Journal of Healthcare Leadership Dovepress

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ORIGINAL RESEARCH

Organizational Culture, Quality of Care and

Leadership Style in Government General Hospitals in
Kuwait: A Multimethod Study
Journal of Healthcare Leadership downloaded from https://www.dovepress.com/

Talal ALFadhalah 1 Purpose: To investigate the organizational culture, assess the quality of care, and measure
Hossam Elamir 2 their association with a transformational/transactional leadership style in six hospitals.
1
Materials and Methods: We used cross-sectional and retrospective quantitative
Quality and Accreditation Directorate,
Ministry of Health, Kuwait City, Kuwait; approaches in government-sponsored secondary-care hospitals. A sample of 1626 was
For personal use only.

2
Research and Technical Support drawn from a frame of 9863 healthcare workers in six hospitals. Followers were surveyed
Department, Quality and Accreditation
using the Multifactor Leadership Questionnaire and the Organizational Description
Directorate, Ministry of Health, Kuwait
City, Kuwait Questionnaire. We reviewed and analyzed one year (2012) of quarterly and annual quality
indicators from the hospitals. Data were analyzed using suitable statistical analyses.
Results: We collected 1626 responses from six hospitals. 66.4% to 87.1% of participants in
each hospital identified their hospital’s organizational culture as transformational, whereas 41
out of 48 departments were identified as having a transformational culture. The percentage of
participants at each hospital rating their leader and organizational culture as transformational
ranged from 60.5% to 80.4%. The differences between leadership style and organizational
culture were statistically significant for four of the hospitals. For most of the quality
indicators, there was a positive, but nonsignificant, correlation with leadership style.
Conclusion: Leaders define and influence organizational culture. The prevailing transfor­
mational leadership style creates and maintains a transformational organizational culture. The
effect of transformational leadership on the quality of care delivered by the organization was
measured in this study, and showed a positive and nonsignificant relationship between
generic quality indicators and the transformational style.
Keywords: transformational leadership, Multifactor Leadership Questionnaire,
Organizational Description Questionnaire, generic indicators

Introduction
In healthcare organizations, nothing plays a more significant role in shaping
organizational culture, improving quality of care, and enhancing patient safety
than leadership.1–3 Leadership has been described as “a process whereby an indi­
vidual influences a group of individuals to achieve a common goal”.4(p6) Since the
Correspondence: Hossam Elamir emergence of a definition that emphasizes control, domination, and centralization of
Research and Technical Support
Department, Quality and Accreditation
power, the topic of leadership has attracted a sizable number of researchers.4,5 For
Directorate, Ministry of Health, Al-Hamra over more than a century, factors such as politics and researchers’ perspectives have
Tower, 8th Floor, Sharq, Kuwait City,
Kuwait influenced the emergence and evolution of leadership theories that include the trait
Tel +965 67767083 approach, the skills approach, the behavioral approach, the situational approach,
Fax +965 22205399
Email [email protected] path–goal theory, and leader–member exchange theory.4 Moral approaches, such as

