Leadership in Health Services

Exploring leadership styles in government hospitals in Kuwait

Talal ALFadhalah, Hossam Elamir,
Article information:
To cite this document:
Talal ALFadhalah, Hossam Elamir, (2019) "Exploring leadership styles in government hospitals in
Kuwait", Leadership in Health Services, https://doi.org/10.1108/LHS-11-2018-0059
Downloaded by Buffalo State – the State University of New York At 08:12 25 June 2019 (PT)

Permanent link to this document:

https://doi.org/10.1108/LHS-11-2018-0059
Downloaded on: 25 June 2019, At: 08:12 (PT)
References: this document contains references to 50 other documents.
To copy this document: permissions@emeraldinsight.com
The fulltext of this document has been downloaded 5 times since 2019*
Access to this document was granted through an Emerald subscription provided by emerald-
srm:145263 []
For Authors
If you would like to write for this, or any other Emerald publication, then please use our Emerald
for Authors service information about how to choose which publication to write for and submission
guidelines are available for all. Please visit www.emeraldinsight.com/authors for more information.
About Emerald www.emeraldinsight.com
Emerald is a global publisher linking research and practice to the benefit of society. The company
manages a portfolio of more than 290 journals and over 2,350 books and book series volumes, as
well as providing an extensive range of online products and additional customer resources and
services.
Emerald is both COUNTER 4 and TRANSFER compliant. The organization is a partner of the
Committee on Publication Ethics (COPE) and also works with Portico and the LOCKSS initiative for
digital archive preservation.

*Related content and download information correct at time of download.

 The current issue and full text archive of this journal is available on Emerald Insight at:
www.emeraldinsight.com/1751-1879.htm

Leadership in
Exploring leadership styles in government
government hospitals in Kuwait hospitals in
Kuwait
Talal ALFadhalah and Hossam Elamir
Department of Quality and Accreditation, Ministry of Health, Kuwait

Received 28 November 2018

Abstract Revised 23 March 2019
Downloaded by Buffalo State – the State University of New York At 08:12 25 June 2019 (PT)

Purpose – This paper aims to determine and assess leadership styles in six government general hospitals. Accepted 5 April 2019

Design/methodology/approach – This is a cross-sectional study that uses a self-administered

questionnaire to determine the leadership styles by self or followers’ rating. The participants were 66 leaders
and 1,626 followers. The data were analyzed using suitable statistical methods.
Findings – The prevailing leadership style of hospitals’ leaders is the transformational style, where self-
rating as transformational is higher than followers’ rating. The demographic characteristics of leaders are
statistically insignificant.
Research limitations/implications – Other health-care settings were not included in the study. In
addition, the study is designed to determine the relationship between variables, not to identify cause and
effect. However, effective leadership has a substantial value and impact in health care. The paper confirms
the existence of a transformational style effect on all organizational outcomes and represents a baseline
for future studies in determining leadership styles and organizational culture types to highlight
improvement areas.
Practical implications – The paper recommends designing training programs to improve
transformational leadership behavior. Moreover, investment in research is needed to understand how to build
transformational leaders. In addition, leaders' recruitment must be conditioned by obtaining a leadership
certification.
Originality/value – This topic is under-researched in Kuwait health-care system. The use of leadership
style as an indicator for a health-care organization's performance is still not well known in Kuwait.
Keywords Transformational leadership, MLQ, Health-care leadership, Kuwait hospitals
Paper type Research paper

Introduction
Today, almost all health-care organizations face a dynamic and complex environment
characterized by rapid technological changes, rising costs, competition, and globalization
(Fraczkiewicz-Wronka et al., 2010; Ginter et al., 2018; Gumusluoglu and Ilsev, 2009; Liebler
and McConnell, 2016; Speziale, 2015). For these reasons, effective leadership has been the
focus of quality improvement activities in many organizations (Conway, 2008; Northouse,
2018; Schyve, 2009), who stated that effective leadership is critical to their success in the
current environment (Oliver, 2006; Schyve, 2009).
Leadership merit and impact have become broadly recognized in the health-care
industry, where the system requires a good leader to bring optimal and effective
management to clinical practice (Oliver, 2006). Leaders in health-care organizations
demonstrate many leadership styles such as classical (situational/laissez-faire) and

The authors would like to acknowledge Kuwait Ministry of Health (MOH) for funding the research
and covering the costs of transportation, purchasing the questionnaires from the publisher, writing Leadership in Health Services
and printing the data collection tools, and statistical analysis of data. The authors would also like to © Emerald Publishing Limited
1751-1879
acknowledge the contribution of Jumana Al-Amir in proofreading this paper. DOI 10.1108/LHS-11-2018-0059
 LHS transactional-transformational (Abualrub and Alghamdi, 2012). Many contributors define a
preferred leadership style, among which are personal beliefs and values, operational
performance, and organizational culture. Contributors may boost some styles while
downplaying others (Abualrub and Alghamdi, 2012).
Kuwait’s health-care system is unique in that the government sector, the main care
provider, is owned, funded, solely regulated, and operated by the Ministry of Health
(MOH) for both individuals and organizations (Mossialos et al., 2018). Other national
systems, for example, the NHS, are regulated by many governing and regulatory bodies:
the Care Quality Commission (CQC), foundation trusts, the Department of Health, and
others (HSE, 2019; NHS England, 2018). In addition, the government's proportion of total
Downloaded by Buffalo State – the State University of New York At 08:12 25 June 2019 (PT)

health expenditure exceeds all similar countries in the Gulf region. Moreover, the health-
care management profession is not well acknowledged, and those in management
positions usually do not receive proper training in related disciplines (Mossialos et al.,
2018).
There are six government general hospitals in Kuwait; each one mainly provides
secondary health-care services and some tertiary services to the population of its respective
health region. The six hospitals, as well as the six health regions, are directed by hospital
directors and health region directors, respectively. Both groups of directors are managed by
the Assistant Undersecretary for Technical Affairs, who, along with the directors, is
appointed by the Undersecretary of the MOH (MOH, 2019).
In 2003, there were 7,291 governmental health-care managers in Kuwait (WHO, 2006),
where the field of leadership styles and their effects on the health-care system is under-
researched (Al-Mailam, 2004). There is a need to invest in management capacity
development through training, leadership programs, and selection of health leaders who can
deliver Kuwait's health priorities (WHO, 2006). Therefore, health-care leadership represents
a priority problem in Kuwait, the subject of the present study. The study aims to measure
health-care leadership styles and test their effectiveness in Kuwaiti government general
hospitals.

Literature review
Leadership
Different leadership styles have been linked to specific contextual demands in many
leadership theories that resulted in better organizational performance (Avolio, 2007).
Leadership has generated a sizable amount of research and theories (Curtis et al., 2011).
One of the present and most widespread leadership theories is transactional-
transformational theory, a principal pattern when discussing effective leadership
(Molero et al., 2007; Northouse, 2018). In 2000, a review article found that one-third of
the research about leadership styles was on transactional-transformational leadership
theory (Lowe and Gardner, 2000). The study of transformational leadership (TFL)
viewed the leader’s behavior on a continuum which expands to include three leadership
styles: transactional, transformational, and non-transactional (laissez-faire) (Emery and
Barker, 2007).
While there is not much literature on leadership styles in Kuwait, the few published
articles from service industries other than health care revealed that TFL and its positive
effects were predominantly explored and found (AlFahad et al., 2013; Alsaeedi and Male,
2013). Moreover, studies from the health-care sector in the Gulf and adjacent countries
reported the same findings (Alloubani et al., 2014; Suliman, 2009).
 Transactional leadership style Leadership in
Transactional leadership (TAL) style is found in the middle of the continuum and is defined government
as the exchange and rewards between leader and followers (Molero et al., 2007). It focuses on
day-to-day functioning. The leader set the goals, and the followers must comply
hospitals in
(Robbins and Davidhizar, 2007). This style of leadership comprises two factors: contingent Kuwait
reward and management by exception. Contingent reward (constructive transactions) is the
first of two TAL factors, where materialistic (or lower-order rewards) are based on the
exchange of privileges such as financial incentives. On the other hand, psychological (or
higher-order rewards) are less common and based on followers’ performance such as trust,
loyalty, and respect (Casida and Parker, 2011). The second factor is management or direction
Downloaded by Buffalo State – the State University of New York At 08:12 25 June 2019 (PT)

(corrective transaction) by exception, where the leader uses corrective criticism, negative
feedback, and negative reinforcement (Northouse, 2018). It may take active or passive form
(Emery and Barker, 2007), where both forms utilize negative reinforcement patterns more
than the positive ones described in the first factor of TAL (Northouse, 2018).

Transformational leadership style

On the left end of the continuum is transformational leadership style (Emery and Barker,
2007). TFL is a process that changes and transforms (Hall et al., 2016). This process also
defines and articulates an inspirational vision, facilitates and communicates the vision
through focusing closely on what followers are attempting to convey, what points are
important to them, and pursues the vision till it becomes real (Northouse, 2018; Robbins and
Davidhizar, 2007). Moreover, TFL holds values, ethics, emotions, behaviors, standards, and
long-term goals in high regard and perpetuates them among staff (Gheith, 2010). TFL style
includes an incomparable way of influencing and motivating followers to achieve
unexpected outcomes by increasing their awareness of the value and importance of the
organization’s goals and objectives (Northouse, 2018).
Moreover, TFL uses a variety of tactics and actions including one-to-one attempts to
influence followers as well as broader attempts to change entire organizations and cultures
(Hall et al., 2016; Robbins and Davidhizar, 2007). TFL style consists of four factors: idealized
influence, inspirational motivation, intellectual stimulation, and individualized
consideration. Because of these factors, transformational leaders can lead followers to their
maximum level of performance (Hall et al., 2016). The absence of any factor has a negative
impact on the leader’s effectiveness. Beyond that, improper use of these factors damages
follower loyalty and, consequently, leadership effectiveness (Gheith, 2010). While TAL style
brings about expected outcomes, TFL style leads to achieving beyond what is expected
(Emery and Barker, 2007; Hall et al., 2016). People who demonstrate TFL style are seen as
more effective leaders with better health-care organizational outcomes than those who
demonstrate TAL style (Molero et al., 2007).

Non-transactional (laissez-faire) leadership style

Non-transactional (laissez-faire) leadership falls at the right end of the transactional-
transformational leadership continuum and embraces the hands-off or let-things-ride
practice (Northouse, 2018). It is a passive leadership style, defined by the absence of
leadership, a total contrast to TFL and TAL styles (Casida and Parker, 2011). Non-TAL is
characterized by a lack of response to followers’ problems and needs and a failure to monitor
their performance (Northouse, 2018). In addition, this style of leader delays decisions, gives
no feedback, abdicates responsibility, and does not use authority, which hinders the
organization’s progress (Casida and Pinto-Zipp, 2008; Molero et al., 2007).
 LHS Leadership style and followers’ job satisfaction
A study conducted in the USA indicated that TFL style was more associated with job
satisfaction than TAL (Emery and Barker, 2007). Another study carried out in 2012 in six
Saudi Arabian public hospitals showed that nurses whose leaders used TFL style had
greater satisfaction. Behaviors associated with TFL style include acceptance, encouraging
followers to take responsibility and be autonomous, and caring for their needs (Abualrub
and Alghamdi, 2012).

Organizational commitment and trust

TFL style can build organizational commitment, which defines the degree to which an
Downloaded by Buffalo State – the State University of New York At 08:12 25 June 2019 (PT)

employee identifies with a specific organization and its goals and desires to retain
membership in it (Tse et al., 2013). Followers are more likely to be committed if the
leader's vision is based on values and moral justifications that are acceptable to them
(Jaskyte, 2004). Organizational trust, a reciprocal process between leader and followers, is
highly correlated with TFL style. TFL style can influence followers' trust through
maintaining their dedication and integrity when their leaders treat them fairly,
demonstrate faith in them, respect them, support them emotionally, and reward them
formally and informally (Tse et al., 2013).

Methodology
The study was conducted using a cross-sectional approach at the six general government-run
hospitals in Kuwait. The study population consists of leaders and followers. Leaders include
hospital directors (6), deputy directors (6), director assistants for administration affairs (6),
and heads of departments (HODs) (clinical, nursing and clinical support departments) (48).
Followers are of two groups: those working under the supervision of hospital directors
(deputy director, director assistants, HODs) (60), and those supervised by the HODs
(physicians, nurses and pharmacists) (9863). The study excluded any employee who worked
less than one year in the studied hospital, because they were still under the probationary
period, as well as trainees and assistant registrar physicians and technicians because they
had no direct contact with leaders. The population size of followers in the six hospitals
ranged between 1,448 and 1,961. The sample size comprises:

Leaders: all hospital directors and HODs (66 leaders); and

Followers: deputy directors, director assistants and HODs (60 leaders), in addition to
a sample of those under the supervision of HODs.

Assuming a mean score of employees' perception of their leader as a transformer = 24.62;

SD = 8.81, and accepted error = 1.5, an alpha of 0.05 and power 80 per cent, the required
sample size was calculated to be 271 per hospital (Daniel and Cross, 2013), based on a
previous study on leadership styles (Al-Mailam, 2004), and was calculated using STATA 10.
The sample of physicians, nurses, and pharmacists was selected using the proportional
allocation method. In addition, the selection of physicians in each hospital from different
departments was also done by using proportional allocation method. Regarding nurses, the
sample was randomly selected in each hospital from all departments, as nurses usually
rotate in different shifts in different departments.
The Multifactor Leadership Questionnaire (MLQ) (Bass and Avolio, 2004), a self-
administered tool, was used. It is available in English and Arabic (2009), and both versions
were used in the study. A vast number of published articles on Transformational/ TAL
utilized the MLQ due to its validity and reliability (Antonakis et al., 2003; Hinkin and
 Schriesheim, 2008; Schriesheim et al., 2009) The questionnaire consists of two forms, a leader Leadership in
form and a rater (follower) form. The questionnaire consists of 45 items that cover different government
factors of leadership:
hospitals in

five factors are identified as characteristic of transformational leadership: idealized
Kuwait
attributes, idealized behaviors, inspirational motivation, intellectual stimulation and
individual consideration;

three factors are identified as characteristic of TAL: contingent reward, active
management by exception, and passive management by exception;

one factor is described as non-transactional (laissez-faire) leadership; and
Downloaded by Buffalo State – the State University of New York At 08:12 25 June 2019 (PT)

three factors are described as the outcome of leadership: extra effort, effectiveness,
and satisfaction.

Demographic and work-related data were added to the questionnaire. A period of one month
throughout 2013 was spent in each hospital to collect data from respondents using the
questionnaire.
Calculation of the mean score of leadership styles was done where the larger mean
score of transactional or transformational factors indicates the leadership style is
transactional or transformational. The calculation was done through formulas 1 and 2 as
follows:
Formula 1: Mean score of leadership factor

Score of all respondents on items related to a specific leadership factor

¼
Number of items for the same factor X Number or respondents

Formula 2: Mean score of each leadership style

Sum of the mean scores of leadership factors related to a specific leadership factor
¼
Number of factors for the same leadership style

The same was followed for calculating the mean score of the three factors that described
outcomes (extra effort, effectiveness, satisfaction).

Statistical analysis
SPSS 15.0 was used in data analysis. The p # 0.05 was used as the cutoff value for statistical
significance (p-value).
(1) Descriptive statistics:

Count and percentage: Used for describing and summarizing qualitative data;
and

Minimum, maximum, arithmetic mean (x) , standard deviation (SD): Used as
measures of central tendency and dispersion, respectively, for normally
distributed quantitative data.
(2) Analytical statistics:

Chi square (x2): Used to test the association between two qualitative variables or to
detect the difference between two or more proportions. Monte Carlo Exact Test:
Used when x2 is not valid (> 20 per cent of the expected cells have count less than
5) and for tables larger than 2 X 2;
 LHS
t-test: Used to compare two sample means;

One-way analysis of variance (ANOVA): Used for testing the difference
between more than two groups’ mean;

Simple correlation (r): Measures the degree of association between quantitative
variables;

McNemar’s chi square test: Used for assessing the difference in leadership
styles as rated by followers; and

Regression analysis: Implemented to study factors influencing the leader to be
transformational according to followers’ rating in the studied hospitals. Another
Downloaded by Buffalo State – the State University of New York At 08:12 25 June 2019 (PT)

regression model was implemented for factors most affected by the

transformational leadership style.

Results
According to the self-rating of leaders of all hospitals, they considered themselves more
transformational than transactional, except the head of the intensive care unit in hospital B,
who considered himself a transactional leader (Table I). In addition, the head of A&E (the
Accident and Emergency Department) in hospital E, as well as the head of the laboratory in
hospital F, rated themselves as both transformational and transactional leaders. Both leaders
have the lowest mean score of transformational style, while the head of the intensive care unit
in hospital B was rated as the second lowest. On the other hand, the heads of the pediatrics and
A&E in hospital B rated themselves with the highest mean score of transformational style.
All followers rated their leaders as transformational leaders, except the followers of the
head of pharmacy in hospital A and the head of surgery in hospital C, who rated their
leaders as transactional (Table I). The highest-rated transformational leader by his followers
was the head of medicine in hospital F, while the lowest-rated transformational leader by his
followers was the director of hospital E.
In terms of total outcome based on effort, effectiveness, and satisfaction, the highest
mean self-rating in all hospitals was scored by the head of A&E in hospital B and the head
of nursing in hospital E (Table I). On the other hand, the lowest self-rated leader was the
head of A&E in hospital E and the head of the laboratory in hospital F. For the total outcome
of the followers’ ratings, the highest followers-rated leader was the head of the laboratory in
hospital A, and the lowest followers-rated leader was the director of hospital E.
The relationship between TFL style and demographic and work-related characteristics
of both hospitals’ directors and HODs are not statistically significant. The mean score of
transformational directors aged 50 years and above was higher than that for directors less
than 50 years of age. Female directors had a higher mean than male directors. All hospitals’
directors were Kuwaiti, holding an MD degree, and had spent at least one year in their
current position. The mean score of transformational hospitals’ directors was highest for
directors who had spent 20 years and above in their hospitals. For HODs, the
transformational mean score for those aged 50 years and above was higher than the younger
ones. Male HODs had a higher mean score than females.
Looking at the demographic characteristics of followers in the six studied hospitals, there
are statistically significant differences regarding age, gender, and nationality between the
departments of medicine with p-values of 0.003, 0.001, and 0.001, respectively. On the other
hand, there are no statistically significant differences regarding them in laboratory,
intensive care unit, and pharmacy. For the rest of the departments, age is statistically
significant in surgery and nursing departments (p= 0.033, p# 0.001), while gender is
 Downloaded by Buffalo State – the State University of New York At 08:12 25 June 2019 (PT)

Director Medicine Surgery Pediatrics

Self- Followers’ Director’s Deputy Self- Followers’ Self- Followers’ Self- Followers’
Hospitals rating rating Assistant Director rating rating rating rating rating rating

Transformation leader
A 2.75 2.74 6 1.09 3.10 3.90 3.20 3.27 6 0.61 3.65 2.86 6 0.81 3.40 2.45 6 0.85
B 3.35 2.76 6 0.82 3.35 3.90 3.5 2.51 6 0.71 3.6 2.35 6 0.62 4.0 2.60 6 0.95
C 3.75 2.41 6 0.94 3.55 3.15 3.0 2.93 6 0.55 3.50 2.07 6 1.0 3.55 2.95 6 0.39
D 3.45 3.13 6 0.29 3.20 3.20 3.15 2.96 6 0.67 3.55 2.45 6 0.52 3.70 3.32 6 0.27
E 3.0 1.94 6 0.67 3.0 3.0 3.0 3.01 6 0.71 3.50 2.62 6 0.7 3.05 2.65 6 0.67
F 3.35 2.80 6 0.81 3.65 3.75 3.75 3.46 6 0.13 3.90 2.37 6 0.86 3.70 3.09 6 0.74
Transaction leader
A 2.0 2.16 6 0.53 2.67 2.83 2.67 2.5 6 0.5 2.0 2.31 6 0.59 2.58 2.16 6 0.45
B 2.33 2.44 6 0.46 2.33 2.42 2.58 1.98 6 0.34 2.50 2.06 6 0.37 2.83 2.10 6 0.48
C 2.0 2.08 6 0.68 2.25 2.33 1.75 2.37 6 0.51 1.92 2.23 6 0.44 2.25 2.08 6 0.35
D 2.0 2.38 6 0.23 2.25 1.92 2.25 2.29 6 0.52 2.67 2.17 6 0.23 2.08 2.68 6 0.44
E 1.83 1.86 6 0.34 1.83 1.83 1.83 2.4 6 0.46 1.92 2.14 6 0.3 1.75 2.25 6 0.56
F 2.33 2.39 6 0.56 2.42 2.33 1.42 2.38 6 0.19 2.17 2.19 6 0.53 2.33 2.43 6 0.59
Outcome
A 2.27 2.79 6 1.03 2.75 3.28 2.81 3.23 6 0.58 2.99 2.93 6 0.85 2.86 2.35 6 1.01
B 2.86 2.82 6 0.9 2.86 3.21 3.03 2.49 6 0.87 3.0 2.44 6 0.88 3.21 2.88 6 1.04
C 2.97 2.52 6 1.3 2.97 2.86 2.38 2.83 6 0.72 2.91 2.24 6 0.91 3.0 2.90 6 0.57
D 2.90 3.16 6 0.48 2.81 2.58 2.80 2.96 6 0.77 3.08 2.08 6 0.99 3.09 3.36 6 0.51
E 2.85 1.43 6 0.88 2.41 2.41 2.83 2.93 6 0.91 3.26 2.61 6 0.76 2.62 2.70 6 0.78
F 2.95 2.74 6 0.88 3.05 3.23 2.77 3.48 6 0.35 3.01 2.11 6 1.21 3.11 3.12 6 0.66
(continued)

followers’ rating in
according to leaders’
outcome factors
Mean scores of

self-rating and
leadership styles and
Kuwait
hospitals in
Leadership in

all hospitals
Table I.
government
 Downloaded by Buffalo State – the State University of New York At 08:12 25 June 2019 (PT)

LHS

Table I.
ICU E&D Laboratory Nursing Pharmacy
Hospitals Self-rating Followers’ rating Self-rating Followers’ rating Self-rating Followers’ rating Self-rating Followers’ rating Self-rating Followers’ rating

Transformation leader
A 3.55 3.29 6 0.39 3.45 3.03 6 0.4 3.60 3.03 6 0.5 3.45 2.79 6 0.62 3.8 2.33 6 0.6
B 2.40 2.93 6 0.69 4.0 2.23 6 0.94 3.05 2.51 6 1.10 3.0 2.67 6 0.66 3.45 2.74 6 0.53
C 3.55 3.18 6 0.48 3.40 3.34 6 0.64 3.15 3.26 6 0.47 3.25 2.60 6 0.54 3.45 2.76 6 0.58
D 3.55 3.20 6 0.58 3.25 2.49 6 0.75 3.80 3.08 6 0.25 3.70 2.80 6 0.61 3.50 3.13 6 0.3
E 3.75 2.81 6 0.55 2.0 2.79 6 0.6 3.80 2.77 6 0.83 3.75 2.64 6 0.74 3.80 3.29 6 0.44
F 3.50 3.26 6 0.44 3.25 2.72 6 1.0 2.0 2.75 6 0.36 3.30 2.60 6 0.6 3.45 2.88 6 0.53
Transaction leader
A 2.50 2.57 6 0.38 2.17 2.39 6 0.46 2.50 2.58 6 0.36 2.25 2.25 6 0.50 2.83 2.52 6 0.32
B 2.58 2.31 6 0.28 2.67 2.13 6 0.41 2.25 2.0 6 0.41 2.42 2.18 6 0.45 2.58 2.21 6 0.72
C 2.50 2.55 6 0.41 2.33 2.50 6 0.39 1.58 2.36 6 0.45 3.0 1.90 6 0.14 2.17 2.19 6 0.48
D 2.58 2.15 6 0.48 2.33 2.43 6 0.26 2.33 1.78 6 0.27 2.58 2.13 6 0.44 2.58 2.25 6 0.29
E 2.67 2.15 6 0.5 2.0 2.43 6 0.52 2.17 2.55 6 0.46 2.17 2.22 6 0.64 2.17 3.0 6 0.30
F 2.83 2.46 6 0.32 2.25 2.21 6 0.62 2.0 2.04 6 0.27 2.67 2.12 6 0.41 1.42 2.24 6 0.53
Outcome
A 2.99 3.26 6 0.55 2.90 3.24 6 0.58 3.04 3.5 6 0.38 2.90 2.87 6 0.74 3.27 2.27 6 0.68
B 2.57 2.73 6 1.13 3.33 2.13 6 1.10 2.62 2.94 6 1.23 2.70 2.77 6 0.81 3.09 3.0 6 0.6
C 3.05 3.36 6 0.42 2.85 3.34 6 0.42 2.51 3.32 6 0.36 2.96 2.68 6 0.88 2.85 2.95 6 0.66
D 3.01 3.31 6 0.65 2.82 2.22 6 1.17 3.08 3.12 6 0.4 3.11 2.95 6 0.72 2.97 3.13 6 0.44
E 3.13 2.68 6 0.47 2.0 2.78 6 0.88 3.11 2.96 6 0.77 3.33 2.73 6 0.88 2.83 3.36 6 0.32
F 3.14 3.37 6 0.49 2.73 2.58 6 1.09 2.0 2.67 6 0.53 3.06 2.66 6 0.69 2.53 3.14 6 0.58
 statistically significant in surgery (p= 0.049). The rest of the departments show no statistical Leadership in
significance in the differences of demographic characteristics between hospitals. government
Table II shows the mean scores of the hospital directors’ and HODs’ leadership style
factors according to their followers’ ratings in the six studied hospitals. The idealized
hospitals in
attributes factor of TFL style for the six hospitals’ directors had the highest mean score, Kuwait
while the lowest score was for individualized consideration (Table II). Regarding TAL style,
the contingent reward factor had the highest mean score as compared to the passive
management by exception factor, which had the lowest score (Table II). The inspirational
motivation factor of TFL style for HODs had the highest mean score, while the lowest score
was for individualized consideration (Table II). Regarding TAL style, the factor contingent
Downloaded by Buffalo State – the State University of New York At 08:12 25 June 2019 (PT)

reward had the highest mean score as compared to the passive management by exception
factor, which had the lowest (Table II).
In all studied hospitals, followers of transformational leaders rated extra effort,
effectiveness, and satisfaction improved under this style of leadership (Table III). There was
a statistically significant difference regarding the mean scores of the outcomes (extra effort,
effectiveness, satisfaction) for the two leadership styles in each of the studied hospitals, with
the higher mean score for TFL style (Table III).
Table IV shows some correlation and regression models. It indicates that correlations
between the TFL style for hospitals’ directors with all TFL factors and organizational
outcomes according to their followers’ ratings were strong, direct, and significant. The
highest correlation among TFL factors was with intellectual stimulation, while the lowest
was with individualized consideration (Table IV). For the correlation between TFL style
with organizational outcomes, the highest correlation was with effectiveness, and the
lowest with satisfaction (Table IV). Moreover, the correlations between the TFL style for
HODs with all TFL factors and organizational outcomes, according to their followers’
ratings, were also strong, direct, and significant. The highest correlation among the TFL
factors was with inspirational motivation, while the lowest was with individualized
consideration (Table IV). The highest correlation between TFL style with organizational
outcomes was with effectiveness, and the lowest was extra effort (Table IV).
Table IV also shows multiple regression models for factors causing leaders to be seen as
transformational, according to followers’ ratings. It appears from the table that all the
studied factors contributed significantly to the score of TFL style. These factors contributed
nearly the same in forming the TFL score, according to the followers of HODs, with a slight
increase in the idealized attributes factor, followed by intellectual stimulation factor. The
lowest contributor was the individualized consideration factor. Regarding followers of
hospital directors, again. all the studied factors contributed significantly to the score of TFL
style, with inspirational motivation factor being the highest contributor and individualized
consideration factor being the lowest contributor (Table IV).
Moreover, the table shows a regression model for organizational outcome most affected
by TFL style according to followers’ ratings in the six studied hospitals. Studying items
affected by the increased transformational style of HODs’ score, it can be noticed that
effectiveness was most affected by the increase in the score as regards organizational
outcomes, followed by satisfaction and lastly, extra effort (Table IV). This was the same as
noticed for hospital directors, where effectiveness was the highest, followed by extra effort
and satisfaction, which were nearly equally affected by the TFL style (Table IV).

Discussion
The purpose of the present study was to assess leadership styles. There is a wide
discrepancy between published data on leadership styles in different hospitals in different
 Downloaded by Buffalo State – the State University of New York At 08:12 25 June 2019 (PT)

LHS

ratings
Table II.

departments
and heads of

their followers’
Mean scores of

leadership styles
hospital directors’

factors according to
Transformational leadership style
Idealized Idealized Inspirational Intellectual Individualized
attributes behaviors motivation stimulation consideration Total
Hospitals Mean SD* Mean SD* Mean SD* Mean SD* Mean SD* Mean SD*

Directors A 3.05 0.92 2.73 1.13 3.03 1.04 2.53 1.26 2.35 1.25 2.73 1.09
B 2.98 0.80 2.80 0.83 2.83 0.94 2.53 0.78 2.65 0.91 2.75 0.82
C 2.65 1.23 2.48 1.04 2.45 1.14 2.25 1.04 2.20 0.72 2.40 0.94
D 3.50 0.33 3.15 0.34 3.45 0.62 2.98 0.51 2.55 0.26 3.12 0.29
E 2.23 0.89 2.13 0.49 2.10 0.89 1.73 0.66 1.50 0.82 1.93 0.67
F 3.25 0.82 2.75 0.66 2.78 1.18 2.88 1.00 2.33 0.67 2.79 0.81
Total 2.94 0.93 2.67 0.83 2.77 1.04 2.48 0.96 2.26 0.88 2.62 0.86
Heads of departments A 2.92 0.77 2.79 0.76 3.00 0.78 2.76 0.74 2.61 0.79 2.82 0.66
B 2.67 0.82 2.70 0.78 2.73 0.84 2.56 0.80 2.48 0.80 2.63 0.70
C 2.89 0.77 2.78 0.63 2.98 0.71 2.71 0.76 2.66 0.75 2.80 0.60
D 2.96 0.72 2.85 0.65 3.02 0.75 2.72 0.75 2.60 0.74 2.83 0.61
E 2.86 0.82 2.71 0.77 2.86 0.88 2.62 0.84 2.44 0.82 2.70 0.72
F 2.74 0.79 2.73 0.70 2.89 0.75 2.57 0.78 2.54 0.82 2.69 0.65
Total 2.84 0.79 2.76 0.72 2.91 0.79 2.66 0.78 2.55 0.79 2.74 0.66

Note: *SD: Standard deviation

(continued)
 Downloaded by Buffalo State – the State University of New York At 08:12 25 June 2019 (PT)

TAL style
Active Passive
Contingent management management
reward by exception by exception Total
Hospitals Mean SD* Mean SD* Mean SD* Mean SD*

Directors 2.63 1.25 2.58 0.91 1.28 0.92 2.16 0.53

2.83 0.96 2.70 0.90 1.81 0.89 2.44 0.45
2.38 1.15 2.35 1.20 1.50 1.18 2.07 0.67
3.13 0.40 2.88 0.57 1.13 0.80 2.37 0.23
1.80 0.80 2.13 0.44 1.65 0.83 1.86 0.34
2.83 1.09 2.55 1.09 1.80 1.16 2.39 0.56
2.60 1.03 2.53 0.89 1.53 0.97 2.22 0.51
Heads of departments 2.79 0.80 2.72 0.78 1.36 0.77 2.29 0.49
2.64 0.81 2.51 0.75 1.29 0.87 2.15 0.44
2.80 0.74 2.65 0.74 1.22 0.78 2.22 0.47
2.73 0.78 2.60 0.82 1.18 0.75 2.17 0.45
2.65 0.84 2.62 0.87 1.50 0.91 2.26 0.59
2.72 0.75 2.54 0.79 1.25 0.76 2.17 0.44
2.72 0.79 2.61 0.79 1.30 0.82 2.21 0.49
Kuwait
hospitals in
Leadership in
government

Table II.
 Downloaded by Buffalo State – the State University of New York At 08:12 25 June 2019 (PT)

LHS

Table III.

organizational
Mean scores of

of departments’

followers’ rating
leadership styles
outcome and heads

relationship based on
Organizational outcome
Hospital Leadership style No* Extra Effort t*1 p*2 Effectiveness t*1 p*2
Mean SD*3 Mean SD*3

A TFL 228 2.85 0.71 8.95 #0.001 3.16 0.68 10.89 #0.001
TAL 43 1.78 0.74 1.92 0.74
Total 271 2.68 0.82 2.97 0.82
B TFL 234 2.75 0.83 5.88 #0.001 2.89 0.78 5.41 #0.001
TAL 37 1.73 0.10 1.87 1.10
Total 271 2.61 0.93 2.75 0.90
C TFL 233 2.81 0.74 5.24 #0.001 3.06 0.69 5.62 #0.001
TAL 38 2.25 0.59 2.36 0.81
Total 271 2.74 0.75 2.96 0.75
D TFL 241 2.96 0.76 5.69 #0.001 3.07 0.70 5.16 #0.001
TAL 30 2.10 0.95 2.36 0.80
Total 271 2.87 0.83 2.99 0.74
F TFL 229 2.69 0.79 4.90 #0.001 2.95 0.84 6.08 #0.001
TAL 42 1.90 0.99 2.07 0.96
Total 271 2.57 0.87 2.81 0.91
E TFL 232 2.68 0.73 8.05 #0.001 2.94 0.70 8.00 #0.001
TAL 39 1.65 0.79 1.97 0.72
Total 271 2.53 0.82 2.80 0.78
Total TFL 1397 2.79 0.77 14.76 #0.001 3.01 0.74 15.21 #0.001
TAL 229 1.89 0.87 2.08 0.88
Total 1626 2.67 0.84 2.88 0.83

Notes: No*: Number of followers responses; t*1: t-test; p*2: p-value; SD*3: Standard Deviation
(continued)
 Downloaded by Buffalo State – the State University of New York At 08:12 25 June 2019 (PT)

Organizational outcome
Hospital Satisfaction t*1 p*2 Total
Mean SD*3 Mean SD*3 t*1 p*2

A 3.05 0.63 9.16 #0.001 3.05 0.63 10.95 #0.001

1.93 0.89 1.88 0.73
2.94 0.90 2.86 0.77
B 2.98 0.83 6.02 #0.001 2.87 0.73 6.43 #0.001
1.66 1.29 1.75 1.01
2.80 1.01 2.72 0.86
C 3.22 0.75 4.60 #0.001 3.03 0.64 5.58 #0.001
2.60 0.88 2.41 0.66
3.14 0.80 2.94 0.68
D 3.06 0.97 4.97 #0.001 3.03 0.69 6.11 #0.001
2.15 0.77 2.20 0.76
2.96 0.99 2.94 0.75
F 3.02 0.88 6.33 #0.001 2.89 0.76 6.65 #0.001
2.07 0.97 2.02 0.90
2.88 0.96 2.75 0.84
E 2.99 0.78 5.40 #0.001 2.87 0.66 8.40 #0.001
2.06 1.02 1.89 0.73
2.86 0.88 2.73 0.75
Total 3.07 0.84 14.02 #0.001 2.96 0.69 16.28 #0.001
2.08 1.02 2.02 0.83
2.93 0.93 2.83 0.78

Table III.
Kuwait
hospitals in
Leadership in
government
 LHS locations. In the present study, the results revealed that all hospital directors and HODs
rated themselves to be of TFL style, except the head of the intensive care unit in hospital B,
who rated himself as transactional. The same results were reported by other studies (Mester
et al., 2003; Stanescu and Cicei, 2012), which revealed that the leaders rated themselves as
transformational more than transactional.
These results can be explained in the Kuwaiti context by three main factors. First
is the position appointment policy of MOH, which dictates that individuals who
occupy managerial positions have a limited period that will be renewed depending on
their performance. The second factor is the increasing number of physicians
specializing in hospital management who will compete with them for the position.
Downloaded by Buffalo State – the State University of New York At 08:12 25 June 2019 (PT)

The last factor is the Kuwait Medical Association supervision of governmental

hospitals.
The leaders in this study had lower TFL scores than did leaders in a study
conducted in Turkey (mean 3.90) (Gumusluoglu and Ilsev, 2009), but higher scores than
a study conducted in the USA (mean 2.30) (Avolio et al., 2004). Moreover, they had a
lower score of TAL style than did managers in a study conducted in Saudi Arabia (2.98)
(Abualrub and Alghamdi, 2012) but a score higher than another study conducted in the
USA, which reported 2.10 (Casida and Pinto-Zipp, 2008). According to the score means
mentioned above, leaders in the studied hospitals tend to use TFL style more often than
TAL style, according to their followers’ perceptions, where all were rated by their
followers as TFL style. This finding, as explained in a very recent comprehensive
review of a large number of empirical studies (Hughes et al., 2018), might have resulted
from the idea that transformational leaders, seen by their followers as role models who
understand their followers’ needs, build a supportive environment and then engage the
followers in practices that instill confidence in them. However, in few hospital
departments, followers rated their leaders as transactional. This requires further study
to identify weak aspects of leadership and ways to improve transformational factors for
Table IV. hospital leaders.
Regression model
(beta) for
organizational
outcome, multiple
regression models
(beta) for factors
causing leaders to be
seen as
transformational Transformational leadership style
according to Hospitals’ directors Heads of departments
followers’ ratings, Item r* p*1 Beta p*1 r* p*1 Beta p*1
and correlations (r*)
TFL factor
between TFL style of Idealized attributes 0.88 #0.001 0.2305 #0.001 0.82 #0.001 0.2475 #0.001
hospital directors Idealized behavior 0.89 #0.001 0.2128 #0.001 0.79 #0.001 0.2455 #0.001
and heads of Inspirational motivation 0.88 #0.001 0.2586 #0.001 0.86 #0.001 0.2458 #0.001
departments Intellectual stimulation 0.92 #0.001 0.2400 #0.001 0.85 #0.001 0.2467 #0.001
according to Individualized consideration 0.79 #0.001 0.1913 #0.001 0.77 #0.001 0.2287 #0.001
followers’ ratings Organizational outcome
and leadership Extra effort 0.75 #0.001 0.79 #0.001 0.61 #0.001 0.62 #0.001
factors and Effectiveness 0.87 #0.001 0.85 #0.001 0.77 #0.001 0.77 #0.001
Satisfaction 0.72 #0.001 0.78 #0.001 0.71 #0.001 0.67 #0.001
organizational
outcomes Notes: r*: Pearson coefficient; p*1: p-value
 In analyzing the effect of demographic and work-related characteristics on the self-rating of Leadership in
hospital directors and HODs, there was no significant difference between gender and TFL government
style. This finding supports a study conducted in the USA, which revealed that there was no
significant difference between gender and TFL style (Manning, 2002). Unlike the previous
hospitals in
study, two others conducted in the USA (Casida and Parker, 2011; Eagly et al., 2003) Kuwait
examined the differences between gender and transformational leaders and found that
females have a higher propensity to utilize TFL style. This result overcomes the culturally
rooted – both nationally and to a lesser extent internationally– impression that females
cannot meet the requirements of their leadership roles because they are viewed as being less
competent than their male peers (Downs et al., 2014; Eagly, 2007).
Downloaded by Buffalo State – the State University of New York At 08:12 25 June 2019 (PT)

Reviewing the mean scores for TFL factors of hospital directors according to their
followers’ ratings, the results indicate that the idealized attributes factor had the highest
mean score (2.94), and the lowest (2.26) was the individual consideration factor. For HODs,
the inspiration motivation factor had the highest mean score (2.91), and the lowest (2.55) was
the individual consideration factor. These results explained that followers see their hospital
directors as highly active in inducing honor and pride, communicating the most important
values and beliefs, and considering ethical and spiritual sides when making a decision.
Followers had seen their HODs active in stimulating and increasing followers’ motivation,
drawing spectacular scenes for the future, and conveying confidence that they all can get
there.
On the other hand, both hospital directors and HODs are seen by their followers as acting
weakly in individualized consideration, which points out that leaders are required to allocate
more time to their followers’ training to develop followers’ skills and empower them. The
low mean scores of the individualized consideration factor need some intervention such as a
training program which can support leaders in improving skills to handle the needs of
followers from different socio-economic backgrounds.
In addition, the present study confirms the existence of the effect of the TFL style on
important organizational outcomes, which are the extra effort followers are willing to
expend, the perceived effectiveness of leaders and job satisfaction. This effect is more
evident when the mean scores of the TFL style and the three organizational outcomes are
higher than the mean scores of the TAL style and its outcomes. This means that
transformational leaders are likely to attain leadership effectiveness by achieving
organizational objectives, goals, and assisting their followers to success in their work life.
These leaders have more ability to make followers satisfied and motivate them to put extra
effort into their work (Casida and Parker, 2011).
In the studied hospitals, the mean scores of organizational outcomes according to
followers’ ratings that considered their leaders as transformational were higher than the
mean scores of followers that considered their leaders as transactional. These results are
confirmed by a study which showed that TFL style, compared to TAL style, caused
followers to exert more extra effort, perceive their work units and leaders as more effective,
and feel more satisfied with the work (Molero et al., 2007).
Moreover, according to followers’ ratings, the correlation between the TFL styles of HODs
and hospital directors was a direct, strong significant correlation with extra effort,
effectiveness, and satisfaction, which is supported by other studies (Amirul and Daud, 2012;
Casida and Parker, 2011; Erkutlu, 2008). Furthermore, regression analysis, including the TFL
style and organizational outcomes, found that all the studied organizational outcomes were
significant to the score of TFL style. Effectiveness was the highest contributor according to the
followers of HODs, while the lowest contributor was extra effort. As regards to followers of
hospital directors, effectiveness also was the highest contributor, whereas satisfaction appeared
 LHS to be the lowest contributor. This is partially supported by a landmark paper which reported
that all the studied outcomes contributed significantly to the score of TFL style. The paper
differs in organizational outcomes’ ranking, where satisfaction was the highest contributor, and
extra effort was the lowest (Judge and Piccolo, 2004).

Strengths and limitations of the present study

One of the main strengths of the present study is its cross-sectional design, which measures
different variables in the population of interest at a single point in time and gathers accurate
and less-biased data (Ismail et al., 2009). Another strength of this study is using
Downloaded by Buffalo State – the State University of New York At 08:12 25 June 2019 (PT)

questionnaires as data collection tool where data is analyzed more scientifically and
objectively, and, when quantified, can be used to compare and contrast research papers and
may be used to measure change (Adèr and Mellenbergh, 2008). A number of study
limitations have to be acknowledged. Despite the relatively large sample size, primary and
tertiary health-care organizations were not included in the study. Moreover, this study was
conducted in one type of nonprofit health-care organization and did not include the private
sector. The study is designed to determine the relationship between variables, not to identify
cause and effect. Furthermore, the large amount of data in the present study of six hospitals,
which includes several departments, represented a considerable challenge during the
collection, entry, analysis and interpretation phases. This was experienced during the
authors’ attempts to explore the impact of the statistically significant demographic items of
followers. However, the authors failed to establish an understanding of such impact,
especially with the inconsistency in the statistical significance.

Practice implications
The use of leadership style as an indicator of health-care organizations' performance is still
unrecognized in Kuwait. Therefore, the present study represents a baseline for future
studies in determining leadership styles, organizational culture, and the relationship
between them. This highlights important areas to target while planning for performance
improvement in health-care organizations. It is worth exploring to find out the effect of these
leadership styles on hospitals’ performance, especially the care quality and safety. Based on
the results of the present study, the authors recommend submitting the results of the study
to the Kuwait Minister of Health to explicate the importance of the TFL style and its effect
on health-care services, as well as the importance of openness, communication, and
transparency between leaders and followers. In addition, it is worth looking at the effects of
the leadership styles on quality and safety practices at these hospitals.
At the MOH level, the authors recommend providing training on a regular basis for
hospital leaders to improve TFL behavior and empower the concept of a transformational
culture. In addition, selecting people for managerial positions in health care must require
their satisfactory participation in accredited leadership training programs. In addition,
MOH’s role is to encourage leaders to share governance and provide them with the authority
needed to support them in practicing TFL. Moreover, greater investment in research is
needed to understand how to build transformational leaders and how TFL can be more
effective on organizational outcomes. Further studies on leadership styles are required to
include other health-care settings such as primary and tertiary care facilities. Finally,
hospitals should conduct workshops and courses by researchers to explore the effects of
TFL style on organizational outcomes.
 References Leadership in
Abualrub, R.F. and Alghamdi, M.G. (2012), “The impact of leadership styles on nurses’ satisfaction and government
intention to stay among Saudi nurses”, Journal of Nursing Management, Vol. 20 No. 5,
pp. 668-678.
hospitals in
Adèr, H.J. and Mellenbergh, G.J. (2008), Advising on Research Methods: A Consultant’s Companion, 1st
Kuwait
ed., Johannes van Kessel Publishing.
AlFahad, H., Alhajeri, S. and Alqahtani, A. (2013), “The relationship between school principals’
leadership styles and teachers’ achievement motivation”, Chinese Business Review, Vol. 12
No. 6.
Alloubani, A.M., Almatari, M. and Almukhtar, M.M. (2014), “Review: Effects of leadership styles on
Downloaded by Buffalo State – the State University of New York At 08:12 25 June 2019 (PT)

quality of services in healthcare”, European Scientific Journal, ESJ, Vol. 10 No. 18, pp. 118-129.
Al-Mailam, F.F. (2004), “Transactional versus transformational style of leadership – employee
perception of leadership efficacy in public and private hospitals in Kuwait”, Quality
Management in Healthcare, Vol. 13 No. 4, p. 278.
Alsaeedi, F. and Male, T. (2013), “Transformational leadership and globalization: Attitudes of school
principals in Kuwait”, Educational Management Administration and Leadership, Vol. 41 No. 5,
pp. 640-657.
Amirul, S.R. and Daud, H. (2012), “A study on the relationship between leadership styles and leadership
effectiveness in Malaysian GLCs”, European Journal of Business and Management, Vol. 4 No. 8,
pp. 193-201.
Antonakis, J., Avolio, B.J. and Sivasubramaniam, N. (2003), “Context and leadership: an examination of
the nine-factor full-range leadership theory using the multifactor leadership questionnaire”, The
Leadership Quarterly, Vol. 14 No. 3, pp. 261-295.
Avolio, B.J. (2007), “Promoting more integrative strategies for leadership theory-building”, American
Psychologist, Vol. 62 No. 1, p. 25.
Avolio, B.J., Zhu, W., Koh, W. and Bhatia, P. (2004), “Transformational leadership and organizational
commitment: mediating role of psychological empowerment and moderating role of structural
distance”, Journal of Organizational Behavior, Vol. 25 No. 8, pp. 951-968.
Bass, B.M. and Avolio, B.J. (2004), Multifactor Leadership Questionnaire: Manual and Sampler Set, 3rd
ed., Mind Garden, CA.
Casida, J.J. and Parker, J. (2011), “Staff nurse perceptions of nurse manager leadership styles and
outcomes”, Journal of Nursing Management, Vol. 19 No. 4, pp. 478-486.
Casida, J.J. and Pinto-Zipp, G. (2008), “Leadership-organizational culture relationship in nursing units of
acute care hospitals”, Nursing Economics, Vol. 26 No. 1, p. 7.
Conway, J. (2008), “Getting boards on board: Engaging governing boards in quality and safety”, The
Joint Commission Journal on Quality and Patient Safety, Vol. 34 No. 4, pp. 214-220.
Curtis, E.A., de Vries, J. and Sheerin, F.K. (2011), “Developing leadership in nursing: exploring core
factors”, British Journal of Nursing, Vol. 20 No. 5, pp. 306-309.
Daniel, W.W. and Cross, C.L. (2013), Biostatistics: A Foundation for Analysis in the Health Sciences, 10
ed., Wiley, Hoboken, NJ.
Downs, J.A., Reif, L.K., Hokororo, A. and Fitzgerald, D.W. (2014), “Increasing women in leadership in
global health”, Academic Medicine: Journal of the Association of American Medical Colleges,
Vol. 89 No. 8, pp. 1103-1107.
Eagly, A.H. (2007), “Female leadership advantage and disadvantage: resolving the contradictions”,
Psychology of Women Quarterly, Vol. 31 No. 1, pp. 1-12.
Eagly, A.H., Johannesen-Schmidt, M.C. and Van Engen, M.L. (2003), “Transformational, transactional,
and laissez-faire leadership styles: a meta-analysis comparing women and men”, Psychological
Bulletin, Vol. 129 No. 4, p. 569.
 LHS Emery, C.R. and Barker, K.J. (2007), “The effect of transactional and transformational leadership styles
on the organizational commitment and job satisfaction of customer contact personnel”, Journal
of Organizational Culture, Communications and Conflict, Vol. 11 No. 1, p. 77.
Erkutlu, H. (2008), “The impact of transformational leadership on organizational and leadership
effectiveness: the Turkish case”, Journal of Management Development, Vol. 27 No. 7,
pp. 708-726.
Fraczkiewicz-Wronka, A., Austen, A. and Wronka, M. (2010), “An empirical research on the leadership
and effectiveness in public healthcare organizations: lesson from transition economy”, Journal of
US-China Public Administration, Vol. 7 No. 2, pp. 1-15.
Gheith, N.A.R. (2010), “Reconstructing organization culture through enforcing head nurses
Downloaded by Buffalo State – the State University of New York At 08:12 25 June 2019 (PT)

transformational leadership style”, Australian Journal of Basic and Applied Sciences, Vol. 4 No. 6,
pp. 1288-1296.
Ginter, P.M., Duncan, W.J. and Swayne, L.E. (2018), The Strategic Management of Health Care
Organizations, 8th ed., John Wiley and Sons, NJ.
Gumusluoglu, L. and Ilsev, A. (2009), “Transformational leadership, creativity, and organizational
innovation”, Journal of Business Research, Vol. 62 No. 4, pp. 461-473.
Hall, J. Johnson, S. Wysocki, A. Kepner, K. Farnsworth, D. and Clark, J.L. (2016), “Transformational
leadership: the transformation of managers and associates”.
Hinkin, T.R. and Schriesheim, C.A. (2008), “A theoretical and empirical examination of the transactional
and non-leadership dimensions of the multifactor leadership questionnaire (MLQ)”, The
Leadership Quarterly, Vol. 19 No. 5, pp. 501-513.
HSE (2019), “Who regulates health and social care”, available at: www.hse.gov.uk/healthservices/
arrangements.htm (accessed 16 March 2019).
Hughes, D.J., Lee, A., Tian, A.W., Newman, A. and Legood, A. (2018), “Leadership, creativity, and
innovation: a critical review and practical recommendations”, The Leadership Quarterly, Vol. 29
No. 5, pp. 549-569.
Ismail, A., Halim, F.A., Abdullah, D.N.M.A., Shminan Ahmad, S., Muda, A.L.A., Samsudin, S. and
Girardi, A. (2009), “The mediating effect of empowerment in the relationship between
transformational leadership and service quality”, International Journal of Business and
Management, Vol. 4 No. 4.
Jaskyte, K. (2004), “Transformational leadership, organizational culture, and innovativeness in
nonprofit organizations”, Nonprofit Management and Leadership, Vol. 15 No. 2,
pp. 153-168.
Judge, T.A. and Piccolo, R.F. (2004), “Transformational and transactional leadership: a Meta-analytic
test of their relative validity”, Journal of Applied Psychology, Vol. 89 No. 5, pp. 755.
Liebler, G. and McConnell, C.R. (2016), Management Principles for Health Professionals, 7th ed., Jones
and Bartlett Learning, MA.
Lowe, K.B. and Gardner, W.L. (2000), “Ten years of the leadership quarterly: contributions and
challenges for the future”, The Leadership Quarterly, Vol. 11 No. 4, pp. 459-514.
Manning, T.T. (2002), “Gender, managerial level, transformational leadership and work satisfaction”,
Women in Management Review, Vol. 17 No. 5, pp. 207-216.
Mester, C., Visser, D., Roodt, G. and Kellerman, R. (2003), “Leadership style and its relation to employee
attitudes and behaviour”, SA Journal of Industrial Psychology, Vol. 29 No. 2, pp. 72-82.
MOH (2019), “Organizational structure”, available at: www.moh.gov.kw/en/About-MOH/Organizational-
Structure?img=1-3a (accessed 22 February 2019).
Molero, F., Cuadrado, I., Navas, M. and Morales, J.F. (2007), “Relations and effects of transformational
leadership: a comparative analysis with traditional leadership styles”, The Spanish Journal of
Psychology, Vol. 10 No. 2, pp. 358-368.
 Mossialos, E., Cheatley, J., Reka, H., Alsabah, A. and Patel, N. (2018), Kuwait’s Health System Review, Leadership in
London School of Economics and Political Science, London, p. 88.
government
NHS England (2018), “NHS structure explained”, available at: www.nhs.uk/using-the-nhs/about-the-
nhs/nhs-structure-explained/ (accessed 16 March 2019). hospitals in
Northouse, P.G. (2018), Leadership: Theory and Practice, 8th ed., Sage Publications, LA, CA. Kuwait
Oliver, S. (2006), “Leadership in health care”, Musculoskeletal Care, Vol. 4 No. 1, p. 38.
Robbins, B. and Davidhizar, R. (2007), “Transformational leadership in health care today”, The Health
Care Manager, Vol. 26 No. 3, p. 234.
Schriesheim, C.A., Wu, J.B. and Scandura, T.A. (2009), “A meso measure? Examination of the levels of
analysis of the multifactor leadership questionnaire (MLQ)”, The Leadership Quarterly, Vol. 20
Downloaded by Buffalo State – the State University of New York At 08:12 25 June 2019 (PT)

No. 4, pp. 604-616.

Schyve, P.M. (2009), Leadership in Healthcare Organizations: A Guide to Joint Commission Leadership
Standards, The Governance Institute, San Diego, CA, p. 44.
Speziale, G. (2015), “Strategic management of a healthcare organization: engagement, behavioural
indicators, and clinical performance”, European Heart Journal Supplements, Vol. 17 No. Sl,
pp. A3-A7.
Stanescu, D.F. and Cicei, C.C. (2012), “Leadership styles and emotional intelligence of Romanian public
managers: evidences from an exploratory pilot study”, Revista de Cercetare Si Interventie
Sociala, Vol. 38, pp. 107-121.
Suliman, W.A. (2009), “Leadership styles of nurse managers in a multinational environment”, Nursing
Administration Quarterly, Vol. 33 No. 4, p. 301.
Tse, H.H.M., Huang, X. and Lam, W. (2013), “Why does transformational leadership matter for
employee turnover? A multi-foci social exchange perspective”, The Leadership Quarterly, Vol. 24
No. 5, pp. 763-776.
WHO (2006), Country Cooperation Strategy for WHO and Kuwait 2005-2009, World Health
Organization, Geneva.

About the authors

Dr Talal ALFadhalah graduated in medicine, holds a postgraduate diploma in quality and master’s
degree and PHD in Public health (Hospital Administration). He worked in the Quality and
Accreditation Directorate (Kuwait), where he was appointed as the Head of Accreditation Department
and the Head of Safety Programs. Dr ALFadhalah is a recognized surveyor at the National
Accreditation Program (Kuwait).
Dr Hossam Elamir graduated in medicine, holds a postgraduate diploma in quality and a master’s
degree in health-care management. He worked in the National Guard Health Affairs (KSA) and the
Specialized Medical Centres (Egypt), before joining the Quality and Accreditation Directorate
(Kuwait), where he was appointed as the Head of Quality and Accreditation Department in one of the
general hospitals for seven years, then currently a Leader of a Technical Support Team. Dr Elamir is
a certified professional in health-care quality, a certified professional in health-care risk management
and an international peer reviewer. Hossam Elamir is the corresponding author and can be contacted
at: dr_hossam_elamir@hotmail.com

For instructions on how to order reprints of this article, please visit our website:
www.emeraldgrouppublishing.com/licensing/reprints.htm
Or contact us for further details: permissions@emeraldinsight.com