Leading change in healthcare- thesis_Mulondo_160601
1. Jerry Mulondo_Master’s thesis
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Department of Learning, Informatics, Management and Ethics
Master’s program in Public Health, Health Economics, Policy and Management
Spring Semester 2016
Degree thesis, 30 Credits
Leading change in health care: A narrative study in Sweden
Author: Jerry Mulondo
Supervisors: Carl Savage, PhD, Medical Management Centre, Karolinska Institutet
Pamela Mazzocato, PhD, Medical Management Centre, Karolinska Institutet
Examiner: Andrea Eriksson, PhD, KTH Royal Institute of Technology
May 11 2016
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Declaration
Where other people’s work has been used (either from a printed source, internet or any other
source) this has been carefully acknowledged and referenced in accordance with the
guidelines.
The thesis “Leading change in health care: A narrative study in Sweden” is my own
work.
Signature: _________________________
Date: 2016/05/11
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Abstract
Background
Health systems are facing the double burden of meeting demands for care today, while
making the strategic and structural changes necessary to thrive in the future. Attempts to
address this challenge by developing physician leaders have had modest effects. In addition,
several leadership approaches have been proposed for health care, but with limited empirical
evidence.
Aim
The aim of this study was to explore the leadership approaches associated with positive
change in health care adopted by physician leaders.
Methods
This was a qualitative study using thematic narrative analysis of nineteen interviews with
physician leaders in health care settings from different parts of Sweden. The narratives of the
descriptions of leading change were extracted and analysed for themes. These themes were
then illustrated by developing new narratives.
Findings
Five major themes were identified from the narrative analysis, namely: Evidence-informed
and problem-focused approach, Driving goals from the front, Leaders are facilitators, Vision
guides leadership, and Principles guide leadership. These themes were then linked to
established theories of leadership identified from a literature review.
Conclusion
This study has empirically identified five leadership approaches used by physicians leaders to
implement successful change in health care. These findings suggest that leadership
development programs should draw from a variety of leadership theories to inform their
training curricula. In addition, capabilities for data-informed change processes should be
developed. The role of data and how to manage and use it to inform leadership in health care
also needs more exploration.
Further research is necessary on physician leadership in health care to determine the factors
affecting the choice of leadership style and how it varies among different health care settings.
Keywords: physician leadership, change management, healthcare, narrative analysis
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Table of Contents
Abstract .................................................................................................................................................. 3
Background ............................................................................................................................................ 5
Perspectives on leadership for health care ......................................................................................... 7
Perspectives on positive change ......................................................................................................... 8
Rationale of the study ........................................................................................................................ 8
Aim ........................................................................................................................................................ 9
Research questions ................................................................................................................................. 9
Methods ................................................................................................................................................. 9
Study participants ............................................................................................................................ 10
Data collection ................................................................................................................................. 11
Data Analysis ................................................................................................................................... 12
Ethical considerations .......................................................................................................................... 12
Discussion ............................................................................................................................................ 17
Credibility ........................................................................................................................................ 20
Reflexivity ....................................................................................................................................... 21
Transferability .................................................................................................................................. 21
Strengths and Limitations ................................................................................................................ 21
Implications ..................................................................................................................................... 22
Conclusion ........................................................................................................................................... 23
References ........................................................................................................................................... 24
Appendices ...................................................................................................................................... 30
Appendix A: Semi-structured interview guide ................................................................................ 30
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Background
Health care systems the world over are facing the challenge of adapting to changing times.
The need for adaptation has been caused primarily by the rising costs of health care,
workforce shortages, and a growing burden of chronic disease. This situation is further
complicated by the strain from rising population, shifting demographics along with increasing
demand for affordable and quality health care (World Health Organization 2015; OECD
2015). The failure to adequately address these problems could widen the social gaps in
equitable access to health care and result in failure to attain global targets of universal health
coverage (World Health Organization 2015; Gower 2012). Thus, health systems face the
double burden of meeting demands for care today, while making the strategic and structural
changes necessary for the future.
In order to address these challenges, health systems have adopted a variety of approaches. An
example is Lean health care, which streamlines work processes so as to minimize waste in the
system, while maximizing value for the patient (Mazzocato et al. 2010). Some scholars have
also championed Value based health care, which focuses on linking health outcomes that
matter to patients, with the cost of achieving these outcomes, in order to maximise value
(Porter & Teisberg 2015). Others propose the STEEEP model that calls for all health
organizations to aim for six major objectives: safety, timeliness, effectiveness, efficiency,
equity, and patient-centeredness (Institute of Medicine 2001). It has also been suggested that
health service delivery can be improved by realizing that health care actually has a Triple
Aim of costs, population health and quality of care (Berwick et al. 2008).
