in the military (P < 0.001). Although the highest proportion of students chose politicians as their model leaders (22.7%), this number decreased over time (P < 0.001), and a wider range of occupational groups were represented between 2015 and 2019. Charismatic leadership was the most frequently selected (31.9%), and over time there was a statistically significant (P = 0.004) increase in the selection of transformational leadership. Students tended to choose individuals whose acts of leadership could be seen and applied. Medical leadership education should account for students’ changing perceptions and present a feasible leadership model, introducing specific examples to illustrate these leadership skills.

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Introduction.

Contemporary medical environments are facing complex issues, such as rising costs of treatment and inadequate access to and inconsistent quality of health care 1 . To address the ever-perplexing issues in medicine, there is an increasing need for effective leadership in health care 2 , 3 . In the past, medical care was primarily conducted by an individual physician. In addition, medical education heavily focused on the diagnosis and treatment of illnesses rather than working as a team to provide solutions that ensure higher quality medical care and safety 4 . However, in modern health care environments, a doctor’s role as a leader has become much more significant not only in physician–patient relationships but also in coordinating team-based tasks in the hospital and managing medical organizations 5 . For instance, as the socioeconomic environment becomes an essential component of a community’s health, physicians are expected to exert leadership in organisations that address public health issues 6 . Accordingly, physicians must be prepared to serve as leaders in health care.

Following the increasing need for leadership in healthcare, leadership skills are being included in physician evaluation criteria. The Association of American Medical Colleges has included leadership as the core requirement for medical students entering residency 7 . The Royal College of Physicians and Surgeons in Canada also includes the role of a leader as one of the main capability frameworks and has reflected this in their medical education 8 . Medical schools in the United States are proceeding with various leadership programs and incorporating leadership curricula into their undergraduate medical education 9 . Further, research shows that medical students now recognize the need for leadership education following the changing environment; 85% of medical students agreed that they should be taught leadership communication skills and teamwork abilities during their medical school years 10 . Korean medical educators also attempt to incorporate medical leadership education into medical education curriculum 11 . Yonsei University College of Medicine (YUCM) offers a leadership curriculum, Doctoring & Medical Humanities: Medical Leadership (DMH-ML), which is a core course covering 16 h (two hours per week for eight weeks) and offered to first-year medical students in the final quarter since 2014. The first 3 weeks feature lectures on basic concepts of leadership. The next three weeks are divided into three elective tracks, from which students choose lessons about leadership taken from: (1) the history of Severance Hospital in South Korea; (2) medical missions and international public health development; (3) business aspects of medicine. The final two weeks of the curriculum provide a summary of the topics covered. The written assignment of the course is a leadership model critique whereby students select a leader of their choice, summarize the leader’s accomplishments, and analyse the strengths and weaknesses found in that leadership. The course aims to facilitate medical students’ understanding of the nature of leadership from various leaders and help them recognize that their role as a leader is one of the fundamental responsibilities as physicians. All students who participated in the class submitted the written assignment, and the prompts for the written assignments were not changed between 2015 and 2019.

As no profiles have been reported on the leader models selected by medical students to date, in this study, we aimed to examine the medical students’ perceptions of leadership and provide directions for leadership education by analysing the characteristics and types of leadership models presented in leadership model critique essays.

We analysed a total of 585 essays submitted between 2015 and 2019. After excluding 35 essays that did not present a model, and double-counting 13 essays that presented two individuals, a total of 563 essays were chosen for this study (125 in 2015, 84 in 2016, 113 in 2017, 120 in 2018, and 121 in 2019). Of the 563 essays, 407 (72.3%) were written by male students and 156 (27.7%) by female students. Regarding admission types, 381 students (67.7%) were identified as undergraduate , 153 students (27.1%) as transfer/graduate, and 29 students (5.2%) as military (Table 1 ). We analysed the demographic characteristics of the model leaders selected in the essays (Table 2 ). A total of 563 individuals were selected as model leaders, 499 men (88.6%), 55 women (9.8%) and 9 other (1.6%), such as names of industries. The comparison of the gender ratio between the selected model leaders and the students showed that male students tended to select male leaders while female students were significantly more likely to select female leaders (P < 0.001) (Table 3 ). A total of 331 leaders (58.8%) belonged to the present generation category, and 232 (41.2%) belonged to the previous generation category. The occupational groups of the model leaders were as follows: politics (n = 128, 22.7%), business (n = 121, 21.5%), science (n = 117, 20.8%), sports (n = 45, 8.0%), social activism (n = 34, 6.0%), arts (n = 33, 5.9%), military (n = 32, 5.7%), religion (n = 18, 3.2%), education/law/exploration (n = 7, 1.2%), and other (n = 28, 5.0%). The comparative analysis of the selected model leaders’ occupational groups and the demographic characteristics of the students showed that a statistically significant proportion of female students (P = 0.0014) chose leaders in science, and a statistically significant proportion of male students chose leaders in sports (P = 0.003) (Table 4 ). Further, a statistically significant proportion of undergraduate students (P = 0.049) chose leaders in politics, transfer/graduate students (P = 0.005) chose leaders in science, and military students chose leaders in the military. When we analysed the changes in the occupational groups of the selected model leaders from 2015 to 2019, the decrease in the number of students who chose leaders in politics was statistically significant (P < 0.001), and the increase in the number of students who chose leaders in sports was statistically significant (P = 0.015) (Table 5 ).

Qualitative analysis

We analysed the leadership types of the selected models in 563 essays according to a qualitative framework developed from thematic and content analysis. Based on the analysis, a total of 605 essays were selected (seven essays with no specific category of leadership type were excluded, and 49 essays that presented two types of leadership were counted twice). Six types of leadership were identified in the following order: (1) Charismatic leadership (193; 31.9%) represented by the keywords “authority”, “ability”, “drive”, “firmness”, “determination”, and “strong execution”, (2) Servant leadership (150; 24.8%) by the keywords “sacrifice”, “serving”, “devotion”, “empathy”, “listening”, “respect”, “embrace”, “humility”, and “love”, (3) Collaborative leadership (117;19.3%) by the keywords “communication”, “team”, “cooperation”, “together”, “member”, “network”, and “horizontal”, (4) Transformative leadership (109;18.0%) by the keywords “change”, “innovation”, “creativity”, “novelty”, “pioneering”, “boldness”, “challenge”, and “creation”, (5) Self-leadership (23; 3.8%) by the key phrases “achievement of one’s goals and achievement of tasks”, and (6) Super-leadership (13;2.1%) by key phrases such as “education”, “teaching”, “human resources”, and “making good leaders” (Table 6 ). A comparison of the proportion of the leadership types in the selected models from 2015 to 2019 revealed that the selection of the transformative leadership type has significantly increased (P = 0.004) (Table 7 ).

The role models as leaders selected by students differed on the basis of the students’ gender and admission type. Although male leaders were dominant, the proportion of female leaders selected by female students was higher than that selected by male students. The selection of the contemporary leaders of the present generation was more common than those leaders of the previous generation. A high proportion of the transfer/graduate students, many with bachelor’s degrees in the sciences, chose leaders who worked in science fields, and a high proportion of the military students chose leaders related to the military. These findings imply that students tend to admire models as leaders among the contemporary figures whose acts of leadership can be observed in real-time as well as models with whom they share more in common, such as gender, academic backgrounds, or occupations, likely because the actions and achievements of such leaders are more understandable and more applicable to their own lives. The educational implication of these findings is the importance of role modelling as well as the influence of the informal, hidden curriculum 12 , 13 , 14 , 15 , 16 , 17 . Just as clinical knowledge and skills can be transmitted formally and informally in clinical situations, leadership in health care can also be transmitted through formal and informal means 18 . Although there are individuals officially designated as leaders in healthcare settings, the presence of individuals influencing other persons in informal ways should be acknowledged. Since individuals can be role models regardless of whether they are officially designated as leaders or whether they have an educational intention, medical educators need to understand the role of informal leadership training 19 . Although many medical schools strive to implement leadership education using various methods 20 , they overlook how informal leadership such as students’ experiences in leading and organizational culture play an important role in developing students' leadership skills 21 . Therefore, medical schools need to develop a faculty development program based on the importance of role modelling, recognizing the fact that role modelling can have both positive and negative effects on medical students 22 . A training program to enhance the leadership abilities of the instructors for better transfer of knowledge to the new generation of students is necessary 23 .

The occupations of leaders chosen by the students changed over the course of the 5 years analysed. At first, many students chose politicians as their model leaders, but the percentage of politicians selected decreased over time, and a wider variety of occupations were represented. This change implies that the students’ perceptions of leadership are shifting and that leaders recognized by society are emerging in various occupational fields. Therefore, medical leadership education and research need to incorporate the interdisciplinary and transdisciplinary approaches to meet continuous social changes 22 . Building a leadership curriculum based on a balanced interdisciplinary approach through the theoretical background in various fields, introducing specific examples of leadership in various areas, and having students reflect on case studies will help students develop various leadership-related competencies 24 .

The types of leadership delineated by the qualitative analysis of the essays showed that the most common type of leadership among the six types was the charismatic type, which is the most traditional leadership type. The traditional figure of a physician with ability, a firm and determined mind, the power to execute, and authority remains the most prominent model as a leader for medical students. As the charismatic leadership type tends to parallel the traditional heroic medical practice led by one-person, medical educators need to emphasize the possible limitations of charismatic leadership in the current health care context, which requires a substantially more team-based approach. As the ratio of students choosing diversified leadership types has gradually increased, it can be considered that the students’ primary concept of medical leadership is changing according to changes in medical society.

The second and third types of leadership stated by students were the servant and collaborative leadership types, which were increasingly recognized as essential in the healthcare field. Earlier, the servant leadership, with its image of dedication to treating patients and contributing to the community 18 , was exemplified as the prominent model for healthcare 25 . The function of collaborative leadership has been increasingly emphasized in the changing medical environment where facilitating successful collaboration within teams and flexibly adapting to changes is becoming more important 26 . Moreover, effective team management and cooperation in health care are known to be closely related to improved outcomes in the treatment of patients 27 . The prevalence of the selection of these types of leadership by the students may reflect their correct understanding of the modern health care approach.

The proportion of transformational leadership increased significantly over time. Transformational leadership is a more suitable leadership type for a constantly changing environment such as that of health care where quick adaptation and decision-making are required 25 , 28 . Recently, The fourth industrial revolution is characterised by developments such as precision medicine, AI-based medical treatment, and telemedicine, and related discussions are underway in medical education. This increase in the proportion of transformational leadership indicates that students recognize the importance of leadership that is sensitive to change and can respond quickly and with sound judgment.

When we compared the selected leaders' occupations and leadership types, it was confirmed that the students presented various leadership types in the same occupational group (Supplementary Table S1 ). This finding implied that there is no stereotyped leadership for a specific occupation but that different types of leadership can be manifested depending on the situations and followers in regard to which the leadership is exercised 28 . In other words, physicians as a leader needs to lead organizations, teams, or themselves using various leadership types rather than pursuing one fixed style. Moreover, mature leaders are more proficient in using different types of leadership, and different leadership levels require different skills 29 . These findings suggest that leadership in health care can be learned through case studies of other occupational groups and the curriculum should include various leadership types rather than emphasizing one style.

Limitations

This study has the following limitations. First, the sample of this study is limited to the medical students in South Korea. Considering that effective leadership behaviors are being accepted to be culture-specific, it is difficult to generalize the qualitative analysis conducted on essays collected from a single medical school 30 . Second, although the percentage of students in each admission type corresponds with the average percentages of undergraduate track (70%) and graduate track (30%) admissions in South Korea, the fact that students in the graduate track would have been in their first year of medical school at the time of essay submission is a limitation. Third, it is possible that the essays submitted by the students were influenced by the lectures held in class. In selecting a model leader, the student may have considered leaders, leadership theories, and types of leadership presented by the instructor. Nevertheless, this study is meaningful because it explores the experiences of the medical students over the past five years, analyses leadership recognized by the students, and examines the changes in their perceptions over time.

Conclusions

Whether leadership is innate or acquired remains a matter of debate, but many experts argue that education and experience can teach the skills and behaviours necessary for developing the ability to lead others 23 , 31 . Therefore, a well-designed leadership curriculum that presents feasible leadership models is needed because students imitate familiar and applicable leaders. Further, in the rapidly changing medical environment, leadership roles are diversifying, and students' perceptions of leadership are changing. Therefore, when medical schools encourage the various approaches to leadership required in modern society, students can foster broad skills in medical leadership.

We reviewed all essays submitted in the first-year core course, titled Doctoring & Medical Humanities: Medical Leadership , from 2015 to 2019, to investigate changes in the perceptions of leadership among medical students. The prompt of the essay required students enrolled in the DMH-ML course to select a model leader, summarize that leader’s achievements, and reflect on the strengths and weaknesses of leadership found. We collected a total of 585 essays and performed quantitative and qualitative analysis (Fig.  1 ).

Schematic diagram of quantitative and qualitative analyses on the essays.

Student demographics and data collection

To perform quantitative analysis, we classified the characteristics of the students as well as those of the leaders they selected. We collected demographic information such as gender and type of admission of the medical students at YUCM who submitted the essays and classified them into three groups: (1) undergraduate track, (2) graduate track, and (3) military track. The undergraduate track is a conventional 6-year program in South Korea and is for students who have immediately graduated from high school. The first two years are equivalent to the pre-med years of an undergraduate degree, and the remaining 4 years are equivalent to the medical years (2 years for preclinical and 2 years for clerkship) of medical schools elsewhere. Thus, by the time of their essay submission, students in the undergraduate track would be in their third year having enrolled at medical school. The graduate track is a four-year program for those with an undergraduate degree. Thus, students transfer straight into the medical years, skipping the pre-med years of medical school. This track is typical of admission to medical school in the United States and Canada. In Australia, England, Ireland, Singapore and South Korea, the undergraduate track and the graduate track are mixed (Fig.  2 ) 32 . Finally, the military track is for the military students with an undergraduate degree commissioned by the army.

Schematic diagram of medical educational system in South Korea.

Quantitative analysis

We also classified the gender, generation, and occupational groups of the selected model leaders. We classified the selected leaders as (1) the previous generation if they had passed away before 2000 and (2) the present generation if they had passed away after 2000 or were still living at the time of the study. The occupational groups of the model leaders were classified as politics, business, science, sports, social activism, arts, military, religion, and education/law/exploration. In addition, when students selected an individual with whom they had a personal relationship such as a parent or a character in a book or movie, we classified them as “other”.

After classifying the characteristics of students and leaders, we analysed the characteristics of selected leaders according to the characteristics of students and observed how the students' perceptions of leadership changed over time from 2015 to 2019.

We used a combination of thematic and contents analyses for our qualitative analysis 33 , 34 . Two authors independently analysed each essay. We omitted essays that did not establish a model leader. For essays with two selected leaders, we analysed them as two separate model leaders. The strengths of each selected model leader portrayed by students were summarized. Disagreements were resolved through group discussion and consensus.

In the first step, we extracted the main contents that delineated the selected leaders' performance, strengths, and weaknesses from the essays for thematic analysis. We then, classified these extracted contents by thematic keywords with similar meanings.

Second, we developed a framework for content analysis through a review of previously published literature.

Finally, the result of the thematic analysis was combined with the result of the content analysis. The framework was formed based on six types of model leadership by matching the 10 leadership types (adaptive, authentic, charismatic, collaborative, servant, self, situational, super, transformational, and transactional) selected through the analysis of previous studies with the leadership types described by the students 27 , 35 , 36 , 37 , 38 , 39 , 40 , 41 : charismatic, servant, collaborative, transformational, super-, and self-leadership.

The six leadership model types are defined as follows. Charismatic leadership centres on the leader’s strong charisma and resolute style that allows members to follow the decisions they make 35 . Servant leadership is based on respect for humans, whereby the leader volunteers to serve each member to help develop their full potential 36 . Collaborative leadership is exerted by leaders who establish a horizontal and trusting relationship with members that enables the group to complete the given tasks through cooperation 27 . Transformational leadership recognises the need for a change within the organisation and opportunities for a leader to envision and enact change 37 . Self-leadership is a force that drives leaders themselves to accomplish their goals, whereas super-leadership nurtures other individuals(followers) and empowers them to lead themselves 38 .

Statistical analysis

We used descriptive statistics to analyse the characteristics of the study subjects. We indicated frequencies and percentages for categorical variables, and a chi-square test and linear-by-linear association were performed to analyse the correlation between two categorical variables. Fisher's exact test was performed if the expected frequency was five or less in the chi-square test. All statistical analyses were performed using IBM SPSS ver. 25.0 (IBM Corp., Armonk, NY, USA), and the statistical significance level was set to p = 0.05.

Ethical considerations

The Yonsei University Health System Institutional Review Board (IRB No: Y-2020-0206) approved the study. We used anonymised materials collected in commonly accepted educational settings according to Article 2 of the Bioethics and Safety Act Enforcement Rule in South Korea. The informed consent requirement was exempt from institutional review board approval. All procedures were conducted in accordance with the relevant guidelines and regulations.

