Numerous commentators, scholars, and researchers in the field of healthcare have indicated that regulatory systems, increasing the levels of competition, and target setting are inadequate levers for bringing the fundamental changes needed and improvements required to deal with the channels within healthcare organizations (Ham, 2014). Studies conducted in numerous industries propose that leadership is a central element in the performance of an organization. Leaders that are disciplined are of primary importance in the promotion of excellent organizational performance and moving organizations from good to great levels in any industry including the healthcare industry. These types of leaders assist organizations in the recruitment of-of the right team to provide leadership, developing effective and sustainable growth and development strategies, and creating a culture founded on discipline that is focussed on the creation of high work and organizational performance.
In a study conducted in high ranking healthcare institutions, Keroack et al. (2007) also highlighted that leadership is a critical factor for improved organizational operation and performance. In their study, the leaders were passionate about quality improvement, guaranteeing safety and service with a hands-on approach, and made effort to stay up to date with any current and arising matters.
This chapter involves the review of several past studies from scholarly journals and articles on the role of leaders and leadership in healthcare organizations. The purpose of this review is to highlight the contributions that have been made by past researchers in the area. It comprises of an in-depth review of peer-reviewed articles and submitted research reports within the contexts of the concept of management of change for growth and development of organizations and institutions in the healthcare industry. The chapter also discusses some theoretical foundations and leadership models that support the importance of leadership in health organizations. Therefore, this section provides a discussion of past academic research on the topic of interest and critically reviews these past research on various levels. Finally, it highlights a conceptual framework inherent in any study that provides a summarized holistic structure of this study.
2.2 Leadership – Defined
Leadership as a concept is most of the times constructed as an idea that is beautiful and rarified and often described in a tone that suggests heroic beauty. It is portrayed as a golden object that is often sought after but always beyond the reach of many (Western, 2008). It is also depicted as a seductive undertaking for purposes of selling books on leadership and encouraging enrollment in training courses for meeting the demand for easy answers and quick solutions (Western, 2008). However, practically, the easy solutions to leadership are often useless, harmful, and misleading. Therefore, to move beyond the idealistic concepts it is important to go beyond the surface meaning of leadership and this is the purpose of this subsection.
Leadership is a common term with numerous diverse meanings and like beauty, leadership is said to be known when you see or experience it. This, therefore, implies that leaders and leadership are subjectively defined and in such a case, there is a multitude of perspectives and understandings of the meaning of being a leader and/or witnessing leadership. The term “Lead” is both a noun and a verb hence has a double meaning where the noun could mean “guiding others/being the head of an organization.” The verb, on the other hand, could mean” excelling and being in advance.” Likewise, leadership is used to describe a specific social interaction between people with the term leader denoting an individual that influences others.
Attempts to implement leadership and change in any organization reveals the complexities involved in leadership and the fact that leadership does not only involve a single person and that the comprehension of leadership requires a broader in-depth overview. The review of theories in leadership reveals four common themes that are leadership as a process, leadership as involving the influence of people, the occurrence of leadership within the context of a group and the goal attainment component of leadership.
Therefore, leadership can be defined as defined as the process by which an individual influences others to attain poor accomplish certain objectives and provides direction in an organization in a manner that makes the organization increasingly cohesive and coherent (Sharma & Jain, 2013). It is a process where a person influences a group of individuals to attain a specific common goal. Other scholars indicate that while the above is a good definition, it locates a person/individual as the only source of leadership hence the definition obscures as much as it reveals. This is because it does not clearly define or highlight the nature of the influence, how the influence can structure activities and relationships, and within the setting of a group it does not clearly identify who is the leader.
Therefore, leadership is not a single individual or a particular position, it is a moral relationship between people that is a complex and is founded on trust, commitment, obligation, emotion, and shared vision of the good of an organization. It is the ability of an individual to translate a vision into reality; it is the initiation and maintenance of structure in expectation and interaction and the lifting of a person’s vision to greater sights, raising the performance of an individual to greater standards and building the capacity of a human being beyond their normal limit. A vital characteristic in any good leader is hence their ability to conduct an exploration of the motives and belief systems of individuals at a personal level or a team at the group level in accomplishing change or the perceived vision of success.
