Assessment of Health Managers Leadership Profiles Determined According to Change–Production–Employee Model: A Cross-Sectional Study
ABSTRACT
Background and Aim
Leadership is the process of directing a specific group toward specific goals. Identifying and developing leadership qualities among managers working in healthcare institutions is important for effective healthcare management. The aim is to determine leadership behaviors using the Change, Production, and Employee Model Leadership Scale among healthcare managers.
Methods
It is a cross-sectional analytical study. Data were collected from a public and a private hospital in Izmir province between July and September 2018. A total of 395 employees evaluated 80 supervisors. The Change, Production, and Employee Model Leadership Scale was used to determine leadership qualities. Independent samples t-test and one-way analysis of variance were used to compare scale dimension scores according to sociodemographic work characteristics. Hierarchical clustering and K-means techniques were used to determine leadership styles.
Results
Leadership profiles were identified as Management by objectives (32.5%), Middle-of-the-Road (27.5%), Super (23.75%), and Invisible (16.5%) leaders. Those with female supervisors, permanent employees, and those working fewer than 45 h/week statistically gave higher scores for Change and Employee to their supervisors. Employees in private healthcare institutions statistically gave higher Change scores to their supervisors.
Conclusions
The identification of Management by objectives, Middle-of-the-Road, and Super leader profiles, which demonstrate certain competencies in all three dimensions of Change, Production, and Employee orientation, is evaluated positively. It is believed that this study will contribute to a better understanding of leadership styles in the healthcare sector and will be beneficial in developing effective management strategies.
1 Introduction
Leadership is considered as the process/art of influencing the activities of an organized group toward the creation and achievement of goals [1]. This definition can be expanded in numerous ways. However, it can be said that the common points of these definitions share similarities. The common criteria include having a specific goal, a group of people, and a leader capable of directing this group.
Although the concepts of manager and leader are often used interchangeably, they have distinct differences in certain aspects. Nevertheless, both concepts involve working with a group of people toward specific goals, thus showing similarities in many ways [2]. Management or being a manager is defined as “the effective planning, organizing, and directing of organizational resources to achieve the organization's goals” [3]. The focus of management definitions is to be efficient in achieving the organizational goal, which is the main purpose of management. On the other hand, a leader not only focuses on the organization's goals but also considers more complex variables such as motivation, training, change, and business development. The sources of power for a manager and a leader also differ. A manager gets power from a legal source, i.e., authority, while a leader gets power from the group they influence as well as the authority [4].
1.1 Leadership Theories
There are various approaches in leadership theories, similar to leadership definitions, and different approaches are proposed in this field.
1.1.1 End of 1940s—Trait Approach (Leadership Ability Is Innate)
This theory, which focuses on individual traits and qualities, is based on a very simple philosophy. It is based on the assumption that certain inherent or developable traits such as age, height, IQ, oratory skills, education level, and social relationships are better in leaders compared to others [5, 2]. However, it is known that not everyone with these traits can become a leader, and not every leader possesses all of these traits. Apart from these traits, new approaches have been developed regarding leader behaviors and the structure of groups formed for common goals, leading to the emergence of Behavioral Leadership Theories [6].
1.1.2 1940–1960—Behavioral Approach (Leadership Effectiveness Depends on Leader's Behavior Patterns)
Rather than focusing on individual traits, this approach emphasized leader behaviors. Leader behaviors are assessed and conceptualized through two dimensions: “task orientation” and “employee orientation.” The Iowa University studies, Ohio State University, Michigan leadership studies, and the Blake and Mouton managerial grid model are examples of studies conducted within this framework [5]. However, while focusing on leadership behaviors, not considering situational conditions (such as the work environment and the characteristics of subordinates, as well as the level of the manager) was seen as a shortcoming.
1.1.3 1960–1980—Contingency Approach (Effective Leadership Depends on Situation and Conditions)
This leadership approach suggests that the most appropriate leadership behavior should change based on the situation and conditions. For example, in a work environment dominated by problems of confusion and discipline, task-oriented leaders may be more suitable, while in a stable and balanced work environment, employee-oriented leadership behaviors may be more effective. In addition to the working conditions, the characteristics of subordinates are also emphasized in terms of how leadership behaviors can be influenced.
Leaders may need to adopt different leadership behaviors according to the characteristics of subordinates. A less experienced employee with a lack of knowledge may require a different leadership approach compared to an employee who has been in the same work environment for years and is familiar with the job requirements. For a less experienced employee, “task-oriented leadership” behaviors might be highlighted to help them understand the nature of the job, while for a more senior employee, “employee-oriented leadership behavior” may come to the forefront, allowing for the development of social relationships between the leader and subordinate [7].