In the end, all of these approaches require skilled leadership within health care to guide the
process of initiating and sustaining the improvements needed to adapt to changing times. The
urgency of the need to develop leadership skills of medical workers has been emphasized by
several scholars (Reinertsen 1998; Czabanowska et al. 2014; Stoller 2009; Dickinson et al.
2013). The concern for the quality of leadership has been further strengthened as studies have
established a link between medical leaders and their critical role in cutting health care costs,
reducing morbidity and improving quality of care, especially when physicians are the leaders
(Colla et al. 2014; Goodall 2011; Veronesi et al. 2013). Some progress has been made in
identifying the necessary competencies for physician leaders. The key attributes mentioned
are several, including empathy, initiative, emotional self-awareness, organizational
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awareness, service orientation, developing others and influence (Hopkins et al. 2015;
National Center for Healthcare Leadership 2012; NHS leadership 2011).
In this regard, various leadership training programs have been introduced for both medical
students (Varkey et al. 2009; Steinert et al. 2012) and practicing physicians (Dine et al. 2011;
Scheck Mcalearney 2008; NHS leadership 2011; National Center for Healthcare Leadership
2012; Block & Manning 2007). However, evaluation studies have concluded that these
programs and other leadership training initiatives have achieved modest results (West et al.
2015; Elizabeth D. Rosenman 2014; Frich et al. 2014; Straus et al. 2013; Steinert et al. 2012).
The unsatisfactory results of all these efforts have been attributed to some common
weaknesses of leadership development programs.
First, most leadership programs are grounded in management theories and business values
from other industries and have not been translated well enough to the health care contexts.
The leadership styles that succeed in business culture may not necessarily be applicable to
other settings, such as health care (Gurdjian et al. 2014). Secondly, most leadership training is
focused on individuals, offered in the form of theoretical knowledge, and it is disconnected
from their work environment. As a result of this, leaders usually fail to integrate the new
knowledge into their work processes and so the training has little lasting impact on the
participants (Bergman et al. 2009) and no lasting impact on the organization (Frich et al.
2014; Gurdjian et al. 2014). Finally, there has been limited application of leadership theories
to understand and guide the leadership training in health care. The absence of leadership
theories has limited the study and understanding of what approach to leadership works best in
health care (Steinert et al. 2012; Elizabeth D. Rosenman 2014).
One of the first and obvious challenges of leadership development is coming to terms with
and defining what leadership actually is. Following a study of different definitions, Northouse
described leadership as “a process whereby an individual influences a group of individuals to
achieve a common goal” (Northouse 2015). In defining leadership as a process, he agrees
with the argument that leadership is not merely a trait in the leader. Rather it is a two-way
process resulting from the effect leaders have on their followers and vice versa (Horner 2004;
Day & Antonakis 2012). And, just as there are several definitions of leadership, there are
various models used to explain styles of leadership. These classifications have been based on
among others, the leader’s character (such as trait theory, great man theory), circumstances in
which the leadership occurs (path-goal theory, contingency theory), or the approach used by
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the leader (servant leadership, autocratic leadership, situational leadership) (Northouse 2015;
Dinh et al. 2014; Horner 2004; Day & Antonakis 2012). Leadership is an ever-evolving
subject of research with some new theories formed from combinations of established
theories. Moreover, whereas leadership has been extensively studied in sectors like politics,
business and military science, there has been relatively little empirical study of medical
leaders. This could partly explain why there is limited understanding of what kind of
leadership is most suitable for health care, especially in the case of physician leaders (West et
al. 2015).
Perspectives on leadership for health care
It has been suggested that due to their hierarchical culture and operational systems, medical
organizations would be more inclined to follow a transactional leadership approach (Ham &
Dickinson 2008). Transactional leadership entails the use of rewards or punishment to guide
people to achieve the aims of the group. It has the advantage of reinforcing desired behaviour
and so giving people incentive to comply with team goals. Ham & Dickson (2008) advocated
for such an approach by rewarding physicians for taking up leadership positions. In contrast,
(Schwartz & Tumblin 2002) proposed that combining transformational, situational and
servant leadership styles is best for medical organizations today. Transformational leaders
involve the people in identifying what to change, creating a vision and inspiring them to
achieve that vision. This approach would be desirable in health care because, in comparison
to transactional leadership, it has a more sustainable effect on the people’s motivation and
commitment to the organization (Bass 1990). On the other hand, situational leaders believe
that the best way to lead is not by having one leadership style, but by adapting the approach
used to the ongoing situation. It requires leaders to have a good understanding of the maturity
of their followers and the prevailing circumstances (Hersey & Blanchard 1969). In the
servant leadership approach, the leader puts the well-being of followers first, so that they
maximize their potential. Servant leaders seek to earn authority through serving the people
and to develop a similar attitude in their followers (Greenleaf 1977).
