Ethical Leadership Effects on Medical Laboratory Personnel Accoun

Chapter 1: Introduction to the Study

Ethics are a set of moral principles that derive from cultural norms and values that

sometimes turn into federal regulations or state laws (Brown et al., 2005; Gronowski et

al., 2019; Hartog et al., 2015). Unfortunately, these laws and federal rules are often found

to be ineffective when people face ethical decisions that involve the well-being of

patients and society (Datta, 2020; Gronowski et al., 2019). Ethical practices in laboratory

medicine are defined by either the law of the laboratory’s municipality or a code of

conduct regarding decision-making for clinical laboratory professionals (Wijeratne &

Benatar, 2020). Professionals recognize that there is no study on ethical leadership within

medical laboratory leaders. Additionally, there is no book on ethical leadership for

medical laboratory leaders (Bruns et al., 2015; Wijeratne & et al.,2020). This lack of

knowledge and resources on ethical leadership is due to the fact that medical laboratory

scientists rarely participate in bioethical disputes and are unaware of the vital need for

and importance of ethical leadership in medical laboratory settings, and record ethics as

an operating manual rather than moral responsibility (Afolabi et al., 2015; Madhu et al.,

2019).

Domen (2002) conducted a survey and found that 84% of medical laboratory

professionals believed that ethical issues are underrecognized, and 38% revealed that

their current ethics training is inadequate and impractical for their practice. Bruns (2015)

found that ethical leadership training and teaching is absent in both clinical and medical

laboratories. Moreover, there is no workable theory on ethical leadership that can be

served as a guide to assist medical managers in dealing with ethical dilemmas and

decision making (Shina et al., 2019; Wijeratne et al., 2020). Ethics is crucial in medical

laboratory medicine because medical laboratory employees have a responsibility for the

general well-being of society and members of their community (Datta, 2020).

Nyrhinen (2000) revealed that genetic testing, HIV, prenatal, autopsy, specimen

handling, and labeling are the most ethical problematic examinations in a medical

laboratory, with a range of 46% to 68.2% total errors in the pre-analytic phase (Gamble et

al., 2014). As such examination errors occur during the pre-analytical phase, the results

and interpretations from this analysis are often used for discrimination and stigmatization.

Ethics in medical laboratory settings only focus on collecting specimens, chemical

disposal, information collections, the performance of the test, medical record retention,

and storage (Aggwal et al., 2020; Cocks, 2016; Datta, 2020). While these guidelines are

acceptable for medical laboratory management, in some cases, they are inadequate due to

the lack of theoretical knowledge of ethical leadership and ethical training in medical

laboratory settings (Cocks, 2016; Gronowski et al., 2019; Wijeratne et al., 2020).

Witjeratne and Benatar (2020) stated that the most common ethical dilemmas in

medical laboratory settings are due to negligence and lack of accountability because

physicians or managers sometimes approve forms and reports without review, which

sometimes cause a patient to face life-threatening symptoms or end up in intensive care.

Additionally, employees or physicians are appointed to leadership roles based on long-

term tenancy rather than management skills or experience. They are given responsibilities

with no leadership training nor ethical leadership knowledge for managing employees

(Khalajzadeh et al., 2019). Because medical laboratory managers rely on their training

concerning surgery issues, chemical disposal, patient confidentiality, patient safety, and

record-keeping they have little knowledge on how to model ethical behavior in the

workplace to influence employee ethical and accountability behaviors (Bruns et al., 2015;

Gronowski et al., 2019; Wijeratne et al., 2020).

Goleman (2009) stated that a leader’s attitude can either energize or deflate an

organization. Leadership is crucial for team management, organization functions, and

directions. Health care organizations, especially medical laboratory industries, have

placed little effort in leadership development and training for their assigned management

roles (Ghiasipour et al., 2017, Wijeratne et al., 2020). Ghiasipour et al. (2017) argued that

the absence of ethical leadership research in health care is a social problem that places

stakeholders at risk impacting society's health level. From qualitative analysis, they found

that clinical managers are unfamiliar with leadership theory and lack knowledge of

organizations' behavior for managing employees. While the manager's leadership style

must align with the organization's practice and values, a leader with no ethical standard or

morals can give rise to a toxic work culture that can lead to the downfall of the entire

organization and endanger public safety (Brown et., 2005; Hartog et al., 2015).

Although research on the relationship between ethical leadership and

accountability is scarce, it has shown that leadership integrity plays a significant role in

employee accountability (Waddock, 2004). Unfortunately, in today's world, especially in

medical laboratory settings, employee accountability does not appear to be a common

trend in practice (Balderson et al., 2005; Brown, 2004; Gamble et al., 2014).

Accountability is the obligation and the willingness to accept responsibility for one's

actions and mistakes (Lerner & Tetlock, 1999). Over the years, demand for greater

employee has increased over the years in medical laboratory organizations (Baker et al.,

2004; Brown, 2006). Concurrently, it is believed that employee accountability was easy

to monitor without leadership guidance. However, these assumptions were proven wrong

and resulted in inaccurate laboratory results fatalities in some cases, which impacted

patient treatment due to employee negligence (Baker et al., 2004; Bourne, 2013;

Komarnicki, 2012;).

Ethical issues play a vital role in laboratory medicine. Therefore, managers who

are appointed into leadership must be fully aware of the importance of ethical leadership

in medical laboratory management and decision making (Aggarwal et al., 2021;

Witjeratne et al., 2020). To the present date, the effect of ethical leadership on employee

accountability behavior in medical laboratory settings is unknown because medical

laboratory organizations only enforce ethics through regulations (Datta, 2020). The lack

of knowledge of ethical leadership in medical employees is a social issue that cannot be

ignored and will continue to pose a significant threat to public safety.

Statement of the Problem

Medical laboratory personnel have an obligation to their patients, communities,

and society (Bhagwat & Pai, 2020). The lack of ethical leadership knowledge in medical

laboratory management can give rise to more ethical scandals and malpractice that will

endanger both patients and the public if not addressed (Ghiasipour et al., 2017; White et

al., 2019; Witjeratne et al., 2020). Although researchers have shown that ethical

leadership practice may prevent these detriments, there is a lack of understanding of the

effectiveness of ethical leadership on employee outcomes, especially in laboratory

medicine (Afolabi et al., 2015; Brown et al., 2005). At present, there is no research

regarding the ethical behavior of leaders on employee ethical behavior of accountability

in medical laboratory organizations (Witjeratne et al., 2020). Additionally, professionals

in medical laboratory establishments have limited ethical leadership knowledge for

managing employees (Bruns et al., 2008). They are unaware of the ethical behaviors that

they are supposed to exhibit through social learning to influence the ethical behavior of

accountability in their employees, because ethical leadership studies are conducted in

other areas outside of health care (Brown et al., 2005; Bruns et al, 2008).

Accountability behavior is taking ownership of the results of one’s actions, and

the willingness to accept responsibility and be accountable for that action without

blaming others (Wang, 2016). While the need to strengthen accountability in healthcare

organizations has made its appeal in healthcare studies (Barker et al., 2004; Deber, 2010;

Deber, 2014), the fundamentals of how to influence accountability behaviors through

ethical leadership in medical laboratory organization remained under researched. The

relationship between ethical leadership and accountability behavior in medical laboratory

settings remain undetermined because medical laboratory organizations enforce

accountability only through regulations or state laws rather than ethical leadership

training and teaching (Gamble et al., 2014; Steinbauer et al., 2014). Given that little is

known of the influence of ethical leadership in laboratory medicine, a gap was be

addressed by examining the effect of ethical leadership on medical laboratory personnel

accountability behaviors. Consequently, a study was conducted to examine the effect of

ethical leadership on employee accountability behaviors among medical laboratory

personnel.

Purpose of the Study

This focus of this quantitative study was to determine the effect of a laboratory

manager’s perceived ethical leadership on their assigned laboratory employees'

accountability behaviors. It also explored if the time working for a given medical

laboratory manager moderates the relationship between their assessed ethical leadership

in predicting their laboratory employee’s accountability behaviors. This study promotes

social change by demonstrating the impact of ethical leadership on medical laboratory

staff and increasing awareness of the need for ethics training in medical laboratories.

Research Questions and Hypotheses

The following research questions and associated hypotheses guided this study:

Research Question 1 (RQ1): Does perceived medical laboratory manager ethical

leadership predict their assigned laboratory staff’s employee accountability behaviors?

Null Hypothesis (H01): Perceived medical laboratory manager ethical leadership

does not predict their assigned laboratory staff’s employee accountability behaviors.

Alternative Hypothesis (Ha1): Perceived medical laboratory manager ethical

leadership predicts their assigned laboratory staff’s employee accountability behaviors.

Research Question 2 (RQ2): Does the total of months laboratory staff is assigned

to work for a medical laboratory manager moderate the relationship between their

perception of their managers ethical leadership and the assigned staff’s employee

accountability behaviors?

Null Hypothesis (H02): The time laboratory staff are assigned to work for a

medical laboratory manager does not moderate the relationship between their perception

of their managers’ ethical leadership and assigned staff’s employee accountability

behaviors.

