Leadership
Leadership is "the function of directing or controlling the actions or attitudes of an individual or group with more or less willing acquiescence of the followers". It is possible that simply being an opinion leader may be effective.
Leadership styles have been reviewed
Leadership development in health care is perceived as being many years behind that of other industries.
Leadership affects organizational performance - about 5% to 20% of the variation in profitability is accounted for by leadership.
There is concern about whether the many proposed leadership theories have overlap and redundancies.
Co-leadership, or dual leaders may be advantageous.
The organization of leaders and managers maybe important for healthcare as diverse backgrounds of leaders are needed. In this study, physicians integrated into leadership spots was associated with clinical performance.

# Leadership vs management
An early description distinguishing leadership and management was by Zaleznik in 1977. This have more recently discussed by Petriglieri who argues that we have focused too much on leadership.
THe distinction between management and leadership has become blurred, "managerial work has, for example, been replaced by the more appealing label leadership, used to denote any act of a person in a formal authority position".
A helpful video of recent research on both concepts and the importance of both is available by the Academy of Management

## Informal leadership
Providing a positive voice has benefits:
- "employees can help peers get a status boost from voicing, while also raising their own status, by introducing the concept of amplification"

# Evidence-based management
A gap between what research shows and managers practice has been noted.
Evidence-based management (EBMgt) has been advocated to improve management practices and measurement. This is based on the success of evidence-based medicine and has been called the management-as-medicine motif (MAMM). Concern about the approach of EBMgt has been based on a Cochrane Collaboration review of nursing turnover that focused only on randomized data.
Concerns exists about how well MBA programs,  bridge and practitioner journals, and textbooks teach EBMgt. Perhaps as a result, a gap has been documented between research and human resources practioners.
Alternative approaches to education have been suggested.
The "push, pull, process" approach has been advocated and refers to publishing and disseminating quality research (push), managers learning all to retrieve new research findings after they finish formal education (pull), and systematically assessing publications (process).
Systematic reviews have been encouraged as alternative to narrative reviews for summarizing evidence in business and management research.
Reporting standards have been proposed.
Registration of studies before data collection has been advocated.

## Barriers within leaders
Management students in Australia view evidence-based management (EBMgt) in one of 4 ways:
- EBMgt as an unrealistic way of doing management. 12% or respondents
- EBMgt as a way of doing management in particular situations. 34% or respondents
- EBMgt as a generally useful way of doing management. 45% or respondents
- EBMgt as an ideal way of being a manager. 9% or respondents
The leadership knowing-doing gap may be affected by "motivation, prioritization, and confidence to enact leadership".

# Selection and development of leaders
Individuals with promotive voices rather than a prohibitive voice are more likely to become leaders, especially if they are male.
Evolutionary biology may partly explain selection of leaders.
One study has validated the Peter Principle.
"Emergent leaders showed a higher amount of active gestures and less passive facial expressions than non-leaders" according to eye-tracking studies of teams.

## Personality traits
Among the following 'Big five' personality traits:
- Openness to experience
- Conscientiousness
- Extraversion
- Agreeableness
- Neuroticism
Narcissism may be selected for.

## Dunning-Kruger effect
The selection for narcissism may be related to the Dunning-Kruger effect which has been noted to occur in the self-assessment of leadership skills.
The overconfidence of some individuals may be viewed as competence by other individuals
Aphorisms about selection of leaders:
- Peter Principle
- Dilbert Principle

## Core-self evaluation
Core-self evaluation includes:
- Self-esteem
- Self-efficacy
- Locus of control
- Emotional stability (low neuroticism)
Hypercore selfevaluation has a positive effect on innovation behavior by leaders; however, selfism and overconfidence has a negative effect.
Low managerial self-efficacy and ego defensivism makes managers less likely to solict employee voice, positively evaluate an employee who speaks up, and reduced implementation of employee voice

## Humility
The harm of narcissism in leaders may be mitigated by humility Humility, predicted by self-expansion theory, has been found to increase self-expansion and self-efficacy of followers. However, humility may not be effective in teams that expect a high power distance or expect dominating leaders.
Humility in leaders may be effective when teams have proactive personalities.

