Leadership, and management style and influence on healthcare worker’s job satisfaction and productivity: a scoping review

INTRODUCTION

Health systems globally continue to face difficult situations and turbulent times such as the current COVID-19 pandemic and as such effective and decisive leadership is required in order to come out stronger and meet the expectations of patients. Leadership is known ubiquitously to be the bedrock of organisational success across all disciplines, with healthcare organisations and systems in Low-and-middle-income countries (LMICs) not being exceptions.² Leadership and management have been studied and described variously in many fields such as education, psychology, military, medicine and political science but most converge on common attributes like the ability to influence people, harnessing the potentials of a group of people and the attainment of a common predetermined goal or vision.³ Leadership can thus be defined as the process of influencing a team of people to achieve the visions of an organisation.⁴ The situation is even more exacerbated in LMICs where resources are very limited due to inadequate funding, lack of human resource, poor infrastructure and high illiteracy rates.⁵ This complex and ever-changing nature of health systems in LMICs demand an equally dynamic evolution of leadership and management styles in order to cope with the complex demands of the healthcare workforce and the populations they serve.⁶

Leadership and management styles have evolved over time. There are various leadership and management styles including transformational, transactional, servant, laissez-faire, participative, autocratic and democratic leadership styles.⁷ These leadership styles tend to have influence on the attitudes and motivation of healthcare workers towards work, job satisfaction and productivity.^8,9

Job satisfaction is critical and measures how happy an individual is with their work environment. It is affected by factors such as salary levels, team dynamics, organizational culture, career progression and supervision.¹⁰ Work life quality in the healthcare environment has been attributed largely to leadership styles.¹¹ Previous studies have indicated that job satisfaction significantly depends on the leadership styles.¹²

Servant leadership is a people centred approach to leadership where the focus is on the growth of team members, ensuring good collaboration among team members and placing the benefits of team members first.¹³ Servant leadership, is predominantly relation-oriented leadership with the primary focus being the worker while the organizational outcomes are secondary. This implies that a worker that feels dignified at their work place, gains intrinsic benefits from the job, this impact heir level of job satisfaction and this is similar to what happens in servant leadership.¹⁴

Transformational leadership is a form of person centred and charismatic leadership in which the leader inspires followers towards the attainment of future goals, articulates the vision clearly with optimism and provides meaning and guidance for the task at hand. This type of leader pays particular attention to the individual needs of team members, solicits and takes onboard ideas from team members and stimulates and encourages creativity in the team.¹⁵ The transformational leadership style is argued to be very effective in enhancing job satisfaction.¹⁶

Participative leadership style is a form of leadership style in which subordinates are greatly engaged in decision making processes. The leader listens to the views of the team and incorporates these views into final decisions made. Generally, it tends to influence on worker productivity and job satisfaction.¹⁷ Participative leadership style with emphasis on communication and employees’ rewards have also been shown to be effective in organizations success.¹⁸

In transactional leadership, there is an exchange relationship between the leader and the subordinates in order to get needs met. The focus is more on organizational efficiency, rules, regulations and procedures. These leaders motivate their followers by providing rewards for performance and provide correction and sometimes punishment for non-performance.¹⁹ It is also generally observed to be results oriented and tends to have an effect on job satisfaction and worker productivity.²⁰

In laissez-faire type of leadership, the leader is usually hands-off, does not get involved in the performance of tasks and only comes in to quench fires.²⁰ They allow work to proceed with supervision, often times delegate their duties and virtually allow subordinates to be autonomous.¹⁷

Autocratic leadership is another form of leadership style in which leaders have and exert all power and authority in decision making without any inputs from followers. These leaders rarely listen to advice from followers because of lack of trust, believe only in their abilities and have absolute control over subordinates. This leadership style may be helpful when decision making is urgently required.²¹

Leadership’s role is to create positive work environment that enables professional healthcare workers towards desired outcomes.²² Effective, human resources management and result oriented health leadership is necessary to improve healthcare delivery and job satisfaction among healthcare workforce. Therefore, to ensure job satisfaction among health workers, the healthcare delivery process needs a manager who orients them toward giving the best output. While there are many studies on leadership styles and their influence on healthcare worker job satisfaction and productivity in various contexts, to our knowledge, there is no record of a scoping review done in LMICs to explore the influence of leadership and management styles on health workers job satisfaction and productivity. Hence the need to conduct a scoping review on the leadership styles employed in healthcare facilities in LMICs and their influence on job satisfaction and productivity.

