The hospital and its performance

This hospital was opened in 2004. The performance of the hospital in the quality assurance programme improved significantly between 2010 and 2016: the overall performance score index increased from 42% in 2010 to 83% in 2016.

Organisational structure

The hospital has relatively small clinical units, which are supervised by a doctor and nurse-in-chief. Both interact directly with the hospital director and the provincial health officer (PHO), whose office is located within the hospital. The hierarchical line is therefore short. The managers of the clinical units interact directly with patients (Source: Researcher’s field note, 30/2/2018).

Organisational culture

The hospital is characterised by a strong clan culture. The respondents express strong feelings of belonging to the same entity (esprit de corps).

We become family. The majority of us are like brothers and sisters. We are part of “DART” (a rotating saving group). We go together to weddings, we shop together, we eat together. We love to work together. (NHMH 12, administrator)

Respondents express feeling proud to belong to this group, which facilitates openness of expression, communication and collaboration. Respondents from all cadres indicate that friendliness defines their daily interactions. This, in turn, facilitates trust among group members and their effective cooperation.

Here, we have a strong team spirit. We are open to talk about everything when we are together. Whenever I had an exam at the university, I gently asked my colleague to fill my position for a half day, and afterwards I give her back this service. We accomodate each other and I support her whenever she needs me on her shift. We are all cooperative. (…) Trust, they trust me, this is the most important thing. They know that I will not harm them. If this was not the case, we would be having conflicts and be shouting at each other. (NHMH 8, midwife, midlevel manager)

It was a pleasure to work in teams. A key characteristic of these teams is friendship: staff are considered as friends, we care for each other. I watch over their interests. We held our director in high consideration. I would not have participated to quality circles if I disliked the director. (NHMH 10, doctor)

Age is another connector. Staff tend to identify themselves as belonging to the same age category and this enhances their feeling of group cohesion.

Before, I worked in another hospital where young people were few and were unable to express their opinions to the administration. In this hospital, it is really different. We have the same age more or less, we support each other, we listen to each other. (NHMH 20, nurse anaesthesiologist)

Respondents note there are little status differences between nurses, doctors and administrators, which allows them to identify with the hospital and not just with their specific professional category or age group.

There is no status difference between nurses and doctors. Everyone is a one single corps. (NHMH 6, doctor, specialist)

Our analysis shows that this has implications for staff motivation and organisational commitment. Health workers felt committed to the hospital because they have a strong feeling of ‘being one’, of belonging to the same group with the same ‘esprit de corps’.

What motivates me in this hospital is the work ambiance, the youthfulness and the dynamism of my team members. (NHMH 20, nurse anaesthesiologist)

Another hallmark of the organisational culture in this hospital is the shared beliefs and values concerning integrity and moral conduct.

An important issue in this hospital, thank God, all staff are honest. They do not take bribes. They are not corrupt. Patients do not bribe the surgeon or nobody else here to have a cholesystectomy and they are operated in due time. (NHMH 10, doctor, specialist)

We found that this clan culture was shared by all staff categories and that it remained stable despite the high turnover of hospital directors.

Leadership practices

Since its opening in 2004, there has been a high turnover of hospital directors (table 2). Our analysis shows this had an impact on the organisational climate and on the organisational performance.

From 2007 until the end of 2013, the hospital was managed by chief executive officer 1 (CEO 1). He was a physician with no formal training in management. He adopted a rather distant, transactional leadership style and emphasised compliance with rules and procedures. He retired in December 2013. During this period, the provincial health officer (PHO) continued to play an important role in the hospital. He, too, adopted a strong transactional leadership style, but he was appreciated by staff because they felt he was responsive to their needs. He showed strong consideration for individual staff members and concern for their well-being.

He, may the grace of God be upon him, was severe. He had an administrative attitude. However, he upgraded a resting room for doctors within the operating theatre. He improved our working conditions (offices, sanitary), whereas the former two PHOs did not respond to our needs, even though we relentlessly asked them to. (NHMH 25, doctor)

When there was a farewell, he brought me himself my share of sweets and juices. (NHMH 12, administrator, close collaborator)

He displayed altruistic behaviour and encouraged the continued education of staff. He upheld high ethical standards. Respondents noted that he was a role model and a source of inspiration to hospital staff.

He [The PHO] initiated the quality culture at the hospital. He appointed project managers, he was visionary. Five of the project managers who remained were commited to the quality culture. Although he passed away in 2014, it was him who made who they were. (NHMH 30, senior manager, nurse)

From 2014 to 2016, NHMH was managed by CEO 2. During this period, the hospital achieved the second position in the national quality contest. Our analysis showed that CEO 2 displayed distributed leadership. He fostered the creation of networks and experimented with interdisciplinary committees, which carried out quality circles called ‘Kind heart actions’.

I said, why would not we experiment something. Let’s create committees - it was the first time - to monitor stock management of medical fluids, catering waste or patient catering. We created teams that supervised each activity. We agreed that we would do an experiment with these committees. If it wouldn’t work, auditors would come and tell us what did not work. (NHMH 32, CEO 2)

These interdisciplinary committees included a quality manager, physicians, nurses and pharmacists and this enabled sharing of ideas and creative problem solving. CEO 2 stimulated line managers and members of ‘kind heart action’ committees to adopt a distributed leadership style themselves. This was successful in that a number of staff took up such a leadership style:

I am close to the personnel. I have a nearby management style. I try to be close to physicians. I try not to create tensions and they listen to me a bit. I try to understand their specific needs. (NHMH 11, surgeon, intermediate manager)

The quality circles created conditions that were favourable to close interaction between different staff members across hospital units and departments. As a result, innovative solutions emerged in response to problems.

The former director catalysed teams, he gave us energy. We loved to work with him. We stayed till 8 pm in the evening. We worked during weekends. We worked hard. We were motived to work and perform. Actually, we feel the difference with other leaders. (NHMH 08, midwife)

Our analysis shows that CEO 2 had a clear vision on management and that he was able to communicate that vision, clarifying goals and increasing the mission valence (eg, quality of care, organisational citizenship). It emerges from our data that CEO 2 also displayed nearby leadership: he was responsive to individual staff needs, showed individual consideration and supported them in doing their tasks. CEO 2 enabled dialogue and accepted divergent opinions. This was highly appreciated by staff; it enhanced their self-esteem and perceived supervisor support. This, in turn, increased staff commitment and respect. Staff considered him to be a role model.

The former CEO did not have a distant attitude. When I met him in the hallway, he communicated with me respectfully. He asked me about my personal health: “Is everything ok?”. He greeted everyone. Then when he needed an anaesthesiologist to fill an unplanned shift position outside working hours, I accepted the job because that day he showed consideration for me. (NHMH 02, nurse anaesthesiologist)

The former Hospital director was often close to the field. He was a guy who rolls up his sleeves and organizes himself the emergency cart. He empathized with a nurse who had night shift, wear his pyjama, organized himself the emergency cart. He organizes the medicine cabinet. (NHMH 01, senior manager)

CEO 2 was very dynamic, he was very good as a role model. He involved all personnel. We had several meetings to discuss our concerns and service fonctioning issues. We engaged toward quality objectives. This was a true example for staff motivation (…) The objectives were to improve working conditions, and to understand staff needs, valuing teamwork and participative decision making. (NHMH 31, doctor)

Our data show that the distributed leadership and the quality circle interventions were congruent with the organisational culture described above. CEO 2 provided room for staff discretion (micro-emancipation), for instance, by allowing them to arrange their own shift schedules and working practices, while setting simple rules to guide the overall performance (eg, focus on quality and patient satisfaction). This promoted staff autonomy and thus enhanced employee self-esteem, while addressing staff’s needs for discretion in decision-making.

The former director said: ‘You manage your unit as a team. Do whatever you like in the service. The operating theatre is your kingdom. Then do whatever you like, but what I care for is that patients do not come complaining to me about the quality of service. (NHMH 02, nurse, anaesthesiologist)

Responsiveness to staff needs for discretion through participative decision-making enhanced their organisational commitment.

When leaders involve staff in decision making, staff are committed. Work flows smoothly. (NHMH 23, nurse)

“I told them (the staff) to make the hospital plan they see appropriate. What is your vision of your hospital? I am just a passerby in this hospital. I will stay 2 or 3 more year and quit. It is you who will stay at the hospital. How many hospital directors have you seen? How many provincial health officer have you encountered. You will remain at the hospital. This is why give me your vision about the hospital!]. It is important to involve people in decision making. It is necessary to use what we call in our jargon the participative management. You need to involve them all. This way, you increase their self-esteem, when you ask them how do you prefer this mug (a metaphor) this way or that way. I will bring you the glass you chose. (…) Involving staff in decision making in hospital development plans enhances their sense of belonging. (NHMH 32, CEO 2)

Our analysis shows that during the time of CEO 2, a positive organisational climate emerged within the hospital.

The former CEO was animated. He was open to discussion. He changed the organisational climate. He acquired necessary material, but his stay was short. He did not last long enough, but the hospital was catalysed. (NHMH 25, doctor and operational manager)

CEO 2 left in June 2016 and he was replaced by CEO 3, who had a more distant, laissez-faire leadership style. The staff found his communication style to be poor. Respondents indicated that this led to mistrust between the management team and staff. They mentioned that CEO 3 was not responsive to staff needs (for instance, not addressing problems of shortage of consumables and of maintenance of equipment). This led to increased job pressure and demotivation of staff.

CEO 3 was reluctant to solve problems. He did not want to be bothered. At that time, we had issues with medical waste. We suffered from shortages of bed sheets. An electrocardiograph and tensiometers were not available at the emergency room! (…) Once, he aggressively blamed me for refusing to use non-sterilized instruments due to a broken autoclave . (…) He even passed by me without greeting me at all. Consequently, I stopped complaining about material shortages and tried just to do my night shift with the minimum available material. (NHMH 4, nurse)

The organisational climate was rapidly characterised by perceived organisational politics, which led to tensions within the hospital between union representatives and contributed to strikes. The laissez-faire leadership led to a breach of trust between the staff and the administration and reduced their organisational commitment of the former.

There was not a good organisational climate. This was due to the hospital direction. (…) There were many problems, conflicts, an instable climate. But the CEO did not intervene, he did not make promises, there was no improvement, no initiatives. Even when we asked, we were told there is no budget. (NHMH 31, doctor-in-chief of a clinical department)

We found that CEO 3 managed the hospital on a day-to-day basis: he did not present a vision, organisational objectives nor an action plan. His poor communication with close collaborators and staff contributed to a climate of ambiguity.

Staff were no longer motivated. He made promises he did not keep, they were just promises. There were no means, no defined objective, no engagement to quality or whatsoever, nothing at all. The working conditions were deteriorating! (NHMH 31, doctor)

Low participation in decision-making induced decreased perceived supervisor support and staff resistance. Front-line workers were resisting the directive attitude of CEO 3. They expressed how they appreciate being consulted and involved in decisions that concern them.

CEO 3 was a colleague, a friend. But CEO 3’s leadership was not effective. Why? Because he overrelied on administrative correspondence. He was confronted with staff resistance. (NHMH 25, doctor, intermediate manager)

A good leader is the one who involves his staff in decision making. Obtaining consent from staff is very important. We are committed to decisions taken on the basis of constructive dialogue with staff. For instance, in my specific case, when mobilising a nurse from a service to cover a vacant position in an another service. I did not accept because this decision was forced on me without concertation. This is important even for temporary mutation to cover personal shortage in the intensive emergency units. I do not accept that the director asserts his power on me. I have also the power to say NO !. (NHMH 24, nurse anaesthesiologist)

Trust in CEO 3 was breached when staff perceived him as working behind closed doors and inducing clientelism and nepotism. This was not accepted by staff because it was perceived as incongruent with their shared beliefs about integrity an moral conduct. This perceived organisational politics impacted negatively on their organisational commitment.

With the previous CEO 3, procurement processes were not transparent. Deals with suppliers were shady. He may had sought personal gain…!!. This is his business and he will be sanctioned by God. Our concerns is the patients. We behave in accordance to God’s norms. (…) Nursing staff are committed to the hospital only when the CEO is honest and working correctly! (NHMH 23, nurse)

In October 2017, yet again, a new hospital director was appointed. CEO 4 was the director at the time of data collection. This leader had a formal training in management and he emphasised re-establishing trust between staff and administration by engaging the former in decision-making.

Participative decision making increased the transparency and increased the level of trust. We presented the budget plan to the staff. We worked in a climate of transparency, we had nothing to hide. The result of this meeting was great. This way we gained the trust of the team. (NHMH 07, CEO 4)

Besides, CEO 4 focused on building alliances and gaining trust of informal leaders.

In this hospital, there is a strong level of unionisation. There are many influential people. I worked to gain their trust and included them in the team. I involved them in decision making, besides improving working conditions. We won a lot doing this (NHMH 07, CEO 4)

However, operational staff perceived him as distant transactional leader. CEO 4 reinforced the hierarchical line that was not respected by his predecessor. The information flow was again regulated through the formal hierarchical line. This was perceived by staff as ineffective in dealing with urgent issues and reducing their perceived autonomy support, and consequently reduced their internal perceived locus of control.