Data availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

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These authors contributed equally: I Re Lee and Hanna Jung.

Authors and Affiliations

Department of Medical Education, Yonsei University College of Medicine, Yonsei-ro 50, Seodaemun-gu, CPO Box 8044, Seoul, 03722, Republic of Korea

I Re Lee, Hanna Jung & Shinki An

Eulji University School of Medicine, Daejeon, Republic of Korea

Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea

Jae Il Shin

Yonsei Institute for Global Health, Yonsei University Health System, Seoul, Republic of Korea

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S.A. and J.I.S. designed the study. I.R.L. and H.J. collected the data, and I.R.L., H.J., and S.A. conducted the analysis. I.R.L., H.J., Y.L., S.A. and J.I.S. wrote the first draft of the manuscript. All authors had full access to all of the study data. All authors reviewed, wrote, and approved the final version.

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Correspondence to Jae Il Shin or Shinki An .

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Lee, I.R., Jung, H., Lee, Y. et al. An analysis of student essays on medical leadership and its educational implications in South Korea. Sci Rep 12 , 5788 (2022). https://doi.org/10.1038/s41598-022-09617-8

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Focus: Healthcare in Leadership

For decades, U.S. hospital administrators and medical professionals have operated within a challenging, rapidly changing, and fragmented healthcare system. Today, this environment is even more complex as healthcare reform and market forces transform the way healthcare is delivered and managed.

To help our healthcare clients better understand and focus the development of leaders, we analyzed leadership effectiveness data from nearly 35,000 people working in the field.

The goal of the study was to answer 2 important questions:

• What leadership competencies are most important for healthcare sector organizations?
• How well do healthcare sector leaders perform those competencies?

3 Key Findings of Our Study on Healthcare in Leadership

As outlined in our white paper , the key findings of this research were that:

1. The top priority for leadership development in the healthcare sector is to improve the ability to lead employees and work in teams. This finding speaks to the importance of creating an organizational culture of collaboration.

Leaders in healthcare organizations generally should develop a more participative management style, improve their ability to build relationships and lead teams, and learn to deal more effectively with problem employees .

2. Healthcare organizations also need to create strategies to provide current and future leaders with broad, cross-organizational experiences and learning. Healthcare leaders have gaps in several areas that are essential for learning and long-term success: having a broad functional orientation, self-awareness, and career management.

Organizational training, development, and succession planning, and individual feedback, coaching, and development efforts should address these gaps. This supports what we have been hearing from hospitals about the need for their employees to be able to work across boundaries and communicate more effectively.

3. Healthcare leaders have important strengths, too. The ability to adapt to change and to meet business objectives are strong points for healthcare leaders. They’re resourceful, straightforward and composed, fast learners, and willing to “do whatever it takes.”

These findings show that healthcare organizations have a pool of adaptable and committed leaders — a powerful asset in today’s complicated world.

Access Our Webinar!

Watch our webinar, Leadership in the Future of Healthcare: Befriending Polarity & Paradox , and learn the 6 leadership paradoxes related to leading effectively in the healthcare ecosystem’s “next normal.”

Healthcare in Leadership: Identifying the Gaps

Our research shows that leaders and managers in the healthcare sector are skilled in important areas such as adapting to change, meeting business objectives, and being resourceful. They’re reported to be straightforward, quick studies, comfortable to be around, and skilled at dealing with individual differences. However, healthcare managers and leaders fall short in several crucial areas.

The study showed that the skill ranked by respondents as most important for success in the healthcare sector — the ability to lead employees — rated lower than 14 other competencies in terms of leader performance. Healthcare leaders put a high value on the ability to lead others, yet there is notable room for improvement in how leaders perform in this competency.

Healthcare leaders were also rated lower in performance on related high-value abilities — confronting problem employees, building and mending relationships, and participative management.

Balancing Individual Development & Culture Change for More Successful Healthcare in Leadership

The most successful healthcare organizations create a leadership strategy that builds essential skills and behaviors of individual leaders and invests in its culture. Culture, in concert with the business strategy, drives outcomes. Through a culture of feedback and collaboration, people throughout the organization can develop a full spectrum of capabilities required to lead into the future.

In uncertain times, healthcare companies cannot afford to pour resources into generalized leadership development, hoping that somehow they will end up with the “right” outcomes. Yet, they know leadership talent and technical expertise are necessary to meet the population’s healthcare needs, manage operations, and find innovative and effective solutions to complex challenges.

Well-targeted leadership development initiatives, then, are essential for success. Using our research as a starting point, healthcare organizations have the opportunity to reassess their organizational leadership capabilities and begin focused efforts to develop leaders and create a culture of collaboration.

6 Collaborative Leadership Practices That Will Transform Healthcare Organizations

Keys to success in today’s healthcare industry.

We have developed a model that focuses on 6 essential organizational capabilities — along with key leadership practices — that foster collaboration and are essential for success in this new world order of healthcare.

Organizations that develop a leadership strategy and culture that develop these 6 capabilities will gain a competitive advantage:

1. Collaborative Patient Care Teams.

While collaboration is important throughout the hospital, it is especially important at the patient interface. The ability to ensure patient care is determined not only by technical expertise but also by the leadership effectiveness of all those involved in solving the presenting medical issues.

2. Resource Stewardship.

In an age of increasing accountability, resource stewardship is both a big-picture, system-level obligation and a series of daily decisions. Hospitals need both patient-focused business professionals and business-minded clinicians.

3. Talent Transformation.

Leaders of healthcare systems need to hire and develop talented individuals who can see the next wave of plausible solutions and innovations and lead transformational change. As part of a well-articulated business strategy, healthcare organizations need comprehensive strategies for identifying, hiring, developing, and retaining leadership talent.

4. Boundary Spanning.

The most pressing challenges in hospitals and health systems cannot be solved by one person, one specialty, or one organization. They require expertise, ideas, and support from multiple perspectives and stakeholders. Healthcare leaders must collaborate across boundaries and develop the ability to bridge departmental, cultural, organizational, and industry divides.

5. Capacity for Complexity, Innovation, and Change.

Healthcare leaders must navigate continuous whitewater. While influencing, monitoring, and responding to unfolding change, they must also respond to demographic shifts in the workforce and among patients; technological advances; the tumultuous nature of employee relationships, insurance, and reimbursement processes; and current regulatory practices. Effective change leaders help move people from old established processes to new models of effectiveness.

6. Employee Engagement and Wellbeing.

Why are employee engagement and wellbeing leadership issues? Both impact the very mission of a healthcare organization. For example, research on healthcare effectiveness suggests that quality of care is positively influenced by nurses being satisfied with their jobs and feeling empowered in their roles. Without a proactive focus on employee engagement and wellbeing, the challenges of the next few years also have the potential to create new levels of burnout within the rank and file. Healthcare organizations cannot afford to let patient care suffer due to a lack of ideas, skills, time, and talent.

Read our white paper,  Physician Leadership Development: The Foundation of Health System Transformation , and learn how physician leadership development can be a starting point to solve the challenges faced by the healthcare industry.

Delivering a Collaborative Leadership Strategy for Healthcare

We believe that collaborative leadership in healthcare is necessary for overcoming challenges that the system now faces. Collaborative leadership means the distribution and allocation of leadership power to wherever capability, expertise, and motivation sit. The responsibility of leadership is shared by each and every member of the organization.

A collaborative healthcare in leadership culture requires new mindsets, not just new skills. These take time to develop. Many healthcare organizations have focused their development efforts only on individual leader competencies. For sustainable change, they need to advance both individual and collaborative leadership mindsets. Making the shift to collaborative leadership in an organization requires strategic implementation.

Developing and implementing an effective collaborative leadership strategy comes in 3 phases: Discovery, Design, and Delivery.

• The Discovery phase involves collecting data and intelligence about the strategy, vision, mission, future challenges, political context, and opportunities for the organization. This process enables organizations to identify the leadership capabilities required to face the future and the gap between current and required future capabilities.
• The Design phase involves identifying required leadership capabilities for individual and collaborative leadership and the means to acquire, develop, and sustain those capabilities.
• The Delivery phase involves elements from organizational and individual leadership development alike, targeting culture, systems, and processes, as well as leadership development in synchrony.

In a time when many healthcare leaders are overloaded and uncertain, they may find assurance in knowing that when organizations strengthen leadership, they begin to pry loose some of their most intractable, resistant problems and uncover new directions, solutions, and opportunities.

Collaborative leadership has the power to transform hospitals and healthcare organizations, improving the system today and for the future — to the benefit of patients, families, and caregivers.

Ready to Take the Next Step?

At CCL, we bring 50 years of experience partnering with top healthcare providers to achieve transformational change toward better leadership in healthcare organizations. The experts in our Healthcare Practice can partner with you to provide maximum learning and growth for your healthcare leaders at the individual, team, and system level.

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Based on Research by

Tracy has extensive experience in leading programs and initiatives in the government, nonprofit, and health sectors. During her time at CCL, Tracy directed and expanded our global evaluation function and served as a facilitator for leadership development, program design, and capacity-building programs with nonprofit organizations.

Heather works with CCL staff, global clients, and external evaluators to design and conduct customized needs assessments (discovery) and evaluations for our programs, products, and services. This work includes identifying organizational and leadership needs, articulating outcomes, selecting the most appropriate methods for evaluation, reporting findings, and partnering with key stakeholders to discern actionable insights.

Joan is a seasoned facilitator and designer of innovative, relevant leadership solutions focused on business results. A Board-Certified Executive Coach, she has served as a trusted advisor to CEOs and senior teams. During her tenure at CCL, she also managed our Organizational Leadership solutions practice and was Managing Director for our Colorado campus.

John conducts research and development activities on new and innovative CCL products, including digital leadership tools and AI-driven leadership assessments. His focus is on the future of leadership assessment, and his research interests include strategic 360 feedback, rapid-response personality measures, and digital leadership assessments. He has published extensively in peer-reviewed journals and has taught courses in organizational psychology at North Carolina State University.

During his time at CCL, Michael engaged in both facilitation and research focused on talent management, succession management, high potential leaders, and senior executive leadership. He designed and trained workshops on coaching effectiveness, executive selection, and vision, and he co-designed experiential modules, tools, and activities for programs. Michael also co-authored our Talent Conversations guidebook.

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Leadership in Nursing: Qualities & Why It Matters

4 min read • May, 19 2023

Strong leaders in nursing are vital to help navigate the constant evolution of health care. Nurse leaders do more than balance costs, monitor productivity, and maintain patient and staff satisfaction. They serve as role models and influence health care organizations at all levels. A strong nurse leader motivates their colleagues, setting the tone for a safe, civil workplace with a culture of high morale and job retention.

What Is a Nurse Leader?

A nurse leader is defined by their actions, and not always by a position of authority. Leaders in nursing inspire and influence others to achieve their maximum potential. They use applied leadership in nursing by drawing upon critical thinking skills to manage a team.

Nurse leaders take a broad view of how daily tasks impact the overall goals of the health care organization. They communicate expectations to their team and motivate them to achieve predetermined goals. Nurses can lead from various organizational areas if they project the necessary leadership qualities to influence others.

Leadership Qualities in Nursing

A  nurse leader role combines essential nursing, business, and leadership skills developed through ongoing learning . They must be flexible enough to adapt to technological changes, fluctuating payment methods, new treatment modalities, and regulatory and legislative environments. Critical skills for effective nursing leadership include:

• Communication and Collaboration : These skills can reduce miscommunication, encourage shared decision making, and provide a sense of working together toward common goals.
• Education and Quality of Practice :  Continued professional development  allows leaders in nursing to keep pace with the ever-changing health care environment while striving for excellence by supporting quality, evidence-based practice.
• Environmental Health and Resource Utilization : Leadership in nursing ensures that patient care can be provided effectively in a  safe and healthy environment  while promoting wellness among all health care staff.
• Ethics and Professional Practice Evaluation : Influential nurse leaders model ethical practices to guide decisions, display honesty by being accountable for their actions, and evaluate their adherence to professional practice standards.  Learn more about the Code of Ethics for Nurses .
• Professionalism and Leadership : Leaders in nursing build vital relationships and collaborate with various health care teams on sensitive topics. Using critical thinking skills allows those in nursing leadership roles to analyze decisions impacting the organization. They then clearly explain the rationale in a manner that encourages staff support.

Other nursing leadership skills, such as displaying compassion and empathy, can assist the nurse leader in developing interpersonal relationships and gaining respect in their role.

7 Leadership Styles in Nursing

Nursing  leadership styles can impact job satisfaction ,  nurse retention rates , quality of care, and  patient outcomes . The nurse’s educational background, personality, and work environment may influence their nursing leadership style. Each type of nurse leader role can be valuable when utilized in the right setting.

• The Transformational  nurse leader works to inspire nurses to achieve a greater vision by helping with strength development. This nursing leadership style works well with mentoring.
• The Autocratic  nurse leader makes quick decisions with little input from employees and excels at task delegation. This nursing leadership style may be most effective in an emergency.
• A Laissez-faire  leadership style puts faith in every facet of a well-oiled machine. This method may work well with experienced teams or self-directed nurses.
• The Democratic  nurse leader is collaborative and focuses on team success. This nurse leader might excel in quality improvement roles but may not be effective in situations requiring independent decisions.
• The Servant  nurse leadership style focuses on employee development and individual needs. This method works well with goal-driven environments or as a nurse educator.
• The Situational  leadership style is the most adaptable since it analyzes the situation and determines the appropriate approach. This nurse leader is flexible enough to modify their approach based on the organization or individual’s needs. This style works well with nursing students but may divert from the organization’s long-term goals.
• The Transactional  nurse leader does well with short-term goals by focusing on efficiency and performance. This task-oriented style reduces errors and works well with tight deadlines.

Examples of Leadership in Nursing

Projecting leadership skills in nursing that influences others can allow a nurse to lead without being assigned a specific leadership position. The aspiring nurse leader might:

• Seek out a mentor or become one
• Volunteer for committee roles
• Become involved in the community
• Take educational courses
• Stay current on the latest health care trends
• Get involved with public policy

A nurse aspiring for a nursing leadership role can get a certification or obtain additional degrees specific to nursing leadership to increase their knowledge base and expand upon professional development. But a title and the education aren’t enough to create an effective leader. Nurses and other health care staff need to believe their contributions make a difference in the organization.

Why Is Nurse Leadership Important?

Nurse leaders make a difference in workplace culture and drive positive changes in health care legislation. When a team admires the qualities of their leader, it boosts morale and promotes a psychologically safe workplace, which leads to higher job satisfaction and retention rates. Influential leaders in nursing ensure that the organization's vision is communicated to the nursing staff while  mentoring the nursing leadership of tomorrow .

Explore courses, webinars, and  other nursing leadership and excellence resources offered by ANA .

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Necessary Skills for Leadership in Healthcare

March 6, 2019

View all blog posts under Articles | View all blog posts under Online Healthcare MBA

Effective healthcare leadership requires applying a variety of skills, including being able to manage conflicts between team members, respond to changes across the industry, adhere to patient safety guidelines and optimize a health organization’s financial performance. In leadership roles such as hospital administrator and medical practice manager, today’s healthcare leaders are expected to excel in all of these capacities and many others. So what’s the best way to develop these abilities?

Earning an online MBA with a healthcare focus ― like the HCMBA from the George Washington University ― is a start, as this advanced degree combines traditional MBA coursework with electives and graduate certificate options in multiple aspects of health management. MBA graduates have the managerial and health-specific expertise to implement well-designed strategies at hospitals, clinics and other practices. Let’s look at some of the particular leadership skills that help healthcare professionals stand out in the job market and thrive in their roles.

An Understanding of Costs, Reimbursements and The Bottom Line

The costs of medical care as well as how providers are reimbursed for their services have changed significantly over time. High-deductible insurance plans have become more common, while premiums have also increased substantially. From 2003 to 2018, the average premium for single coverage nearly doubled to $6,896, according to the Kaiser Family Foundation.

At the same time, some medical providers have begun shifting from traditional fee-for-service compensation for services to value-based reimbursement (VBR). The latter model, which is supported by some Centers for Medicare and Medicaid Services programs, evaluates the quality of the care provided in an effort to better align outcomes and costs. It has major ramifications for how providers are paid, and it’s up to health leaders to navigate the transition.

For example, a hospital administrator with an MBA might need to work out the right payment and collection plans, service rates, and patient satisfaction and quality metrics to ensure that the facility is on track to hit its VBR goals. The financial acumen developed in MBA courses in accounting, strategic management, and healthcare quality and outcomes is valuable in handling such tasks.

Conflict Management and Resolution Skills

Conflicts between personnel and departments are common in healthcare settings, due in part to the large number of stakeholders in an environment such as a hospital or clinic. Aside from patients and doctors, nurses and medical staff, there are other engaged parties including department heads, administrators and boards of trustees whose interests also have to be reconciled.

Transformational team leadership in healthcare will ensure that standard processes are in place for remediating conflicts and in turn producing positive outcomes for as many involved individuals or groups as possible. For example, a leader might set up negotiations for a complex problem related to which practitioners patients see when they visit an orthopedics practice.