RESEARCH QUESTIONS

This scoping review used the Arksey and O’Malley’s scoping review methodology to find answers to the following questions as pertains to leadership and management styles impact on health workers job satisfaction and productivity in low- and middle-income countries:²³ 1) What are the different leadership and management styles used in health facilities in LMICs? 2) To what extent does leadership and management styles influence health worker's job satisfaction? 3) What is the influence of leadership and management styles on health workers’ productivity?

This review is also intended to inform healthcare professionals about the different leadership styles in various health facilities as a strategy to improve job satisfaction as well as productivity of health workers in LMIC.

METHODS

Identifying relevant studies

The scoping review employed the Arksey framework for scoping review.²³ The review questions were identified in order to guide the review process and create boundaries with regards to the scope of the study. Databases were randomly searched to identify relevant studies to determine the feasibility of the review with reference to the comprehensiveness and feasibility of the review process. After completing the random search, peer-reviewed articles were sought from the following electronic databases: PubMed, CINAHL, ScienceDirect, ProQuest and Sage. Key search terms strategy was employed using the words “leadership styles”, “management styles”, “health workers”, “productivity” and “job satisfaction”. The search terms and strategy were consistent across all the databases.

Selection of relevant studies

Articles were eligible for review if they met the following inclusion criteria; (a) focused on leadership styles in healthcare, (b) conducted in LMICs, (c) published in English language, (d) published during the decade from May 2012 to April 2022 and (e.) with participant sample limited to healthcare workers.

The review excluded articles involving systematic review, scoping review, literature review and narrative review. Books, conference papers, magazines and protocols were also excluded. Each database was searched by one assigned researcher after which the findings were exported into EndNote 20 to determine duplicates across the five databases. After excluding the duplicates, title and abstract screening was done in excel with two researchers assigned to each database. If articles were found to meet the inclusion criteria, the article was retrieved and read in full by two authors to further assess their applicability. In cases of disagreement, a third-party reviewer was consulted.

Charting data

If an article was eligible for inclusion in this study, relevant data was charted using data charting form developed using google forms. Information on authorship, aim/objective, sample size, sampling techniques, study designs and key findings from the study were systematically recorded using the google form and the results exported to Microsoft Excel (Table 1).

Summarising and reporting results

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 (flow diagram was employed to collate and report the article’s selected on the leadership and management styles and their influence on productivity and job satisfaction of healthcare workers in LMICs.²⁴

RESULTS

Search results

From the initial database search, a total of 1487 articles were identified, from which 519 duplicates were removed. Nine hundred and thirteen articles were excluded after reading the titles and abstracts. And 37 articles were excluded after they were read fully. Eighteen articles were selected for inclusion in this review (Figure 1).

All studies included were quantitative except one study that was a qualitative.²⁵ The majority of studies employed nurses as participants followed by midwifes with one study in Uganda not revealing the category of health workers engaged in the study.²⁰ Out of the eighteen articles included, two were conducted in Iran and three conducted in Jordan.^25-29 Two articles each were conducted in African countries, Ghana and Nigeria.^17,30 The rest of the articles spread evenly across Thailand, Ethiopia, Brazil, Uganda, Rwanda, and China (Figure 2).^20,31-35

Leadership and management styles in health institutions in LMICs

The main leadership styles used in health care institutions included participative leadership style mentioned in 5 studies transformational leadership style mentioned in 11 studies transactional leadership style mentioned in 11 studies laissez-faire leadership style mentioned in 4 studies and autocratic leadership styles appearing in 3 studies.^{15-18,20-32,34,36-38} Other less common leadership styles reported by single or two studies included selling, telling and delegating styles of situational leadership, passive-avoidant leadership style, ethical leadership style, task-oriented, situation-oriented, and relationship-oriented one study that mentioned humble leadership style.^{25,27,28,31,33,35}