Other proposals have suggested that purely transformational leadership approaches (Vimr &
Thompson 2011; Xirasagar et al. 2005), collaborative leadership (VanVactor 2012) or
adaptive leadership (Thygeson et al. 2010) would be most appropriate. Collaborative
leadership emphasizes interaction and interdependency among followers, in order to enrich
skills, ideas and inspiration to achieve the team goal (VanVactor 2012). On the other hand,
adaptive leadership is “the practice of mobilizing people to tackle tough challenges and
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thrive” (Heifetz et al. 2009). Adaptive leadership has two steps, diagnosis and action. First
the leader seeks to understand themselves, the organization and its people, in order to
“diagnose” the problem. Afterwards, the leader does not impose solutions, but mobilizes the
people to identify and solve problems (Thygeson et al. 2010; Heifetz et al. 2009). This
adaptive leadership approach to raising solutions from within the group makes it suitable for
addressing the conflicts and uncertainty that are usually associated with change.
Authentic leadership has also been associated with successful health organizations. A study
by (Wong & Laschinger 2013) found that authentic leadership styles increased the
motivation, work performance and job satisfaction of nurses. Authentic leaders gain influence
by building relationships based on transparency, open communication, valuing the input of
their followers and observing high ethical standards. Such an attitude sustains trust, interest in
the group’s aims, and high performance among team members (Avolio & Gardner 2005;
Gardner et al. 2011).
Perspectives on positive change
The term “Positive change” as used in this paper is based on the model of appreciative
inquiry by (Cooperrider & Whitney 2005). This model was used as the guiding framework
for the interview guide, which generated the data for this study (See Appendix A).
(Cooperrider & Whitney 2005) argue that common approaches to change, which focus on
finding and fixing problems, create a negative mindset and a feeling that change is difficult.
In contrast, appreciative inquiry works on the premise that people tend to “evolve in the
direction of questions that are asked most often” (Cooperrider & Whitney 2005). Instead of
asking “What is wrong”, appreciative inquiry asks “What is right”. Thus, by asking positive
questions or questions that focus on the good things, people can search, reflect and discover
the good within their organization or situation. These good aspects are the foundation on
which to start the process of personal and organizational change. The people can then
visualize what changes could be made and redesign their ways of working in order to achieve
these desired changes.
Rationale of the study
The various suggestions of leadership approaches in health care underscore the need for more
research into this subject. There is need to understand what approach would work best in
health care and why. This study focused on physician leaders, in order to build on knowledge
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from previous studies which found physician leaders have greater impact on health care than
non-physician leaders (Colla et al. 2014; Goodall 2011; Veronesi et al. 2013).
Due to various changes occurring within and outside health care organizations in response to
the challenges they are facing today, this study focused not just on leadership, but leadership
during times of change. The knowledge gained form this study would provide more clarity on
what skills and qualities are necessary for successful leadership in healthcare today. Such
information would be valuable to academic and medical organizations in designing effective
physician leadership programs. The end result would be more competent physician leaders, to
guide health organizations in delivering services more efficiently and make strategic changes
to cope with the challenges in health care.
Aim
The aim of this study was to explore the leadership approaches associated with positive
change in health care adopted by physician leaders.
Research questions
The above aim was addressed through one research question, namely:
Which leadership approaches can be identified from experiences of leading positive change
in health care?
Methods
Study design
This was a qualitative study using thematic narrative analysis (Riessman 2008). It was based
on secondary data from previously conducted interviews with physician leaders from
different parts of Sweden. A qualitative approach is suitable for an in-depth exploration of the
experiences of the participants in leading change in their organizations (Creswell 1998). It
allows the researcher to develop a clear understanding of the context in which the participants
acted and the thought processes that influenced their actions. By listening to people narrate
their experiences and analysing such reports, we are better able to understand their experience
during those events (Creswell 1998).