## Masters in Business Administration
CEOs with a MBA may or may not underperform other CEOs due to emphasizing short-term business outcomes or personal gain rather than sustainability.
It is not clear that the curricula in masters programs reflect best research.

## Leadership training
Leadership training can be effective.
In academic health center], the effect of leadership training may be more to the benefit to advancement of the trainee that to improvement of the institution.
The self-esteeem and mindset of the trainee may determine whether the trainee focuses improvement on self versus organization.
Leadership training in healthcare may be more effective if taught in conjunction with institutional projects.

# Leadership styles related to worksite climate
Leadership research is complicated by construct proliferation and construct redundancy
Leadership style affects  work climate.
Leadership styles in health care may affect institutional finances, specifically operating margins.
Early categorization of leadership styles was by Lewin in 1938 who labeled styles as autocratic, democratic.
The terms transactional and transformation were introduced by Weber in 1947.  Weber said the charismatic leader was a transformer and the bureaucratic leader was transactional.
Similar concepts are Theory X and Theory Y management by Douglas McGregor in 1960. Theory X is transactional and Theory Y is transformational.
The concept of transactional versus transformation leadership was using the Multifactor Leadership Questionnaire (MLQ) first proposed by Bass in 1978.
Measurement of transactional versus transformation leadership using the was first proposed by Bass in 1985.
Bass added the concept of laissez-faire leadership in 1997.
Leadership styles may effect burnout of employees who are physicians and non-physicians as well the burnout of the leaders themselves..

## Laissez-faire
Laissez-faire may be the most common of the destructive leadership patterns.
Laissez-faire, in health care, is associated with low subordinate job satisfaction and effort. In other industries, laissez-faire is also associated with reduced team performance.
Among physicians, management by passive exception and laissez-faire and may overlap.

## Transactional
The transactional style may have arose from early views of leadership:
- Adam Smith wrote about the worker, It is the interest of every man to live as much at his ease as he can.
- Frederick Taylor later added that the worker is so stupid that the word percentage has no meaning to him, and he must consequently be trained by a man more intelligent than himself.
Transactional leadership is associated with the following of the Big 5 Personality Traits:
- Agreeableness
- Extraversion
- Openness (insignificant)
- Conscientiousness (insignificant)
- Neuroticism (negative association)
When converting from transactional to empowering leadership, teams may transiently function more slowly.

### Management by exception: active

### Management by exception: passive
Among physicians, management by passive exception and laissez-faire and may overlap and management by passive exception may be within laissez-faire.

### Outcomes of transactional leadership
Transactional leadership tactics were found by a meta-analysis in 2004 to positively and significantly affect the following compared to transformational leadership:
- Transformational leadership had a higher validity than did contingent reward: follower satisfaction with leader and leader effectiveness
- Contingent reward had significantly higher validity: follower job satisfaction and leader job performance
Other studies have found benefit from transactional leadership
Transactional leadership, if leading to zero-sum assessments by employees, can be problematic.