Influence of leadership style on job satisfaction

Transactional, laissez-faire, directive or autocratic, humble and participatory leadership styles were found to have varying degrees of influence on healthcare worker job satisfaction.^{17,30,33,38,39} Twelve articles studied transformational leadership and its influence on job satisfaction.^{17,20,25,27–29,32–34,36,37,39} In ten out of the twelve articles, transformational leadership was found to be positively correlated with job satisfaction.^{17,20,27–29,33,34,36–38} One article stated that there was a huge potential for transformation leadership to positively influence job satisfaction but did not go any further to establish the magnitude of this potential relationship.³⁷

Transactional leadership closely follows transformational leadership in terms of correlation with job satisfaction and healthcare worker preference. Seven out of nine articles that studied the influence of transactional leadership on job satisfaction, indicated that there was positive correlation between leadership style and job satisfaction.^{17,20,26,27,30,33,37} One study reported no influence of transactional leadership on job satisfaction.²⁸ Transactional leadership was however found to be negatively correlated (r=−0.137, p=0.011) with nurses’ job satisfaction and intention to stay in one of the articles.¹⁷

The laissez-faire leadership style, also called passive avoidant style of leadership, was the least preferred by healthcare workers in the seven articles that reported on it.^{17,30,31,33,34,36,37} It was found to be negatively correlated to job satisfaction in 83% of the studies. One article found a negative correlation (r=-0.240) between laissez-faire leadership style and healthcare worker job satisfaction.²⁷

Autocratic, participative and humble leadership styles were the least reported on. In all participative leadership, autocratic and humble leadership styles had two, one and one articles showing positive correlation with job satisfaction respectively. Participative leadership did not show any significant influence on job satisfaction.²⁶ Autocratic leadership had one article reporting negative influence on job satisfaction.¹⁷

Influence of leadership and management styles on health workers productivity

Seven articles out of the 18 articles included in the review reported some key findings on the influence of leadership on the productivity of health workers.^{17,20,25,32,33,36,39}

One of the studies showed that ethical leadership style motivated some of the staff to provide better services to the patients²⁵ Another study showed that Nurses with more than one job were not motivated to provide better services to patients as a result of personal bullying by supervisors.³³

Transformational leadership style in health facilities encouraged 67% of health workers to provide better health services to the patients.²⁰ All four leadership styles (i.e. Autocratic, Transformational, Transactional, and Participative leadership styles) had a positive correlation with productivity although to varying degrees.³⁴

Highlighting the existence of a positive effect of leadership styles on the well-being of nurses recorded high productivity in the Lebanese hospitals.³⁸ A positive relationship was also found between a laissez-faire leadership style with job stress and anticipated turnover.³⁹

DISCUSSION

This scoping review provides an overview of leadership and management styles that are employed in health facilities in LMIC and their implication on job satisfaction and productivity. The majority of studies suggest that predominantly transformational and transactional leadership were employed by leaders in healthcare institutions while fewer leaders practice laissez-faire and autocratic leadership. Leadership styles such as situational leadership are uncommon among health workers most likely because leaders of healthcare workers are carefully selected following procedures and not arising out of situations.

Nil: No key findings on the influence of leadership style on health workers’ productivity.