Such a situation can be tricky to navigate, since it might entail dealing with doctors who prioritize their autonomy, along with patients who have simple ailments that could be treated by a physician’s assistant (PA) but who prefer to see an actual MD. Each conflict will be unique and require a specialized approach.

Healthcare leaders should have the communication skills to serve as effective negotiators and mediators who can minimize the damage of conflicts while also making necessary improvements to processes and working relationships. They should also apply what they have learned in resolving conflicts to the recruiting and hiring processes that they often oversee.

Organizational Change Management

Healthcare environments are constantly evolving. Whether the changes involve new reimbursement models or adjustments in the workloads of doctors and PAs, there’s always the possibility of significant shifts in how a medical practice operates, and health leaders have to be prepared.

A change management strategy in healthcare must encompass everything from how medical personnel and vendors are credentialed to the upgrade cycles for equipment and software in the IT department. Accordingly, a healthcare leader might perform tasks such as:

• Keeping up with applicable changes in the regulatory landscape, including shifts to VBR and rules pertaining to electronic health records
• Identifying causes of medical error and implementing improvements that prioritize patient safety and satisfaction
• Managing an organization after a merger or acquisition, or preparing for the possibility of such a transaction
• Better aligning care delivery with patient expectations, such as through the implementation of telehealth programs or online scheduling portals
• Planning and conducting trainings for personnel so they follow institutional guidelines and regulatory obligations
• Overseeing the rollout of a new IT system such as one that uses cloud-based components

Ultimately, leaders must be proactive in how they manage change in their healthcare organizations. The high stakes of delivering safe and effective care, plus the many moving parts of the health ecosystem, means that a purely reactive approach can put patients and providers at risk. Transformative leaders will anticipate and plan for major changes so patients and teams aren’t left behind.

A Concerted Focus on Patient Safety

We mentioned medical errors earlier, but this issue deserves more attention, as it is one that leaders like hospital administrators will have to confront regularly. Between 250,000 and 400,000 people die annually in the U.S. from preventable errors in hospitals.

These issues can include anything from incorrect dosages of medications to computer errors that misclassify a patient or corrupt data about their condition. Healthcare leaders are responsible for recognizing where and why life-threatening errors occur and introducing the appropriate measures for eliminating them.

An administrator might set up a standardized reporting process for documenting errors, implement specialized technologies that help minimize routine errors in workflows like physician order entry and oversee trainings on best practices for error avoidance. All of these measures can help make the environment safer for patients.

How Can an Online Health MBA Help Develop Leadership Skills?

The online GW HCMBA features a wide-ranging curriculum with courses in MBA subjects such as accounting and strategic management, alongside healthcare-specific electives and graduate certificate options. Moreover, the program’s applied focus helps students reliably put what they’ve learned into practice in real-world healthcare environments so they’re prepared to take on the diverse responsibilities of a modern healthcare leadership role.

To learn more about actual student outcomes for MBA graduates, visit this page . You can also download the program’s brochure for additional details.

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Learn More About the Healthcare MBA Program at GW

Health Care Leadership

What do you need to lead a business in the health care sector?

About Health Care Leadership

Why is health care so expensive in America? How can digital technologies improve outcomes? What is the impact of racial disparities on patients and providers? 

Health care is a complex, multidisciplinary endeavor, requiring leaders to direct and motivate diverse teams representing varying educational and cultural backgrounds as well as different business functions. 

Health Care Leadership is designed for emerging leaders in provider, payer, and life sciences organizations. The series includes courses in business strategy, economics, and digital health, delivering key lessons in leadership and management for today’s health care landscape. Taken together, these courses allow you to develop a comprehensive approach to health care leadership and consider strategies for an ever evolving sector.

Health Care Leadership courses are developed with health care professionals in mind. Harvard University faculty guides you through topics with a specific focus on the current state of the US health care system and how you can apply innovative strategies to make improvements within your organization. 

Health Care Leadership Courses

Innovations in teamwork for health care.

In this course, experts from Harvard Business School and the T.H. Chan School of Public Health teach learners to implement a strategy for organizational teamwork in health care.

Health Care Strategy

Learn from HBS Professor Leemore Dafny how to align the principles of business strategy with the unique challenges and structures of health care organizations to capture value, define your mission, and lead your organization to success.

Health Care Economics

Taught by Harvard Medical School faculty, this course provides insights into the interactions between industries in the US health care sector and teaches what economic forces are shaping health care.

Reducing Racial Disparities in Health Care

In partnership with the Disparities Solutions Center at MGH, this course will help you deliver high-quality health care to all through organizational change.

Digital Health

Digital technologies and big data offer tremendous opportunities to improve health care.

Earn A Certificate of Specialization

The Health Care Leadership Certificate of Specialization offers participants a Learning Path to accelerate their professional development. This Learning Path provides unparalleled access to a faculty of experts who introduce cutting-edge solutions to current industry challenges using the methods you can only find at Harvard.

Participants can take courses that are part of the Health Care Leadership Learning Path in any order, but we suggest they begin with  Health Care Economics ,  then move on to complete any two of the courses listed above to gain deeper insights and expertise based on their professional needs. 

Those who successfully complete three courses from the Health Care Leadership Learning Path within 18 months will earn a Certificate of Specialization, which can elevate professional standing and signify to employers a commitment to growth and lifelong learning.

In less than 18 months, learners will develop relationships with other rising leaders around the globe and cultivate skills they can immediately apply to advance their careers, strengthen their teams, and become changemakers within their organizations.

How To Get Started

Begin your Health Care Leadership Learning Path by applying for the next cohort of Health Care Economics   or one of the other courses listed above. 

LEARN MORE ABOUT LEARNING PATHS

Who Will Benefit

Rising Leaders

Researchers - Entrepreneurs

Medical Providers

Doctors - Nurses - Clinicians

Administrators

Support Staff - Insurers - Managers

About the Faculty

These series courses represent the breadth and depth of Harvard University and its faculty. Learn from professors across disciplines—from Harvard Medical School to Harvard Business School—and hear from experts in leading industries around the globe. Benefit from this wide ranging expertise, studying topics from different points of view and with different categories of emphasis.

Health Care Leadership Courses in Development

In the internet age, and especially with social media, anyone can believe themselves an expert in a given field. While false information can be dangerous in a variety of contexts, reliable public health information can be a matter of life and death. This course aims to present the challenges and opportunities faced by health experts and public health advocates, scholars, journalists, and those working in related fields to promote effective dissemination and comprehension of information about and related to public health. 

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Leadership of Health Care Essay

• To find inspiration for your paper and overcome writer’s block
• As a source of information (ensure proper referencing)
• As a template for you assignment

Modern Implications of Health Care Leadership

Leader or administrator: opposition or convergence middle east context, distributed leadership in healthcare, leadership competencies for healthcare, healthcare leaders’ skills in change management, leadership under the conditions of turbulence in healthcare, works cited.

In modern high-tech healthcare, human resources have a heterogeneous structure. They cover a wide range of specialists ‑ doctors, medical workers (nurses, midwives, rehabilitologists, laboratory assistants, etc.), psychologists, social workers, programmers, lawyers, teachers, economists, etc. To achieve effective human resources management when working with personnel in the health care organization, leaders and managers must implement a broad team approach. If the members of a team join forces and focus on expressing their real potential, minimizing shortcomings, the team’s goals will be successfully achieved. The consolidation and integrity of individual team members are key to the success of the organization. Often medical organizations with fewer employees achieve better results than those with a large number of medical specialists.

The experts developed guidelines for organizing teamwork in the healthcare sector. They focus on the fact that strong leadership can help solve problems in the process of reforming national health systems. It is noted that it is important to involve all interacting entities and subjects in the work to ensure the necessary integration. According to the above recommendations, successful leadership in the process of improving healthcare combines three sets of skills (Fitzgerald et al. 227-239):

• “Specific knowledge” (service-specific knowledge) ‑ an understanding of how clinical services work and what is required to provide high-quality services;
• “Improvement knowhow” ‑ improvement skills in the health sector, covering techniques adapted from the industry, such as lean manufacturing, Six Sigma, TQM, etc., as well as clinical methods such as clinical audits and studies;
• “Change management skills” ‑ skills that include conflict resolution, building support coalitions, overcoming resistance to change, transmitting the vision to staff, patients, the public, and stakeholders.

It may be noted that the assessment of effectiveness from the point of view of various interacting entities is significantly different (it is about budget, social, medical effectiveness, etc.). Bearing in mind the activity and nature of managerial work and the functions of a leader, as well as the variety of personal qualities that a manager should have, such as, for example, insight, ambitiousness, self-confidence, communication skills, responsiveness, adaptability, it becomes clear that this should to be a kind of an ideal person, combining all these qualities. That is why it is necessary to form an effective management team, demonstrating good leadership skills, which will become a tool for the guaranteed success of a medical organization. Nevertheless, the observations and studies of the leaders of medical institutions in different countries, for example, with the use of Belbin test, showed a very low level (4%) of people with skills of leadership, which means that the role of a leader is replaced by administration and this is a serious obstacle to effective management (Barr 113-123). It is time for the administrator’s halo to give way to the realistic image of the new health care manager.

Meanwhile, the administrator has strictly fixed professional training background, pursues mainly short-term goals, is limited in communications, being a ‘fan’ of tradition, uses mostly ready-made recipes and solutions “from above,” with poorly developed and unused imagination, with no sense of humor. The manager-leader is strategically oriented, pursuing long-term goals, communicative, flexible, creative, breaking stereotypes, focused on finding innovative solutions, active, successfully coping in unusual situations, with a highly developed imagination and sense of humor. The leader’s style reflects his characteristic behavior, approach and attitude towards subordinates in decision making and the exercise of power. The bipolar model of management or leadership style is traditionally considered ‑ authoritarian and democratic, but it is important to know that there are intermediate nuances among them.

In general, the effectiveness of a leader depends on the needs of solving common problems, the individual needs of team members and the need to support the group. The choice of the medical profession is the result of humane motives and beliefs, but this is not enough for effective personnel management in a medical organization. Effective management requires the manager at any time to know not only what and how people work, but also what meaning they put into their work and what satisfaction they get from it.

One should treat with great respect and understanding the role and efforts of those health managers who seek to cope with the difficult task of effectively managing the professionals involved in their structures and organizations. This is because being a manager and simultaneously a real, not only formal, leader is not an easy task, but for many people this is the job they dream of. In the minds of those who are not familiar with the profession, being a manager means commanding and receiving a lot of money, but the important question is whether this is really so? In fact, this is a kind of challenge to the professional and personal qualities of a leader. This activity requires managerial competence, which does not only mean special knowledge in a specific professional field, but also skills in the field of strategic thinking; ability to communicate with people at different levels; ability to lead people and motivate them; gather a team of professional employees united by one goal, ready to make the necessary changes in accordance with the requirements of the time; negotiation skills, etc. (Dye 42). Thus, the ability of a manager to combine management with leadership is important. Such knowledge, skills, and behavior are primarily achieved through education and gaining experience, because leadership, in accordance with the thesis of Adair, is both a quality and a role that can be learned (35). Thus, management (control) and leadership represent subsystems of one system.

In one study, based on a survey conducted among 220 healthcare managers and 730 hospital medical workers, a number of key management competencies were clarified and a model was drawn up for developing leadership competencies in the healthcare field, in accordance with general standards for the use of data obtained on the basis of best practices that determine the requirements for competent performance of work and the necessary personal qualities in accordance with the specifics of healthcare and its management (McLaughlin 17). It provides a general framework for modeling the key managerial skills needed to optimize managerial training for the effective management of human resources in a healthcare organization. At the same time, personal qualities, self-reflection and mental stability represent the basis of managerial competencies.

However, this does not mean that some cannot learn the rules and principles of good management, while others cannot lead teams. In addition, in everyday life, it is always necessary. This is because both sides of the leader are inseparable, and which of the two will be more visible and look more important depends on the personality structure, the nature of the organization and the specifics of the situation. As Ts. Vodenicharov, one of the leading Bulgarian strategists in healthcare management, notes, “Efficiency is the key to a successful business because it develops in a competitive environment… The main tool is information, and the main condition is the psyche. We must shape the mind of the winner…” (qtd. in McLaughlin 21).

The question of what makes a person a leader has long been of interest to specialists in the field of management and social psychology. One of the most famous answers to this question is given by the theory of great people, which claims that if a person has a certain set of key personality traits, then he will be a good leader, regardless of the nature of the situation in which he is. If this theory is true, then one must identify the key aspects of the personality that make a person a great leader. Will it be a combination of mind, charisma, and courage? Which is better: to be an extrovert or an introvert? Should we add a little ruthlessness to this mixture, as N. Machiavelli suggested? Or, maybe, high-moral people are the best leaders?

Some fairly weak relationships between personality traits and leadership do exist. For example, leaders usually have a slightly higher intelligence than non-leaders, are driven by a stronger desire for power; they are more charismatic, better socially prepared, and more flexible and adaptive. However, in general, it can be said that strong relationships between personality traits and success of leadership practice do not exist. Not surprisingly, it turned out that only a small number of personality characteristics are related to the effectiveness of leadership, and even existing relationships are usually quite weak. Too often, in management practice, the so-called fundamental attribution error is made when the causes of a person’s behavior are sought in his personality traits, neglecting the influence of the situation (Leggat 36). However, namely the situation is more important for understanding human behavior than personality traits. Thus, to understand the leader’s behavior and the mechanism for making managerial decisions, it is necessary to take into account not only his personal characteristics, but also the social situation in which he is. In other words, we must consider both the human’s personality and the situation in which he has to play the role of leader. According to this point of view, in order to become a leader, it is not enough to be a “great man,” but one needs to be the ‘right person at the right time’ and in the right situation. For example, the head physician of a medical institution can act very successfully in some situations and fail in others.

It is known that some leaders are better at routine daily work, while others act better in extreme situations. Thus, the effectiveness of leadership style depends on the situation, psychological characteristics, training and motivation of subordinates, and is situational in nature (Arroliga et al. 84). That is why the problems of leadership and its effectiveness are currently being considered from three interrelated positions presented in Table 1 (LeGrand 86).

Table 1: The main approaches to solving problems of leadership and leadership effectiveness

It should be remembered that ‘production’ tasks can be divided into unitary, separable, additive, conjunctive, and disjunctive (Table 2) (Hanaway 64). Naturally, the leadership style in the implementation of each of them must correspond to the task at hand.

Table 2: Types of tasks solved

Currently, there are several theories of leadership that focus simultaneously on the personal properties of the leader, on the characteristics of his environment and followers, as well as the situation in which the leader acts. The most famous of the theories of this kind is Fred Fiedler’s situational theory of leadership, which states that the effectiveness of a leader depends on the extent to which the leader is task-oriented or is oriented on relationships, and on the extent to which the leader controls the group and exercises his influence on it. Thus, leaders can be divided into two types: 1) task-oriented and 2) relationship-oriented (Arroliga et al. 100-102). A task-oriented leader is more concerned with the work being done properly than with the relationships between employees and their feelings. A relationship-oriented leader is primarily interested in what feelings and relationships arise among employees.

The cornerstone of Fiedler’s situational theory is the assertion that neither of these two types is more effective than the other in all circumstances. It all depends on the nature of the situation, namely, what is the degree of control of the leader and his influence among the members of the group. In a situation of “high control,” the leader builds strong relationships of the interpersonal nature with subordinates, and his position is clearly considered by followers in the group as quite influential and dominant, and the group’ work is well structured and clearly defined. In the situation of “low control,” the opposite phenomenon takes place ‑ the leader has a bad relationship with his subordinates, and the work that the group should do is unclear.

According to experts in the field of group dynamics and management, task-oriented leaders are most effective in situations with either a very high or a very low level of control (Bolden 72). In cases of “high control,” people are happy, everything goes smoothly and there is no need to worry about the feelings of subordinates or their relationships. Here the leader, paying attention only to the completion of the task, achieves the best results. When the control of the situation is low, the task-oriented leader is better able to organize the situation and bring at least some order into the confused and uncertain working environment. By focusing on the work, the leader can do a lot to increase productivity and labor efficiency, while he is not able to change the human nature and prevailing human relations in a short period. However, in situations of medium degree of control, the most effective are relationship-oriented leaders. In this case, everything goes smoothly, but still it is necessary to pay some attention to the problems arising from human feelings and poor relationships in the group. A manager who is able to smooth out these roughnesses acts most effectively in such a situation. Thus, according to Fiedler’s theory, task-oriented leaders achieve the best results when the control of the situation is very high or very low, while relationship-oriented leaders are most successful in situations of moderate control (McLaughlin 15).

It should be borne in mind that the effectiveness of a leader and the very ability to be a leader are different concepts and are evaluated according to different criteria. An outstanding leader can be a poor manager and lead his followers in an unknown ‘place’ with the most deplorable results. Such examples, both among historical figures and among ordinary leaders of various organizations, are more than enough. At the same time, modest leaders with even slightly pronounced leadership traits can achieve significant results in their field of activity. Of course, one should not confuse the effectiveness of the leader with his abilities to occupy and hold the office. These are different competencies, although there are still cases when people are nominated and appointed to senior positions in accordance with their professional educational background and work experience.

