University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA LEADERSHIP STYLE AND QUALITY HEALTH CARE DELIVERY A CASE STUDY OF THE MARGARET MARQUART CATHOLIC HOSPITAL, AT KPANDO IN THE VOLTA REGION OF GHANA BY RICHARD ADZOBU (10251288) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL IN HEALTH SERVICES MANAGEMENT DEGREE JULY, 2015 University of Ghana http://ugspace.ug.edu.gh DECLARATION I hereby declare that except for the references of other people‘s work which I have duly acknowledged by citing, the work presented here is by my own effort. No part of this work was previously presented in any form to the University or to any other body. ………………………… ……………………………… RICHARD ADZOBU DATE (10251288) i University of Ghana http://ugspace.ug.edu.gh CERTIFICATION I hereby certify that this thesis was supervised in accordance with the procedures laid down by the University ……………………… ……………………………… DR. LILY YARNEY DATE (SUPERVISOR) ii University of Ghana http://ugspace.ug.edu.gh DEDICATION This thesis is dedicated to God the almighty father for His love, directions, grace and supplies throughout my education. Secondly, to my blessed mum who fought tooth and nail to push me through secondary education, not forgetting my dear wife; Mavis Nanafio Adzobu who stood by me through thick and thin, my lovely daughter Chara Setiam and my son, Pius Senyanu from whom I derived inspiration when the going was getting tough. iii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT Since the lowest form of gratitude is considered a virtue and the highest form of ingratitude vice, I deem it highly imperative to register my sincerest appreciation, first to the almighty God, who alone knows the plans He has for everybody‘s life, and how best to bring those plans into fulfilment. I am particularly grateful to Dr Lily Yarney, my supervisor, whose guidance, suggestions, contributions and encouragement brought this work this far. My heartfelt appreciation goes to the Deputy Director of Nursing Services-Rev. Sister Magdalene Toffah and Mr Emmanuel Handson Torde, the administrator at the Margaret Marquart Catholic Hospital for their support during my data collection. Finally, to my colleagues, study mates, siblings and lecturers, I say God bless you tremendously for everything I derived from you. iv University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENT DECLARATION i CERTIFICATION ii DEDICATION iii ACKNOWLEDGEMENT iv TABLE OF CONTENTS v LIST OF TABLES x ABREVIATIONS xi ABSTRACT xiii CHAPTER ONE: INTRODUCTION 1.0 Background of the Study 1 1.1 Statement of the Problem 4 1.2 Objectives of the Study 6 1.3 Research Hypotheses 7 1.4 Justification of the Study 7 1.5 Conceptual Framework 8 v University of Ghana http://ugspace.ug.edu.gh 1.6 Definition of Key Concepts 9 1.7 Organization of the study 10 CHAPTER TWO: LITERATURE REVIEW 2.0 Introduction 11 2.1 Leadership 11 2.2 Leadership and Management 12 2.3 Theories on Leadership 13 2.4 Transformational Leadership 15 2.5 Transactional Leadership 17 2.6 Acquisition of Leadership Style 18 2.7 Quality in Healthcare 20 2.8 Determinants of Quality Healthcare Delivery 20 2.8.1 Organizational Culture and Quality Healthcare Delivery 21 2.8.2 Human Resource Management and Quality Healthcare Delivery 22 2.8.3 Patient centeredness and Quality Healthcare Delivery 24 2.8.4 Health Information System and Quality Healthcare Delivery 24 vi University of Ghana http://ugspace.ug.edu.gh 2.9 Leadership in Healthcare 28 2.10 Leadership and Quality Healthcare Delivery 32 CHAPTER THREE: RESEARCH METHODOLOGY 3.0 Introduction 34 3.1 Research Design 34 3.2 Research Approach 35 3.3 Study Area 35 3.4 Population 37 3.5 Sampling Technique and Sample Size 37 3.6 Sources of Data Collection 38 3.7 Research Instrument 39 3.8 Variables of the Study 40 3.9 Process of Data Collection 41 3.10 Data Analysis 42 3.11 Ethical Consideration 44 vii University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR: RESULTS AND DISCUSSION 4.0 Introduction 46 4.1 Background Information of Respondents 46 4.2 Leadership Styles in the various Wards 48 4.3 Quality Healthcare Delivery in the various Wards 49 4.4 Leadership Styles 49 4.4.1 Transformational Leadership Style 49 4.4.2 Transactional Leadership Style 50 4.4.3 Liasez-Faire Leadership Style 51 4.5 Summary of Leadership Style 51 4.6 Quality of Healthcare Delivery 52 4.7 Relationship between Leadership Styles and Quality Healthcare Delivery within the various Wards 52 4.8 Relationship between Leadership Styles and Quality Healthcare Delivery 57 4.9 Discussion of Findings 59 viii University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE: SUMMARY OF FINDINGS, CONCLUSION AND RECOMMENDATIONS 5.0 Introduction 63 5.1 Summary of Findings 63 5.2 Conclusion 64 5.3 Recommendations 64 5.4 Limitation 65 5.5 Direction for Future Study 66 REFERENCES 67 APPENDICE 76 ix University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 3.1: Cronbach Alpha Values 44 Table 4.1: Background Information of Respondents 47 Table 4.2: Leadership Style in the various Wards 48 Table 4.3: Quality of Healthcare Delivery in the various Wards 49 Table 4.4: Transformational Leadership 50 Table 4.5: Transactional Leadership 50 Table 4.6: Laissez Faire Leadership 51 Table 4.7: Summary of Leadership Styles 51 Table 4.8: Indicators of Healthcare Delivery 52 Table 4.9: Relationship between Leadership Style and Quality Healthcare Delivery within the Medical Ward 54 Table 4.10: Relationship between Leadership Style and Quality Healthcare Delivery within the Children's Ward 54 Table 4.11: Relationship between Leadership Style and Quality Healthcare Delivery within the Maternity Ward 55 Table 4.12: Relationship between Leadership Style and Quality Healthcare Delivery within the Surgical Ward 56 Table 4.13: Relationship between Leadership Style and Quality Healthcare Delivery within the Child and Reproductive Health Ward 57 Table 4.14: Relationship between Leadership Styles and Quality Healthcare 58 x University of Ghana http://ugspace.ug.edu.gh ABBREVIATIONS/ ACROYNMS CDC Centre for Disease Control CHAG Christian Health Association of Ghana CHPS Community Based Health Planning and Services DHMIs District Health Management Information System FRLT Full Range Leadership Theory HICT Health Information and Communication technology HIS Health Information System HIT Health Information Technology HIV/AIDS Human immunodeficiency Virus/Acquired Immune Deficiency Syndrome HRM Human Resource Development IOM Institute of Medicine MDGs Millennium Development Goals MLQ Multifactor Leadership Questionnaire MRI Magnetic Resonance Imaging NHIS National Health Insurance Scheme OCQ Organisational commitment Questionnaire RGN Registered Nurses RPE Recovery Preference Exploration xi University of Ghana http://ugspace.ug.edu.gh SPSS Statistical Package for Social Sciences TB Tuberculosis UTIs Uterine Infections WHO World Health Organization xii University of Ghana http://ugspace.ug.edu.gh ABSTRACT The main purpose of this study is to investigate the effect of leadership style on quality healthcare delivery at the Margret Marquart Catholic Hospital at Volta Region of Ghana. A descriptive cross- sectional design utilising a quantitative approach was employed for the study. Utilising a convenient sampling technique, one hundred and ten staff nurses from the Hospital were sampled. Analysis of data was carried out with the use of the Statistical Package for Social Sciences (SPSS). Analysis of data was mainly descriptive and correlational in nature. Findings of the study revealed that staff nurses perceived transformational leadership styles as the most dominating among nurse leaders than transactional and laissez-faire leadership style. Again, it was evident that transformational leaders of the Hospital exhibited individual motivation as a feature of their leadership characteristics. Furthermore, the study demonstrated a high level of quality healthcare delivery in the Hospital, with special reference to patient centeredness. Finally, the study revealed a significant and a positive relationship between transformational leadership styles and quality healthcare delivery, whiles transactional and laissez-faire leadership styles had no significant relationship with quality healthcare delivery. It is recommended that nurse leaders should demonstrate more of individual motivation and improve on contingent reward as a means to improve quality healthcare delivery. Also, future researchers should focus on comparing the effect of leadership style in different contextual settings, be it inter, or intra-regional. xiii University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.0 Background to the Study The delivery of Quality health care within the health care industry is not just a concept, but a significant yardstick to the well-being of patients and the financial survival of the industry. Seeing the importance of quality health care delivery, Aldanan, Piechulek and Al-Sabir (2001) highlighted that most developing countries are increasingly showing interest in the assessment of quality of health care delivery through national policies and programmes. The authors testified that, countries like Zambia, Ghana and South Africa are heightening up quality health care delivery. Zambia for example started a national quality assurance programme in 1994 ahead of other African countries (Adindu, 2010). The South African National Policy on Quality in Health Care provides the means of improving the quality of care in public and private sectors, sets objectives of government to assure quality and continuously improve health care by measuring the gap between standards and actual practice (Mseleku, 2007). In Ghana, health programmes and policies are in place to enhance health care quality. These policies include the National Health Insurance Scheme (NHIS), and the Community-based Health Planning and Services (CHPS). The National Health Insurance Scheme (NHIS) was established by the National Health Insurance Act, 2003 (Act 650) and the National Health Insurance Regulation, 2004 (L.I. 1809) with the view to improving the financial accessibilities of Ghanaians, especially the poor and the vulnerable, to quality basic healthcare service and to limit out-of-pocket payments at the point of service delivery (Gobah & Zhang, 2011). The Community-based Health Planning and Services (CHPS), on the other hand was initiated to bring healthcare to the doorstep of the community (Esena, 2013). This is to say that, the CHPS is a national programme that bridges the gap in healthcare access 1 University of Ghana http://ugspace.ug.edu.gh (reducing health inequalities and promote equity of health outcomes by removing geographical barriers to health care). It must be recognized that quality in healthcare has received diverse definitions which has led to different priorities and different goals, depending on the perspective of the constituents (the patients, their family, healthcare providers and professionals, regulators, insurers, and employers (Buttell, Hendler, & Daley, 2007). A universal definition of healthcare quality was formulated by the Institute of Medicine (IOM) in 1990. According to the IOM, quality consists of ―the degree to which health services for individuals and populations increase the likelihood of a desired heath outcome and are consistent with current professional knowledge‖ (IOM, 1990). Notwithstanding this definition, the IOM recommended four pillars for improving quality in health care organisations. These recommended pillars include leadership, learning from errors, performance standards and expectations for safety, and implementation of safety systems. Similarly, based on review of literatures, Bradley et al. (2010), identified leadership as part of seven identified factors of improving quality in health care organisations. Taking a closer look at the 1990 IOM report and the Bradley et al. (2010) report or guide for defining, measuring and improving quality of healthcare delivery, it can be concluded that one of the most decisive factors that possibly influence quality health care is leadership. Leadership is broadly considered as a pivotal instrument to operative on health-care system (Mosadeghrad, 2014; de Savigny & Adam, 2009; Vriesendorp et al., 2010). It is also one of the World Health Organization‘s Building Blocks of Health Systems (WHO, 2010). Discussions on how to better national governance in universal health, such as the case of the Accra Agenda for Action (Sridhar, 2009), and the African Leadership Forum (1988), are common. The World Health Organisation (2009), emphasized that national level leadership, within a healthcare organisation characteristically 2 University of Ghana http://ugspace.ug.edu.gh comprises putting policies in place, and overcoming planned direction, management of resource allocation, and observing policy targets and results. At the operative level, primary health care, hospital and district facility administrators are answerable for translating inputs and resources such as money, personnel, materials, equipment and structure into actual services that culminate into health results which respond favourably to the needs of the populace. As part of the efforts to improving managerial and leadership capacity in Ghana, a Leadership Programme (LDP) has been rolled out to arm health managers with the knowledge and skills in management and leadership to empower them utilize the limited resources available to achieve the objectives of their institutions (Ghana Health Service, 2009). However, in a current turbulent healthcare environment, a right leader who can stimulate a team to articulate innovative ideas to improve upon quality outcome is essential. In summary, the concepts of leadership style and quality health care delivery are very critical in healthcare organisations. According to Khan (2011), the utilization of these concepts regularly determines how organizations achieve their goals and objectives. Even though these concepts are closely related, they also differ in terms of meaning and application. Goetsch and Davis (2011), highlighted that in as much as they may be different in concept, the success of each concept in an organization depends on the working of the other; that is, when applied in a given organization, the two are rarely separable because they are intertwined. Leadership requires many elements, such as competencies, characteristics, and traits which yield an effective leadership mode capable of driving quality management and sustaining long- term evolution of the organization. A synthesized integration of these elements can drive forward a leader‘s ability to effectively influence an organizations such as healthcare organisations. It is in the light of this, that this study is interested in investigating leadership style and quality healthcare delivery. 