Alternative Hypothesis (Ha2): The time laboratory staff are assigned to work for a

medical laboratory manager moderates the relationship between their perception of their

manager’s ethical leadership and the assigned staff’s employee accountability behaviors.

Theoretical Framework

Social Learning Theory

Bandura's social learning theory (SLT) has been used by professionals to

understand the mechanism of unethical behavior and the influence of ethical leadership

on employee outcomes (Brown et al., 2005). SLT suggests that behavior is learned

through observation and learning (Bandura, 1977). In relationship to unethical behavior

in the workplace, employees can learn ethical or unethical behavior through observation

to determine what behaviors are expected and rewarded. When employees learn what

actions are considered acceptable by their leaders, unethical behavior is eliminated

(Brown et al., 2005). SLT is used to explain the characteristics that contribute to ethical

leadership and how ethical leaders influence ethical behaviors in their employees.

Employees look up to their leaders for ethical guidance and feedback. When the leaders

act as credible role models, the employees value the behavior and learn to model the

ethical behavior observed (Brown et al., 2005; Copeland, 2016; Trevino et al., 2014).

Knowing this, medical laboratory managers using the SLT can learn what behavior to

follow and exhibit to influence ethical behavior of accountability in their employees.

Moral Disengagement Theory

Bandura's (1999) moral disengagement theory (MDT) is used in ethical studies

because it is used to focus on why employees engage in certain behaviors and how

employees tend to justify their unethical behaviors to avoids guilt or consequences from

their deviant behavior and maintain balance with their personnel moral standard. The

employee will try to validate a decision that results in deviance and deactivation from

their internal moral standard (Bandura, 1999; Tillman et al., 2018). For example, if an

employee makes a mistake, the employee may lie to their leader and fail to take

accountability for their actions if that employee believes that reporting their mistakes will

place their job security in jeopardy. Unlike SLT, MDT does not imply modeling; the

theory focuses on employee moral justification and leadership practice on employee

deviance (Gang, 2018). Research has shown that employees with low moral

disengagement are more sensitive to ethical leadership and that employee perception of

ethical leadership is more robust when the employee's moral disengagement is low

(Bonner at al., 2016). The MDT suggests that ethical leadership relationship with

followers goes beyond role modeling (Bandura, 1999; Moore et al., 2019). Through

cognitive processing ethical leaders can reshape how their followers form their moral

decisions to decrease deviant behaviors and organizational corruptions (Moore et al.,

2019). Given scholarly consensus that the MDT is valid in ethics studies, it was applied

in this study.

Nature of the Study

The study delivered instruments online to examine the predictive relations of

ethical leadership and accountability behaviors of medical laboratory employees. Ethical

leadership was measured using Kalshoven et al.’s (2011) Ethical Leadership at Work

Questionnaire (ELWQ), a questionnaire proven to be reliable for measuring ethical

leadership outcomes and unethical behaviors in the workplace (Kalshoven et al., 2011;

Wijesekara et al., 2018). Accountability behavior was assessed using Wood and

Winston’s (2007) Leader Accountability Scale (LAS). The LAS is highly desirable for

leadership selection, development, and leadership effectiveness research (Khurrum, 2006;

Wood et al., 2007). A regression analysis, using SPSS, was used to examine the

predictive relations of medical laboratory managers ethical leadership influence on the

accountability behaviors of medical laboratory personnel. A moderation analysis was

conducted to test whether the time medical laboratory staff serve under a given manager

influences the relationship between a manager’s assessed ethical leadership and their

staff’s self-reported employee accountability behaviors. The population of medical

laboratory employees sampled for this study reside in Western upstate New York.

Definition of Terms

The definitions of the terms and variables presented below provide an

understanding of the concepts used throughout the study.

Accountability behavior: The ability to take ownership of one’s action without

passing the blame to someone else with the willingness to take responsibility for that

action (Deber, 2014).

Employee engagement: The level of psychological investment and commitment

an employee has towards an organization with the willingness and ability to contribute to

its success (Yi-Jia et al., 2008).

Ethical leadership: A form of leadership, where the individual leads by example

and demonstrates appropriate behavior and applies morals standard in decision making

(Brown et al., 2005).

Health care organization: A health system organization that provides health

services such as treatment, diagnosis, cure for disease, illness, or injury, and is often the

first point of contact with health care practitioners and professionals to provide primary

care, secondary care, and public health (Cocks, 2016).

Medical laboratory employees: Individuals who worked in clinical pathology,

anatomy pathology, blood bank, chemistry, histology, pathology, genetics, microbiology,

toxicology, clinical biochemistry, cytogenetic laboratories, hospitals, clinics, and private

physician offices responsible for conducting tests that provide information on patients'

diagnostic, treatment, and prevention of disease (Cocks, 2016; Majkić-Singh,2017;

Wijeratne et al., 2020).

Medical laboratory manager: A person who is trained and understands the

effectiveness and efficiency of medical laboratory operations and functions; plans and

implements laboratory procedures, ensures staff compliance, provides administrative

support, resolves the problem, and monitors the laboratory. A medical laboratory

manager primary role is to ensure that their employees comply with the laboratory rules

and regulations and ensure that the laboratory is well maintained to increase work

efficiency and quality (Gamble et al., 2014; Wijeratne et al., 2020).

Moral disengagement: A psychological process where the individual is convinced

that an ethical standard does not apply in a particular situation (Bandura, 1999; Bonner at

al., 2016).

Servant leadership: A form of leadership where the individual focus is to serve all

the stakeholders in the organization. Servant leaders share their powers in decision

making with their employees and encourage innovation (Greenlaf, 1970).

Social change: A way in which society develops overtime to promote better

living, create policies, make necessary changes, increase awareness, and fight against

social injustice to promote better living conditions (Sablonniere, 2017).

Transformational leadership: A leadership style where the leader inspires,

motivates their followers. The leadership style relies on leader-member exchange because

the leader does not make demands of their followers and does not require their followers

to work harder to get rewarded. Transformational leadership is comprised of four

components: charisma, motivation, inspiration, and stimulation (Bass & Avolio., 2000;

Bruns, 1978; Herold et al., 2008).

Transactional leadership: A leadership style that is based on self-interest. Leaders

with this leadership style tell their employees what is expected from them to be rewarded

while relying on reward and punishment to influence employee and rely on self-

motivated employees to accomplish the organization's goals and (Brown et al., 2005;

Kanungo & Mendonca., 1996).

Unethical behaviors: Actions that fall outside that which is deemed morally right

and acceptable, lack moral principles, and do not adhere to moral conduct (Gang, 2018).

Assumptions

A general assumption was that the participants were honest and truthful in their

responses from the survey. Participants can often choose to give an answer that they

believed might be more desirable to the researcher (Trett et al., 2012). Another

assumption was that participants had a sincere interest in the research with no other

motives, and that the research sample represented medical laboratory employees. The

final assumptions were that the participants had enough insights and interaction with their

manager to respond the survey, and that the findings from the study are beneficial for

large medical laboratory organizations that specialized in medical testing and contribute

to promoting social change.

Scope of the Study

The study was limited to medical laboratory managers and medical laboratory

employees. Medical laboratory employees take up management roles as leaders with

minimal help from the physician and administrator of their practice and are expected to

maintain the laboratory work efficiency to increase profit (Kippist et al., 2009). Medical

laboratory employees are required to adhere to high ethical standards. Like any other area

in medicine, there are unique ethical issues that directly affect medical laboratory

practice. Consequently, there is a lack of ethics research in medical laboratory medicine

(Grotowski et al., 2019; Madhu et a., 2019). For the purposes of this study, a single

population of 55 medical laboratory employees in Western upstate New York were

selected to focus solely on medical laboratory employees rather than more broadly on

other health care professions. Due to the nature of the population, the results from this

study are unlikely to be generalizable to other populations in health care.

Limitation of the Study

A limitation that occurred in this study was that some of respondents did not

respond to most of the survey and exited before completion. To manage this limitation,

the target audience in the Survey Monkey Target Audience collector and demographic

questionnaire was adjusted to send the survey to the right respondent who matched the

criteria of the demographic questionnaire with reminders every 2 weeks. The Survey

Monkey Target Audience collector options from SurveyMonkey also made sure that the

survey was sent to a specific population of medical laboratory personnel based on

demographics, employment status, gender identification, time assigned under current

manager, number of years of employment and age. Another limitation was that the time

under current manager may vary between participants, where employees may have

worked for a previous manager for a much more extended period. To manage this

limitation, participants were asked in the demographic questionnaire to record the time in

month that they have spent under their current laboratory manager. Another limitation

was the possibility of missing of data due to sample attrition resulting in a difference

between the initial and the ending sample (Mason, 1999). The sample size analysis from

the G* Power 3.1 software indicated that 55 participants was an appropriate sample for

the study. Therefore, to account for sample attrition, a 10% margin was added to the

sample size and total of 61 participants was sample. An additional limitation was that this

study focuses on large medical laboratory organizations specializing in medical testing.

Therefore, the findings from this study might not reflect other specializations in small

medical laboratory settings, especially hospitals laboratories.