From the works of Nick Bloom, Rafaella Sadun and John Van Reenen, it is clear to what extent good managerial practices are important for the effectiveness of the hospital. Also, these researchers found that the most significant positive effect is an increase in the share of managers with medical education (qtd. in Alloubani 26). In other words, the separation between medical and managerial competencies in hospitals is associated with poor management.

The idea that healthcare organizations should be managed by physicians is consistent with observations from many other industries. Specialists in different fields (the same expert leaders as doctors in medical institutions) are in one way or another connected with more effective management of organizations in such different areas as university education (where scientific leaders improve the quality of research), basketball (i.e., the trainers, when those who played for the team of all stars achieve success in the NBA), and the Formula 1 race (where former racers become excellent team leaders).

For example, American Mayo Clinic’s website claims to be managed by a doctor, because “it helps ensure a constant focus on the core value ‑ the patient’s needs” (Berry and Seltman 145). Because doctors take into account the interests of patients throughout their career path when they come to leadership positions, this is expected to bring a more patient-centered strategy (Berry and Seltman 146). In a recent study, where managers and subordinates were compared using random sampling, it was found that the leader with expertise in the core business is associated with a higher level of employee satisfaction and there is a small number of people who want to quit; this also applies to medical leaders (Vender 362-365). Perhaps they know how to increase the satisfaction of other doctors, thereby increasing the effectiveness of the entire organization.

However, the Arabic management style is greatly influenced by the religious traditions of Islam, family and friendly relations, and community interests. For a more complete presentation of the driving forces of the Islamic style of business management, the Islamic business concept should be considered. First of all, it should be noted that this concept is based on ethics. In Arabic, the concept of ethics is expressed as “ahlak,” which means “motivation of behavior” (McLaughlin 110). The concept of motivation, as it is known, includes intrinsic intention, will and determination, and behavior is a way of life and human action; obviously, motivation underlies behavior. That is why Muslim dogma is aimed at developing incentives for pious acts and a righteous lifestyle.

Let us consider some important characteristics of the Arab system of leadership, management, and motivation. The system of labor motivation is based on the desire to obtain new authoritative powers. The quality control system is based on social responsibility, in particular, on religious norms. The hierarchy of control is of the vertical type, and a rigid management structure is one of the most frequent organizational characteristics. The mobility of the control system is reduced due to the combination of a rigid hierarchy with an underestimation of the importance of a time resource (there is no awareness of the significance of the time limitations of all processes, including communicative ones), and, therefore, the speed of decision-making is small, which makes decisions implementation difficult. In healthcare organizations, this can be a critical influence factor.

At the same time, in the Middle East and North Africa, noncommunicable diseases such as heart disease (an increase of 44%), stroke (an increase of 35%), and diabetes (an increase of 87%) cause an unprecedented number of cases of premature death and disability (El-Saharty 14-15). Potentially manageable risk factors such as an unhealthy diet, high blood pressure, obesity and overweight, as well as smoking all contribute to the growing burden of noncommunicable diseases in the region. However, there is an evident lack of relevant programs for raising public awareness.

Moreover, the significant progress made by the Arab countries of the Middle East and North Africa over the past decades has reversed due to political unrest and civil wars that have swept the region. This reversal is especially noticeable in the health systems of Egypt, Jordan, Libya, Syria, Tunisia, and Yemen, which were previously steadily improving. Until 2010, in these countries, there was an increase in life expectancy, a decrease in the size of damage from infectious diseases, as well as decrease in the level of infant and maternal mortality. However, disruptions in health systems today exacerbate the suffering and calamities caused by the many conflicts in the region. These are the findings of a recent study by the authors of The Lancet magazine. It analyzes the data of the Global Burden of Disease 2013 report to identify the effects of deterioration in the health systems of the Eastern Mediterranean countries (Mokdad et al. e704-e706). At the same time, not a single region has changed in such a radical way as the Arab world, and these transformations are continuing.

Of course, the level of economic development and the country’s financial capabilities determine the nature and trends in the development of the healthcare sector. Studies show that Kuwait, Qatar, and the UAE are the best countries in the region in terms of creating a healthcare system that can respond quickly in different circumstances. According to WHO experts, they rank from 26th to 30th place in the world in terms of healthcare among 191 countries covered by the sample (Babar 237, 405). It is interesting to note that in the UAE, in the “pre-oil era,” medical care came exclusively from abroad. The first hospital appeared there, according to some sources, in the 40s of the last century and was designed for 38 beds with a single doctor ‑ a retired colonel of the English army. With the active assistance of the United States, three hospitals of the American Mission in Sharjah, Abu Dhabi, and Ras al-Khaimah were built in the 50-60s of the 20th century. The entire staff consisted of Americans and Canadians (Koornneef et al. 116). Accordingly, this also determined the vector of development of leadership patterns in medical staff behavior.

Of course, current events are changing the situation in the field of public health, but this effect will fully manifest itself only after years. Popular protests helped to reveal crucial social issues, among which there are unemployment, poor social and health services, exclusion. These are the main social determinants of health that public healthcare should deal with. There is a huge task ‑ to rebuild the institutions of the health system, for example, in Libya. For the first time in decades, new democratically elected governments will have to live up to the expectations of voters in all sectors, and public health is no exception.

The presence of civil society represents an important factor for public health. However, the changes that can be observed at present cannot automatically produce results. There can be a lag between in public health changes and social policy modifications and they can not keep pace with the mood of the masses and political changes, especially when narrow interests and conservatism dominate in medical and healthcare institutions. The changes will depend on whether the masses who receive the new impulse will promote, directly or through their new representatives, new policies and practices suitable for public health. Organized civil society groups and health professionals can play a crucial role here, as together they can manage this process. In such circumstances, effective and competent leadership is of utmost importance. Dent et al. states that health professionals recognize that WHO and other international organizations have already played an important role in the development of public health in the region and promoted consolidation of its foundations in education, research, and practice (35-36). On the basis of goodwill, these organizations can facilitate further changes.

Professionals in the field of health care in every country became part of social mobilization, in case when political transformations are taking place, making the most of their social position and respect among the people in advocating the democratic movement. Indeed, once the critical situation has been resolved and modification begins, health professionals, within the framework of the health care system, are able to play a crucial role in ensuring respect for people’s demands for dignity, participation, democracy, and accountability, as much as these requirements are treated by their new governments. Thus, the responsibility of leaders in health care at each level increases many times over. In such conditions, the need for studying and borrowing best practices from world experience in healthcare leadership, with organic integration into national and regional models of management and leadership, is obvious. Health professionals can also play an important role in organizing broader health discussions in the region, from the traditionally narrow topic of health services to a wider range of social, economic, and political determinants of health.

A number of studies come to the conclusion: if the manager from his own experience understands what is necessary to perform the work at the highest level, then he is more likely to create the right working atmosphere, set adequate goals and properly evaluate the contribution of everyone (Weiss et al. 43). When the ‘model doctor’ is ‘at the helm,’ he is also able to send a signal to external interested parties (for example, new employees or patients) about the organization’s priorities.

Finally, one can expect that a talented doctor, hiring other doctors, knows what a good employee should be. It can also be assumed that medical leaders are more tolerant of “crazy ideas” (like the innovative idea of the first coronary bypass surgery performed by Rene Favarolo at the Cleveland Clinic in the late 60s). For example, the Cleveland Clinic opens up new talents and gives freedom to people with extraordinary thinking (Leggat 20). It is also important that the clinic management is ready to put up with a reasonable level of failure, which is an integral part of scientific activity and progress.

Moreover, it should be noted that within the framework of public health, it is not possible to solve the universal – and, it seems, insurmountable ‑ problem of rising costs. In many cases, attempts to control costs through government regulation lead to problems with access to health services, either to delays in providing care, or to direct regulation. Trying to solve this dilemma, many countries weaken state control and introduce market mechanisms, in particular, patient participation, market pricing of goods and services and increased competition between insurers and providers (McLaughlin 114). However, such actions in the Arab countries are unlikely to be approved, due to traditional cultural specifics.

Physicians seem to become the most effective leaders precisely because they are doctors. However, good leadership also requires social, that is, so called ‘soft,’ skills. Health care is one of the few areas where lack of teamwork can really cost patients their lives, and at the same time, doctors are not taught ‘team play.’ There is no evidence that namely team players choose the medical profession. In fact, the superiority of medical managers in hospitals seems even more outstanding when one considers the obstacles that physicians must overcome. Physicians are traditionally trained in a command-administrative atmosphere, being heroic single healers who cannot easily work together. Thus, a paradoxical situation is developing: medical training as a whole is more likely to hinder the manifestation of outstanding leadership qualities. For this reason, doctors need more systematic special leadership training.

The pioneer of one of these educational models was Paul Taheri, general director of the clinic at the Yale School of Medicine, which provides leadership training for doctors. He focused on two points: first, doctors get acquainted with the fundamental principles of doing business in the healthcare sector, and also develop personal leadership skills through a program that takes one day a month for a year. Taheri sends about forty clinic employees a year to pass it. For those doctors whose leadership qualities are manifested during this stage of training, the next step is MBA. It is noted that in leadership educational programs, doctors have always been trained along with other doctors, but they are specially “taken out” from the surroundings of a medical institution and immersed in a safe learning environment of a business school (Leggat 29). Internal programs have been developed by many other Western institutions, including Virginia Mason, Hartford Healthcare, and the University of Kentucky. There is an increasing consensus that leadership training for doctors is an extremely important matter. Such training will increase the number of leading doctors and provide great benefits from their leadership. However, in the countries of Middle East, leadership programs for doctors are not very common yet.

Theoretical approaches to the definition of leadership and its models are very diverse. In particular, distributed leadership, based on the transfer of managerial functions in solving common problems, allows obtaining higher performance indicators than in case of mono-leadership, due to the effective use of employees’ competencies. If we are talking directly about leadership in healthcare organizations, it is advisable to recall the theory of “emotional intelligence” and the theory of the “engine of leadership” (Weiss et al. 30).

In the model of distributed leadership in the implementation of a specific project, leaders at different periods of time should be different people whose competencies most closely correspond to a particular phase of the project. An attempt to “generalize the conceptual and empirical literature on the concept of distributed leadership, as well as on related concepts (shared, collective, collaborative, emergent, democratic leadership, co-leadership),” was undertaken by Bolden (13-28). In his opinion, distributed leadership, on the one hand, is a means of increasing the effectiveness and involvement of staff using the leadership process as such to achieve the most favorable effect, and on the other hand, in some situations, leadership can be divided and/or democratic, but this is not at all necessary to be considered distributed one. Bolden identified three basic properties of distributed leadership: (1) leadership is a spontaneous feature of a group or network of interacting individuals; (2) openness of the boundaries of leadership takes place; (3) expert knowledge is widespread among many, not among some (13-28).

Fitzsimons, James, and Denyer proposed the following key characteristics of distributed leadership (qtd. in LeGrand 45-49):

• Leadership does not only belong to those who are assigned formal leadership roles; it is also carried out by many individuals in the organization;
• Leadership practice is formed through the leaders and followers interaction, and within the organizational context;
• Cognition is “stretched” over the participants and the contextual aspects in which they are located;
• Effectiveness implies the development of the action potential using the tools of “joint action” (concertive action), “joint activity” (co-performance) or “joint organization” (conjoint agency).

Given the complexity of the field of research on distributed leadership, as well as the presence of other forms and models of leadership related to it (joint, widespread, democratic, etc.), it seems to be impossible to establish a clear framework for the concept of “distributed leadership.” In practical application, the listed approaches are not mutually exclusive, but become more complementary to organize the interaction of participants and increase the effectiveness of joint management activities. Therefore, distributed leadership is a transferred leadership, which is determined by the priority of competencies of participants at a particular stage of activity, in frames of shaping a single team in both horizontal and vertical directions within the organization (Harris 24-35). Based on the results of a large-scale CCL study to identify the necessary competencies for the development of leadership in healthcare organizations, and also taking into account the existing theoretical approaches to distributed leadership, three key competencies that are of priority importance for the implementation of a distributed leadership model in medical organizations are identified (Weiss et al. 62-63):

• Collective management;
• The formation and restoration of relations;
• Self-awareness.

The following two questions should be considered further. Are there differences in the set of competencies of a leader in healthcare organizations in a distributed leadership model? What factors influence the formation of competencies of distributed leadership in healthcare organizations?

Experts have found that successful medical organizations usually pay great attention to the quality of medical care and close relations between medical and administrative workers, and also quickly adopt new methods of work (Henwood 12). This thesis indicates the development of such competencies as the formation and restoration of relations in the team, collective management, the presence of which is determined by developed emotional intelligence and self-awareness, which, in turn, is important when mastering new working methods.

In 2012-2013, a large-scale study of ACO (Accountable Care Organizations) was conducted, during which it was found that leadership plays a key role in the implementation of the ACO model (Turner 109). So, 51% of such organizations are managed by doctors, the share of doctors in the majority in the governing councils is 78% for such medical institutions (Turner 110). The leadership of doctors is seen as a means of collective management that helps to achieve success in changing medical practice and the financial model of medical services. It was noted that clinicians not only make decisions that determine the quality and effectiveness of patient care, but also have the technical knowledge to make a strategic choice regarding long-term approaches to providing medical services (Turner 111).

This approach, of course, leads to an increase in the volume of work performed and an increase in the cost of services. The quality of medical services is improved due to the high interest and responsibility of staff, but at the same time, resource efficiency does not increase. Up to 40% of clinic staff have a professional burnout syndrome, but nevertheless, about 36% of them are planning career growth with a leader and note improvements in the workplace, respectful attitude to staff, informing about changes in the organization, motivation to develop talents and competencies (Shanafelt et al. 433-436).

The main priority in leadership development is improving the ability to manage subordinates and work in a team. Of particular importance is the creation of an organizational culture of cooperation, involving subordinates in decision-making. Leaders need to improve their networking and problem-solving skills. At the same time, organizations in the health sector need strategies to provide a wide organizational experience, training, self-awareness for a leader, for employees capable of working across borders and interacting more effectively.

Health care has become an extremely complex industry: the balance of quality and price, technology and the human factor places increasingly high demands on physicians. These tasks require outstanding leaders; there was a time when it was believed that doctors were poorly prepared for the role of leaders, because due to the specifics of their selection and training, they most likely turned out to be “heroic lone healers,” as it was mentioned above. However, evidence clearly shows that times are changing and this fact should be taken into account. The emphasis on healthcare, where the patient is at the center of everything, as well as on efficiency in achieving medical results, leads to the fact that now doctors are prepared for leadership.

Speaking about the competencies of leaders in healthcare organizations, based on the criterion of long-term success, the following general provisions can be formulated:

• In winning organizations, there are leaders at all levels;
• In order to ensure effective leadership at all levels of the organization, top-level leaders should educate leaders at lower levels of government;
• To educate new leaders, existing leaders must have the so-called teachable point of view;
• Current leaders must be proficient in the education of new leaders. In other words, it is not enough just to be a leader, but it is important that the leader is effective, able to motivate his followers and possess a pronounced emotional intelligence, which he constantly improves.

Vender defines leadership as “a combination of responsibilities, attitudes, skills and behavioral characteristics that enable an individual to highlight the best qualities in the organization’s staff to ensure sustainable development” (363). In listing the character traits and skills of a leader, the author, first of all, mentions talent, strong character, and emotional perception. The following six priority competencies for leadership development were revealed by McLaughlin (110-113):

• The involvement of staff. The ability to involve employees in the activity process is an extremely volatile skill that requires ingenuity when interacting with people. Managers and executives who are effective in personnel management invest in others and are experienced managers and motivators.
• Collective management. Effective leaders use collective management to engage others, reach consensus, and influence decision making. Managers who understand the importance of collective management encourage people around to share ideas and information, provide feedback and showcase prospects, and they listen to them. Such leaders interact well with people, keep others up to date, involve staff in the process of change, and address issues from various angles.
• The formation and restoration of relations in the team. Managers should establish and maintain strong relationships with employees based on respect, diplomacy, and fairness. Such managers are able to communicate with different people and easily enlist the support of colleagues, senior management and clients. Managers with negotiation skills fulfill their tasks using the experience of cooperation and finding a common position. At the same time, they try to understand the position of others before drawing conclusions or making decisions.
• Self-awareness. Effective leaders have a clear idea of their strengths and weaknesses and how their behavior affects others. A person with a high level of self-awareness seeks feedback and learns. He admits his own mistakes, learns from them, and moves on to correct the situation.
• Broad organizational capabilities. Leaders with broad organizational capabilities have experience working in several functional areas and interact with people whose interests, experience and points of view are competing.
• Formation and management of the team. Effective leaders choose the right combination of people in a team who together have the experience, knowledge, and skills necessary to achieve a task or carry out ongoing work. They set clear goals, resolve conflicts, and motivate team members.