The secondary analysis was motivated by the need to explore a new research question using
the available data. This was also enhanced by the rich nature of the data (Heaton 2008; Long-
Sutehall 2010). In addition, due to the busy nature of the study participants’ work, it was
deemed difficult to access the same group of respondents again (Long-Sutehall 2010). Thus,
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the work done in the context of this thesis started with the analysis of the qualitative data
previously collected by two researchers at Karolinska Institutet.
Narrative analysis works on the basis that language and stories are the most direct way that
people use to convey the meaning they find in life’s experiences (Riessman 2008). However,
these stories are not usually told in a structured format with beginning, middle and an end.
A narrative approach allows the researcher to reconstruct the story in a chronological order
that reveals the meaning more clearly to the audience. In addition, using narratives allows for
the understanding of how the meaning people derive from their experiences determines their
actions in those situations (Riley & Hawe 2005). This cause-effect relationship is best
revealed when events are arranged in sequential order that shows how one event led to
another (Greenhalgh 2005). Therefore, by reconstructing the story, the researcher can even
uncover hidden meanings that could have been missed by the storyteller.
Study participants
Purposive sampling was used in order to ensure a well-informed group of respondents who
could provide detailed narratives of their experiences of leading change in their health
institutions (Creswell 1998). First, a group of senior physician leaders with many years of
insight into the Swedish health care system, was identified by researchers at the Medical
Management Centre, Karolinska Institutet. Afterwards, another group of emerging physician
leaders was selected from the MedUniverse list of nominees for the “Future Physician
Leader” prize. MedUniverse is an independent online platform where Swedish physicians can
share knowledge and discuss professional experiences with peers (Meduniverse 2016). The
criteria for the MedUniverse nomination were: physicians aged 45 years or less, with
evidence of being visionary, influential role models in leadership roles within Swedish health
care. More participants were added by snowball sampling, using referrals from the initial
respondents, until saturation was achieved (Creswell 1998; Guest et al. 2006).
The twenty-one respondents consisted of eleven senior executives and ten emerging leaders
from various fields of health care in Sweden. Their professional backgrounds were in
academia, research, medical consultancy, pharmaceuticals, and hospital management. Twenty
of the respondents had medical degrees and one had a degree in dentistry. Fourteen of them
had a PhD, nine were active in clinical work and six had formal business education. In
addition, two emerging leaders and six senior executives had international management
experience. Nine of the respondents were female. Characteristics of the respondents are
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summarised in Table 1.
Table 1: Summary of respondents’ characteristics
Characteristics Senior Executives
(n=11)*
Emerging leaders
(n=10)
Total
(n= 21)
Sex
Female
Male
2
9
5
5
7
14
Qualification
PhD 10 4 14
Professors 2 0 2
Business education
(MBA BSc or BA)
3 3 6
Clinically active 2 7 9
Non-clinical work
Consultancy
Industry
Research
2
3
10
5
3
4
7
7
14
* 11 interviews were done, but only the nine in English were analysed
Data collection
The data was obtained through semi-structured interviews conducted by two researchers from
the Medical Management Centre, Karolinska Institutet, from October 2013 to June 2015. The
interview guide was developed and pilot-tested by the researchers to ensure trustworthiness
(Elo et al. 2014). Respondents were contacted via email. Eighteen face-to-face interviews
took place in locations convenient for the respondents (mostly their offices) and three
interviews were done over the phone. The questions explored the leadership background of
the respondents, what motivated them to lead and what traits and attitudes they considered
valuable to their work. The respondents also suggested ways in other health workers could be
trained to develop similar leadership traits. One section of the interview asked them to
describe an experience of leading what they regarded as positive change within their
organization. They were encouraged to give detailed descriptions and asked to explain any
parts that seemed unclear to the interviewer. Interviews were conducted in English except for
two which were in Swedish, as preferred by those respondents. The interviews lasted from
sixty to eighty minutes. They were digitally recorded and later transcribed verbatim. The two
researchers compared the transcripts with the audio recordings to verify their accuracy. Due
to time constraints and the lengthy process required for back translation and verification of
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translated text, the two transcripts in Swedish were excluded from this secondary study.
Data Analysis
The data analysis was done in a series of steps as described by (Riessman 2008; Greenhalgh
2005). First, the author did a review of published literature on physician leadership to
discover the available knowledge on the subject. This review provided knowledge on existing
theories of leadership which would be used later in the analysis. The full transcripts of the
interviews were then read repeatedly to understand the background of the respondents and to
gain familiarity with the data. This was followed by extraction of the narrative in which the
leaders reported their experience of leading change (narrative finding). Each narrative was
then read several times to identify its core themes from the respondents’ accounts of their
actions and experiences. These themes were then compared to the rest of the interview to
identify additional text that could explain and support conclusions made about the data.
