Self-perception of leadership styles and behaviour in primary health care

The concept of leadership has been studied in various disciplines and from different theoretical approaches. It is a dynamic concept that evolves over time. For this reason, scientific literature has defined leadership in different ways. In general, it is defined as a multidimensional process, involving a position of influence within a group, in a setting that seeks to achieve objectives that reflect a common vision [1, 2].

There are few studies in our field in the perception of their leadership style of managers. No pure style, both of them are mixed but the more increase of one or the other, can either to encourage or to introduce changes and improvements.

In the primary health care (PHC) setting, managers’ leadership style is defined as a set of attitudes, behaviours, beliefs and values. This is undoubtedly influenced by the task, values, and context of management, in addition to the evolution of the health system itself [3]: most health institutions of the country still have hospital-centred values and a hierarchical culture in which economic incentives depend on best performance (pay for performance). Thus, a discussion about the need for transforming leaders in the clinical setting is required [4, 5].

Factors related to leadership style are divided between those focused on the leader and those focused on the context in which the leader performs. For example, leadership can be considered as simply an attribute of a person’s innate characteristics and his/her position in the hierarchy, or else it can be thought as a function distributed amongst various professionals in a group [6]. Self-perception of leadership style can also be determined by a person’s values, job satisfaction, gender, profession and management experience [7]. However, effective leadership is defined as that which tends to cause innovations [8, 9] and deep changes within the organization [10, 11]. In the context of the APS, the complexity of the processes and structures of territorial management has been increasing since the reform of primary care began in 1985 and was a major change in the organization of the whole health system [12]. In parallel, professionals and managers have developed new tasks and management functions, increasing the number of services, structures and welfare projects. Clinical leaders and managers have been distributed throughout the territory with some variability profiling, which has contributed to framing trends in management models, self-management and teamwork [13].

Scientific literature identifies and evaluates various leadership styles [14]. Traditionally, the most frequently studied form has been transactional leadership (TRL), although in recent years, transformational leadership (TFL) has been the style more frequently encountered in the literature, since it comprises the expectations and objectives of professionals, not only in their exchanges, but also in their expectations for changing values, attitudes and beliefs within the group or team [15]. Indeed, this is precisely the style that we think should be introduced in organizations that base their healthcare models on interdisciplinary and teamwork, focusing on people’s needs. Professionals with clinical experience and a comprehensive knowledge of PHC are the very factors that may ensure TFL, while carrying out all those services necessary to meet the needs and new health situations of the population [14]. While there is no clear consensus on the skills and behaviours needed to take on TFL, they include the following: competency, self-confidence, creativity, collaboration, empathy, and the ability to enjoy success. Various studies show that this style encourages teamwork and the acceptance and use of innovation by organizations, resulting in continuously improving results. That is why nowadays, PHC managers with a TFL profile area model of effective leaders prepared for change [16].

Recent studies suggest that effective leadership translates into positive results for the health system as a whole, but especially for professionals, and has a direct beneficial impact on patients [17]. Certain leadership styles have been associated with a better quality of life, as perceived by health professionals, and retention of excellent professionals increases [18]. Effective leadership strengthens professional autonomy and clinical management, allowing changes in managerial actions so they are more focused on the needs of patients and communities, and less directed towards responding to the needs of obsolete hierarchical–administrative systems.

The hypothesis of the study aims to find out if this transactional leadership style is the most self-perceived by managers in the field of Primary Health Care and if some factors such as age, sex, profession, office, managerial experience and increase are the entity providing transformational leadership.

Thus, the objectives of this study were: (I) to describe and learn about the self-perception of behaviours and leadership styles among PHC managers; (II) to determine the influence of the leadership style on job satisfaction, efficiency, effort, and willingness to work in a team; and (III) to determine the relationship between age, gender, profession, type of manager (Team Manager or Deputy Manager), years of management experience, and the type of organization.

A total of 140 responses were obtained, which means a response rate of 54.26 %. Eighty-five percent (85 %) of the surveyed managers were PHC professionals of the ICS and the remaining 15 % belonged to Associative Entities (Ref Decree) or health consortia. Most participants were nurses (61.4 %) and the predominant gender was female (75 %). Regarding work category, Team Managers were mainly physicians (71 %) and females (61.9 %). The average age of the entire sample was 49 years; the average age of the Deputy Managers was 50.5 while that of Team Managers was 47.5. With regard to the period of occupying leadership roles, most participants had been in their respective position for more than 5 years. Characteristics of respondents are shown in Table 1.

The results obtained by applying the Cronbach’s alpha coefficient show that the instrument used was highly reliable (α = 0.924) on all 82 items, proving its homogeneity.

The factorial structure of the MLQ obtained in this study is partly similar to that presented by Bass and Avolio [18], in which a clear distinction was found between TFL and TRL styles, especially laissez-faire. However, as already confirmed by the authors of the instrument and the numerous authors who have used the MLQ in their studies [24], small differences can be identified that may be due to cultural differences, environment and employment context.

It should be noted that the MLQ questionnaire has been used mainly in the format that assesses managers from the point of view of other professionals. However, in this study, we aimed to evaluate the self-perception that managers have of their own leadership style, which may also explain differences with other authors.