In addition, there are specific challenges in managing health personnel. Thus, leaders can benefit from the development of leadership and interpersonal skills that are necessary to create focus, alignment and commitment within the organization. This task requires skills such as employee coaching, effective delegation, talent recruitment, and change through others (McLaughlin 37). It was found that achieving high organizational performance, according to employees, is possible if the leader has developed skills in resource efficiency, is straightforward, knows how to work under stressful conditions, is stress resistant, and is ready for self-learning (McLaughlin 38). Moreover, such competencies as staff involvement, collective management, the formation and restoration of relations in the team and self-awareness are of high or medium importance, but do not lead to high efficiency of the organization. The reasons for this imbalance are quite obvious: difficulties in the formation and restoration of relations in the team, solving staff problems, difficulties in introducing changes, and others mentioned above do not allow employees to understand the effectiveness of collective management, and managers to identify the potential of employees necessary to improve business performance.

Factors inhibiting the development of a leader should be noted: problems in interpersonal relationships; difficulties in forming and managing a team; difficulties in implementing changes or adaptation (resistance to changes, learning from mistakes); inability to meet business goals (difficulties in fulfilling promises and completing work); straightforwardness of functional orientation (lack of depth of control outside functions) (Bolden 129). Moreover, the real healthcare leader is most effective in the following competencies: intercultural communication, giving freedom for subordinates, and self-learning (Table 3) (McLaughlin 126).

Table 3: Leadership Effectiveness: Health Leaders Performance

The traditional classification of power and leadership effectiveness offers five types of power (or influence): the power of reward, coercion, expert, and legitimate and referential power. Each type of power has its own characteristic features of implementation, conventionally called “commitment,” “consent,” and “resistance” (Turner 82). The most favorable option ‑ commitment ‑ is possible if the subordinate and the leader have a common goal and the leader’s requests are convincing; a less favorable outcome in the form of consent is realized if the subordinate is indifferent to the goals set. Resistance to the leader, as an active avoidance of his requests or demands, arises if the leader’s behavior is arrogant and insulting. From this position, it is of interest to predict leadership success for the leader of the medical team.

Studies of the social position of the leader, his personal characteristics showed that not only the quality of ‘production,’ but also the psychological climate in the team and the satisfaction of the performers by the work largely depend on the level of leader’s qualifications and focus of his activities (Bolden 12). According to the literature on leadership qualities and skills, the most important personal characteristic of a leader is the level of development of his organizational and communicative traits. The results of the research using the KOS-2 method showed that the majority of “bosses” (67.2%) showed high organizational qualities (of which: gradations “high” ‑ 33.6% and “very high” ‑ 33.6%), a half showed communicative qualities (of which: 16.6% ‑ “high,” 33.4% ‑ “very high,” p> 0.05). The number of persons with low indicators of the considered qualities is insignificant (communicative ‑ 8.3%, organizational ‑ 16.4%, p> 0.05). Moreover, the communicative qualities of gradations “high” and “very high” are more common among general practitioners (14.2% versus 7.1%) and non-treatment doctors (22.5% versus 9.0%), p <0.05. The average value of the indicator of organizational qualities in the group of bosses is higher than communicative (M ± m are respectively 14.6 ± 0.97 and 13.2 ± 0.89, p <0.05). The average communicative and organizational abilities of doctors in this group are higher than in other groups (p <0.05 with indicators of model groups of doctors) (Turner 87).

Thus, despite its legitimate origin, leadership in medical professions has an expert nature of influence. Leaders, as a rule, are ‘shaped’ professionals with at least 10-15 years of work experience and certain leadership qualities and skills. At the same time, negative tendencies in the personal positions of leading doctors complicate the implementation of leadership roles and lead to stress in the psychological situation in the team, which is a risk factor for the development of social and professional maladaptation. In particular, the low level of communicative control and emotional disturbances in communication manifested by a number of doctors in the group of bosses are risk factors for implementing such a form of ineffective leadership as the “resistance” of subordinates. In turn, the high level of communicative and organizational abilities of leaders allows predicting the high effectiveness of the role functions of these leaders in the form of “commitment” of subordinates.

An analysis of the professional biography of doctors in the model group of managers in one of the empirical studies allowed researchers to conclude that leadership in medical professions, according to the traditional classification of power (French & Raven, 1960), is represented by the power of an expert, the source of which is the experience, knowledge, and abilities of a person perceived by colleagues. If, for other areas of expertise, the expert’s competence may not affect interpersonal relations, and leadership remains informal, then for the head doctor, it is the type of influence that is formalized into leadership supported by legitimate authorities. For the medical profession, there is such an expert-corporate concept as “consultation” (council of physicians), the decision of which is determined by the reference influence of more experienced and competent professionals.

In particular, the achievements of modern medicine and primarily surgery are largely associated with the development of anesthesiology and intensive care. The effective work of medical organizations largely depends on the proper organization of the work of the heads of resuscitation and anesthesiology departments of medical institutions, which ensure a clear rhythm and coordination in the work of the entire medical organization, solve issues of systematic professional development of employees, monitor the quality of medical care, and contribute to the creation of good psychological climate in the team and the introduction of the latest diagnostic and treatment methods. The first ranking places in the list of functions of the department head are occupied by various types of work with the team for the control of work, training, education. Moreover, the list of managerial functions is quite wide, and they are associated with the coordination of work, operational regulation of situations, planning and monitoring the implementation of plans, team motivation, organization of innovations, work with documents of different plans, communication.

The authors suggest some definite strategies for the implementation of managerial competencies divided according to the functional basis for achieving management goals, represented by four main groups (Turner 64-65):

• Control strategies aimed at monitoring business situations. These include regulation of activities, a regular reporting system, regular group sessions, arrangement of working hours, encouragement and punishment, and the creation of a motivation system.
• Stabilizing strategies to maintain stable service relationships in the dyad “head-employee.” This is the creation of traditions, the definition of norms and values, the formation of a corporate culture, the stability of interpersonal relationships and the predictability of managerial decisions, the uninterrupted operation of technical means, and the stability of material conditions.
• Strategies for employee development. Such strategies include professional development, creating conditions for personal growth, staff rotation, conducting professional contests, seminars, conferences, mentoring, creating an evaluation and career development system, and creating a reserve for leading positions.
• Transforming strategies reflecting the change and improvement of circumstances in the innovative direction: creating an innovative environment, encouraging innovation, supporting innovative, creative solutions, critical thinking.

The development of managerial competence of middle managers involves the allocation of a system of its determinants, the necessary psychological and acmeological conditions and factors. Acmeological factors are grouped as follows. General objective means psychological requirements for the profession, the introduction of a diagnostic center for personnel assessment, as well as the formation of a reserve group for promotion; general objective-subjective ones mean psychological readiness of managers for the very process of developing managerial competence and the practical implementation of existing managerial knowledge and skills; general subjective ones are related to the effectiveness of the leader, his competitiveness.

Special (specific) factors are innovation, credibility, cooperation, discipline, mentoring. In the healthcare sector, these factors contribute to the achievement of high performance indicators, affect the success and professional and personal development of managers. Identified psychological factors are closely interrelated; their structure is mobile and depends on the specifics of the professional activities of managers. The components of the determination of managerial competence do not exhaust the entire complexity of this phenomenon, which necessitated the development of a psychological and acmeological model that indirectly reflects the totality of its components which imitate the development of managerial competence of middle managers – for example, heads of anesthesiology and intensive care units.

Accordingly, technological support for the process of developing leadership and managerial competence of middle managers is represented as psychological and acmeological support in the form of a comprehensive program, for example (Turner 67-69):

• Organizational and procedural. It is represented by the strategy aimed at the realization of managerial competencies and is grounded on the implementation of such factors as “demand, professionalism, the possibility of development, continuous development, continuous self-education, a favorable acmeological environment, and a positive image” (Turner 67-70).
• Innovatively developing. This block is based on the development of such qualities as innovation, credibility, discipline, cooperation, mentoring. At this stage, training is being conducted on the development of strategies for implementing managerial competencies.

The development of managerial competencies and strategies for their implementation as a system involves the development of each type and ensuring their integration. The training program for leaders can be built on the basis of an analysis of the identified managerial competencies and strategies for their implementation and is intended for mid-level managers of a medical organization with management experience of up to two years. In the process of training, topics can be presented that contribute to the development of managerial competence, while positively influencing the motivation of activity and individual psychological characteristics. The training course for leaders can be conducted on the basis of independent modules, each of which has semantic completeness. In the course of work mini-lectures, business cases, group discussions, exercises and role-playing games with video feedback can be used.

At the reflective-analytical stage, the tasks of forming the presentation and concentration of participants’ attention on one of the main characteristics of managerial activity ‑ its focus ‑ are solved. Participants should be invited to analyze their own work experience through a structured interview. The work takes place in pairs, where one of the participants interviews the other to determine the focus of his/her activities as a leader. To achieve this goal, participants in several small groups also analyze the situations proposed by the trainer for analysis. The result represents leaders’ understanding of the direction of managerial activity: the individual, the team, the result, and self-understanding.

In the process of further work, an interactive session can be held to identify the dominant strategies that managers use to achieve management goals. The result of this part of the training is the understanding by managers of their own strategies for implementing managerial competencies and their systematization. The purpose of the modular phase is to improve and develop strategies for the implementation of managerial competencies. In the group of managers, four subgroups can be distinguished, working on a modular basis on various issues of managerial competence:

• Module 1. Value-based management competence.
• Module 2. Normally-oriented managerial competence.
• Module 3. Individually-oriented managerial competence.
• Module 4. Collectively-oriented management competence.

In each module, one can consider four groups of strategies for implementing managerial competencies: controlling, stabilizing, developing, transforming. During the work, interactive sessions and group discussions are used. It is rational to build questions for discussion in subgroups on the basis of the presented modules. The goal of the final transformative-implementing stage of the training is the implementation in practice of the knowledge gained in the second stage. Leaders can be divided into two groups: expert observers and practical implementers (implementing executive). The result of work in this block will represent a reflective analysis of an expert observer and the experience gained by the implementing executive.

It is expected that, when conducting psychological training, the average values of creativity indicators are increased, affecting the development of skills of creatively, non-standard approach to solving business issues and tasks. As a result of the training, changes should take place in the preferred behavioral strategies ‑ in particular, the decrease in average group-wide indicator for the domination and withdrawal strategies can be observed, while the indicators for the cooperation and compromise strategies are increasing (Turner 70). Thus, it is obvious that after the training, managers will prefer to choose the most effective strategies for behavior in a conflict situation, which are cooperation and compromise. In a difficult situation of choice on significant aspects of interaction with people, the actions of leaders are aimed at resolving conflict situations without undue tension (as is the case with the use of a domination strategy).

Also, it should be noted that among the methods of describing leadership existing today, the most effective is the method of describing leadership behavior through a set of key competencies. Competencies are qualitatively different from the earlier practice of enumerating personality traits in that the emphasis is placed on behavior as an external manifestation of these traits in combination with skills and knowledge through the prism of motivational components. The ability to observe the degree of manifestation of competencies under the condition of a pre-compiled model allows evaluating their expressiveness in a particular person in objective manner.

Unlike the terms widely accepted in the literature that characterize organizational or structural changes and their management at the organization level, the authors in the field of healthcare define the concept of “change” as a change in the position of the object under consideration or its constituent parts (blocks), taking into account the choice of new areas of activity of the object leading to qualitative transformations of his condition, and the concept of “change management,” in turn, is defined as a targeted impact of active actors in various fields of activity in order to increase efficiency, competitiveness both at the organization level and at the industry level, as well as influence the economy as a whole (Suchman 22).

In recent years, the organization of effective medical activity in healthcare institutions has been regarded as multi-level, built on the principles of strategic management and marketing, using the tools of change in the process of reforming the industry and individual organizations (Suchman 30). According to the concept of organizational development, a medical institution should be considered holistically. Leaders must think and work simultaneously at four different levels (Gabel 11-13):

• Operational: what kind of activity are we doing well, should we continue in the same direction?
• Corrective: what are we not doing well and what needs to be improved? Where is the “disease” of our organization?
• Perspective: what new should we introduce in order to expand the coverage of the population, improve the quality or increase the market share?
• Preventive: what do we need to keep under control in order to prevent failure and not to collide with the iceberg?

The organizational development of a medical institution can be represented in the form of the following aspects: 1) the stages and processes through which the organization passes as it grows and ripens; 2) “diagnosis” and “treatment” to achieve the best position of the organization in making changes in response to the actions of external and internal factors. Change Management represents a continuous, cyclical process that includes the following elements: determining the purpose of the organization; statement of individual tasks (concreteness, measurability, attainability, acceptance, limitation of funds, written fixation, indication of terms); definition of roles (innovative tasks ‑ changes in work and increasing efficiency; operational tasks; personnel tasks); personal development planning; making changes; final check. In addition, it is proposed to evaluate changes to consider the performance management system as a process that (Suchman 60):

• Combines the goals of the organization with the individual tasks of its employees;
• Allows employees to receive regular feedback on their results;
• Provides a basis for identifying personal development needs of individual employees;

Moreover, the assessment of the leadership of changes at the level of the head of the healthcare organization includes determining the degree of effectiveness of the organization, namely, the situations are possible when the head:

• Systematically transforms the main aspects of the organization’s work, seeks to create such an organizational climate when changes become the norm, and existing practice is constantly being reviewed;
• Actively seeks the possibility of significant changes in many areas, anticipates changes long before they occur, and therefore the leader is well prepared for changes; always welcomes changes and actively encourages new ideas of the organization;
• Regularly initiates changes; anticipates all obvious changes; always welcomes changes and carries them out with optimism;
• Often initiates changes. Anticipating obvious changes, the leader honestly tries to adapt to them. Generally welcomed changes and new ideas;
• Takes the initiative regarding changes, but only under pressure from outside; anticipates most, but not all, of the obvious changes; sometimes makes no attempt to adapt to them; may be reluctant to make changes, but when the purpose of the changes is clear, he responds to them;
• Rarely is the initiator of changes; cannot anticipate or prepare for change; is hostile to new ideas.

The change management system in medical institutions, especially in the context of industry reforms, provides significant assistance to managers, allowing them to follow a systematic approach to managing the process of change in the organization, identifying and solving tasks involving changing job functions and the formation of new skills that are needed according to the reform, and finally providing clear accountability. In addition, the introduction of changes is based on feedback, which leads to improved performance, including systematic self-monitoring, the necessary reassessment, and so on in a spiral upward. The stated approach assumes an ever-increasing role of individual medical institutions in the process of increasing the effectiveness of healthcare.

Since modern management is focused on everything new (concepts, theories, models, technologies), it will be very interesting to analyze, as best practice, the experience of the world-famous American clinic Mayo, existing since the 1900s, the activity of which indicates the possibility of using the correct concept of organization management for many decades. American Mayo Clinic is the world’s first comprehensive non-profit medical multifunctional organization that unites almost all specialties into a common system of doctors, unlike most highly specialized medical institutions in the United States. About 80% of the clinic’s doctors take part in scientific research, and there are Nobel laureates.

The success of the organization and the longevity of its brand are explained by brilliant clinical results, multifunctional service, and effective change management. As a result of the use of system engineering in the organization, the application of the Six Sigma quality improvement program, the following results were achieved: the time required for patients to complete all prescriptions was reduced by 60%; net operating profit over three years increased by 40%; each patient’s service time was reduced by 6 minutes; the number of daily prescriptions increased, which gave an additional income of more than 4 million dollars in a year; 24-hour work of diagnostic laboratories accelerated diagnosis and reduced hospitalization time (Gabel 40-41). An example of a Mayo clinic demonstrates success in the field of healthcare management: as a result of self-organization, the institution is constantly evolving; the staff is self-learning. Moreover, Mayo Clinic’s Career and Leadership Program offers training in managing change.

It is interesting to note that, despite the diametrically opposed health models in different countries, in particular when comparing the countries of Middle East and the countries of West, there are examples of solving problems through successful innovations, when a specific shortcoming of a country’s health system turns into an advantage or new opportunities, like in countries experienced Arab Spring events, which was mentioned above. Thus, “radical innovation” are possible – for example, private health insurance as the fastest growing and most popular component of the benefits package provided by the employer to employees. However, in the context of rising health care costs, there is another innovation ‑ “separation,” that is, the transfer of a whole range of medical services requiring high costs from hospitals to other places (Gabel 18-19). Thus, attempts with different vectors can be made: either to reduce the planned priority for free treatment, or to optimize costs by creating outpatient surgical centers, hotel-treatment complexes, etc.

It is obvious that changes in the organization of healthcare as an open socio-economic system are organizational, technological, informational, economic, and other innovations, the implementation of which is based on their interconnection and mutual influence, taking into account industry specifics. Changes in health care contribute to success (increase in efficiency) if they focus not on one variable, but simultaneously on several. At the regional or municipal level (at the mesoscale), change management should include the following: improving the system of planning and economic support of healthcare based on modern industry norms and standards, taking into account the incidence rate and the needs of the population for types of medical care, reasonable cost standards; the introduction of programs to reduce morbidity and mortality, resource optimization based on methods of economic and mathematical modeling, a program-targeted approach.