After the identified themes were discussed with the primary researchers (MJ, CS and PM), a
table was created to extract data about what were determined to be important aspects in each
narrative. The following aspects were identified: key drivers, overall approach to change, key
strategies and steps in the change process, how the leader related to others, and the essence of
the story in 1-2 sentences. Each row of information from the table was printed out on paper.
The data in each row provided the themes which were used to categorize the narratives into
five thematic groups.
Later, for each theme, one narrative provided a frame, which was then enriched and refined
with phrases and concepts from the other narratives which shared that theme (narrative
construction). The pauses, interviewer comments and other breaks in the original
conversation were removed in order to create a flowing text that could be easily read, while
retaining the original meaning. This resulted in the creation of condensed narratives that
illustrated each theme, but maintained the general sequence of events from the original story.
This process of rebuilding narratives is characteristic of narrative analysis (Riessman 2008;
Greenhalgh 2005). The analysis was done using Microsoft Word 2013.
Ethical considerations
The participants were informed by email about the purpose of the study and verbal consent
was sought before the interviews were done. Participation was voluntary and the respondents
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were assured of anonymity and confidentiality in handling the information they provided.
The respondents were not given any compensation for participating in the study. The study
was approved by the Stockholm regional ethical vetting board (2015/197-31/5).
Findings
The data analysis process involved identifying key aspects of each narrative finding (See
Table 2 for an example).
Table 2. Sample from table of extracted narratives.
Narrative
#
Key driver Overall approach
to change
key strategies
and steps in the
change process
Relating to
others
Essence of the
story? (1-2
sentences)
1 Achieving goals
through working
with creative,
skilled people
Leading by
example and
galvanizing skilled
people to get the
goals
Being a role model
by walking the talk
Using reward
systems to create
an org. culture by
promoting people
with the right
attitudes and
behavior – role
models.
People are the
means for
achieving a
goal. His role is
to keep the
goals in focus
and find good
people
I know what my
goals are. Now I
need to find the
skilled and
creative people
who would
achieve these
goals. I promote
them in the
organization to
reward or
suppress certain
types of behavior
and attitudes.
By comparing each narrative finding, five dominant themes were identified:
1. Evidence-informed and problem-focused approach
2. Driving goals from the front
3. Leaders are facilitators
4. Vision guides leadership
5. Principles guide leadership
Each theme was then summarized with a narrative construction that described the leaders’
different approaches to leadership. Each of these themes and the narrative construction are
presented below. The source(s) for the narrative constructions are indicated with the numbers
in parentheses referring to the appropriate respondent.
Theme 1: Evidence-informed and problem-focused approach (Respondents 7 and 10)
These leaders stressed the importance of having reliable data to guide their leadership roles.
The data was used to understand the present status of the organization and which problems
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needed to be solved. With this information, they could confidently defend their arguments for
change to both their followers and external stakeholders. By using data, they could also
measure the effect of any interventions made and progress towards organizational goals.
These leaders believed that organizations could be improved by having well-functioning
processes for the accurate collection and handling of data.
As the director of this hospital, I realized something had to change if we were to increase our
reimbursement. First, we had to take a step back and try to understand the situation in the
organization. The best way to do this was to identify the most important indicators, measure them
and use that data to understand the whole process. In that way, we identified what the problem was
and then we could explore possible solutions. This was the most critical step. With the reliable data
available, I could confidently stand before the entire organization and defend the case for changing
our coding system. By improving our coding and patient survey systems and measuring the correct
parameters, we got quality data to track our progress. More importantly, this also increased our
reimbursement. I believe information is important for any leader to make wise decisions about the
organization, its people, work processes and the clients. It was not just about gathering data, but
working with it, using it to analyse questions and problems to come up with evidence-based
solutions. I absolutely advocate for collecting and using data. It is what makes good leaders within
health care.
Theme 2: Driving goals from the front (Respondents 1, 2, 6, 9, and 18)
These leaders had a visible presence, at the forefront of change in their organizations. They
had clear goals in mind and focused on achieving results as soon as possible. This was done
whether they were physically present or driving the work process from a distant location.
By making quick decisions and executing them swiftly, they set the momentum of change in
the organization and gave the people an example to follow. They identified skilled, results
focused employees whom they groomed using rewards and promotions to become junior
leaders in the organization. They understood how the different people, systems and
departments in the organization worked. In this way, the different needs in each department
could be anticipated and activities prioritized accordingly.