Quantitative research involves a structured questionnaire with close-ended

questions. Therefore, a structured questionnaire limited the outcomes of the study. The

nature of the self-report survey limits the outcomes of the research because respondents

have limited options of responses, then the additional information in-depth interview can

provide (Simon 2011; Younus 2014). Therefore, it was important that the design of the

study aligned with the population, and that the correct target group was selected to obtain

the maximum amount of reliable and valuable data.

Significance of the Study

The findings of this study support an understanding of ethical leadership on

employees' moral actions in laboratory organizations and fill the gap in current research.

Additionally, the findings can be used as a guide for medical organizations in the

fundamental effect of ethical leadership on employee behaviors in medical laboratories.

Last, the findings support the ongoing need for ethical leadership studies in medical

laboratory practice.

Ethical dilemmas are presented daily in medical laboratory settings. Although

laboratory employees do not come into direct contact with patients, the lack of ethical

practice and ethical leadership failures can cause life-threatening events that can interfere

with public safety and society (Gronowski et al., 2019; Witjeratne et al., 2020). As ethical

dilemmas continue to surface in medical laboratories, the professionals who are assigned

leadership roles are often left unaware of the importance of ethics in their decision

making (Khalajzadeh et al., 2019). Furthermore, they are often unaware of the behavior

that they are supposed to exhibit to their subordinates to eliminate unethical behaviors

and increase accountability in their department (Khalajzadeh et al., 2019; White et al.,

2019). The findings of this study cover a gap in ethical leadership literature in laboratory

medicine, where ethics studies are currently non-existent, and raise awareness on the

need for ethical leadership studies in medical laboratory organizations. Furthermore, the

result from this study can help promote better work environments for employees and help

create new policies and ethics training that help decrease unethical behaviors in the

workplace.

Summary and Transition

While laboratory organizations rely on studies from other health care professions

to guide their practice, managers in laboratory medicine do not have a current model on

ethical leadership to guide their practice (Gronowski et al., 2019). Furthermore, the

ethical leadership training that these managers received is inadequate and insufficient for

their management roles, and do not address the ethical issues that uniquely affect medical

laboratory practice (Bruns et al., 2015; Gronowski et al., 2019; Wijeratne et al., 2020).

Chapter 1 presented the need for ethical leadership in the medical laboratory setting. The

purpose, problem, and reference to previous literature presented the beneficial factor of

ethical leadership in organization management and practice. The presented study

addressed that gap by examining the predictive relations of ethical leadership medical

laboratory managers on the accountability behaviors of the medical laboratory personnel

they supervise. This study can contribute to the promotion of social change by improving

workplace conditions for medical laboratory personnel. The result of this study raised

awareness of the importance of ethical leadership in medical laboratory management.

Chapter 2 presents a literature review of the theories and fundamental concepts of

the study. The chapter focuses on the theoretical concept of leadership. Leadership

theories, including transformational, transactional, servant, and ethical leadership, are be

discussed. The concept of accountability and what is known about the relationship

between ethical leadership and accountability are addressed. Chapter 3 covers the

research design, methodology, the population, including participant selection,

instrumentation, data collections, and analysis, are discussed. Threats to validity, ethical

procedure, and participants' protections are also explored. In Chapter 4, data provided

from medical laboratory employees from Western New York are analyzed. The

assessments used for the research are the ELWQ and LAS and were distributed using

SurveyMonkey. Chapter 5 reviews the findings of the study and makes connections

between the findings to the literature and the theoretical framework. The limitations of

the study are explored, and recommendations for future research are provided.

Chapter 2: Literature Review

This chapter contains literature on the theoretical foundations of leadership with

the definitions of the concept, including current research findings that address ethical

leadership and accountability. From a theoretical basis leadership theory, transactional

leadership, transformational leadership, servant leadership, ethical leadership,

accountability behavior and ethical leadership, SLT, and MDT are discussed. Previous

researchers have argued that ethical leadership has an impact on employee outcomes. In

this chapter, theoretical and empirical research that focuses on ethical leadership, power

and leadership, accountability behaviors, and impacts on employee accountability

behavior are reviewed. The literature review compares ethical leadership with other

leadership theories to understand concepts that appear to be similar.

Literature Search Strategy

The keywords that were used to conduct this literature search included ethical

leadership, unethical behavior, moral justification, harassment in the workplace,

deceptive behaviors, workplace and ethics, workplace accountability, ethic in laboratory

medicine, laboratory medicine management, and leader characteristic, leadership and

accountability, laboratory ethics, medical ethics, laboratory management, power and

leadership, leadership and ethics, and leadership theories. Databases that were used for

the search included ResearchGate, Emerald Insight, ProQuest, Education Source, Psych

info, Psych articles, Business Source Complete, EBSCO, ScienceDirect, Walden

University Dissertation & Theses database at Walden University, SAGE Journals, and the

Social Citation Index.

Leadership Orientations

Leadership theory is one of the most researched and debated topics in social

psychology, management studies, and industrial/organizational psychology (Connell et

al., 2002; Pfeffer, 1993). Scholars continue to seek more information regarding what

makes a good leader (Anderson et al., 2015; Mutswa, 2016; Oludolapo et al., 2019).

According to Northhouse (2016), individuals commonly seek new information on

becoming a great and effective leader. The result of this curiosity has resulted in

increased leadership studies over the years (Brown et al., 2005; Hartog et al., 2015).

Organizations use leadership research to identify employees with leadership skills to

significantly improve organizational functions, productivity, and proficiency (Bass,1990;

Butts, 2012; Northouse, 2016).

Lussier and Achua (2010) stated that an organization's future strongly relies on its

leadership because leaders can help increase employee productivity; increase

organization revenue; promote changes; and increase positive attitude, performance,

engagement, loyalty, and job satisfaction. Throughout the years, leadership researchers

recognized that different leadership styles and approaches contribute to leadership theory

and complexity of leadership (Bass,1990; Brown et al., 2005; Burns, 1978).

Traditionally, the most common leadership approaches are autocratic, participative,

laissez-fare, transactional, and transformational leadership. In recent years, servant,

authentic, and ethical leadership have been added to that list. The following sections

provide additional context on each of these leadership styles.

Autocratic Leadership

Autocratic leadership, also known as authoritarian leadership, is a leadership style

characterized by authority where the individual has dominance over all decisions and

allows little input from group members (Chioma et al., 2017). Individuals with this

leadership style make decisions based on their judgment without cooperation and

engagement from their followers and use reward, coercion, or punishment as tools to

motivate their subordinates (Lopez, 2014; Schoel et al., 2011). Studies reveal that

autocratic leaders can harm an organization by forcing their followers to perform tasks

based on their ideas of success rather than shared vision (Cherry, 2016; Srivastava, 2016).

As power is the dominant attribute of autocratic leadership (Schoel et al., 2011),

individuals with this leadership style show little value to employee creativity, which often

leads to low employee engagement and satisfaction, as well as lack of trust and teamwork

(Amanchukwu et al., 2015; Blomme et al., 2015; Kan et al., 2015).

Autocratic leadership is mainly preferred in intensive or critical care practice

because often, the physician is the only one in the team with the requisite skills and

knowledge to diagnose and select the appropriate treatment for patients (Yun et al.,

2005). During a surgical procedure, trauma, and acute resuscitation where there is little

time for collaborative decision making, the physician often instructs the staff on what to

do and makes decisions based on justifiable need without staff input (Samarakoon et al.,

2019; Sanftou et al., 2017). Autocratic leadership studies in healthcare primarily

examined critical care employee opinions and not employee outcomes (Sanftou et al.,

2017; Vance et al., 2002). This leadership style tends to promote diagnostic error because

the leader is often unwilling to share information with their staff to retain power. Having

no tolerance for mistakes it may cause staff members to remain silence due to fear of

being blame even if they have critical information or have observed a behavior that the

physician overlooks (Mantous et al., 2011; Stanfou et al., 2017; Yun et al., 2005).

Participative Leadership

Participative leadership is a leadership style where team members participate in

the decision-making process (Xu, 2017). This leadership style is the total opposite of

autocratic leadership because the leaders facilitate employee engagement in the

management process and integrate their followers’ skills and knowledge into the

decision-making process before arriving at a final decision (Chioma et al., 2017;

Srivastava, 2016). As a result, employees feel more engaged, valued by their leader and

are more motivated to work efficiently (Srivastava, 2016; Xu, 2017). Studies show that

participative leadership significantly influences employee communication and

satisfaction, improves patient health, and reduces job turnover (Batti et al., 2012;

Musinguzi et al., 2018; Xu, 2017). Additionally, in health care, employees participating

in decision-making are more motivated to carry out team functions and responsibilities

(Musingisi et al., 2018; Xu, 2017).

Srivastava (2016) showed that participative leadership leads to trust development

among subordinates, he also found that the leadership style is only effective when

employees are motivated to share their knowledge (Srivastava, 2016). Despite the

positive outcomes of participative leadership on employee satisfaction and organizational

change (Pardo-del-Val et al., 2012), the leadership style is more successful in motivated

employees (Chery, 2016). Even when all employees contribute to the decision-making,

the leader still spends much time and effort to make even a small decision, due to

conflicts and lack of resolution during decision making (Samarakoon, 2019). Further,

disadvantages that are known to emerge in participative leadership are slow motivation,

conflicts, and loss of time during decision-making, which can be critical during an

emergency when quick decisions are needed for patient care (Chery, 2016; Mantous,

2011; Nagendra, 2016; Xu, 2017).

