Drivers and barriers in the practice of health-specific leadership: A qualitative study in healthcare

Abstract

BACKGROUND:

Managers have a significant impact on the health and well-being of employees, particularly when the managers lead in a health-specific way and intentionally foster their employees’ health. However, the data on contextual and individual factors influencing the practice of health-specific leadership is at present limited.

OBJECTIVE:

To survey the experiences of healthcare managers with health-specific leadership skills and identify the drivers and barriers in the practice of health-specific leadership.

METHODS:

Semi-structured interviews were conducted with 51 managers from 18 geriatric-care facilities in Germany, between November 2014 and February 2015. The interviews were analysed through qualitative content analysis.

RESULTS:

In their reports, managers mentioned several drivers and barriers in the practice of health-specific leadership. These drivers and barriers were found at the leader level, the employee level, and the organizational level. The factors identified relate to the theoretical aspects of health-specific leadership: health value, health awareness, health behaviour, and role modelling.

CONCLUSION:

For successful practice of health-specific leadership, the findings suggest a more holistic approach for worksite health promotion. Managers should promote personal initiative that benefit employee health, encourage their employees to exhibit healthy behaviour themselves, address organizational resources and restrictions, and gain competencies in change management.

Keywords

Nurses facilitators inhibitors well-being context

1 Introduction

In western countries, nurses experience high levels of work-related physical, social, and mental stress [1 –3]. These stressors affect the physical and mental health of employees [4 –6] and result in more health complaints and inactive periods due to sick leave [7, 8]. Under these circumstances, supporting employee health and well-being is a major challenge in the healthcare sector. Leadership plays a central role in work-related stressors and occupational health in the healthcare sector [9], especially when leaders deliberately focus on the promotion of health [10]. As leadership does not take place in a vacuum, contextual factors influence the impact of leadership on employee health and have to be considered as influencing factors [11]. The study reports qualitative findings on the factors influencing the practice of health-specific leadership in healthcare.

In the past decades, many studies have investigated the influence of leadership on employee health and well-being [12 –14]. The results show that positive leadership styles, such as transformational leadership [15], leader-member exchange [16], authentic leadership [17], resonant leadership [18] and ethical leadership [19] are related to better employee health status. Similar findings were reported by Cummings and her colleagues for the healthcare sector [9]. The authors identified relationally-focused leadership behaviour (e.g. transformational leadership style, supportive leadership style) to be associated with lower stress, emotional exhaustion, or job tension. Task-focused leadership behaviour (e.g. passive management by exception, laissez-faire leadership style) showed higher levels of emotional exhaustion and poorer emotional health. However, negative leadership behaviour also influences employee health. A meta-analysis showed that destructive leadership behaviour is related to lower well-being and higher stress levels among subordinates [20].

In recent years the concept of health-specific leadership has become popular. Health-specific leadership is understood as the managerial intent to be more focused on employee health rather than on performance or other objectives. Gurt and his colleagues define health-specific leadership as “ . . . the leaders’ explicit and therefore visible consideration of and engagement in employee health” [10]. Leaders can engage in employee health in different ways, for instance by implementing health promotion measures at the workplace, using job and workplace design to reduce work-related demands, encouraging their employees to behave healthier or creating an organizational climate of health [10, 21]. Hence a positive effect on employee health and well-being can not only be understood as a side-effect of leadership but as an intended outcome as well. Health-specific leadership can be distinguished from more general leadership styles such as transformational leadership or leader-member exchange [10, 22]. Franke and Felfe [23] define four aspects of health-specific leadership: health behaviour, value of health, health awareness, and role modelling. Health behaviour refers to any health-related action by the supervisors, such as giving feedback, providing information on promoting health, changing work conditions or job design. Value of health refers to the leaders’ interest in their own health and the health of their employees. Feeling responsible for someone’s health motivates leaders to show health-oriented behaviour and engage in health-supporting actions at the workplace. Supervisors with a positive attitude towards health-specific leadership are more likely to apply such leadership style [24]. Health awareness refers to the supervisors’ awareness of the health-status, job demands, and resources of their employees as well as potential interventions. Managers should also be sensitive to changes in their employees’ health status. Health awareness among managers can be understood as a necessary base to show adequate health-related behaviour and interventions. These three aspects can be related to employee health as well as the manager’s own health. This relationship between staff-care and self-care indicates the relevance of the fourth aspect: health-related role modelling. By taking care of their own health, supervisors give their subordinates a direction towards healthier behaviour. If employees perceive their supervisors as role models, managers can have greater impact on their employees’ behaviour and satisfaction [25]. Recently, Franke and her colleagues [22] provided further evidence on the effects of health-specific leadership. The longitudinal study showed that employees take more care of their own health and therefore have fewer health complaints if they perceive their supervisors as health-oriented leaders [22].

Whereas these results support the concept of health-specific leadership, there is no research on the contextual factors that influence this kind of leadership. Since leadership does not take place in a vacuum, contextual factors interfere with leadership behaviour [11]. Therefore, the research should also be linked to relevant factors, such as environmental, organizational or individual characteristics [11, 26], in particular for the relation between leadership and employee health [21]. Previous studies underpin the relevance of different factors that impact the managers’ influence on employee health and well-being, such as culture [15], work climate [27], social support [28], job characteristics [29, 30], employee personality [31], their self-efficacy [28], managers’ strategies and attitudes [32], managers’ competencies [33], and managers’ personalities [34]. The studies indicate various factors on the environmental, organizational and individual level that hinder or facilitate leadership behaviour and its effects on the health outcomes of employees. However, the results are insufficient for forming a structured and comprehensive overview of the relevant contextual factors for several reasons: 1) Pervious studies selectively focus on investigating single factors or levels and lack to combine and integrate different factors and levels of analysis. 2) They in particular disregard interrelatedness of different factors, how they may interact, complement and counterbalance each other. For instance organisational characteristics could affect individual behaviour of employees and managers and vice versa. 3) They exclude managers’ perspective on the relevance of the examined factors. Managers’ individual experience is a valuable source to provide insight in drivers and barriers in the practice of health-specific leadership. Further, health-specific leadership is distinguishable from more general leadership styles [22]. This might mean that different factors are relevant for health-specific leadership behaviour. There is no study known to the authors that takes managers’ perspectives into account and explores systematically influencing factors on leadership in healthcare. It is unclear as to which contextual factors are relevant for health-specific leadership practice and research and how they relate to each other. The present study addresses these shortcomings and provides insight on the relevance of different factors and their interrelatedness for health-specific leadership. Introspection and self-reflection by managers are essential for understanding the factors which influence leadership behaviour in practice, as well as for leveraging health-specific leadership in healthcare. Understanding the drivers and barriers helps in successfully practising health-specific leadership and, therefore, also in fostering employee health in healthcare.

2 Method

The aim of the study is to identify drivers and barriers in the successful practice of health-specific leadership in the healthcare sector and relate them to each other. The present study examines the perception put forth by managers in the practice of health-specific leadership in healthcare facilities. The results add insights on health-specific leadership based on the experience of managers, and provide valuable information on the factors that hinder and facilitate the application of health-specific leadership.

An exploratory study was conducted for this paper, whereby in-depth interviews were used to analyse the experiences of the participants in the practice of health-specific leadership. This method is adequate for deepening our understanding of complex and insufficiently explored topics [35].

2.1 Sample

The participants were recruited from a mailing list of regional healthcare services in Lower-Saxony, Germany. The facility managers were invited to participate in the study and if interested, they were requested to further recruit staff members in managing positions within their companies. Fifty-one managers from 18 geriatric healthcare services participated in the study. The participants held different management positions: director/head of management (HM, n = 18), nursing management (NM, n = 15), sector management (SM, n = 8), deputy nursing management / deputy head of management (DM, n = 8), and residential group management (RM, n = 2). Forty-two out of 51 participants (82%) were female.