Journal of Healthcare Leadership 2021:13 243–254 243

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ethical and authentic leadership, have gained traction since outcomes.21 Generic quality indicators are one type that
the start of the new millennium.4,6 measure aspects of care relevant to most patients regard­
Healthcare executives, directors, and managers can less of their diagnosis or care setting.22,23
enact different leadership styles and influence their fol­ Acknowledging that this field is under-researched in
lowers’ actions.3,7–9 Leaders approximate or choose their the Kuwait/Arab region despite its high importance and
style based on a combination of their beliefs, values and impact,21,24 the objective of this paper is to explore and
performance, with contributions from organizational cul­ assess organizational culture and quality of care, and mea­
ture and norms, which favor some leadership styles and sure their association with transformational/transactional
disfavor others.3,10 The most commonly researched and styles of leadership in the hospitals studied. The rationale
applied leadership theories are those founded on relational behind focusing on transformational leadership is because
aspects of leadership, particularly transformational it is among the most recurrent theories in research,5,11 in
leadership.5,11,12 Transformational leadership is “the pro­ addition to being one of the most effective leadership
cess whereby a person engages with others and creates styles in health services,25,26 and has a prominent impact
a connection that raises the level of motivation and mor­ on growth of leadership development strategies.12 This
ality in both the leader and the follower”.4 paper is the second from a research project aimed at
Transformational leaders can help to develop, shape, and assessing leadership styles, organizational culture, patient
maintain a desired organizational culture. They do so by safety initiatives, and quality of care in six government
creating and infusing the values, beliefs, and perceptions general hospitals in Kuwait. The first paper reported the
that they believe are necessary and good for the leadership styles in the six government general hospitals.24
organization.3,13 Manifested in some characteristics as orga­ We present here an analysis and discussion built on the
nizational innovation and learning, organizational culture is previous finding that transformational leadership is
defined as the shared basic assumptions learned by staff that predominant.
distinguish their organization from other similar entities.6,14
Organizational culture is a variable that significantly influ­
Materials and Methods
ences an organization’s outcomes. A leader’s interactions
with followers, their approach to addressing problems, reac­
Setting
This was a multicenter study conducted at the six govern­
tion to competition, and implementation of new strategies, all
ment general hospitals (coded A, B, C, D, E, and F) in
influence organizational culture.3,15 The stronger and more
Kuwait. At the time of data collection, the government
unified the staff values, beliefs, and perceptions are, the
healthcare system in Kuwait was providing the majority of
stronger the organizational culture.6,14 A predominant cul­
secondary healthcare services at these six general acute
ture in a healthcare organization ensures consistent behavior
care hospitals.24 Hospital beds ranged between 398 and
between its members, which reduces conflict and creates
866 in number.27 The six hospitals have the following
a healthy working environment.3,16
clinical and allied health departments: medicine, surgery,
Quality of care is an indispensable component of
pediatrics, intensive care unit (ICU), accident and emer­
a healthcare organization’s performance.13,17 It depends
gency (A and E), laboratory, nursing, and pharmacy.
on many factors, such as planning and provision of ser­
vices that meet patients’ needs, acquiring and allocating
resources, providing sufficient staff, nurturing a culture Study Instrument and Data Collection
that fosters quality and safety, and setting priorities for This is a multimethod study conducted with cross-
improvement.7,13,18 The World Health Organization char­ sectional and retrospective quantitative approaches.
acterizes high-quality healthcare services as effective, safe, A period of one month in 2013 was spent in each hospital
and people-centered.19 Only healthcare leaders have the collecting data from followers using two self-administered
resources and control to exhibit characteristics that influ­ paper-based questionnaires: the Multifactor Leadership
ence and support good quality and safety.3,18,20 Healthcare Questionnaire (MLQ) and the Organizational Description
quality can be assessed by quality indicators, quantitative Questionnaire (ODQ).28,29 These questionnaires have two
measures used to evaluate and monitor the processes of versions, one to be answered by the leader, the other by
care, customer service, and different aspects of the orga­ followers. In this paper, survey respondents are referred to
nization that are known to contribute to the quality of its as followers.

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The heads of the quality offices were assigned as points ● Percentage of patients discharged from the general
of contact in their respective hospitals. They approached surgical department without undergoing an operation.
potential participants in their break rooms and explained ● Unscheduled return to operating theatre within 48
the aims and requirements of the study. Those who volun­ hours during the same hospital admission.
tarily agreed to participate received copies of the study
instrument inside envelopes marked with a unique identi­ Although four of the five indicators are surgical, all
fier code. Participants’ names were recorded under this have a target to decrease the percentage/number. In other
code in a register to facilitate the retrieval of answered words, the lower the indicator result, the better the perfor­
questionnaires inside the sealed envelopes. The registers mance of the hospital and the quality of care. Table 1
were collected and retained by the lead author, who presents more information about the five indicators.
destroyed them upon receiving all the completed forms.
The MLQ consists of 45 items that cover different factors Study Population and Sampling
of leadership: characteristic of transformational leadership,
We preferred that followers have direct contact with their
characteristic of transactional leadership, non-transactional
respective leader, and thus we excluded trainees and assistant
(laissez-faire) leadership, and the outcome of leadership. For
registrar physicians and technicians. Subjects who had spent
example, “Avoids making decisions” is a sample item in the less than one year in the hospital were also excluded. Hence,
“Rater Form”, which the respondent rates on a five-point the study population consisted of 9863 individuals represent­
scale: 0 = Not at all, 1 = Once in a while, 2 = Sometimes, 3 ing the following professions: physician, nurse, and pharma­
= Fairly often, and 4 = Frequently, if not always.29 cist. The population size of professionals in all categories in
The ODQ consists of 28 statements split into two: 14 the six hospitals ranged between 1448 and 1961. Based on
odd-numbered statements support a profile of transactions, a previous study on leadership styles,31 the required sample
and 14 even-numbered statements deal with transforma­ size for this study was calculated using STATA 10 to be
tional attributes. Each statement describes the general 271 per hospital. The calculation was performed assuming:
organizational behavior and beliefs of transformational or
transactional leaders. The respondents were asked to indi­ 1. A mean score of employees’ perception of their
cate whether they believe the statement is true (T) or false leader as a transformer = 24.62.
(F) for their organization. A third category (?) can be 2. A standard deviation (SD) of = 8.81 and accepted
selected if the respondent is indecisive or cannot say. error = 1.5.
“We negotiate with each other for resources” is a sample 3. An alpha of 0.05 and a power of 80%.32
transactional statement, whereas “We trust each other to do
what’s right” is a sample transformational statement.28 Physicians in each hospital from different departments,
The retrospective quantitative approach reviewed and nurses, and pharmacists were selected using proportional
included statistics on the generic quality indicators only. allocation. We aimed to keep the sample size from each
These indicators are five in number and were collected in stratum proportional to the stratum size. The proportional
each hospital for the year 2012.30 They are analyzed quarterly allocation provides a self-weighted sample and requires no
and reported annually as a measure of the quality of care in the additional weighting to estimate unbiased population
parameters.33,34 As the rotation schedules of nurses typi­
government hospitals of Kuwait. The indicators were devel­
cally differ by department, the sample of nurses was ran­
oped by the Quality and Accreditation Directorate in 2002 for
domly selected in each hospital from all departments.
use in all government hospitals in Kuwait. They are:

● Percentage of patients discharged against medical Data Management and Analysis

advice in inpatient departments. Transactional and transformational leadership style and
● Percentage of elective operations cancelled on organizational culture scores were calculated from the
the day of, or after, admission. MLQ and the ODQ data, respectively, as follows:28,29
● Percentage of lengths of stay for appendectomy
operations of five days and over. 1. MLQ:

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Table 1 Generic Indicators Information

Indicator Indicator Statement Numerator Denominator Type of Data Target
Name Statement Statement Indicator Reported
as

Discharge Percentage of patients The number of Total number of hospital Outcome, Percentage Decrease
against discharged against medical discharged against discharges per rate-based in
medical advice advice in a hospital medical advice per department excluding percentage
department deaths or transfers to
other hospitals

Cancelled Percentage of elective The number of last- Total number of scheduled Process, Percentage Decrease
operations operations cancelled on minute cancelled elective operations in the rate-based in
the day of, or after admission operation lists operation lists excluding percentage
A and E theater
operations or day-case
surgeries

Long post- Percentage of patients The number of patients Total number of patients Outcome, Percentage Decrease
appendectomy discharged from general discharged from discharged from general rate-based in
length of stay surgical department after five general surgical surgical department after percentage
days, or more from department after five five appendectomy
appendectomy days, or more from
appendectomy

Non-operated Percentage of patients The number of patients Total number of patients Process, Percentage Decrease
discharges discharged from general discharged from discharged from the same rate-based in
surgical department without general surgical surgical department percentage
undergoing an operation department without excluding deaths or
undergoing an transfers to other
operation hospitals

Unscheduled The number of patients who Description of Not applicable Outcome Number Decrease
return for have underwent a surgical indicator population: in number
operations procedure and returned to Each patient who
the operating theatre within returned to the
the same hospital admission operating theater
within the same
admission

Items on the MLQ are rated on a five-point scale. We used Sum of the mean scores of leadership factors related
Formulae 1 and 2 to calculate the mean scores of leader­ to a specific leadership style
Number of factors for that
ship styles:
leadership style

● Formula 1: Mean score of leadership factor = ● The higher of the two scores from Formula 2 indi­
cated whether leadership was transactional or
transformational.
Score of all respondents on items related
to a specific leadership factor
2. ODQ:
Number of items for that factor
�number of respondents ● Transactional culture score: add one for each
odd-numbered statement marked as true and sub­
● Formula 2: Mean score of each leadership style= tract one for each odd-numbered statement

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marked as false. demographic and work-related characteristics of followers