Laissez-faire Leadership

Laissez-faire style is a form of leadership where the leaders fail to take

responsibility for themselves and their subordinates (Allen et al., 2013; Chery, 2016).

Employees perceive individuals with this leadership style as absent and withdrawn

leaders who have no interest in their follower’s growth and show little effort to form a

relationship with their followers (Arenas et al., 2018; Bass, 1985; Northhouse, 2010).

Laissez-faire leadership involves a hands-off approach where the leader puts more of the

responsibility if not all in the hands of their followers while being available for feedback

(Gilani et al., 2014). Zareen et al. (2015) found that laissez-faire leadership can be

effective where employees are highly motivated and capable of completing tasks

independently. In these cases, the autonomy given by laissez-faire leaders increases

satisfaction and learning opportunities in employees with high intrinsic motivation

(Cilliers et al.,2008; Zareen et al., 2015).

Researchers found that laissez-faire leadership is the most ineffective and most

destructive leadership style (Avolio & Bass, 1995; Chery, 2016). Leader avoidance

behavior and lack of guidance causes employees to be less motivated and less productive,

due to the lack of structure, support, and lack of appreciation (Chery, 2016; Ekmekci,

2016; Samarakoon, 2019; Skogstad et al., 2014), which leads to poor group performance,

missing deadlines, avoidance in communication, lack of cohesiveness within-group,

conflicts, and deferral decision-making (Allen et al., 2013). Quantitative research reveals

that both laissez-faire and transactional leadership adversely affect job satisfaction and

weaken interpersonal relationships in health care workers (Chaudhry et al., 2012;

Madlock et al., 2008; Samarakoon, 2019). Further, laissez-faire leaders appear to have

low level of engagement with team members and lack emotional intelligence skills that

often result in lack of trust between the leader and the employee and can also result in

unethical practice (Avolio & Bass, 1995; Ekmekci, 2016; Northouse, 2010; Tosunoglu,

2016).

Transactional Leadership

A transactional leader focuses on allocating assets and using contingent rewards

to direct followers to achieve organizational goals and obtain desired behaviors (Bass,

1985; Washington et al., 2014). A transactional leader uses reinforcement, power, and

punishment to motivate employees by appealing to an individual need rather than the

group goals (Northouse, 2010). Leaders in this category set goals and expectations for

their employees and offer a reward when the standard is met (Bass, 1990; Fletcher et al.,

2018; Saros, 2001). An example of a transactional leader is a politician who looks to win

votes by promising new policies that will help their followers, which also works for

his/her interest (Paramova & Blumberg, 2017).

Bass (1990) stated that transactional leadership style negatively affects employee

performance and development because a transactional leader does not focus on forming a

relationship with their employees and do not set the effort to increase creativity and

leadership skills. In the workplace, managers with transactional leadership style focus

more on organizational functions, sustaining status quo, and stability (Barbuto, 2005;

Sultana et al., 2015). Under a transactional leader, employee outcomes rely on reward

and the leader's ability to determine which reward will increase employee motivation,

engagement, and satisfaction (Osborne et al., 2017). Nevertheless, the reward and

incentives program used for the employee performance, and to increase motivation are

often found to be ineffective in transactional leaders because they often fail to determine

which incentive programs are best suited for their employees. Studies show that

employees who earn livable wages are less motivated by financial rewards (Aguinis et

al., 2012; Kulchmanov et al., 2014; Randall et al., 2006). Additionally, employees who

do not want leadership roles or are intrinsically motivated will not show a change of

performance because they will find the rewards unbeneficial (Aguinis et al., 2012;

Barbuto, 2005; Hay, 2013). This roadblock often causes transactional leadership to be

ineffective because the leader fails to analyze their employee's needs to increase

productivity, growth, motivation, and innovations (Bass, 10985; Northouse, 2010; Sultan

et al., 2015).

Transformational Leadership

Transformational leadership is one of the most researched leadership styles

because it focuses on charismatic behavior, followers' development, organizational

culture, and change (Bass & Riggio, 2006; Bryman,1992). Transformational leadership

gained popularity over the years because of its critical role in employee motivation,

workgroup performance, and employee satisfaction (Antonakis, 2012; Bass & Riggio,

2006; Herold et al., 2006). Bruns first developed the transformational leadership theory in

1978. The theory states that transformational leaders focus on satisfying the basic need of

their followers while inspiring individuals to provide new solutions and ideas to create a

better work environment (Bass, 1999; Bruns, 1978; Sfantou et al., 2017). Herold et al.

(2008) defined transformational leaders as individuals who understand the value of their

establishment and align their goals with their employees. The leadership style influences,

encourages, empowers, and motivates employees to take pride in their work and focus on

the organization's well-being (Lussier & Achua, 2010; Yi-Jia et al., 2008).

Transformational leadership has some transactional content where both the leader

and the follower work together to attain a higher level of motivation and achieve their

goals (Aviolo et al., 2004; Aviolo et al., 2011; Bass, 1990). Further, transformational

leadership is often present during organizational development and changes, making this

leadership style an essential aspect in any work setting (Yi-Jia et al., 2008).

Transformational leadership plays a crucial role in employee performance, job

satisfaction, and engagement (Yi-jia et al., 2008). A transformational leader inspires

involvement by allowing employees to be creative without micromanaging. This buy-in

also creates a healthy work relationship between the organization, the employees, and the

leader (Huang et al., 2009; Singh, 2019; Zhang & Bartol, 2010). Employees inspired by

their transformational leader are more likely to increase work performance, commitment,

and satisfaction (Gillet & Vandenberghe, 2104).

Charisma is one of the main components of transformational leadership, yet,

researchers found a difference between transformational leadership, which may

incorporate charismatic qualities, and charismatic leadership (Aviolo et al., 2004; Bass,

1990). Transformational leaders engage in charismatic behavior by motivating and

influencing their followers to achieve better work outcomes and influence their followers

to be committed to the organization's changes and values (Aviolo, 2004). In contrast, a

charismatic leader increases commitment and collaboration in employees and increases

work proficiency by showing confidence in their ability and capabilities (Bass, 1990;

Aviolo et al., 2004; Van Knippenberg & Sitkin, 2013). Ethics studies reveal that a

transformational leader can behave both ethically or unethically based on their moral

values, power misusage, or when decision-making is based on personal gain (Felix et al.,

2016; Keely, 1995; Krishnan et al., 2000; Muhammad et al., 2016). Koroll (1994) stated

that transformational leadership has its place in health care because medical laboratory

personnel need to have a manager who acts as a role model, projects ethical conduct, and

applies changes and resources to increase the quality of work-life, patientcare,

community satisfaction, and employees' motivation (Baqer et al., 2018; Kaluku et al.,

2018).

Servant Leadership

Servant leadership has raised significant disagreements on leadership over the

years (Eva et., 2019; Gandolfi, 2018). How can an individual be a leader and a servant at

the time? Greenleaf first introduced servant leadership in 1970. Servant leaders

demonstrate assertive moral behavior toward their employees and focus on their

employees and team members rather than their own needs (Chung, 2011, Hale & Field.

2007; Udani et al.,2013). Servant leaders see their leadership position as a responsibility

rather than a privilege; they are ethical and attentive to the concerns and needs of their

followers (Hale & Fields, 2007; Greenlaf, 1977). Servant leaders nurture their followers,

empower their followers to develop their full capacities and provide support to employees

to achieve tasks and goals (Greenleaf, 1970). A servant leader includes employees in

decision-making; this input increases team cohesiveness, work engagement, and trust

between employees, clients, and stakeholders (Melchart et al., 2010; Saleem et al., 2020).

Research shows that servant leadership plays a role in employee retention by

creating a sense of belonging in the employee and establishing a positive work

environment (Chen et al., 2002). One of the primary goals of servant leadership is to

create a healthy work environment, establish a platform for growth, increase

organizational performance, and create a positive impact on society (Greenleaf, 1970).

Servant leaders recognize their follower's ability and contribution and influence their

subordinates to achieve their full potential and personnel goals (Al Afeshat et al., 2019).

A servant leader positively influences work relationships and collaboration between

employees to increase a healthy work environment and culture (Burton et al., 2017; Hu &

Liden, 2011; Melcher & Bosco., 2010).

Scholars found that servant leadership significantly influences employee

performance, commitment, organizational trust, task performance of subordinates,

employee satisfaction, and retention (Asefat & Farida, 2019; Saleem et al., 2020). In

organizational settings, servant leadership has gained its popularity, in part, due to its

ethical component (Sousa et al.,2017). Servant leaders empower, protect their employees,

and chose professional goals based on the organization's objectives (Muhammed et al.,

2016). Servant leadership is often found to be the preferable leadership style in health

care organization because a servant leader applies ethical principles in their practice

(McMahone, 2012), focuses on their team, develops trust, and empowers team members

to increase patient satisfaction, and improve the value of patient care (Trastek et al.,

2014). Servant leaders have been shown to promote ethical work climate in health care

organization, reduce the cost of marketing for inpatient recruiting, and decrease patient

care costs to provide a more sustainable, high-quality health care system (Schwartz et al.,

200).