1.1.4 Change-Oriented Leadership (Development of the CPE Model Leadership Behavior Determination Scale)
In the early 1990s, Ekvall and Arvonen introduced a third dimension of effective leadership alongside two well-known dimensions, which they called “Change-oriented leadership” [8]. Later, the scale was retested with 3857 participants from 13 different countries in various sectors and hierarchical structures, and the stability of the three-factor structure was observed [9, 8].
With the definition of transformational leadership and its establishment in leadership practices, the communication between leader and follower has evolved from a task-oriented (or, in other words, autocratic-based) relationship to a process of influencing individuals (transformational process) [10]. Transformation-oriented leaders, in line with a defined common goal, involve increasing the motivation of their subordinates and adapting quickly and appropriately to changing conditions throughout the process.
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Profile 1 (Transactional leader): Defined as a leader who is highly task-oriented, moderately employee-oriented, and weak in change orientation.
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Profile 2 (Idea skirt): Defined as a leader who constantly tries to support change with new ideas without caring about the ideas of his subordinates and colleagues, and without considering the organization's hierarchy.
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Profile 3 (Invisible leader): Defined as an uncertain and symbolic leader but not a real leader.
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Profile 4 (Domineering entrepreneur leader): Defined as a leader who progresses toward specific goals with change-oriented projects but has a low tolerance toward his subordinates.
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Profile 5 (Middle-of-the-Road leader): Defined as the average leader who can apply moderately three leadership behaviors, neither excelling nor failing in any of them.
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Profile 6 (Management by objectives): Management by objectives leaders are primarily job-oriented, moderately employee-oriented, and change-oriented leaders.
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Profile 7 (Super leader): Defined a “super leader” who can apply change, production, and employee-oriented leadership style behavior at an acceptable level.
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Profile 8 (The gardener leader): Provides the appropriate environment and conditions for employees to enhance their creativity, that is, a suitable climate like a gardener. It is a leadership style with high change and employee orientation.
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Profile 9 (Autocratic leader): This type of leader is characterized by minimal tolerance toward his subordinates and is directive and controlling.
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Profile 10 (Nice guy): This type of leader shows a weak orientation toward tasks and change, but a moderate orientation toward employees.
1.2 Healthcare Sector and Leadership
Identifying and developing the leadership characteristics of managers working in healthcare institutions is crucial for the effective continuation of healthcare management. Due to technological advancements, expectations from health managers increase with the increase in both the number and variety of services offered in health institutions.
Frequent changes in the positions of healthcare managers, like many other personnel in healthcare institutions, hinder the formation of institutional awareness and damage leadership practices. Effective leadership at all levels of the health system is vital to address these challenges in health institutions.
In healthcare organizations, for leadership development, it is crucial to be prepared for constantly changing and evolving conditions, to have a conflict-free and peaceful work environment for the development of the leader–follower relationship, and to approach challenges with a problem-solving mindset, free from blame [11].
The healthcare sector has a complex structure in terms of environmental and organizational factors, and this complexity creates specific challenges for leadership practices due to the differences in these factors. Healthcare institutions and organizations are faced with regulatory environmental factors beyond their control. For example, the sociodemographic and sociocultural characteristics of the region where healthcare services are provided, healthcare policies, and technological advancements can be considered as environmental factors.
Healthcare leadership is an extremely complex process and cannot be fully addressed. Ultimately, leadership involves collaboration between leaders and followers, and between people and systems, continuously adapting to challenges [12].
In healthcare organizations, improving healthcare services requires an approach from a visionary and innovative leader who can plan, implement, and monitor health projects [13].
In many studies conducted in healthcare institutions, it has been demonstrated that the leadership styles of managers are related to staff retention, staff development, job satisfaction, employee satisfaction, and burnout syndrome associated with work-related stress [14, 15].
It is crucial to identify the leadership characteristics of healthcare managers and address any deficiencies identified. Identifying the leadership qualities of middle-level hospital managers will lay the foundation for subsequent work. The primary aim of this study is to evaluate healthcare managers from the perspective of their subordinates and to identify their leadership profiles based on the subordinates' viewpoints.
