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PHYSICIAN PERCEPTIONS OF LEADERSHIP EFFECTIVENESS

OF FRONT-LINE MANAGERS IN HOSPITALS

Renate G. Ilse

CHERYL ANDERSON, PhD, Faculty Mentor and Chair

HALEY CASH, PhD, Committee Member

RONALD DOWD, DrPH, Committee Member

Christy Davidson, DNP, Interim Dean, School of Nursing and Health Science

A Dissertation Presented in Partial Fulfillment

Of the Requirements for the Degree

Doctor of Health Administration

Capella University

March 2015

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Abstract

The purpose of this research study was to better understand the factors that influence

physician perceptions of leadership effectiveness in front-line managers. By contributing

to trust and respect of management, physician perceptions of leadership effectiveness

have been linked to physician engagement and subsequently to better organizational

performance and outcomes. Using qualitative research methodology and face-to-face

interviews, this study found that hospital physicians ascribed greater leadership

effectiveness to managers who had good communication skills, managed conflict well

and who were able to get things done in their patient care areas. While these behaviors

are also mentioned in leadership competencies used as an organizational measure of

leadership effectiveness, a significant portion of managers’ formal role expectations

included activities that were not valued by physicians. Using the adaptive leadership

model suggested by complexity theory, these findings were used to propose specific

enabling leadership behaviors that could help increase physician engagement and

physician perceptions of manager effectiveness. This study is significant because

developing greater physician engagement has been shown to be one of the most effective

strategies for improving general financial performance, enhancing patient outcomes and

increasing organizational success in today’s highly competitive healthcare environment.

These results offer an alternative to existing top-down efforts at increasing physician

engagement and provide helpful information for organizations that seek to increase

manager skills in building collaborative physician relationships. While the research was

targeted on a specific hospital study site, these types of system pressures are affecting all

hospitals in Canada and the United States and successful implementation would set the

stage for broader adoption throughout the healthcare system.

Dedication

This dissertation is dedicated to Remington, whose patience and silent support

made this achievement possible.

Acknowledgments

Thank you to my family; your patience and support on my journey made this

achievement possible, especially the endless hours you spent listening to my ideas and

frustration and keeping things going while I studied and wrote. Thank you to the

physicians at work, you know who you are, for listening, supporting and providing

advice. Thank you to Sonia, for your unfailing support and belief in me. A special thank

you to my mentor, Dr. Cheryl Anderson, for stepping up when I needed you. Finally,

thank you to my committee members, Dr. Haley Cash and Dr. Ronald Dowd; without

you this couldn’t have been done.

Table of Contents

Acknowledgments v

List of Tables ix

CHAPTER 1. INTRODUCTION 1

Introduction to the Problem 1

Background of the Study 5

Statement of the Problem 8

Purpose of the Study 9

Rationale 10

Research Questions 11

Significance of the Study 11

Definition of Terms 13

Assumptions and Limitations 14

Nature of the Study 15

Organization of the Remainder of the Study 17

CHAPTER 2. LITERATURE REVIEW 18

Introduction to the Literature Review 18

Theoretical Framework 18

Physician Perceptions of Leadership Effectiveness in Hospital Managers 25

Generic Qualitative Inquiry 34

Literature Review Summary 35

vii

CHAPTER 3. METHODOLOGY 36

Introduction to Chapter 3 36

Research Design 36

Generic Qualitative Research 39

Target Population and Sampling 40

Setting 42

Instrumentation/Measures 42

Data Collection 44

Data Analysis 46

Ethical Considerations 47

Chapter 3 Summary 49

CHAPTER 4. RESULTS 50

Introduction to Chapter 4 50

Site Description 50

Description of Sample 51

Research Methodology Applied to Data Collection and Analysis 52

Data Analysis Procedures 53

Major Themes 57

Other Comments and Observations 67

Factors Affecting Organizational Perception of Leadership Effectiveness 68

Major Organizational Themes 69

Chapter 4 Summary 72

viii

CHAPTER 5. DISCUSSION, IMPLICATIONS, RECOMMENDATIONS 73

Introduction to Chapter 5 73

Review of the Research Questions and Purpose 74

Summary of Results 74

Discussion of Results 77

Significance 84

Implications for Practice 85

Limitations 86

Recommendations for Future Research/Study 87

Conclusion 88

REFERENCES 90

APPENDIX A. STATEMENT OF ORIGINAL WORK 108

APPENDIX B. INTERVIEW GUIDE 110

List of Tables

Table 1. Participant Demographic Overview 53

Table 2. Three Most Frequently Used Descriptive Words 55

Table 3. Three Most Important Factors in Influencing Perception 57

Table 4. Presence of Major Theme in Participant Interviews 58

Table 5. Factors Affecting Organizational Perception of Leadership Effectiveness 69

Table 6. Frequency of Descriptive Words in Leadership Competency Tool 70

Table 7. Summary of Major Themes in Physician and Organizational Factors 77

CHAPTER 1. INTRODUCTION

Introduction to the Problem

Physician engagement is one of the foremost health care administration topics of the

decade. The recent literature is filled with calls for action and descriptions of current engagement

initiatives (Clark, 2012; Daly, 2013; Denis, Baker, Black, Langley, & Lawless, 2013; Dickson,

2012, Frattaroli, Webster, & Wintemute, 2013; Grimes, & Swettenham, 2012; Johnson, 2014;

Kaissi, 2012aa; Milliken, 2014). Despite over three decades of discussion and action, physician

engagement issues continue to headline at health care conferences (Beckman, 2014; Dickson,

Reid, Van Aerde, 2014; Marino, & Faber, 2014; Riskind; 2014). Improving the relationships

between hospital physicians and front-line managers represents and unexplored opportunity for

meaningful improvement in physician engagement.

The concept of physician engagement developed out of the body of evidence surrounding

employee engagement. Employee engagement has been widely discussed in human resources

literature for years and has long been considered critical in improving organizational

performance (Attridge, 2009; Gruman, & Saks, 2011; Kular, Gatenby, Rees, Soane, & Truss,

2008; Macey, & Schneider, 2008; Robinson, Perryman, & Hayday, 2004; Schaufeli, Salanova,

Gonzalez-Romá, & Bakker, 2002; Saks, & Gruman, 2011). Although physicians typically are

not hospital employees, the increasingly intertwined fortunes of hospitals and physicians have

resulted in growing interest in physician engagement as a means to improve hospital

performance.

Physician engagement is important because, where physicians are actively and

collaboratively engaged in hospital operations and performance improvement, their organizations

perform better financially and have higher patient satisfaction, better overall quality, higher

staff/physician satisfaction rates and lower staff/physician turnover (Gosfield, 2010; Kaissi,

2012aa; Rice,, & Sagin, 2010). Physicians have been shown to hold greater influence on hospital

operations than either administrators or other paramedical and allied health professions

(Hamilton, Spurgeon, Clark, Dent, & Armit, 2008). Ultimately, physicians attract patients to

hospitals and physicians drive utilization and cost (Armour et al., 2001; Halpert, Pearson,

LeWine, & McKean, 2000; Paller, 2005).

For decades, the relationship between physicians, hospital administrators and front-line

managers has been characterized by conflict, suspicion, lack of collaboration and sometimes

outright hostility (Bettner, & Collins, 1987; Robinson, 2001). Over the last few years the health

care system has been suffering from further deteriorating relationships (Burns, Goldsmith, &

Muller, 2010; New Jersey Department of Health, 2008; Payton, 2012), fueled by stronger

competition, demographic shifts, reimbursement cuts and public demands for accountability and

quality improvement (Carlson, & Greeley, 2010). Greater regulation and escalating financial

pressures on both hospitals and physicians from the Affordable Care Act has further increased

tensions (Beckman, 2011; Harbeck, 2011; Payton, 2012). This continuing system pressure to

decrease costs and improve quality has highlighted the importance of a positive relationship

between management and physicians and emphasized the need for collaboration.

Despite discussions and interventions to increase physician engagement that go back

more than twenty-five years (Bettner, & Collins, 1987), there is still abundant recent literature

describing the ongoing crisis and the need for greater physician engagement (Clark, 2012; Daly,

2013; Denis et al., 2013; Dickson, 2012, Frattaroli et al., 2013; Grimes, & Swettenham, 2012;

Johnson, 2014; Kaissi, 2012aa; Milliken, 2014; Payton, 2012; Sears, 2012), Past initiatives have

had variable and only limited effectiveness (Baker, & Denis, 2011); some efforts at physician-

hospital integration have worked in the short term, but there have also been some spectacular

failures (Fraschetti, & Sugarman, 2009). It is clear there is still considerable opportunity for new

and innovative ways of engaging physicians.

Most existing/published efforts aimed at improving physician engagement have been

focused on building broad alignment between key physician groups and the hospital, as well as

engaging physician leaders in the process of hospital administration (Shortell et al., 2001). These

types of initiatives are most often high level, structural and strategic, including system outreach,

monetary incentives, hospital-physician integration, physician participation on strategic

committees, and stronger medical leadership infrastructure (Buller, 2003; Carlson, & Greeley,

2010; Fralicx, 2012; Gosfield, 2010; Kaissi, 2012aa). People most closely involved in these

initiatives are typically hospital board members, hospital executives and senior medical

leadership representatives.

While strategic alignment is important, most of a hospital physician’s daily interactions

occur with other direct care providers and front-line managers, not with hospital board members,

hospital executives or even physician leaders. It is the behavior of individual physicians that has

the major impact on quality and utilization for hospitals (Hamilton et al., 2008; Paller, 2005) and

the role of the front-line nurse manager is pivotal in creating enabling environments for building

effective, productive and influential ongoing relationships with medical staff (Kaissi, 2005;

McSherry, Pearce, Grimwood, & McSherry, 2012; Whiley, 2001). Improving physician-front-

line manager relationships represents an excellent opportunity to further enhance physician

engagement.

There is considerable support in the literature about the importance of front-line

managers in building collaboration and improving outcomes. They bring organizational goals

and objectives to the front-line caregivers, shape behavior, build engagement and remove

barriers (Cipriano, 2011; Grimes, & Swettenham, 2012). Front-line managers are most often the

individuals responsible for enforcing hospital policies and managing physician behavior on a

day-to-day basis. They must be able to engage physicians to become willing “followers” who

support organizational goals as, in most cases, physicians are not employees of the hospital and

cannot be forced into participation or compliance.

Leaders cannot lead unless they have willing and engaged followers (Chaleff (2003).

Followers have specific expectations about how leaders should behave and will typically choose

whether or not to accept leadership based on conformity to their expectations, trust, perceived

leadership competence and believed worthiness of role and power (Kenney, Schwartz-Kenney,

& Blascovich, 1996; Kaissi, 2012aa; Suderman, 2011). Followership also increases in

proportion to the number of interpersonal interactions that are seen as being positive and

meaningful (Bujak, 2003). Increasing positive interactions and improving alignment between

physician expectations and leadership behavior could increase physician engagement and

collaboration between physicians and managers.

Therefore it would be helpful to better understand what physicians expect from front-line

managers, specifically, how they determine leadership competence and what factors contribute to

their conscious and sub-conscious decisions to accept manager influence. Then, if physician

expectations differ from organizational role definitions and expectations of management

performance, efforts could be made to bridge that gap

Background of the Study

The fractured relationship between hospital administration and physicians has had many

unfortunate consequences. Physicians are asking to be paid for nonclinical duties they previously

did voluntarily; some are refusing to serve on hospital committees, service the emergency

department or take call; some are limiting the number of patients they will visit in a day; others

lie for patients on insurance and hospital billing claims; still others are opening physician-owned

practices that directly compete with hospitals for market share – all symptoms of lack of

physician engagement (Brown, 1983; Carlson, & Greeley, 2010; Holm, 2008; Hunter, 2001;

Sade, 2012). Aside from the obvious financial and quality implications of this behavior,

declining physician engagement across the broader health care system has also been identified as

a key contributor to more physicians opting for early retirement or reduced practice hours,

leading to increasing concerns over shortages of primary care practitioners, surgical specialists

and hospitalists (Fraser, 2010; Sheldon, 2011; Voelker, 2009). Without addressing the issue of

physician engagement, hospitals will not be able to meet current and future performance

expectations.

Despite the conflicts, hospitals need physicians as they attract patients to the hospital and

the physician is typically the only provider who can admit and discharge patients, order tests,

dictate treatment and document the course of medical care for many coding/billing purposes

(Kaissi, 2012a). Physicians may have obligations around administrative/committee work,

teaching, and on-call coverage but ultimately do not pay to use hospital facilities. They must

voluntarily comply with hospital policies and procedures. At the same time, increased threat of

litigation/malpractice claims often result in higher costs from defensive workups, more lab tests

and redundant diagnostic procedures (Baicker, Fisher, & Chandra, 2007).

Hospitals have tried to break their dependence on physician goodwill, by strengthening

utilization management policies, procedures and restricting access to specific resources.

However, physicians then find ways to sabotage these rules and regulations, increasing “stat”

orders and insisting on critical or defensive interventions (Pfifferling, 2008). Managers,

following organizational direction, try to improve compliance, but find themselves cajoling,

threatening and negotiating behavior changes and compliance (Harris, 1977).These kinds of

behaviors are intrinsically dissatisfying and do not build positive relationships.

In theory, good managers, as defined by the typical competency-based frameworks used

in hospitals (NHCL, 2012) should be able to drive better performance and greater compliance

from physicians. However, there is ongoing evidence that experiences and personal connections

affect physician engagement (Kaissi, 2012aa) and that willingness to follow a leader is ultimately

based on subjective world view (Bujak, 2003; Chaleff, 2003; Kenney et al., 1996; Kaissi,

2012aa; Suderman, 2011) rather than traditional leadership competencies.

“Good” Leadership and Physician Perspectives

“Good” leadership means different things to different people. At the broadest level,

leadership is a process if influencing others to achieving organizational goals and objectives

(Kruse, 2013). In addition to the virtually infinite different subjective views on good leadership,

there are a multitude of formal definitions, theories and models, including transformational

leadership, servant leadership, wise leadership, transactional leadership and many more

(Kellerman, 2007; Mazyck, 2008; Nonaka, & Takeuchi, 2011; Ramsey, 2003; Rolfe, 2011). In

health care, most organizations today have adopted the widely supported National Center for

Healthcare Leadership (NCHL) model for assessing leadership competencies (NCHL, 2012) and

use this, or some similar/related model, to guide and evaluate leadership performance in

managers. The NCHL Model defines twenty-six competencies, including communication,

financial management and human resources management, grouped into the three domains of

transformation, execution and people.

While these usually accepted measures of front-line manager effectiveness focus on

traditional leadership competencies including transformation, execution and people skills

(DeOnna, 2006; NCHL, 2012; Ten Haaf, 2007), and the extent to which managers can influence

employees and other stakeholders to work towards organizational objectives (Cooper, &

Nirenberg, 2004), senior leaders throughout the health care system suggest that physicians

appear to judge competence by a different measures than the traditional leadership competencies.

Even physician executives, who are most likely to have recognized leadership and management

training, have usually been through physician leadership programs that heavily favor traditional

management skills such as financial management, conflict resolution, business strategy, and

organizational behavior rather than soft skills and relationship-building (Physician Leadership

Program. 2013; Preparing Physicians to Lead, 2013). Since most physicians have no formal

education on the topics of leadership assessment and management skills and interact with front-

line hospital managers and other administrators intermittently, often transactionally, they make

their judgments about leader effectiveness based on incomplete information and perception

rather than through any formal or validated performance assessment tools.

Differing perceptions are significant because perception is the process by which we

interpret and make meaning the world around us (Lindsay, & Norman, 1977). Perceptions are

often subconscious, based on past experiences, values, prejudices, self-interest and other

attitudes, and have been shown to be more important than reality in the decision-making process

(Potgieter, 2011). In the absence of conflicting information, and sometimes despite conflicting

information, perception invariably becomes reality in the mind of the perceiver. Furthermore,

these perceptions and expectations may actually affect actual manager performance (Inamori, &

Analoui, 2010; Livingston, 2009). Perceptions eventually create their own reality.