Authentic Leadership

The rapid increase of ethical scandals in organizations and government agencies

both nationally and internationally in recent years indicates that there is a need for

authentic leaders (Landez, 2018; Peus et al., 2012; Bagdasarov & MacDougall, 2016).

Although the knowledge of authentic leadership is still embryonic, the leadership style is

known to increase positive behavior, quality of life, work productivity, trust, and job

satisfaction (Avolio et al.,2005; Chan et al., 2005). Additionally, research shows that

authentic leadership is the biggest predictor for job satisfaction and organizational

commitment (Jensen et al., 2006). In healthcare management, the leadership style has

been shown to improve patient care, work engagement, and mental health (Al-Marri et

al., 2020; Coxen et a., 2016). Authentic leaders have strong moral standards and values;

they lead with purpose and possess a strong awareness of who they are as individuals and

how they behave (Avoli et al., 2005; Avoli et., 2014). According to Northouse (2015),

followers observed their authentic leaders’ behaviors based on three categories

intrapersonal, interpersonal, and development. The intrapersonal category of an authentic

leader is the internal qualities that the leader possesses, the knowledge of the leader, and

self-perception (Northouse, 2015). Authentic leaders lead with integrity and transparency

by engaging in communication with their followers to influence feedbacks and make

decisions based on internalized convictions and moral reasoning (Avolio & Gardner,

2005; Hannah et al., 2003; Leroy et al., 2015).

Authentic and ethical leadership are very similar with different concepts. Both

leadership styles have comparable fundamental frameworks: balanced processing,

relational transparency, self-awareness, and authentic behavior (Ilies et al., 2005;

Kalshoven et al., 2011). However, Authentic leaders are practical and expect their

followers to follow the same guidelines in which they operate (Saeed et al.,2020); though

the practice brings positive outcomes, it might not always be ethical base on the leader

moral values (Saeed et al., 2020; Sendjaya et al., 2016). At the same time, ethical leaders

are theoretical, and authentic whose leadership are based on ethics and morals (Saeed et

al., 2020).

Ethical Leadership

Ethical leadership falls under two categories: 1) the character of the leader, and 2)

the action of the leader (Brown et al., 2005). Ethical leaders influence their followers

through role modeling, interpersonal relations, communication, reinforcement, and

ethical decision-making (Brown et., 2005; Trevino et., 2006). While understanding the

influence of ethical leadership on subordinates is still on its infancy, professionals

continue to face roadblocks when conducting ethical studies base on the belief that ethics

can be thought from experience, rather than theoretical knowledge or empirical studies,

and that their knowledge on ethical leadership is sufficient any discipline (Hartog et al.,

2009; Price, 2000). Further scholar that examines the influence of ethical leadership on

subordinated only focus on the moral characteristics of the leader, not the leader’s action,

issues of ethics and ethical leadership studies, and the mediating effect in which ethical

leaders influence employee behaviors (Avolio et al., 2009; Schminke et al., 2005).

Research suggested that leaders can influence ethics through motivation (Lord et

al., 2001), unfortunately, the belief and style of practices are sometimes found to be

inadequate, and resulted misinformation, or malpractice of ethics in the workplace (Bruns

et al., 2008; Lord et al 2001; Price, 2000) Ethical leadership is about the leader's actions,

who they are as individual, how they apply ethic in decision making, including their

relationship with their followers (Brown et al., 2005; Khalshoven et al., 2011; Zang et al.,

2018). Ethical leader follows ethical values, takes his/her employee and organization into

consideration, and applies ethical principles and standards during decision making (Curtis

& O’Connell, 2011; Treviño et al., 2003).

Unethical leadership can affect lower-level employees (Brown et al, 2010). When

the leader fails to take accountability and engages in malicious behavior, it affects their

followers, and encourages their followers to engage in similar behaviors (Brown et al.,

2010). The aftermath from the unethical leader behavior not only affects the

organization's culture, but it also affects employee morale, decreases employee

satisfaction, and gives rise to a toxic work environment, with an increase of employee

turnover (Brown et al., 2005; De Hoogh et al., 2008; Mulki et al., 2007).

Unethical leadership often goes unrecognized because leaders sometimes foster or

ignore unethical behavior among employees without reprimand (Ashford, 1989, Brown et

al., 2010). Employees often engage in unethical behavior to increase organizational

performance, by trying to help the organization, the employees often disregard the

organization's policy or standard of operation (Brown et al., 2010). When ethical leaders

exhibit moral behavior, it has a positive effect on the employee that can also result in

positive outcomes (Brown et al., 2005; Moore et al., 2019). Thiel et al (2018) found that

through leader and member exchange ethical leadership increased employee

performance, engagement, and commitment.

Brown et al. (2005) stated that there are two ethical leadership elements: a moral

person and a moral manager. A moral person in ethical leadership focuses on the

character of the individual and traits built on fairness, honesty, respect, openness,

integrity, care, trust, and ethical principles (Brown et al., 2005; Trevino et al., 2000).

Leaders with these characteristics are found to be welcomed by their followers; they are

active listeners to their follower's concerns to identify problem in the organizations

(Brown et al., 2005). A moral manager in ethical leadership represents how the leader

uses their power and leadership position to influence ethical principles and ethical

behavior through role-modeling (Gang, 2018; Trevino et al., 2000; Zang et al., 2012), and

influences ethical behaviors of accountability by relating the employee's ethical behavior

to the organization's management system (Brown et al., 2005; Resick et al., 2018).

Summary of Leadership Orientations

Leadership is not always straightforward; it is not a one size fit all for all

organizations and situations. Each leadership style has advantages and impediments, as

well as an appropriate use for specific situations. Understanding the leadership style that

aligns with the organization's needs for practice can give managers a sense of control on

how to influence their employees’ behaviors and become effective leaders. The table

below provides a summary comparison of the eight common leadership based on findings

from leadership research.

Ethical Leadership Considerations

Ethical leadership is important in medical laboratories because it influences

positive collaboration between employees and helps create ethical workplace culture to

provide high-quality service that is safe for patients and society (Gamble et al., 2014).

Every day brings new ethical issues; ethical leaders can help medical laboratory

employees develop a better understanding of ethical principles and promote ethical

behavior through role modeling (Brown et al., 2014; Gamble et al., 2014; Pronovost et

al., 2018; Saxena et al., 2014). In health care industry moral disengagement have been

found to pose a serious threat to patient care, and public safety by displacing

accountability of unethical act into another source (Hyatt, 2017). For example, a

healthcare professional might disregard a patient's pain in fear of addiction or

undermining the patient's discomfort by blaming their judgment on organization policy.

According to Hyatt (2017), this type of justification, and displacement, may lower the

quality of care for the patient and threaten the patient's autonomy where the patient feels

pressured or coerced to participate in treatment that they were against or to remain

inpatient care for a more extended period.

Ethical leadership has been found to decrease employee moral disengagement

(Zhao et al., 2018). It is crucial in healthcare, especially in medical laboratories, because

moral disengagement behaviors do not merely occur at a personnel level but also occur at

the organization level (Hyatt. 2017). Therefore, a healthcare organization must improve

ethical education to discourage deviant behaviors.

Ethic leadership education and training are important in health care organization

because it helps create a culture of accountability that teaches employees to know when

to hold themselves accountable and speak up when they witness unethical behaviors

(Deber, 2014). In behavioral science, the SLT seeks to elucidate how behaviors are

learned and how the performance and behavior of leaders affect the work environment

(Brown et al., 2014). In medical laboratory environments, the modeling of ethical

behaviors by laboratory leaders is essential to help set high moral ground, build trust,

respect, credibility, and collaborations to create a healthy workplace culture (Pronovost et

al., 2018).

Evidence showed that more than 98,000 Americans died each year from medical

errors due to medical mistakes and limited accountability (Gamble et al., 2014; James,

2013; Pronovost et al., 2018), and further revealed that many of these fatal mistakes

could have been avoided if the employees had followed ethical and accountability

practice (Pronovost et al., 2018). Other evidence revealed that more than 2000 people

were ill after drinking water that was contaminated with E.coli resulting in the death of 6

individuals ( Cote et al..2017), while an investigation in the medical laboratory that is

responsible for the water monitoring showed no wrongdoing, further investigations

showed that the error of the laboratory malpractice occurs during the pre and post-

analytic phase due to inadequacy, negligence and lack of accountability resulting in a 1

billion dollar class-action lawsuit (Cote et al., 2017; Hipel et al., 2003; Walkerton

Inquiry, 2000). These unfortunate events present the need for ethical leadership and

employee accountability in medical laboratory environments.

A culture of accountability can help health organizations provide better care,

improve trust and positive work culture (Pronovost et al., 2018). However, the practice of

accountability starts with the leader, regardless of the leadership style and orientation

(Pronovost et al., 2018). The practice of accountability is essential in leadership because

it not only influences employees who have direct contact with the leader it also influences

lower-level employees to practice accountability behavior and reduce a work culture of

silence where unethical behaviors go unreported (Deber, 2014; Pronovost et al., 2018).