Transactional culture score ¼ Total of in these hospitals. The age group 30–39 years was the
most represented age group in all six hospitals, followed
odd numbered statements
by 40–49 years. Females represent two-thirds of the sam­
that were true Total of odd numbered
ple, and non-Kuwaitis represent seven-eighths. In hospitals
statements that were false
B and D, the relative majority held a graduate degree,
Transformational culture score: add one for each even- whereas in hospitals E and F the relative majority held
numbered statement marked as true and subtract one a diploma. Other than age and category of pharmacist, all
for each even-numbered statement marked as false. the followers’ demographic and work-related characteris­
Transformational culture score ¼ Total of tics show statistically significant differences between the
even numbered statements six hospitals.
that were true Total of even numbered The complete analysis of the MLQ is outside the scope
statements that were false of this paper and was reported previously.24 It showed that
●
The indecisive or cannot say statements (?) were all followers rated their leaders as transformational lea­
scored as zero. ders, except the followers of the head of pharmacy in
● The higher of the two scores indicated whether the hospital A and the head of surgery in hospital C, who
rated their leaders as transactional.24
culture was transactional or transformational.
Notably, followers rated their transformational leaders
SPSS 23.0 was used to analyze the data. A p value ≤ 0.05 with lower scores than the leaders’ self-rating, except for
was considered to indicate statistical significance. The analysis the heads of medicine in hospitals A and E. The same was
of the quantitative data included univariate descriptive (means, true of heads of ICU, A and E, and Laboratory in hospitals
standard deviations, frequencies, percentages) and bivariate B, E, and C, respectively. Another relevant finding is the
(chi-squared tests, Pearson’s correlation) analyses to examine low mean scores (2.35–2.86) of heads of surgical depart­
the association between the leadership style, organizational ments. Among all heads of departments, heads of surgical
culture, and quality of care.
departments achieved the lowest ratings as transforma­
tional leaders in three hospitals (D, E, and F) and
Ethical Approval and Consent to the second lowest in two hospitals (A and B). The head
Participate of surgery in hospital C was identified as a transactional
Ethical approval and consent to conduct the study was granted leader. Appendix 1 shows the data relevant to this part of
by the Standing Committee for Coordination of Health and the study.
Medical Research in Kuwait (219/2012). We confirm that all A comparison of the organizational cultures of the six
methods were conducted in accordance with the relevant hospitals shows that hospital D had the highest percentage
guidelines and regulations of the Standing Committee for rating for a transformational style (87.1%), followed by
Coordination of Health and Medical Research in Kuwait. hospitals C and F (80.1% and 75.3%, respectively)
Participating hospitals provided permission for the study to (Table 3). The lowest rating was recorded for hospital
take place, and hospital and respondent identities were coded B (66.4%). Departmental organizational culture styles
to ensure anonymity and remained confidential. Participants were mainly transformational except in Surgery, ICU, and
provided voluntary verbal informed consent after receiving an Pharmacy in hospital E (52.9%, 55.6%, and 75.0%, respec­
explanation of the value, benefits, and risks of the study, and tively), A and E and Laboratory in hospital D (60.0% and
their questions were satisfactorily answered. Verbal informed 66.7%), and Medicine in hospital B (59.1%), where it was
consent was approved by the Standing Committee for a transactional culture. In hospital C, transformational and
Coordination of Health and Medical Research in Kuwait. transactional cultures were equally represented in the phar­
macy department (50% each). Across the hospitals, the
Results departments of Medicine and Nursing showed statistically
With 1626 responses from six hospitals, the response rate significant differences in regards to organizational culture.
for the two questionnaires was 100%. Table 2 shows the Two hospitals (D and E) showed statistically significant

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Table 2 Demographic and Work-Related Characteristics of Followers (Respondents) in the Six Studied Hospitals
Demographic and Work-Related Characteristic Hospital (n. 271) Total n (%) p

A n (%) B n (%) C n (%) D n (%) E n (%) F n (%)

Age 0.051
20–29 35 (12.9) 45 (16.6) 50 (18.5) 39 (14.4) 63 (23.2) 40 (14.8) 272 (16.7)
30–39 120 (44.3) 125 (46.1) 129 (47.6) 143 (52.8) 118 (43.5) 133 (49.1) 768 (47.2)
40–49 75 (27.7) 62 (22.9) 59 (21.8) 66 (24.4) 63 (23.2) 60 (22.1) 385 (23.7)
50 + 41 (15.1) 39 (14.4) 33 (12.2) 23 (8.5) 27 (10.0) 38 (14.0) 201 (12.4)

Gender < 0.001

Male 87 (32.1) 82 (30.3) 106 (39.1) 56 (20.7) 101 (37.3) 92 (33.9) 524 (32.2)
Female 184 (67.9) 189 (69.7) 165 (60.9) 215 (79.3) 170 (62.7) 179 (66.1) 1102 (67.8)

Nationality < 0.001

Kuwaiti 27 (10.0) 51 (18.8) 25 (9.2) 19 (7.0) 48 (17.7) 27 (10.0) 197 (12.1)
Non-Kuwaiti 244 (90.0) 220 (81.2) 246 (90.8) 252 (93.0) 223 (82.3) 244 (90.0) 1429 (87.9)

Education 0.014
Diploma 104 (38.4) 83 (30.6) 101 (37.3) 98 (36.2) 94 (34.7) 105 (38.7) 585 (36.0)
Graduate 104 (38.4) 115 (42.4) 101 (37.3) 125 (46.1) 87 (32.1) 103 (38.0) 635 (39.1)
Post-Graduate Diploma 0 (0.0) 1 (0.4) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.4) 2 (0.1)
Masters 36 (13.3) 32 (11.8) 39 (14.4) 32 (11.8) 44 (16.2) 34 (12.5) 217 (13.3)
PhD 27 (10.0) 40 (14.8) 30 (11.1) 16 (5.9) 46 (17.0) 28 (10.3) 187 (11.5)

Current Position 0.043

Employee 240 (88.6) 242 (89.3) 256 (94.5) 251 (92.6) 256 (94.5) 249 (91.9) 1494 (91.9)
Unit Head 31 (11.4) 29 (10.7) 15 (5.5) 20 (7.4) 15 (5.5) 22 (8.1) 132 (8.1)

Period spent at current position 0.012

1–9 181 (66.8) 190 (70.1) 195 (72.0) 194 (71.6) 211 (77.9) 179 (66.1) 1150 (70.7)
10–19 56 (20.7) 59 (21.8) 60 (22.1) 61 (22.5) 41 (15.1) 72 (26.6) 349 (21.5)
20 + 34 (12.5) 22 (8.1) 16 (5.9) 16 (5.9) 19 (7.0) 20 (7.4) 127 (7.8)