3 University of Ghana http://ugspace.ug.edu.gh 1.1 Statement of the Problem Leadership in healthcare within our Ghanaian context is driven by long service, experience, academic qualification, and sometimes, political affiliation. Theories on leadership styles are however not taken into consideration to identify the inherent leadership qualities, personal beliefs, interests, aspirations and conviction of the appointee to ensure they best suit the position they are to occupy. When critical attention is not given to the leadership style of an individual, based on the inherent leadership qualities, attendant problems usually arise in the areas of productivity, monitoring, and organizational effectiveness (Kim, 2004; Sander, 2007), which in the long run, negatively affect the services of the healthcare industry. It is an axiom that to be a doctor, one needs seven years of post-secondary education, a nurse needs three years to make a diploma, but a leader within the healthcare setting needs on one day interview, or a three day orientation to be a good leader. If one actually wants to create transformational leaders for the progress of our countries institutions, then one must embrace leadership education which is currently missing in our institutions. It is therefore not surprising that healthcare institutions are confronted with a myriad of challenges, including a crunch in health service delivery, and difficulties in dealing with the pressures and numerous enigmas by healthcare organizations (van-dan Boom, Nsowah-Nwamah & Overbosch, 2004; Sakyi, Atinga & Adzei, 2012; Owusu-Bempah, Amoako, Frempong, & Assampong, 2013). In the midst of declining revenues and rising expenses, as well as increasing service demands due to population growth, the need to improve quality care and patient safety in healthcare is diverse and complex (Savage, Taylor, Rotarius, & Buesseler, 1997). This implies that it is incumbent on leaders in healthcare settings to have management talent sophisticated enough to match the complexity of the healthcare environment. Therefore, the right leadership style is needed in the healthcare environment. 4 University of Ghana http://ugspace.ug.edu.gh Leadership is considered by this study as not just a matter of occupying position and authority, also but having the appropriate influence, and foresight, creating a level playing field for all to function effectively, having the desire to serve and the ability to combine resources effectively to achieve a set target. When leaders with these abilities are placed in positions in healthcare settings, it ensures the free flow of information, effective and efficient use of resources, good interpersonal relations among workers, culminating in high productivity. The most excellent way to measure the performance of the healthcare sector in terms of leadership may be to research into the leadership styles currently in use to determine whether there is the use of the appropriate approach to leadership, and where possible, recommendations made. Extant literature on leadership styles in healthcare settings worldwide, show a positive trend in the use of leadership styles outside Africa. Among the reviews, a study by Ratnamiasih, Govindaraju, Prihartono, and Sudirman, (2012), on leadership and hospital service quality, revealed that a leadership style such as transformational leadership positively influence the quality of service in the hospital setting in Indonesia. But where this was absent, the consequences were devastating. Another study conducted in Iran by Attari (2013), on the impact of transformational leadership on nurse psychological empowerment, revealed a strong impact of transformational leadership on nurses‘ psychological empowerment, while there were weak performances where other leadership styles were evident. A related study on transformational and transactional leadership, by Jabnoun and Al-Rasasi (2005), revealed that service quality was found to be positively related to all transformational leadership dimensions. ALnidawy, Ahmad, and Omran (2014), researched on the effect of transformational leadership in confronting the challenges of the quality of health services by using total quality measurement in the Jordanian private health sector. This study found out that there was a 5 University of Ghana http://ugspace.ug.edu.gh positive effect of transformational leadership in confronting the challenges of quality in health services. The reviews above were all emphatic on the role leadership qualities play in quality health delivery outside Africa, with special reference to transformational and transactional leadership qualities. With focus on Africa, less research has been conducted with regards to leadership and its role in quality health care delivery. A research conducted by Curry, Taylor, Guey-Chi Chen, and Bradley (2012), attests to this fact by highlighting that ―literature regarding leadership has been developed primarily in the context of high-income settings. Less research has been done on leadership in low-income settings, including sub-Saharan Africa, particularly in health care.‖ (pp 2) In the Ghanaian context, limited literature exists on leadership and quality healthcare delivery, and even with that, few had tried to relate leadership to quality healthcare delivery. The inadequacy of literature on leadership in healthcare within the Ghanaian setting, brings in its wake the challenge of not identifying, or knowing the negative impact those lapses in leadership is having on quality healthcare delivery. And this, if not tackled would have the tendency of creating a vicious cycle of systemic impediments to quality healthcare delivery in the country. This research therefore sought to investigate the effect of leadership style on quality healthcare delivery, with the Margaret Marquart Catholic Hospital as a case study. 1.2 Objectives of the Study The general objective of this study was to investigate leadership style and quality healthcare delivery. The following are the specific objectives of the study. 1. To determine the predominant leadership styles in the various wards of the Margaret Marquart Catholic Hospital 6 University of Ghana http://ugspace.ug.edu.gh 2. To assess the level of quality healthcare delivery in the various wards of the Margaret Marquart Catholic Hospital 3. To find out the relationship between leadership style and quality healthcare delivery in the Margaret Marquart Catholic Hospital. 1.3 Research Hypotheses 1. H0: Transformational leadership style has no relationship with quality healthcare delivery H1: Transformational leadership style has a positive relationship with quality healthcare delivery 2. H0: Transactional leadership style has no relationship with quality healthcare delivery H1: Transactional leadership style has a positive relationship with quality healthcare delivery 3. H0: Laissez-faire leadership style has no relationship with quality healthcare delivery H1: Laissez-faire leadership style has a negative relationship with quality healthcare delivery 1.4 Justification of the Study A wealth of knowledge and experience in enhancing the quality of healthcare has accumulated globally over many decades. In spite of this wealth of experience, the problem frequently faced by policy-makers at country level in both high-middle-income and low-middle-income countries is to know which quality strategies complemented by, and integrated with existent strategic initiatives, would have the greatest impact on the outcomes delivered by their health care facilities. Leadership is fundamental in quality management, because, there is clear evidence that quality initiatives fail to realize their desired outcomes if there is no strong and consistent leadership support at every level for the action being taken. In the absence of strong and sustained leadership across the health system, any new strategic interventions are therefore unlikely to succeed. For the best outcomes to be achieved, 7 University of Ghana http://ugspace.ug.edu.gh strong leadership and support for quality needs to come from national and community leaders, as well as leaders of health-service delivery organizations. This study may promote a focus on quality in healthcare facilities and provide decision makers and planners with an opportunity to make informed strategic choices to advance quality improvement focusing on leadership. 1.5 Conceptual Framework The conceptual framework that the researcher used is self-developed and is shown in Figure 1. It presents the three main leadership styles of the Full Range Leadership Theory (Transformational, Transactional and Laissez-faire). Five most popular strategic areas potentially useful in improving quality healthcare delivery as postulated by the Institute of Medicine (IOM) (1990), and the World Health Organisation (WHO) (2010), were selected based on the researchers own discretion. These strategic areas include organisational culture, resource management, standards and regulations, patient centeredness and health information systems. Figure 1.1: Relationship between leadership style and quality health care delivery Types of Leadership style Constructs under quality healthcare Result Transformational Organisational culture Quality healthcare Transactional Resource ma nagement delivery Standards an d regulations Laissez-Faire Patient cente redness Health information systems 8 University of Ghana http://ugspace.ug.edu.gh 1.6 Definition of Key Concepts Leadership: Leadership is a process whereby an individual influences a group of individuals to achieve a common goal (Northouse, 2003). From the above definition of the term leadership, one can understand that it includes the process by which an individual influences others. The outcome of the process is nothing but to achieve a common goal through the commitment and willingness of both leaders and followers. In general, leadership is about relationship. Above all, it is about working with, and guiding people in new directions; it is about integrity and trust; achieving the most positive interaction between leaders and followers, customers, employees, shareholders, etc. Quality: quality has been defined differently by different authors. Pioneers of quality management practices such as Gavin, Juran, Crosby, Deming and Feigenbaum all provide their individual definitions of quality concepts. To Garvin (1987), quality was defined by investigating eight principle dimensions: performance, features, reliability, conformance, durability, serviceability, aesthetics and perceived quality. Juran (1951), defines quality as ―fitness for use‖ and focused on trilogy of quality planning, quality control and quality improvement. Similarly, Crosby (1996), defined quality as ―conformance to requirements or specifications‖ that is based on customer needs. Crosby (1996), proposed the 14 steps for zero defects quality improvement plan to achieve performance improvement. According to Deming (1986), quality is a predictable degree of uniformity and dependability, at a low cost and suited to the market. He also proposed the 14 principles of quality management to improve productivity and performance goals of organisations. Finally, Feigenbaum (1983), considers quality to be the embodiment of produce and service, which are characteristic of selling, production and conservation, through which the produce and service come in line with the anticipations of customers. 9 University of Ghana http://ugspace.ug.edu.gh 1.7 Organization of the study The report is organized into five chapters. Chapter one looks at the general overview of the study, the problem statement, the study objectives, research hypotheses, and justification, as well as the organization of the study. The second chapter focuses on a theory related to the research topic and a review of related literature on leadership style and quality healthcare delivery. The third chapter (chapter three) deals with the research methodology, which includes: research design, population, sampling technique, sample size, sources of data, research instrument and data analysis procedure. The fourth chapter presents the analysis and discussion of the study. The fifth and final chapter, presents summary of major the findings of the research, recommendations, and the general conclusion for the study. 10 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.0 Introduction This chapter presents literature review related to the purpose of this study. It involves examining documents such as journals, scholarly articles, dissertations books, and magazines that have a bearing on the study being conducted. The main purpose of reviewing the literature is to determine what has been done already relating to the research topic that is being studied. The chapter consists of two main broad sections; the theoretical literature review and the empirical literature review. 2.1 Leadership Leadership is an issue of prime importance and an area where research is frequently carried out especially among the organizational sciences. The exact composition of leadership cum its connection to vital conditional variables such as subordinates satisfaction, dedication, and presentation was uncertain. According to Luthans (2005), leadership continues to be a 'black box' or an unexplainable conception. Leadership behaviours and styles have had effects and will continue to have effect on individuals and on the results of organizations. A research conducted by James (2003), revealed the need for leaders to come up with better ways of satisfying clients, varying organizational structures, and answering burdens of brilliant staffs. Since leadership behaviours bring about diverse results, leadership at the policymaking level is laden with managers who desire to adopt best practices and presentations in their organizations (Kouzes & Posner, 2002). 11 University of Ghana http://ugspace.ug.edu.gh According to Kleinman (2004), those best practices can easily be translated into better results in other th parts of the organisation. The actual scientific research on leadership begun in the early 20 century and got improved till now. The first scientific study focused on the type of behaviours, abilities, sources of power, traits, aspect of a situation that identifies a leader‘s capacity to influence people and to effectively tackle group goals and objectives (Marriner-Tomey, 1993). Within our current dispensation, research considers leadership as an aspect of role differentiation due to social interaction processes (Bass, 1981). According to research by Bass and Avolio (2004), leadership is considered to have the ability to increase the maturity of people in leadership and enables them to meet their followers‘ expectations and needs. This made the desire to meet individual needs to shift to the desire to meet the needs of a group. While one moves with zeal and desire to meet group needs, that individual‘s needs are also automatically met. This leads to a more profound form of an exchange process and a relationship that can be considered as transformational. This has a lasting effect on the results or outcomes of leadership. 2.2 Leadership and Management Leadership and management are often erroneously considered to be the same. However, studies regarding leadership and management reveal distinct differences between these two concepts. According to French, Rayner, Rees and Rumbles (2009), a simple differentiation between management and leadership would be that management is concerned with the daily running of the organisation, while leadership has more to do with inspiration and long-term change. Management can be distinguished from leadership in that the former focuses on problem solving as well as planning, 12 University of Ghana http://ugspace.ug.edu.gh organizing, leading and control the use of resources, while the latter provides inspiration and motivation to gain subordinate support for the attainment of long-term goals. Thomas (2006), distinguishes between management and leadership in terms of output. The output of management is making the right decisions, while strong business results are the output of leadership; hence the importance of leadership as a contributing factor to service quality. Similarly, Yielder and Codling (2004), argue that management refers to systems, tasks, goals and results, whereas leadership focuses on human relations, organizing people and creating a vision of what might be as well as adopting a culture that can achieve that vision. Furthermore, according to Spendlove (2007), although there are a number of similarities between leadership and management, they are differentiated by the fact that leadership involves influencing people to achieve desired outcomes or goals. The focus of management is more on the organisation‘s current activities and the implementation of policies. In addition, Drafke (2009), contends that leadership deals with people‘s behaviour and it is only one aspect of management. Management is a broader concept that includes leadership as well as non- behavioural functions that do not immediately affect others. Drafke (2009), concurs with French et al (2009), and indicates that management is a process of planning, organizing, leading and control, whereas leadership is about inspiring people. Thompson (2009), argues that although leadership is a crucial task of management, anyone can be a leader. Equally important, Kouzes and Posner (2007) state that leadership is everyone‘s business; it is also a behaviour that can be taught and learnt. 