## Transformational
Transformational leadership has the following dimensions (4 I's), the first two, Idealised Influence and Inspirational Motivation, when combined are charisma:
- Idealized Influence (role modeling).
Attributed: My supervisor acts in ways that build my respect Note that Aviolo found that "displays power and confidence" was the lowest loading factor for charisma.
Behavior: "talks enthusiastically", My supervisor talks to us about his/her most important values and beliefs
- Attributed: My supervisor acts in ways that build my respect Note that Aviolo found that "displays power and confidence" was the lowest loading factor for charisma.
- Behavior: "talks enthusiastically", My supervisor talks to us about his/her most important values and beliefs
- Inspirational Motivation, My supervisor expresses his/her confidence that we will achieve our goals. Motivation may be better provided by beneficiaries of a company's services rather than the company's leadership.
- Individualized Consideration (of followers), "focuses your strengths", My supervisor spends time teaching and coaching me
- Intellectual Stimulation. "suggests different angles", My supervisor seeks differing perspectives when solving problems
Teaching charisma, Idealised Influence and Inspirational Motivation, has been studied.
Transformational leadership is associated with the following of the Big 5 Personality Traits:
- Extraversion (strongest)
- Openness
- Agreeableness
- Conscientiousness
- Neuroticism (negative association)
Authentic leadership and ethical leadership may actually be tranformational leadership.
This style may be the most effective in healthcare on employee responses and clinical outcomes.
Transformational leadership may increase employee thriving and decrease burnout.
Transformational style may better promote team learning behaviors than a transactional style.
Compared to transformational leadership, in transformational leadership the leader's focus is on the employees rather than the organization.
Transformational leadership may build on transactional leadership, "for transformational leadership to be effective,the leader must first build trust and follower responsiveness on the basis of tangible, transactional processes perceived as fair."
Transformational leadership may cause leader emotional exhaustion and subsequent leader turnover intentions, especially when followers are low in conscientiousness or competence.

### Measurement
Transformational leadership can be measured with the proprietary Multifactor Leadership Questionnaire (TLQ)  or other instruments.

## Enabling or Empowering leadership
Enabling leadership attempts to bridge the needs to innovate and to produce. Enabling leadership is based on complexity leadership theory.
Empowering leadership is defined variably but includes:
- Autonomy support. Autonomy adds to mastery. Perceived autonomy is associated with less burnout.
A more detailed summary is proposed by Spreitzer:
- The First Discipline: Empower the Person Who Matters Most
- The Second Discipline: Continuous Vision and Challenge
- The Third Discipline: Continuous Support and Security
- The Fourth Discipline: Continuous Openness and Trust
- The Fifth Discipline: Continuous Guidance and Control
Similar concepts are:
- Gardener leadership
- Servant leadership Servant leadership may promote thriving.
Employee perception of servant leadership and the factors of self-determination theory are more likely to have extra-role behavior.
Covey describes the four roles of leadershipmodeling, pathfinding, alignment, and empowerment
Spears described the 10 characteristics of servant-leaders as" Listening, Empathy, Awareness, Healing, Foresight, Persuasion, Conceptualization, Stewardship, Community Building, and Commitment to People's Development 
- Employee perception of servant leadership and the factors of self-determination theory are more likely to have extra-role behavior.
- Covey describes the four roles of leadershipmodeling, pathfinding, alignment, and empowerment
- Spears described the 10 characteristics of servant-leaders as" Listening, Empathy, Awareness, Healing, Foresight, Persuasion, Conceptualization, Stewardship, Community Building, and Commitment to People's Development 
- Types of leadership that focus on giving employees decision-making but may not include giving employees information to guide their decision-making.
Shared Leadership
Distributed leadership
Servant leadership
Participative Leadership
Democratic leadership
- Shared Leadership
- Distributed leadership
- Servant leadership
- Participative Leadership
- Democratic leadership
Empowering leadership may be compatible with AGILE development, which may conflict with command and control leadership.
The World Health Organization recommends participatory leadership as one of 4 reforms needed for primary health care, leadership reforms need to steer away from either command and control or laissez-faire disengagement towards a participatory style
In health care administration, physician leaders have difficulty relinquishing control and feel threatened by empowering others.

### Impact
Shared leadership may improve team performance according to a meta-analysis of 42 studies.
Empowering leadership may improve performnce
Empowering leadership is consistent with the principle of subsidiarity.
- "Just as it is gravely wrong to take from individuals what they can accomplish by their own initiative and industry and give it to the community, so also it is an injustice and at the same time a grave evil and disturbance of right order to assign to a greater and higher association what lesser and subordinate organizations can do. For every social activity ought of its very nature to furnish help to the members of the body social, and never destroy and absorb them."