Employee accountability is one of the focuses of the study; therefore, a review on

accountability, and the relationship between ethical leadership, employee accountability

is important in this literature review to strengthen the case of the need for employee

accountability in medical laboratory settings.

Accountability

Not many studies have been conducted on ethical leadership and employee

accountability (Ghanem & Castelli, 2019). Studies that were conducted focused on

leadership accountability and the importance of accountability in ethical leadership rather

than investigating the effect of ethical leadership on employee accountability (Ghanem et

al., 2019). Accountability behavior is the ability to take ownership of one’s action and the

willingness to take responsibility, answer, and accept the consequences for that action

without shifting the blame to someone else (Tetlock, 1999; Wang, 2016). Tetlock

suggests that an employee must be aware of the accountability behaviors portrait by their

leader before they can engage in that behavior (Tetlock, 1999). Because only when an

employee is held accountable by their leaders that they become aware of the

accountability condition expected from them and more likely engage in ethical behavior

(Paolini et al., 2009).

In healthcare, accountability is crucial because it requires medical professionals to

acquire special skills and knowledge to provide better care for their patients, and to

respect legal and social standards (Batti et al., 2014). At the same time, professionals

believe that healthcare professionals will always be accountable for their actions due to

fear and legal recommendations (Gamble et al., 2014). Cox (2010) reveals that medical

professionals' accountability depends more on morals, self-accountability, leader’s

behavior, and concern for the public interest. If the employee perceived moral principles

and judgment to be absent in their leaders, it would affect employee accountability and

negatively affect the work culture and development (Cox, 2010; Gustafson, 2013; Lerner

& Tetlock, 1999).

Lack of accountability in any organization can lead to severe erosion of ethical

practice (Ghanem & Castelli, 2019). Therefore, the role of the leader is to ensure that

employees understand the importance of accountability and ethical decisions (Deber,

2010; Ghanem & Castelli, 2019; O'Brochta et al., 2012). Leaders should model

accountability and should learn to hold their employees accountable because lack of

accountability can severely affect an organization and pose a severe danger to society,

whether it is physical, financial, or mental (Brown et al., 2016; Deber, 2010). Medical

laboratory accountability falls under four categories: finances, regulations, information,

and incentives (Deber, 2010). Throughout these four categories, regulation was found to

be the primary approach use by medical laboratory organizations to achieve

accountability (Gamble et al.,2014). Reason for this approach is regulations are required

for high-quality laboratory practice, patient care, and because medical laboratory enforces

ethics only through laws and regulations (Gamble et al., 2014). Nevertheless, as medical

laboratories are highly regulated, there is a need to increase employee accountability

during the pre-post-analytical phase and point-of-care testing (Cote et al., 2017; Deber,

2010). While accountability continues to be of great interest in healthcare organizations,

especially medical laboratories, studies showed that the phenomenon could be

unpredictable and hard to manage without leadership and policy direction (Deber, 2014;

Gamble et al., 2014). Unfortunately, these studies were conducted in other sectors outside

of healthcare, leaving with the unknown of understanding the influence of ethical

leadership on medical laboratory employee accountability.

Related Theory

The moral disengagement and the social learning theory have helped

professionals understand employee behavior, leadership, and unethical practice (Brown et

al., 2005; Tillman et al., 2017). In health care, the MDT help understands how healthcare

practitioners justify unethical behaviors by switching blame or accountability on their

managers or organization policy (Hyatt,2017). Studies on ethical leadership and lack of

accountability in health care have made both the MDT and SLT great candidates for this

study. In medical settings, employees can learn ethical and unethical behavior through

observation (Brown et al., 2005). Therefore, medical laboratory managers must act

following ethical standards, and aware that they are being monitored by their employees,

and understand that how their employees perceive them determine their success in

establishing a healthy work environment where accountability is held to a high standard

(Brown et al., 2005; Brown et al., 2014; Cox, 2010)

Social Learning Theory

Over the years, professionals relied on the SLT to understand ethical leadership's

influence on employee outcomes (Brown et al., 2005). SLT provides an understanding of

why an employee perceives a particular characteristic of a manager as displaying ethical

leadership (Brown et al., 2005). SLT argues that followers perceived a leader as an

ethical role model when the leader leads with high moral values and ethical principles

(Bai et al., 2017; Bandura; 1977; Brown et al., 2005). SLT also helps to explain how

ethical leaders influence their followers through learning, engagement, observation, and

guidance (Bandura, 1977; Brown et al., 2005).

According to SLT, behaviors are learned through interaction, experiences,

environment, and knowledge (Bandura, 1977). While Bandura (1977) argues that a

person's behavior will never occur from these factors alone, he suggests that role

modeling plays a crucial role in influencing ethical behavior in employees (Bandura,

1977; Brown et al., 2005; Trevino et al., 2005). Bandura (1977) states that when an

individual notices something that occurs in their environment, it stimulates memories of

the noticed events. The individual, in turn, reproduces the behavior. When the individual

reproduced the behavior, the environment delivered a reinforcement or consequence for

that behavior that forced the individual to analyze if the behavior is acceptable or not

acceptable (Bandura, 1977; Brown et al., 2005).

SLT suggests that ethical leaders can influence their employees through role

modeling. The psychological process of role modeling entails observation, identification,

and anything learned through experience. Employees can learn what behavior is expected

through role modeling (Bandura, 1977; Brown et al., 2005). While studies suggest that

role modeling is an essential aspect of leader behavior, it is also essential that leaders

observe the employee behaviors to correct unwanted behaviors (Bai et al., 2017). While

an ethical leader is known to be charismatic, to promote respect, fairness, and altruism,

these behaviors might not be interpreted the same way by all employees (Bai et al., 2017;

Yussen & Levy, 1975). Therefore, being the observant ethical leader can help understand

how employees interpret, understand, and practice ethical behavior to illustrate and

influence ethical behavior in employees (Bai et al., 2017; Bandura, 1991).

Moral Disengagement Theory

MDT suggests that when individuals violate their moral standards, it creates

psychological imbalance and cognitive discomfort that force them to disassociate

themselves from the consequences to avoid taking accountability for their unethical

behaviors (Bandura, 1999). MDT describes why individuals often tried to justify their

unethical behaviors and why they fail to take accountability and face the consequences

for their actions (Bandura, 1999; Liu et al., 2012; Moore et al., 2015).

According to Bandura (1999), MDT involved eight components: moral

justification, euphemistic labeling, fair comparison, displacement of responsibility,

distorting consequences, and reducing identification or dehumanization. MDT discusses

moral justification as when an individual seeks to justify an action against an ethical

standard. Then engage in euphemistic labeling to reshape their emotions and cognition by

comparing their act as less harmful to another individual's actions (Bandura, 1999).

Furthermore, the individual displaced responsibility by avoiding taking accountability for

their actions and distancing themselves from the consequences (Bandura, 1999; Moore et

al., 2015). Cognition distortion occurs when the individual ignores the consequences for

their action and denies their unethical behavior by blaming another individual for actions

and believing that their victim is responsible and influences their deviant act (Bandura,

1999).

Research indicated that moral disengagement mediates the relationship between

ethical leadership and employee unethical pro-organizational behavior (Hsieh et al.,

2020). Through cognitive influence, ethical leaders help their employees recognize and

understand what is ethically wrong and influence their employees to abandon moral

disengagement behaviors (Hsieh et al., 2020; Tillman et al., 2018). Tillman et al. (2018)

argued individuals’ response to others' unethical practices differs from individuals.

Further, subordinates’ moral disengagement influence how they perceived their

supervisor as an ethical leader (Tillman et al., 2018). Employees with low moral

disengagement are more likely to be influenced by their leader's moral disengagement

behavior than employees with high moral disengagement (Bonner et al., 2016).

Hsieh and colleagues (2020) investigated the influence of ethical leadership and

employee ethical behavior on unethical pro-organizational behavior and evaluate the

mediating effect of the moral disengagement on the relationship between ethical

leadership and employee unethical pro-organizational behavior. They found that moral

disengagement mediates between ethical leadership and employee unethical pro-

organizational behavior. Additionally, employee ethical behavior moderates the

relationship between ethical leadership and employee unethical to organizational

behavior and found that the relationship between moral disengagement and employee

unethical pro-organizational behavior is weak when the employee ethical behavior

increases (Heish et al., 2020).

MDT suggests that individuals often separate themselves from their morals to

justify their behavior and rationalize their behavior (Bandura, 1999). The individual

unethical behavior often provokes guilt and shame in the individual that creates an

ongoing cycle that will not refrain the individual from engaging in unethical behavior

even if it causes mental discomfort (Bandura, 1999; Tillman et al., 2018). Therefore, the

displacement of responsibility from the individual will continue to cause that individual

to engage in post-moral disengagement as a coping mechanism to lessen their guilt and

perceives their deviant act as justifiable (Bonner et al., 2014; Tillman et al., 2018).