With each manager-physician interaction, physicians accumulate information that is

filtered through their perceptions about the manager/organization and that affects the probability

of engagement and compliance with organizational goals and objectives. If the factors

influencing physician perceptions differ from the traditional leadership competencies, and/or

from the competencies that are encouraged and rewarded by the organization, dissonance and

conflict may result (Kissick, 1995; Reay, & Hinings, 2009; Waldman, & Cohn, 2007). Therefore,

understanding the factors that influence physician perceptions of manager competence, and

hence physician engagement, could allow managers to modify behavior to more effectively

influence physician engagement

Statement of the Problem

Hospitals today have an urgent need to find innovative approaches to building physician

engagement. Existing efforts have not yielded sustainable results and none address the essential

issue of daily physician-manager interactions at the front line and the effectiveness of

physicians’ relationship with the front-line manager of the patient care unit (Baker, & Denis,

2011; Fraschetti, & Sugarman, 2009). Better physician-manager collaboration will improve

physician engagement and enhance organizational performance.

In the daily work on patient care units, physician compliance and willingness to

acknowledge leadership and direction of management is related to the extent that they

trust/respect manager leadership skills (Chaleff, 2003; Kenney et al., 1996; Kaissi, 2012a;

Suderman, 2011). However, manager behaviors and performance expectations are based on

competency frameworks that may not align with expectations of physicians, whose world views

differ from those of administrators (Kaissi, 2012a; Klopper-Kes, Meerdink, Van Harten, &

Wilderom, 2009; von Knorring, de Rijk, & Alexanderson, 2010; Waldman, & Cohn, 2007).

Differing expectations lead to conflict and distrust (Kissick, 1995; Reay, & Hinings, 2009;

Waldman, & Cohn, 2007), minimizing physician engagement and potentially manager

effectiveness. Although it has been shown that physicians and administrators have different

world views and that they have different priorities at the front line of patient care, there is little

evidence or research about what exactly they do view positively in terms of manager behaviors

and activities. Gaining a better understanding of what manager behaviors and activities

physicians value, will create an opportunity to improve alignment between formal organizational

manager role expectations and physician perspectives.

Purpose of the Study

The purpose of this action research project was to determine what factors influence

physician perceptions of leadership effectiveness in front-line managers, which affected how

physicians decided whether or not to trust, accept leadership from and collaborate with, front-

line managers. This purpose was relevant to current health care system challenges because

physician perceptions of leadership effectiveness can be linked to physician engagement and

subsequently to organizational efficiency and effectiveness.

First, an initial qualitative study, consisting of face-to-face interviews of a sample group

of physicians was used to collect data on how physicians judge effective leadership performance

in front-line managers in hospitals. Then, the results of these interviews were compared against a

typical leadership competency model used by hospital administrators to judge effective

leadership performance in front-line managers and analyzed using a complexity theory lens.

Finally, based on the results of the above research, and using an adaptive leadership model

suggested by complexity theory (Avolio et al., 2009, Uhl-Bien, Marion, & McKelvey, 2007), a

specific intervention with leadership behavior changes was proposed to help improve alignment

between physician and administrator perspectives.

Rationale

This action research was undertaken to find ways of improving physician engagement at

the study site, a hospital in Ontario, Canada. The research results were used to design an

intervention aimed at creating an enabling environment for increasing alignment between

physician and administration expectations of leadership behavior in front-line management, on

the premise that increased alignment would decrease physician disengagement and improve

collaboration.

Since the target organization is facing massive system change and incremental funding

reduction over the next three years (Ontario Health Coalition, 2012; Ontario Ministry of Health,

2012), improved collaboration and efficiency is critical to organizational survival. In addition,

both the local health care region and Ontario as a whole are suffering from ongoing and

potentially crippling physician shortages in many specialties (Singh et al., 2010). Recruitment

and retention of internists, hospitalists and physician assistants are all persistent challenges and

any initiative that improves competitiveness in this area is helpful. Improved alignment in

perspectives should enable increased efficiency, better outcomes and improved satisfaction for

staff and physicians (Accreditation Canada, 2010).

If successful, the project results should be transferable to other hospitals in the region and

province, since they are all facing similar challenges with physician engagement and funding

reductions (Hutchinson, 2010; Ontario Health Coalition, 2012). These types of pressures are also

being experienced elsewhere in Canada and the United States (Carlson, & Greeley, 2010;

Dickson, 2012; Kaissi, 2011; Robinson, 2001) and so the project has the potential to make a

broader contribution to health care administration.

Research Questions

Primary Research Question: How do hospital physicians judge leadership effectiveness

of front-line managers?

Secondary Research Question 1: How do physician perspectives differ from those in a

current competency-based leadership effectiveness evaluation model used by administrators?

Secondary Research Question 2: What intervention(s) could improve alignment between

administrator and physician perceptions of leadership effectiveness?

Significance of the Study

This action research study was pursued in order to find a new opportunity for enhancing

organizational performance at the study site hospital, which operates in an increasingly complex,

challenging and competitive environment. Managers at the target organization, and in other

hospitals around the country, have being asked to provide ongoing patient care services out of

shrinking budgets while meeting increasingly stringent quality and reporting requirements. They

enforce hospital utilization policies and communicate performance targets, mediating between

increasingly unhappy physicians and often disenfranchised employees. But ultimately

physicians, not managers, drive utilization and demand, and managers have no formal authority

over physician behavior.

Existing/published efforts to improve physician engagement in supporting hospital goals

and objectives have focused on high level, strategic and structural interventions (Bettner, &

Collins, 1987; Buller, 2003; Carlson, & Greeley, 2010; Fralicx, 2012; Gosfield, 2010; Kaissi,

2011). People involved in these initiatives are typically hospital board members, hospital

executives and senior medical leadership. While strategic alignment is important, most of a

hospital physician’s daily interactions occur with other direct care providers and front-line

managers, not with hospital board members and executives. The role of the front-line manager is

central in creating enabling environments and in building effective ongoing and mutually

beneficial relationships with medical staff (McSherry et al., 2012; Whiley, 2001).

Front-line manager complain about lack of physician responsiveness, excessive physician

resource utilization, inadequate physician presence on inpatient units and poor physician

communication with patient family members. Physicians, in turn, chafe against what they see as

increasing regulation and obstructive bureaucracy, while complaining about poor care

coordination, lack of communication restrictive policies and excessive focus on money and

efficiency. Conversely, physicians are more visible on units where they have positive

relationships with the coordinating front-line manager. They are also more easily engaged in

supporting hospital targets and more willing to attend meetings where they respect the

organizing manager, while allegedly ignoring meeting invitations from others.

Gaining a better understanding of physician expectations of front-line manager leadership

roles helped identify the gap between physician and organizational expectations and evaluate if it

could be bridged by one or more of physician education, improved communication,

modifications to manager role or more specialized manager training. In addition to increasing

engagement, improved relationships between managers and physicians will increase quality of

work life for both groups and improve collaboration, which in turn will increase productivity and

enhance outcomes, customer satisfaction and patient safety (Accreditation Canada, 2010;

Amabile, & Kramer, 2012).

Definition of Terms

Bundled payments set a reimbursement rate for an episode of care rather than for

individual interventions (Burns, 2013; Draper, 2011).

Employee engagement means that employees exert discretionary effort beyond the basic

requirements of the job and work to create additional value without being asked (Kruse, 2012).

Followership means that leaders cannot lead without followers and that leadership is a

relationship created actively by both the leader and followers (Oc, & Bashshur, 2013).

Hospitalists are physicians who specialize in inpatient medicine rather than in the typical

service lines of surgery, medicine, cardiology etc. (Wachter, & Goldman, 1996).

Leadership Competencies: When a person is described as having competency in a

specific field, they are stated to have the all of the required knowledge, skill and judgment to

perform effectively in that field (Hollenbeck, McCall, & Silzer, 2006).

Physician Engagement means that physicians are actively involved in the planning and

delivery of care and also in supporting the pursuit of organizational objectives.

Physician-hospital integration refers to the process of devising more formal and mutually

beneficial relationships between physicians and hospitals, such as expanded hospitalist programs

or partnership agreements and professional service agreements.

Utilization management refers to the deliberate control of resource consumption in

hospitals.

Value-based purchasing (or pay-for-performance) is an effort to increase health care

system efficiency where hospitals are reimbursed based on how well they meet predetermined

performance targets rather than by fee-for-service.

Assumptions and Limitations

This research was premised on a series of logical conclusions which, while founded in

comprehensive literature review, still ultimately led to an assumption about the validity of this

series of conclusions. This sequence began with evidence that 1) physician satisfaction was a

critical issue in health care today 2) that it was declining 3) that existing engagement efforts have

had limited success and there was a need for novel approach 4) that manager actions at the front

line were important in communicating organizational objectives 5) That physician attitudes

towards managers affected the extent to which physicians were willing to listen to managers and

engage in activities related to organizational objectives 6) That while there was evidence that

physician attitudes were based on different world view and socialization from traditional

administrative views, there was little evidence about what actual factors influence their

perceptions.

This researcher assumed that the factors influencing physician perceptions of leadership

effectiveness of front-line managers were different from those in traditional leadership

competency models and that these factors could be described, measured and compared. The

study also assumed that a sufficient number of physicians would volunteer to be interviewed and

that they would be truthful in their interviews.

Because of the subjective nature of qualitative research, this project was subject several

limitations. Interviewees may not have been aware of their own biases, prejudices and

perceptions about what constitutes leadership effectiveness. Past and existing relationships

researcher / interviewee relationships and organizational position may have influenced interview

responses and discussion. Despite assurances of anonymity, interviewees may have felt inhibited

by concerns over confidentiality. Finally, this was an action research project in which

organizational context is relevant and influential in interviewee responses, which could be seen

as a limitation on the generalizability of the work.

Nature of the Study

This study was based on the conceptual framework provided by complexity theory. In

complexity science scholars suggest that interdependence and independent action exist

simultaneously and both rational and irrational behavior can coexist (Cooksey, 2001). Through

the combination of many simple patterns and relationships, there are infinite outcomes and

possible actions. Complexity science borrows from many other disciplines, including biology,

sociology, computer science, economics, anthropology (Zimmerman, Lindberg, & Plsek, 2009),

and studies how systems actually behave rather than how they are expected to behave.

Complexity theory provided a relevant and helpful framework for thinking about the

relationship between front-line managers and hospital physicians. In complexity theory, the

hospital is viewed as a complex adaptive system (CAS) and described as a set of relationships

between autonomous agents, with infinite interconnections and the capacity to learn from

experience and alter behavior (Zimmerman et al., 2009). All of these independent agents (such as

physicians and managers) act locally and independently, according to their own plan and agenda.

In general, people do not all behave the same way when faced with similar circumstances and

much of human behavior is not predictable or even explainable. Even with many shared

experiences and agreed upon goals, people may choose different actions.

Historically, leaders have been encouraged to try to influence and control in order to

drive alignment towards a common vision (Marion, & Uhl-Bien, 2001). Complexity theory

holds that human behavior does not respond well to such efforts at control because of the reality

of free choice/human agency and unexplained actions and responses (Heylighen, 2006). When

faced with traditional efforts to drive alignment, these stakeholders may respond by developing

coalitions to protect their own interests and visions however, given the right set of enabling

circumstances, they can also act collaboratively, co-dependently and supportively (Marion, &

Uhl-Bien, 2001).

Instead of aiming to control or direct, the role of an adaptive leader is to support and

enable learning, creativity, and desired behavior in the complex organizational system,

particularly in those functioning predominantly with knowledge workers such as physicians

(Uhl-Bien et al., 2007). Adaptive leadership embraces the evolutionary, creative and learning

activities that leaders must facilitate to stimulate collaboration. Rather than being directive or

manipulative, adaptive leadership supports and coaches the activities of the many free agents

comprising the system (Avolio et al., 2009; Uhl-Bien et al., 2007).

Complexity theory has been used to describe and explain many phenomena in health care

systems and hospitals, including unexpected consequences of government interventions (Reece,

2008), differential leadership success in hospitals (Ford, 2009), adaptive interventions in primary

care (Litaker, Tomolo, Liberatore, Stange, & Aron, 2006), planning physician governance

(Lindberg, Herzog, Merry, & Goldstein, 1998) and hospital change management (Dattée, &

Barlow, 2010). It has also been used in dissertation research to look at the impact of

environmental change on hospitals (Penprase, 2007). In the case of front-line leadership in

hospitals, complexity theory suggests that an adaptive leader could facilitate alignment of goals

and that the organization could create enabling structures that also support collaboration among

free agents (Uhl-Bien et al., 2007; Zimmerman et al., 2009).

In summary, complexity theory is founded on a viewpoint that reality is subjective,

changing and relational. Meaning is created out of the complex relationships among people and

between people and the environment. As such, complexity theory will well support dissertation

research that is aimed at better understanding the perceived reality of physicians and managers as

it relates to the leadership effectiveness of front-line managers in hospitals.

Organization of the Remainder of the Study

The remainder of this research study includes sections on the literature, methods, analysis

and discussion. Chapter 2 presents an aggregation of the relevant current literature related to the

research and theoretical framework. Chapter 3 provides details of the qualitative research

methodology and study design. Chapter 4 describes the results of the study and the analysis of

the data. Finally, chapter 5 includes discussion of the results, limitations, conclusions, and

recommendations for future research.

CHAPTER 2. LITERATURE REVIEW

Introduction to the Literature Review

This dissertation focused on the relationship between physicians and front-line managers

in hospitals. This relationship is important because it affects not only the extent to which hospital

physicians are present and engaged at point of care, but also the probability that they are willing

to follow the leadership of the manager and support organizational objectives. The research

specifically addressed physician perceptions of leadership effectiveness in front-line managers.

The review of the relevant literature begins with a brief discussion of generic qualitative

inquiry and then presents a more detailed review of the theoretical framework used in

interpreting interview responses and suggesting an action research intervention. This is followed

by a comprehensive review of the current knowledge about perceptions of leadership and the

leader-follower relationship of front-line leaders and physicians. The section is completed by a

discussion on the need for further research as presented in this dissertation study.

Theoretical Framework

Complexity science was the theoretical framework used in discussing the physician

interview results and in proposing an intervention to build alignment between physician and

organizational views on leadership behavior. Complexity theory was selected because it is

broadly applicable to the current state of healthcare where multiple stakeholders are experiencing

disruptive changes, competing priorities and paradoxical incentives, yet must collaborate to

optimize their own position. This section of the literature contains a review of some of the

foundational thinking in complexity theory, a discussion of how complexity theory particularly

applies to healthcare and then an explanation of how complexity theory suggests leaders can be

more effective.

Complexity science challenges the linearity that permeates much traditional economic,

management and systems theory, where systems are viewed as the sum of their parts and end

results are predictable outcomes of a series of prescribed steps (The Physical World, 1998).

Linear models assume that there is an inherent order to things, that the world largely progresses

in an expected sequence, and that a specific amount of one variable produces a relatively

proportional amount of change in the other (Brettel, Greve, & Flatten, 2011). As an alternative,

complexity science draws from many different theories and disciplines, studying patterns of

relationships, self-organizing behavior, surprising outcomes and unintended consequences

(Zimmerman et al., 2009). In the economic and then leadership contexts, this difference is

important because, in linear models, leaders can reasonably expect that particular leadership

inputs, including the active application of traditional theory, rewards, coaching, planning and

analysis, will produce desired level of employee behavior and system response. In complexity

theory this is not the case and studies of complex adaptive systems suggest alternate behaviors.

Complex adaptive systems are the cornerstone of the research and literature in

complexity science. By definition, complex adaptive systems are open and dynamic, containing a

wide variety of components or agents that are interconnected and interdependent (Beinhocker,

1997). Each of the components, agents or groups of agents acts independently, according to self-

interest and based on a specific knowledge set and personal circumstances, but is influenced by

the behavior of other agents; any central control is illusory, as outcomes and consequences are

ultimately determined by the connections, conflicts and collaborations of the many independent

agendas (Beinhocker, 1997; Zimmerman et al., 2009). The range of possible outcomes is infinite,

not only because of the variety of possible interactions, but because the system and agents learn

from experience and demonstrate evolutionary and emergent behavior (Beinhocker, 1997; Uhl-

Bien et al., 2007; Zimmerman et al., 2009). The characteristics of complex adaptive systems,

especially the combination of independent behavior but interdependent outcomes, suggest that

enabling behavior and mutual interests can be more effective than attempts to control – and this

thinking can be applied to hospitals.