2.3 Theories on Leadership Before discussing the foundational theory for this research study, one must understand how earliest theories have progressed to transformational and transactional leadership. Firstly, the Great Man 13 University of Ghana http://ugspace.ug.edu.gh Theory holds it that ―leaders are born and not made‖, giving rise to the idea that effective leaders will evolve naturally when needed (Bass & Bass, 2008). Early studies on leadership highlight that leaders lead people, mostly from an aristocratic and elevated position, or level, like a King, a President, or a Prime Minister. The authors; Derue, Nahrgang, Wellman, and Humphrey (2011), noted that individual traits influence leadership effectiveness. However, Derue et al. (2011) believed, leadership behaviours fluctuate between inherent traits and the followers‘ reactions to the leader. In the 1950s, behavioural theories laid emphasis on the development of leaders over inherited abilities. Moving away from the leader centric approach, researchers began exploring how leaders relate and interact with followers. Bass and Bass (2008), posited how Stogdill identified several personality traits and skills as critical to the success of leaders, most of which could be considered learned behaviours applicable in different situations. Additionally, Bass noted how Blake and Mouton‘s (1964), Managerial Grid introduced the balance between task and people. In the 1960s, the approach to leadership style or behaviour, was changed according to specific demands of a particular situation, which led to a spate of situational or contingency theories. The basic premises of these approaches are that no method will always be the best method. Differences in the leaders‘ personalities, followers‘ personalities, the task to be done, the urgency and/or importance of the task, the degree of the task structure, ability and expertise of the followers, and many other factors, together, determine what would be most appropriate and effective within specific situations. The major contingency models of leadership include Fiedler‘s leadership effectiveness model, House‘s path-goal theory, Hersey and Blanchard‘s (1969) situational leadership model, and Vroom and Yetton‘s decision-making model. 14 University of Ghana http://ugspace.ug.edu.gh Transformational, transactional and laissez faire leadership style under the Full Range Leadership Theory (FRLT) was preferred to any other leadership style due to their important features. The Full Range Leadership Theory was developed to broaden the range of leadership styles being studied from the paradigms of initiation of structure and consideration (Bass & Avolio, 2004), to a new paradigm of leaders‘ impact on followers' effort and performance as well as on group and organizational performance (p. 17). 2.4 Transformational Leadership In recent years, transformation and innovation have raised a lot of concern in every organization (Bass, Jung, Avolio, & Berson, 2003). In view of this, leaders are taking pragmatic steps to change the structure and processes in all types of organisations. Such efforts may include but not limited to downsizing, innovation, re-engineering, and restructuring, which requires strong leadership. As a result, Politis (2002), highlights that leadership is increasingly changing from information and knowledge gate keeping to knowledge creation and knowledge sharing for all employees. Leaders who can match their organisations to innovation are likely to exhibit transformational leadership (Bass & Avolio, 1993). Researchers have developed differing yet complementary definitions of transformational leadership. Burns (1978), defined transformational leadership as the process of pursuing collective goals through the mutual tapping of leaders‘ and followers‘ motives toward the achievement of an intended change. Followers are driven by moral needs, the need to champion a cause, or the need to take a higher moral stance on an issue; according to Burns, focusing on these needs makes leaders more accountable for their followers. Bass, Avolio, and Goodheim (1987), suggest that transformational leadership motivates followers to work for transcendental goals and higher levels of self-actualizing needs rather 15 University of Ghana http://ugspace.ug.edu.gh than simple exchange relationships. These definitions suggest that transformational leaders create a dynamic organisational vision that often necessitates a change in cultural values to reflect greater innovation. There are four factors that present the basic components of transformational leadership and are defined by (Bass, 1997; Bass & Avolio, 1990), as follow: (a) Idealized Influence: These leaders are self-confident, persistent, highly competent, and willing to take risks. (b) Individualized Consideration: Leaders with individualized consideration provide a supportive climate in which they offer personal attention and treat each employee individually. Such leaders listen and share an individual‘s concerns, while simultaneously helping to build the individual‘s confidences (Avolio, Waldman, & Yammarino, 1991). (c) Intellectual Stimulation: This type of leadership promotes intelligence, rationality, and careful problem solving (Bass, 1990; Northouse, 2001). As a result, followers are encouraged to try new approaches and develop innovative ways of dealing with organisational issues. (d) Inspirational Motivation: Transformational leaders inspire and motivate by providing meaning and challenges for their followers, using simple language, symbols, and images (Bass, 1997). Leaders are able to have followers involved in envisioning attractive futures with the company; they create clear expectations that the follower wants to meet and also demonstrate their commitment to the goals and shared vision (Avolio, et al., 1991). Transformational leadership therefore is concerned with the performance of the followers and the development of followers to achieve their potentials (Bass & Avolio, 1993). Bass (1990), views transformational leadership as going beyond the focus on the exchange between leaders and followers, to a broader view that elevates the interest of employees, and also stimulates employees to look beyond their own interests to what benefits the group, and encourages employees to accept the 16 University of Ghana http://ugspace.ug.edu.gh organisation‘s missions as their own. Bass (1985), contends that transformational leaders operate out of deeply held personal value systems that include justice and integrity. Followers trust transformational leaders because such leaders are always concerned for the organisation and the followers. Such leaders encourage followers to seek new ways to approach their jobs, resulting in inspirational motivation and intellectual stimulation (Bass, 1985). Thus, transformational leaders are able to generate greater creativity, productivity, and effort. 2.5 Transactional Leadership Several authors have suggested that most existing theories of leadership, such as the Ohio State studies, Fielder‘s Model, the Path-goal Theory, etc hold the view that leaders transact with their team members (Bass, 1985, 1990; Robbins, 2001). In contrast with transformational leadership, transactional leader-follower relationships are based on a series of rational exchanges that enable each follower to reach his or her own goals (Bass, 1985, 1990). In these exchanges, transactional leaders clarify the different roles that a follower must play, and the task requirements they must complete, to reach their personal goals and fulfil the organisation‘s mission (Kuhnert & Lewis, 1987). In practice, transactional leaders define and communicate what work the follower must do, how it will be done, and the rewards he or she will receive for successfully completing the stated objectives. As a result, employees understand their job roles and the expectations set for them by the leader and the organisation. In addition, employees are motivated and directed to achieve expected standards of performance, because, transactional leaders clarify what the followers receive for the specific level of effort, and/or the performance required of them (Avolio et al., 1991). Rewards for the expected performance may include, but not limited to, satisfactory performance ratings, pay increases, praise 17 University of Ghana http://ugspace.ug.edu.gh and recognition, and better work assignments, depending on the organisational context. According to Bass (1995, 1997), there are several different types of behaviour inherent in transactional leadership. (a) Contingent reward: The leader provides contingent rewards for good effort and good performance, and recognises accomplishments in order to reinforce appropriate behaviours and discourage inappropriate behaviours. (b) Management by exception: These leaders maintain a status quo and intervene when employees do not meet acceptable performance levels. (c) Laissez-Faire: This is described as the avoidance, or absence of leadership. The behaviour of leaders here entails avoiding decision making and abdicating responsibilities. 2.6 Acquisition of Leadership Skills The acquisition of leadership skills has been conceptualised differently by different scholars or authors. The following theories, explain how leadership skills are acquired. Congenital or Trait Theory This theory posits that, effective leaders are born with physical, social and personal traits or characteristics, not limited to height, integrity, intelligence, self-confidence, strong values, attractiveness, and creativity. The theory argues that, leaders are born and not made, that is to say that, leadership is innate and not developed through learning (Mann, 1959; Stogdill, 1948). Further research on this theory reported that, 12% of all leadership research published between 1990 and 2004 featured the keywords ―personality and leadership‖, an indication that in the acquisition of leadership skills, an individual‘s personality traits cannot be done away with (Judge & Bono, 2004). In another study 18 University of Ghana http://ugspace.ug.edu.gh conducted by Lord, De Vader and Alliger (1986), it was found out that there is a significant meta- analytic correlation leadership perceptions and intelligence, masculinity and dominance. One major drawback of this theory is that, it failed to take into account other important factors that contribute to effective leadership, such as, environmental and situational factors, making it too simplistic. Situational or Contingent Theory This theory believes that leadership depends upon each individual situation, and no single leadership style can be considered the best (Hersey & Blanchard, 1969). For Hersey and Blanchard, there are different tasks which require a different leadership style in each situation. The founders of the theory, explained that, goal setting, capacity to assume responsibility, education, and experience are main factors that make a leader successful, and not limited to the leadership style. The theory, further stated that, for a leader to be successful, the abilities and maturity of followers is a critical factor, as well. Acquired Leadership/ Behavioural Theory The above school of thought, has it that, leaders are groomed or nurtured. They believe that good leaders are not necessarily born with leadership skills but may acquire them, with the right conditioning. The theory focused on behavioural patterns rather than physical, social or mental characteristics. These theories resulted from research that began at Ohio State University in the late 1940s. The focus was on how leaders behaved towards followers, that is, the interaction between leaders and followers. Research on behavioural theory identified two types of behaviours, namely, task, and person-oriented behaviour. The former refers to the leader‘s focus on the achievement of goals while the later focuses on the building of interpersonal relationships. Thus the behavioural theory of leadership focuses on certain behaviours that differentiate effective leaders from ineffective leaders (Gronfeldt & Strother, 2006). 19 University of Ghana http://ugspace.ug.edu.gh It is important to note that, none of the leadership theories discussed above could strictly apply in a situation or real life practice, but rather the synergy of them work effectively, in real life. 2.7 Quality in Healthcare Defining quality in health care is problematic due to the multiple disciplines and professionals responsible for client care, and diverse clients with infinite needs to be satisfied. At an individual level, the term quality describes a product or service that satisfies ones expectations, then used as yardstick, or standard for assessing and measuring future experiences with similar product or service. This means that, quality of service even at the individual level is measured against expectations and standards. The most durable and widely cited definition of healthcare quality was formulated by the Institute of Medicine (1990). The IOM (1990), defines quality in health care as the degree to which health services for individuals or a population increase the likelihood of desired health outcomes, and consistent with current professional knowledge. Quality of care means health services provided by every health worker benefit patients without causing harm. Quality of care demands attention to the needs of patients and clients, using tested methods that are safe, affordable reduce deaths, illness, and disability (Offei, Bannerman, & Kyeremeh, 2004). Donabedian (1990), argues that quality comprises two parts, technical and interpersonal. The scientific component concerns application of science and technology by health professionals. The interpersonal however, deals with the social and psychological interactions that prevail during care process between clients and practitioners. 2.8 Determinants of Quality Healthcare Delivery Despite the existence of numerous measurements, or determinants of quality in healthcare delivery, this part of the literature review is interested in reviewing five major areas potentially useful for improving upon quality healthcare delivery. These include (1) organisational culture, (2) resource 20 University of Ghana http://ugspace.ug.edu.gh management, (3) standards and regulations, (4) patient centeredness, and (5) health information systems. 