Before we did not have a chief medical officer; we had a chief nursing officer and an administrator. Everything worked smoothly. Now, progressively a distant management style is implemented. Tasks are regulated within supervisors’ spans of control. Administrative correpondance has to follow the formal flow of information. The chief nursing officer is distant, as if you talk to a corpse. A group of employees is favoured over others. A minority group is kept apart. Now, it is politics that prevail! (NHMH 12, administrator)

This approach, too, enhanced staff’s perception of increased organisational politics. Staff perceived negatively the hierarchical structure implemented by CEO 4 as reducing their ability to participate to decision-making and problem resolution and this reduced the dynamics of interaction between health units.

With the actual CEO 4, we now have a chief nursing officer, a chief medical officer; no more committees were created. We need to wait long for things that are simple and practical. We are told to respect the hierarchical line. We are not well received. Some objectives are now decided without concertation with the operational staff. (NHMH 31, doctor-in-chief of clinical department)

The Chief Nursing Officer reduces my interaction with the direction, stipulating that I am under his direct supervision and not under the hospital director’s supervision. (NHMH 08, nurse, intermediate manager)

By providing resources and improving work conditions, however, job pressure was reduced and the work climate progressively improved.

The service is running, we have good activity statistics. What is lacking is quality of care. Staff need more efforts from managers to provide adequate resources to improve working conditions (standardisation of patient flows, providing tools) in order to maintain the staff’s motivation and performance. (NHMH 31, doctor)

Summary of the findings

Our initial programme theory stated that “public-oriented health care organizations that are well performing are likely to be characterized by a high congruence between leadership styles and practices, organisational characteristics and individual staff attributes. More specifically, managers adopt an appropriate mix of transactional, transformational and distributed leadership styles that fits the mission, goals, organisational culture, and nature of tasks of the organisation as well as the individual characteristics of the personnel in terms of age, gender, professional profile and motivation.”

Our findings confirm the second part of our initial programme theory. Given the nature of hospitals as hybrid professional and mechanical bureaucracies, in which staff with different professional backgrounds need to collaborate in order to be effective, effective leaders adapt their leadership style to the different cadres and individuals as needed. We found that this adaptation of leadership style enhances staff PSS and POS and this contributes to the satisfaction of their basic psychological needs.

We found that laissez-faire leadership decreased the levels of POS and staff motivation by being less responsive to their basic psychological needs. Lack of vision and goal setting created a climate of ambiguity and conflict of roles. The inadequate enforcement of the hierarchical structure and high job pressure, which staff could not cope with, contributed further to a general malaise during some periods. This led to further mistrust between administration and staff and demotivation of staff.

We confirmed that transactional leaders are effective if they offer the employee the necessary support and ensure adequate working conditions. By improving the latter, transactional leaders reduce job pressure, and by implementing a clear hierarchical line, they reduce role conflicts. This explained why under the directorship of CEO 1, doctors were motivated, although they perceived that their leader was effectively asserting his power and control. However, if transactional leaders are felt to be distant, this tends to reduce the perceived autonomy support and the satisfaction of the need for mutual respect (relatedness), leading in turn to reduced motivation.

Our study showed that transformational leadership enhanced staff self-esteem and perceived autonomy support. Our findings indicate this contributed to expressed mutual trust between the director and the staff.

We found that under CEO 2, distributed leadership contributed to better interaction between staff from different health units and to improved communication flows, creative problem solving and a reinforced clan culture. Distributing leadership and embedding it throughout the organisation, combined with engaging staff in decision-making, led staff to perceive their activities as depending on their own volition (eg, planning the shift schedule). This increased their perceived autonomy support, and as a consequence, staff felt more committed to the organisational goals. This stimulated them to adopt extra-role activities (such as working off duty hours).

In short, our results show that leaders can contribute to better staff motivation if their leadership style matches the expectations of the different cadres. For professional cadres, this means effectively enabling and supporting them, as well as unit managers to take up their professional responsibilities. Other cadres may expect a more directive approach that is structuring and clearly indicating the task distribution, combined with close supervision. Leaders should adapt their practices accordingly—one size does not fit all.

We summarised our findings using the ICAMO heuristic tool in four plausible causal configurations presented below and summarised in table 3. It presents causal configurations confirmed by our empirical data.