I brought in to lead a pharmaceutical organization of about six thousand people. It was clear in my
mind that I was here to fix the organization. As a leader, my primary function is to ensure that the
group is working, like a well-oiled machine, that we have the right resources in place. I see myself as
a football coach, I want to be on stage and lead the team. It is very important that the leader is seen
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can’t just tell people to change – they have to want to change. I motivate them to change by painting
a clear picture of the future that they want to be part of. That is what gets them enthusiastic and
motivated to work. My role is to be an inspiration to people, so that they feel like they are capable of
doing things themselves. That way, in the end they get all the credit and believe they did it on their
own.
Theme 5: Principles guide leadership (Respondents 3, 15 and 20)
These leaders were guided by their personal principles and values. Once the leader knew their
principles, it gave their work purpose and direction. Their values included such ideals as
transparency, equity and service to others. These clear principles and values, guided them
both in making decisions and in their approach to their patients, clients, followers, and other
people they interacted with. Even when they encountered resistance to change, they stuck to
their values. In this way, they set a standard for the organization and attracted to themselves
people who shared the same attitude as they did.
The greatest challenges I faced in leading change was as head of the academic department. Before I
mention how I handled it, I will tell you what comes first. I believe leadership begins with knowing
who you are and what you believe in. The leader’s personal principles set the tone for the entire
organization. You need to be clear about what you stand for and let that guide you in leading
change. When you know your principles, you can align them with what your purpose is in the
organization. This gives meaning to your work, however humble your position may be in the
organization.
When I was a junior doctor, I knew I was there for the good of my patients, to serve them and adapt
to what they needed. In every role since then, I used the same attitude, doing what was necessary to
make the work of others easier. I believe in transparency and fairness for all. When I called for
increased financial transparency in my department, there was a lot of resistance from different
people. But over time, they came to see my point and that was the only way I could win them over
to my side. All worthwhile change will meet difficulty or resistance, but when you stick with your
principles, it offers you a strong foundation on which to stand and endure. I believe that is the way
you make things better and bring lasting change in the organization.
Discussion
This study explored the approaches used by physician leaders in Sweden to lead successful
changes in their organizations. The findings show that the physician leaders used a variety of
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leadership approaches, just like was the finding of some other studies (Chapman et al. 2014;
Xirasagar et al. 2005). Within each of the five themes, both emerging and senior physician
leaders were represented. This suggests that no particular leadership style was favored by the
junior or senior leaders.
In the first group under the theme of “Evidence-informed and problem focused approach”,
the leaders relied greatly on data to guide their leadership role. This preference for using data
was not mentioned in the previous leadership approaches advocated for medical settings.
However, the need for evidence based management of health care organizations has been
proposed by some scholars (Axelsson 1998; Walshe & Rundall 2001). The argument for
“evidence based healthcare management” was inspired by the reported success of “evidence
based practice of medicine”. This approach to medicine emphasizes the use of data from
research and clinical trials in the diagnosis and management of patients. Since it had worked
for clinical medicine, there was reason to believe that it research different styles of
management in health care could yield data that supports the use of one management style
over another. The narratives in this theme suggest that there could also be a case for evidence
based leadership approach to health care.
In contrast, the leaders in the second group, (Driving goals from the front) were very action
oriented and never had a high regard for data. They manifested transactional leadership in
their use of rewards to honour performance and suppress undesired qualities in their teams
(Bass 1990). The leaders’ high level of proactivity is also consistent with entrepreneurial
leadership, which had not been previously advocated for health care. Entrepreneurial
leadership has been defined as “influencing and directing the performance of group members
toward the achievement of organizational goals that involve recognizing and exploiting
entrepreneurial opportunities” (Renko et al. 2015). Such leaders usually act quickly to take
advantage of opportunities for the benefit of their organizations. Such skills could be relevant
for leaders to exploit changes that occur within or outside the health care organization.
The third group (Leaders are facilitators) depicted collaborative leadership (VanVactor 2012)
in their tendency to assemble people to communicate, bond and maximize the skills and
knowledge available in the group. Their approach was also typical of adaptive leadership in
the way the leaders first sought to understand the problem, then supporting the people to
gather and discuss possible solutions (Heifetz et al. 2009). In addition, they manifested
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resonant leadership (Boyatzis & McKee 2005), which was not mentioned previously in
relation to health care. Resonant leaders have high emotional intelligence, seek a personal
level connection with their teams and foster harmony in their teams. They take time to build
relationships based on trust, not on manipulative or transactional tactics.