Period spent at current hospital 0.008

1–9 143 (52.8) 157 (57.9) 167 (61.6) 179 (66.1) 179 (66.1) 164 (60.5) 989 (60.8)
10–19 78 (28.8) 78 (28.8) 75 (27.7) 70 (25.8) 59 (21.8) 79 (29.2) 439 (27.0)
20 + 50 (18.5) 36 (13.3) 29 (10.7) 22 (8.1) 33 (12.2) 28 (10.3) 198 (12.2)

Category

Physicians 0.044
Consultant 6 (2.2) 12 (4.4) 10 (3.7) 5 (1.8) 4 (1.5) 6 (2.2) 43 (2.6)
Senior specialist 3 (1.1) 2 (0.7) 6 (2.2) 7 (2.6) 8 (3.0) 2 (0.7) 28 (1.7)
Specialist/ Senior general practitioner A 9 (3.3) 8 (3.0) 10 (3.7) 4 (1.5) 11 (4.1) 5 (1.8) 47 (2.9)
Senior registrar/ Senior general practitioner B 10 (3.7) 23 (8.5) 15 (5.5) 5 (1.8) 25 (9.2) 14 (5.2) 92 (5.7)
Registrar/General practitioner 46 (17.0) 33 (12.2) 31 (11.4) 30 (11.1) 55 (20.3) 41 (15.1) 236 (14.5)

Nurses < 0.001

Head specialist 5 (1.8) 6 (2.2) 1 (0.4) 3 (1.1) 2 (0.7) 3 (1.1) 20 (1.2)
Senior specialist 9 (3.3) 5 (1.8) 7 (2.6) 7 (2.6) 4 (1.5) 9 (3.3) 41 (2.5)
Specialist 24 (8.9) 7 (2.6) 11 (4.1) 17 (6.3) 12 (4.4) 20 (7.4) 91 (5.6)
Senior nurse 73 (26.9) 47 (17.3) 64 (23.6) 37 (13.7) 43 (15.9) 49 (18.1) 313 (19.2)
Nurse 81 (29.9) 121 (44.6) 112 (41.3) 151 (55.7) 103 (38.0) 116 (42.8) 684 (42.1)

Pharmacists 0.225
Head specialist 0 (0.0) 2 (0.7) 1 (0.4) 0 (0.0) 1 (0.4) 0 (0.0) 4 (0.2)
Senior specialist 2 (0.7) 1 (0.4) 0 (0.0) 1 (0.4) 0 (0.0) 2 (0.7) 6 (0.4)
Specialist 0 (0.0) 2 (0.7) 0 (0.0) 2 (0.7) 0 (0.0) 0 (0.0) 4 (0.2)
Senior pharmacist 3 (1.1) 0 (0.0) 1 (0.4) 0 (0.0) 2 (0.7) 1 (0.4) 7 (0.4)
Pharmacist 0 (0.0) 2 (0.7) 2 (0.7) 2 (0.7) 1 (0.4) 3 (1.1) 10 (0.6)

Notes: (%): Percentage; p: p-value (Statistically significant at p ≤ 0.05, highly significant at p ≤ 0.001).
Abbreviation: n, number.

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Table 3 Organizational Culture Styles Based on the Followers’ Rating in Departments of the Six Studied Hospitals
Department Organizational Hospital pa
Culture Type
A (n=271) B (n=271) C (n=271) D (n=271) E (n=271) F (n=271) Total
(n=1626)

n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Medicine Transformational 15 (83.3) 9 (40.9) 19 (79.2) 19 (90.5) 21 (84.0) 7 (77.8) 90 (75.6) 0.002
Transactional 3 (16.7) 13 (59.1) 5 (20.8) 2 (9.5) 4 (16.0) 2 (22.2) 29 (24.4)

Surgery Transformational 8 (61.5) 11 (57.9) 6 (66.7) 6 (85.7) 8 (47.1) 7 (53.8) 46 (59.0) 0.636
Transactional 5 (38.5) 8 (42.1) 3 (33.3) 1 (14.3) 9 (52.9) 6 (46.2) 32 (41.0)

Pediatrics Transformational 15 (68.2) 10 (83.3) 10 (62.5) 9 (90.0) 27 (73.0) 17 (81.0) 88 (64.6) 0.565
Transactional 7 (31.8) 2 (16.7) 6 (37.5) 1 (10.0) 10 (27.0) 4 (19.0) 30 (25.4)

ICU Transformational 6 (75.0) 6 (66.7) 8 (80.0) 5 (100.0) 4 (44.4) 9 (90.0) 38 (74.5) 0.172
Transactional 2 (25.0) 3 (33.3) 2 (20.0) 0 (0.0) 5 (55.6) 1 (10.0) 13 (25.5)