Study results have some similarities with those obtained by Morales and Molero, who also observed a predominance of TRL compared to TRL, although in their case, the MLQ was completed by professionals and not by managers [25]. Likewise, Ana Rodríguez Gonzalo studied leadership in the hospital setting, using the MLQ, and identified both styles with a clear predominance of TRL [26].

In general, most managers, regardless of their gender, give themselves high scores in the socially desirable factors (TFL and TRL) and low scores on the least valued factors (e.g. laissez-faire).

This tendency to self-praise is also confirmed by observing the perceptions of efficiency, extra effort and satisfaction expressed by managers, especially when they are nurses.

With regard to the main objective of the study (to determine self-perceived leadership style and behaviour of PHC managers), we can state that, taken as a whole, managers see themselves to having a transactional style; this observation is clearly significant in female nurse managers. It is worth mentioning that in the “contingent reward” factor, female managers also give themselves higher scores than men, which may reflect a greater tendency towards maintaining the status quo of the team.

The “contingent reward” factor involves using psychological rewards, such as acknowledgement of a job well done. Since female managers are more likely oriented to the development of their professionals and to taking care of their personal and professional growth, this could explain their greater acknowledgement of the teams they lead, and consequently, their higher self-assessment in this domain than in men.

On the other hand and as mentioned above, leaders’ self-assessment probably reflects not only their own behaviour, but also the stereotype that exists in our society about leadership.

It should also be mentioned that, in general, nurse managers score themselves as significantly more transformational in “individualized consideration” and “idealized influence -attributes”. If we take into account that there is a greater number of female nurses, this result shows great similarities with those obtained by Molero and Isabel Cuadrado [27], in which women in general were more transformational, although not significantly.

In relation to gender, we noted that it has been obtained the majority of the answers by women and it is also noted that women perceive themselves significantly more transactional than men (3.35 vs 3.18), as well as more transformational, although differences in the score are smaller (3.32 and 3.24, respectively). These results are in line with those obtained by authors such as Bass and Avolio [28], Bass and cols. [29], but they are contradicted by other studies, such as the one conducted by Druskat [30].

Finally, with respect to the laissez-faire factor, like Bass [31], we found that women tend to have less passive leadership behaviours than men, although differences are on the verge of significance (1.24 vs. 0.99).

Variables such as age, type of organization, and years in the position do not have too much effect on leadership styles in general. Only in the Catalonian Health Institute teams did we see higher scores in both transactional and transformational styles.

Regarding correlations, the study also found high correlations between TFL and satisfaction and efficiency scores. In general, correlations between TFL and organizational factors, they are high, coinciding with the investigations of Bass and Avolio [19] and many more studies. There is, however, an important difference between men and women and being a physician or a nurse: for nurses, the TFL is more related to subordinate efficiency rather than satisfaction, while the opposite happens in the case of physicians. A possible interpretation of this result would be that since fewer nurses are traditionally Team Managers than physicians, they think that a good leadership style (transformational) increases efficiency, resulting in satisfaction of professionals.

The opposite happens with physicians, since they take for granted their team efficiency and consider that TFL increases satisfaction.

More studies in which the views of professionals regarding the leadership styles of their managers are required to answer how they perceive their leaders and the impact these leaders have on their daily lives.

The main limitation of the study consisted of a relatively low response rate to the self-administered questionnaires sent by e-mail. Strategies implemented to improve this rate were: prior notification, personalized letters, prepaid reply envelopes [20, 21, 32].

However, the majority of the questionnaires have been completed totally, even its high number of items, so the possibility of an error “no answer” it is reduced. Nevertheless, in the questionnaire, has been participated professionals with many different management profiles.

Although we cannot know the characteristics of the people who did not answered or did not answer correctly, given the anonymity of the survey, the similarities between the socio-demographic characteristics of study subjects and those of the expected population of primary care managers in our setting allow us to be reasonably confident of the validity of the results obtained.

The vast majority of the responses to items included in the MLQ questionnaire may have been strongly influenced by the principle of social desirability (as it was expected), although this impact should be reduced by the anonymous nature of the questionnaire. The length of the questionnaire may condition the response rate (response exhaustion, lack of time) [33].

As the teams included belong only to the Barcelona area, this implies that the results are less generalizable.

Multifactor Leadership Questionnaire (MLQ) is one of the most widely used tools to measure leadership, as people perceive it. The questionnaire is supported by a solid theoretical and empirical basis and by its extensive application, both internationally and nationally, in measuring leadership styles and behaviours.

Describing how PHC managers (Team and Deputy Managers) perceive their own leadership style offers us updated information in the primary health care setting. The results have exposed a scenario in which two leadership styles coexist, although TRL seems to be the predominant one, as discussed in the study hypothesis. This could be due to the traditional management strategy to praise and economically reward, based on instruments such as management by objectives, established more than 10 years ago in the majority of organizations of our health care model.

If we take into account that the transformational styles are characterized as generators of self-confidence, they should match the perception of support, guidance and training by the health care professionals. Therefore, more studies exploring the vision of professionals should be conducted.

In today’s dynamic environment in which populations are constantly changing, transformational leaders would represent a key factor for better achievement of goals and health outcomes.