2.8.1 Organizational Culture and Quality Healthcare Delivery With its many definitions and meanings, culture has always been difficult to pin down (Braithwaite, Hyde, & Pope, 2010). Anthropological and sociological approaches tend to define culture as a set of attitudes, beliefs, customs, values and practices which are shared by a group (Alvesson, 2002). The group may be defined in terms of politics, geography, ethnicity, religion, or some other affiliation. The features which define the group may be shown in the form of symbols, language, artefacts, oral and written tradition and other means (Brown, 1995). One of the cardinal functions of these manifestations of a group‘s culture is to establish a distinctive identity and thereby provide a means by which members of the group can differentiate themselves from other groups. According to Schein (1997), culture, in this view, functions as a coordinating device. Institutions such as the health sector, are therefore formed and held together by the beliefs members hold about one another and the world. Healthcare organizations are value driven and consequently strive for excellence in meeting the needs of their patients in a caring, healing, quality focused and safe environment (Carney, 2002). Developing a culture of healthcare safety is a global priority whereby open reporting, where adverse events are reported, analysed and learned is needed. Kearsey (2003) found that a correlation existed between a healthy workplace environment and a healthy patient. Miller, et al. (2009), postulated that technical and team competence are both necessary competencies needed to achieve high reliability in order to ensure safe patient care. Thus, clinical managers are well placed to deliver ethical health care, due to their professional background, that is firmly grounded in ethics and values and safe care, and because of their understanding of the ethical conflicts that can occur in health care delivery (Carney, 2006). 21 University of Ghana http://ugspace.ug.edu.gh Another factor, highlighted in the literature, dwells on how culture influences quality healthcare delivery in terms of performance. Jacobs, Mannion, Davies, Harrison, Konteh and Walshe (2013) examined the association between organizational culture and performance in hospitals. Their study revealed that organizational culture varies across hospitals over time. This variation is at least in part associated and predictable with a variety of organizational characteristics and routine measures of performance. In consonance with this, Carney (2011), highlighted that organizational culture is more complex than previously thought. In her study, she revealed that several cultural influences such as excellence in care delivery, ethical values, involvement, professionalism, value-for-money, cost of care, commitment to quality and strategic thinking were all found to be key cultural determinants to quality care delivery. To elucidate aspects of organizational culture associated with hospital performance in preoperative antibiotic prophylaxis using quantitative data in a multi-dimensional study, Uwaka, Tanaka, Morishima, and Imanaka (2014), revealed that hospitals with a high score in organizational culture were more likely to adhere to the Japanese and Centre for Disease Control (CDC) guidelines when compared with lower scoring hospitals. 2.8.2 Human Resource Management and Quality Healthcare Delivery Human Resource Management (HRM) is a significant management activity in every organization, of which the health sector cannot be excluded. HRM is centred on the development of both individuals and the organization as a whole. Thus, the function of HRM is not limited to securing and developing individual workers talent, but also, deals with engineering and implementing programs, or activities, that enhance coordination and cooperation between workers in an organization in order to nurture 22 University of Ghana http://ugspace.ug.edu.gh organizational development. The key functions of HRM include resourcing, performance, reward systems, learning and development, and employment relationship (McKinnies, 2012). Studies have shown the importance of HRM functions in developing the quality of healthcare services. A paper by Kabene et al. (2006), concluded that the management of human resources is critical in providing a high quality of healthcare. Therefore, it is important to consider HRM in healthcare and more research needed to develop new policies. Ofori-Okyere and Aboagye (2015), also noted that HRM functions such as support systems and the retention of best talents in healthcare, are critical to the delivery of quality healthcare to patients. Elarabi and Johari (2014), noted that the effectiveness and efficient management of human resources in healthcare settings is essential to the delivery of medical service and patient satisfaction. In their study, strong evidence was observed on how effective HRM can improve healthcare quality and performance of hospital staffs. The area of training and development is core to Human Resource Management (HRM), which in turn, produces quality in healthcare delivery. Weaver et al. (2014), noted that patients are safer and receive higher quality of care as a result of in-service training of health professionals. Adding to this, Alnasir and Jaradat (2013), highlight that primary healthcare centres are ideal places for optimal training due to smaller group training situation, and the benefit of students facing actual patient setting. The association between hospital conscription and the quality of healthcare delivery continues to be a noteworthy concern for health services scholars, healthcare administrators, policymakers and clients. Tubbs-Cooley, et al. (2013), revealed that, less patients with one doctor or nurse are less likely to be readmitted. In addition, Kunaviktikul, et al. (2008), identified the relationships between nurse staffing, including nursing working hours per patient day; and patient outcomes of patient falls, pressure ulcers, and uterine infections (UTIs). The findings show a statistically positive relations between nursing 23 University of Ghana http://ugspace.ug.edu.gh working hours per patient day, and three adverse patient outcomes; patient falls, pressure ulcers and UTIs. From the review, it is no gainsaying that the practices of human resource management are very important in health sector and modern hospitals should have alternative approaches for practicing HRM successfully. Senior management in hospitals should have a clear strategic direction and clear objectives to improve the management of employees and staff in hospitals. 2.8.3 Patient centeredness and Quality Healthcare Delivery Patient-centred care is a concept that is used in the health services literature to describe health care that is guided by the needs and values of the patient, rather than the health care system, organization, or the health professional (Institute of Medicine, 2001). It has been used as a framework for the evaluation of health care services, and for proposing reform of the health care system. Patient centred care (also called person centred, client centred, or patient focused care), has been adopted as an ideal form of practice in a number of health care professions, including medicine, nursing, occupational therapy, and rehabilitation (Radwin, Cabral & Wilkes, 2009; Leplege, Gzil, Cammelli, Lefege, Pachoud & Ville, 2007). Patient centred care has also been examined as a health care process leading to certain kinds of health and patient-satisfaction outcomes. Some studies have shown significant associations between the adoption of patient centred care practices, and improved health care outcomes. Other studies are less conclusive. Mead and Bower (2002), reviewed the literature on patient centred communication in primary care consultations and patient satisfaction outcomes. They found eight studies which evaluated the patient- centeredness of primary care physicians‘ communications, and they concluded that the link between patient-centered communication styles and patient satisfaction was weak. There did not appear to be 24 University of Ghana http://ugspace.ug.edu.gh much of a relationship between the degree of patient-centeredness in the physician‘s consultation with the patient and the patient‘s level of satisfaction with the visit. Mead, Bower and Hann (2002), conducted a study in which they used the Roter Interaction Analysis System to assess the degree of patient-centeredness of 173 videotaped general practitioner consultations. They sought to discover whether there was an association between a patient-centered consulting style, and patient satisfaction and enablement. They found that patient-centered behaviours on the part of the physician did not predict satisfaction, or patient enablement. Zandbelt, Smets, Oort, Godfried, and de Haes (2007), examined the importance of patient-centred communication by internal medicine physicians. They found that physicians‘ patient-centred communication was associated with patients‘ active participation in the health care encounter. Surprisingly, they found that physicians‘ inhibiting behaviour, which was considered not to be patient- centred, was also positively associated with patients‘ active participation in the visit. They hypothesized that inhibiting behaviour was the physicians‘ response to patients‘ increased participation in the visit. Patient centred care principles have been associated with a recovery orientation in the rehabilitation of patients with severe physical disabilities (Stineman, Kurz, Kelleher & Kennedy, 2008). Stineman et al. (2008), used a technique called Recovery Preference Exploration (RPE) to determine the relative significance of a variety of functional activities to people with severe disabilities. RPE enabled the participants to specify which activities were most important to them in their rehabilitation. Stineman et al. concluded that RPE was a patient-centred method for conducting treatment planning and assessment with people in rehabilitation settings. 25 University of Ghana http://ugspace.ug.edu.gh Radwin, et al (2009), explored the relationship of several patient centred nursing interventions— individualization of care, responsiveness, proficiency, and care coordination—with outcomes for cancer patients. They found that individualization of care was associated with three desired health outcomes: authentic self-representation, optimism, and sense of well-being. The patient centred nursing interventions of responsiveness and proficiency were related to subsequent trust in nurses. 2.8.4 Health Information System and Quality Healthcare Delivery Health Information Systems (HIS) is one of the six essential and interrelated building blocks of a health system. A well-functioning HIS should produce reliable and timely information on health determinants, health status and health system performance, and be capable of analysing this information to guide activities across all other health systems (WHO, 2007). Thus, an HIS enables decision-makers at all levels of the health system to identify progress, problems, and needs; make evidence-based decisions on health policies and programs, and optimally allocate scarce resources (WHO, 2008), all of which are key elements in the success of large-scale efforts to achieve health improvements (Peerman, Rugg, Erkkola, Kiwango & Yang, 2009). A study on the impact of ICT-tools in health care delivery in sub-Saharan hospitals revealed that patient identification, financial management and structured reporting improved significantly after implementation of well adapted ICT-tools in a set of 19 African health facilities (Verbeke, Karara, & Nyssen, 2013). Appropriate HIS are seen as crucial to strengthen the health system in developing countries and pursuing the Millennium Development Goals (MDGs) (Acheampong, 2012). On the ground, however, HIS and especially hospitals information systems development in developing countries has proved difficult due to the high cost of initial start-up, poor computer skills by health personnel, culture, poor maintenance and the lack of policy to spearhead the implementation of the 26 University of Ghana http://ugspace.ug.edu.gh system (Acheampong, 2012). Amidst these challenges, HIS can nevertheless potentially reduce patient waiting times, reduce hospital operations, improve inter-professional communication and collaboration, and enhance better resource allocation (Acheampong, 2012). Health Information and Communication Technology (HICT) has the potential to reduce patient waiting time and improve satisfaction. Long patient waiting times for patient seeking medical treatment are a big issue for both developed and developing countries. A study by Kabashiki and Moneke (2014), revealed the absence of a significant association between HICT use, and referral waiting times. However, a significant correlation was found to exist between (1) HICT use and health information sharing effectiveness, (2) HICT use and physician satisfaction and (3) HICT use and patient‘s satisfaction. In an effort to systematically review published evidence on the impact of health information technology (HIT) or health information systems (HIS) on the quality of healthcare delivery, Jamal, McKenzie and Clark (2009), highlighted that out of 23 studies, 17 assessed the impact of HIT/HIS on health care practitioners‘ performance. A positive improvement, in relation to their compliance with evidence-based guidelines was seen in 14 studies. Studies that included an assessment of patient outcomes, however, showed insufficient evidence of either clinically, or statistically important improvements. Although the number of studies reviewed was relatively small, the findings demonstrated consistency with similar previous reviews of this nature in that the wide scale use of HIT has been shown to increase clinician‘s adherence to guidelines. A study on the impact of ICT tools on health care delivery in sub-Saharan African hospitals revealed that patient identification, financial management, and structured reporting improved significantly after implementation of adapted ICT tools in a set of 19 African hospitals (Verbeke, Karara, & Nyssen, 2013). 27 University of Ghana http://ugspace.ug.edu.gh In the area of reproductive health and healthcare utilization, the use of ICT has gained much prominence. Worldwide, about 28700 women die each year from mostly preventable complications related to pregnancy and childbirth. A disproportionately high number of these deaths occur in sub- Saharan Africa. With this global challenge, Oyeyemi and Wynn (2014) called for cell phones to be given to pregnant women as a means of improving services and increasing their utilization of primary health care systems. In line with this, Abeka-Nkrumah, Guerriero, and Purohit (2014), highlighted that the use of technology is both positive and significant. They concluded that ICT has a good capacity to influence women‘s demand of health information, and recommended the need to take into consideration, maternal health policies and interventions. In Ghana, the District Health Management Information System (DHIMS) software application is primarily used for data capture, aggregation and generation of management report. However, this software has been replaced with the District Health Information System (DHIS2), which carries out similar but improved functions of the DHIMS) (Acheampong, 2012b). Acheampong (2012b), noted that electric power supply, internet connectivity, resistance to new technology and lack of maintenance culture pose a challenge in the utilization of ICT in the health sector of Ghana. 