2 Materials and Methods
2.1 Type and Population of the Research and Sample Selection
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Units providing healthcare services: Employee Health Unit, Internal Medicine Clinic, Dermatology Clinic, Endoscopy, Physical Therapy Clinic, Thoracic-Cardiovascular Surgery Clinic, Thoracic Surgery Clinic, Pulmonology Clinic, Ophthalmology Clinic, Day Hospital, Hemodialysis, Infectious Diseases Clinic, ENT Clinic, IVF Unit, Blood Collection Unit, Cardiology Clinic and Angio, Central Laboratory, Neurology Clinic, Neurosurgery Clinic, Nuclear Medicine, Oncology Clinic, Orthopedics Clinic, Pathology, Psychiatry Clinic, Urology Clinic.
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Units providing technical and support services: Information Technology, Central Sterilization, Technical Services Directorate, Security Unit, Patient Admission Points, Kitchen, Tailoring.
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Mid-level administrative units: Chief Physician's Office (Forensic Secretariat, Nursing Services Directorate, Salary Accounting, Correspondence), Report Office.
It aimed to reach all 550 employees in the public hospital and 76 employees in the private institution by visiting the units providing health, administrative, technical, and support services. In the study design, since subordinates evaluate their superiors, arrangements have been made to protect the identities of the subordinates and address their concerns.
During data collection, 53 individuals marked the options without reading the questions in front of the researcher. These employees were reminded to read the questions and provide answers appropriate to each item. However, these individuals did not agree to answer the scale questions again. Therefore, for data reliability, the responses of these 53 individuals were not included in the evaluation.
Each unit was visited at least three times, and after providing information about the study, surveys were distributed in sealed envelopes to those who agreed to participate. The envelopes were collected at a time suitable for the participants (no later than 1 week after the surveys were distributed). For this reason, no sampling method was used for participation in the study. Since the number of people working in the units was known, if 50% of the survey target for a particular unit was reached, a fourth visit could not be conducted.
2.2 Research Variables
The primary dependent variable is the scores obtained in the leadership dimensions according to the CPE Model Leadership Scale.
Independent variables include age, gender, department, duty in the department, length of service, working hours, participation in management-related training, and the gender of the manager.
2.3 Data Collection Tool
The data collection tool consists of two sections and a total of 50 questions. The first section includes 14 questions about sociodemographic characteristics. The second section contains 36 items that comprise the CPE Model Leadership Scale.
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Change-oriented leadership is defined as a manager who creates vision, is open to new ideas, does not delay in decision-making, encourages cooperation, is not overly cautious, and does not exhibit excessive stress in adhering to the existing plan.
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Production-oriented leadership is defined as a leader who is directive, controlling, and primarily considers structure/hierarchy.
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Employee-oriented leadership is defined as the type of leadership in which human relations are prioritized within the dimensions of leadership.
The Turkish validity and reliability study of the CPE Model Leadership Scale was conducted; Cronbach's α values were determined as 0.956 for the Employee-Oriented Leadership dimension, 0.917 for the Production-Oriented Leadership dimension, and 0.926 for the Change-Oriented Leadership dimension [16].
2.4 Data Evaluation
Statistical analyses were performed using the SPSS software version 26. Descriptive analyses were presented with mean and standard deviation, frequency, and percentages. One-way analysis of variance (ANOVA) was used to compare the mean scores of the three dimensions given to the managers according to the occupational groups, and since variances were not homogeneously distributed, Dunnett's T3 test, one of the post hoc tests, was used to identify the source of differences. The T-test was used in independent groups to compare the scale dimension scores given by employees to their managers according to sociodemographic, educational, and working life characteristics.
2.5 Determining Leadership Profiles
Employees rated 36 items with a 4-point scoring scale to determine the frequency of the behaviors of their immediate managers (Never = 0 points, Rarely = 1 point, Sometimes = 2 points, Often = 3 points, Always = 4 points).
The total scores for each of the three dimensions of the CPE Model Leadership Behavior Determination Scale were calculated and divided by the total number of items in each dimension to determine the overall average dimension scores for the study group. When determining leadership styles, the mean and standard deviations for each of the three dimensions were also calculated for each manager. The average scores for the three dimensions for each manager were evaluated using Hierarchical Cluster Analysis to gain an initial understanding of the number of clusters [17].