Power in Leadership

Power and Leadership, from the perspective of social psychology, are viewed as

having the ability to influence, modify or change the behaviors or attitudes of an

individual or a group (French & Raven, 1959; Northouse, 2001). Lunenburg states (2012)

that great leaders have common characteristics; they have the vision to achieve goals and

have the personnel power to accomplish them. At the same time, power can be perceived

as a negative attribute in both research and practice because leaders can use their power

for unethical purposes (Lunenburg, 2012). Power is universal and plays a significant role

in organizational outcomes, and employee motivation, especially in health care

(Lunenburg, 2012; Saxena et al., 2019). Power and leadership are linked; leaders use

power to accomplish organizations' goals. However, power can negatively impact

organizational functions if unproperly managed (Raven, 1993; Saxena et al., 2019).

Therefore, it is empirical that leaders understand how power operates to be more

equipped to influence subordinates and become effective leaders (Lunenburg, 2012;

Nelson et al., 2012).

Social psychologists French and Raven (1959) analyzed the source of power in

organizations and proposed five bases of power legitimate, reward, coercive, expert, and

referent. Six years later, Raven (1965) added information power. Connection power was

also added by other researchers (Ansari, 1979; Bhal et al., 2000; Howel et al., 2000).

French and Raven (1959) suggested that power is sorted into two categories: formal and

informal. Expert and referent power are characterized as informal power because they are

derived from personnel power sources and exist without any recognized authority or

subordinates to manage (Lunenburg, 2012; Raven et al.,1959). Legitimate, reward and

coercive power are characterized as formal power because they are generated from

positions of authority.

Individuals with formal power uphold a dominant position on subordinates

(Raven et al., 1959, Raven, 1993). Research reveals that formal and informal power can

give rise to desirable or undesirable organizational outcomes (Ansari et al., 2008; Raven,

1993; Samarakoon, 2019). Greater use of informal power in an organization is related to

higher organizational commitment, job satisfaction, and organizational citizenship

behavior (Kovach, 2020; Raven, 1993). In contrast, formal power is related to a high

level of absentees, job burnouts, and decreased organization productivity (Ansari et al.,

2008; Kovach, 2020; Raven, 1993).

Legitimate Power

Legitimate power is a person's ability to influence others’ behaviors because of

the power he/she holds in the organization (Lunenburg, 2012; Raven et al., 1959).

Individuals with legitimate power are assigned their leadership or authority position by

contract that defines the manager’s job characteristics, responsibilities, and organization

policies (Ansari et al., 2008; Lunenburg, 2012). In the workplace, individuals with

legitimate power can give commands and ask their subordinates to complete tasks within

the jurisdiction of their authority (Ansari et al., 2008; Kovach, 2020; Raven et al., 1959).

Furthermore, those with legitimate power have the authority to hire new or terminates

employees, conduct performance appraisals, and set goals for employees (DuBrin, 2009;

Lunenburg, 2012). Ansari et al. (2008) found that legitimate power can decrease

employee motivation, creativity, and engagement. Additionally, legitimate power can

create organizational conflict because subordinates are only influenced by the

authoritarian title the person uphold and will only comply if they perceived the use of

power as legitimate and understand the leaders right to influence (Ansari et al., 2008;

Jones et al., 2016; Samarakoon, 2019).

Reward Power

Reward power is an individual's ability to influence others' behavior by providing

a reward (Lunenburg, 2012; Raven et al., 1959). Such rewards can be a job promotion,

more responsibilities; financial incentives such as pay, raises, or bonuses; praise,

empowerment, or recognition for hard work (Lunenburg, 2012). A manager can use

rewards to motivate, influence, and control employee behavior (Raven, 1993). Reward

power has been shown to increase work performance and employee empowerment when

the manager explains the behavior that is being rewarded and creates a clear link between

the reward and the behavior (Ansari et al., 2008; Lunenburg, 2012; Raven et al., 1959).

When communication and the reward are established, it creates a positive work

environment and creates an optimal relationship between the employee and the manager

(Jones et al., 2016; Nelson et al., 2012; Randolph et al., 2011).

Research shows that reward power can be unstable and does not always maintain

employee motivation and satisfaction (Faiz, 2013); if the reward being offered does not

attain the employee’s need or is not valued, it can give rise to job dissatisfaction and

disengagement (Lai et al., 2011). Further, financial rewards can be inconsistent because it

does not guarantee that the employee’s behavior will remain positive after their financial

need are met (Bashman et al., 1996; Lai et al., 2011; Singh et al.,2016). Further, power

reward can give rise to unethical behavior and poor work quality because an employee

might engage in unethical behavior to earn the reward (Bachman et al., 1966; Kovach,

2020); this can create competition in the workplace, reduce teamwork, and group

productivity where the employee might switch his/her attention on the reward rather than

their work quality (Kovach, 2020; Raven et al., 1959).

Expert Power

According to French and Raven (1959), expert power is characterized as informal

because it does not rely on any formal position of authority and is derived from

individuals who possess specific skills, experience, knowledge, expert advice, and

respected information (Lunenburg, 2012; Raven, 1993). A study revealed that individuals

with expert power do not always possess leadership skills and are often assigned their

authoritarian position base on outstanding performance (Goncalves, 2013). Without

proper knowledge on how to apply leadership skills and how to exercise their power to

manage and influence their employees, these managers will never become effective

leaders and will never gain the respect they need to affect their subordinates’ behaviors

(Raven, 1993; Goncalves, 2013). Knowledge is power, and people always welcome

expert advice when perceived as creditable and trustworthy (Kovach, 2020; Luthans,

2011; Raven et al., 1998). In healthcare, patients follow their doctor's or medical

practitioners’ advice because they acknowledge that they have the expertise and unique

skills in the medical field (Kreitner et al., 2010). However, experts of power can be

unreliable because the person given the information must be trustworthy, and their

credibility must have relevance (Luthans, 2011). For example, a medical practitioner

advising on finance, computer science, or politics might not be perceived as relevant.

Therefore, the medical worker does not have expert power in these fields (Lunenburg,

2012; Luthans, 2011).

In the workplace, it has been shown that expert power positively influences

subordinates with internal locus, increasing motivation and satisfaction in these

employees (Ansari et al., 2008; Kovach, 2020). Additionally, these individuals are often

included in top decision-making due to their expertise, even if they are low-level

employees (Nebus, 2006). However, different findings were observed in employees with

external locus because an individual with expert power can be perceived as egocentric by

other employees and often have poor communication skills and poor face-to-face

interaction when delivering their message (Nadaee et al., 2012; Nebus, 2006).

Referent Power

Referent power is a person's ability to influence others’ behaviors based on a

positive relationship built on admiration and respect for that individual (Raven,1993). In

the workplace, a manger often possesses referent power over their subordinates by

influencing the employee to partake or complete a particular task because of their

friendly relationship (Bartos et al., 2009; Gabel, 2012; Lunenburg, 2012). Today social

media influencers, such as celebrities, exercise referent power over their fans and

followers based on admiration (Craig et al., 2006).

Marketing research shows that some celebrities have the power to influence

individual’s choices on the product they buy (Craig et al., 2006). For example, Lebron

James or Oprah Winfrey, who are not experts in skincare products or clothing creation,

can influence their fan base to blindly buy a product they promote because they identify

these products as their favorites (Craig et al., 2006). YouTube is one of the major

platforms for social influencers and product marketing (Hou, 2019). YouTube influencers

grow their fan base from their charismatic behaviors and positive energy and influence

others through allure disposition, approval, and admiration to purchase a product they

recommend for profit (Hou, 2019; Kovach, 2020; Vecchio,1997).

Scholars reveal that referent power is the most critical managerial tool because

managers who possess referent power continue to gain power over time by modeling

behavior they expect to see in their subordinates over a long period (Biong et al., 2010;

Lunenburg, 2012). In the workplace, referent power is found to be positively associated

with employee performance, commitment, organization climate, and growth, leader’s and

employee’s satisfaction, behavior compliance, trusting relationship between the

employee’s and the leader with the decrease of employee absentees (Bartos et al., 2008;

Kovach, 2020; Lunenburg, 2012; Raven et al.,1998)

Coercive Power

Coercive power is identified by French and Raven (1959) as the use of force,

public shaming, withholding information, excluding specific individuals in a meeting, not

approving time off, sexual harassment, threatening to terminate, or withholding

promotion or bonuses to punish the employee. Employees working with a manager with

coercive power often carry out projects and are forced to work in projects out of fear of

losing their job or annual bonus (Ansari et al., 2008; Raven et al., 1998). Misusage of

coercive power in the workplace should be avoided because it gives rise to employee

frustration, dissatisfaction, fear, work stress, and alienation (Biong et al., 2010; Kovach,

2020). Though coercive power may lead to compliance of employees, the compliance and

engagement are frequently found to be temporary (Tuner, 2005), and often results in a

decrease in employee performance, involuntary compliance, decrease of trust with high

turnover rates (Hoffman et al., 2017; Lunenburg, 2012; Tuner, 2005).

A manager often uses coercive power to reduce unwanted behavior and absentee

employees (Kovach, 2020). While the use of coercive power might reduce the behavior,

it often results in employee resistance with the decrease of motivation because these

employees often perceived their managers as bullies who uses their legitimate authority

to force them into submission (Raven et al., 1998; Saxena et al., 2019; Teven, 2006;

Thoresen et al., 2003). Research has shown that employees who work for a manager with

coercive power are less motivated and less proactive, they only do the bare minimum

(Taucean et al., 2016). They do not volunteer to participate in a project or additional work

(Taucean et al., 2016). Additionally, employees working with managers with coercive

power are reported to have increasing health issues, poor work relationships and are less

likely to succeed within the organization (Fredrickson et al., 2008; Kovach, 2020;

Taucean et al., 2016).