2.9 Leadership in Healthcare Due to the changes that occur in the society over the past few decades, require a change in focus of leadership research in the field of health. Indicators for the need for change included the growing demand for leaders in the health and social service fields; the increased gender and cultural diversity in the workplace; the globalization of organizations; rapidly changing work environments; and the information and technology revolution (Vance & Larson, 2002). Leadership is one of the main factors that affected employee engagement and retention. The structure and culture of hospitals influence 28 University of Ghana http://ugspace.ug.edu.gh leadership behaviours, and additional research that includes both the external and internal environmental factors and results in measurable outcomes is needed. A descriptive correlational study conducted by McGuire and Kennerly (2006), examined the relationship between the key variables: leadership style of nurse managers, and the organizational commitment of staff nurses working on their respective units. Nurse leaders that demonstrated transformational leader characteristics promoted a higher sense of commitment in their followers. The measurement instruments included a demographic form, the Multifactor Leadership Questionnaire (MLQ) Form 5X (Bass & Avolio, 2004) to measure transformational and transactional leadership characteristics, and the Porter and Smith (as cited in McGuire & Kennerly, 2006) Organizational Commitment Questionnaire (OCQ) to measure organizational commitment. The research found that nurse managers rated themselves higher on transformational leadership than did their staff nurses. Furthermore, the research demonstrated statistically significant correlations between the staff nurses' scores on the MLQ and the OCQ except for the transactional subscale labeled management-by-exception. The strongest positive correlation was 'idealized influence' also called charismatic leadership. Finally, the study revealed no significant correlation between the nurse managers' self-assessed leadership characteristics, and the degree of organizational commitment demonstrated by their staff nurses. The research work by Anthony et al. (2005), recognized that successful nurse managers held the same principles found in servant leadership, and considers servant leadership as the new paradigm of nursing leadership. Neill and Saunders (2008), described servant leadership as a powerful skill set that was particularly effective in regard to nursing leadership. Servant leadership was often applied to nursing management and was founded on the belief that nurse leaders are motivated to serve their 29 University of Ghana http://ugspace.ug.edu.gh employees who in turn served others (Anderson et al., 2010; Anthony et al., 2005; Neill & Saunders, 2008; Northouse, 2010). Northouse (2010), explained that there had been an increased interest in servant leadership since its development by Robert Greenleaf in the early 1970s. The approach had not been uniformly defined, resulting in different measures of the construct. A common theme running through the different servant leader perspectives was related to the importance of leaders' attention to the needs of their followers. Dunham-Taylor (2000), examined a national sample of 396 randomly selected hospital nurse executives, and 1,115 staff nurses in the United States. The study participants rated the nurse executives' leadership style, staff nurse extra effort, staff nurse job satisfaction, and work group effectiveness using Bass and Avolio's Multifactor Leadership Questionnaire (MLQ). The results from the study found that nurse executives were more transformational, they achieved higher staff nurse job satisfaction and higher work group effectiveness. The study also suggested that effective leaders exhibited characteristics of both transformational and transactional management styles. The IOM (2004), Keeping Patients Safe: Transforming the Work Environment of Nurses, identified creating and sustaining trust throughout the organization as a critically important leader quality. Laschinger and Finegan (2005), explained that nursing management had to regain and maintain the trust of their employees to meet the impending nurse shortage. Laschinger, et al. (2007), tested a theoretical model linking nurse managers' perceptions with their supervisors and empowerment to job satisfaction in a sample of 141 hospital-based nurse managers. They hypothesized that a higher quality leader-member exchange (LMX) would result in higher levels of nurse manager job satisfaction. The results of the study indicated that higher quality relationship between nurse manager and supervisor resulted in a greater sense of empowerment both 30 University of Ghana http://ugspace.ug.edu.gh environmentally and psychologically and as a result, nurse managers were more likely to be satisfied with their job. The results of the study indicated that nurse managers had a reduced intent to leave the job because of their job satisfaction. The relationships that nurse leaders developed with their staff could influence staff satisfaction and retention. Anderson, Manno, O'Connor, and Gallagher (2010), used a national database of nursing quality indicators to analyse the characteristics of exemplary nurse managers as identified by their staff that supports staff nurse job satisfaction and retention. The recommendations from the study included a focus on leadership techniques of servant leadership, and to incorporate elements of nurse leader visibility and communication with the values of respect and empathy. Neill and Saunders (2008), conducted a study to describe the experience of the nurse leaders that implemented servant leadership at the George E. Wahlen Veterans Affairs Medical Center in Salt Lake City, Utah and consistently earned exceptional rankings in quality patient care and increased professional satisfaction in nursing practice. Ten principles of servant leadership that could be applied in nursing practice included listening, empathy, healing, awareness, persuasion, conceptualization, foresight, stewardship, committed to the growth of people or 'people builders', and building community. Nursing management is a difficult and challenging task. Leadership style in nursing management was the research study conducted by Sellgren, Ekvall, and Tomson in 2006. Questionnaires were sent to nurse managers and their subordinates to assess the preferred leadership behaviour in three areas: change, production and employee/relation orientations. The questionnaire was also used to assess the subordinates' perceptions of their manager's leadership behaviour. The conclusion of the study found that subordinates preferred managers with more clearly expressed leadership qualities than those demonstrated (Sellgren et al., 2006). 31 University of Ghana http://ugspace.ug.edu.gh A field study conducted by Purvanova, Bono, and Dzieweczynski (2006), linked transformational leadership behaviours to employees' perceptions of their jobs. The employees' perceptions included the significance, meaningfulness, and importance of their work. The managers rated job perceptions to employees' citizenship performance. The results of the study indicated a positive link between managers' transformational leadership behaviours and followers' citizenship performance. Employees who reported managers that engaged in transformational leadership behaviours, rated their jobs as more challenging, meaningful, and significant (Purvanova et al., 2006). 2.10 Leadership and Quality Healthcare Delivery Quality is a process that begins with a vision which is actively promoted by the organizational leader. Its achievement requires an effective leadership that will be in a position to build a healthy organizational culture. Clearly, leadership is one of the important issues of quality management. According to Ulle and Kumar (2014), the success of an organization is by sustained leadership with a purpose, communication among teams, and total commitment by the top management who focus on customer satisfaction. In a study carried out by Alharbi and Yusoff, (2012), to determine the relationships between leadership styles and quality management practices in Saudi public hospitals, it was revealed that transformational leadership style had a significant, positive relationship with quality management practices. However, it was evident that though, the transactional and laissez-faire leadership styles were found to be significant, they had a negative relation to quality management practices. Based on their results, it was recommended that hospitals recruit leaders with transformational style, and also hold seminars to train current leaders to become more transformational. 32 University of Ghana http://ugspace.ug.edu.gh Similarly, a research paper on the role of transformational leadership in impacting the level of total quality management implementation in the higher education sector, revealed that transformational leadership dimension has positive influences and significance towards the practices of total quality management in the selected universities of the study (Argia & Aismail, 2013). In an exploratory study to identify factors affecting the quality of healthcare services provided in Iranian healthcare organisations, Mosadeghrad (2014), noted, that healthcare quality can be improved by a supportive visionary leader. In an integrative review of studies, Alloubani, Almatari, and Almukhtar (2014), stated that several research studies in the field of leadership have found that transformational leadership attributes and behaviours have a positive relationship with organizational outcomes such as teamwork success, effectiveness, staff satisfaction, commitment, extra effort and more. Moreover, transformational leadership processes have been found to enhance followers‘ work-oriented values and shape self- efficiencies of followers. In a related study, Safari and Sabouri (2014), revealed that managers‘ application of knowledge in principles of total quality management in the statistical population, was higher than medium, and styles of collaborative, persuasive, and delegating leadership were directly related to the level of applying total quality management. Also, it was found that the style of commanding leadership was inversely related to the level of applying total quality management. In fact, the more the commanding style of leadership was used, applying principles of total quality management was less considered. 33 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE RESEARCH METHODOLOGY 3.0. Introduction This chapter describes the research methods employed in carrying out the study. The chapter has been distinctively sectioned for easy reading and consistency. It includes the research design, research approach, study area, population, sampling technique and sample size, sources of data, research instrument, variables for the study, the process of data collection, data analysis procedures and ethical considerations. 3.1. Research Design This study followed an explanatory cross-sectional design to determine the relationship between leadership style and quality healthcare delivery (the study variables). Thus, it attempts to clarify how, and why, there is, or not, a relationship between leadership styles (transformational, transactional and Laisez-faire) and quality healthcare delivery within the context of the Margaret Marquart Catholic hospital. As Saunders, Lewis and Thornhill (2009) noted, explanatory research is about studying a situation, or a problem, in order to explain the relationships between the variables. Hence, explanatory study design was used to determine and explain the relationship between the dependent variable; quality healthcare delivery, and the independent variable; leadership styles (transformational, transactional and Laissez-faire). A cross-sectional design was employed because the study was carried out at one particular time and not over several periods. The choice for a cross-sectional design is that it is economical, with reference to data collection, and also enabled the researcher to identify attributes of the specific population. 34 University of Ghana http://ugspace.ug.edu.gh 3.2. Research Approach A quantitative approach was employed for both data collection and data analysis. Quantitative research is a study whose findings are mainly the product of statistical summary and analysis. This approach was employed because of the application of a structured questionnaire during data collection. Also, data was analysed using quantitative methods. This followed the hypothetical-deductive method where hypotheses were formulated in order to confirm or disprove the final results. The results were then used to draw inferences from the entire population. 3.3. Study Area The study area for this research is the Margaret Marquart Catholic Hospital which is located at Kpando; the capital of Kpando District in the Volta Region of Ghana. The district lies within latitudes 6 º20‘N and 7 º0.5‘N, and Longitude 0 º17‘E. The Kpando District shares boundaries with the Biakoye District in the North, the Hohoe District to the East, and the newly created South Danyi District in the South. The Volta Lake which stretches over 80k, demarcates the Western boundary. The District covers a total land area of 820 square kilometres, representing 4.5% of the Volta Region with almost 30% of the land being submerged by the Volta Lake (Ghana Statistical Service, 2010). The population for the District as released by the 2010 census was 93,649, with males representing 44,553 and females representing 49,096. The population structure is young, with about 38.1% aged between 0-14, and lower than the regional average of 41.1%. The aged population, that is, people with ages 60 years and above account for 9.8%, while the economically active population of 15 years to 59 years is represented by 52% (Ghana Statistical Service, 2010). The population pyramid is therefore of a bell-shaped with a broad base, which tapers off with increasing age. 35 University of Ghana http://ugspace.ug.edu.gh With a young population, the district is characterized by a high dependency ratio. There are however, exceptions in the age groups 5 – 9 years, 55-59 years and 60-64 years, which have larger populations than those of their immediate younger groups for both males and females. With increasing age, the structure looks slightly thinner for the males than the females, indicating that, at the older ages, the proportion of males is lower than that of the females, except for the age group 15-19. The District economy is mainly dominated by agricultural activities, and it is estimated that about 62% of the active population is engaged either directly, or indirectly, in this sector (Ministry of Agriculture Report, 2012). The Margaret Marquart Catholic Hospital is a Christian Health Association of Ghana (CHAG) institution, and the biggest health facility within the entire Kpando District. It was established on the rd 3 of February, 1960 by GRAIL sisters, a religious congregation within the Roman Catholic Church. Historically, the visionaire; Margaret Marquart, came with Anita and Philip to start the Hospital in a girls school classroom, given to them by the community, before soliciting funds from Miseror; an organization in Germany. They then put up the entire current buildings. The Hospital itself has done some extensions to the maternity and children‘s wards, which could be considered current structures (Hospital Record, 2013). The other new innovations added currently include a gynaecological theatre and an eye clinic that was started in1998 but has no permanent doctor. The Hospital has an MRI unit yet to be operational, a pregnancy scan, and an x-ray unit. Currently, the nursing population stands at 150, with 65 enrolled nurses, out of which 2 are due for retirement, 48 registered nurses, 27 midwives that are RGNs 27, 10 enrolled nurses who are mid wives, 6 out of which were due for study leave, with 4 having finished 36 University of Ghana http://ugspace.ug.edu.gh serving their bonds and ready to join their husbands elsewhere. On the part of doctors, the Hospital has one Gynaecologist, 4 doctors, and 7 medical assistants. As at the time of this research, the allocation of nurses to the various wards included children wards- 29 nurses, surgical ward 21 nurses, medical ward, 28 nurses, and maternity ward, 46 nurses. There is a ward for AIDS patients, and TB patients. A weighing and maternity issues unit named Child Reproductive and Health Unit (CRHU) has 10 nurses. The Margaret Marquart Catholic Hospital was considered as appropriate because of its position as the largest health facility in the entire District, and also because it serves as a referral hospital for health centres in other districts. Moreover, its position as a CHAG institution, forbids workers from going on strike. This attribute of the Hospital enabled the researcher to have a continuous contact through the data collection period. 