In complexity theory, the hospital is viewed as a complex adaptive system (Best, Saul, &

Willis, 2013; Zimmerman et al., 2009). The independent agents in hospitals that are most often

cited include physicians and managers, however may include any stakeholder group with both

independence of action and agenda as well as interconnected outcomes, such as patients, staff,

unions, governments, insurers, and many other stakeholders. (Zimmerman et al., 2009).

Managers, physicians and staff act locally and independently, according to their own plan and

agenda but, given the right set of enabling circumstances, have demonstrated collaborative and

codependent actions for mutual benefit (Best et al., 2013; Dickson, 2012; Zimmerman et al.,

2009). This evidence suggests that front-line managers could use enabling behaviors to facilitate

mutually beneficial outcomes with physicians and other stakeholder groups in their areas and has

been further studied in complexity leadership theory.

Historical Leadership Teaching

Existing knowledge and teachings on leadership dates back to the industrial age, founded

in the work of the classical theorists such as Taylor, Weber and Fayol (Chalcraft, 2009) and

originated at a time that was characterized mass production, departmentalization, standardized

education, hierarchical organizations and economies of scale (Drucker, 1998). These scientific

theories of management were succeeded by post-bureaucratic, systems theories that advocated a

more situational and transformative leadership approach in the flattened organizations and team-

based environments of the late 20th century (Ledlow, & Coppola, 2011). However, in the

complex working environments of the 21st century knowledge economy, information, innovation

and flexibility are the key drivers of success (Uhl-Bien et al., 2007), and traditionally accepted

leadership skills and activities do not provide sufficient explanation or direction. Many business

leaders and scholars, including renowned leadership scholar Henry Mintzberg, have concluded

that traditional leadership thinking and training is falling short of what is needed and is not

providing the right direction to today’s managers (Thompson, 2008). This is particularly true in

healthcare where continuing upheaval and disruptive change has created a burning need for new

ideas and new solutions (Begun, Zimmerman, & Dooley, 2003; Beinhocker, 1997). These gaps

between traditional leadership theories and the ongoing disruptive changes in healthcare in

healthcare have catalyzed the development of complexity leadership theory.

Traditional leadership theory assumes that there is an inherent order to things, that the

business planning progresses in an expected sequence, and that managerial cycles can be

established to achieve organizational goals (Uhl-Bien et al., 2007). Leaders are expected to find

ways to motivate followers and to direct them in performing effectively and efficiently (Zaccaro,

& Klimosky, 2001). Founded in a linear and mechanistic approach, most leadership theories are

prescriptive and predictive through group functioning models, strategic planning approaches, and

performance management systems, and are aimed at exerting control on the natural tendency

towards system disorder (Ford, 2009). Even human relations models of transformational

leadership focus on inspiring employees to buy into the organizational vision and to building

commitment to achieving organizational goals (Bass, 1985; Huxham, & Vangen, 2000). These

models focus on the predictable and controllable aspects of management at a time when health

care is increasingly unpredictable (Uhl-Bien et al., 2007) and organizations can instead work on

building capacity for learning, creativity and adaptability (McKelvey, & Boisot, 2003). This is

unpredictability is particularly relevant to the current state tension between hospitals and

physicians.

Complexity Science and Leadership Theory

Complexity science is a relatively recent concept through which scholars attempted to

address the disorganized realities of living and leading in the knowledge era. In the world of

complexity science, interdependence and independent action exist simultaneously and both

rational and irrational behavior coexist (Cooksey, 2001). Today’s health care organizations meet

the previously described criteria of complex adaptive systems. They demonstrate highly

complex, diverse organizations with multiple interconnected elements that function both

independently and collaboratively. The system has evolved into its present state in a relatively

short period as a result of multiple mergers, alliances and adaptations to market forces and

legislation. They exhibit self-organizing behavior in organizational sub-culture, advocacy

groups, physician practice groups and ad hoc interdisciplinary teams (Begun et al., 2003; Best et

al., 2013; Zimmerman et al., 2009). The larger health care system is composed of smaller

complex adaptive systems (hospitals, governments etc.), which are, in turn, composed of even

smaller ones (physician groups, family health teams, unions, committees), and all of these

systems evolve both in a mutual and interdependent way (Zimmerman et al., 2009). This

complex adaptive structure has many implications for healthcare leaders.

A fundamental reality of healthcare today is that there is little direct authority or control

over the many agents. At the highest level, complexity theory suggests leaders embrace

uncertainty and change and that instead of aiming to control or direct; the goal of leadership

should be to support and enable learning, creativity, and adaptation in the complex

organizational system, particularly those functioning predominantly with knowledge workers

(Uhl-Bien et al., 2007). This means that the leaders need to understand new frameworks of

thinking about work and leadership and then develop specific new leadership skills to function

effectively in this environment.

The Role of the Leader in Complex Adaptive Systems

In describing the desirable leadership behaviors, complexity theory borrows from post-

heroic leadership literature where the leader is a facilitator or catalyst rather than driver of

behavior (Denis et al., 2013; Fletcher, 2004; Ford, & Ismail, 2006). Successful post-heroic

leaders are those who can encourage, enable, facilitate, support and generally create conditions

under which collaboration happens and positive emergent behavior results (Fletcher, 2004; Yukl,

1999). Successful relationships between stakeholders are those founded in mutual influence

instead of control (Bradford, & Cohen, 1998). Clearly these kinds of behaviors require very

different skill sets and new thinking. These kinds of behaviors and required skills have been

adopted into complexity leadership theory.

More specifically, Uhl-Bien et al. (2007) describe adaptive and enabling leadership as

overarching functions required in complex adaptive systems. Adaptive leadership refers to

evolutionary, creative and learning activities in which leaders must engage as these activities

emerge naturally from interactions within the complex adaptive system. Rather than being

directive or manipulative, adaptive leadership supports and facilitates the desirable relationships

and activities of independent agents within the system. Adaptive leadership is required in work

groups, meetings, boardrooms and at the front line. An example of adaptive leadership is

engaging others in brainstorming and “what if” scenario analysis, as well as fostering

interprofessional collaboration (Avolio et al., 2009). As the leader adapts to the situation and

stakeholders of the day and assesses the current requirement, the leader can then focus on

enabling the desired actions and outcomes.

Enabling leadership then works as a catalyst which helps adaptive functions flourish.

Enabling leadership also creates the appropriate organizational conditions to foster adaptive

relationships and facilitates the flow of knowledge and creativity from adaptive structures (Uhl-

Bien et al., 2007). An example of enabling leadership is working to remove bureaucratic

obstacles as well as barriers to participation and openness (Avolio et al., 2009). In addition to

these overarching functions, complexity leadership theorists suggest three required behaviors for

leaders in organizing, following vision and influencing (Uhl-Bien et al., 2007). Details of these

specific behaviors are as follows:

 First, leaders must encourage self-organization by recognizing and exploiting the

unpredictable nature of the complex adaptive organizations in health care. They must

be able to harness the full potential of employees, partners, physicians, customers and

all other stakeholders.

 Second, leaders must be anchored by their vision, but allow that vision to evolve as

the system evolves. By providing vision and boundaries, leaders can allow employees

and potential collaborators to act based on their experience and co-evolve with the

system.

 Finally, because leaders have limited influence on change processes, leaders should

focus energy and attention where they can influence effectively. They must learn to

confront the bases of conflict between stakeholder groups in a changing organization

and to see them as opportunities rather than obstacles.

This new framework of thinking about relationships and leadership behaviors presents new

opportunities for addressing the relationship between physicians and front-line managers.

The Utility of Complexity Theory

Complexity leadership theory provides a useful framework for analyzing physicians’

perspectives on leadership in front-line managers, acknowledging that physicians and managers

have different views and goals that sometimes conflict, but ultimately they are dependent on

each other for success. Complexity leadership theory has been broadly applied in healthcare

leadership literature and suggests improved collaboration and outcomes (Best et al., 2013;

Zimmerman et al., 2009). Ultimately, the manager’s role as leader is to adapt to the changing

views and needs of multiple stakeholders and to create an enabling environment in which all

stakeholders can realize a measure of success. By better understanding those physician views and

needs, specifically their perspectives and expectations from front-line managers, leaders could

engage physicians more effectively in mutually beneficial behaviors.

Physician Perceptions of Leadership Effectiveness in Hospital Managers

There is little direct research and existing literature about physician perceptions of

leadership effectiveness in hospital managers, however inferences can be made from related

literature. This this section discusses the general role of perception in determining effective

leadership, specific evidence that physicians are more engaged when the manager is a credible

and effective leader, previous research on physician perspectives on managers as leaders, and

finally related research demonstrating differences in perceptions of leadership effectiveness

between different stakeholder groups.

The Role of Perception in Determining Effective Leadership

Much of healthcare leadership research has been focused on identifying the most

important leadership skills and competencies; that is, it is leader-focused. Examples include

transformational leadership and authentic leadership (Avolio et al., 2009). However, there is also

substantial and more general leadership research that is follower-focused, specifically examining

the quality of the relationship between the would-be leader and potential followers (Hall, &

Lord, 1995; Howell, & Hall-Merenda, 1999; Kellerman, 2007; Liden, Wayne, & Stillwell, 1993;

Rentsch, & Hall, 1994; Suderman, 2012). This research on implicit leadership suggests that the

actual knowledge, skills and behaviors of a leader are less important than follower and other

stakeholder expectations of how the leader should behave (Schyns, 2006; Schyns, & Schilling,

2010). This type of research aligns well with the complexity theory approach to relationships that

are both independent and interdependent.

Implicit leadership research has demonstrated that both social and leadership perceptions

are developed quickly and consistently according to the expectations and beliefs of the perceiver

(Liden et al., 1993; Lord, & Maher, 1991; Murphy, & Zajonc, 1993). People quickly evaluate the

environment and the would-be leader against their own pre-existing belief structure in ways that

may have little to do with objectively measured leadership competencies. Based on these rapid

and usually subconscious assessments, individuals make long-lasting conclusions, & decisions

about worthiness of followership (Hall, & Lord, 1995; Howell, & Hall-Merenda, 1999;

Suderman, 1012). Rentsch, & Hall (1994) showed that members of the same work groups

develop similar schemas for assessing leadership (intra-group consistency). This view is

corroborated by research on actual leadership evaluations that demonstrated strong intra-group

agreement (Bradley, Allen, Hamilton, & Filgo, 2008). There is also evidence that different

groups develop different schemas (inter-group inconsistency) and definitions on leadership

(Shertzer, & Schuh, 2004) and that these schemas can lead to constraining beliefs about

leadership (Astin, & Astin, 2000). While this research seems generally applicable to health care,

there is also confirmation through applied healthcare leadership research.

Specific healthcare research studies have provided empirical evidence on the impact of

perception. The research supported the notion that perceptions of leadership effectiveness can be

different from actual effectiveness, as measured by traditionally accepted evaluation methods

such as leadership competency assessments (Klopper-Kes, Siesling, Meerdink, Wilderom, & van

Harten, 2010). Based on this evidence, understanding the perceptual framework of physicians in

relation to front-line manager effectiveness is important.

Evidence Linking Physician Engagement to

Leadership Effectiveness in Managers

Administrators/managers are central in building physician engagement in hospitals

(Dickinson, & Ham, 2008) and their effectiveness depends on a variety of factors including the

individual experiences of physicians with managers and personal connections established within

the organization. These experiences affect physician perceptions about managers, including trust,

understanding and respect (Kaissi, 2012a), which in turn affect physician alignment, willingness

to cooperate with others and engagement in shared activities (Montgomery, 2001; Trybou,

Gemmel, & Annemans, 2011). The type and scope of the relationship between physicians and

administrators has emerged over time as a result of the structure and evolution of hospitals and

formalized healthcare systems.

Historically, as soon as there was separation of administrative and clinical functions in

the hospital environment, it meant that physicians had to be able to trust that managers would be

effective in overseeing hospital operation and patient care, and that they would not interfere with

physician autonomy in their clinical domain (Kaissi, 2005). Over the past two decades much has

changed in the physician-organization relationship and full physician autonomy over clinical

decisions no longer exists; today, because of accountability and efficiency requirements,

hospitals increasingly have become involved in the clinical domain, engaging in

utilization/quality management and implementation of evidence-based protocols (Orland, 2011;

Wagner, Gulácsi, Takacs, & Outinen, 2006). Physicians must be able to trust that managers will

only interfere reasonably and appropriately in clinical decisions - which is perhaps more difficult

than staying out of the clinical domain entirely.

While physician trust in hospital management is affected by the extent to which they

respect managers and believe they are able to effectively carry out their duties, it is also affected

more generally by leadership power (Hospital Check-up Report, 2007; Kaissi, 2012a). Since, in

most cases, managers have little or no hierarchical power over physicians, they need to rely on

other sources of power to elicit physician collaboration, such as referent and knowledge power

(Fuqua, Payne, & Cangemi, 1997; Isosaari, 2011). This once again supports the need for

physician trust and respect of the manager’s leadership.

While the existing evidence around the importance of trust, respect, and referent power is

considerable, little research exists on how physicians actually decide whether a manager is an

effective leader and how they come to trust, respect and support the manager. In an ideal world,

there would be good alignment between organizational and physician expectations, evaluations

and conclusions. Hospitals would hire, train, evaluate and retain excellent managers and

physicians would support these managers. However, continuing reports about the conflicted

relationships between physicians and hospital administration as well as their sometimes

conflicting goals suggests this is not the case (Burns et al., 2010; Payton, 2012; Robinson, 2002).

Research into the quality of the physician-manager relationship is helpful in further

understanding what has contributed to this fractured relationship.

Existing Research on the Quality of Physician-Manager Relationships

General research about differences between manager and physician culture and world

view provides additional helpful information in predicting lack of alignment between physician

and organizational perspectives of leadership effectiveness in managers. In general, the body of

research around physician-manager relationships overwhelmingly reports that physicians have

broadly negative feelings towards hospital managers in general (Alexander, Brewer, &

Livingston, 2005; Bujak, 2003; Edwards, 2003; Klopper-Kes et al., 2009; Klopper-Kes,

Meerdink, Wilderom, & van Harten, 2011; O'Hare, & Kudrle, 2007). These unfavorable views

have been attributed to the four key areas of negative stereotypes, cultural differences,

conflicting goals and changes in health system incentives and societal expectations.

Negative stereotypes. As a group, physicians have been found to hold stereotypical

views of hospital managers as being low in social status, uniformed, uninterested in physician

needs and not worthy of the amount of power they wield (Edwards, 2003; Klopper-Kes et al.,

2009; Klopper-Kes et al., 2011; O'Hare, & Kudrle, 2007). Individual manager competence can

be irrelevant as physicians, beginning with low expectations, decide that a manager’s ongoing

efforts to advance organizational goals reinforce distrust and the situation creates win-lose

relationships between managers and physicians (Alexander, Brewer, & Livingston, 2005; Bujak,

2003, Edwards, 2003). With manager turnover, repeated organizational restructuring and often

fleeting daily interactions, physicians may have little opportunity to get to know managers as

individuals and can easily slide into basing their behaviors and opinions on the archetype of a

bottom-line driven manager.

Cultural differences. Physicians and managers also have been shown to have broad

cultural differences, which invariably produce opposing views in daily activities as well as

interprofessional conflict (Kovner, Elton, & Billings, 2000). Managers are conditioned into

hierarchical behavior, focusing on building collaboration and valuing relationships/harmony.

These are activities that are fundamentally affiliative and collectivist (Bujak, 2003; Degeling,

Kennedy, & Hill, 2001; Kaissi, 2005; O'Hare, & Kudrle, 2007). Because of hospital planning

cycles and the requirement to engage many stakeholders, managers also generally need to take a

long view; activities such as gaining consensus and acquiring new equipment may take months

or years.