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“− −” (very low orientation) if < −1 standard deviation (SD)
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“−” (low orientation) if between −1/2 SD and −1 SD
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“− +” (moderate orientation) if between −1/2 SD and +1 SD
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“+” (high orientation) if between +1/2 SD and +1 SD
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“+ +” (very high orientation) if > +1 SD
In the study conducted by the developers of the scale with 3857 people in 13 different countries, 10 different leadership profiles were determined using this method. Since our study was conducted in a single sector with a limited number of participants, only 4 out of the 10 leadership profiles were observed. The coding of the four leadership profiles is shown in Table 1.
| Change oriented | Production oriented | Employee oriented | ||
|---|---|---|---|---|
| 1 | Invisible leader | − − | − − | − − |
| 2 | Middle-of-the-Road leader | + − | + − | + − |
| 3 | Management by objectives | + − | + | + − |
| 4 | Super leader | + + | + + | + |
| 5 | Transactional leader | − − | + | + − |
| 6 | Idea skirt | + | − − | − − |
| 7 | Domineering entrepreneur leader | + + | + + | + − |
| 8 | The gardener | + + | — | + + |
| 9 | Autocratic leader | − − | + | − − |
| 10 | Nice guy | — | − − | + |
- Source: Ekvall and Arvonen [9].
Although the number of employees evaluating each manager was not standardized in the study, this variability was taken into account in the analysis. This issue was managed using hierarchical clustering analysis. The average scores of each manager in the Change-oriented, Production-oriented, and Employee-oriented leadership dimensions were calculated, and the managers were grouped into four separate clusters through hierarchical clustering analysis. These clusters were formed based on the deviation of the managers' average scores from the overall average, thereby minimizing the impact of variability in the number of evaluators on the results.
Although the number of employees evaluating each manager was not standardized in the study, this variability was taken into account in the analysis. This issue was managed using hierarchical clustering analysis. The average scores of each manager in the Change-oriented, Production-oriented, and Employee-oriented leadership dimensions were calculated, and the managers were grouped into four separate clusters through hierarchical clustering analysis. These clusters were formed based on the deviation of the managers' average scores from the overall average, thereby minimizing the impact of variability in the number of evaluators on the results.
3 Results
A total of 626 employees were offered participation, and 93 people declined. Since 53 participants marked all the items as the highest score in front of the researcher without reading them at all, 20 of them did not fill out the questionnaire despite visiting 3 times at different times, and 1 person was on maternity leave, they were excluded from the study. As a result, 443 employees were evaluated within the scope of the study. The sociodemographic, educational, and working life characteristics of the study group are presented in Table 2.
| Public N | Private N | Total N (%a) | ||
|---|---|---|---|---|
| Gender (n = 442) | Male | 148 | 15 | 163 (36.9) |
| Female | 244 | 35 | 279 (63.1) | |
| Working in a managerial position at any time (n = 443) | 83 | 22 | 105 (23.7) | |
| Participation in management-related training (n = 443) | 119 | 21 | 140 (31.6) | |
| Gender of the manager (n = 440) | Male | 163 | 0 | 163 (37.0) |
| Female | 227 | 50 | 277 (63.0) | |
Public Mean ± SD |
Private Mean ± SD |
Study group Mean ± SD |
||
|---|---|---|---|---|
| Age | 38.38 ± 8.24 (Min 20, Max 68) |
34.7 ± 12.3 (Min 20, Max 60) |
37.91 ± 8.87 (Min 20, Max 68) |
|
| Time elapsed since the commencement of employment (months) | 141.67 ± 97.92 (Min 1, Max 420) |
45.4 ± 72.9 (Min 1, Max 360) |
131.4 ± 100.2 (Min 1, Max 420) |
|
| Weekly working time (hours) | 46.44 ± 25.18 (Min 33, Max 455) |
48.9 ± 6.7 (Min 35, Max 61) |
46.7 ± 23.9 (Min 33, Max 455) |
|
- Abbreviations: Mean ± SD, mean ± standard deviation; Min, minimum; Max, maximum.
- a % out of the total number is presented.
In total, 63% of the participants are women, 24% have previously worked in a managerial position in the healthcare field, and 32% have participated in management-related training. In private healthcare institutions, all managers were identified as women, while in the overall population, 63% of the managers are women. The average age, along with the standard deviation, is 38 ± 8.9, with a lower average age observed among those working in private institutions. When evaluating the length of employment, the average is found to be 131 months (10 years). The wide standard deviation (SD = 100) of the employment duration is a noteworthy finding, indicating a heterogeneous group in terms of work experience. The average weekly working hours are found to be 47. In general, it has been determined that those working in private institutions have a lower average age and employment duration, but a higher weekly working hour compared to those working in public institutions (Table 2).