3.4 Population The population for this study consisted of all workers in Margaret Marquart Catholic Hospital in the Volta Region of Ghana. A sample frame for the study included all the nurses found at the Hospital. The purpose for selecting nurses as target population for this study was that nurses are the immediate healthcare givers of patients. Secondly, they constitute a larger population of the health care centres or organizations; therefore they have the capacity to either negatively or positively influence the quality of healthcare delivery. 3.5. Sampling technique and Sample size In this study, the convenient sampling technique was employed to select participants for the study. Looking at the stressful working condition and environment of the target population, it was deemed 37 University of Ghana http://ugspace.ug.edu.gh appropriate to choose the convenient sampling technique, since the respondents-the staff nurses and nurses in general usually run on shifts and some were not interested in participating in the research. A sample of 110 nurses was drawn for the study. The criteria for selecting participants included the following: Nurses who work in the wards, all nurses working as subordinates to the ward in-charge, and all nurses with a health certificate from any recognised institution. The reason was to ensure that only the qualified category of respondents took part in the process. 3.6. Sources of Data The study made use of both primary and secondary data. A survey questionnaire was used as the primary source of data collection. The questionnaire was designed to address the research objectives and hypothesis. This was in the form of a Likert scale anchored by a five point rating, ranging from 1 to 5. Secondary sources of data were obtained through review of published literature such as journal articles, and published text-books which relate to the research topic under consideration. These were obtained from credible online sources such as the Journal of Health Management, LANCET, PubMed, Escohost, Emerald, among others. Keywords such as quality in healthcare, leadership in healthcare, and others were used to enable the researcher do an extensive online search. The researcher also made use of secondary data from hospital records. These sources were reviewed to give an insight into the search for primary information. They gave an insight on the selection of variables, and the discussion of the findings. 38 University of Ghana http://ugspace.ug.edu.gh 3.7. Research Instrument A questionnaire was used as the main research instrument for the study. The questionnaire was sectioned into three parts, namely, the background information, leadership styles, and the quality of healthcare practices. The background information measures the characteristics of the respondents. The purpose of this information was to provide a pictorial background of the respondents. The background information had variables such age, gender, marital status, educational level, and work related factors such as length of service and department allocated. Leadership style was measured using an adapted and modified instrument known as the Multifactor Leadership Questionnaire (MLQ Form 5X), as developed by Bass and Avolio (1997). The MLQ contains 36 statements that measure key aspects of leadership behaviour (transactional, transformational and laissez faire). These statements were modified to suit the study area. The instrument is measured on a five point Likert scale, scoring from 1 to 5. The interpretation of the scores is as follows: 1= ―not at all‖, 2= ―once in a while‖, 3= ―sometimes‖, 4= ―fairly often‖, and 5= ―always‖ (Bass & Avolio, 1997). The questionnaire has been found to be reliable and valid by several authors. In a study conducted by Bass and Avolio (1997), a reliability scale (Cronbach Alpha) of 0.71 to 0.96 was found. Also Lowe, Kroeck, and Sivasubramaniam (1996), found a reliability of 0.80. Finally, Avolio, Bass, and Jung (1999), concluded that reliability of each individual factor of the MLQ ranges from 0.74 to 0.94. Avolio et al. (1999), further noted that the reliabilities in each data set of the MLQ Form 5X were reliable for measuring, or determining leadership styles. Given the reliability of the scales, this survey questionnaire was deemed appropriate for this study. 39 University of Ghana http://ugspace.ug.edu.gh Since quality is a multi-dimensional construct, five determinants (patient‘s centeredness, organizational culture, human resource management, standards and regulations, and health information systems) of quality of healthcare delivery were identified through an extensive review of literature. In total, twenty-nine (29) statements, or items were employed to measure the quality of healthcare delivery. The items or statements were in a form of a five-point Likert scale. Scoring of the scale ranges from 1=strongly disagree to 5=strongly agree. Each determinant of quality of healthcare obtained a good reliability coefficient, ranging from 0.77 to 0.9. (See table 3.1 for details on reliability and appendix for sample questionnaire). 3.8. Variables for the Study The following variables were used for the study: A dependent variable, which refers to a variable that is simply measured by the researcher. It is the variable that reflects the influence of the independent variable. In this study, the dependent variable was quality healthcare delivery. This construct was measured by five determinants of quality healthcare delivery, namely, organizational culture, patient- centeredness, human resource management, health information systems, and standards and regulations. Independent variables, which are the factors that can be varied, or manipulated in an experiment. The independent variable(s) are those, which will have a hypothesis to influence the dependent variable(s). The independent variable in this study is leadership styles, (transformational, transactional and laissez- faire leadership styles). 40 University of Ghana http://ugspace.ug.edu.gh 3.9. Process of Data Collection Before data collection, a pre-test of the questionnaire was done, using 20 nurses at the Ridge Hospital in the Greater Accra Region. This was to test the suitability of the questionnaire. It also allowed for the evaluation of the questions for relevance, comprehension, meaning and clarity. The process helped to ascertain the validity and the reliability of the research instrument, because, fine-tuning was done to make the questions simple, meaningful and relevant before the actual data collection. Permission was sought from the management of the Margaret Marquart Catholic Hospital before data collection. Also, a written consent form was signed by the respondents individually as and when they came into the wards. Two research assistants were employed and trained by the researcher to help in the data collection. They were chosen based on their knowledge of the Hospital setting, since they were ward assistants before leaving for school. The purpose of the study was unambiguously spelt out to the respondents, and they were further informed that taking part in the research was purely on voluntary grounds. Participants were also told that they could opt out of the study without any penalty. A survey method of data collection was used and this was done in three main ways. Questionnaires were distributed to 60 respondents who filled and returned them the same day. Secondly, 40 respondents were given questionnaires to take home and return them at their own convenience, but not later than a week. The third category were respondents who either were too busy attending to clients, or putting records right, or even felt lazy reading. Therefore, the questionnaires had to be read to them by the researcher, and the appropriate answers ticked accordingly. It attracted a response rate of 100%, representing 110 respondents. There were a few missing responses with individual questionnaires, and these were excluded from the analysis, and this accounted for the variation in the number of participant responses or the ‗N‘ values. 41 University of Ghana http://ugspace.ug.edu.gh The data was analysed and the presence of leadership styles determined. Additionally, the level of quality healthcare delivery was determined and the relationship between leadership styles and quality healthcare was derived. It is worth mentioning that the respondents were limited to only the staff nurses in the wards, and not the nurses in charge, since they were the focus of the study and were not allowed to influence or interfere with the process. Verbal permission however, was sought from them to permit their subordinates to participate in the study. 3.10. Data Analysis Procedure Data was analysed with the application of the Statistical Package for Service Solution (SPSS) version 20.0 software. All questionnaires received were referenced and items on the questionnaire coded to facilitate data entry. ―Missing data‖ codes were created for questions which were not answered. In addition, questions with no answers were considered as missing data and excluded from the data analysis. After data coding, the next phase of the analysis was data cleaning which entailed checking for errors on entry. Analyses of data was divided into two main parts, namely descriptive and inferential. Descriptive analysis was employed to give the description of all variables in the study. The descriptive analysis was achieved using frequency tables, mean values and standard deviation values. In the analysis, the variable or statement with the highest mean value represented its most occurring frequency in the ward. In addition to this, variables or statements of the respondents with the lowest standard deviation value represented its closeness to the rating, or no significant variation in the various ratings of the respondents. Descriptive statistics was used because it enabled the researcher to meaningfully describe the distribution of scores or measurements. 42 University of Ghana http://ugspace.ug.edu.gh Inferential statistics was performed, using the correlational analysis to determine the relationship between leadership styles and quality healthcare delivery. The choice for this analysis was because correlation measures both the strength and significance of a relationship unlike chi-square that measures the significance of the relationship. To determine the relationship between leadership styles and quality healthcare delivery, the Pearson correlations coefficient (r) was used. When the Pearson‘s correlation coefficient (r) is greater than 0.50, it indicated a strong relationship between leadership style and quality health delivery. Also, when the r value is around 0.30 it indicates a moderate relationship and finally, when the r value was less than 0.20, it was an indication of a weak relationship. For the purpose of this study, a Correlation was conducted with a significance level of 0.05. Data reliability was computed to measure the internal consistency and average correlation of the instrument. The average correlation was measured using Cronbach‘s alpha coefficient which ranges between 0 and 1 (Kipkebut, 2010). Higher alpha coefficient values indicated that there was consistency among the statements in measuring the concept of interest. As a rule of thumb, acceptable alpha should be at least 0.70 or above. George and Mallery (2003), provided the following rule of thumb ―≥9= excellent, ≥ 8= good, ≥ 7= acceptable, ≥ 6= questionable, ≥ 5= poor and ≤ 5= unacceptable‖ (p.231). The implication of this is that a high value for Cronbach‘s alpha, indicates good internal consistency of the items on the scale. The table below represents the Cronbach Values of each variable in this study. 43 University of Ghana http://ugspace.ug.edu.gh Table 3.1: Cronbach Alpha Values Construct Cronbach's alpha N of items Idealized Influence (Attribute) 0.741 4 Inspirational Motivation 0.852 4 Idealized Influence (Behaviour) 0.824 4 Intellectual Stimulation 0.774 4 Contingent Reward 0.857 4 Management by Exception (Active) 0.904 4 Management by Exception (Passive) 0.709 4 Laissez Faire 0.821 4 Patient Centeredness 0.789 7 Resource Management 0.855 9 Health Information System 0.768 5 Standard and Regulation 0.947 5 Organisational Culture 0.881 3 Source: Field Data, 2015 3.11. Ethical Considerations The following ethical considerations were adhered to when conducting the research Voluntariness/consent The purpose of the study was explained to all participants and a written consent was obtained before data collection. Participation in the study was completely voluntary, and the right to withdraw at any point in the study was made known to all participants. Participants were also given the right to skip any question which they considered to be sentimental without any penalty. Potential risks This study avoided any physical risk or harm. However, it must be noted that some questions might be seen as personal, or emotionally sensitive. 44 University of Ghana http://ugspace.ug.edu.gh Potential benefit/compensation Participants of the study were duly informed before their participation that there would be no direct material or financial benefit for their participation, but rather, their participation might bring a them sense of satisfaction for participating in an important study that may likely help formulate health policies to improve upon the standard of leadership behaviour and quality healthcare delivery in the Hospital Privacy/ confidentiality All information from participants was kept confidential, thus, personal identifiers such as names were not included during data collection. In addition, information obtained from participants was not altered. Data storage and usage All information obtained was electronically stored and password protected in a personal computer, and access was limited to only the researcher and the supervisor. 45 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS AND DISCUSSIONS 4.0. Introduction This chapter presents the results and discussions of the study findings. The results have been structured in line with the research objectives. Some respondents failed to answer some questions hence, a missing value was marked. A total frequency of less than 110 responses in the analysis implied that there were some missing values. All missing values were excluded from the analysis. For example, in table 4.1, a total frequency for higher level of education attainted was 107 instead of 110. This is an indication that three respondents failed to provide the appropriate data on their educational level. 