The above hierarchical and collectivist management culture characteristically clashes

with the entrenched expert and far more individualistic culture found in physician groups,

complete with expectations of clinical autonomy, immediate action and reductionist decision-

making (Kaissi, 2005; Waldman et al., 2003). This expert culture has been found to contribute to

a physician view of managers as intellectually weak, without any common educational

background, true professional status or solid evidence-based training. Managers are further

viewed as lacking in respect for individual physician expertise, competency and skills (Cejka

Search, 2013). With such conflicting belief systems, differing expectations and conflicting

behaviors can be anticipated.

Goals and objectives. The manager-physician differences continue in the most basic

professional goal of each group, most often cited as physicians pursuing the good of the

individual patient compared to managers aiming to serve the best interests of patients as a group,

including setting priorities and allocating scarce resources (Bujak, 2003). In addition, because

managers are often involved in work that superficially appears to have little to do with the daily

activities of physicians and front-line patient care, they are sometimes perceived as uninterested

in patient welfare and good clinical outcomes (Edwards, 2003). The resulting and seemingly

inevitable conflicts are further exacerbated by continuing system changes.

System changes. Ongoing health reform and health system pressures often seem to

naturally pit administration and physicians against each other. First, heath care funding reform

forces managers to focus on driving efficiency and cost containment. Since physicians

ultimately drive utilization and resource use, these efficiency initiatives often impinge on

physician autonomy (Beckman, 2011; Gosfield, 2010; Grimes, & Swettenham, 2012). Increased

regulation and demands for accountability also result in management pressuring physicians about

evidence-based care, performance metrics, appropriateness and value (Degeling, Maxwell,

Kennedy, & Coyle, 2003). Consumerism, including the broad societal movement to improve

patient experience, adds to these pressures (Klopper-Kes et al., 2010). Finally, physicians

themselves are demanding shorter work hours and resisting efforts to involve them in

committees and hospital driven improvement initiatives, again placing managers and physicians

at odds. Without some way of finding common ground, these differences appear irreconcilable.

Research on Perceptions of Leadership Effectiveness from Related Fields

Applied research on perceptions of leadership effectiveness in related contexts can

provide helpful information supporting the idea that physicians and hospital administration

would have different perspectives. This research includes evidence that followers ultimately

interpret behavior based on self-interest (Kellerman, 2007) and that their perceptions of

leadership effectiveness may differ by hierarchical position, gender, culture and the quality of

leader-follower relationship. In particular, the literature related to manager vs. nonmanagers

perspectives is relevant.

Qualitative research has shown that, in studying hierarchical differences, managers may

have substantially different perceptions about leadership effectiveness when compared to

nonmanagers (Muchiri, Cooksey, Milia, & Walumbwa, 2011; Pulakos, Schmitt, & Chan, 1996).

In addition, analysis of leadership perceptions as measured in 360-degree feedback and other

multi-rater environments also found broad lack of agreement across stakeholder groups. While

managers at all levels principally value vision, supportive leadership and integrity,

nonmanagement employees rank leadership behaviors that demonstrate fairness, equality and

honesty more highly (Muchiri et al., 2011; Pulakos et al., 1996). Since physicians would fall into

the nonmanagement category in the organizational hierarchy, again, conflicting expectations are

inevitable.

Applied Research on the Impact of Culture on Leadership Perceptions

As presented earlier, physicians and managers occupy different cultural contexts leading

to fundamentally different world views. In addition to this specific situation, several researchers

have demonstrated that culture can generate broad differences in perceptions of leadership

effectiveness. Yan (2005) found generalized cultural differences in perceptions about leadership

across key dimensions such as power distance (acceptance of power inequities), uncertainty

avoidance, individualism/collectivism, and fatalism across cultures. Yancey, & Watanabe (2009)

found some cultures value personality in evaluating leadership as compared to others that value

skills and knowledge. Ford, & Ismail (2006) also demonstrated significant differences across a

variety of cultures. Holt, Bjorklund, & Green (2009) demonstrated that perceptions about good

leadership varied by cultural background, age and education. Therefore, the anticipated probable

impact of these physician-manager cultural differences is supported by more general research on

the impact of culture.

In addition to general research, it is also possible to extrapolate from other industries,

including the military, to healthcare (Kaissi, 2012b). The military, which has its own set of

beliefs and artifacts, has existing research results that are relevant in demonstrating the impact of

culture on leadership perception. Specifically, Hinchman, Magone, Marshall, & Stoddard (2009)

administered a leadership perception survey developed by Kouzes, & Posner (2007) to military

personnel at a training facility. They found statistically significant differences in 13 of the 20

surveyed characteristics of admired leaders when comparing the results of military personnel to

the general population in the original survey (Hinchman et al., 2009). These types of ongoing

differences in perceptions of leadership can also be extrapolated from research into the impact of

gender on perception.

Muchiri et al. (2011) demonstrated that men and women judge leadership effectiveness

differently. Gender stereotyping has been shown plays a role in influencing leadership

perceptions when analyzing perceived leadership planning and foresight (Pratch, & Jacobowitz,

1996). As physicians are more apt to be male while hospital administrators are more apt to be

female (Global Health Observatory Data Repository, 2014), this research is relevant and

provides additional support.

Finally, the familiarity in the relationship between physicians and managers can also be

considered. Research has demonstrated that the physical and metaphorical distance in the

relationship between the observer and the leader also impacts observer perception of leadership

performance and subsequent ratings (Howell, & Hall-Merenda, 1999; Lord, Brown, Harvey, &

Hall, 2001). Personal observation has shown that physician-manager interactions on patient care

units are often fleeting and superficial, with little time for true familiarization; similarly,

physician and manager offices are rarely co-located. Both situations support continues

incongruence in views.

In summary, there is little direct research into how physicians decide to trust managers, or

how they decide if managers are effective leaders, but much supporting evidence has been

extracted from related relevant research. Expectations have been shown to be important in

perceptions of effective leadership and the research overwhelmingly suggests that physicians, as

a group, and hospital administration would have fundamentally different expectations and

therefore perceptions of leadership effectiveness.

Generic Qualitative Inquiry

In research where there is no intent to investigate ethnographic phenomena, to do detailed

case investigations or to develop a theory as a result of the research, generic or noncategorical

qualitative inquiry is an accepted approach (Caelli, Ray, & Mill, 2003; Merriam, 1998;

Sandelowski, 2000; Thorne, Kirkham, & MacDonald-Emes, 1997). In generic qualitative

inquiry, researchers are not guided by an established set of philosophical assumptions, but

instead seek to understand the social reality constructed by a group of individuals (Merriam,

1998) in this case, the perspectives of hospitals physicians on leadership effectiveness in front-

line managers.

Caelli et al. (2003) and Merriam (1998) suggest that to maintain rigor in generic

qualitative research, the inquiry must contain theoretical positioning by establishing a lens

through which the data are examined and interpreted. This dissertation research is approached

through a complexity theory lens. They go on to describe analysis of data that identifies recurring

patterns, themes, categories, or factors that pervade the data and correlate with the theoretical

framework. This approach is used throughout this dissertation research.

Literature Review Summary

This chapter provided a summary of the research and existing evidence that is relevant to

this study. The research showed that physician perceptions of leadership effectiveness in front-

line managers are important because favorable perceptions can lead to greater physician

engagement which, in turn, can generate improved collaboration and greater probability of

favorable outcomes for both organization and other stakeholder groups. There is a broad body of

relevant and related research about physician views on administrators, evidence of cultural and

perceptual differences between stakeholder groups, and research on how leadership perceptions

can be influenced by the specific evaluation schema of the perceiver; however, to date, there has

been no specific research on how physicians judge leadership effectiveness and what factors

generate favorable perceptions. Complexity theory was shown to provide a helpful interpretive

lens that fits well with the unpredictability and multiple stakeholder agendas that exist in

healthcare today and provides a useful framework for suggesting improvements. Generic

qualitative inquiry was shown to be applicable in this situation. This study will add specific new

leadership knowledge that may serve as a foundation for improved physician engagement and

collaboration.

CHAPTER 3. METHODOLOGY

Introduction to Chapter 3

This chapter describes the research approach, design, sampling, analysis and other

methodological information relevant to this research. High quality manager-physician

relationships contribute to physician engagement and are critical to quality, effectiveness and

efficiency in hospitals (von Knorring et al., 2010) and so the researcher selected a generic

qualitative, descriptive, research design in order to gain an understanding of how physicians

judge leadership effectiveness in front-line managers. The researcher interviewed hospital

physicians about the perceptions, opinions and feelings they had experienced about the

leadership of front-line managers with whom they had worked over the course of their careers.

Research Design

Qualitative Research

This dissertation used qualitative research design. Qualitative research is widely used in

healthcare research and characterized by the following common features (Campbell, 2014;

Creswell, 2003; Holloway, 1997; Sandelowski, 2004):

1. Through qualitative research, investigators try to better understand the experiences,

thinking, attitudes and/or behaviors of a target group.

2. Qualitative research aims to interpret, understand and explain patterns of behavior

that have been observed in a specific situation or culture.

3. Instead of measuring and quantifying, qualitative research typically describes

observations in words, identifying connections and common themes.

4. Qualitative research is also most often exploratory and open-ended, approached from

the perspective of the target population and allowing the patterns to emerge naturally

instead of constructing bounded approaches that limit participant comments.

This dissertation study followed this general qualitative design and used open ended questions

with physicians as the target population.

Qualitative research has been described as an appropriate choice in specific situations

where quantitative research is not possible and other factors favor more generalized inquiry

(Campbell, 2014; Creswell, 2003; Curry, Nembhard, & Bradley, 2009; Krasner, 2001;

Sandelowski, 2004; Westbrook, 1994). These factors include:

1. The research question is an effort to understand how or what, with an emphasis on

understanding and describing rather than on identifying and measuring specific

relationships between variables.

2. The goal is to explore the topic in a general way, as opposed to developing a theory.

3. The researcher wants to develop detailed insight and understanding of a specific

phenomenon or worldview.

4. There is little existing research on the topic. Qualitative research is usually a first step

that is applied in situations where there is little existing research and data about the

subject and can be very helpful in generating a model or hypothesis for further study

by other methods.

5. The researcher wishes to gain an understanding of behavior in the subjects’ natural

setting, free of any artificial influences or contrived circumstances. Qualitative

research is most often naturalistic, that is, it studies behavior and thinking in the

participants’ natural environment rather than in a laboratory or some other

manufactured environment.

6. Instead of trying to determine absolute truth, naturalistic qualitative research is

focused on the truth as perceived by the participants and influenced by their world

view. Most often, qualitative research uses interviews or focus groups to collect

participant thoughts and experiences.

7. The researcher has a specific interest in and personal relationship with the topic of

study, rather than simply conducting objective analysis. The interviewer is a part of

the study environment.

8. The researcher has sufficient time for field research and thematic analysis of the

resultant data.

9. Both the reviewers of the research and the participants in the study are open to

qualitative research design.

10. The researcher wishes to approach the study as a learner rather than as an expert.

All of these described circumstances are highly relevant to this research. In this

dissertation, the researcher wished to understand how physicians determine effective leadership

in front-line managers. The goal was to explore the topic generally and to learn what factors

influence physicians in their determination of leadership effectiveness and understand how the

physician worldview affects their judgment. There is little published research on how hospital

physicians decide if a front-line manager is an effective leader. Stakeholder behavior in hospitals

is highly contextual and therefore studying behavior in the actual environment is preferable. The

researcher is actively employed in the study site and wishes to learn more about physician-

manager relationships. Finally, qualitative research is widely used and supported in healthcare

services research (Bradley, Curry, & Devers, 2007).

Generic Qualitative Research

This dissertation research used a generic qualitative approach. Generic qualitative

research is often simply referred to as qualitative research, but to distinguish it from other forms

of qualitative research it has also been called basic descriptive research, noncategorical research,

interpretive description and exploratory research (Merriam, 1998; Sandelowski, 2000; Thorne et

al., 1997). It is different from other specific qualitative approaches, such as phenomenology,

grounded theory and ethnography, in its simplicity (Thomas, 2006). This simplicity made it

attractive for a beginning examination of the relatively unexplored relationship between hospital

physicians and frontline managers.

Generic qualitative research is used where the researcher desires to develop a

straightforward, first level description of the target population perspectives without any intention

of developing a theory or rules of behavior, or of having to resort to complex philosophy or

technical language (Thomas, 2006). General qualitative research is becoming increasingly

common in healthcare as clinicians and administrators seek to answer elegant and useful

questions, but have neither the time nor formal research background to develop highly theoretical

approaches (Caelli et al., 2003). It provides a general and practical approach to examining real-

world problems in a healthcare setting (Cooper& Endecott, 2007) and lends itself to easy

understanding by nonacademic readers. This current study addressed the real world problem of

hospital physician engagement by exploring their perspectives on frontline managers and

suggesting alternative leadership approaches.

Target Population and Sampling

The target population for this research study consisted of physicians currently working in

the selected acute care hospital and who have daily interactions with front-line managers. The

initial goal was to recruit 6-8 participants, however nine physicians eventually participated in this

study. This sample size is supported in qualitative research projects where the inquiry is

relatively narrow in scope, the topic clear, the interviewees are a homogeneous and articulate,

and where the interview is focused on gaining a better understanding of a specific phenomenon

rather than generalizing to a large population or testing a hypothesis (Crouch, & McKenzie,

2006; Dworkin, 2012; Mason, 2010; Morse, 2000).

The research drew volunteers from the full-time physicians with current privileges at a

hospital in Ontario, Canada. Site permission was obtained for use of organizational resources,

communication systems, contact lists and attendance at meetings . The initial plan was to recruit

participants through signs posted in the doctors’ mailroom , verbal presentations and handouts at

physician meetings and, if necessary, specific e-mail solicitations for participants. However, the

researcher began participant recruitment during the summer months, by which time all

department and medical advisory committees were on summer hiatus, making presentation to

these groups impossible. Also, despite a two month-long posting of the research study

recruitment poster in physician areas, no volunteers came forward to participate. The successful

method for recruiting participants was the internal e-mail solicitation method. Personally

addressed e-mails sent out to staff physicians yielded ten qualified volunteers; however, one

physician withdrew from the study prior to data collection.

In order to ensure they had had significant experience with the physician/manager

relationship and had had sufficient time to develop opinions on manager effectiveness,

prospective participants were screened to establish they had been practicing in a hospital setting

for at least three years. Any doctors who did not regularly visit patient care area with front-line

managers were excluded. Doctors with sole reporting through the surgical program, where the

researcher is employed, were also excluded from participation in order to avoid any perceived

conflict of interest. Most of the recruitment conversations were conducted electronically,

however if a prospective participant asked for any clarification of further explanation, a follow

up telephone conversation was initiated.

After obtaining preliminary agreement, qualified prospective participants were provided

with a detailed consent form for private review prior to conducting an interview. During both the

process of soliciting volunteers and of obtaining consent, it was made clear that participation was

entirely voluntary and that failure to participate would in no way affect any future access to

hospital resources. On finding out that the interviews were to be recorded, one participant

subsequently withdrew consent and did not follow through on the interview. This left nine

participants from the original 10 volunteers. The final sample population included men and

women, physicians and surgeons, and also represented a variety of cultures and medical

specialties. The interviewed doctors were all very experienced, had each been in practice for over

ten years, and had worked at this organization for at least four years each.

Confirmed, qualified volunteers were scheduled for a face-to-face interview that was

recorded using a digital audio recorder. Participants were asked to verbally confirm that they had

read and signed the consent form and that they were aware that the conversation was being

recorded. They were also informed that they would be e-mailed an interview transcript for

review, at which time they could withdraw from the study and/or add/delete comments.

Setting

This dissertation research was conducted at a community hospital in Ontario, Canada.

The organization consists of two campuses, several community-based mental health clinics and a

walk-in clinic. This facility was selected because the researcher is employed there as program

director of surgery. As with most hospitals today, managers at this organization continue to be

challenged with shrinking budgets and increasing accountability for documenting and improving

the quality of care. The health system in which the organization operates is increasingly

competitive as mergers and program divestments threaten traditional internal and external

relationships. As physicians drive costs through their control of lab tests, imaging tests,

prescribing and length of stay, physician engagement is increasingly important on maintaining

competitive position. As noted earlier in this dissertation, the organization is facing massive

system change and incremental funding reduction over the next three years (Ontario Health

Coalition, 2012; Ontario Ministry of Health, 2012), improved collaboration and efficiency is

critical to organizational survival. In addition, both the local health care region and Ontario as a

whole are suffering from ongoing and potentially crippling physician shortages in many

specialties, reinforcing the need for physician engagement and retention.

Initial site permission was obtained from the CEO in 2013 and updated in spring of 2014.

Permission was also sought from the organizational research ethics board (REB). This committee

provided a waiver for research with academic purposes.

Instrumentation/Measures

This qualitative research was conducted through individual, face-to-face interviews using

an interview guide developed by the principal investigator with input from Capella staff at the

Dissertation Colloquium (see Appendix B). This interview guide was field tested though

interviews with five individuals with relevant credentials: two physicians with leadership

responsibilities and three hospital administrators with formal leadership training.

Field Testing

The purpose of field testing was to identify any potential problems with the interview tool

such as confusion about the meaning of the questions or misinterpretation of individual terms or

concepts (Brancato et al., 2006; Scheuren, 2004). The testers were asked to consider:

1. Whether the instructions were clear in explaining the type of information needed

2. Whether the questions flowed well and led to natural elaboration by the interviewee

3. Whether the questions generated helpful and appropriate types of information

considering the research questions and the overall goal of the research

4. Whether the questions would elicit individual perspectives on leadership

effectiveness

5. Whether the interviews could reasonably be completed within a targeted 60 minutes,

based on market research evidence that physician willingness to complete/participate

drops by two-thirds beyond sixty minutes (Maciolek, & Palish, 2009)

6. Whether they prospective participants could reasonably be expected to discuss the

stated topics openly and honestly, given the insider position of the researcher

Each expert confirmed the appropriateness and utility of interview questions. They all

stated that they believed the instrument would accomplish the study goals and that they had no

concerns about interviewee participation or openness. Interviewers were also asked for specific

suggestions for improvement. One tester suggested an additional clarifying question, which was

eventually incorporated into the interview guide.

Data Collection

Data collection commenced after receiving the appropriate approvals from both the

Capella Institutional Review Board and the study hospital Research Ethics Board as well as

completing the Pre-Data Collection Conference call. Participants were recruited and screened as

described in the sampling section of this chapter and then booked for a face-to-face interview

with the researcher. Initially there were ten volunteers but one withdrew on hearing that the

interviews would be recorded and only nine interviews were scheduled. The participants were

offered the option of meeting in the researcher’s office, the participant’s office or a separate

meeting room. Three chose to be interviewed in their own offices and the remainder selected the

researcher’s office.

The Interviews

The interview guide was designed to generate physician opinions and perspectives on

front-line manager leadership effectiveness. At the beginning of the interview session, each

participant was asked if they had any questions and the digital recorder was turned on. The

researcher also took notes throughout the interview to document any items that needed

clarification or exploration later in the session. Before commencing the actual interview, the

researcher requested verbal confirmation that the participant understood and had signed the

consent form, and that they were aware of being recorded. The researcher then provided a brief

review of the study methodology, including restating that the purpose of the interview was to

understand how physicians judged leadership effectiveness in managers, specifically front-line

managers in hospitals. For the purpose of this interview, and for clarification and consistency,

participants were provided with a written definition of leadership as follows: “The process of

social influence in which one person can enlist the aid and support of others in the

accomplishment of common tasks or organizational goals” (Chemers, 2000, p27).

The actual interview commenced with a grand tour question regarding a participant’s

general experiences with and opinions about leadership in front-line managers. This was

followed with in-depth probing around their specific experiences with managers they deemed to

be good or bad leaders. Participants were asked to identify specific incidents, experiences and

interactions or that caused them to consider a manager as either a good or bad leader and to share

their beliefs and opinions on the subject.

Initially, some of the participants struggled to differentiate between leadership and

management; however, they were repeatedly brought back to the definition provided at the

beginning of the interview. The interviewees were all highly engaged in the topic and

commented that they enjoyed the reflective process and personal insight that was stimulated by

the interview. While the interviews were scheduled for 60 minutes each, most physicians

answered the questions thoroughly in around 45 minutes.

At the end of the interview, participants were thanked for their participation and were

informed that the interviews would be transcribed and sent to them by hospital e-mail for their

review. Again, they were reminded that they could add or delete comments at that time, or

withdraw from the study if they desired. The recording was stopped at that point.

From interview to interview there was a high level of repetition of comments and

consistency in the perceptions and opinions expressed by the participants; after five or six

interviews it became apparent that there were diminishing new insights offered up. After nine

interviews, there was definite saturation in interview results and this confirmed that the planned

sample size provided was sufficient (Dworkin, 2012; Mason, 2010; Morse, 2000; O’Reilly, &

Parker, 2012). The entire process of interviewing the nine participants took over two months due

to recruiting delays and difficulty scheduling interviews and mutually agreeable times.

Transcribing and Validating the Interview Output

All interviews were recorded on a digital audio recorder. The files were downloaded to a

secure laptop. The electronic file was labeled with a unique identifying number and was

uploaded by file number only to secure cloud storage for retrieval by a research assistant. The

research assistant had previously signed a confidentiality agreement and required specific access

permission for each file retrieval. The original recording was retained on the secure laptop,

stored only by unique identifying number. The key for the identifying numbers was stored

separately in a locked filing cabinet.

The research assistant returned completed transcripts to the researchers secure hospital e-

mail. Once the transcripts were received back from the transcriptionist, the researcher reviewed

them for accuracy by comparing them to the original audio recording and handwritten notes

taken at the interview. Any comments or references that specifically identified the participant,

the hospital or a specific manager were removed. Final transcripts were sent to the individual

participants for review and confirmation. All participants confirmed that the transcript was

acceptable and did not request any changes. Final copies were printed and stored securely with

the relevant handwritten notes for later analysis.

Data Analysis

The interviews, interview transcripts and accompanying notes were reviewed using

general qualitative analysis techniques. These techniques are inductive and aimed at coding and

interpreting the participant comments (Saldaña, 2009). They included listening to each interview

as a whole, reviewing each interview as text, reviewing each interview for first order themes,

reviewing each interview for clustering of themes, reviewing the interview set for overall

themes, developing a taxonomy for describing the results, and then describing overarching

themes (Hycner, 1985; Morrissette, 1999, Thomas, 2006). Specific analysis was done for

frequency of occurrence of descriptive words (Baptiste, 2001). Each interview was reviewed

repeatedly for less obvious connotations, subtext and metaphors that could be important in

understanding perspective. Any areas that were emphasized or repeated by an individual

participant were also highlighted. Initially, the researcher had planned to use a computerized data

analysis software package; however, the small sample size and high degree of consistency

among participant responses made this unnecessary.

In the case of this research study, the desired output was a set of factors or characteristics

describing how physicians judge leadership effectiveness. These factors will be examined in the

discussion portion of the thesis, comparing them to factors presented in the leadership

competency model used in evaluating managers at the research site for performance appraisal

purposes.

Ethical Considerations

This dissertation research followed the Capella University best practice guidelines for the

protection of human research study participants (Capella, 2013; U.S. Department of Health and

Human Services, 1979). The research qualified as low risk and received research ethics waiver

from the study hospital Research Ethics Board and was deemed Exempt by the Capella

Institutional Research Board.

General Ethical Considerations

All participants were provided with a detailed description of the planned research and

interview expectations and then were given the opportunity to ask questions before agreeing to

participate. Consent was obtained in writing and participants were informed they could withdraw

at any time. During the consent process, participants were informed that, in addition to

publishing as part of the professional dissertation, the overall results would potentially be:

 Shared with the hospital leadership team members

 Used in for broader publication in journal articles

 Presented at healthcare leadership conferences

 Used as the foundation for further research

Participants were also reassured that no one would know who had been interviewed in the

study and that they could not be specifically identified in the publication in any specific way.

The research invited volunteers from the approximately 500 physicians with privileges at

the study hospital. Although all the participants ended up being recruited via e-mail, signs were

initially posted in the physician mailroom and all eligible physicians had an opportunity to

volunteer. All required policies on recordkeeping, safeguarding data, preserving privacy and

anonymizing the results were followed. Prospective participants were reassured that any

participation or nonparticipation would not affect their status or current/future access to

resources. Interviews were conducted in private and any identifiable comments were anonymized

or removed from the transcripts. All physician interview results were aggregated and in no way

attributed to specific individual respondents.

Ethical Implications Related to the Researcher

This dissertation research project was undertaken as an insider. While the researcher’s

insider status and personal credibility facilitated access, recruitment and organizational support

for the project, it was important to reassure participants about confidentiality. Although the

interview topic was low risk and nonthreatening, it was deemed safer to exclude physicians with

a sole resource dependence through the researcher’s surgical program in order to avoid any

potential perception of conflict of interest.

Ethical Implications Related to the Broader Organization

The researcher undertook research on a topic that could have implications for

administrator and physician relationships and which also could affect individual working

relationships (Moore, 2007). In any organization there are always people who resist change to

the status quo, usually because of fear about loss of power, influence, comfort or other desirable

state (Piderit, 2000). Therefore, it was important to get stakeholder buy-in up front and

throughout the project, managing relationships so as to mitigate this sort of risk. Throughout the

research process, the CEO, physician and administrative leaders were kept apprised of the

project and offered an opportunity to ask questions and comment.

Chapter 3 Summary

This chapter presented a detailed description of the research design choice, sampling,

instrumentation, data collection, analysis and other methodological information. In this

dissertation research, the investigator used a generic qualitative approach in to gain a better

understanding of hospital physicians’ perceptions of leadership effectiveness in front-line

managers. Minor adjustments to planned recruitment strategies and data analysis were needed,

however overall data collection and analysis proceeded well and provided a considerable amount

of very consistent and helpful information for further study.

CHAPTER 4. RESULTS AND ANALYSIS OF DATA

Introduction to Chapter 4

Chapter 4 describes and analyzes the results of the physician interviews that were

conducted in order to better understand physician perspectives on leadership effectiveness in

front-line managers in hospitals. The interview recordings, interview transcripts and

accompanying notes were examined using general qualitative analysis techniques in order to

produce a set of factors that affect physician perceptions of leadership effectiveness. Specifically,

analysis begins with a description of the site and participants, followed by a brief discussion of

observations made by interviewer during the interviews. The chapter then presents a more

detailed analysis of the interview content, including frequency of descriptive word use, listing of

most important factors as identified by interviewees, thematic grouping and clarification of

interpretation of themes. Finally, the chapter includes a brief description of the factors that have

been identified as important by the organization in judging leadership effectiveness, presenting a

summary of the competencies described in the organizational leadership performance evaluation

tool.

Site Description

The study site is a multi-site Canadian community hospital situated in Ontario, Canada.

The hospital is provincially funded through the Ontario Ministry of Health. Currently there are

approximately 500 physicians with hospital privileges. In addition, there are many other

categories of physicians, including affiliated general practitioners, locums, and some transient

physicians in observerships or other educational positions. While the hospital has experienced

periodic challenges in recruiting physicians in some specialties, overall there has been little

voluntary turnover in the fulltime staff physician complement and many physicians have spent

their entire careers at this hospital. However, continuing funding changes in the province and

recent regionalization several specialty services have resulted in unwelcome and disruptive

changes in physician manpower and resource allocation, leading to increasing uncertainty and

discontent.

Like many other health care institutions in Canada and the United States, the study site

has also used a variety of formal and informal process improvement methodologies to drive

efficiency and maintain a favorable financial position. Employees are required to attend

performance improvement training and expected to participate in a variety of performance

improvement events. Physicians are encouraged to be involved but participation levels are much

lower than with employees and management.

Description of Sample

Physician volunteers for this study were initially solicited from among the full-time,

active physicians via poster in the physician mailroom. When this initial recruitment yielded no

volunteers, more targeted recruitment was undertaken with personal invitations sent via e-mail.

Ten physicians responded favorably to the targeted recruitment. These volunteers were reviewed

to ensure they had each worked with front-line managers for at least three years. One volunteer

subsequently withdrew before signing the consent form. Eventually, nine physicians were

interviewed. Of the nine physicians interviewed, there were eight men and one woman. Each had

a different primary medical specialty and all had been with the study hospital for over five years.

Each of the interviewees had at least some leadership experience during their career. Detailed

demographics are presented in Table 1 below and are broadly grouped by age and experience to

prevent identification of subjects.

Table 1. Participant Demographic Overview

Demographic Category Distribution

Clinical Specialties Subspecialty Medicine *

Cardiology

OB/GYN

Gastroenterology

Radiology

Internal Medicine

Critical Care

Administration

Emergency Medicine

Age Range Early Career - 3

Mid-Career - 3

Late Career - 3

Gender Male - 8

Female - 1

Formal Leadership Experience Low - 4

Medium - 2

High - 3

Research Methodology Applied to Data Collection and Analysis

The nine study participants were interviewed individually in an office setting, three in the

participant’s office and six in the researcher’s office. As described in the Methods section, the

interviewees were reorientated to the purpose of the study, the consent process and the planned

interview procedure. All of the participants were highly engaged, expressing general interest in

the topic and in seeing the results of the study. Interviews lasted from forty-five minutes to sixty

minutes.

At the beginning of the interview, each participant was given a written definition of

leadership and the definition was read aloud. The stated definition was “The process of social

influence in which one person can enlist the aid and support of others in the accomplishment of

common tasks or organizational goals,” (Chemers, 2000). They were invited to ask for

clarification if needed, however all expressed confidence in understanding the definition and

exploratory nature of the interview.

Data Analysis Procedures

Initial Observations by Interviewer

Initially, some of the participants struggled to focus on the concept of leadership as

opposed to management and more specifically organizing behaviors; however, they were

repeatedly brought back to the definition provided at the beginning of the interview.

Nevertheless, the balance of the factors presented by participants ended up falling

disproportionately into activities traditionally associated with managing (planning, organizing

controlling) as compared to leading (setting vision, motivating, inspiring, aligning).

Throughout the interview the participants appeared very comfortable with the interview

topic and were easily able to recall examples of both good and bad leaders from among their

experiences with front-line managers. They were readily able to describe behaviors, skills and

incidents that both positively and negatively influenced their perceptions about the managers’

competence. They were quick to recall specific examples of bad leadership and specific incidents

that contributed to their feelings about managers but described good leadership in more general

terms.

By the end of the third interview, it was apparent that there was a high degree of

consistency in the physician perspectives, with all of participants presenting variations on the

three themes of communication, listening and getting things done. Within these most common

themes, there emerged two overarching perspective. First, in general, managers who took the

time to listen, understand and respond to the physicians’ perspective and situation were seen as

good leaders. Managers who exhibited hasty reactions and acted without full information or

consultation were generally viewed as rigid and ineffective in being able to move forward on the

business of running their units.

Descriptive Data Analysis

Initial descriptive data analysis began with examining frequency of descriptive word use.

Using an online word frequency analysis tool (Huot, 2007), and excluding common words, a list

was generated of the words most commonly used in each interview. This list was compared

across interviews and the results are presented in Table 2.

Table 2. Three Most Frequently Used Descriptive Words

Participant Most Frequently Used Descriptive Word

Most Common Second Third

1 Communication Accessibility Values

2 Communication Vision Transparency

3 Communication Listen Strategic

4 Communication Fair Decision

5 Communication Listen Knowledge

6 Knowledge Respect Listen

7 Communication Knowledge Open

8 Respect Listen Communication

9 Conflict Responsive Transparent

In six of the nine interviews communication was the most frequently used term and it was

in the top three of seven interviews. Across all interviews, the most commonly used descriptive

terms were about communication, listening, followed by knowledge and respect. If grouped

together, transparent/transparency also fell into this list. These results are consistent with the

initial observation that communication and listening were two pervasive themes.

During the course of the interview, and after discussing factors that affected their

impressions of a leader’s effectiveness, participants were asked to specifically select and identify

the three most important factors from among those they had discussed. For purposes of this

analysis, approximate match/interpretation was used rather than exact wording. The results of

this forced ranking are listed in Table 3.