3.1 Determination of Leadership Profiles From the Point of View of the Participants
Since the unit where 395 of 443 participants worked was stated, the leadership profiles were determined over 395 people. The average and standard deviation values given by these 395 employees to 80 managers for the 3 dimensions were as follows: Change-oriented leadership dimension 2.48 ± 0.60, Production-oriented leadership dimension 2.80 ± 0.57, and Employee-oriented leadership dimension 2.68 ± 0.61.
When the mean scores of the managers for all three dimensions were evaluated by Hierarchical clustering analysis, it was observed that four clusters were formed. The leadership profiles determined according to the deviation values of the mean values of the change, production, and employee dimensions of the four clusters from the overall average are presented in Table 3. The leadership profiles, in order of frequency, were Management by objectives (n = 26, 32.5%), Middle-of-the-Road (n = 22, %27.), Super (n = 19, 23.75%), and Invisible (n = 13, 16.75%) (Figure 1).
| Leadership profiles | N (%) | Change oriented | Production oriented | Employee oriented |
|---|---|---|---|---|
| Management by objectives | 26 (32.5) | Moderate | High | Moderate |
| Middle-of-the-Road Leader | 22 (27.5) | Moderate | Moderate | Moderate |
| Super leader | 19 (23.75) | High | Very high | Very high |
| Invisible leader | 13 (16.25) | Low | Low | Low |
3.2 Comparison of Scale Scores According to Sociodemographic Characteristics
Those with female managers, those who are permanent employees, and those working < 45 h/week gave their managers statistically significantly higher scores for Change- and Employee-Oriented Leadership. It is seen that employees in private health institutions gave their managers statistically significantly higher scores for Change-Oriented Leadership compared to those in public institutions, and though not statistically significant, they also gave higher scores in the other two dimensions (Table 4).
| Change | Production | Employee | |||||
|---|---|---|---|---|---|---|---|
| Mean ± SD | p | Mean ± SD | p | Mean ± SD | p | ||
Manager's gender |
Female (n = 163) | 2.47 ± 0.86 | 0.006 | 2.81 ± 0.76 | 0.147 | 2.64 ± 0.89 | < 0.001 |
| Male (n = 275) | 2.24 ± 0.88 | 2.69 ± 0.82 | 2.27 ± 0.96 | ||||
| Gender of the participant | Female (n = 163) | 2.40 ± 0.84 | 0.671 | 2.78 ± 0.75 | 0.723 | 2.54 ± 0.91 | 268 |
| Male (n = 275) | 2.37 ± 0.91 | 2.75 ± 0.81 | 2.44 ± 0.97 | ||||
| Attending any management-related training | Yes (n = 140) | 2.49 ± 0.89 | 0.085 | 2.81 ± 0.77 | 0.454 | 2.57 ± 0.93 | 0.300 |
| No (n = 299) | 2.34 ± 0.86 | 2.75 ± 0.79 | 2.47 ± 0.93 | ||||
| Age | 37 years and younger (n = 217) | 2.35 ± 0.91 | 0.214 | 2.72 ± 0.84 | 0.125 | 2.46 ± 0.98 | 0.181 |
| Over 37 years of age (n = 215) | 2.45 ± 0.82 | 2.84 ± 0.71 | 2.58 ± 0.88 | ||||
| Employment status | Permanent (n = 186) | 2.42 ± 0.78 | < 0.001 | 2.74 ± 0.71 | 0.367 | 2.55 ± 0.83 | < 0.001 |
| Company employee (n = 136) | 2.08 ± 0.91 | 2.66 ± 0.83 | 2.11 ± 1.00 | ||||
| Weekly working hours | 45 h or less (n = 283) | 2.67 ± 0.87 | 0.001 | 2.81 ± 0.73 | 0.97 | 2.63 ± 0.84 | < 0.001 |
| Over 45 h (n = 153) | 2.50 ± 0.80 | 2.67 ± 0.97 | 2.27 ± 1.05 | ||||
| Time elapsed since employment** | 114 months and below | 2.36 ± 0.91 | 0.504 | 2.76 ± 0.83 | 0.932 | 2.48 ± 0.97 | 0.584 |
| Over 114 months | 2.41 ± 0.84 | 2.77 ± 0.73 | 2.53 ± 0.90 | ||||
| Type of institution | Private (n = 48) | 2.51 ± 0.89 | 0.306 | 2.89 ± 0.81 | 0.364 | 2.77 ± 0.92 | 0.039 |
| Public (n = 391) | 2.37 ± 0.87 | 2.75 ± 0.78 | 2.47 ± 0.93 | ||||
- Note: Italic values indicate statistically significant results p < 0.05.