2.3. Four Factors of Leadership
There four factors that are inherent in leadership and theses include the leader and the leader here should have an honest personal awareness and knowledge and evoke trust and confidence to the others (Sharma & Jain, 2013). Second is the followers and it is vital to note that different people require different leadership styles and hence the leader should understand people with the fundamental point of doing this is understanding their needs, emotions, personality, attributes, and motivating factors (Sharma & Jain, 2013). The third is a communication where there should be two-way communication as this plays a significant role in building or harming the relationships within the organization (Sharma & Jain 2013). Finally, it is the situation and this refers to the ability to lead in varying situations that demands sound judgment of situations and adopting the most appropriate leadership style
2.4. Types of Leadership
The styles and/or types of leadership are often classified on the basis of the behaviors that are used for evoking or influence change at all levels and in any situation. Therefore there are different types of leadership and these areas discussed below.
2.4.1. Transformational Leadership
The concept of transformational leadership was first postulated by James MacGregor Burns in 1978. According to Burns, transformational leadership is a relationship containing mutual simulation and elevation converting followers into leaders and may convert these leaders into agents of morality (Odumero, 2013). It takes place when a single individual or a group of people engage with each other in a manner that both the leaders and the followers elevate each other to levels at greater levels of morality and motivation (Odumero, 2013). The core of this style of leadership is the ability to empower and motivate individuals within an organization and the moral aspect of leadership. The goal is transforming individuals and organizations in a literal sense that is changing their minds and hearts, enlarging their vision, insight, and understanding, and clarifying their purposes (Odumero, 2013). It also involves making the individuals behaviors to be congruent with their personal or organizational beliefs, values, and principles and bringing about permanent, self-perpetuating, and momentum building changes.
2.4.2. Transactional Leadership
Transactional leadership is also known as autocratic leadership and in this type of leadership, the leader acquires commitment from the people he/she is leading on the foundation of the provision of direct compensation and security among others in exchange of reliable work (Odumero, 2013). It is also referred to as managerial leadership whose focus is on specific roles namely supervision, organization, and performance of the group. The leaders here are not focused on changing the future but just maintaining the status quo (Odumero, 2013). The focus is on finding faults and deviations in the work that is being done.
2.4.3. Situational Leadership
Situational leadership theory (SLT) postulates that effective leadership demands rational comprehension of the situation and having the appropriate response and not a charismatic leader having a group of followers (McCleskey, 2014). In SLT there is no single approach to leadership and the approaches vary depending on the situation (McCleskey, 2014). However, leaders are required to identify the most vital roles and priorities and consider the level of readiness of their followers through the analysis of the abilities and willingness of the group (McCleskey, 2014). Depending on such variables, the most appropriate style of leadership is applied.
2.4.4. Charismatic Leadership
Charisma is the ability of a leader to exercise diffuse and intensive influence over other people’s values, belief systems, behavior, and performance of others through their own behavior. It is postulated that charismatic leaders transform the self-concept of the followers and links the follower’s identities to those of the organization (Shastri et al., 2010). Charismatic leadership is reliant on the persuasiveness and charm of the leader and these leaders are driven by their convictions and commitment to their goals and objectives. These leaders communicate high expectations to their followers and evoke much confidence in the abilities of the followers to meet the organizational goals (Shastri et al., 2010). This behavior from the leaders increases a sense of competence and self-efficacy from the being led that consequently improves the organizational performance.
2.4.5. Participative Leadership
Participative leadership can be described as a process of making joint decisions or sharing the decision making influenced by the superior and their subordinates. This style of leadership places its focus on the follower’s intrinsic motivation. This type of leadership can contribute to the intrinsic motivation through the enrichment of the jobs of the subordinates via the creation of autonomy, variety, and empowerment.
2.4.6. Democratic Leadership
Democratic leadership style is a process of leadership where the leader has a master-master relationship with the members of a group. The leader employs a consultative method for encouraging the participation of group members in making decisions (Nemaei, 2012). It is described as a process of jointly making decisions or at least having an influence that is shared by the leader and their subordinates (Nemaei, 2012). Leaders using this style place emphasis on the participation of the group, discussion, and making group decisions. Democratic leadership comprises of working with the group to ensure that decisions are made sensibly and fairly (Nemaei, 2012). The purpose is to ensure full group participation in making decisions.
2.4.7. Laissez-faire Leadership
This type of leadership involves non-interference allowing complete freedom to all employees with no specific means of attaining goals. The leadership style is centered on people and the group is allowed by the leaders to make their own decisions without interference (Nemaei, 2012). The leader hopes the group will make the right decisions with the main advantage being it gives freedom from the team members to make decisions and the members won these decisions (Nemaei, 2012). No control and/or guidance is offered in this style and hence wrong decisions can impose negative organizational effects.
2.5. Types of Organizational Change
The phrase “organizational change” is regarding a significant change within the organization, for example, the reorganization or addition of major new products and/or services. This is when compared to smaller changes, for instance, the adoption of a new computer procedure (Cummings & Worley, 2014). It is a process where organizations optimize organizational performance as it strives to achieve its ideal state. From a passive point of view organizational change takes place as a reaction to the ever-changing environment or as a crisis response (Cummings & Worley, 2014). On the other hand, a proactive perspective organizational change is a process that is triggered by a manager who is progressive. Organizational change often appears as being a vague phenomenon, but the in-depth comprehension of organizational change can be attained when looked into in various dimensions as discussed below.
2.5.1 Organizational-wide versus Subsystem Change
Change taking place in the entire organization involves a major restructuring, new collaboration, or right-sizing the institution. Organizations require this type of change to evolve to a different level in the organizational cycle, for instance, moving from a reactive, entrepreneurial organization to a more stable and planned development. According to experts, successful organizational change requires a cultural change. Subsystem change, on the other hand, comprises of the inclusion or removal of a product and/or service or expansion of clinic hours in a healthcare context.
2.5.2. Transformational versus Incremental Change
Transformational change is also referred to as radical change or quantum change and this type of change comprises of changing the fundamental organizational structure and culture (McNamara, 2006). For instance, changing from a hierarchical structure (top-down) to developing self-directing teams and business re-engineering that dismantles the major components and processes of an institution and reassembles them again but in the more optimal manner (McNamara, 2006). Incremental change, on the other hand, refers to a series of small planned steps that occur progressively. These are, for example, increasing efficiency through the implementation of computer systems over time and continuous quality improvement (McNamara, 2006). Incremental change is always taking place without the knowledge of the leaders.
2.5.3. Remedial Versus Developmental Change
Remedial change is the type of change that is planned or established to deal (remedy) with a particular situation (McNamara, 2006). These situations are, for example, increase the efficiency of employees or operations, reducing staff burnout, improving organizational performance, increasing organizational proactivity and reducing their reactivity, or addressing budgetary issues (McNamara, 2006). Project implemented to bring about remedial change are often focused and urgent as they are targeted at addressing a major problem that is occurring presently (McNamara, 2006). It is easier to establish whether the change has been achieved or the project’s success if in the end the problem has been solved or it still exists. Developmental change is more general and targeted at making an already efficient organization become increasingly successful (McNamara, 2006). This is, for example, products expansion or increasing the number of patients being served. Projects in developmental change are general and remedial depending on the specificity and importance of the goals to be achieved.
2.5.4. Unplanned Versus Planned Change
Unplanned (reactive) change takes place due to a major and sudden occurrence in the organization. This causes the members to respond in a reactive manner and in a disorganized fashion (McNamara, 2006). This type of change takes place, for instance, when the Chief Executive Officer leaves an organization suddenly, the occurrence of significant problems in public relations, or poor performance of a product among other disruptive situations. Planned change, on the other hand, takes place when the need for a major change in an organization is recognized by the leaders who then proactively put up a plan to attain the change (McNamara, 2006). Planned (proactive) change hence occurs with the implementation of the Strategic Plan, reorganization plan, and other actions to initiate change. Although planned change is founded on a pre-prepared plan it often does not occur in a very organized manner (McNamara, 2006). Instead, it takes place in a chaotic and disruptive manner than expected.
2.6. Leadership and Organizational Change Management
Change management can be described as an approach that is structured in the transitioning of individuals, teams, and organizations from the present state to a state that is desired presently or in the future with the aim of fulfilling or implementing the vision and strategy of an organization. It is an organizational process that is targeted at empowering the employees to accept and embrace any changes in the current environment. There are several streams of thought that have molded the practice of change management and these areas discussed below.
Change as a systematic when the management of change is considered to be a formal process for change in the organization including a systematic approach and knowledge application. Change management here refers to the definition and adoption of corporate strategies, structures, procedures, and technologies to tackle change that arises from internal and external conditions. Change management is also considered to be a method of transitioning people that is it is a critical part of any project that leads, manages, and enables individuals to accept new processes, technologies, structures, and values. It is considered to be activities that help in the transition from the current way of working to the desired one. Finally, it is a competitive tactic that is the continuous process of aligning the organization or institution with the existing marketplace and market conditions in more responsible and effective manner than the competitors.
A leader is a vital individual in the process of change as they are responsible for making the change process as unproblematic as possible. There various reasons as to why leadership is important and these are tied to the role the leader plays in change management and these include first the leader as the sponsor in managing to change. This is because the leader is the advocate for change and they act as representatives that keep the change in front of the individuals they lead and they do not let the initiative for change to be ignored as they are using their political and institutional capital to ensure the change occurs – they are the champions of change. Secondly, the leader is also the role model as they are often willing to lead the change. Leaders demonstrate attitudes and behaviors expected by their followers and these followers watch them for maintaining consistency between the actions they take and the words they speak to establish whether they really believe in the change.
Thirdly, the leader is also the decision-maker as they control the resources required for change. These resources are, for example, people, equipment, and finances just to mention a few. Therefore, they have the power to make decisions affecting the change initiative. These leaders have the power to accept or decline the change initiatives within their spectrum of control. They leverage the authority to make decisions and chose the options that support the initiative. The leader here as a maker of decisions is decisive and set priorities that support and promote the change process. Fourth, the leader and leadership act as the face and voice of change as they communicate and share information to keep the individuals updated and encourage them. They balance the change message being transmitted to remain relevant to the reports they provide to match the overall message of change. They ensure transparency and consistency of the message passed.
Last but not least, leadership provides motivation for the change as they generate the urgency and importance of the change and evoke commitment and passion for achieving the change. They recognize individuals that are doing well in the change process and understand the difficulties involved in the process and the importance of motivation to keep individuals moving forward. They provide energy and empathize with the followers. Finally, leadership provides enforcement using their authority as they ensure accountability for change. They ensure agreements made are upheld and ensures everyone participates in the change and everyone changes according to the organization’s requirements. They comprehend the obstacles of change and attempt to eliminate them. They also ensure that individuals that do not adhere to the changing face the consequences.
2.7. Factors Contributing to Resistance to Change
Developing a successful strategy for change and the role leadership plays in dealing with resistance to change requires an in-depth understanding of the factors that lead to resistance. From this understanding, one can establish the steps to be undertaken to deal with the change. These factors include lack of awareness and knowledge that is being unaware and lacking the knowledge of the areas that require change. Evidence indicates that healthcare professionals are most of the time unaware and unfamiliar with the latest evidence-based treatment guidelines. They may also be aware of the new guidance issued but do not understand how they should change how they are presently working. They also feel that these guidance undermines their autonomy and hence resist changes. In addition, the motivation which is a fundamental aspect of any organization. If the healthcare professionals do not receive external motivation or do not have internal motivation to change, they resist the change being implemented.
Another aspect that promotes resistance is acceptance and belief systems where the beliefs and attitudes held by an individual influence the level of acceptance of change. For instance, another professional in healthcare found it difficult to accept new treatment guidelines if it goes against other guidelines that have been issued with other professional bodies or opinion of a person with influence. There are those practitioners that doubt whether the recommendations are a reflection of the existing evidence or if they will have better treatment outcomes and these create resistance. Furthermore, it is the skill level and this is because specific skills are required for implementing change and the competency for continuing the change. Healthcare professionals that lack these skills may resist the change or may require time to train and acquire the skills which may resist the immediate implementation of a particular change.
Practical factors also act as resistors to change and these are, for instance, inadequate resources, lack of personnel, or problems in the establishment of service delivery. Finally, there are other uncontrollable factors that bring about resistance to change such as the financial and political environment that negatively impacts the followers’ motivation and capacity to change.
2.8. Leadership’s Role in Dealing with Resistance to Change
Resistance to change is a continuous problem and this is both at the level of the organization and the individuals. This resistance stifles the efforts put in place to improve the organizational performance (Lorenzi & Riley, 2000). Many change efforts are initiated in healthcare organizations and other institutions at humongous costs only to be later stopped by the resistance among the employees to change (Yukl, 2010). Leaders guide an organization through the change process and the leaders are, therefore, the key to shaping the intentions of the employees in resisting organizational change (Nodeson et al., 2012). This implies that the behaviors of the leaders determine the success of the organization in adapting to the change.
The personal attributes of leaders influence the choices that are made in the organizations and these consequently influence the attitudes and beliefs of the followers. Employees do not resist change if they are directed by their leaders in the correct path (Berson et al., 2008). For instance, the attitude of leaders such as positive thinking and willingness to take risks would result in positive decision making. Organizational here referring to the individuals working in the organization. Avolio et al. (2004) indicate that the decisions and behaviors of the leaders influence the beliefs and attitudes of the people who follow them. Therefore, to eliminate any form or resistance, they must capture the minds, hearts, and beliefs of the whole organization’s employees that can be attained through the development of an organizational culture that is founded on shared belief systems.
Followers resistance in an organization can be perceived as the commitment to an organization based on shared goals and vision. In addition, the resistance may be due to an imminent conflict between the personal needs and the organizational needs and in view of this the leader can deal with this form of resistance through the understanding of each individual’s needs (Nodeson et al., 2012). This is known as individualized consideration where the leaders distinguish the employee’s needs that conflict with those of the organization and provide the appropriate feedback. In leadership and resistance, the focus is placed on the roles and responsibilities (Nodeson et al., 2012). It is vital that the there is a distinction between leadership and management as this will help the leaders to focus on the potential of all the members of the organization.
Most individuals do not like change and the find it unpleasant with the common reaction being resisting this change. The unpleasantness arises due to the fear of the unknown and the consequent uncomfortability as the daily common routines one is used to and is always in control of are suddenly taken away (Nodeson et al., 2012). It is only a secure person (a leader) in this context that can experiment on new ways of doing the thing and this requires a particular level of risk-taking (Nodeson et al., 2012). This type of risk-taking ability results in change, but most individuals do not like to venture into the unknown. In such an instance, leaders are required to be the example and provide direction to increase the confidence and sense of control of the followers. Therefore, without the leaders who possess the adequate tools for coping with change, the followers either withdraw or resist the change (Nodeson, et al., 2012). Therefore, to deal with the resistance the leaders are required to teach and train the followers on the necessary tools and skills and support those individuals that set the right example instead of punishing them as often done by managers.
Furthermore, leaders are also responsible for managing emotions to make the required organizational and individual changes. This generates a feeling of belongingness and the security that employees are needed to be part of the change process up to the top management level (Guttman, 2008). Moreover, the leadership should always stay a step ahead if there are more changes in the future and help manage the employees to eliminate chances of future shock that may promote resistance (Guttman, 2008). Finally, the leader should have a comprehension of all the mindsets of the followers that is whether they are narrow-minded (having limited education, sociocentric, deceptive, arrogant) as this contributes to resistance. Understanding such mindsets allows for the establishment of a collaborative approach to implementing change that promotes teamwork (Guttman, 2008). Finally, the leader should precisely know the needs and wants of the people and select the appropriate attitude for individuals to promote good interactions (Nodeson et al., 2012). They are required to make an articulation of the strengths and weaknesses of the followers and collaboratively assist in dealing with them.
2.9. The process of Managing Change
Leadership in the field of healthcare is extremely challenging and maintaining a competitive advantage in the healthcare field while leading an organization requires constant change (Campbell, 2008). To deal with the change and assist individuals in transitioning smoothly through the transition to new ways of doing things in the healthcare set up, the Kotter’s change model that comprises of 8 steps can be used.
These steps are first creating an urgency that is developing a sense of urgency regarding the need for change to initiate the initial motivation for rolling out the change. Second is forming a powerful coalition that is acquiring support from the key and influential people within the organization to support the change (Kotter, 2007). The third is creating a vision for change that is generating ideas and solutions for an existing problem and linking it with a mission and vision that individuals in the organization can easily comprehend. Fourth is communicating the vision that is passing the information about the change to the employees (Kotter, 2007). Fifth is eliminating any obstacles and this involves dealing with any factors that may lead to resistance to change as those discussed earlier. Sixth creating short-term targets that will provide short-term successes and act as motivators for achieving long-term change. Seventh is building on the short-term changes that are launching other change-oriented activities (Kotter, 2007). Finally, anchoring the changes within the organizational structures this involves making the changes a core component of the organizational culture and making the change visible in all the activities of the organization.
Source: (Mulder, 2014).
2.10. Conceptual Framework
The conceptual framework provides a relationship between the concepts, empirical research, and the theories for advancing and systemizing knowledge regarding related issues and concepts (Rocco & Plakhotnik, 2009). For this study, the conceptual framework is the context of health organizations and serves the purpose of guiding empirical work inherent in this study to promote the understanding of the determinants and mechanisms through which change occurs and the challenges experienced in the change process.
This section has provided the concepts inherent in having organizational change. It is evident that the process does not involve a single individual but the entire multidisciplinary team in the healthcare setting. Effective leadership requires the understanding of both the individual’s and organizational needs and implementing the appropriate skills to eliminate any resistance to the change. The paper provides a discussion of all these components and vital areas in managing change and a model for implementing the change.
This study involved a review of research conducted in the past with a focus on the role leadership plays in managing change within healthcare organizations as is the topic of the study. The first extensive review of literature resulted in the selection of 20 articles that focussed on the management of change. A further three rounds of searching was done that began with a broad search of general articles. The second round involved a refining of the articles selected in the first review and this was based on the framework that was presented previously. During this second review, the following keywords were used, “leadership,” “management,” “organizational management”, “leading in organizations,” leading healthcare organizations,” and “managing health organizations.” These words guaranteed that issues relating to change were within the realm of organizational management and leadership.
An examination of the selected list was then made to correct any existing errors, for instance, the removal of double entries and articles that on a closer outlook made no analysis of leadership and management of change within healthcare organizations. In addition, if they did not meet other formal requirements such as a period of publication, journal it was published, and the language used. After this review, 10 articles remained that were reviewed further but in greater detail. This final review comprised of summary and data classification where the articles were individually reviewed and labeled based on the dominant themes related to the area of interest that is the content, context, process, and outcomes (leadership). The general information and information based on content was then acquired from the articles and these were to help with data classification. The overall classifications were founded on the categories of the author, the journal it was published in, and the year of publication.
The factors that were taken into consideration during this review were more specific and included leadership, change, leadership and managing change, change in healthcare organizations, leadership in the healthcare organizations, resistance to change, and implementing change in healthcare organizations. Moreover, the articles summaries were noted down for purposes of bringing out the insights and relevance of conducting such a review. At this stage, more articles shortlisted earlier were further excluded as they did not meet the threshold set of the year of publication, a journal published, and relation to the research topic. Based on the reviews 6 journals were deleted from the list and 1 more that was initially not present added. The final list comprised of 5 sources that were further reviewed in depth.