Information Power

Information power is the ability to provide information to enable decision-making

(Bartos et a., 2008). Information power has not been investigated thoroughly as the other

base of power associated with leaders' success but has been found to distinguish success

between successful and unsuccessful entrepreneurs (Ansari et al., 2008). Information

power is based on the perception that leaders with a high level of information power have

a greater chance of compliance from their subordinates and are more likely to succeed in

their leadership role (Erchul et al.,2001, Goncalves, 2013). Information power is an

excellent resource for entrepreneurs because they need to gather accurate information

through their social network to apply to their new business ventures and execute their

ideas (Ansari et al., 2008; Bossidy et al., 2002).

Though information and expert power have some similarities, scholars argue that

both have distinct constructs (Ansari,1990). Expert power is the entrepreneur's personnel

skills and knowledge, whereas information power is the entrepreneur's ability to secure

accurate information that contributes to the growth and success of their business (Ansari

et al., 2008). In the health care setting information, power plays a crucial role in patients

care (Bartos et al., 2008). Communicating information is vital for clinicians because they

utilize both expert and referent power to provide critical information that is perceived to

be trustworthy and persuasive by their patients (Bartos et al., 2008). In clinical settings,

nurses exercise a high level of information power because they spend direct contact with

patients (Lipley, 2006); this relationship causes the physician to rely on the information

they received from the nurse to make informed medical decisions for the patient care

(Paynton, 2008).

Connection Power

Connection power is about networking; it is based on the perception that

successful entrepreneurs are well connected with powerful individuals (Ansari, 1990;

Ansari et al., 2008; Bhal et al., 2000). Connection power is the ability to gain influence

from an acquaintance (Ansari, 1990). In the business world, the connection of power is

crucial because an individual can use their connection power to build a coalition with

others, to get jobs done, and serve as a mediator to secure deals between entrepreneurs

(Ansari et al., 2008). Studies reveal that an entrepreneur’s social network is crucial for

their success and can be used as a natural resource to their business (Aguinis et al., 2008;

Kilduff & Tsai, 2003).

Entrepreneurs are also perceived to have a high level of referent, information,

expert, connection, and reward power and use their connection power to promote their

ideas when dealing with constituents and influential individuals (Ansari, 1990; Ansari et

al., 2008). Appropriately used connection of power can be beneficial to employee

professional growth and can bring positive outcomes in decision making (Ansari et al.,

2008). Connection of power mainly rely on communication; when the individual shares

knowledge about their connection and professional strengths a manager can use the

information to assign the employee to a specific project and demonstrate that they value

their opinions during decision making (Cullen-Lester et., 2016). The benefit of

connection of power, when used effectively through awareness and communication, is

that employees can use it at all levels within the organization to promote career and

information resources (Ansari et al., 2008; Saxena, 2019).

As mentioned previously, one of the abilities of a leader is to influence others

(Northouse, 2016). Regardless of the leadership style, a leader must possess the ability to

influence employees to follow the organization's policy, mission, and value at an

individual, group, and organization level (Hartog et al., 2011; Northouse, 2016).

However, a leader’s ability to influence his/her employee depends on the type of power

the leader possesses within that organization (Haller et al., 2018; Saxena et al., 2019).

In health care environments, employees with expert power are often included in

decision-making due to their expertise. Similarly, medical professionals often possess

expert power over their patients because the patient-perceived them to be knowledgeable

in their field (Kreitner et al., 2010). Power and leadership are essential to influence

employee behavior change and influence employees to get things done (Saxena et al.,

2019). Information power is crucial in medical settings because physicians often rely on

their nurse or medical laboratory analysis to provide a proper diagnosis and treatment for

their patients (Paynton, 2008). While informant power is known to be beneficial in health

care settings (Paynton, 2008), a leader with an autocratic leadership style who shows

little value to their subordinate cooperation might choose to dismiss the employee

information and create a treatment plan without their staff cooperation (Stanfou et al.,

2017).

Research on power is still premature because most research conducted on power

base solely investigated leadership style rather than employee outcomes. About ethical

leadership, a study found that expert and referent power plays a crucial role in the

relationship between ethical leadership and employee outcomes through role modeling

(Haller et al., 2018; Hoogh et al., 2009), an ethical leader with referent power can

influences employees to perceive them as a role model, indicating that socially

responsible power use within the boundary of ethical leadership may be the key to help

understand ethical leadership effect on employee outcomes (Haller et al., 2018; Hoogh et

al., 2009; Vevere, 2014).

Summary and Transition

The literature presented in this chapter reinforces the importance of ethical leader

and employee accountability in a medical laboratory. Medical laboratories provide 80%

of data for diagnostic, monitoring, and treatment of patients. Additionally, they hold

responsibilities to society to use their resources efficiently to provide accurate results

useful to public health for disease control and monitoring; therefore, providing a high

quality of laboratory service should be prioritized in practice, which was one of the

critical components this study addresses. In recent years of ethical scandals in medical

laboratories severely affected public safety resulting in death, long-lasting critical illness

and some cases, and misdiagnosis. The need for ethical leadership and employee

accountability has made it appeal in healthcare studies; yet there is little evidence

regarding what measure and protocol ethical leadership should follow to increase

accountability in medical laboratory employees.

Power is an essential process in an organization. Getting things done and

managing employees requires power. While referent and expert power have been shown

to have a positive relationship with ethical leadership in employees’ outcomes through

role modeling (Hartog et al., 2011), very little is known about the effect of ethical

leadership and power on employee accountability and the relationship between power

and leadership style on employee outcomes, especially in medical laboratory medicine. In

this literature review, the different bases of power were discussed, and scholarly findings

on the effectiveness of each power base were presented.

There are numerous studies on autocratic, participative, laissez-faire,

transactional, transformational, servant, authentic, and ethical leadership, as well their

outcomes on employees' behaviors and organization functions. As the antecedent and

outcomes of ethical leadership on employees' accountability remained under-researched,

all of which are beneficial for medical laboratory organizations. We have yet to

understand the predictive effect of a leader’s ethical behavior on employee accountability

in medical laboratory organizations. Understanding the effect of ethical leadership on

employee ethical behavior of accountability professionals in medical laboratory settings

through the SLT and the MDT can help medical laboratory leaders understand the

behavior, leadership practice, and power ability they need to influence ethical behaviors

in their employees.

In Chapter 3, the research design, methodology, the population, including

participant selection, instrumentation, data collections, and analysis, are discussed. Treat

to validity, ethical procedure, and participants' protections are also explored. In Chapter

4, data provided from medical laboratory employees from Western New York are

analyzed. The assessments used for the research are the ELWQ and LAS and were

distributed using SurveyMonkey. Chapter 5 explores the findings of the study and make

connections between the findings to the literature and the theoretical framework. The

limitations and implications of the study are explored, and recommendations for future

research are provided.

Chapter 3: Research Methods

This quantitative study examined the influence of ethical leadership on

employees' accountability behaviors in medical laboratory settings and whether time

assigned to a manager, measured in months, moderated the relationship between the

perception of a manager’s ethical leadership and the assigned staff’s employee

accountability behaviors. Medical laboratory employees are responsible for conducting

tests, collecting samples, monitoring, treating, and diagnosing diseases. Medical

laboratory employees often work in hospitals, physician offices, clinics, or private

laboratories. As their work plays a significant part in health care and environmental

safety, medical laboratory employees are trained and educated for their positions and job

functions (Cocks, 2016; Gamble et al., 2014; Wijeratne et al., 2020). Within laboratory

settings, medical laboratory managers or supervisors often have many years of

experience, with advanced training and knowledge of laboratory functions. However,

these medical laboratory managers are often left unaware of the importance of ethical

leadership in medical laboratory practice. Additionally, they are unaware of the

importance of ethics in decision-making and the characteristics needed to influence

ethical behavior in their employees (Bruns et al., 2015; Gronowski et al., 2019;

Khalajzadeh et al., 2019).

Even though ethical leadership studies in medical laboratory organizations are

scarce, there is a plethora of research on the importance of ethical leadership in general

(Ghiasipour et al., 2017; Wijeratne et al., 2020). To date there is no current research that

examines the influence of ethical leadership in medical laboratory settings on employee

accountability behaviors. This study explores the effect of ethical leadership in medical

laboratories and examine the relationship between accountability behaviors and ethical

leadership.

This chapter covers the research design, explains the study's methodology, and

describes the instruments used to measure ethical leadership and accountability

behaviors. It also overviews the sampling procedures, data collection, cleaning process,

and data analysis using a multiple regression approach. The validity, ethical procedures,

and participants' protection are then presented.

Research Design and Rationale

Upon approval by Walden University’s Institutional Review Board, a quantitative

analysis to examine ethical leadership's influence on accountability behaviors in medical

laboratory employees was conducted. Walden University’s approval number for this study is

12-01-21-0786234.

The research questions and hypotheses for this study were: