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

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

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.

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:

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:

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:

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:

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:

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.

4.1 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].