As with earlier analysis, there was a high degree of consistency in the responses to these

questions with seven of the nine participants ranking “good communication” as one of the three

most important attributes of an effective leader. This was followed by “knowledge and

understanding of the business and priorities” (cited by four participants) and “able to get things

done” (ranked by 2 participants).

When asked to rank characteristics of an ineffective leader, “poor communication” tied

with “inability to get things done,” each ranked in the top three by five participants. Lack of

insight and understanding of business and priorities was ranked in the top three by four

participants.

These rankings provide a helpful indicator of participants’ views on relative importance,

however many of the factors presented above also occurred in the conversation during the

interviews with other participants, despite not being ranked in their top three. For this reason, an

overall list of general themes was compiled and then each interview was assessed for

confirmation of the presence or absence of this theme in descriptions of either good or bad

leaders. For a factor to be ranked, it had to have been mentioned by at least 50 percent of the

interviewees (five out of nine). These results are presented in Table 4.

Table 3. Three Most Important Factors in Influencing Perception

Participant Good Leaders Bad Leaders

1 Good communication

Understand priorities

Able to get things done

Poor values

Inaccessibility

Poor communication

2 Vision and planning

Good communication

Process improvement/Lean

Poor communication

Lack of transparency

Inability to get things done

3 Intelligent

Think things through

Good communication

Poor communication

Lack of insight/understanding/priority

Inability to get things done

4 Knowledge/understanding/priority

Good communication

Fairness/equity

Lack of insight/understanding/priority

Poor communication

Lack of fairness

5 Strong work ethic

Good communication

Knowledge/understanding/priority

Lack of respect

Lack of insight/understanding/priority

Inability to get things done

6 Spend time at front line

Knowledge/understanding/priority

Understand own limitations

Poor relationship/understanding of staff

Don’t understand/spend time on unit

Lack of confidence in own abilities

7 Good communication

Trusted by staff, & physicians

Knowledge/understanding/priority

Lack of insight/understanding/priority

Poor communication

Lack of relationship with team.

8 Honesty, & integrity

Organized

Collaborative, & respectful

Inability to get things done

Not respected by their team

Bad attitude toward criticism

9 Able to get things done

Transparency

Good communication

Inability to get things done

Failing to engage stakeholders

Needing too much direction

Table 4. Presence of Major Theme in Participant Interviews

Theme Participant Number

1 2 3 4 5 6 7 8 9 Total *

1. Communication, listening, open to new ideas X X X X X X X X X 9

2. Getting things done, organized, decisive X X X X X X X X X 9

3. Understanding, & insight, informed, priorities X X X X X X X X 8

4. Deal with conflict, & bad performance promptly X X X X X X X 7

5. Fairness, honesty, transparency, & equity X X X X X X X 7

6. Relationships, collegiality, collaborative X X X X X X X 7

7. Accessibility, visibility X X X X X 5

8. Shared goals, vision, & values X X X X X 5

* A “9” in the total column means that the stated theme was present in all nine interviews

Major Themes

As discussed earlier in this chapter, there was a high degree of consistency in the overall

themes that occurred during the physician interviews. While the frequency of occurrence of these

themes is reported above, this section includes a more detailed presentation of each theme.

These explanatory details were provided by the participants when prompted. For example, when

a participant cited good (or bad) communication as affecting their perception of leadership

effectiveness, they were asked “What do you mean when you say good communication?” Details

of the themes are described below, with participant number indicated after individual quotes.

Most Pervasive Themes (~90-100% of interviewees)

Communication, Listening, and Openness to New Ideas. When asked to describe good

managers, most of the participants immediately raised the topic of communication, “Being able

to communicate to doctors what the issues are amongst staff, that is a key” (P1); those who did

not rank it as first did eventually identify it as important. When pressed to describe good

communication, participants went on to talk about inclusive behavior, consultation and direct

engagement of physicians, such as “…good communication skills, discussing the problem,

understanding more of their point of view and asking their input in and opinion” (P7). Most

participants expressed a desire to be involved in a leadership conversation, rather than being

unilaterally dictated in their activities and behaviors. They expressed a dislike of being told what

to do, “…the approach they took was to be somewhat dictatorial in terms of trying to put things

into place, because that was really the only tool they had” (P6). They wanted managers to

communicate directly with them regarding the issues and activities that were important to the

organization and the unit, and also to explain about changes and new initiatives. There were

repeated comments about aggravating memos, signage and decisions that were communicated

without any context, “But it really annoys all the doctors when they send out these random e-

mails” (p4). These types of communications were viewed as annoying, pointless and most often

ignored.

On further discussion, the interviews invariably progressed to complaints about managers

who were not seen to listen. Many participants complained about managers who said no (or

variations thereof) without taking the time to hear to the physician perspective, commenting that

bad leaders “…are totally incapable of listening and considering a point of view that is other than

theirs” (P3). Physicians commented that they understood about organizational constraints and

cutbacks but that unilateral decisions were irritating. They commented that they knew they

couldn’t have everything, but felt that there should at least be a discussion before they were told

no as in, “…challenging the physician’s viewpoint without really trying to understand why the

person wanted something done” (P6).

Finally, the participants generally agreed that while oral communication was important,

an effective manager should be able to argue persuasively for additional resources through

writing proposals and making presentations as required by their position.

Gets Things Done, Organized, Decisive. In addition to communication, “getting

things done” was the other unanimously identified factor that physicians deemed important for

good leadership at the front line. Examples of comment include:

“Those (good) managers they are more problem solvers than anything else” (P2).

“In some ways the ideal unit manager is almost like a concierge. You know getting things

coordinated and organized” (P6).

“Being able to deliver on specific projects or items or deliverables. Being able to actually,

completed projects” (P9).

Most often their descriptions centered on managers who were perceived as not taking

action on departmental needs or physician requests, “Not forgetting and not being forgetful”

(P5). A recurring refrain was of physicians and/or nurses asking for supplies, repairs, changes

etc., but never hearing back nor seeing any evidence of follow up. In addition to identifying this

as a communication issue, the interviewees said they felt this was evidence of lack of interest in

running the unit well or too much focus on being liked, “…cost of having good relationships

versus achieving something” (P2).

Physicians also commented that good managers just made things happened, while bad

managers found excuses or simply ignored problems/issues. Several physicians added that they

were frustrated when managers took too long to get things done because the managers wanted to

have too many meetings with too many stakeholders – and that many issues were discussed far

too long. Physicians felt it was important for managers to be able to understand that “not

everything is a meeting,” and that sometimes a simple and timely decision would suffice.

“..And that they don’t get caught or bogged down with trivia things that stall processes

and prolong situations without getting to the point of the situation. They eliminate

bureaucracy and micromanaging tries to understand situations as quickly as possible and

provide a solution” (P5).

“Sometimes you have to say no that is not possible we discussed that thanks very much

but we’re moving on…(some managers) they call meetings about everything and are too

cautious about making fundamental decisions about quality or safety,”(P2)

These comments sometimes appeared to conflict with the interviewees’ stated desire for

inclusive behavior and enough consultation by good manager.

Finally, physician comments usually explicitly or implicitly often circled back to the

manager helping the physician to be more effective, e.g., “The best manager is the one that

allows me to do my job” (P9).

Understanding, & Insight, Informed, Priorities. The third most often cited (eight of

nine participants) factor that influenced physicians’ perspectives of leadership effectiveness was

usually expressed as some variation of understanding and insight. Participants felt that good

leaders understood what was going on in their unit, correctly identified and acted on unit

priorities, and had the required information on which to base decisions, to “make a sensible

independent judgment of the situation that is unfolding, and come up with an independent and

helpful response” (P3).

Several participants also commented that good leaders not only understood what was

going on in the relevant patient care area, but also had a good understanding of what was

happening elsewhere in the organization and the healthcare system. After these opinions were

heard, participants were asked if they thought a clinical background in the managed area was

important. While one physician felt it was important, the others said that the manager mostly

needed enough background and information to make intelligent and defensible decisions:

“You really have to understand how things work otherwise there is no way you can do it”

(P1).

“You can’t give them any direction if you are lacking the understanding” (P4).

“They should know everything that is happening and understanding the milieu” (P7).

During the above discussions, the issue of intelligence also surfaced. While two

participants deemed intelligence was important, most felt that the manager just needed to be

“smart enough.” Several did add that “smarts” was more important than “smart,” and went on to

talk about how important it was for managers to filter through to the truth from among the many

different perspectives and stories in their areas.

“It is not like knowledge smart but street-smart” (P4).

“I don’t think necessarily that the nurse or the chief or whoever has to be the brightest

person, but they do have to have a decent working knowledge of what they’re dealing

with” (P6).

Highly Ranked Themes (~75% of participants)

Deal with Conflict/Bad Performance Promptly. Seven out of the nine participants

identified a manager’s ability to manage conflict as being important in influencing perceived

leadership effectiveness. The physicians said that conflicts in their respective areas were

relatively frequent and most often stemmed for interpersonal issues, resource allocation or poor

performance. The physicians admired managers who were able to manage such conflict

promptly, effectively and without creating excessive disruption in the clinical area.

“If there is an issue that needs to be dealt with, it is kind of dealt with” (P1).

“…But if there are issues they didn’t let them sit for a long time” (P2).

“(Managers should” be prepared to address defects or to address attitudes that are bad or

poor work habits” (P6).

“Able to handle conflict very easily were very well” (P8).

In particular, they wanted managers to speak to the people involved in a conflict directly and

immediately, rather than getting involved in second-hand information or waiting for issues to

resolve on their own. Confrontations of any sort were considered undesirable and they felt

physicians, in general, responded poorly where the manager lost control of the situation or was

unable to defuse and manage bad behavior from staff or physicians.

“(Bad managers work)…in a very confrontational do this this way” (P1).

“They were able to accept this feedback in a nonconfrontational way” (P8).

The subject of physician engagement and consultation emerged again in the discussion of

conflict management. Physicians wanted to be approached directly and immediately when the

conflict or issue was pertinent to them as physicians or individuals, but didn’t want to be dragged

into or exposed to issues that they felt were irrelevant or frivolous. The physicians also

commented that managers should not be afraid to seek assistance or escalate if they found that

they were unable to deal with a problem independently, “Knowing when to escalate something

and when to manage it at the level that they are and to get it dealt with” (P6).

The final underlying theme in managing conflict was that good leaders facilitated

settlement of conflict situations and created reasonable resolution, whereas bad leaders ignored

conflict/bad behavior or dictated solutions and rash responses that were ill-conceived and

ultimately disruptive or ineffective.

“There is not a knee-jerk response, they listen and assess, they process, and then respond

in a thoughtful way” (P3).

“The instinct should be, can this wait? Will things be the same tomorrow if we do not

address the now?” (P5).

Fairness, Honesty, Transparency, & Equity. Words such as fairness, honesty,

transparency and equity also surfaced in seven of the nine interviews. These words occurred

most often in discussing resource allocation to physicians and the way in which staff and

physicians were treated.

“You have to be really consistent and you have to be pretty transparent” (P2).

“You can pack all those into being trusted” (P7).

“The managers that I like are the ones who are open and honest and upfront” (P9).

With regards to resource allocation, participants expressed frustration over what they

perceived as inequitable access to resources or questionable organizational decisions (whether

made by the individual manager or not). Where some physicians got more equipment, more

clinic time, or preferred time slots without any apparent explanation, or when requests were

turned down without explanation, they inferred favoritism. They said they liked managers who

explained resource distribution openly and shared the rationale behind other decisions. Again,

they commented that they understood the scarcity of resources and that it was impossible to

please everyone, but that they wanted transparency to in process.

“We really need to understand why they are doing things” (P1).

“…and take to their managers their concerns, their observations, about the inequities in

access” (P3).

“I think that people want that feedback even if you cannot do anything” (P4).

Similar comments were made around the subject if perceived staff favoritism and

confidentiality. Physicians felt negatively towards managers who they felt did not treat staff

fairly or equitably, or who gained personally from decisions.

“You really need to be able to trust that you can give whatever information to that person

and it will be dealt with in a tactful and professional way.” (P1).

“As long as you are fair and you’re objective, it goes a long way towards solving the

problem” (P4).

“An example (of a bad leader) would be making a private conversation or publicizing

their e-mail or verbally a private conversation” (P8).

Relationships, Collegiality, Collaboration. Although the words related to collaboration

occurred in the earlier discussions of inclusive behavior, getting things done and stakeholder

engagement, the topic also appeared in conversations about maintaining relationships. Physicians

felt it was important for managers to develop rapport with their physicians and staff, with

sufficient face time and interest in others so that they could build foundational relationships. The

interviewees generally identified a need for managers to engage socially with others in their

work environment. The physicians felt this could be done through coffee/lunch, after work

activities or simply ongoing personal interest and small talk, but they suggested the goals should

be respect and collegiality, rather than close friendship. The participants felt negatively about

managers who became over-involved in the loves of their constituents or who share unnecessary

personal details. Specific comments included:

“There is a rapport where you can discuss things” (P1).

“It’s not a friend-friend relationship” (P2).

“[Bad managers] have little, if any, people skills” (P3)

“They would come and chit chat and would be laughing, you don’t need that. You don’t

need the manager to be friends, just friendly” (P4).

“They have to know where the boundaries are” (P5).

“People can be willing to do your stuff if they know that you care about them” (P7).

“I realize sometimes to be a good leader you don’t, you can’t do everything to cater to

your team” (P9).

In an extension of these discussions, some participants went on to talk about the need for

managers to be able to read people well so that they could individualize their responses to people

and situations. They also discussed a need for interpersonal awareness, in order to better assess

when intervention was needed and not.

“It is about understanding how people think, how people feel, and applying it to whatever

they are doing and how you manage various situations” (P5).

Remaining Common Themes (>50% of participants)

Accessibility, visibility. More than half of the interviewees identified access to the

manager and manager visibility in the clinical area as important. The commented that the could

not get to know and trust a manager who was never available or present on the unit; they also

said that a manager couldn’t possibly know what was important to the staff, physicians or unit

operations if the manager was never there. References to manages being stuck in their offices or

never around were common. This topic of conversation also seemed to be rife with emotion and

frustration, as those participants mentioning it became louder and more emphatic when

discussing these issues. Some physicians sounded angry that they were subject to the dictates of

someone who was not around and did not see the results of their decisions.

“You need to sit down and talk and you can't get them” (P1)

“We kind of called it like sitting in her glass tower…she was never around so there’s no

way she could know what was going on” (P4).

“They are not there to lead from a distance; they are there to be a part of the team and to

give insights” (P6).

“It is not just somebody who parachutes in every now and then, screws everything up,

and then walks away” (P9).

In addition to valuing manager presence and visibility, the participants discussed a need

to be able to contact the manager and to get a timely response; being able to e-mail or call a

manager (and get a response) was helpful, but face-to-face contact and personal interaction was

preferred in most cases. The notions of access, visibility and prompt response circled back to the

earlier identified issue of getting answers and explanations to physician requests. Managers who

were not sufficiently visible were perceived as being uninterested, unavailable and hiding from

problems and decisions.

“You can pick up the phone and call them. E-mail them and they answer” (P1),

“You should be able to respond reasonably promptly in a day or two at the most” (P5).

Shared goals, vision, & values. Five of the nine participants also talked about the

importance of shared values and common goals. While physicians talked explicitly common

goals and some of the specific goals mentioned by physicians included putting the patient,

organization and team first, during further discussion physicians elaborated that they wanted the

manager to support and share physician goals and values, as opposed to developing and agreeing

on mutual goals.

“Things go off the rails when my vision and that of the clinic manager are not the same”

(P1).

“They understood my goals were” (P2)

“They basically understand the same value system I do” (P3).

“I want the same thing for you and your unit as you do. But just not in that way” (P4).

“It is getting stuff done for the patient first and foremost” (P6).

“They have reasonable vision and expectations for what they hope to accomplish in a

department” (P8).