4.1. Background Information on Respondents The majority of nurses were females, representing 63.60%, n = 70, while only 36.60%, n= 40 were males. In addition, it was noted that the majority of the nurses, representing 89.10%, n=98, were within the ages of 20 and 29, while only10.90%, n= 12 of the nurses, were within the ages of 30 and 39. Furthermore, the study indicated that most nurses, approximately 74.50%, n= 82, were not married, while only 25%, n=28 were married. A significant number of nurses, representing 95.30%, n= 102 were Diploma holders, while only 4.70%, n= 5 of the nurses, were Degree holders. Mention must be made of the fact that, about half of the respondents; 51.40%, n= 55, had been working with the Hospital for 2 to 3 years. And, 37.40%, n= 40 of nurses had been with the organisation for less than a year, while 11.20%, n= 12 had been with the organisation for four (4) years, or more. 46 University of Ghana http://ugspace.ug.edu.gh Table 4.1: Background Information of Respondents Variables Frequency Percent Gender Male 4 0 3 6.40 Female 70 63.60 Total 110 100.00 Age 20-29years 9 8 8 9.10 30-39years 12 10.90 Total 110 100.00 M arital Status Single 82 7 4.50 Married 28 25.50 Total 110 100.00 Higher Education Attained Diploma 1 02 9 5.30 Degree 5 4.70 Total 107 100.00 Years Spent in this Organisation Less than 1 year 40 37.40 2-3years 55 51.40 Four years and above 12 11.20 Total 107 100.00 Ward Medical Ward 24 22.40 Maternity Ward 41 38.30 Children's Ward 22 20.60 Surgical Ward 14 13.10 Child and Reproductive Health Ward 6 5.60 Total 107 100.00 Source: Field Data, 2015 47 University of Ghana http://ugspace.ug.edu.gh Finally, the study revealed that 22.40%, n= 24 of the nurses, worked in the Medical Ward, while 38.30%, n= 41 worked in the Maternity Ward, 20.60%, n= 22 worked in the Children‘s Ward, 13.10%, n= 14 worked in the Surgical Ward, and finally, 5.60%, n= 6 worked in the Child and Reproductive Health Ward. (Table 4.1) 4.2. Leadership Style in the various Wards Transformational leadership was the most dominant leadership style exhibited in all the wards. This was followed by transactional leadership, and finally laissez-faire. The ward with the most dominant transformational leadership style was the Surgical Ward (n= 14, 3.76). This was followed by the Medical Ward (n= 24, 3.69). The Child and Reproductive Health Ward (n= 6, 3.50) took the third place. This was followed by the Maternity Ward (n= 41, 3.20), and finally the Children‘s Ward (n= 22, 3.08). Table 4.2: Leadership Style in the various Wards Wards Transformational Transactional Laissez-Faire (M) (M) (M) Medical Ward 3.69 2.70 1.58 Maternity Ward 3.20 3.02 2.32 Children‘s Ward 3.08 2.75 2.00 Surgical Ward 3.76 3.06 1.96 Child and Reproductive Health Ward 3.50 3.36 2.17 Source: Field data, 2015 48 University of Ghana http://ugspace.ug.edu.gh 4.3. Quality of Healthcare Delivery in the various Wards The Child and Reproductive Health Ward (n= 6, 4.43) recorded the highest quality of healthcare delivery. This was followed by the Medical Ward (n= 24, 4.11). The Surgical Ward (n= 14, 3.65), recorded third in terms of quality healthcare delivery. This was followed by the Maternity Ward (n= 41, 3.60), and finally, the Children‘s Ward (n= 6, 3.09). Table 4.3: Quality of Healthcare Delivery in the various Wards Wards Quality of Healthcare Delivery (M) Medical Ward 4.11 Maternity Ward 3.60 Children‘s Ward 3.09 Surgical Ward 3.65 Child and Reproductive Health Ward 4.43 Source: Field data, 2015 4.4. Leadership Styles 4.4.1. Transformational Leadership Inspirational Motivation with a mean value of 3.60, (n=105), was perceived as the dominant transformational leadership style exhibited by the nurses in-charge of wards in the Margret Marquart Catholic Hospital. This was followed by intellectual stimulation with a mean value of 3.36, (n=105), idealized influence (Behaviour), with a mean value of 3.35, (n=105), and idealized Influence (Attribute), with a mean value of 3.27, (n=105). Individualised consideration with a mean value of 3.25 (n=105) was perceived as the least transformational leadership style exhibited by the nurses in- charge. An overall mean value of 3.37, (n=105), was an indication that nurses in-charge of the various wards at the Hospital mostly practicing transformational leadership. 49 University of Ghana http://ugspace.ug.edu.gh Table 4.4 Transformational Leadership facets of transformational leadership N M ean S td. Deviation Idealized Influence (Attribute) 105 3.27 0.78 Idealized Influence (Behaviour) 105 3.35 0.57 Idealized Consideration 105 3.25 0.75 Intellectual Stimulation 105 3.36 0.70 Inspirational Motivation 105 3.60 0.79 Total 105 3.37 0.55 Source: Field Data, 2015 4.4.2. Transactional Leadership Contingent reward was perceived as the highest type of transactional leadership among nurses in- charge, with a mean value of 3.41 (n=105). This was followed by active management by exception and passive management by exception, with a recorded mean value of 3.19 (n=105), 2.13 (n=105), respectively. The overall mean value of 2.91 implied that nurses‘ in-charge of wards in the ospital sometimes practised transactional leadership. Table 4.5 Transactional Leadership Statements N Mean Std. Deviation Contingent Reward 105 3.41 0.76 Management by Exception (Active) 105 3.19 0.90 Management by Exception (Passive) 105 2.13 0.84 Total 105 2.91 0.49 Source: Field Data, 2015 50 University of Ghana http://ugspace.ug.edu.gh 4.4.3. Laissez Faire Leadership The overall mean rating of 2.03 (n=95), indicates that nurses in-charge of the various wards at the hospital do not demonstrate laissez faire leadership style in their execution of duties. Table 4.6: Laissez Faire Leadership Statements N Mean Std. Deviation Nurses in-charge avoid getting involved when important issues arise 105 1.85 1.28 Nurses in-charge are mostly absent when needed 103 1.64 1.18 Nurses in-charge usually avoid making decisions 97 2.28 1.25 Nurses in-charge often delay responding to urgent questions 97 2.59 1.24 Total 95 2.03 0.87 Source: Field Data, 2015 4.5. Summary of Leadership Styles The findings indicate that transformational leadership style, with an overall mean value of 3.37 (n=105), was recognised as the most practised leadership style exhibited by nurses in-charge of wards in the Margaret Marquart Catholic Hospital. This was followed by transactional leadership, with an overall mean value of 2.91 (n=105), and finally laissez faire leadership, recording an overall mean value of 2.03 (n=105). Table 4.7: Summary of Leadership Styles Behaviours N Mean Std. Deviation Transformation leadership 105 3.37 0.55 Transactional leadership 105 2.91 0.49 Laissez Faire Leadership 105 2.03 0.87 Source: Field Data, 2015 51 University of Ghana http://ugspace.ug.edu.gh 4.6. Quality Healthcare Delivery The findings indicated that patient centeredness, organizational culture, standards and regulations, with mean values of 4.07 (n=105), 4.02 (n=97), 3.88 (n=97) respectively, were the major determinants of quality healthcare delivery at the Margaret Marquart Catholic Hospital. In addition, resource management and health information systems, with mean values of 3.45 (n=105) and 2.73 (n=97) respectively, were moderately considered as determinants of quality healthcare delivery. The total mean of 3.66 (n=97), was an indication that quality healthcare delivery at the Hospital was high. Table 4. 8: Indicators of Healthcare Delivery Std. Indicators of Quality Healthcare Delivery N Mean Deviation Patient Centeredness 105 4.07 0.99 Standards and Regulations 97 3.88 0.67 Resource Management 105 3.45 0.74 Health Information Systems 97 2.73 0.99 Organisational Culture 97 4.02 2.16 Total 97 3.66 0.70 Source: Field Data, 2015 4.7. Relationship between Leadership Style and Quality Healthcare Delivery within the various Wards It was indicated that, in the Medical and Children‘s Wards, there was no statistically significant relationship between leadership styles and quality healthcare service. Thus, transactional, transformational and laissez faire leadership styles were not significantly related to quality healthcare service in both wards (p > 0.05). See Table 4.9 and 4.10 for details. There were statistically significant and positive relationships between transformational leadership and quality healthcare delivery in the Maternity Ward (r = 0.806, p < 0.05). Thus, transformational 52 University of Ghana http://ugspace.ug.edu.gh leadership was positively associated with quality healthcare delivery such that when supervisors in the Maternity Ward exhibited more of transformational leadership, quality healthcare delivery increased significantly. However, transactional leadership and laissez faire leadership styles were not significantly related to quality health care delivery in the Ward ([p > 0.05]. See Table 4.11 for details) In the Surgical Ward, there was a significant positive relationship between transformational leadership and quality healthcare delivery (r = 0.88, p < 0.05). This meant that the higher the transformational leadership, the higher the quality healthcare delivery in the Ward. However, the results suggested that, transactional and laissez faire leadership styles were not significantly associated with quality healthcare delivery (p > 0.05). See (Table 4.12 for details) In the Child and Reproductive Health Ward, all the leadership styles were significantly related to quality healthcare delivery. There was a highly significant negative relationship between transformational leadership and quality healthcare delivery in this Ward (r = -0.991, p < 0.05). This suggested an inverse relationship between transformational leadership style and quality healthcare delivery. Hence, leaders in the Ward who demonstrated less of transformational leadership, tended to record significantly higher level of quality healthcare delivery, than leaders who demonstrated more of transformational leadership. Transactional and Laissez-faire leadership styles were positively related with quality healthcare delivery. However, transactional leadership was found to be more significantly related to quality healthcare delivery (r = 0.964, p < 0.05), than Laissez faire leadership (r = 0.892, p < 0.05). Thus, leaders who demonstrated more of transactional leadership recorded a higher level of quality healthcare delivery than those who demonstrated more of laissez faire leadership. (See table 4.13 for details) 53 University of Ghana http://ugspace.ug.edu.gh Table 4.9: Relationship between Leadership Style and Quality Healthcare Delivery within the Medical Ward Transformati Transactio Laissez Faire Quality onal nal Leadership Healthcare leadership leadership Pearson Correlation 1 -.266 -.215 .355 Transformational Sig. (P value) .208 .313 .088 leadership N 24 24 24 24 ** Pearson Correlation -.266 1 .765 -.230 Transactional Sig. (P value) .208 .000 .279 leadership N 24 24 24 24 ** Pearson Correlation -.215 .765 1 -.223 Laissez Faire Sig. (P value) .313 .000 .295 Leadership N 24 24 24 24 Pearson Correlation .355 -.230 -.223 1 Quality Sig. (P value) .088 .279 .295 Healthcare N 24 24 24 24 **. Correlation is significant at the 0.05 level. Ward = Medical Ward Source: Field Data Analysis Table 4.10: Relationship between Leadership Style and Quality Healthcare Delivery within the Children's Ward Transform Transaction Laissez Faire Quality ation al leadership Leadership Healthcare leadership ** Pearson Correlation 1 .645 -.268 .329 Transformation Sig. (P value) .001 .228 .135 leadership N 22 22 22 22 ** Pearson Correlation .645 1 .288 .048 Transactional Sig. (P value) .001 .193 .832 leadership N 22 22 22 22 Pearson Correlation -.268 .288 1 -.236 Laissez Faire Sig. (P value) .228 .193 .291 Leadership N 22 22 22 22 Pearson Correlation .329 .048 -.236 1 Quality Sig. (P value) .135 .832 .291 Healthcare N 22 22 22 22 54 University of Ghana http://ugspace.ug.edu.gh **. Correlation is significant at the 0.05 level. Ward =Children‘s Ward Source: Field Data Analysis Table 4.11: Relationship between Leadership Style and Quality Healthcare Delivery within the Maternity Ward Transform Transactio Laissez Quality ation nal Faire Healthcare leadership leadership Leadership ** Pearson Correlation 1 .148 -.212 .806 Transformation Sig. (P value) .357 .183 .000 leadership N 41 41 41 41 Pearson Correlation .148 1 .076 .230 Transactional Sig. (P value) .357 .635 .148 leadership N 41 41 41 41 Pearson Correlation -.212 .076 1 -.193 Laissez Faire Sig. (P value) .183 .635 .226 Leadership N 41 41 41 41 ** Pearson Correlation .806 .230 -.193 1 Quality Sig. (P value) .000 .148 .226 Healthcare N 41 41 41 41 **. Correlation is significant at the 0.05 level. Ward = Maternity Ward Source: Field Data Analysis 55 University of Ghana http://ugspace.ug.edu.gh Table 4.12: Relationship between Leadership Style and Quality Healthcare Delivery within the Surgical Ward Transforma Transactio Laissez Quality tion nal Faire Healthcare leadership leadership Leadership ** Pearson Correlation 1 .489 -.428 .888 Transformation Sig. (P value) .107 .166 .000 leadership N 12 12 12 12 Pearson Correlation .489 1 .531 .344 Transactional Sig. (P value) .107 .075 .274 leadership N 12 12 12 12 Pearson Correlation -.428 .531 1 -.494 Laissez Faire Sig. (P value) .166 .075 .103 Leadership N 12 12 12 12 ** Pearson Correlation .888 .344 -.494 1 Quality Sig. (P value) .000 .274 .103 Healthcare N 12 12 12 12 **. Correlation is significant at the 0.05 level. Ward = Surgical Ward Source: Field Data Analysis 56 University of Ghana http://ugspace.ug.edu.gh Table 4.13: Relationship between Leadership Style and Quality Healthcare Delivery within the Child and Reproductive Health Ward Transforma Transactio Laissez Quality tion nal Faire Healthcare leadership leadership Leadership ** ** ** Pearson Correlation 1 -.991 -.945 -.991 Transformation Sig. (P value) .000 .004 .000 leadership N 6 6 6 6 ** ** ** Pearson Correlation -.991 1 .980 .964 Transactional Sig. (P value) .000 .001 .002 leadership N 6 6 6 6 ** ** * Pearson Correlation -.945 .980 1 .892 Laissez Faire Sig. (P value) .004 .001 .017 Leadership N 6 6 6 6 ** ** * Pearson Correlation -.991 .964 .892 1 Quality Sig. (P value) .000 .002 .017 Healthcare N 6 6 6 6 **. Correlation is significant at the 0.05 level. Ward = Child and Reproductive Health Ward Source: Field Data Analysis 4.8 Relationship between Leadership Style and Quality Healthcare Delivery within all the Wards Transactional leadership was not significantly related to quality health care delivery (p = 0.13). Therefore, the null hypothesis was accepted, whiles the alternative was rejected. It was further revealed that there was no significant relationship between laissez faire leadership and quality health care delivery (p = 0.15), indicating that neither the null, nor the alternative hypothesis stood. 