This review, which reveals potentials of transformational leadership in influencing job satisfaction of healthcare workers, has further established a positive correlation between transformational leadership style and job satisfaction. This finding agrees with a systematic review by Cummings who revealed that significant health workers were satisfied with their job when they work with transformational leaders.⁹ This therefore implies that health workers tend to be satisfied with their job when they are motivated and inspired by a leader who serves as a role model while empowering them to work. This finding is also evident in a study by Lok and Crowford that demonstrated a positive relationship between transformational leadership and job satisfaction.¹⁶

In contrast to transformational leadership, there is negative correlation between laissez-faire leadership style and job satisfaction. Similarly, autocratic leadership style which is a direct opposite of laissez-faire leadership style has demonstrated negative correlation with job satisfaction and this was also seen in the systematic review by Cummings.⁹ The exhaustion attributed to meeting the expectation of an autocratic leader without room for innovation and creativity can be the resulting factor for low job satisfaction among health workers. Transformational leadership style which is relationally focused, and considers the emotional response of healthcare workers continuously demonstrates a positive influence on job satisfaction. This study agrees with a study that argues that workers prefer the consideration and inspiration and aspects of transformational leadership style.⁴⁰ Conversely, task focused leadership styles like laissez-faire leave workers unsatisfied with their job with resultant increase in turnover intention.^41,42

Health worker productivity has also been shown to be influenced by leadership styles. Transformational leadership according to our findings shows a trend of increasing productivity and effectiveness among healthcare workers while laissez-faire leadership style consequently decreases productivity. Health workers under laissez-faire leadership are sometimes demoralized leading to poor attitude towards work hence the negative influence on productivity. These findings corroborate with similar studies conducted in other healthcare institutions.^8,9,43,44 Other leadership styles that promote productivity at the health facilities are participative, transactional and authoritative leadership styles. Participative leadership style with emphasis on communication and employees’ rewards have also been shown to be effective in organizations success.¹⁸ The implication of these findings is that in order for productivity to be increased in the healthcare facilities a combination of features from the various leadership styles will come in handy. Involving team members in decision making which is typical of participative leadership style combined with setting of specific goals that are rewarding in the case of transactional leadership styles and inspiring and empowering that occurs in transformational leadership styles can create synergistic effect resulting in increased productivity.

According to our review some studies reported a weak relationship and others a negative correlation between transactional leadership and job satisfaction. Our findings support another study that also found that in a short term transactional leadership tends to be more effective as compared to the long term.⁴⁵ This can be attributed to the unsustainable system of rewarding people when they achieve set goals in transactional leadership system. Transactional leadership can be sustained only if the leader has the power to punish followers who fail to deliver on set goals and reward followers consistent with achieving goals. However, leaders in healthcare facilities in LMICs that are mainly public facilities may not have the resources to regularly reward followers neither the power to solely punish ineffective followers. These consequentially will lead to healthcare workers that are demotivated and unsatisfied with their jobs leading to low productivity. Employing transactional leadership with leaders who do not have the absolute power to punish will produce in followers who lack commitment and diligence to duty leading to poor service delivery in health facilities^46,47

Limitation

The review included only published peer reviewed articles introducing the bias of missing out on findings outside that inclusion that could be relevant. Published works tend to over report positives. The study also did not consider review of citations of selected articles which could be a possible source of relevant studies for inclusion. The scoping review failed to consider the varied tools, framework and models of the selected articles. These varieties can introduce differences in conceptualization and measure of leadership styles. Future scoping reviews should consider selection and analysing of studies based on the varying tools. The majority of studies included in the review are quantitative, future researches should consider qualitative and mixed methods to study leadership styles and implications on job satisfaction and productivity. A greater number of studies employed nurses and midwifes as study participants. Future researches should focus on other cadres of healthcare facilities as respondents to understand the dynamics in leadership across the different cadres in LMICs.

CONCLUSION

This scoping review highlights the various leadership styles employed in health facilities in LMIC and their influence on healthcare workers job satisfaction and productivity. Health facilities in LMICs have employed mainly transformational, transactional, participatory and laissez-faire leadership styles that have varying degree of influence on health workers job satisfaction. Transformational leadership style has proven to positively influence job satisfaction and productivity while laissez-faire leadership demotivate healthcare workers. In order to improve health care services and productivity for client as well as job satisfaction for healthcare workers, transformational leadership trainings will have to be intensified. This will create leaders with relational skills and a work environment that motivate and allows innovation, creativity and an inspiring atmosphere satisfactory to both leaders and followers to be effective and efficient in providing quality healthcare.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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