- ** Two groups were formed based on the median value of the duration from the start of employment.
Although statistically significant differences were not detected, it is observed that females, those who have received any management-related training, those in higher age groups determined according to the median value, and those with longer tenure in their careers gave higher leadership scores to their managers.
3.3 Comparison of Leadership Dimension Scores by Occupational Groups
Scale dimension scores given to the manager according to the occupational groups are statistically significantly different in the Change- and Employee-oriented leadership dimensions, and there is no significance in the Production-oriented leadership dimension (Table 5). Health professionals gave the highest score in the Change and Employee dimensions. Dunnett's T3 post hoc analysis was performed to determine which group caused the difference between the groups. In the post hoc analysis, a significant difference was found between the Change- and Employee-Oriented Leadership dimension scores of health professionals and technical support service employees (pChange = 0.009, pEmployee = 0.002). As a result, the difference is due to the low Change and Employee dimension scores given by technical and support service employees to their managers (Table 5).
| Change | Production | Employee | |
|---|---|---|---|
| Healthcare professionals (n = 192) | 2.55 ± 0.80 | 2.83 ± 0.72 | 2.68 ± 0.86 |
| Technical and support employees (n = 36) | 2.27 ± 0.90 | 2.75 ± 0.87 | 2.33 ± 1.07 |
| Office workers (n = 66) | 2.25 ± 0.89 | 2.66 ± 0.75 | 2.47 ± 0.91 |
| F = 5.55 p = 0.004 | F = 1.26 p = 0.283 | F = 5.55 p = 0.002 |
- Note: One-way analysis of variance (ANOVA) results. Mean ± SD, mean ± standard deviation.
4 Discussion
4.1 Assessment of Leadership Profiles From the Participants' Perspective
A total of 395 employees evaluated 80 managers. Cluster analysis revealed that the average scores of managers were grouped into four different clusters. Leadership profiles were determined according to the deviation of the mean values of the clusters in all three dimensions from the overall average. In order of frequency, four different leadership profiles were identified: Management by objectives, Middle-of-the-Road, Super, and Invisible leadership.
Due to the study being conducted in a single sector and with a limited number of managers evaluated, it was not possible to identify the ten leadership profiles determined by Ekvall and Arvonen. However, the most common Middle-of-the-Road, Super, Management by objectives, and Invisible leaders in this main study were also found in our study [9].
In a study conducted in South Africa, where numerous managers from various industries were evaluated, ten different leadership profiles were identified; however, five of them did not match the leadership profiles specified by Ekvall and Arvonen. Nevertheless, the leadership profiles identified in this study are newly defined leadership dimensions by researchers concerning the literature. Since it was carried out in different sectors and different leadership profiles were defined, no comparison could be made between this study and leadership profiles [18, 19].
Similar to our study, there are two studies conducted in healthcare institutions where managers were evaluated, and profiles were determined using the CPE scale. The most common leadership profiles identified in these studies are Middle-of-the-Road, Invisible, and Super leadership profiles [19, 20]. Consistent with these studies, three leadership profiles were identified with similar frequency in our study as well; however, the Middle-of-the-Road Leadership profile, which was not identified in these studies, was determined as the most frequently observed leadership profile in our study.
A goal-oriented leadership profile primarily consists of leaders who are oriented toward production, with moderate levels of employee and change orientation. Management by objectives leadership is leadership in which goals are communicated to employees to achieve both the continuity of the current work order and measured developments without risk [9]. Given this definition, it is not surprising that it was identified as the most frequently observed leadership profile in our study. In an environment with a high workload like a hospital, a moderate level of change-oriented leadership profile is compatible with our study findings due to high production orientation, as well as the fact that the group includes healthcare workers with a certain level of academic competence.
The leadership profile, which was found to be the second most common in our study, is the Middle-of-the-Road leadership profile, which has an average similar score in all three dimensions. We can evaluate leaders with this profile as those who adapt to changing situations and can highlight different leadership characteristics when necessary. This leadership style, which can vary according to the current situation, was found to be effective in the field of health in two previous studies [19, 20].
A Super leadership profile was detected in the third frequency. These leaders are defined as leaders who can show a high degree of leadership behavior in all three dimensions. A similar frequency of strong leadership profiles was found in two previous studies using the CPE Scale in the healthcare field, and it was found to be effective in the field of health [19, 20].
