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BY: JOHN D. (JACK) RUDNICK, JR., Ed.D.

Mr. Rudnick is administrator, Holy Family Home, Melbourne, KY; assistant professor, business administration, Thomas More College, Crestview Hills, KY; and adjunct faculty instructor, Health Services Administration, Xavier University, Cincinnati.

Model Encourages Leaders to Transcend Personal Ambition

As U.S. health care grows larger and more complex, health care systems and hospitals are increasing their efforts to recruit well-trained clinical professionals and mission-oriented leaders.¹ Such organizations seek competent professionals who can manage resources effectively in this highly complex field. Students who are pursuing management degrees and graduates who are launching new careers provide a pool of potential leaders.² Executives from other fields, as well as health care workers seeking careers as leaders, are others who could fill a leadership role.³

Recent research has called attention to a widening gap between competencies required for future leaders, on one hand, and the current availability of potential leaders possessing such competencies, on the other. The competencies required of health care leaders are different from those required of leaders in other fields. Health care leaders distinguish themselves when they have the resources to craft a distinctive approach to meeting the profession's unique challenges, which include the life-and-death nature of the work, as well as its emotional and financial demands.⁴

Health care appears to have an adequate supply of senior leaders at present, but some experts believe that the executives most likely to become future leaders will need assistance with their development. Failure to provide needed training could create a leadership void, those experts say.⁵

Competent leaders possess a definable set of professional and personal skills, values, and traits. A health care leader must be thoroughly familiar with his or her organization's programs, and must have the knowledge and skills required to run them. In addition, he or she must be dependable, think independently, possess integrity and high moral values, be politically aware of others, and be able to work in teams within the health care hierarchy.⁶ These requirements are very demanding. There is a growing consensus that an approach called "transformational leadership" is the model that progressive and aspiring leaders will embrace to help them meet the demands of the work.⁷

What Is "Transformational Leadership"?
"Transformational leadership" is a concept introduced nearly 30 years ago by the political scientist James MacGregor Burns.⁸ He had developed the idea from his biographical studies of Franklin Delano Roosevelt, John F. Kennedy, and Lyndon Johnson. The notion has since been put to use by a number of leadership theorists.

Transformational leadership is a process of mutual exchange between leaders and followers involving reward-based transactions.⁹ It is a model that encourages leaders to "raise one another to higher levels of motivation and morality."¹⁰ In 1980, two years after Burns published his book Leadership, a leadership expert named Bernard Bass sought to develop a distinction between "transactional" leaders, on one hand, and "transformational" leaders, on the other.¹¹ Bass's work was later refined by Lee G. Bolman and Terrence E. Deal.

According to Bolman and Deal, transactional leaders approach their followers offering to exchange one thing for another — for example, jobs in return for votes, or government subsidies in return for contributions to political campaigns. By contrast, transformational leaders are visionaries who recognize their constituents' need to attain higher goals and who move them toward realization of that need.¹² By helping people work toward their goals in this way, transformational leaders can improve the quality of human conduct throughout an organization.¹³

The practices associated with transformational leadership are observable and learnable; these leaders' aim is to foster attitudes and assumptions that promote employees' loyalty to the organization's mission and vision.¹⁴ Transformational leaders are future-oriented, committed to planning, open-minded, and dynamic. They serve as role models and set a standard for high employee expectations by encouraging employees to think beyond themselves.¹⁵

A critical feature of transformational leadership is its proactive nature. Transformational leaders are "event-makers" who transcend their own interests and seek higher-order needs.¹⁶ The leadership they provide is the product of an ongoing process — a quest for self-actualization — rather than a one-time achievement.¹⁷ This process requires a continuous self-assessment of style and behaviors, as well as an ability to adjust and change. Leaders defined by the transformational model closely resemble those whom people visualize when trying to picture an ideal leader.¹⁸ Transformational leadership is an ethical pursuit that fosters and requires a moral climate.¹⁹ Principled leaders model and encourage principled behavior in their followers.²⁰

Followers of Transformational Leaders
Transformational leaders inspire ("breathe new life" into) followers by sharing with them the organization's vision, communicating clearly about authority levels and boundaries for empowerment, and making necessary resources available for personal and professional fulfillment.²¹ Leaders who embrace this model cultivate their followers' potential and challenge them to develop the skills, talents, and natural tendencies they bring to an organization. Inspiring leaders resolve to help followers move through the "hierarchy of human needs" (popularized by the psychologist Abraham M. Maslow) toward its pinnacle, "self-actualization."22

Leaders who motivate and engage followers create an ideal environment for succession planning and the development of new leaders who will be moral agents. A transformational leader erects the necessary "scaffolding" for a follower's growth by providing tools and support mechanisms that include:

• Clear expectations
• Training
• Leader visibility and availability
• Ethics committee support for difficult clinical situations
• A continuous quality improvement (CQI) process
• Human resource support systems

Mapping of Transformational Concepts
Four distinct behavioral traits define transformational leaders:

• They are charismatic and often serve as an ideal for the other members of their organization.
• They inspire and motivate their followers.
• They provide intellectual stimulation.
• They pay considerate attention to their followers' needs.23

A more detailed examination of any one of these traits will illustrate its importance to an organization. Charismatic leaders, for example, will be admired, respected, and trusted for their behavior; and their followers will want to emulate them.24 Charismatic leaders help create an atmosphere of motivation and inspiration that provides meaning, optimism, and enthusiasm that can endure over long periods of time and help perpetuate the organization's mission.

Integrity
Integrity lies at the heart of leadership.25 A person of integrity will be seen as whole and uncorrupted. Leaders with this motivating and inspiring quality often create a culture that values diversity of thought and encourages innovation. Such leaders emphasize the needs of others, an emphasis that fosters ethical and moral conduct. In such an atmosphere, the value of integrity becomes self-evident. When one examines effective and thriving organizations, one consistently notes that their leaders exude personal integrity.

Integrity is the foundation upon which leaders build their lives. Honesty and truth define and complement this foundation and support the quest of the potential leader for a personal, effective leadership style.26 Integrity is rooted in a leader's spirituality — a blend of conscience and values.27 As a core personal virtue, integrity requires the leader-to-be to make an introspective analysis of his or her beliefs and behavioral tendencies. In transformational leaders, integrity informs every aspect of their decision making and requires them to integrate theory and concept in order to lead effectively in particular, concrete environments. Integrity is the core value leaders should embrace when they map their career blueprint.

As important as integrity is, however, transformational leaders realize that the wrong kind of application can turn this virtue into a negative trait. "Absolute integrity" — refusal to compromise — can make a leader feel compelled to express and insist on his point of view in any and all situations.28 Wise transformational leaders avoid "absolute integrity."

Innovation
Innovation is critical to an organization's long-term viability. Leaders bear responsibility for creating a culture that is receptive to creativity and conducive to change. Explosive technological growth, for example, requires ongoing adaptation and change. Since innovating is a highly complex process, strong leadership is necessary to establish its value and need. The way leaders, working as role models, shape culture and values will have a direct impact on an organization's ability to innovate.29

An organization seeking to promote innovation will encourage in its leaders the traits that constitute transformational leadership (charisma, inspirational motivation, intellectual stimulation, and the ability to give followers individualized attention). Leaders of innovative organizations try to create an infrastructure that removes obstacles to innovation. Innovative leaders are creative risk takers who recognize and appreciate the creativity of others. They look ahead to the future and closely observe other organizations, looking for examples of how to further innovate. They also keep an eye on socioeconomic trends that support and promote innovation.

As noted earlier, leaders who champion innovation must establish a culture receptive to creativity and conducive to change. Before undertaking an important innovation, an organization should first determine whether its culture and leadership style will support the effort. Leaders who are taskmasters or analyzers tend to thwart innovation, as do leaders who overemphasize productivity and effectiveness, cohesion and teamwork, and goal achievement and empathy.

In some health care organizations, the organization's very structure and culture thwart innovation and entrepreneurship.30 The CQI movement has done much to improve overall clinical and management efficacy in a field that is enormously complex. However, culture and tradition can inhibit unconventional thinking and problem resolution within the organization. People accustomed to an overly structured organizational culture can create arbitrary boundaries and be slow to change.

A Sense of Social Responsibility
A strong sense of social responsibility is another factor that, historically, enables an organization to improve its reputation and performance. In defining social responsibility, one writer includes "the obligation of businessmen and unions to pursue policies and make those decisions that follow those lines of action which are desirable in terms of the values and objectives of individuals and our society as a whole."31

As a ministry, Catholic health care has a very strong sense of social responsibility. The Catholic Health Association's (CHA's) community benefit initiative is a good example of transformational leadership in the service sector. CHA began the initiative by gathering from its member organizations information concerning the various services they provide to their communities. With this information, CHA then created a fact-based account of these benefits.

In the past, many such organizations had not "told their story" about community benefit, and, as a result, had been in danger of losing their not-for-profit tax status, since community members were not always aware of the organization's value to the area. The community benefit initiative is a way for organizations to quantify what taxpayers would be responsible for if these not-for-profits were to go out of business and leave a void for the community to fill. A community benefit report identifies both qualitative and quantitative contributions to the health care organization's local community.32

For example, the importance of a primary care clinic to the community may not be huge in quantifiable terms. But because such a clinic can eliminate long emergency room waits — and reduce the number of costly emergency room visits — its community can benefit significantly from the clinic's presence. The community benefit initiative has proven to be a tremendously innovative and successful strategy in staving off government attempts to alter the tax-exempt status of not-for-profit health care organizations.

Other Leadership Models
Other leadership models can be employed to complement the transformational leadership.

Servant Leadership This model, described by Robert K. Greenleaf in 1970, stresses such attributes as listening, empathy, healing, awareness, persuasion, conceptualization, foresight, stewardship, commitment to human growth, and community building.33 The model presents leadership as an influence process that helps people accomplish goals and appreciate the importance of vision and effective implementation. There are close similarities between the "transformational" and "servant leader" models.

Leadership Competency This model, first described by Carson F. Dye and Andrew N. Garman, emphasizes objective skills assessment and plan development. The 16 competencies that constitute the model include values such as ethics and integrity, thinking and problem solving, communicating, embracing diversity, strategic planning, and risk taking.34 The competencies serve both as benchmarks and as a contextual framework for determining which leadership model may be appropriate to the particular stage of a person's career. Effective leadership requires each leader-to-be to discover the style best suited to his or her personal tendencies and environment.

Toward the Future
The potential threat of a future leadership gap in health care lends urgency to the study of models like transformational leadership. In this model, integrity emerges as a key leadership quality, as well as a foundation for developing a management philosophy. The innovations resulting from transformational leadership-style thinking inspire further creativity within an organization. Other models may provide significant benefits as well. In any case, it is imperative that health care organizations begin considering their future leadership needs and making plans to meet them.

NOTES

1. H.-J. Bechtle, "Interview with Jeptha Dalston," Journal of Healthcare Management, vol. 5, no. 3, May-June 2000, pp. 142-147.
2. T. Dolan, "Mentoring at Every Level," Healthcare Executive, vol. 19, no. 5, 2004, p. 6.
3. A. Garman and L. Tyler, "Succession Planning at the Top," Healthcare Executive, vol. 21, no, 4, 2006, pp. 57-59.
4. C. Dye and A. Garman, Exceptional Leadership: 16 Critical Competencies for Health Care Executives, Health Administration Press, Chicago, 2006, pp. xiv-xv.
5. Dolan.
6. M. Nowicki and J. Summers, "The Benevolent Autocrat: Is It the Right Fit for the Times?," Healthcare Financial Management, vol. 57, no. 10, October 2003, p. 84.
7. D. Sofarelli and D. Brown, "The Need for Nursing Leadership in Uncertain Times," Journal of Nursing Management, vol. 6, no. 4, July 1998, pp. 201-207; and R. Spinelli, "The Applicability of Bass's Model of Transformational, Transactional, and Laissez-Faire Leadership in the Hospital Administrative Environment," Hospital Topics, vol. 84, no. 2, Spring 2006, pp. 11-17.
8. J. M. Burns, Leadership, Harper, New York City, 1978.
9. B. Smith, R. Montagno, and T. Kuzmenko, "Transformational and Servant Leadership: Content and Contextual Comparisons," Journal of Leadership and Organizational Studies, vol. 10, no. 4, 2004, pp. 80-91.
10. J. Kouzes and B. Posner, The Leadership Challenge, Jossey-Bass, San Francisco, 2002, p. 153.
11. B. Bass, Bass and Stogdill's Handbook of Leadership: Theory, Research, and Managerial Applications, Free Press, New York City, 1990, p. 20; and L. G. Bolman and T. E. Deal, "Reframing Leadership," in J. Kouzes, ed., Business Leadership: A Jossey-Bass Reader, Jossey-Bass, San Francisco, 2003, pp. 86-110.
12. Bolman and Deal, p. 105.
13. Bass, pp. 609-610.
14. K. Jaskyte, "Transformational Leadership, Organizational Culture, and Innovativeness in Nonprofit Organizations," Nonprofit Management and Leadership, vol. 15, no. 2, 2004, pp. 153-168.
15. Jaskyte, p. 156.
16. Bass, p. 20.
17. Dye and Garman, p. xvi.
18. Bass, p. 611.
19. K. Parry and S. Proctor-Thompson, "Perceived Integrity of Transformational Leaders in Organizational Settings," Journal of Business Ethics, vol. 35, no. 2, 2002, pp. 75-96.
20. Engelbrecht, A. van Aswegen, and C. Theron, "The Effect of Ethical Values on Transformational Leadership and Ethical Climate in Organizations," South African Journal of Business Management, vol. 36, no. 2, 2005, pp. 19-26.
21. Spinelli, p. 12.
22. Spinelli, p. 11. Maslow (1908-1970) argued that human needs could be seen as a pyramid, with basic physiological needs (food, shelter) at the bottom and, in ascending order, physical and emotional safety needs; social needs (love, sense of belonging); esteem needs (self-esteem, respect from others); and self-actualization (acceptance without complaint of the world and the self as they are).
23. Smith, Montagno, and Kuzmenko, p. 83.
24. R. Alban-Metcalfe and B. Alimo-Metcalfe, "An Analysis of the Convergent and Discriminant Validity of the Transformational Leadership Questionnaire," International Journal of Selection and Assessment, vol. 8, no. 3, 2000, pp. 158-175.
25. Engelbrecht, van Aswegen, and Theron, p. 21.
26. M. Greer, "Continuing the Leadership Quest: Safety," Professional Safety, vol. 47, no. 2, 2000, p. 9.
27. J. Rudnick, Jr., Adoption and Spirituality: A Practical Guide and Reflections, Willis, Florence, KY, 2000.
28. R. Greenleaf, On Becoming a Servant Leader, Jossey-Bass, San Francisco, 1996, p. 45.
29. Jaskyte, p. 155.
30. F. Phillips and A. Garman, "Barriers to Entrepreneurship in Healthcare Organizations," Journal of Health and Human Services Administration, vol. 28, no. 4, Spring 2006, pp. 473-484.
31. T. J. Zenisek, "Corporate Responsibility: A Conceptualization Based on Organizational Literature," Academy of Management Review, vol. 4, no. 3, 1979, pp. 359-368.
32. T. Eckels and J. Trocchio, "Model Refines Quantification of Community Service," Healthcare Financial Management, vol. 46, no. 2, 1992, pp. 34-37.
33. L. C. Spears, ed., Insights on Leadership: Service, Stewardship, Spirit and Servant Leadership, John Wiley & Sons, New York City, 1998, pp. 3-6.
34. Dye and Garman, pp. 197-202.