Other Comments and Observations

During the course of the interviews, participants often used leadership and hospital jargon

to describe behaviors or skills that they felt were important in good leaders. In some cases, on

further discussion, it became evident that not all the interviewees were using the term with the

same interpretation. For example, while eight out of nine interviewees commented that strategic

planning and/or strategic management were important skills for good leaders, there was little

consistency in ultimate meaning. When asked to elaborate on what they meant by strategic

planning/management, participants described skills such as how to approach problems,

developing innovation, formulating a reasonable plan and being able to achieve goals. Only one

participant used the term in its traditional context as a process for setting priorities and focusing

the use of human and other resources. Lean management was also mentioned, but only once in

the context of an organizational philosophy of creating customer value and incremental,

employee led improvement. Other participants described variations of generic process and

quality improvement. Specific comments included:

“It’s not that common they are called on to develop strategy (P1).

“If you are good at strategizing, that comes from applying some of your skills, some of

your knowledge, and having a good way of analyzing problems (P5).

“Able to look at a situation and say listen this is what we are doing well for this is what

we can do better (P8).

Factors Affecting Organizational Perception of Leadership Effectiveness

In order evaluate any potential difference or conflict between organizational expectations

and physician perspectives, a list of factors affecting organizational perception of leadership

effectiveness was also required. The leadership competency tool currently in use at the study site

was used as a representation of the organizational perspective. This tool includes eight thematic

groupings in which essential behaviors desired in leaders are described. These themes are listed

in Table 5.

Table 5. Factors Affecting Organizational Perception of Leadership Effectiveness

Factors Affecting Organizational Perception of Leadership Effectiveness

1 Collaboration/ Influence

2 Business Acumen/ Organizational Awareness

3 Planning, & Coordination/ Results Orientation

4 Service, & Quality Orientation

5 Developing Others

6 Holding Self, & Others Accountable

7 Visionary Leadership

8 Interpersonal Sensitivity/ Leadership Presence

Within the broad thematic groupings contained in the leadership competency assessment

tool there are detailed descriptions of the specific activities, skills and behaviors that are

expected of front-line managers. As with physician factors, these descriptions were first assessed

for the frequency of descriptive words, excluding common connecting words, and then

descriptive words were ranked. This word frequency ranking is presented in Table 6.

Table 6. Frequency of Descriptive Words in Leadership Competency Tool

Frequency Ranking Descriptive Word(s)

1 Goals, & Objectives

2 Develop/development

3 Accountable

4 Performance

5 Quality

6 Achieve

7 Collaboration

8 Influence

9 Standards

10 Priorities

Major Organizational Themes

The summary descriptions of the specific desired activities, skills and behaviors

designated in the organizational leadership competency tool are presented below as extracted

directly from the tool.

Collaboration/ Influence. Collaboration/Influence involves the intention to collaborate

and engage constructively with others, to be part of a team, to work together, as opposed to

working separately or competitively. Collaboration involves promoting a positive climate,

resolving conflict, and creating alignment within and across internal and/or external

groups/partners. Influence implies an intention to advocate, motivate, persuade or influence

others in order to gain their support and commitment. It includes the desire to effectively gain the

support and collaboration of others.

Business Acumen/ Organizational Awareness. Business Acumen/ Organizational

Awareness involves the ability to understand the business implications of opportunities and

decisions and to implement successful business strategies that improve the functioning of the

organization. It requires an awareness of issues, processes and outcomes as they impact the

organization’s and stakeholders’ strategic direction. It is the ability to understand the key

relationships, diverse interest groups and power bases within one's own and other organizations.

Planning, & Coordination/ Results Orientation. Planning, & Coordination/ Results

Orientation involves the ability to plan and coordinate work, understand and effectively manage

resources, prioritize steps to be taken, anticipate potential issues/barriers and develop

contingency plans to address these, and execute individual and team activities in a way that

ensures the achievement of a set of objectives. It includes the personal drive and need to

achieve results and the ability to focus one’s attention on accomplishing key objectives and

positive outcomes for oneself and one's team. Personal development and welcoming new

challenges is important. Effectively assesses and manages risk and measures/evaluates results.

Service, & Quality Orientation. Service, & Quality Orientation is the desire to provide

quality, patient-centered care. It means focusing one’s efforts on discovering the expressed and

unexpressed needs of customers, patients and stakeholders, and meeting these needs. It is about

ensuring quality and patient safety in the delivery of services and complying with existing rules,

regulations and legislation. It is expressed in the monitoring of service information, insisting on

clarity of roles and expectations and setting up and maintaining systems that enhance quality and

maximize efficiencies.

Developing Others. Developing others is the genuine intent to foster the long-term

learning or development of others through coaching, managing performance and mentoring in

order to stretch and challenge others to actualize core values of the healthcare system, achieve

higher level goals and develop new skills/competencies. The individual’s actions are driven by a

genuine desire to develop and empower others, rather than simply a need to transfer skills to

complete tasks.

Holding Self, & Others Accountable. Holding Self, & Others Accountable involves

establishing appropriate levels of responsibility, holding others accountable for delivery of

agreed upon objectives and implementing appropriate positive/negative consequences. It requires

holding team members and/or others accountable to execute to high standards of excellence and

holding self accountable to the same or higher standards. It involves providing clear directions,

priorities and expectations and consistently monitoring performance and providing corrective

feedback when performance is not up to the standards. It also includes confronting performance

issues directly and promptly and not hesitating to take action (e.g., terminating poor performers)

when improvement is not forthcoming.

Visionary Leadership. Visionary Leadership is the ability to inspire others to work

toward common goals by increasingly engaging and empowering them. This includes focusing

the team on priorities, leading and supporting the team through change, holding the team

accountable, soliciting the team’s input to form plans and inspiring the courage to challenge team

process and the commitment to achieve personal, team and organizational goals.

Interpersonal Sensitivity/ Leadership Presence. Interpersonal Sensitivity/Leadership

Presence involves acting to understand and respond appropriately to the concerns of others. It

involves practicing active listening when interacting with individuals or groups. It includes the

ability to reflect on verbal and non verbal behavior and communicate effectively. It also requires

the ability to develop and maintain a sense of presence and emotional maturity that reflects an

awareness of one’s own strengths and limitations and the impact of one’s behavior on others.

Chapter 4 Summary

This chapter presented a description of the data and analysis of the physician interviews

that were conducted in order to answer the first research question about factors affecting

physician perceptions of leadership effectiveness in front-line managers. The interviews were

assessed for word frequency, participant priority rankings, major themes and relative occurrence

of major themes. Overall, physicians most highly ranked communication, listening, getting

things done and dealing with conflict effectively.

For comparison and later discussion, the chapter also similarly presented the factors

affecting organizational perception of leadership effectiveness. Chapter 5 includes discussion of

the results, a comparison of physician and organizational factors, suggestions for alignment of

factors, limitations, conclusions, and recommendations for future research.

CHAPTER 5. DISCUSSION, IMPLICATIONS, RECOMMENDATIONS

Introduction to Chapter 5

The purpose of this research study was to better understand how physicians judge

leadership effectiveness in front-line managers, how their judgment differs from organizational

perspectives on leadership effectiveness, and how the gap can be bridged in an effort to improve

physician engagement in hospitals. The study addressed a gap in the current leadership research

on physician-manager relationships and manager-led physician engagement. Previously,

physician engagement efforts have been mostly high level, structural and strategic, focused at the

senior management level.

Chapters 1 and 2 described the urgency of the need for better physician engagement, the

inadequacy of existing initiatives and the opportunity presented by focusing on the physician

relationship with front-line managers. These chapters also presented evidence that physician

perceptions of leadership effectiveness in managers are important in driving engagement and

discussed the applicability of complexity leadership theory in enabling productive and effective

relationships in hospitals. Chapter 3 described the explained the research approach, design,

sampling, analysis and other methodological information. Chapter 4 described the results of the

physician interviews and the identified factors that affect physician perspectives of leadership

effectiveness in front-line managers. The chapter also described a currently used organizational

framework for determining leadership effectiveness and presented similar format to the interview

analysis in order to facilitate comparison.

Chapter 5 summarizes the results of the research study, compares the factors affecting

physician and administrative perspectives on leadership effectiveness in front-line managers, and

suggests some actions that could be implemented to help bridge the gap and improve alignment

and increase manager effectiveness in engaging physicians. This chapter also presents

limitations, implications for practice and opportunities for subsequent research.

Review of the Research Questions and Purpose

This research study identified a primary research question to be answered through

physician interviews as well as two secondary questions to be addressed in the discussion. These

research questions were as follows:

Primary Research Question: How do hospital physicians judge leadership effectiveness

of front-line managers?

Secondary research question 1: How do physician perspectives differ from those in a

current competency-based leadership effectiveness evaluation model used by administrators?

Secondary research question 2: What intervention(s) could improve alignment between

administrator and physician perceptions of leadership effectiveness?

Summary of Results

Physician Perspectives on Leadership Effectiveness in Managers

When asked to discuss behaviors, skills, relationships or incidents that contributed

favorably to their perceptions of a manager’s leadership effectiveness, physicians most often

used words such as “communication” and “listening” followed by “knowledge, respect and

transparency.” As a result of thematic analysis, the most common themes in the interviews were

communication, getting things done and understanding priorities. Being able to address conflict

and disagreement was also highly ranked and also emerged as an embedded topic in many other

themes. The full list is presented below in Table 7. When specifically asked to identify which of

the factors they had discussed were most important, again, the most consistently chosen attribute

was “good communication.” This was followed by “knowledge and understanding of the

business and priorities” and “able to get things done” (ranked by 2 participants). When asked to

discuss factors that negatively influenced their perceptions about a manager’s leadership

effectiveness, bad communication was most often the first response. This was followed closely

by comments about rigidity and inability to get things done.

Overall, there was a high degree of consistency from interview to interview and

considerable congruence in physician views. This is consistent with the literature findings that

physicians share a strong common group identity and common views (Bradley et al.2008).

Physicians easily recalled incidents of bad leadership that had occurred many years ago,

consistent with the literature findings that perceptions develop quickly and consistently (Liden,

et al, 1993; Lord, & Maher, 1991; Murphy, & Zajonc, 1993). In aggregate, the identified themes

repeatedly circled around the subject of keeping the physicians informed. They wanted to know

what was happening on the units, to get feedback on their requests, to have updates on

organizational performance and to get clear explanations about resource allocation and activities

that affected their work. They did not want to have to get involved in things that they perceived

were not relevant to them. It appeared that they felt they had little other avenue through which

get this information and valued managers who were able to help. The second recurring topic

within the major themes was about activities that helped physicians to get their work done. Lack

of information, staff conflicts, rigid managers, incompetent staff and inadequate resources were

variously described as disruptive and interfering with their ability to do their job, and they highly

valued managers who addressed these problems effectively.

Organizational Perspectives on Leadership Effectiveness in Managers

A comparable analysis of the competency framework used by the study organization in

assessing leadership effectiveness in managers found the following words to be the most

commonly used: goals/objectives, develop/development, accountable, performance and quality.

The organizational framework presents eight themes of evaluation but does not ascribe any

relative importance to these themes. These are summarized in Table 7 below.

For ease of comparison the major themes identified by both physician interviews and

organizational framework are summarized in Table 7 below. With physician factors, those at the

top of the list appeared more frequently.

Table 7: Comparison of Physician and Organizational Themes.

Factors Affecting Physician Perceptions of

Leadership Effectiveness

Factors Affecting Organizational Perceptions

of Leadership Effectiveness

Communication, listening, open to new ideas

Getting things done, organized, decisive

Understanding, & insight, informed,

priorities

Deal with conflict, & bad performance

Fairness, honesty, transparency, & equity

Relationships, collegiality, collaborative

Accessibility, visibility

Shared goals, vision, & values

Collaboration/ influence

Business acumen/ organizational awareness

Planning, & coordination/ results orientation

Service, & quality orientation

Developing others

Holding self, & others accountable

Visionary leadership

Interpersonal sensitivity/ leadership presence

Discussion of Results

This discussion of the results of the research study focuses first on understanding and

interpreting the physician and hospital perspectives, then on suggesting interventions for

bridging the gap and improving physician engagement.

Understanding Physician and Hospital Perspectives

From an overall perspective, the general literature on leadership and physician opinions

about management demonstrated good predictive value around factors that were likely to affect

physician perceptions of leadership effectiveness. First, the value that physicians placed on

getting things done in and organized and decisive way is consistent with the evidence that the

highly individualistic physician culture values performance, with expectations of clinical

autonomy, immediate action and reductionist decision-making (Kaissi, 2005; Waldman, et al.,

2003). This documented highly individualistic physician culture also supports the interview

results of physicians valuing behaviors that help physicians be more effective.

The theme of trust and transparency correlates well with reports in the literature that

physicians use trust as a yardstick in deciding whether administrators are able to effectively carry

out their duties (Hospital Check-up Report, 2007; Kaissi, 2012a). During the interviews, several

participants explicitly used the word trust in describing effective managers, while others went on

to use related descriptors such as transparency, confidentiality and honesty. In their examples,

physicians referenced situations where they needed to have faith in manager behavior and also in

the importance of managers behaving consistently and predictably.

In general, many of their comments around relationships referenced mutual respect and

appropriate social boundaries are consistent with the literature in describing physicians and

believing they have little in common with managers (Edwards, 2003; Klopper-Kes et al., 2009;

Klopper-Kes et al., 2011; O'Hare, & Kudrle, 2007). Several physicians specifically stated they

were looking for respect and collegiality, not friendship. No physicians made any references to

the personal life of managers expect in describing perceived negative behaviors where personal

life interfered with work.

The remaining comments in areas such as communication and vision are easier to

understand in contest of the organizational competency expectations. Comparison of

organizational and physician factors showed that, while there were many words and themes that

were common to the two groups, there were also significant areas of difference. The topics of

communication, getting things done and dealing with conflict appear in both groups, with a

greater emphasis on communication in the physician results. There are several themes that

appear in the hospital framework that are nonexistent or barely mentioned in the physician list.

These include developing others, visionary leadership, interpersonal sensitivity, accountability,

and service/quality orientation. While all of the physician themes are embedded within the

hospital competency framework, the physicians attributed higher priority to communication with

physicians, listening, fairness and conflict resolution. Overall, these factors that have been

identified as being important in influencing physician perspectives on leadership in front-line

managers are helpful and interesting, but are much more meaningful when viewed in the context

of physician culture, thinking and relative priorities.

Culturally, physicians have been shown to exhibit strong intra-group identification and

have little perceived commonality with managers; they do not respect managers in the same way

as they do physician colleagues and generally view them as not having a unique and highly

valued professional skill set (Edwards, 2003; Klopper-Kes et al., 2009; Klopper-Kes et al., 2011;

O'Hare, & Kudrle, 2007). The literature shows that, as a group, physicians are highly focused on

the care of their individual patients and those activities that affect and support their ability to

deliver that care; they have little interest in the broader, and in their view irrelevant and

peripheral, activities of the hospital (Bujak, 2003; Edwards, 2003). At the same time, hospital

physicians have become highly dependent on hospitals and managers for access to resources,

interpretation of rules and regulations, and navigating hospital bureaucracy (Burns et al., 2010;

Kaissi, 2005). Also, the parallel medical staff organization, developed primarily for

credentialing, is structurally less well organized than the hospital hierarchy for communication

and sharing information (Burns et al., 2010); therefore the physician must rely on other sources

to stay informed about relevant organizational issue. It is not surprising that most physicians

would view managers as being central to helping address the above needs and gaps – and highly

value those managers who can do it most effectively.

Considering the primary role of the hospital as caring for patients as a group and the

resulting need for efficiency, effectiveness, regulatory compliance and accountability (Bujak,

2003; Burns et al., 2010; Edwards, 2003), the hospital competency themes of developing others,

visionary leadership, interpersonal sensitivity, accountability and service/quality orientation are

rational choices. The fact that they barely appear in the physician list of priorities is to be

expected, as historically the issues of efficiency, effectiveness, regulatory compliance and

accountability have not been relevant to physicians (Burns et al., 2010). Tasks such as regulatory

compliance and developing staff are all issues related to the operation of the facilities where

physicians do their work but are not the work of physicians themselves.

These interpretations and distinctions are important for two reasons. First, understanding

physician thinking and priorities is helpful in considering where the best leverage opportunity is

for changing physician perspectives on manager effectiveness. Second, the key differences are

important because a substantial amount of a front-line manager’s daily work is spent on activities

that do not register on physician radar. At best, the physicians are oblivious to the workload and

activities – at worst they may view these activities as irrelevant and distractions from the

business of caring for their patients. Attempting to interest or educate physicians around these

activities is unlikely to be successful. Moving forward, this information can be used in

suggesting how best to intervene in the manager-physician relationship to have physicians see

managers as more effective.

In summary of the above discussion, the research and analysis to this point has answered

research questions one and two as follows:

1. Primary Research Question: How do hospital physicians judge leadership

effectiveness of front-line managers?

Answer: In general, physicians as group value manager activities that help address

physician knowledge/information needs and which help physicians do the work that

they deem important. Specifically, physicians view good communication, listening,

getting things done and mediating conflict as important activities in demonstrating

leadership competence. They place little value on activities they deem to be

peripheral or not relevant to the work of physicians. These results were consistent

with the related literature on leadership, physician hierarchical relationships, manager

stereotypes, and physician culture and goal orientation.

2. Secondary Research Question 1: How do physician perspectives differ from those in

a current competency-based leadership effectiveness evaluation model used by

administrators?

Answer: While both hospitals and physicians value communication, getting things

done and managing conflict, a significant portion of the manager’s organizational role

expectations include activities that are not valued by physicians. Again, these results

are consistent with the literature in that many of these not valued activities have no

direct connection to physician effectiveness and daily work. While many of these

peripheral manager activities actually do affect physicians, the connections between

physician goals and the manager activities of developing others, visionary leadership,

interpersonal sensitivity, accountability and service/quality orientation are too distant

to be of immediate relevance to physicians.

Suggested Enabling Interventions

This section of chapter 5 addresses Secondary Research Question 2: What intervention(s)

could improve alignment between administrator and physician perceptions of leadership

effectiveness? The theoretical framework used for proposing action is that of complexity

leadership theory.

The cornerstone of complexity leadership theory as it relates to this study, is the notion of

the hospital as a complex adaptive system within which there exist multiple free agents and

diverse alliances over which managers have little control and virtually no ability to direct (Ford,

2009). In this instance, the managers and hospital physicians who provide and direct patient care

at the front lines are part of different identifiable sub-cultures, each with unique characteristics,

belief systems, goals and processes (Begun et al., 2003). These physicians and managers must

work independently to achieve their individual goals, but also collaboratively to affect change

where their goals intersect (Begun et al., 2003; Ford, 2009; Uhl-Bien et al., 2007). Instead of

attempting to control, direct or educate, the manager’s role in a complex adaptive system is to

adapt to the tensions of the relationship and design circumstances that would make it more likely

that the interests of the independent and interdependent groups coincide.

Based on the desirable leadership behaviors described in the complexity science literature

and the results of the study on physician perspectives on leadership, it is possible to suggest a set

of enabling activities. These five related leadership behaviors are adapted from research and

publications by Avolio et al. (2009), Begun et al. (2003), Ford (2009) and Uhl-Bien et al. (2007).

In the description below, the theoretical approach is described first. This is followed by an

explanation of the specific application to this study situation and then finally, a specific

organizational/individual intervention is suggested.

1. Enabling Behavior: Big Picture Thinking

Make specific efforts to understand the big picture and recognize the contextual

differences between agents within the complex adaptive system.

Explanation: Managers must be able to understand that physicians are a unique sub-

culture, with unique characteristics, belief systems, goals and processes. As a group

they cannot me treated the same as other employees, managers, volunteers etc.

Organizations must help managers to understand the contextual differences between

different interest groups and move away from the one-size-fits all leadership teaching

Example: Specific manager training sessions on communicating/working with

different stakeholder groups including physicians, board members, nurses etc.

2. Enabling Behavior: Listen to Informal Network

Explanation: Listen to the informal communication network to better understand the

desired vehicles and instances of communication for different stakeholders. Managers

must listen and observe which communication methods work best with individual and

groups of physicians.

Example: If physicians never read e-mails or attend morning team huddles, these are

not suitable vehicles for communicating important information to them.

3. Enabling Behavior: Encourage information Flow and Idea Exchange:

Explanation: Seek diversity and differences of opinion by both seeking and providing

information in formats most suited to the individual stakeholder groups. As preferred

communication methods are better understood, managers should use these vehicles to

solicit and share information. Managers need to find out what kind of information is

most important to physicians and learn to package necessary organizational

communications in those contexts. This is both to learn from physician perspectives

and to meet physician information needs. Managers must be able to assess what is

important to communicate to physicians and what is not …avoiding information

overload.

Example: When communicating essential with physicians, managers need to provide

the why (including “what’s in it for me?” - not just the actual message. Managers

should also explain what is done with information/feedback collected from physicians

so that it is not the proverbial bottomless pit.

4. Enabling Behavior: Remove Unnecessary Obstacles

Explanation: Managers must be able to allow physicians to contribute on their own

terms. Rigid structures for communication, requesting resources, or participating in

hospital initiatives are unlikely to gain physician cooperation and engagement. While

specific policies, procedures and forms are necessary for safe and efficient hospital

operation, when possible, managers should strive for flexibility.

Example: Physicians should not be required to complete lengthy

requisitions/proposals simply for management convenience or bureaucracy.

5. Enabling Behavior: Steer Rather than Direct

Explanation: Provide opportunities for realization of mutual goals. This has been

likened to riding the wave rather than swimming against the current. Focus on the

destination, not the means for getting there. Hard deadlines, mandated practices, long

standing directives and rules are frustrating without context or purpose, and are

usually ignored. Focus on the goal and negotiate the means. Mutually agreed

approaches and practices are more likely to generate cooperation.

Example: Instead of mandating a procedure for physician-to-physician handover,

discuss what approaches are acceptable to still meet the goal of safe transfer of care.

In summary, this section of chapter 5 discussed the results of the research in the context

of the literature and specifically answered the primary and secondary research questions. The

above listed enabling behaviors, based on complexity science, would increase the probability that

physicians view a manager as being an effective leader and may lead to improved physician

engagement at the front line.

Significance

Hospitals around the world are struggling with out-of-control spending, increasing

demand for patient care services, and growing expectations around quality and accountability

(Allen, 2013). Implementation of value-based purchasing and other pay-for-performance

measures is intensifying these pressures (Nelson, 2013). Developing greater physician

engagement has been shown to be one of the most effective strategies for improving general

financial performance, enhancing patient outcomes and increasing organizational success in

today’s highly competitive environment (Buller, 2003; Burns et al., 2010). In addition, hospitals

with better physician engagement show significantly greater profitability as measured by

adjusted revenue per patient day and revenue per admission (Paller, 2005). Existing high level,

strategic efforts to improve physician engagement have had only limited success (Dickson, 2012;

Kaissi, 2012). This research focused instead on the on the relationship between physicians and

front-line managers. A literature review demonstrated that there is a link between link physician

perceptions of leadership effectiveness in front-line managers and the extent to which physicians

are engaged and willing to follow support the organizational activities. This study provided new,

specific information about what factors influence physician perceptions of leadership

effectiveness in front-line managers and added to past research about more generic physician

perspectives on management as a group. This study supports a new and unexplored approach to

increasing physician engagement that will provide helpful information for organizations that

seek to increase manager skills in building collaborative physician relationships.

Implications for Practice

This research has suggested a set of five specific leadership behaviors intended to

facilitate greater physician engagement at the study site hospital in Ontario, Canada. Grounded in

complexity leadership theory, these types of behaviors have been shown to contribute to creating

an enabling environment in highly complex, knowledge worker organizations, of which hospitals

are an example (Avolio et al., 2009; Begun et al., 2003; Ford, 2009; Uhl-Bien et al., 2007).

These general leadership behaviors have been adapted to create hospital-specific actions for

increasing physician perception of leadership effectiveness and overall engagement.

Growing political intervention in health care, ongoing funding reform and increasing

competition from surrounding hospitals (Ontario Health Coalition, 2012; Ontario Ministry of

Health, 2012; Singh et al., 2010), have all contributed to making physician engagement a critical

imperative for the study hospital, but as with most hospitals today, few resources are available

for large scale engagement programs. These proposed actions have minimal costs. The

suggested behaviors can be implemented either all together or one at a time. Some of the

behaviors, such as learning to consider physician context in management actions, could be

incorporated into existing ongoing leadership training provided to managers in the study

organization, but at the same time individual managers can adopt some of these actions on their

own and with little risk. Better alignment between physicians and managers will also contribute

to improved satisfaction for staff and physicians (Accreditation Canada, 2010).

While the research was targeted on a specific hospital study site, these types of system

changes pressures are affecting all hospitals in Canada and the United States (Carlson, &

Greeley, 2010; Dickson, 2012; Kaissi, 2011; Robinson, 2001) and successful implementation

would set the stage for broader adoption throughout the healthcare system.

Limitations

While there was general interest in this research subject from administrators and

physician leaders, this study experienced challenges in recruiting the required minimum number

of physician participants with no volunteers through and open call for participants. This seems to

indicate a broad lack of physician interest and engagement in the topic. Eventual interviewees

were then recruited with a more targeted e-mail campaign and it is possible that the interviewees

do not adequately represent the opinions of all physicians. They are also all from a single

community hospital. However, the literature indicates strong physician intra-group correlation in

thinking and behavior (Edwards, 2003; Klopper-Kes et al., 2009; Klopper-Kes et al., 2011;

O'Hare, & Kudrle, 2007). Also, the results from interview to interview were highly consistent.

These two factors suggest that it is highly likely that there would be good correlation with the

perceptions of other physicians both in the study site and the system as a whole.

As noted earlier in this document, this study was undertaken as insider research. It is

possible that physicians were unwilling or felt unable to share full information. It is also possible

that physicians were not entirely aware of their own biases, thought processes and decision

criteria. With individual interviews and no opportunity for group discussion, there was no

opportunity for developing consensus on factors influencing their perspectives on leadership

effectiveness in managers. Finally, the potential participants were restricted to those physicians

not fully assigned to the researcher’s surgical program. It is possible that full-tome surgeons

could have different views on leadership effectiveness.

Recommendations for Future Research/Study

While there is a great deal of published research on physicians and their general

perceptions about management and administration as a group, there is little published research on

their relationships with individual managers and the factors influencing those relationships. This

study contributed a beginning to exploring this relationship by studying factors that influence

physician perceptions of leadership effectiveness in front-line managers.

The logical extension of the current research is to validate the findings of this study with

a similar study in a completely different hospital, possibly a large teaching hospital or a United

States hospital. As noted in the limitations, because of the researcher’s role in the study site,

full-time surgeons were excluded from eligibility to participate in this study. It is possible that

surgeons could have different views on leadership behavior in managers. It would be worthwhile

to investigate if there were significant differences in perspectives between groups of physicians

with different specialties (e.g., psychiatrists, surgeons, pediatricians, cardiologists).

It would also be helpful to test the hypotheses that the suggested enabling behaviors by

managers will actually influence physician behavior in a meaningful way. It is possible that even

if physicians become more engaged and happier, they still may not make meaningful changes to

their in-hospital behaviors and utilization patterns. While there is good published research

around the validity complexity theory and adaptive leadership, there is also related research that

suggests managers can only actually influence less than 15% of what goes on around them (Ford,

2009).

Finally, the underlying goal of this research was to suggest a new way to address the

current gap in physician engagement, by focusing activities on front-line managers and

physicians instead of the high level strategic approach. There is much opportunity to further

explore the physician manager relationship and the possible and probable organizational and

stakeholder benefits to improving that relationship.

Conclusion

Chapter 5 has presented a discussion of the results of the research into factors that

influence physician perceptions of leadership effectiveness in front-line managers, compared the

results with organizational perspectives and suggested actions to improve alignment and increase

physician engagement. Both the broader healthcare system and the study organization are facing

increased pressure to improve performance; better physician engagement is a critical driver of

improved outcomes, efficiency and stakeholder satisfaction for throughout the healthcare system.

Unlike in the past, where hospitals and physicians operated independently or in parallel, today

their futures are increasingly intertwined and they can only success together. This research

presents new and helpful information that can contribute to improving that shared future and

could provide a foundation for further research by those interested in physician-manager

relationships and physician engagement.

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APPENDIX A. STATEMENT OF ORIGINAL WORK

Academic Honesty Policy

Capella University’s Academic Honesty Policy (3.01.01) holds learners accountable for the

integrity of work they submit, which includes but is not limited to discussion postings,

assignments, comprehensive exams, and the dissertation or capstone project.

Established in the Policy are the expectations for original work, rationale for the policy, definition

of terms that pertain to academic honesty and original work, and disciplinary consequences of

academic dishonesty. Also stated in the Policy is the expectation that learners will follow APA

rules for citing another person’s ideas or works.

The following standards for original work and definition of plagiarism are discussed in the

Policy:

Learners are expected to be the sole authors of their work and to acknowledge the

authorship of others’ work through proper citation and reference. Use of another person’s

ideas, including another learner’s, without proper reference or citation constitutes

plagiarism and academic dishonesty and is prohibited conduct. (p. 1)

Plagiarism is one example of academic dishonesty. Plagiarism is presenting someone else’s

ideas or work as your own. Plagiarism also includes copying verbatim or rephrasing ideas

without properly acknowledging the source by author, date, and publication medium. (p. 2)

Capella University’s Research Misconduct Policy (3.03.06) holds learners accountable for research

integrity. What constitutes research misconduct is discussed in the Policy:

Research misconduct includes but is not limited to falsification, fabrication, plagiarism,

misappropriation, or other practices that seriously deviate from those that are commonly

accepted within the academic community for proposing, conducting, or reviewing research,

or in reporting research results. (p. 1)

Learners failing to abide by these policies are subject to consequences, including but not limited to

dismissal or revocation of the degree.

http://www.capella.edu/assets/pdf/policies/academic_honesty.pdf

http://www.capella.edu/assets/pdf/policies/research_misconduct.pdf

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APPENDIX B. INTERVIEW GUIDE

The key research questions to be asked in assessing physician perceptions of leadership

effectiveness in front-line managers.

1. Background: Brief explanation of the study purpose and methodology: The purpose of this interview is to understand how physicians judge leadership effectiveness in managers,

specifically front-line managers in hospitals. For the purpose of this interview, I’d like you

to keep in mind the following definition of leadership: “The process of social influence in

which one person can enlist the aid and support of others in the accomplishment of common

tasks or organizational goals.” 1

2. Tell me about your general experiences with front-line managers (grand tour question) Now let’s talk specifically about leadership effectiveness in front-line managers

3. I’d like you to think about a manager or managers who you felt were really good leaders….can you please describe what made you think about them that way?

Follow up questions if needed

a. Were there any specific behaviors that particularly contributed to your feelings about their leadership skills?

b. What about manager relationships with physicians and staff? Can you please talk about how these affect your perception of their leadership skill?

c. What kinds of specific skills or knowledge do you think are important for a manager in order to be seen as a good leader?

d. In considering what we just discussed, what do you see as the three most important activities/ behaviors/ activities/ competencies/ characteristics of a good leader in a front-

line manager position?

4. I’d like you to think about a manager or managers who you felt were really bad leaders….can you please describe what made you think about them that way?

Follow up questions if needed

a. Were there any specific behaviors that particularly contributed to your feelings about their leadership skills?

b. What about manager relationships with physicians and staff? Can you please talk about specific relationship factors that negatively your perception of their leadership skill?

c. Were there any specific behaviors or skills (present or absent) that affected how you felt about the manager’s leadership skills

d. In considering what we just discussed, what do you see as the three most important activities/ behaviors/ activities/ competencies/ characteristics that negatively affect your

view of a manager’s leadership skills

5. Is there anything else you would like to tell me about how you decide if a manager is an effective leader or not?

1 Chemers, M. M. (2000). Leadership research and theory: A functional integration. Group Dynamics: Theory,

Research, and Practice, 4 (1), 27-43. DOI; 10.1037//1089-2699.4.1.27