The Invisible leader was identified at a concerning frequency of 16.25%. Possible reasons for the emergence of the “Invisible Leader” profile include inadequate leadership training, high workload, weak organizational structures, and unclear roles [21-23]. Inadequate leadership training may result in managers lacking effective communication and decision-making skills. Assigning managers based on administrative or political factors, rather than experience and leadership abilities, may lead to an increase in the “Invisible Leader” profile. This situation could prevent managers from establishing effective communication with their teams and cause them to adopt a passive role in healthcare service delivery. In this context, it is clear that for healthcare managers to be more visible and effective, leadership training for healthcare managers, organizational structure, and merit-based appointment systems need to be strengthened [24].
4.2 Assessment of the Results of the Comparison of Scale Scores of Sociodemographic Characteristics
It is observed that employees in private health institutions gave statistically significantly higher scores in terms of Change and Employee Leadership to their managers than public institution employees, and though not statistically significant, they gave higher scores in the other two dimensions as well. In a study examining leadership behaviors and job satisfaction in different service businesses and using the same leadership scale, similar to the results of our study, it was observed that employees of private institutions gave higher scores to their managers in terms of Change, Production, and Employee than employees of public institutions [25].
When comparing the scale dimension averages given by employees to their managers according to sociodemographic, educational, and work-life characteristics, it was found that employees with female managers, permanent employment status, and working < 45 h/week statistically significantly gave higher Change and Employee scores. In a study conducted in different departments of the health sector, the behavior scores of female managers toward the employees were determined by our results [26]. Consistent with the results of the study, in healthcare sector studies conducted using different scales and dimensional criteria, it is observed that higher scores were given to female managers in terms of change-transformation-oriented leadership [27, 28].
Gender-related leadership behaviors are an important topic of discussion, especially in fields like healthcare, where leadership may differ between female and male managers. Studies have shown that female leaders tend to adopt a more transformational leadership style. The change-oriented leadership style is characterized by traits such as empathy, communication, and collaborative decision-making [29, 30]. This may explain why the female managers in our study group scored higher on employee-oriented leadership behaviors (such as communication, empathy, and teamwork).
Gender-related leadership behaviors are an important topic of discussion, especially in fields like healthcare, where leadership may differ between female and male managers. Studies have shown that female leaders tend to adopt a more transformational leadership style. The change-oriented leadership style is characterized by traits such as empathy, communication, and collaborative decision-making [29, 30]. This may explain why the female managers in our study group scored higher on employee-oriented leadership behaviors (such as communication, empathy, and teamwork).
In women, it is seen that the leadership score given to their managers was higher in those who received any training related to management, those in higher age groups determined by the median value, and those with longer tenure in working life. Though not statistically significant, this finding was interpreted as important. In a study in which healthcare professionals evaluated their managers, similar to our study, it was found that when the working time increased in the unit, the leadership behavior score given to the managers in the higher age group increased [31].
Similar to our study, a study evaluating hospital managers found significant differences in terms of gender, job position (nurse, patient consultant, administrative staff), work unit (administrative services, medical services), and managerial positions (junior, senior). However, no significant differences were observed regarding variables such as age, marital status, education level, years of professional experience, and years of employment within the institution [32]. In a study evaluating the effective leadership behaviors of nurse managers, it was reported that effective leadership behaviors were more frequently observed among those who had been working for a longer period of time [33].
4.3 Evaluation of the Comparison of Leadership Dimension Scores by Occupational Groups
Scale dimension scores given to the manager by occupational groups were found to be statistically significantly different in terms of change and employee dimensions, and the highest score was given by health professionals. In post hoc analyses conducted to determine which group caused the difference between the groups, it was understood that the difference stemmed from the low scores given to managers by technical and support service employees. In a study evaluating situational leadership styles perceived by healthcare professionals, where similar leadership dimensions (transformational, transactional, laissez-faire) were measured, it was found that patient service employees gave significantly lower transformational leadership scores to their managers compared to medical services and administrative services employees, consistent with the results of our study [33].
5 Conclusion
Leadership characteristics were evaluated from the perspective of employees in two public and private healthcare institutions, and various leadership profiles were identified. Management by objectives leaders, who have a high degree of task orientation along with a moderate degree of employee and change orientation, were the most frequently identified leadership type in our study. Subsequently, Middle-of-the-Road leaders, Super leaders, and Invisible leaders were identified in order of frequency. Identification of Management by objectives, Middle-of-the-Road, and Strong leader profiles, which demonstrate certain competencies in all three dimensions of change, production, and employee orientation, is a positive finding. Identification of Invisible leaders, who demonstrate insufficient competency in all three dimensions, is also a remarkable finding, and it indicates the need in this field. The healthcare sector is a critically important field in terms of its consequences. It is considered that the study contributes to this field by identifying the leadership characteristics of healthcare managers and revealing the need for improvement in identified deficiencies. The limited scope of the study in one public and one private healthcare institution is seen as a limitation, and it is recommended that future studies be planned to include primary healthcare institutions and health directorates.