The visionary style of leadership used in theme 4 (Vision guides leadership) was
characteristic of transformational leadership. By painting a clear picture of the desired future,
they challenged the people to achieve a higher ideal. They too had elements of collaborative
leadership, in getting their teams to work together and resonant leadership in seeking to
understand how the group could work together in line with the shared big vision of the future.
Under the fifth theme (Principles guide leadership), the leaders depicted servant leadership
(Greenleaf 1977) in the way they put the needs of the team first. The leader gained influence
through serving their people and seeking to improve their wellbeing.
This is closely related to Level 5 leadership. Jim Collins defines a Level 5 leader as one who
“exhibits a paradoxical mix of personal humility and professional will” (Collins 2006). Just
like the servant leader, such leaders are determined, humble and tend to put the well-being of
their followers first. Furthermore, the leaders in this theme were guided by strong personal
convictions and principles. Such an approach is typical of principle centred leadership,
authentic leadership and value based leadership. According to (Covey 1992), principle-
centred leaders are guided by their principles. These principles are like a compass that always
shows the leader what direction is “true North” and so helps them to make the right decision
in times of uncertainty. Covey (1992) also asserts that “Principle-centeredness” starts at the
individual level, then the interpersonal, managerial and organizational levels.
As highlighted earlier, authentic leaders are guided by their experience, personal attributes
and high moral standards to develop similar characteristics in their people (Avolio & Gardner
2005; Gardner et al. 2011). On the other hand, value-based leadership involves connecting
the values or moral principles of the organization to the personal values of its people. This
brings the people into harmony with the values of the organization and creates a sense of
unity and shared identity in the group. Value based leaders sustain this commitment by
continuously reminding their people of these values and leading by example (Mills &
Spencer 2005).
The emphasis on strong values and principles among the leaders in this theme could find
particular relevance for leading change in health care. Much as it is necessary for leaders to
20. Jerry Mulondo_Master’s thesis
20
adapt to changing times, there is also need for strong values to create a sense of stability and
preserved identity amid the turbulence of change. The emphasis by value-based, authentic
and principle centred leaders on ethics and putting people first is in alignment with the high
ethical standards, integrity and care for people in need that are attributes cultivated among
physicians. It could be one of the reasons why these leadership styles fit in well with health
care settings where having strong values and integrity are regarded as qualities of successful
health care professionals (BMA Medical Ethics 2013).
Physicians serve a major role in health care, which includes building relationships of trust as
they save lives and provide medical care to patients. The physicians are bound by a strong
ethical code to preserve life and relate to both patients and fellow medical staff in with
respect, ethics and integrity (BMA Medical Ethics 2013; West et al. 2015). This is the
guiding philosophy as they perform their duties both in clinical and non-clinical contexts.
This includes among others hospitals, pharmaceutical companies, medical schools, health
consultancy whose leaders were represented in this study.
Generally, the findings of this study agree with previously proposed approaches to leadership
in health care. One question that this study raises is whether similar approaches to leadership
would apply in both clinical and non-clinical settings. It seems that leadership styles were not
dependent on years of experience. In other words, the leaders under each theme were both
senior and emerging leaders and from various work settings. For example the theme of
“principles guide leadership” included a senior professor, an experienced health consultant
and a junior doctor.
Methodological considerations
Given that this was a qualitative study, trustworthiness is discussed in terms of credibility,
dependability, transferability and reflexivity (Guba & Lincoln 1994).
Credibility
First, the semi-structured interview guide was piloted by the researchers to ensure open ended
questions to collect in-depth descriptive data. During the interviews, the respondents were
encouraged to tell detailed stories about their experience and to clarify any unclear areas.
This provided rich detail for the analysis and gave the interviewers a better understanding of
the context in which these narratives were created. The stories were not broken down into
codes so as to preserve the as much of the original structure and meaning as possible.
21. Jerry Mulondo_Master’s thesis
21
Since it was a secondary analysis, a description of the methods used in both the primary and
secondary studies was given, to enhance the validity (Heaton 2008; Elo et al. 2014).
The reason for the secondary analysis and ethical considerations were also mentioned in this
study to enhance transparency.
Dependability and confirmability
The accuracy of the interpretation was enhanced by the verbatim transcripts of the interviews
and by involving the primary researchers (Long-Sutehall 2010). The author performed the
initial analysis, which was then reviewed by the three primary researchers, who had
experience in qualitative analysis. Any differences in the categorization were then discussed
to ensure that the findings sufficiently represented the original narratives. This combined
analysis by a team with both insider and outsider perspective from different backgrounds
enhanced the dependability and confirmability of the analysis. Other information about the
study context, participant characteristics and selection criteria were included to enhance
dependability.