A and E Transformational 6 (60.0) 5 (55.6) 6 (100.0) 2 (40.0) 7 (70.0) 4 (57.1) 30 (63.8) 0.408
Transactional 4 (40.0) 4 (44.4) 0 (0.0) 3 (60.0) 3 (30.0) 3 (42.9) 17 (36.2)

Laboratory Transformational 3 (100.0) 5 (71.4) 6 (85.7) 1 (33.3) 4 (80.0) 6 (75.0) 25 (75.8) 0.539
Transactional 0 (0.0) 2 (28.6) 1 (14.3) 2 (66.7) 1 (20.0) 2 (25.0) 8 (24.2)

Nursing Transformational 141 (73.4) 130 (69.9) 160 (82.1) 189 (87.9) 126 (76.8) 150 (76.1) 896 (78.0) <0.001
Transactional 51 (26.6) 56 (30.1) 35 (17.9) 26 (12.1) 38 (23.2) 47 (23.9) 253 (22.0)

Pharmacy Transformational 3 (60.0) 4 (57.1) 2 (50.0) 5 (100.0) 1 (25.0) 4 (66.7) 19 (61.3) 0.352
Transactional 2 (40.0) 3 (42.9) 2 (50.0) 0 (0.0) 3 (75.0) 2 (33.3) 12 (38.7)

Total Transformational 197 (72.7) 180 (66.4) 217 (80.1) 236 (87.1) 198 (73.1) 204 (75.3) 1232 (75.8) <0.001
Transactional 74 (27.3) 91 (33.6) 54 (19.9) 35 (12.9) 73 (26.9) 67 (24.7) 394 (24.2)

pb 0.749 0.163 0.278 0.016 0.016 0.508 0.002

a b
Notes: %: Percentage (per department). Difference between culture type in a department across all hospital (tested by Monte Carlo Exact Test); Difference between
culture type in a hospital across all departments (tested by Monte Carlo Exact Test). p: p-value (Statistically significant at p ≤ 0.05, highly significant at p ≤ 0.001).
Abbreviations: n, number; ICU, intensive care unit; A and E, accident and emergency.

differences with respect to organizational culture across the discharges against medical advice (7.9%) and hospital
departments. B had the lowest (1%). Hospital B had the highest percen­
Table 4 indicates that the percentage of followers who tage of cancelled operations (12.9%) and hospital D had
believed that they have both a transformational leader and the lowest (9.3%). Hospital C had the highest percentage
transformational organizational culture ranged from 60.5% of length of stay of five days or longer after appendectomy
(hospital B) to 80.4% (hospital D). The percentage of (46.6%) and hospital D had the lowest (14.1%). Hospital
followers who believed that they have a transactional lea­ D had the highest percentage of discharge from the surgi­
der, as well as a transactional organizational culture, ran­ cal department without an operation (54.5%) and hospital
ged from 4.1% (hospital E) to 7.7% (hospitals A and B). E had the lowest (32.3%). The differences between hospi­
The percentage of followers who believed that they have tals with respect to these four indicators are statistically
a transformational leader, but rated their organizational significant. For the number of unscheduled returns for
culture as transactional ranged from 8.5% (hospital D) to operations, hospital A had the highest (56 cases) and
25.8% (hospital B). The differences between leadership hospital C had the lowest (9 cases).
style and organizational culture were statistically signifi­ Table 5 shows the relationship between generic quality
cant for hospitals A, B, E, and F, with p values of < 0.001, indicators and the transformational leadership style of
< 0.001, 0.002, and 0.002, respectively. heads of departments in the six hospitals. It is worth noting
Table 4 also shows the generic quality indicator (four that a negative correlation is desired. The correlation
surgical, one nonsurgical) results from 2012 in the six between transformational leadership style and both the
hospitals. Hospital F had the highest percentage of percentage of discharge against medical advice and

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Table 4 Summary of Leadership Style, Organizational Culture Style, and Generic Indicators at the Six Studied Hospitals
Hospital Total p*

A B C D E F

n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Leadership style 0.674

Transformational (TFL) 228 (84.1) 234 (86.3) 233 (86.0) 241 (88.9) 229 (84.5) 232 (85.6) 1397 (85.9)
Transactional (TAL) 43 (15.9) 37 (13.7) 38 (14.0) 30 (11.1) 42 (15.5) 39 (14.4) 229 (14.1)

Organizational culture style < 0.001

Transformational (TFC) 197 (72.7) 180 (66.4) 217 (80.1) 236 (87.1) 198 (73.1) 204 (75.3) 1232 (75.8)
Transactional (TAC) 74 (27.3) 91 (33.6) 54 (19.9) 35 (12.9) 73 (26.9) 67 (24.7) 394 (24.8)

Leadership style x Organizational culture style

TFL x TFC 175 (64.6) 164 (60.5) 191 (70.5) 218 (80.4) 167 (61.6) 180 (66.4) 1095 (67.3)
TFL x TAC 53 (19.6) 70 (25.8) 42 (15.5) 23 (8.5) 62 (22.9) 52 (19.2) 302 (18.6)
TAL x TFC 22 (8.1) 16 (5.9) 26 (9.6) 18 (6.6) 31 (11.4) 24 (8.9) 137 (8.4)
TAL x TAC 21 (7.7) 21 (7.7) 12 (4.4) 12 (4.4) 11 (4.1) 15 (5.5) 92 (5.7)
McNemar p < 0.001 < 0.001 0.068 0.533 0.002 0.002 < 0.001

Generic Indicators (2012)

% of discharge against medical advice 5.0 1.0 4.9 7.6 2.2 7.9 < 0.001
% of cancelled operations 11.3 12.9 9.5 9.3 12.3 10.4 0.047
% of length of stay for appendectomy ≥ 5 days 20.2 23.5 46.6 14.1 14.9 35.4 < 0.001
% of discharge without operation 48.8 39.2 47.1 54.5 32.3 48.1 < 0.001
Unscheduled return for operations 56 17 9 11 48 16

Notes: %: Percentage; *Monte Carlo Exact Test; p: p-value (Statistically significant at ≤ 0.05, highly significant at ≤ 0.001).
Abbreviations: n, number; TFL, transformational leadership; TAL, transactional leadership; TFC, transformational culture; TAC, transactional culture.

percentage for a length of stay for five days or longer after that the majority of followers that view their department
appendectomy were very weak,35 nearly null, negative, heads as transformational, considered their organizational
and nonsignificant (r = −0.03, p = 0.957 and r = −0.09, culture as transformational. This is consistent with the
p = 0.872, respectively). The correlation between transfor­ findings of many studies that assessed the relationship
mational leadership and the percentage of cancelled opera­ between transformational leadership style and transforma­
tions was moderate,35 negative, and nonsignificant (r = tional organizational culture and reported that there was
−0.37, p = 0.468). The correlation between transforma­ a significant correlation and positive impact with overall
tional leadership and the number of unscheduled return for transformational leadership practices.3 Moreover, the
operations was strong,35 negative and nonsignificant (r = transformational leadership style has a positive and sig­
−0.71, p = 0.111). The correlation between nificant impact on organizational innovation36,37 and
a transformational leadership style and the percentage of learning,38,39 which are among the primary components
discharge from the surgical department without operation of the essence of organizational culture.14 This might also
was moderately35 positive, but nonsignificant (r = 0.49, explain how the transformational leadership style indir­
p = 0.329). ectly creates a transformational culture.
Many studies have found a relationship between trans­
Discussion formational leadership style and the quality of care in
The results of the study reveal that there was a greater hospitals.3,40,41 Because the generic quality indicators of
frequency of respondents rating their hospital culture more the government health system report the unwanted occur­
transformational than transactional. These findings could rences—the lower the better—this study shows that there
be explained by hospital leaders more often displaying was a negative nonsignificant correlation between
a transformational leadership style than a transactional a transformational leadership style and most of the indica­
one. This likely has a great effect on shaping and preser­ tors analyzed (Table 5). This relationship might exist
ving the culture of the hospital. The results also indicate because of the support and follow up the transformational

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Table 5 Relationship Between Generic Quality Indicators and Transformational Leadership Style of Heads of Departments in the Six
Studied Hospitals
Generic Quality Indicators Heads of Departments Transformational Leadership Style

r p

Percentage of discharge against medical advice −0.03 0.957

Percentage of cancelled operations −0.37 0.468
Percentage of the length of stay for appendectomy ≥ 5 days −0.09 0.872
Percentage of discharge without operation 0.49 0.329
Number of unscheduled return for operations −0.71 0.111
Notes: r: Pearson coefficient; p: p-value (statistically significant at p ≤ 0.05, highly significant at p ≤ 0.001). Correlation coefficient interpretation guidelines.36;>0.00–0.30:
weak correlation; >0.30–0.70: moderate correlation; >0.70–1.00: strong correlation.

leaders provide to their hospital quality officers, who are however weak, of this trainable leadership style on staff
responsible for the implementation of these generic indi­ performance.44 This analysis is highly relevant to the
cators. Moreover, the characteristics of the transforma­ current study because it addresses two issues: the low
tional leadership style, such as influencing, advising, and scores of transformational leaders and the weak impact
being attentive to followers’ needs could be factors in the of transformational leadership on quality. Being
improvement of the followers’ performance, reflecting an a trainable leadership style, acquiring and improving trans­
amelioration of the hospital’s quality indicator statistics. formational behavior will be an extremely desirable goal.
That the correlation is statistically insignificant implies the Once leaders improve their transformational behavior,
presence of confounding factors that should be their impact on improving quality of care will be profound.
investigated.
Many factors might have contributed to the nonsigni­ Strengths and Limitations
ficance of the mostly weak to moderate correlation The majority of articles published on the topic of transfor­
between leadership styles and generic quality indicators. mational leadership and quality of care assessed the style
Firstly, the percentages on transformational culture within of leadership in nursing. This study was conducted in
the surgical departments are statistically insignificant multiple centers that represent the country-wide secondary
(Table 3). Moreover, the mean scores of the transforma­ healthcare services, and included a relatively large number
tional heads of surgery are among the lowest compared to and variety of professions and authority levels among the
other departments (Appendix 1). Given the fact that four participants. The multimethod design of the study allowed
of the five reported indicators are surgical, the low scores the exploration of several relationships between different
of the heads of surgical departments largely explain the components and subjects. It also facilitated triangulation
weak effect transformational leadership has on the quality and a wider view of the topic. Furthermore, this is the first
indicators. Secondly, the studied indicators reflect the per­ study in Kuwait and the region to report on transforma­
formance of the hospital as a whole, whereas leadership tional leadership style, transformational organizational cul­
styles are assigned to individuals. The third factor is ture, quality of care indicators, and their interrelationships.
related to the discrepancies between the scores from self- Also, we overcame the potential biases of case series and
ratings and followers’ ratings, which is associated with case reports with the cross-sectional design, which allowed
a more negative organizational culture. Authors noted the collection of data for measuring different variables in
that if leaders rated themselves more positively than their the population sample at a single point in time.45
followers, hospital performance, in general, might be However, some limitations must be acknowledged.
affected.42 To overcome such a limitation, studies recom­ Although a recent systematic review and a research article
mend to train and educate current and future leaders on the from the region reported the predominance of transforma­
topic of leadership, including its styles and the effective tional leadership,46,47 some might claim that the transfor­
use of its strengths.1,2,8,41,43 mational leadership represented in the current study
A recent meta-analysis found that increasing transfor­ reflects social desirability bias, cultural influences, hiring
mational behavior might strengthen any positive impact, practices, and management education. Another bias that

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might have affected our study is selection bias, as we results in this context suggest that leaders are shapers
selected quality indicators solely for their availability. and influencers of their organizational culture.
The small number of quality-of-care indicators, being pri­ The transformational leadership style has a positive
marily surgical, and the nature of reporting unwanted effect on the quality of care delivered by an
occurrences did not allow the robust evaluation of the organization.3,40,41 This effect can be measured using indi­
quality of care that we sought. In addition, there might cators that compare the healthcare organization’s perfor­
be other confounding factors not studied here that resulted mance to an external reference or “gold standard”.
in the nonsignificant negative correlation between quality However, it is not enough to be a transformational leader,
indicators and a transformational style of leadership. leaders have to improve their transformational behavior to
Also, the study could not investigate differences in maximize the gains of this effective leadership style.43,44
leadership style based on the nationality of the leaders, The relationship between a transformational leadership
because 63 of the 66 leaders studied were Kuwaiti. The style and quality indicators was measured in this study.
study included neither private sector hospitals nor other There is a positive impact, of mostly weak to moderate mag­
care delivery settings within the government sector (pri­ nitude, of transformational leadership on the quality of care
mary, tertiary, and quaternary healthcare services). Finally, represented by generic quality indicators. However, this
the study explored the relationship between culture and impact was found to be statistically insignificant for a couple
quality with only one leadership model. This does not of possible reasons. The results suggest an opportunity exists
merit conclusions about the inferiority or superiority of to enhance the quality of care if transformational leadership
a transformational leadership style over other leadership could be improved. Effective transformational leadership can
styles or say anything about how other leadership styles be improved through training, education, experience, and pro­
affect culture or outcomes in healthcare organizations.2,48 fessional development. This field should be further explored to
conceptualize the confounding and mediating factors that
impact the effectiveness of a practiced leadership style.
Practice Implications
The requirement for continuing professional development
in the healthcare profession makes a culture of learning Abbreviations
and transforming more desirable. Therefore, training and A and E, accident and emergency; ICU, intensive care
development programs are essential for leaders to develop unit; MLQ, Multifactor Leadership Questionnaire; ODQ,
a strong vision and philosophy to communicate expecta­ Organizational Description Questionnaire; SD, standard
tions, develop others, and lead healthcare organizations to deviation; TAC, transactional culture; TAL, transactional
meet strategic objectives.1,2,41 This is critical for those in leadership; TFC, transformational culture; TFL, transfor­
management roles within Kuwait’s health system because mational leadership.
they rarely undertake adequate training in related fields.49
Fortunately, the transformational leadership style has Acknowledgments
a noticeable influence on how leadership development The authors acknowledge and thank Prof. Hoda H. Zaki
strategies evolve.12 for her guidance and contribution.
This study provides insight into a complex and impor­
tant regionally under-researched area. We invite research­
Disclosure
ers to explore and compare the different leadership styles
The authors report no conflicts of interest in this work.
and models. We desire further collaboration with the qual­
ity indicators team to reflect on how to advance the current
indicators program.
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