### Measuring empowerment
Multiple instruments are available.
The Empowering Leadership Questionnaire (ELQ) has been proposed to measure this style. The ELQ measures either categories:
- Coaching
- Informing. Examination of the 6 questions in this scale suggest informing here does not fit with information sharing as proposed by complexity science.
- Leading By Example
- Showing Concern/Interacting with the Team
- Participative Decision-Making
Servant leadership can be measure with a 28-item or an abbreviated 7-item servant leadership scale:
- My manager can tell if something work-related is going wrong
- My manager makes my career development a priority
- I would seek help from my manager if I had a personal problem
- My manager emphasizes the importance of giving back to the community
- My manager puts my best interests ahead of his/her own
- My manager gives me the freedom to handle difficult situations in the way that I feel is best
- My manager would NOT compromise ethical principles in order to achieve success

### Benefits
Empowering leadership is associated with:
- Performance, organizational citizenship behavior, and creativity according to a meta-analysis as compared transformational leadership and leadermember exchange
- Creativity and innovative behavior ( = .36), contextual performance ( = .33), withdrawal behaviors ( = .28), and job performance ( = .25) according to a meta-analysis.
- Increased employee intrinsic motivation and creativity
- Increased productivity by implementing Strategic Human Resource Management (SHRM) as compared to initiating operational improvements
- Increased knowledge sharing and team efficacy which led to increased performance.
- Increases work engagement via work meaningfulness or empowering leadership has been proposed for healthcare.
Servant leadership behavior may be more effective than narcissism and a serving culture is positively related both to restaurant performance and employee job performance.

### Harm
Servant leadership may be costly to the leader
Two contradictory faces of empowerment are :
- Enabling
- Burdening

# Contingency or situational theories
In this approach, the role of the leader is contingent on the situation.
This includes:
- Tannenbaurm's and Schmidt's continuum introduced in 1958
- Hersey's and Blanchard's situational leadership in 1969.
- Vroon and Yetton's contingency model in 1973
- Heifetz's Adaptive leadership introduced in 1997

# Modulators of impact of leadership styles

## Characteristics of subordinates
Goal diversity of subordinates moderator relative effectiveness of leadership styles, "low authority differentiation is beneficial for teams homogeneous in goal orientations and detrimental for teams diverse in goal orientations."
Regulatory fit theory has found:
- Subordinates high in locomotion prefer leaders who have "'forceful' leadership style, represented by 'coercive', 'legitimate', and 'directive' kinds of strategic influence'
- Subordinates high in assessment prefer leaders who have "'advisory' leadership style, represented by 'expert', 'referent', and 'participative' kinds of strategic influence'

### Regulatory focus
Regulatory focus theory poses that people vary in their goals:
- Promotion-focus on hopes and accomplishments, also known as gains
- Prevention-focus based on safety and responsibilities, also known as non-losses
Focus may also predict jealousy and envy.

### Core-self evaluation
Core-self evaluation includes:
- Self-esteem
- Self-efficacy
- Locus of control
- Emotional stability (low neuroticism)
Hypercore-self evaluation predicts job satisfaction and performance.

## Characteristics of leaders

### Leaders'encoding processes
Leaders' encoding processes may be important:
- Mindsets: fixed and growth
- Goal orientations
- Mindsets: deliberative and implemental mindsets
- Regulatory focus.
Mindset interventions have been reviewed.

### Learning-from-failure / optimism
Leadership change behavior is key for post-failure success. This includes sensemaking and problem formulation and reformulation to fine innovation post-failure.
Leader optimism is associated with performance and citizenship behavior.

### Leader humility
Leaders who share criticism of themselves can increase the sense of psychological safety of their workforce.
Sharing personal stories may increase workforce trust in leaders via authenticity and empathy.

### Leader narcissism
Leader narcissism may be harmful.

### Leader information sharing
In general, leaders do not share enough informatoin.

## Leaders' work load
Executive job demands may hinder innovation.

# Complexity leadership theory
Enabling leadership is based on complexity leadership theory.
Complexity science has been proposed as a framework for health care organization since early this century.
Complexity science has been proposed as a framework for Learning Health Systems.
Complexity leadership has been criticized for explaining organizational behavior rather than managing organizations.
Complexity leadership theory has varying descriptions of the metatheme of leadership (see table).
Anderson and McDaniel proposed in 2000 that key leadership tasks are:
- Relationship building
- Loose coupling
- Complicating
- Diversifying
- Sense making (such as positive and negative feedback)
- Learning
- Improvising
- Thinking about the future
A model of of learning based on complexity science has been developed.
Complexity Leadership Theory, also called Complex systems leadership theory, was proposed in 2006. Based on this theory, Hazy has proposed leadership skills similar to Anderson and McDaniel:
- Generative (information gathering/generative/ functions)
- Administrative (information using/convergence/administrative functions)
- Community-building
- Information gathering
- Information using (such as positive and negative feedback)
Uhl-Bien has proposed that tasks of enabling leadership, which is an outgrowth of complexity leadership are:
- Brokerage - fostering of ideas that are triggered at the intersection of networks
- Leveraging  Tension
- Linking Up - "Creating or energizing network connections that enable information flows, or amplify movements, to feed and fuel emergence."
- Tags and Attractors - "Listening for language (messages, stories) and symbols (pictures, objects) that stick in a system and attract energy & using them to create tags to amplify and channel emergence"
- Simple Rules
- Network Closure
Complexity Leadership Theory is consistent with open book management.
Complexity leadership is consistent with positive deviance.
Complexity Leadership Theory may be seen as an evolution of Heifetz's adaptive leadershi
Complexity Leadership Theory is consistent with knowledge-oriented leadership, which is defined as "an attitude or action, observed or imputed, that prompts the creation, sharing, and utilization of new knowledge in a way that seems to bring a shift in thinking and collective outcomes."

## Implementations

### Agile and constructive deviance
Constructive deviations are "ad hoc experiments performed with the intention of achieving some purpose; this idea is distinct from the notion of positive deviance which is a post hoc analysis and intervention technique used to identify positively performing subgroups (outliers) in populations facing many of the same challenges".
Agile coaches are consistent with complexity leadership theory and enabling leadership.

### Fractal
Fractal organization is consistent with complexity leadership and includes:

### Positive deviance
Positive deviance is consistent with complexity leadership theory and learning health systems.

## Measurement
Complexity Leadership tactics can be measured with 3 concepts:
- Knowledge-oriented Leadership
- Knowledge Management Capability (technological, structural, cultural, application, acquisition, sharing)
Example: cultural (highest loading questions):
My organization takes advantage of new knowledge.
My organization quickly applies knowledge to critical competitive needs.
My organization quickly links sources of knowledge in solving problems.
- Example: cultural (highest loading questions):
My organization takes advantage of new knowledge.
My organization quickly applies knowledge to critical competitive needs.
My organization quickly links sources of knowledge in solving problems.
- My organization takes advantage of new knowledge.
- My organization quickly applies knowledge to critical competitive needs.
- My organization quickly links sources of knowledge in solving problems.
- Open Innovation
Another survey has been proposed and construct validated. The instrument consists of 10 items in 2 scales. Response format asks frequency that employees observe leadership tactics with Likert responses ranging from 'Never' to an average of daily:
- Generative (information gathering). Hazy also describes this as "Resilience Leadership Mode...to address risk (variance) by promoting the value potential of optionality"
Supporting difference of opinion
Providing resources and time to try new things
Encouraging learning visits to other organizations
Encouraging new approaches
Forgiving failure
- Supporting difference of opinion
- Providing resources and time to try new things
- Encouraging learning visits to other organizations
- Encouraging new approaches
- Forgiving failure
- Administrative (information using). Hazy also describes this as "Effectiveness Leadership Mode...to maximize return (expected value) by driving the potential value of efficient operations"
Driving accountability
Setting objective metrics of success or failure
Quieting voices which distract from the purpose
Asking people to invest more time and energy
Establishing specific targets and deliverables.
- Driving accountability
- Setting objective metrics of success or failure
- Quieting voices which distract from the purpose
- Asking people to invest more time and energy
- Establishing specific targets and deliverables.
Practice  Reserve (PAR) can be measured.
Reciprocal learning may be measured.

## Compoenents of complexity leadership

### Community building / networking / linking up
"Network leaders engage in brokering connections across the network of jazz musicians; or building status through connections to central people," the latter may be more important.

### Sensemaking
Sensemaking includes semantic sensemaking.

# Persuasion and issue selling
Aristotle's rhetoric can be a framework for persuasion Green proposes:
- "a rhetorical sequence that starts with pathos, moves to logos, and ends with ethos will have a rapid rate of initial adoption, a broad diffusion, and a slow abandonment"
- "pathos may initiate change, logos implement it, and ethos sustain it"
Issue selling has been studied by Dutton and Ashford and updated by Lu Lu proposes the use of:
- Influence tactics
Rational persuasion, for example, Use facts and logic to try to make a persuasive case for your proposed idea
Inspirational appeal, for example, Say your proposed idea is an opportunity to do something really exciting and worthwhile
Consultation, for example, Ask your supervisor to suggest how you could make your idea more helpful to him or her with a task or problem
Collaboration, for example, Offer to provide any assistance the supervisor would need to make the idea happen
- Rational persuasion, for example, Use facts and logic to try to make a persuasive case for your proposed idea
- Inspirational appeal, for example, Say your proposed idea is an opportunity to do something really exciting and worthwhile
- Consultation, for example, Ask your supervisor to suggest how you could make your idea more helpful to him or her with a task or problem
- Collaboration, for example, Offer to provide any assistance the supervisor would need to make the idea happen
- Enactment behaviors
Drawings: Illustrate the idea through such means as written descriptions, PowerPoint presentations, drawings, or storyboards
Enacting: Conduct a pilot or simulation to show how the idea could work
Prototypes: Develop a prototype or other sample to demonstrate the value of the idea.
- Drawings: Illustrate the idea through such means as written descriptions, PowerPoint presentations, drawings, or storyboards
- Enacting: Conduct a pilot or simulation to show how the idea could work
- Prototypes: Develop a prototype or other sample to demonstrate the value of the idea.

# Leadership tactics related to worksite innovation
(see enabling leadership and complexity leadership above)
Innovation can be classified as:
- "Inbound OI involves identifying and acquiring knowledge from external sources"
- "Outbound OI involves exploitation of a firms knowledge and technology through commercialization in the external market"
Organizational cultural influences on innovation has been systematically reviewed. Cultural attributes include:
- Learning  culture
- Adhocracy culture
- Clan rather than hierarchical culture
- Low power distance culture
Once tactic to foster innovation is to concentrate on lead users

# Religion and faith in leadership
The role of religion and faith in leadership is being increasingly explored.
The Bhagavad Gita may inform positive leadership
, especially verse 2:47.
Religiosity may widen gender pay gaps.

# Comparison of leadership approaches
Directive leadership and hierarchy may help in the short run, but harm in the long run.

# Complications of leadership
Power may lead cerebral changes in those given power. This may lead to hubristic syndrome
The Earned Dogmatism Effect may lead to close-mindedness.

## Employee turnover
Leadership affects employee turnover
Rates of employee turnover, especially voluntary turnover, affects organizational performance.