Change management in healthcare organizations (at the micro level) to a critical degree depends precisely on the competence of leaders and should be based on a synthesis of multi-level and integrative approaches, ensuring the achievement of a synergistic effect from the introduction of innovations at the macro-, meso- and micro levels. To effectively manage change in healthcare organizations, it is necessary to provide the following:

• Create a change management model from interconnected control units for the design, implementation, motivation, evaluation, informational support of changes using the information-analytical system, which will allow building a single, interconnected change management process;
• Establish the optimal proportions of production processes and resource support of medical services to achieve medical, social, economic efficiency;

In an organization, as an open system, the mission of a formal leader is to approve and ensure the implementation of a strategy of regular changes aimed at constantly improving the effectiveness of the organization. The basis for the successful implementation of changes is the idea of their implementation. The idea of making changes cannot arise in the minds of ordinary employees or management representatives, and then make their way upstairs. However, the easiest, shortest, and, therefore, effective way of carrying out organizational changes is the path that is initiated by representatives of the organization’ leadership, who have full power to implement the idea, as well as sufficient personal authority to form a ‘camp’ of supporters of reforms and strengthen the driving forces for change. In order to achieve maximum results in the creation of constructive ideas regarding the implementation of organizational changes, a leader can act in two directions:

• As the creator of the psychological climate and conditions that allow gaining confidence in the need for change;
• As an organizer, that uses his status and power, individual influence and organizational resources to restructure the organization, resolve conflicts between individual employees or departments.

The effectiveness of change management is associated with the agreement between the leader and most of the organization’s employees regarding the goals of the reform. In order to reach agreement on the goals of the change, the leader must solve a number of problems (Gabel 63-65):

• Define the purpose of the changes in concepts and terms that are accessible to the understanding of the ‘bulk’ of employees. A defined goal should be easily remembered by members of the organization.
• Build and develop confidence in the idea and goals of change.
• Develop a common vision of the goal.
• Develop change strategies on this basis.

The extent to which changes implementation is effective is associated with the formal leader’ activities in the process of shaping responsibility for the changes end result, for all categories of subordinates: senior management, middle management, and ordinary employees. The responsible attitude of subordinates to their duties is directly related to ensuring their respective powers and freedom of decision-making. At the same time, close connection and integration of individual goals and interests of group members with organizational goals, implementation of needs, representation and protection of interests of both individual group members and the team as a whole is necessary. This eliminates the possibility of the activity of destructive groups and leaders, which are detrimental to the organization, and also increases the authority of the leader in the eyes of employees and the importance of business leadership compared to purely emotional one.

The theoretical basis of modern research in the field of organizational leadership is the approach according to which one cannot become an effective manager without being a leader, and vice versa. In other words, management and leadership are regarded as identical or closely interrelated phenomena. Consideration of management and leadership as synonymous concepts is also possible because effective leaders play two main roles ‑ charismatic and architectural. The charismatic role is the person’s ability to predict the future, motivate and inspire employees based on this vision. Performing an architectural role, the leader solves issues related to the structure of the organization, planning, control system, and encouragement of subordinates. Thus, a leader cannot exist only in one of these ‘forms,’ as each of them is of great importance in a management situation. This is especially important when external environment in the industry is highly dynamic and even turbulent. Namely this can be observed in today healthcare industry in the Middle East, mainly due to instability of political and social situation throughout the Middle East region.

Such exceptional turbulence of the external environment determines the need for leaders to be able to accept challenges and act effectively in the face of change. In an increasingly unpredictable and competitive modern dynamic economy, business entities require a new, high-quality form of leadership (creative, innovative, effective, project, transformational, responsible, charismatic, political, etc.). Health organizations are increasingly faced with the need for change, so today, more than ever, the ability of leaders to lead in transitional times is being tested. It is advisable for organizations operating in a complex dynamic environment with a high degree of uncertainty to permanently change. In this regard, the ability to carry out changes, to respond flexibly to them, to adapt to changing environmental conditions or, even more significantly, to directly change the environment itself, is the most important characteristic of modern market participants, ensuring their long-term competitiveness. Change management skills are particularly important in such circumstances.

Optimization is often limited to staff reduction measures: layoffs under the guise of restructuring. It is possible that in the conditions of merciless competition, it will be necessary to make a painful decision to reduce staff ‑ anyway, to ‘lose weight in front of a marathon’ (Leggat 127). However, weight loss alone will not lead to victory in the race. To win, one needs to fight hard; instead of the usual cost reduction, a leader should think about initiatives that will give advantages in the medium term, stimulate growth, actions that will fundamentally change the work of the organization and, importantly, investment in leadership and talent development.

In rapidly changing conditions, there is an increasing need for creative leaders ‑ those who act proactively, predict and direct the intentions of others, constantly discover something new and understand that people are driven by emotions. Their activities, first of all, are aimed at the following: increasing the efficiency of creative and intellectual activities, overcoming the deficit of ideas, rethinking the concept of development, maximizing the use of followers’ creative and team potential. Creative leaders can turn challenges into opportunities; therefore, it is clear that in modern conditions of reality, it is not power leaders who win, but creative leaders.

When Satya Nadella became Microsoft CEO in February 2014, he delved into the ambitious transformation process to make the company competitive in the field of mobile and cloud technologies. This process included strategic, organizational, and cultural change. At that time, Microsoft’s culture was based on internal competition, which did not facilitate learning. Nadella approached the problem thoroughly ‑ he laid the foundation of leadership for his vision of life and a culture of learning. The goal of the employees was not a limited desire to look smarter against the background of others, but the desire to grow, listen, learn, and awaken the best qualities in people. From the very first days, Microsoft employees noticed these changes in culture ‑ a vivid example of the fact that for Microsoft the interests of people have become a priority. Although this example does not apply to the healthcare sector, it nevertheless represents one of the best practices appropriate for use by leading physicians.

Studies show that effective leaders are characterized by the use of different management styles that they apply depending on the situation and the task at hand (Henwood 97). It is difficult to act flexibly, Daniel Goleman noted, but one can learn this, and it is necessary to pay attention to it, as a variety of leadership styles helps increase the effectiveness of the organization (qtd. in Henwood 99).

It is known that the main theories of leadership include the following: the theory of personality traits, situational theory, the theory of the determining role of followers. Recently, the so-called relational theory (“synthetic” approach to leadership) has appeared and gained popularity, whose supporters are trying to synthesize the above approaches and overcome their limitations.

The availability of leadership training opportunities (theory of leadership training) is also indicated by many significant factors. Systematizing professional literature, it can be noted that the conclusions of many studies indicate the importance of using a large number of styles by managers. The practice of successful leaders shows the importance of an imperceptible transition from one style to another depending on the situation (LeGrand 9). Recognizing the importance of leadership development, it is advisable to determine the leadership qualities that need to be used and developed, and in a certain way restructure the personnel development system, organizational culture, in order to timely identify potential leaders, educate them, and professionally promote them in organizations.

We can say that the range of qualities that a leader needs at the stage of innovative transformations should include a number of important elements: global thinking, the ability to anticipate new opportunities, the desire to develop staff, creativity, ingenuity, the ability to work with a team and partners, support for constructive innovations, a sense of change, technological competence, desire for competitive advantage, personal excellence. Leadership in the modern world is transforming ‑ it is the leadership of innovation and change, the leadership of progressive innovative teams. Innovative leadership requires not to stop at some point but to look ahead, form new trends and be especially sensitive to possible shortcomings, preventing their development into serious problems.

Today, healthcare organizations are actively implementing innovative ideas through the development of innovative projects, overcoming resistance to changes, and implementing innovative projects with a high degree of effectiveness. Thus, the project leadership competency is realized, which is included in the organizational block of competencies and, accordingly, the characteristics represented by the initiative and the results, and it will undoubtedly occupy one of the important positions in the competency model of managerial talent (Scott 85).

The basis for the implementation of project leadership is the project culture ‑ a relatively new, but very relevant and significant component of the professional culture of the modern leader, which must be actively developed and enhanced due to its progressiveness, vitality, practical orientation, cultural conformity, meeting the needs of the formation of a new quality and contributing to the formation of social maturity of staff. The project culture should be considered as the basis of the leader’s readiness for innovation, the development and implementation of new technologies, representing a combination of different project methods for transforming reality, actively using modern methods of forecasting, strategic and operational planning, design, execution and evaluation of the achievement of the planned indices (Turner 26-29). It is advisable to cite the following as arguments in favor of the need for the formation and development of a project culture: acts as a kind of problem-solving education; defines a new, modern, innovation-oriented look of any business entity; contributes to a change in the type of thinking of project participants; implements innovative ideas of a personality-oriented approach; changes the competitiveness of the organization and the leader himself.

It is important to emphasize that the achievement of the results is facilitated by transformational leadership, that is, a unique style in which the leader’s commitment to help people with whom he actively collaborates is positioned; he helps them build a professional career, improve their qualifications and grow. On the other hand, this type of leadership helps to unleash the power of followers. Leaders are focused on creating a training organization, and as a result, an atmosphere is created that facilitates the transformation of the system. In order to be a transformational leader, it is needed to have creative potential.

In recent years, a large number of institutes, training centers and experts on the problems of leadership development have appeared. However, the challenge for many people in health care industry is still to master effective leadership methods. This is explained by the inadequacy of quantitative research showing which management style contributes to the achievement of positive results. Knowledge of theories does not provide an answer to the problematic issues of the development of a medical organization, but sets the course of action. However, following some concept, it is necessary to realize and take into account the presence of a number of features that complicate the development of leadership qualities. At the same time, still, the most ideal leader is a type that combines emotional, business, and informational components. It is necessary to be able not only to consider abilities in people, but also to find stimulating mechanisms for their disclosure, thereby demonstrating responsible leadership, i.e., creating an environment in which people and entire organizations move together towards their desired goals through self-development.

The “responsibility” competency, manifested in the ability to anticipate the consequences and the ability to comply with the agreements, can be presented in a five-level format. At the first level, the leader limits his actions to the zone of responsibility and accordingly chooses his responsibility according to the situation; he agrees on the development of various options for events and fulfills instructions on time; receives assistance in resolving the problem and complies with the agreement; learns from mistakes and successes and provides a result, despite the circumstances; determines and evaluates the consequences of decisions (social, economic, political) and takes responsibility for decisions made.

Chinese philosopher Lao Tzu wrote: “A leader works best when people are barely aware that he exists… When… the work is completed,.. the goal is achieved, they all will say: “We did it ourselves” (Turner 14). Currently, some leadership experts associate leadership success with the ability to grow followers who do not actually need leaders. This idea, as the quote from Lao Tzu shows, is not new, but its application to leadership in modern organizations is a noticeable departure from the mainstream theory of leadership. In addition, the term “new era” seems to be an adequate symbol for ideas, each of which characterizes a decrease in the role of leadership behavior in its traditional sense and an increase in the responsibility of those who follow (followers).

The Multiple Linkage Model proposed by Yukl assumes that the effectiveness of a group (or an organization’s production unit) depends on the six elements described in Example 1 below. The leader’s task is to find out which of the following elements are most important for a particular group and whether they are present in sufficient quantity, and then help the group fill in the existing gaps. For example, when the work is complex and the work is intense, the efforts of subordinates and their dedication become especially important (Hanaway 42). In this case, the role of a leader is as follows: make sure that the situation helps people to make maximum efforts and be committed to the cause. The example of Yukl Multiple Linkage Model is given below.

The effectiveness of the production unit (group, team, organization) depends on the following:

• The level of effort, devotion and responsibility shown by subordinates in carrying out the assignment.
• The degree to which subordinates understand what they need to do and if have the skills to do this.
• The use of effective methods of work and the corresponding organization of labor.
• To what extent the members of the production unit are ready for cooperation and collective work.
• The resources and support available to the manufacturing unit.
• To what extent the efforts of the production unit are consistent with the actions.
• Other units of the same organization.

If the described elements are underdeveloped or absent, the leader must provide them through actions such as saturating the work and rewarding the desired behavior. If this attempt of his is effective, the group has all the conditions for success and is moving towards achieving high results. At the moment, not many studies have been conducted trying to prove the validity of this model, but what has been done confirms the basic premise (Hanaway 20-22, 34).

A similar approach to increasing the role of subordinates and reducing the role of leadership in organizations is proposed by Hackman and colleagues (qtd. in Arroliga et al. 113). From this point of view, the leader’s task is to create and maintain favorable working conditions for the group. The leader does everything necessary so that the group makes sufficient efforts, uses the skills, knowledge, and experience necessary to complete the task. For example, by carefully selecting group members and teaching them problem-solving skills, a leader can increase the group’s chances of success. An ideal group is one where everything functions so smoothly that there is no need for leadership in its traditional sense.

At a time when many organizations are getting rid of superfluous levels of management, experimenting with collaborative management and often resorting to the use of work teams, leadership in these organizations must inevitably move away from traditional forms and move in the direction described by Yukl and Hackman (qtd. in Arroliga et al. 114). In the new era, the third parameter ‑ group orientation ‑ must be added to the main parameters of the leader’s behavior ‑ task orientation and employees. A leader whose behavior is oriented toward the group (facilitates the work of the group) should ask questions that help the group identify and resolve problems; train the group in work and collaboration skills; give group members advice on resolving problems; facilitate the interaction of the group, ensuring the proportional participation of group members, summing up differences and coincidences in opinions and arranging “brainstorming sessions”; mark the boundaries of the group; coordinate group activities; and provide formal and informal group recognition (Arroliga et al. 116). At the same time, traditional studies of group dynamics can be noted to take advantage of them in the new era.

Manz and Sims wrote a lot about the fact that the best leader (“super leader”) is the one who turns the vast majority of the people following him into leaders for themselves (qtd. in Alloubani 59). The basic premise behind super leadership is that a person must first become a leader for himself; then he or she must transfer these skills to subordinates. Success comes when subordinates cease to need a leader. Thus, the first step towards super leadership is to become a leader for self. This is achieved by combining behavioral techniques (including determining one’s own goals, self-observation and self-reward) and cognitive techniques that use positive and constructive thinking patterns (such as talking with oneself, building mental images and mental rehearsal) to create opportunities for work and life. The second step is to set an example of such “self-leadership” to others, giving them the opportunity to see that it brings success, and rewarding others for their own successes in self-leadership.

The third and fourth steps of the leader in implementing the super leadership plan are demonstrating confidence in the capabilities of subordinates, encouraging them to set goals for themselves and help form positive thinking models. The fifth step is to ensure that subordinates include rewards in their own work, and make constructive comments when necessary. Organization of work in team form is the sixth step, and, finally, the super leader contributes to the formation of a positive organizational culture that helps achieve high performance.

Manz and Sims illustrate their views with real-life situations, but not enough research has been done on the super-leader approach, as well as on many other new leadership concepts, to draw any conclusions. In one study, it was shown that some of the basic principles contribute to the successful completion of a group’s work (qtd. in Henwood 124), but in another one, super leadership was not as effective as traditional leadership in stimulating civic behavior among employees (Henwood 125). However, civic behavior includes altruism, integrity, steadfastness, courtesy, and the performance of civic duties. The data of Schneick, Damler, and Cochran undermine the concept of Manz and Sims in that, theoretically, all of these behaviors should stem from effective super leadership (qtd. in McLaughlin 179). These are also those patterns of behavior that can be expected to become increasingly more significant as many manufacturing organizations continue to transform into labor communities.

True leaders always reveal their true greatness in an era of change, or in a period of liminality. This term was introduced by the Belgian anthropologist Arnold van Gennep, who was the first to study the patterns of how different cultures indicate transitions from one age state to another (for example, from youth to adulthood, in his book The Rites of Passage (LeGrand 122). The central one is the liminal (or threshold) phase. Some time later, commenting on the work of van Gennep, anthropologist Victor Turner explained this period as “the moment when, according to the cultural scenario, those moved from one phase to another are freed from the requirements of established norms in society. At this moment, they are essentially located simultaneously, as it were, between and outside the positional structures of the legal and political systems of society. In this difficult period, anything can happen between ordered worlds” (qtd. in LeGrand 123). Organizations are also periodically forced to go through such painful transitional stages, and namely during this liminal phase, leaders exert the greatest influence on the activities of their team.

Often, surrounded by chaos, leaders must be able to build a strategy for the new world, as well as help all members of the team to accept the necessary changes as an inevitable fact. A classic example of such leadership in an era of change is the advent of Louis Gerstner at IBM in 1993. Like a paratrooper, thrown behind enemy lines to withdraw units from the encirclement, he inspired the team to take a fresh look at the situation at that time, achieving an increase in corporate capitalization and profits of more than 40% (LeGrand 126-127). For example, despite advanced medicine, the American health care system remains one of the main problems of the United States. The blame is the unbearable prices that taxpayers and the state are forced to spend on medical services. Most medical facilities in the country are private and set tariffs themselves. So, the call of ordinary ambulance can cost the patient without insurance of several thousand dollars and more. However, it is unlikely that anyone will be able to explain where exactly this amount came from. Bills for surgery and other complex procedures can reach hundreds of thousands. A person who has been diagnosed with a serious illness runs the risk of remaining bankrupt. For failure to pay the required amount in some states, the debtor may be sent to prison.

It should be noted that the main trend of recent years, common to all developed countries of the world, is the constant increase in health care costs. Its main reasons were changes in the demographic composition and structure of the incidence of the population, as well as the constant introduction in clinical practice of the latest achievements of medical science and technology. The essence of the current situation in health care is revealed by the law of diminishing returns, according to which an increase in the use of one factor of production at a constant value of other factors at a certain stage leads to a decrease, and then to the termination of the return on it (Bradley and Taylor 18). In health care, this pattern is manifested by a decrease in the effectiveness of medical care in the face of a steady increase in the cost of its provision.

According to the WHO concept, the activity of the health care system is considered effective if it achieves three main goals of its functioning: improving the health of the nation, meeting medical activities with the legitimate expectations of the population, maintaining fairness in the allocation of resources and receiving medical care (Leggat 27). This modern approach is in good agreement with the previously existing one and becoming a classic methodology for assessing the effectiveness of health care. Usually, efficiency is understood as the degree to which specific results are achieved at certain costs. However, with regard to health care, such an unambiguous interpretation of this concept is not entirely acceptable. Traditionally, the effectiveness of health care is evaluated from three positions: medical, social, and economic.

Medical effectiveness, being primary in relation to its two other components, is measured by the degree of achievement of the medical result. On an individual level, it means recovery or improvement in health status, restoration of the lost functions of individual organs and systems. At the level of healthcare institutions, medical effectiveness is measured by many special indicators, such as the following: the specific gravity of cured patients, a decrease in cases of the transition of the disease to a chronic form, etc. (Barr 60). At the individual level, social effectiveness is understood as the degree of patient satisfaction with interaction with the healthcare system. At the industry level as a whole, it is measured by indicators of public health. Moreover, medical effectiveness is closely intertwined with social efficiency: increasing one is impossible without improving the other.

Now, health care has reached the limit of its medical effectiveness. One of the possible ways to further increase it is the implementation of constructive interventions in the emotional state of a person as an important component of health and social interaction between the main participants in the medical services market. This is confirmed by the phenomenon of negative emotional response of patients to the insufficiency of medical information provided by specialists in the process of interaction with contact health personnel (Sarto and Gianluca 85-90). The lack of understanding of the mechanism of this compensatory phenomenon by the doctors and nurses leads either to its neglect, or to an incorrect interpretation. Both cases, complicating achievement of a necessary medical result, reduces medical efficiency.

As a result, today, an increasing number of specialists recognize the need for thorough knowledge by medical workers of the emotional and social context of patients’ lives. Many scientists write about the need for its study, and the research in this area in recent years has constituted an independent scientific field (Arroliga et al. 247). In order to find internal reserves for increasing the medical efficiency of the healthcare system, a comparative analysis of the theoretical and conceptual constructions of emotional intelligence and the features of their use in the clinical practice of doctors of various specialties is carried out. To describe the nature of the emotional state of individuals and the social interaction between them, researchers use two basic concepts: social intelligence and emotional intelligence. Many experts view them as synonyms, explaining that communication is the basis of both concepts (Arroliga et al. 248). Their partial identification is associated with the allocation in the structure of emotional intelligence of a number of socio-communicative abilities: social skills, awareness of social interaction, perceptual-interpretive recognition of emotions in the process of interpersonal interaction. Obviously, a high level of emotional intelligence in any organization, especially in healthcare institutions, should be demonstrated primarily by leaders who, using the practices characteristic of transformational leadership, will create the necessary level of emotional intelligence among followers.

A leader-doctor with a high level of emotional and social intelligence should focus on both members of his team and patients. He is obliged to sensitively capture the various demands of people, dictated by their social and demographic position, as well as value orientations. One of the important qualities of a leading doctor is his ability to understand other people. This feature suggests the presence of pronounced empathy, as a stable characterological trait.

The importance of leaders in the management of scientific and practical healthcare institutions has always been and remains extremely high. However, it increases even more during the transition period, when certainty is lost, the system of familiar relationships, management and financing schemes is changing. In these conditions, the leader and his qualities completely depend on the survival and development prospects of many teams. Henwood writes that in the context of the reform of the national healthcare systems, special attention should be paid to the organization of teamwork and strong leadership (22-24). The successful reforms are usually accompanied by a number of positive effects: strong financial management, high ethical values and staff motivation, as well as lower absenteeism and stress (Henwood 21-35). Based on the clinical leadership model, matrices and clinical leadership models have been developed that characterize the behavioral models of healthcare leaders (Henwood 28). For the Middle East countries, such specific models have not been proposed yet; however, some national developments of other countries can be successfully applied to the health care systems and patterns of leadership in these countries.

In particular, the concept of clinical leadership used in Ireland’s healthcare organizations allowed leaders to “make it easier to create effective working relationships between doctors and managers,” that is, to develop the competency of “building and restoring relationships in a team,” as well as increase productivity and create a competitive environment (Sarto and Veronesi 86). The positive effects of clinical leadership on various performance indicators are also described by Italian researchers (Sarto and Veronesi 85-95).

As part of the implementation of health care reforms in Australia, their success was noted related to ensuring team work of personnel and the formation of interprofessional practices (Brownie et al. 252-253). The importance of the participation of doctors in the management of hospital business processes and resource efficiency, as well as labor productivity in them, was demonstrated on the basis of interviews with 170 managers and department heads conducted by McKinsey and the London School of Economics. A case study of 11 healthcare organizations in London and the Midland region (Great Britain) was consisted on the basis of 175 interviews with managerial staff, clinicians, as well as doctors who combine management and clinical responsibilities. Research questions were posed: (1) whether clinical and non-clinical managers can understand and fulfill their duties and use them to change the service in the provision of medical services; (2) in addition to understanding and fulfilling, what additional factors are responsible for individual or organizational differences in the effectiveness of changes (Legatt 99).

As a result, it was found that for the progress of changes in multidisciplinary organizations, it is necessary to create the basis for good interprofessional interactions. In the majority of cases examined, the relationship between clinicians and managers was identified by the respondents as healthy, but somewhat detached; however, such a conclusion cannot be drawn about the relationship between doctors: within the organizations, interactions were weak, not conducive to the provision of quality medical services. The role of the “hybrid employee,” building the relationship between managerial and clinical link, seems to be extremely important, since within the framework of the distributed leadership model, the competence of forming and restoring relations in the team is needed (Weiss et al. 24). On the contrary, the cases of successful organizations revealed the presence of a small group of senior managers who work effectively together, collaborate and consult, respecting each other’s points of view. The effective activities of such groups are also noted by the staff of the organization (Weiss et al. 27). In this context, another competency of distributed leadership is considered ‑ collective management.

Researchers have shown the presence of dispersed leadership, due to which personnel are involved in changes at various levels of managerial and professional experience. Distributed leadership has the following characteristics that characterize the competencies of a leader (Kane et al. 18-26):

• There is a supportive and active senior management team striving to be involved in the implementation of changes;
• Clinical managers and senior clinicians work, as a rule, within the organization (and sometimes beyond organizational boundaries), providing leadership, advice to colleagues, negotiating resources and constantly pushing for change;
• Individual clinicians (of all specializations and wide experience) wish to perform certain tasks, are enthusiastic and energetic.

Among the shortcomings, the authors indicate the possibility of a “hole” in the dispersed leadership system due to the lack of support for changes at a certain level of leadership or within control groups. They note that reforms emphasize the need to improve the workforce (staff) and ensure flexibility, which requires a more sophisticated recruitment strategy and investment in workforce development (Dye 34). All this fits into the distributed leadership model and its three core competencies.

When describing the model of dispersed leadership, the authors pass to the term “distributed leadership” and draw a number of conclusions using the example of three successful cases (Konradt 293):

• There are no examples of individualized leadership. The features of distributed change leadership are in multi-level key teams supported by a wide range of employees.
• Top management provides a framework and resources for change. Mid-level leaders push for change, interpret the strategy at the national level to meet local needs, involving and linking staff to each other.
• Doctors-managers, that is, both managers and clinicians with social and clinical trust, play the connecting role between organizational areas.
• Many different competing processes are used cumulatively, and a combination of people and processes is carried out (Fitzgerald et al. 227-238). As a result, Fitzgerald et al. proposed a multi-level model of the influence of distributed leadership on improving the provision of medical services, the effectiveness of which was supported by healthy interprofessional relations (227-238) (Fig. 1).

A study of 40 health systems was devoted to the integration of health services aimed at improving treatment outcomes and optimizing costs (Carter et al. 48-53). It was found by its authors that three common features are common to successful integrated health care systems:

• They focus on those segments of the population in which health care spending is usually the highest (for example, segments of the elderly and patients with chronic diseases);
• Key processes for the provision of medical services are adjusted in such a way as to ensure the effective work of multidisciplinary teams of specialists;
• Systems are introducing a number of important support components that enable integrated health care.

Formed strong partnerships between all participants in the service delivery process make it possible to create a “virtual” integrated health care system even in those countries whose health systems are fragmented to one degree or another. To ensure the effective operation of this model, it is necessary that all participants are ready to optimize the main work processes. Advanced integrated service systems use predictive modeling algorithms combined with expert judgment from doctors (Carter et al. 48-53).

In one of the studies, in 23 works selected for in-depth analysis, the competence of distributed leadership “collective management” is mentioned in 22 cases, “formation and restoration of relations in a team” ‑ in 16 cases, “self-awareness” ‑ in 12 cases. The characteristics “emotional intelligence,” “creativity,” and “clinical competencies” were found in 10, 4, and 18 publications, respectively, selected as factors that are interrelated with the manager’s competencies under consideration (Barr 80-82). In 18 publications, it was reported that the leader must have clinical competencies in order to be a leader not only in managing a healthcare institution, but also in a medical environment, as well as understand the nuances of providing medical care. Another related factor is creativity, which is mentioned only 4 times, but always in combination with clinical competencies and emotional intelligence (18 references to clinical competencies; 4 references to creativity; 9 references to emotional intelligence) (Barr 83-84).

In 12 works, the competence “self-awareness” was mentioned together with the competence “formation and restoration of relations” or “collective management.” The leader’s self-consciousness consists in the ability not only to lead, but also to obey, which is possible only with high self-efficiency and pronounced emotional intelligence: self-consciousness is coupled with emotional intelligence ‑ 10 references out of 12. Formation and restoration of relations in a team is possible only with a developed leader’s self-consciousness. In the studied sample of publications, from 15 mentions of competence “formation and restoration of relations in the team,” in 12 cases they are associated with “self-awareness” (Barr 86). Self-awareness makes a more significant contribution to ensuring the sustainability of the distributed leadership competency model.

Obviously, this is due to the fact that one of the conditions for the successful implementation of the distributed leadership model is trust between team members, which must be sustainable and systemic. The competence of the head is the basis for increasing the effectiveness of the organization. At the same time, emotional intelligence and such competencies as the formation and restoration of relationships in the team and self-awareness are interconnected and in combination with clinical competencies and creativity affect the effectiveness of the medical organization.

The theory and research of leadership began with the idea that effective leaders as people have a special feature that sets them apart from everyone else. This idea has been replaced by the hypothesis that effective leadership is only a matter of choosing the “right” patterns of behavior; this idea gave way to a view of leadership as a process of mutual influence. Currently, leadership concepts are apparently developing towards the idea that optimal leaders are those who accept their role by teaching subordinates how to be a leader for themselves.

From modern research and leadership theory, we can confidently draw a number of conclusions. These conclusions are not based on any single research or research direction, but on the consideration of relevant literature and best practices. The context of a large part of this literature is a traditional manufacturing organization, and related conclusions may seem (or be) inappropriate for various structures. However, at the moment, most organizations are structured, partially or completely, according to the traditional model, with the patterns mentioned below.

• The behavior patterns of people in leadership positions can be divided into two general categories ‑ task-oriented behavior and people-oriented behavior. These two groups of behaviors affect different processes, and the results they bring are not necessarily related. In general, task-oriented behavior affects workers’ performance more, while people-oriented behavior is more reflected in the satisfaction of subordinates with work. Then, to a certain extent, the following is true: which emphasis is more important depends on which result is more important, provided that the task is completed satisfactorily. There is no evidence that leader-oriented behavior based on people can fully compensate subordinates for lack of success in their work.
• Elements of the organizational situation are important in that they tell the person acting as a leader which behavioral emphasis is most appropriate. In general, task-oriented behavior is apparently more important when the work being done is not routine, is performed in extreme or dangerous conditions, and is done by people who are inexperienced, have poor knowledge of the work, or are not too interested in independent work. If the work is of a routine nature which is performed in comfortable and familiar conditions by people who do not need clues, people-centered behaviors are more important; they, apparently, contribute to the task, helping to compensate for the negative aspects of the sometimes quite boring production situation. In some cases, for example, when competent and independent people do work that they like and that they know well, the best option would be, apparently, with limited or no leadership; in this case, job competence and knowledge act as an effective substitute for leadership.
• The personal characteristics of a leader are important not because they are in good agreement with a certain natural ability to lead, but because they affect the perceptions of those who need to lead. These perceptions, in turn, affect the willingness to follow the leader and reactions to the behavior of the leader. The widespread adherence to stereotypes regarding the appearance and behavior of the “true leader” makes it inevitable to conclude that people who most fully meet these ideas (or have a ‘mysterious’ quality called charisma) have every chance of becoming effective leaders. Knowing that a person’s individual characteristics play an important role in evaluating other people’s leadership role in practice rarely directly affects the selection of leaders in organizations. It is unrealistic for organizations to select bosses, managers, and administrators based on whether they look and act the way people expect leaders to look and act. However, more recent studies still suggest that some individual characteristics determined using tests (and not subjectively evaluated by people) associated with success in work. Once such tests are recognized as valid, they become useful sources of information when selecting people for leadership positions, especially in health care organizations.
• Leadership is not a one-way phenomenon. Successful leadership represents a process of influence; in organizations, this influence is only to a certain extent regular. It also depends on the interaction of each person holding a leadership position with his individual subordinates (and superiors). This interaction is reversible; that is, the reaction of subordinates affects how the leader will behave in the future, which, in turn, affects the reactions of subordinates, etc.
• Many people who currently hold leadership positions must have more diverse and/or different skills, not just traditional ones. Today, work is increasingly organized in a group form, and it is expected that leaders will turn these groups into brigades, and then they will be trained in how to carry out effective self-government and carry out work with a minimum of external guidance. The skills and behaviors required to achieve these goals need not be the same that ensure leadership success in traditional work planning environments. Graen and Uhl-Bien (qtd. in Hanaway 35) have developed a convenient scheme to bring together the conclusions presented above and the research behind them. As shown in the Table 3, this scheme is based on three primary areas of leadership research ‑ the leader, the subordinate, and the relationship between them. Of the approaches to leadership discussed here, characterological theories, early behavioral approaches, and probabilistic theories fall into the leader-based category in the table. The willingness to follow, the model of vertical dual relationship and the theory of exchange between a leader and a group member, are relationship-based approaches; leadership concepts in the new era are mainly focused on the ‘driven’ one (follower).

Table 3: Three leadership approaches (by area)

An analysis of Graen and Uhl-Bien shows that each of these approaches has a right to life. Which is best depends on the circumstances, and the words “depends on circumstances” is the motto of all probabilistic theories. The traditional probabilistic leadership theories postulate that the correct behavior of a leader depends on the situation. Table 3 presents what can be called a meta-probabilistic theory; that is, the most appropriate theoretical approach (based on a leader, relationship, or follower) depends on the situation. Based on this position, the decisive question in leadership research is not “what makes a person a good leader?”, but “what provides good leadership?”. Such a rearrangement could take the theory and research of leadership to a new level. Instead of discussing the features of a particular approach, organizational psychologists and other researchers could move on by studying the cumulative and interactive effects of the variables generated by each area of research to get a more complete picture of the leadership process. Once the proper set of answers is found for each of these areas, taken together, the next question could be how to influence these areas in order to increase the effectiveness of leadership, which, being connected with the followers and the situation, forms leadership as a significant additional component that fills in the gaps and encourages people to go beyond the usual limits. It seems that the time has come when the study of leadership in healthcare itself must go beyond the traditional limits so that it continues building up efforts to increase leadership effectiveness.

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Earning A Master’s In Healthcare Administration: Here’s What You Should Know

Updated: May 23, 2024, 6:57am

Key Takeaways

• A master’s in healthcare administration, or M.H.A., is a graduate degree that serves professionals pursuing careers on the business side of healthcare.
• This degree usually takes two to three years to complete, with part-time and full-time tracks available. Programs may take place online or on campus.
• Healthcare administration master’s candidates can specialize in areas such as finance, human resources and leadership.
• Coursework for a master’s in healthcare administration covers topics like change management, finance and budgeting, healthcare law and ethics, and health policy.
• M.H.A. degree holders can pursue careers as medical and health services managers, nursing home administrators and more.

If you’re interested in advancing in your healthcare administration career, consider grad school. A master’s in healthcare administration (M.H.A.) can prepare you for senior leadership roles focused on improving healthcare delivery and enhancing organizational effectiveness.

An M.H.A. degree can help you qualify for well-paid, high-level job opportunities in hospitals, clinics, nursing facilities and other healthcare sector organizations such as pharmaceutical and insurance companies. This degree helps you build management and leadership skills that you can take with you to any job in healthcare administration .

If you want to make a difference in the healthcare industry from the business side of things, keep reading to discover how to earn an M.H.A. We’ll cover admission requirements and common courses, explain what accreditation to look out for and explore several careers you can pursue after you graduate.

Why You Can Trust Forbes Advisor Education

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What Is Healthcare Administration?

As the population ages and advancements in research and technology lead to new treatment options, the healthcare sector is booming. This fast-evolving field needs competent managers and administrators as much as it needs the clinicians who provide direct patient care.

This field attracts individuals who combine a passion for healthcare with strong analytical, organizational and leadership skills. Some people transition into administration positions from the clinical side of the healthcare industry, while others may come from business backgrounds.

What Is a Master’s in Healthcare Administration?

A master’s in healthcare administration builds the skills and knowledge essential for executive and managerial positions in the field. The curriculum includes finance and budgeting, management strategies, legal and ethical issues, health policy, employee relations, human resources, problem solving and ensuring that patients receive the proper care.

Students can choose on-campus or online master’s in healthcare administration programs . This degree usually entails between 36 and 45 credits and takes two to three years to earn, but exact program length varies depending on the curriculum and whether you study full time or part time. Some accelerated programs take as little as 15 to 16 months to complete.

Admission Requirements for a Master’s in Healthcare Administration

Each program master’s in healthcare administration program determines its own admission requirements, but typical standards include:

• Application
• Bachelor’s degree in healthcare administration or a related field
• Transcripts from previous degrees or coursework
• Minimum GPA (typically 3.0)
• Letters of recommendation
• Personal essay
• Statement of purpose

Common Courses in an M.H.A. Degree Program

Below we list a few common courses for M.H.A. degree programs. Keep in mind that your program’s courses may vary since each college determines its own curriculum.

Data-Driven Healthcare

This course explores the types of data used in healthcare organizations and how to leverage this data in the decision making process. Students learn about computing architectures, data creation and management, and methods for interpreting and analyzing metrics.

Change Management and People Leadership in Healthcare

This course looks at how human resource management fundamentals apply in healthcare environments. Students learn about recruiting and retaining employees, training and education, evaluating employee performance, discipline and dismissal considerations, strategic planning and essential communication techniques for healthcare leadership.

Financial Management in Healthcare Organizations

This course covers the financial aspects of healthcare management, such as terminology, financial forecasts, spreadsheet applications, and budget development and management. Enrollees also learn to interpret financial statements and calculate return on investment.

Healthcare Operations Management

Students in this course develop analytical skills to improve and integrate operational processes. Coursework covers research methods, quality management, systems analysis, data analytics and data visualization. Learners use design and construct models, create spreadsheets, and analyze and report results.

Health Policy

This course covers everything you need to know about policy making and politics as they pertain to the healthcare field. Coursework explores political concepts, models of policy making systems, policy impact on leadership and administration, and how policies affect an organization’s objectives and goals.

Capstone Experience or Internship

Most healthcare administration master’s programs require a capstone project, an internship or both. These experiences allow you to apply the knowledge gained from your master’s program in real-world settings. Projects may focus on research or solving real-world problems in a local medical facility or healthcare organization.

Specializations for Master’s Degrees in Healthcare Administration

You may be able to select a specialization or concentration for your master’s degree. Offerings vary among programs, but below are a few typical specializations for M.H.A. degrees.

This concentration explores business valuation, mergers and acquisitions, and advanced financial statement analysis. A finance specialization may suit you if you plan to work as a risk and insurance consultant or in a similar leadership position in the health insurance industry.

Public Administration

A public administration concentration covers public policy analysis, healthcare administration, fundamentals of public administration, and policies and initiatives of community economic development. If you plan to work as a medical and health services manager, community health consultant or public health educator, you might specialize in public administration.

Human Resources

A human resources specialization focuses on human resource development and management, compensation and employment issues, and workforce planning. This concentration may be a good option if you plan to work as a human resources manager in a healthcare setting or as a director of nursing, practice administrator or corporate health director.

Strategic Management

Specializing in strategic management involves a focus on executive leadership and management concepts, organizational design, workforce planning and employment, and strategic management and marketing. This may be a good option if you plan to work as a medical and health services manager, operations manager or administrative services manager.

Supply Chain Management and Logistics

This specialization focuses on logistics, supply chain management, total quality management and operations management. With a supply chain management and logistics concentration, expect to learn how to bring an idea for a healthcare product or service to fruition. This may be a good concentration if you plan to work as a logistics programs director or production manager in the healthcare field.

This concentration covers team building skills, financial processes, employee management and strategies for improving patient care. Since leadership skills are essential to any healthcare administration role, a leadership specialization can benefit any career path in this field.

Accreditation for M.H.A. Degrees

The Commission on the Accreditation of Healthcare Management Education (CAHME) provides accreditation for on-campus and online healthcare administration master’s degree programs. CAHME measures programs against a set of competency-based standards to ensure they provide quality education. Accreditation signifies that a program has met or exceeded those standards.

The Council on Education for Public Health (CEPH) provides accreditation for public health programs. Some M.H.A. degrees exist within public health departments, in which case they may be accredited by CEPH instead of or in addition to CAHME.

What Can You Do with an M.H.A.?

An M.H.A. degree can open up several strong career paths, including those listed below. While a bachelor’s degree is the minimum education required for each of these roles, employers may prefer or require applicants to hold a master’s in healthcare administration or a related field. We sourced salary data from the U.S. Bureau of Labor Statistics (BLS) and Payscale .

Medical or Health Services Manager

Median Annual Salary: $110,680 Minimum Required Education: Bachelor’s degree Job Overview: Medical and health services managers may also be called healthcare administrators or healthcare executives. These professionals manage medical services in specific departments or entire facilities, depending on their role. Medical and health services managers determine and implement rules, goals and processes for the departments or facilities they oversee.

Nursing Home Administrator

Average Annual Salary: Around $99,600 Minimum Required Education: Bachelor’s degree Job Overview: Nursing home administrators oversee the day-to-day operations of nursing homes and nursing care facilities. They hire and train staff, manage admissions, ensure patients are receiving the best care, negotiate contracts, oversee building maintenance, and develop and manage budgets.

Hospital Administrator

Average Annual Salary: Around $95,000 Minimum Required Education: Bachelor’s degree Job Overview: Hospital administrators handle hospitals’ everyday operations. They hire and oversee staff, develop plans for improvement, oversee expenditures and budgets, allocate funds, ensure compliance with local and federal laws, and ensure the hospital operates according to its goals, vision and values.

Practice Administrator

Average Annual Salary: Around $78,800 Minimum Required Education: Bachelor’s degree Job Overview: Practice administrators oversee the operation of medical practices. They recruit physicians, nurses and other personnel to ensure the practice is adequately staffed. They also negotiate contracts, prepare training and staffing budgets, address customer concerns and make sure the practice has everything it needs to run properly.

Director of Nursing

Average Annual Salary: Around $98,400 Minimum Required Education: Bachelor’s degree Job Overview: Directors of nursing oversee the operations and performance of nursing units. They supervise and direct the work of nursing staff, ensure patients receive quality care, provide training to staff, conduct performance evaluations, ensure compliance with local and federal laws, and perform various other tasks within their departments.

Frequently Asked Questions (FAQs) About M.H.A. Degrees

Is a master’s degree in healthcare administration worth it.

Whether a master’s in healthcare administration is worth it for you depends on your career goals. If you want to move into a high-level management position in healthcare administration, then yes, this degree may benefit your career.

What degree is best for healthcare administration?

The best healthcare administration degree for you depends on your desired role and where you want to work. For many jobs in the field, a healthcare administration associate degree or a bachelor’s in healthcare administration is enough to get your foot in the door. More advanced positions may require a master’s degree in healthcare administration.

What is the difference between an M.H.A. and an M.B.A. in healthcare administration?

An M.B.A. provides in-depth knowledge of business processes that apply to many different industries. Choosing a healthcare administration concentration as part of your M.B.A. degree equips you to apply those business processes in a healthcare setting. An M.H.A. includes many of the same business concepts as an M.B.A., but provides deeper insight into the healthcare industry’s specific needs and challenges.

How much does a master’s in healthcare administration cost?

Tuition prices for master’s in healthcare administration programs typically mirror those of other graduate programs. The National Center for Education Statistics reports that graduate tuition rates averaged $12,596 a year at public institutions and $28,017 at private schools as of the 2020–2021 academic year.

How much can you make with a master’s in healthcare administration?

A master’s in healthcare administration can lead to many different occupations with varying salaries, but Payscale reports an average annual salary of about $83,000 for professionals with M.H.A. degrees. Medical and health services managers—a broad category that includes a wide array of healthcare administration roles—are among the most highly paid professionals in the field, with the BLS reporting an average annual wage of over $110,000 for these workers.

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Sheryl Grey is a freelance writer who specializes in creating content related to education, aging and senior living, and real estate. She is also a copywriter who helps businesses grow through expert website copywriting, branding and content creation. Sheryl holds a Bachelor of Arts in Mass Communications from Indiana University South Bend, and she received her teacher certification training through Bethel University’s Transition to Teaching program.

The 6 most common leadership styles & how to find yours

Throughout history, great leaders have emerged, each with their own particular leadership styles.

Leadership in itself is a somewhat fluid principle. Generally, most leaders adapt their leadership styles to suit their situation. This is particularly true the longer they lead; they adapt their leadership style as they learn and engage with their employees.

To become a more successful leader, leaders must understand their current leadership style. In this article, we’ll answer the question “what is a leadership style?” , then look at 6 of the most common leadership styles and their effectiveness.

The six most common leadership styles are:

• Transformational Leadership
• Delegative Leadership
• Authoritative Leadership
• Transactional Leadership
• Participative Leadership
• Servant Leadership

What is a leadership style?

A leadership style refers to a leader’s methods, characteristics, and behaviors when directing, motivating, and managing their teams . A leader’s style is shaped by a variety of factors, including personality, values, skills, and experiences, and can have a significant impact on the effectiveness of their leadership.

Their leadership style also determines how leaders develop their strategy , implement plans and respond to changes while managing stakeholders’ expectations and their team’s well-being.

In many cases leaders will express a wide-range of leadership styles – and will likely adapt this dependent on their situation. However, leader will often have one pre-eminent style that they tend to express more often.

Why is it important to know your own leadership style?

As a leader, understanding your leadership style is critically important. When you understand your leadership style, you can determine how this affects those you directly influence. It also helps you find your leadership strengths and define which leadership skills to develop.

Some leaders can already categorize their current leadership style, recognizing whether this makes them effective. Or how their employees see them. But it is not always so defined. It is usually the case that leaders can categorize their style; however, they often exhibit traits of many other leadership styles.

Detailed feedback is one easy way to know your leadership style. Asking those who you lead to provide you with open and honest feedback is a helpful exercise. Doing so will allow you to adapt your style’s characteristics within your day-to-day responsibilities as a leader.

1. Transformational Leadership

We’ve likely all been in a group situation where someone took control, communicating with the group and creating a shared vision. Creating unity, developing bonds, creating energy, and instilling passion. This person is very likely to be considered a transformational leader.

Transformational leadership is a leadership style that emphasiz es change and transformation . Leaders who adopt this approach strive to inspire their followers to achieve more than they ever thought possible by tapping into their potential. This type of leadership can be highly effective in organizations looking to make significant changes or transformations.

Some of the key characteristics of transformational leadership include:

A focus on the future: Transformational leaders always look ahead and think about what needs to be done to achieve the organization’s goals. They inspire their followers to do the same.

A focus on change: Transformational leaders are comfortable with change and understand it is necessary for organizational success. They work to ensure their followers are comfortable with change and can adapt to it.

A focus on people: Transformational leaders see the potential in every one of their followers. They strive to develop their followers’ individual strengths and abilities so that they can reach their full potential.

Read more about transformational leadership »

2. Delegative Leadership

Often referred to as “laissez-faire,” a  delegative leadership  style focuses on delegating initiative to team members. This is generally known as one of the least intrusive forms of leadership; this translates to “let them do.” This is therefore considered a very hand-off leadership style.

Leaders who adopt this style have trust and rely on their employees to do their jobs. They don’t micromanage or get too involved in providing feedback or guidance. Instead, delegative leaders allow employees to utilize their creativity, resources, and experience to help them meet their goals.

This can be a successful leadership strategy if team members are competent and take responsibility for their work. However, delegative leadership can also lead to disagreements among team members and may split or divide a group.

It can be challenging for newcomers to adapt to this style of leadership or staff members to develop an understanding of who is ultimately in charge and responsible for outcomes. Therefore, this leadership style must be kept in check.

Read more about delegative leadership »

3. Authoritative Leadership

Authoritative leaders are often referred to as visionary. Leaders who adopt this style consider themselves mentors to their followers. Not to be confused with authoritarian leadership, authoritative leadership emphasizes a “follow me” approach. This way, leaders chart a course and encourage those around them to follow.

Leaders who display authoritative traits tend to motivate and inspire those around them. They provide overall direction and provide their teams with guidance, feedback, and motivation. This promotes a sense of accomplishment or achievement.

The authoritative leadership style relies heavily on getting to know each team member. This allows a leader to provide guidance and feedback on a more personalized level, helping individuals to succeed. This means authoritative leaders need to be able to adapt, particularly as the size of their team grows.

Authoritative leadership is very hands-on, but leaders must be cautious not to micromanage. This is a tendency with this style, which can be overbearing for team members and create negative sentiments.

Read more about authoritative leadership »

4. Transactional Leadership

Transactional leadership, often referred to as managerial leadership, is a leadership style that relies on rewards and punishments. This leadership style clearly emphasizes structure , assuming individuals may not possess the motivation needed to complete their tasks.

With this reward-based system, a leader sets clear team goals or tasks. Leaders also clarify how their teams will be rewarded (or punished) for their work. Rewards can take many formats but typically involve financial recompenses, such as pay or a bonus.

This “give and take”  leadership style  is more concerned with efficiently following established routines and procedures than making transformational organizational changes.

Transactional leadership establishes roles and responsibilities for each employee. However, it can lead to diminishing returns if employees are always aware of how much their effort is worth. Therefore, incentives must be consistent with company goals and supported by additional gestures of appreciation.

Read more about transactional leadership »

5. Participative Leadership

Sometimes referred to as democratic leadership, participative leadership is a leadership style that encourages leaders to listen to their employees and involve them in the decision-making proces s. This leadership style requires leaders to be inclusive, utilize good communication skills, and, crucially, be able to share power/responsibility.

When a leader adopts a participative leadership style, this encourages collaboration through accountability. This often leads to a collective effort of a team to identify problems and develop solutions instead of assigning individual blame.

This leadership style has historically been prevalent and utilized by many leaders in many organizations. However, as working habits have changed (accelerated by the COVID-19 pandemic) and teams have become more decentralized, this leadership style is more complicated.

Spontaneous, open, and candid communication is often associated with a participative leadership style. Remote working or virtual teams can make this particularly challenging to maintain.

Participative leadership is often favored as it helps to build trust with employees. Empowering them and encouraging them to share their ideas on essential matters, demonstrating their value to a team.

Read more about participative leadership »

6. Servant Leadership

Servant leadership is a leadership style that puts the needs of others first . It emphasizes creating strong relationships with those around you and focuses on enabling them to reach their full potential. As a leader, it requires focusing on understanding the people you are working with and developing their abilities, while also setting a good example and understanding their personal goals.

At its core, servant leadership is about ethical decision making ; if one follows this model they will be more likely to make decisions based on what is right for everyone involved, rather than just benefitting a select few. This approach fosters an environment where creativity and problem-solving thrive as team members feel empowered to suggest new solutions and build upon each other’s ideas .

Furthermore, following the principles of servant leadership can result in improved communication between all involved parties – from senior management to front-line employees. By taking into account the opinions of subordinates, leaders can prevent any potential conflicts while maintaining both healthy relationships and peaceful work environments. Ultimately, these qualities help create a stronger sense of loyalty amongst team members which consequently leads to increased productivity overall.

Read more about servant leadership »

How to find your leadership style? 

Choosing a leadership style that works for you can make you a more effective leader. Whether you manage a large or small team, your leadership style heavily impacts how your team sees you. Here are a few points that can help you get started.  

Firstly, being clear about your goals and what you want to achieve is essential. Once you have a clear vision, it will be easier to communicate your ideas to your team and inspire them to follow your lead. 

Secondly, experiment! There are many different leadership styles, and the best way to find your own is to experiment with different approaches and see what works best for you and your team.  

Finally, remember that leadership is not about being perfect but authentically leading. When you lead from a place of passion and purpose, others will naturally be drawn to you and your message. Remember, as a leader, it is vitally important to be open to (and to seek actively) feedback and be willing to adjust your approach as needed.

Which style resonated with you? Do you think that your current leadership style is effective?

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