This study was conducted in two healthcare institutions in a province, which limits the generalizability of the findings to other healthcare institutions. Although the research was conducted in a single city, Izmir is the third largest province of Türkiye and a cosmopolitan region that receives health staff from all over Türkiye and from all origins and cultures. Additionally, the findings of the research are valuable in terms of how they can be applied to similar healthcare institutions and the sector in other regions, as they reflect the key elements of management practices in secondary and tertiary healthcare institutions. It is likely that the reforms in the Turkish healthcare system, particularly the changes made within the framework of the Health Transformation Program that started in Turkey in 2003, have had similar effects across healthcare institutions nationwide. However, local dynamics and healthcare infrastructure in different regions, as well as differences in the healthcare workforce, can influence the development of leadership profiles. Future studies, including leadership research conducted with more healthcare institutions from different regions and participants from various levels, could increase the generalizability of the findings and help us better understand the impact of local dynamics.
The identification of the Management by objectives, Middle-of-the-Road leader, and Super leader profiles, all demonstrating a certain level of competence in all three leadership dimensions (change, production, and employee), is considered a positive finding. However, the identification of the Invisible Leader, who showed no competence in any leadership dimension with a frequency of 16%, is considered a noteworthy finding. Although the study was conducted with a limited population and in only two healthcare institutions, the current findings are valuable in highlighting the need for leadership training.
Although the data collection period is 2018, the fundamental elements of the reforms and changes implemented within the framework of the Health Transformation Program, which was initiated in Turkey in 2003, are still valid in secondary and tertiary healthcare institutions. For this study, data were collected from two healthcare institutions, one from the secondary and the other from the tertiary level. The performance-based payment systems, hospital management autonomy, and the privatization of public healthcare services, which were introduced through the Health Transformation Program, have led to fundamental changes in the delivery of healthcare services, and these structural changes continue to have an impact to this day. However, the Health Transformation Program has also led to negative effects such as the commercialization of healthcare services and the deepening of inequalities. In this context, the 2018 data still provides a valid and meaningful foundation for the healthcare management practices in secondary and tertiary healthcare institutions. Additionally, the data from this period reflect a critical time when major changes in the healthcare sector began and the healthcare management processes began to take shape.
6 Limitations
In our study, the number of employees evaluating a supervisor was not standardized, leading to a lack of standardization in assessing managers on a unit basis. Although data were collected from two different institutions (public and private) to increase variation, both belong to the healthcare sector, which limited the variation in managerial profiles. Another limitation is that this study focused solely on identifying the leadership traits of hospital managers; managers from primary healthcare institutions (e.g., family health centers, district health directorates) were not evaluated. Therefore, the study is limited in assessing the leadership profiles of managers across the entire healthcare sector. It is recommended that future studies be designed to include all levels of healthcare.
Our study was designed as a cross-sectional study, which allowed us to focus on the leadership profiles of healthcare managers within a specific time period. However, this design does not show how these profiles evolve over time. To gain deeper insight into the development of leadership behaviors, future research is recommended to adopt a longitudinal approach.
Author Contributions
Ozden Ozilice: conceptualization (equal), formal analysis (equal), investigation (equal), methodology (equal), writing – original draft (equal), writing – review and editing (equal). Bulent Kilic: conceptualization (equal), formal analysis (equal), investigation (equal), methodology (equal), project administration (equal), supervision (equal), writing – review and editing (equal).
Acknowledgments
We gratefully acknowledge the participants of this study for their invaluable contributions during the interviews. Additionally, we thank the public and private hospital administrations for permitting us to collect data.
Ethics Statement
Approval for our study was obtained from the Non-Interventional Research Ethics Committee of Dokuz Eylul University (Decision No: 2017/16-41).
Consent
Before data collection, written informed consent was obtained from all participants. They were informed about the objectives and scope of the study, and assured that their participation was entirely voluntary, anonymous, and confidential.
Conflicts of Interest
The authors declare no conflicts of interest.
Transparency Statement
The lead author Ozden Ozilice affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.
Open Research
Data Availability Statement
Data available on request from the authors. The data that support the findings of this study are available from the corresponding author upon reasonable request.