Reflexivity
Narrative analysis is a very subjective process, involving a back and forth process of reading,
reflecting and referring back to the original data. Thus there is a risk that the author may get
so embedded in the data, lose objectivity and impose new meaning in the re-written
narratives which is different from that expressed by the respondent (Bell 2002; Riley & Hawe
2005). The interpretation of meaning in the story is always subject to the researcher’s
interpretation. In this case, the author was a physician with a background in leadership, which
could have affected the perspective with which he approached the analysis.
Transferability
The study involved physician leaders from various specialities of health care, including
hospitals, pharmaceutical industry, medical consulting and academia. This enhanced the
transferability of the findings to different health care settings.
Strengths and Limitations
This study has several strengths. First, it links established leadership theories to the
approaches used to lead change in health care. In this way, it seeks to explore if leadership
theories that have been proposed for health care do have any practical relevance in today’s
22. Jerry Mulondo_Master’s thesis
22
times of change. Secondly, it involved both emerging and senior physician leaders, in both
clinical and non-clinical settings. Thus, it offers a broader insight into the attitudes and
approaches used by physician leaders in their different roles in health care. Finally, due to its
focus on leadership in times of change, it is very relevant to health organizations today,
which are challenged by changes, both in their internal and external environments.
There are some limitations to this study. It was based on a Swedish population and this may
limit its transferability to different cultural or organizational settings. This is because
different cultures have different approaches to leadership (House 2004). Also, the study only
involved physician leaders and its findings may not apply to non-physician leaders in health
care. Finally, due to the nature of the study design, it could not determine the effect of various
factors on the choice of leadership style. Thus, the influence of age, gender, years of
experience and work setting among others, could not be conclusively determined from this
study.
Implications
The findings of this study have several implications for leadership in health care. First, this
study revealed that physician leaders use various approaches to leading change. Leadership
development programs could therefore be designed in a way that exposes physicians to
various approaches to leading change. This would help the leaders in the reflective process of
improving their leadership styles by learning from others. Secondly, it was interesting to note
the emphasis that physician leaders place on the importance of data in leading change. This
suggests the need for more research into what kind of data physicians would find most
important and how to use that data to guide leadership decisions. This would add to the
research that has already been done on evidence based management in health care.
In addition, health organizations could benefit from building or improving their capacity for
proper collection, analysis and use of data to guide leadership decisions.
Finally, future studies could adopt a mixed methods approach, to explore what factors affect
choice of leadership style and what leadership style would be best suited to different sectors
within health care. Such robust studies could also generate evidence about the long term
effectiveness of different leadership theories proposed for health care. This could help health
organizations and leadership trainers to know what leadership approaches would offer the
best investment for their limited resources.
23. Jerry Mulondo_Master’s thesis
23
Conclusion
This study found that physician leaders used a variety of leadership styles in leading change.
It also found that several leadership approaches such as use of evidence to inform decisions
and principle centred leadership were closely connected to the values, attitudes and ethics of
physicians. There is need to understand what factors influence choice of leadership style, in
order to generate evidence in support of leadership approaches for different sectors of health
care. This would help to develop competent leaders in health care, who can steer their
organizations through turbulence of change that health institutions face in the 21st century.
Acknowledgements
I would like to thank Carl Savage, Pamela Mazzocato and Mairi Jüriska, for the supervisory
guidance and support. Thank you for the valuable comments and sharing your knowledge
about the exciting field of medical management research. I am also grateful for the help and
advice from George Keel, Rafik Muhammad and the team at the Medical Management
Centre, Karolinska Institutet.
My gratitude to the physician leaders who spared the time to share their insights on this very
intriguing subject. Thanks to the faculty and the course leader Ulrika Schudt Haardt for
facilitating such a conducive learning environment.
I am very grateful to the Swedish institute and the Swedish people for the generous
scholarship that funded my studies in Sweden.
Finally, my deepest thanks to my parents; Aunt Beatrice, Uncle Edmund, Paul and Salima
Mulondo, and my dear wife Ruth…this work is dedicated to you.
Thanks to the Lord Jesus, my guide and model of the greatness in servant leadership.
“Let the senior among you become like the junior and the leader like the servant.” Luke 22:26.
24. Jerry Mulondo_Master’s thesis
24
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