2.2 Data collection

To address the research question we developed a semi-structured interview guide. This guide was further discussed with two independent researchers to consider all relevant topics. The interview method was based on the problem-centred interview by Witzel [36]. This method allows the researcher to collect qualitative data about a certain topic (‘problem’) by a semi-structured guide. The participants were asked to introspect and link each question to a certain example or situation from their experience as managers. By reflecting on these situations, the participants usually retrieve the relevant information more easily and their answers show a higher level of practical relevance and reliability [36]. The interview guide included the following topics:

General understanding of leaders’ influence on employee health

Successful practice and drivers for health-specific leadership

Insufficient practice and barriers in health-specific leadership

The face-to-face interviews were conducted at the participants’ workplaces between November 2014 and February 2015 and ranged from 40 –60 minutes in length. The interviews were digitally recorded and transcribed.

The approval of the research ethics committee was obtained from the university. The main ethical concern was related to the guarantee of participants’ anonymity and general data security. To address the concern and to meet the requirements of national data protection law, participants signed a written agreement of data protection and assurance of anonymity. To ensure confidentiality for the participants, all data was documented anonymously and stored and processed as per the data protection principals of the university.

2.3 Data analysis

The data was analysed by using qualitative content analysis, a qualitative method to systematically and comprehensibly describe the meaning of given material [35]. Firstly, the transcripts of the interviews were screened to get an overview and a general understanding of the data. Secondly, a preliminary coding frame was developed with an integrated approach [35]. For this purpose, categories were defined and developed data-driven by subsumption [37]. In this step, the transcripts of the interviews were screened for meaningful passages. These passages were labelled with codes and either added to existing subcategories or new subcategories were generated. Thirdly, the coding frame was adapted based on a discussion with and review by two independent researchers. The categories and subcategories were checked for consistency by comparing them to each other and to passages from the transcripts. Fourthly, the final coding frame was applied to the whole material, by coding the meaningful passages and assigning them to the sub-categories. The software MAXQDA 11 was used to analyse the data [38].

The trustworthiness of the research was assured by implementing several strategies in the research design and process. Thereby the four criteria of credibility, transferability, dependability, and confirmability were addressed [39]. A standardized approach for data collection and process was instructed and applied. Frequent briefing sessions within the research team were held to discuss the interpretation of the data. The interview guide, and the categories and codes were evaluated by two independent researchers. The coding-system was checked for consistency. The meaningful passages were recoded after a duration of eight weeks. The coefficient of agreement over time was 82.29 %. To ensure credibility, participation was voluntary. The purpose of the study was explained in detail and participants’ anonymity and data protection was ensured. Furthermore, the present article reports detailed information about the sample, data collection and data analysis. Meaningful excerpts of the data are presented for readers to judge the credibility of the findings.

3 Results

Our analysis identified drivers and barriers that are influencing factors in the practice of health-specific leadership at the leader, employee, and organizational level. The identified drivers and barriers were assigned to categories and are summarized in Tables 1 and 2. These categories were subsequently related to four aspects of health-specific leadership based on previous research: health value, health awareness, health behaviour, and role modelling.

Table 1
Drivers in the practice of health-specific leadership

Categories Drivers

Leader level Employee level Organizational level

Health value

Economical perspective Self-responsibility Supportive head of management

Meaning of work

Positive vision

Health awareness

Healthcare-specific knowledge -¹⁾ Interpersonal interaction

Role modelling

Personal demarcation -²⁾ -²⁾

Serenity

Stress regulation

Health behaviour

Willingness to take risks Accountability Sufficient financial resources

Pragmatism Willingness to change Sufficient time resources

Critical self-reflection Planning reliability

Flexibility Possibilities for flexible work design

Decisiveness Positive team climate

Persistence Multipliers within the team

Creativity and innovative capacity Exchange within the management team

Exchange within external networks Transparency and employee participation

Categories	Drivers
Health value
	Economical perspective	Self-responsibility	Supportive head of management
	Meaning of work
	Positive vision
Health awareness
	Healthcare-specific knowledge	-¹⁾	Interpersonal interaction
Role modelling
	Personal demarcation	-²⁾	-²⁾
	Serenity
	Stress regulation
Health behaviour
	Willingness to take risks	Accountability	Sufficient financial resources
	Pragmatism	Willingness to change	Sufficient time resources
	Critical self-reflection		Planning reliability
	Flexibility		Possibilities for flexible work design
	Decisiveness		Positive team climate
	Persistence		Multipliers within the team
	Creativity and innovative capacity		Exchange within the management team
	Exchange within external networks		Transparency and employee participation

Note: 1) No drivers were found in the data analysis. 2) Role modelling refers only to the leader as an individual.

Table 2

Barriers in the practice of health-specific leadership

Categories	Barriers
	Leader level	Employee level	Organizational level
Health value
	Lack of commitment to health promotion issues	Lack of self-responsibility	Insufficient support within the management team
	Low priority given to the issue	Employees’ lack of interest
Health awareness
	-¹⁾	-¹⁾	Lack of interpersonal interaction
Role modelling
	Insufficient personal demarcation	-²⁾	-²⁾
Health behaviour
	Lack of time	Habitual behaviour	Lack of financial resources
	Difficulties to convey the issue		Lack of time resources
	Impatience		Lack of personnel resources
	Insufficient health- specific knowledge		Lack of planning reliability
	Lack of persistence		Insufficient possibilities for work design
			Negative team climate
			Workload

Note: 1) No barriers were found in the data analysis. 2) Role modelling refers only to the leader as an individual.

3.1 Leader level

Leader level includes any aspects within the individual leader/manager, such as knowledge, attitudes or competencies. The participants described several drivers and barriers influencing health-specific leadership at the leader level. For each of the four aspects of health-specific leadership in theory, drivers and barriers have been found. With respect to health value, an economical perspective on health promotion, a positive vision and a reminder of the meaning of healthcare work were mentioned as facilitating factors. Supporting the employee health is not only a matter of goodwill but also affects economical and performance outcomes. However, a low priority for health issues and lack of commitment to health promotion issues were mentioned as hindering factors on the leader level.

With respect to health awareness, healthcare-specific knowledge helps managers understand employee working conditions and demands, and to address their needs.

With regard to health behaviour, certain proactive attitudes, including persistence, flexibility, decisiveness, pragmatism, and the willingness to take risks were mentioned as individual drivers. Referring to the willingness to take risks, one participant emphasized the importance of acting in a health-supportive way instead of inaction, although barriers might threat the outcome:

‘Of course, we make mistakes, but at that time we were in the planning phase, and we said, we can’t forecast every eventuality . . . Sometimes it will fall flat if you plan too long.’ (HM 2)

Besides these attitudes, creativity and innovative capacity, exchange within external networks and critical self-reflection were mentioned as drivers on leader level. Reflecting on their own behaviour and measures helps leaders to learn from their mistakes. However, some intrapersonal aspects of managers are also described as hindering factors for health behaviour. Participants mainly mentioned impatience and lack of persistence as relevant barriers. As successful outcomes can seem delayed, it is difficult for managers to hold on to health-supportive behaviour. Persistently making employee health a subject of discussion can be challenging for managers. Besides this, insufficient health-specific knowledge and difficulties in conveying the issue were mentioned as further intra-individual barriers for managers.

With regard to health-related role modelling, possibilities for stress regulation as well as serenity and personal demarcation were mentioned as drivers. Coping with stressful situations helps managers take care of their own health. However, insufficient personal demarcation was mentioned as a barrier. One participant stated that it is helpful to know his/her own limitations and that he/she cannot satisfy all employee needs:

‘I will never make everyone happy and satisfied, but I can live with these cutbacks.’ (NM 13)

3.2 Employee level

Employee level includes any aspects within the individual employee, such as knowledge, attitudes or competencies. The drivers and barriers described at the employee level relate to the theoretical aspects health value and health behaviour. The self-responsibility of employees was mentioned as a driver for leaders’ health value, whereas a lack of interest and lack of self-responsibility serve as barriers. If employees do not take responsibility for their own health, managers are limited in their capacity to affect employee health behaviour:

‘It is the lack of interest of my colleagues for their own, personal health. Uhm, then you can talk a lot, provide a lot, try a lot.’ (HM 16)

With regard to health behaviour, participants mentioned employee accountability and willingness to change as individual drivers, whereas habitual behaviour was mentioned as a barrier. For managers, it can be difficult to support employee health if the employees are stuck to habitual behaviour, for instance, routinized workflows that are harmful to their health.

3.3 Organizational level

Organizational level includes any aspects within the context of the organization, e.g. resources, structures, social interactions. Participants describe several drivers and barriers influencing health-specific leadership at this level. The influencing factors relate to health value, health awareness and health behaviour. Support within the management team is essential for maintaining the health value of the managers. A supportive head of management was particularly described as a relevant driver, as it often implies more resources, flexibility, and a larger scope of action for managers.

With regard to health awareness, the extent of interpersonal interaction was mentioned as a relevant driver. While a high level of exchange between supervisors and employees helps managers notice employee demands and health status, a lack of personal contact with the employees can hinder the managers’ ability to understand the individual working situations and limits of his or her employees, and thereby, his own health-awareness.

In terms of health behaviour, supporting employee health often requires additional financial, personnel and time resources. Limited time resources were the most tremendous barrier mentioned in the interviews. A lack of time for instance lowers the employee’s chance to participate in health activities and health promotion programmes. Due to restrictive legal provisions, healthcare facilities experience limited personnel resources and higher workloads for employees in general, which leads to increased probabilities of unhealthy work practices:

‘Because of the lack of time they say: ok, with bedding assistant I need 10 minutes, without I need 5 minutes. So I will do it without [assistant].’ (HM 8)

Participants also mentioned a high turnover rate and a lack of planning reliability as hindering factors for health behaviour in managers, as it implies low reliability and continuity. Besides these organizational resources, work design and possibilities to change those were mentioned organizational characteristics. Designing the workplace and workflow helps mangers support employee health, for instance, by roster arrangements or flexible job rotations. However, certain workflows and tasks are inevitable to ensure healthcare provisions and these often limit the possibilities for work design:

‘Of course, in theory it sounds good to provide job rotation and what not. But in healthcare it is only possible to a limited extent.’ (HM 13)

Furthermore, participants mentioned exchange within the management team as well as transparency and employee participation as additional drivers. Involving employees in decisions concerning health issues and the planning process, helps managers gain acceptance for new ideas and changes. As participants reported, multipliers within the team should be actively involved. These employees can convey the issue to their colleagues. A positive team climate was also mentioned as a driver for showing health behaviour, whereas a negative team climate was mentioned as a barrier.

4 Discussion

The aim of this study was to identify factors that influence the practice of health-specific leadership in healthcare facilities. The results show drivers and barriers on (a) leader level, (b) employee level, and (c) the organizational level. These were related to all four aspects of health-specific leadership (value, awareness, role modelling, and behaviour) based on previous research. Drivers and barriers were related mostly to health behaviour. It seems behavioural aspects were clearer to retrieve as participants were asked to reflect certain examples or situations from their experience.

Links to role modelling were only found on the leader level since it refers only to the leader as an individual. In addition, drivers and barriers are partially interrelated across and within the categories. For instance, managers’ creativity, willingness to take risks, as well as exchange with external networks on the leader level can bring up new ideas and create new possibilities for flexible work design on the organizational level. At the organizational level too, different factors are interrelated. Support from the head of management may be linked to financial or personnel resources, whereas interpersonal exchange and interaction in general may lower difficulties in conveying the issue and foster employee willingness to change. Previous research supports the present results by pointing out the relevance of several influencing factors found in this study. The key findings are discussed below.

4.1 Managers’ personal initiative

In terms of health behaviour, most drivers at the leader level relate to a proactive ‘hands-on’ mentality of the manager, such as decisiveness, willingness to take risks, flexibility, persistence and pragmatism. Proactive, self-starting and persistent behaviour can be understood as personal initiative. Taking a personal initiative results in an active approach to change the environment consonant with organizational goals [40]. Based on these goals, personal initiative is associated with different performance outcomes [41]. For health-specific leadership, employee health can be understood as the key performance outcome [22]. Showing initiative enables managers to actively support employee health and show health-supporting behaviour. Therefore, managers’ personal initiative can be interpreted as a central individual driver for successful practice of health-specific leadership. Concordant results were found in a study by Baer and Frese. The authors found personal initiative as a facilitating factor for organizational innovation and change processes [42]. With regard to managers’ self-care, personal initiative can also result in stress reduction [43] and thereby strengthen health-related role modelling. However, the relevance of personal initiative as a driver on the leader level is limited. Proactive behaviour can refer to different goals [44]. If managers prioritize not on employee health but on other outcomes, they might show personal initiative in areas not relevant to health-specific leadership. The concept of health-specific leadership addresses this issue through the aspect of health value. Only if managers are interested in employee health, are they motivated to show corresponding health behaviour [22]. It is also conceivable that managers show a high interest in health promotion and show personal initiative to implement health promotion measures, but the organizational goals do not prioritize employee health. In this case, limited support on the organizational level – as discussed below in 4.3. – could limit the relevance of personal initiative on health-specific leadership. Additionally, personal initiative by managers depend on further individual factors, such as relevant knowledge and personality factors (e.g. need for achievement, action orientation, and psychological conservatism) [41]. To conclude, personal initiative can be understood as an important driver for health-specific leadership. Future research should further investigate this relevance and the influence of personal initiative on health-specific leadership.

4.2 Employees’ willingness to change

At the employee level, accountability and willingness to change were mentioned as drivers, whereas habitual behaviour and a lack of interest were mentioned as counterpart barriers. The employees’ individual motivations and willingness to show health behaviour and participate in health promotion activities were the most important factors mentioned in the successful practice of health supporting behaviour. The relevance of an individual’s intention to change can be found in several common theories on health behaviour (e.g. Health Belief Model, [45], Transtheoretical Model, [46]) and are widely and empirically supported [47, 48]. The manager’s influence on employee health is limited if the individuals are not ready to change. Therefore, managers need to raise employees’ health awareness, self-efficacy and point out effects of healthy behaviour. However, an employee’s intention towards healthy behaviour is not always relevant to worksite health promotions. For instance, managers can show health-specific leadership behaviour and influence employee health by creating health-promoting workplaces that are not reliant on the employee willingness to change. Fostering job characteristics, such as autonomy, skill variety, task identity, task significance, and feedback from the job, support employee satisfaction and reduce anxiety, stress and burnout [49]. Also reducing irregular or overtime work could reduce health impairments [8]. Future research should further investigate the relevance of employee willingness to change as an important driver for successful health-specific leadership.

4.3 Organizational resources and restrictions

At the organizational level, sufficient financial, personnel and time resources are crucial drivers for the successful practice of health-specific leadership; whereas a lack of these resources is mentioned as a barrier. In a previous study, limited financial resources were found to be the main reason behind healthcare managers not being able to implement measures for health promotion [50]. Organizational support was also found to be a relevant resource before. Research in the field of occupational health and safety point out the importance of a supportive head of management for supervisors to manage occupational health and safety [51]. Furthermore, possibilities for flexible work design are relevant organizational characteristics. Wilde and her colleagues [24] identified organizational possibilities in job design as a significant predictor for initiating health-specific leadership. As mentioned above, leaders can support employee well-being by creating health-promoting workplaces and tasks that foster job characteristics, such as autonomy, skill variety, task identity, task significance, and feedback from the job [49]. However, barriers at the organizational level may be linked to specifications of the healthcare sector. Task requirements and legal frameworks can limit managerial possibilities to support employee health. For instance, legal restrictions on patient-staff ratio or wages can result in insufficient personnel and time resources, as well as a high workload. Insufficient possibilities for work design are also based on the needs of primary healthcare provision. This relation points out the relevance of environmental factors functioning as a framework for organizations as well as for individual staff members to act in. Horstmann and Eckerth already emphasized the relevance of environmental factors for leadership in the healthcare sector [52]. In the future, scholars should further investigate the relevance of organizational resources and restrictions as influencing factors for health-specific leadership.

4.4 Relevance of change management

The findings of this study indicate that the health behaviour of managers is often associated with health promotion interventions and measures. The literature on worksite health intervention emphasizes the relevance of planned change management processes [53, 54]. The drivers and barriers identified in this study support this perspective. Several identified factors were also found to be relevant to manage change processes. For instance, transparency and employee participation in the process can be understood as a guiding principle for occupational health interventions [55]. Participation in the decision process is a key predictor for employees’ openness to change [56]. Providing relevant information and communicating the purpose and sense are essential in this context [57, 58]. As another study showed, support within the management team is important for the implementation of health intervention at the workplace. While senior managers set high priority on the issue, middle managers take on a more proactive role. They engage the staff in participation, foster discussions, decide specific measures and monitor the process of implementation [59]. The results from previous research point out the relevance of change management for health-specific leadership. Therefore, managing the implementation of health-specific behaviour has to be considered an additional driver for health-specific leadership. Future research on health-specific leadership should further investigate the relevance of change processes and change management.

4.5 Limitations

There are several limitations to this study. In general, qualitative findings are open to interpretation. Although we implemented several strategies in the study design and procedure to assure trustworthiness, researchers’ subjectivity affects the framing of the interview questions and interpretation of the findings. In addition, study participation was voluntary and can cause sample bias since only managers with an interest in the topic participated. However, we are confident about the credibility of the findings as participants held different management positions and large sample size can create data saturation. The transferability of the findings to other settings and countries has to be viewed with caution. In particular national specifications in the healthcare sector vary in different national settings. However, we can assume transferability in the international context and to different settings. Similar frameworks and challenges are known to occur in other western countries [1, 2] and health-specific leadership shows generic characteristics, overarching sectoral specifics [60].

5 Conclusion

The study contributes a deeper understanding of health-specific leadership and could improve practice in healthcare services and nursing. The findings emphasise the relevance of different factors that influence the practice of health-specific leadership. Furthermore they support the theory of health-specific leadership since the identified drivers and barriers relate to all four aspects of the theory. To further validate the explorative findings, the results should be reviewed in quantitative studies and different national settings. Further theoretical examinations of the findings should be conducted.

The findings of this study point at the relevance of factors that influence the practice of health-specific leadership. They emphasize the complexity of successful health-specific leadership in the organizational context and underpin the need for a holistic approach for systematic health promotion. Thereby, supporting employee health has to be considered in context of individual and organizational factors. These results indicate implications for leadership practice and training. Personnel development programmes should foster managers’ self-reflection and self-care as well as competencies for change management and health-specific knowledge. Reflecting on their own role and intentions could help them show personal initiative in supporting employee health and act as a role model. When implementing specific measures for occupational health promotion, managers could facilitate successful implementation by managing the change process. But employees also need to be willing to change their health behaviour. They should therefore be sensitized about their individual responsibility towards their health and be motivated to exhibit healthy behaviour. However, some organizational barriers also result from restrictive legal frameworks in the healthcare sector. Reviewing these provisions on a political level appears promising and could ease successful practice of health-specific leadership and effective health promotion in healthcare facilities.

Conflict of interest

None to report.

Footnotes

Acknowledgements

The study was conducted as part of the greater research project, ’Innovation-Incubator Lueneburg’. The project was funded by the European Union and the German federal state of Lower Saxony. Grant number: CCI 2007DE161PR001.

The authors thank all participants for their time and valuable contributions to this study. The authors also acknowledge Christian Otto and Ivonne Poetschke who evaluated and discussed the categories and coding system.

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