57 University of Ghana http://ugspace.ug.edu.gh Finally, transformational leadership was found to have a significant and positive relationship with quality health care delivery at the Margaret Marquart Catholic Hospital (r = 0.402, p = 0.00). This allowed for the acceptance of the alternative hypothesis, and the rejection of the null hypothesis. This is an indication that when the level of transformational leadership increased, the level of quality health care delivery increased moderately. On the other hand, when the level of transformational leadership decreased, the level of quality health care delivery also decreased. Table 4.14: Relationship between all Leadership Styles and Quality Healthcare Transform Transactio Laissez Quality ation nal Faire Healthcare leadership leadership Leadership ** ** Pearson Correlation 1 .164 -.341 .402 Transformation Sig. (P value) .095 .000 .000 leadership N 105 105 105 105 ** Pearson Correlation .164 1 .334 .148 Transactional Sig. (P value) .095 .001 .132 leadership N 105 105 105 105 ** ** Pearson Correlation -.341 .334 1 -.142 Laissez Faire Sig. (P value) .000 .001 .147 Leadership N 105 105 105 105 ** Pearson Correlation .402 .148 -.142 1 Quality Sig. (P value) .000 .132 .147 Healthcare N 105 105 105 105 **. Correlation is significant at the 0.05 level (2-tailed). Source: Field Data Analysis of all Leadership Styles 58 University of Ghana http://ugspace.ug.edu.gh 4.9 Discussion of Findings Transformational leadership style emerged as the dominant leadership style among nurses in-charge of wards at the Hospital. This is an indication that nurses‘ in-charge harness the ideas of their subordinates in addition to theirs to achieve a common goal for the development of the hospital. Another significant finding related to a higher mean value of inspirational motivation as a transformational leadership characteristic among nurses‘ in-charge of the wards. This is an indication that nurse‘s in-charge inspire and motivate their subordinates, challenging them to do more by using symbols, images and simple language. Furthermore, individualised consideration recorded the least mean value as a transformational leadership characteristic among nurse‘s in-charge. This is an indication that nurses‘ in-charge, sometimes create a congenial atmosphere for their subordinates, by giving personal attention to the needs of individual staff. Findings from this study with regards to the dominance of transformational leadership style, are consistent with a previous study carried out by Abosliaigah, et al., (2014). Their study demonstrated that staff nurses showed a high sense of transformational leadership than transactional and laissez-faire leadership styles. Other studies carried out by Kleinman (2004), Tyczkowski, Vandenbouten and Reilly (2015), it also revealed that nurse leaders consistently perceive a high mean frequency of transformational leadership behaviour, as compared to transactional leadership behaviour. However, findings of a study by Waleed and Charuwan (2014), revealed a low level of transformational leadership to a high level of transactional leadership. Transformational leaders are characterized by motivating employees to do more than is required of them, and gaining a sense of commitment through their vision and confidence, towards transforming the Hospital. This matches with the assertion by Robbins and Davidhison (2007), that transformational 59 University of Ghana http://ugspace.ug.edu.gh leaders tend to foster open communication, horizontally and vertically by, providing inspiration and enthusiasm, and creating harmony among their staff. In view of these characteristics, Negussie and Demissie (2013), highlights that staff nurses prefer a transformational leadership style to a transactional leadership style. Globalization and technological advancement in today‘s world have led to continuous changes in the duties, or activities in health care service provision. Even more so, health care service provision has become complicated with the continuous development in therapeutic skills. In light of this, the value of health care services lies in the capacity to improve the health outcomes of individuals, which health outcomes, are broadly conceptualized to mean how satisfied clients are with the services being provided which in turn lead to quality healthcare delivery. The findings of this study, have shown that the quality of healthcare at the Margret Marquart Catholic Hospital is of a high standard. Since the measurement of quality is a multidimensional, this study reviewed five factors that contribute to quality in healthcare provision. In an analysis on how these factors help in promoting the quality of healthcare, patient centeredness recorded the highest mean, with an implication that the Margaret Marquart Catholic Hospital put more premium on the values, suggestions and the complains of their patients in order to promote quality of healthcare. Patient centeredness is one of the main building blocks of quality healthcare delivery as stated by international organisations, such as, the World Health Organisation and the Institute of Medicine (IOM). The Institute of Medicine (IOM) (2001), averred that patient centeredness is based on the needs and values of patients, rather than the health system. Several studies have been conducted on the invaluable significance patient centeredness has on quality healthcare delivery. 60 University of Ghana http://ugspace.ug.edu.gh Zandbelt, Smets, Oort, Godfried, and de Haes (2007), examined the importance of patient-centred communication by internal medicine physicians, and found that physicians‘ patient centred communication was associated with patients‘ active participation in the health care encounter. Likewise, Radwin, et al (2009), explored the relationship of several patient centred nursing interventions, such as the individualization of care, responsiveness, proficiency, and care coordination with outcomes for cancer patients, and revealed that just like the case of Margret Marquart, individualization of care is associated with three desired health outcomes: authentic self- representation, optimism, and sense of well-being. The patient-centred nursing interventions of responsiveness and proficiency were related to subsequent trust in nurses. Steward, Brown and Donner (2000), observed that a patient-centred approach that included increased patient participation during the first visit, reduced patients‘ anxiety and their perceived need for further investigation and referrals. Furthermore, Fiscella, Meldrum and Franks (2004), noted that when patients felt that physicians had an understanding of their medical problems, and how they were affecting their lives, they might have greater trust in the physicians, resulting in decreased requests for further testing and consultation. This study therefore, strived and delved into how patient-centred approaches were incorporated in decision making to ensure patient satisfaction. This was achieved by tailoring the questionnaire to solicit the right response that depicted the existence of patient- centeredness or otherwise at the Margret Marquart Hospital Based on Pearson‘s correlation analysis, the study showed a significant and positive relationship between transformational leadership styles and quality healthcare delivery. Transactional and laissez- faire leadership styles had no significant relationship between them and quality health care delivery. Because of the transformational leadership qualities exhibited by nurses‘ in-charge, their subordinates performed their duties effectively and efficiently with confidence and pride. This made their patients 61 University of Ghana http://ugspace.ug.edu.gh repose some level of trust in them. It was therefore not a surprise to see patients from other districts such as Hohoe, Afadjato and many others thronged the Hospital for medical care and attention. The findings in this study are in line with a study by Ratnamiasih, et al. (2012), on leadership and hospital service quality. Their study revealed that transformational leadership positively influences the quality of service in the hospital setting in Indonesia. Another study conducted in Iran by Attari (2013), on the impact of transformational leadership on nurse psychological empowerment, revealed a strong impact of transformational leadership on nurse‘s psychological empowerment, while there were weak performances, where other leadership styles were evident. A related study on transformational and transactional leadership, by Jabnoun and Al-Rasasi (2005), revealed that service quality was positively related to all transformational leadership dimensions. Alnidawy, Ahmad, and Omran (2014) researched on the effect of the transformational leadership in confronting the challenges of the quality of health services by using total quality measurement in the Jordanian private health sector, and found that there was a positive effect of transformational leadership in confronting the challenges of quality in the health services. 62 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE SUMMARY OF FINDINGS, CONCLUSION AND RECOMMENDATIONS 5.0 Introduction This chapter addresses the following issues: (1) to determine the predominant leadership styles in the various wards of the Margaret Marquart Catholic Hospital, (2) to assess the level of quality health care delivery in the various wards of the Margaret Marquart Catholic Hospital, and (3) to find out the relationship between particular leadership styles and quality health care delivery at the Margaret Marquart Catholic Hospital. Key findings are presented according to the issues. This chapter therefore presents key findings and places them in a larger perspective, using extant literature. Additionally, conclusion, recommendations, limitations, practical applications, and opportunity for further research are presented. 5.1 Summary of Findings The findings of this study are summarised as follows: Nurse leaders at the Margaret Marquart Catholic Hospital observed a high sense of the transformational leadership style. Another important aspect of this finding is that, individual motivation, as an attribute of the transformational leadership style, was most frequent among the leaders. The study further revealed that leaders of the Hospital sometimes practised transactional leadership. Secondly, the study found a high level of quality healthcare delivery at the Margret Marquart Catholic Hospital with a mean value of 3.66 (n=97) 63 University of Ghana http://ugspace.ug.edu.gh Finally, the study showed a significant and positive relationship between the transformational leadership style, and quality healthcare delivery. Transactional and laissez-faire leadership styles had no significant relationship with quality healthcare delivery. Studies such as Attari (2013), Ratnamiasih et al (2012), and Alloubani et al (2014), attest to this finding. 5.2 Conclusions Leadership is indispensable to the progress, sustainability, continuity, as well as, the success of every organisation. Within the healthcare setting, quality of service delivery is a prerequisite for patients‘ wellbeing. It behoves on leaders within the healthcare setting, to engender quality healthcare delivery through the use of appropriate leadership styles that will ultimately lead to patients‘ wellbeing. The result from this study has revealed that the transformational leadership style was the dominant leadership style exhibited by leaders at the Margaret Marquart Catholic Hospital. The study further revealed that the quality of healthcare delivery at the Margaret Marquart Catholic Hospital was high. Patient centeredness, organizational culture, and standards and regulations, were considered as the most recurrent determinants of quality of healthcare at the Hospital. Finally, the study found a significant and a positive relationship between transformational leadership style, and quality health care delivery. Transactional leadership and laissez-faire leadership styles did not significantly relate to quality healthcare delivery. 5.3 Recommendations The study found that there was significant and positive relationship between the transformation leadership style and quality healthcare delivery. 64 University of Ghana http://ugspace.ug.edu.gh Based on the finding, it is recommended that Leaders of the Hospital should adopt all aspect of transformational leadership style, in order to render better healthcare delivery. Another finding showed that individual motivation, as an attribute of transformational leadership style, was most frequent among leaders at the hospital. Based on this finding, it is recommended that various aspects of transformational leadership style should be adopted and practised at the various health institutions to observe the results. More studies should be conducted on the role leadership plays in quality health delivery across the country, and Africa as a whole. 5.4 Limitations There are a number of limitations to this study that need to be discussed when considering the findings. The first limitation includes the scope of the study. This study looked specifically at assessing only nurse‘s leaders or, supervisors of the Margaret Marquart Catholic Hospital. Using nurses‘ in-charge, or supervisors at the Margaret Marquart Catholic Hospital, indicates a sample size that is low on diversity in relation to job position. Therefore, results may be limited in their application to other organizations. This research only utilized the follower-ratter of the MLQ, in which followers rate their leaders their leadership behaviour and did not explore leader‘s perceptions regarding their own transformational, transactional and laissez-faire leadership behaviour. In order to get a more comprehensive view concerning the MLQ leadership behaviours, it would be ideal to additionally use the self-rating MLQ. This also may help to account for any favouritism when completing the survey. 65 University of Ghana http://ugspace.ug.edu.gh 5.5. Direction for Future Study Further study should be carried out to find out other variables and situational factors on the relationship between leadership style and quality healthcare delivery. Also, future researchers should focus on comparing the effects of leadership styles in different contextual settings, be it inter, or intra regional. 66 University of Ghana http://ugspace.ug.edu.gh REFERENCES Acheampong, E. K. (2012a). Electronic health record system: A survey in Ghanaian hospital. Online Journal of Public Health Informatics. Vol 1: pp 164-179 Acheampong, E. K. (2012b). The state of information and communication technology and health information in Ghana. Online Journal of Public Health Informatics. Vol 14. No 2. Abeka-Nkrumah, G., Guerriero, M., & Purohit, P. (2014). ICTs and maternal health utilization. Evidence from Ghana. International Journal of Social Economics. Vol 41 (7), pp. 518 – 541 Adindu, A. (2010). Assessing and assuring quality of healthcare in Africa. African Journal of Medicine Sciences. Vol. 3 (1): pp 31-36 Alharbi, M., & Yusoff, R. Z. (2012). Leadership styles, and their relationship with quality management practices in public hospitals in Saudi Arabia. Journal of Management. Vol 1 (10): pp 59-67. Alloubani, A. M., Almatari, M., & Almukhtar, M. M. (2014). Review: effects of leadership styles on quality of services in healthcare. European Scientific Journal. Vol. 10 (18) Alnasir, F. A., & Jaradat, A. A. K. (2013). The effect of training in primary healthcare centers on medical students clinical skills. International Scholarly Research Notices (ISRN) Family Medicine. Alvesson, M. (2002). Understanding Organisational Culture. London: Sage. Anderson, B., Manno, M., O'Connor, P., & Gallagher, E. (2010). Listening to nursing leaders: Using national database of nursing quality indicators data to study excellence in nursing leadership. Journal of Nursing Administration. Vol 40: pp 182-187. Attari, M. (2013). The impact of transformational leadership on nurse psychological empowerment. Spring. Vol 2(2): pp 71-76 Avolio, B. J., Bass, B. M., & Jung, D. I. (1999). Re-examining the components of transformational and transactional leadership using the Multifactor Leadership Questionnaire. Journal of Occupational and Organizational Psychology. Vol 72: pp 441– 462 Avolio, B. J., Waldman, D. A., & Yammarino, F. J. (1991). Leading in the 1990‘s: The four I‘s of transformational leadership. Journal of European Industrial Training. Vol 15(4): pp 9-16. Bass, B. M. and Avolio, B. J. (1997). Full range leadership development: Manual for the multifactor leadership questionnaire. CA, Mind Garden Bass, B. M. (1981). Stogdill's handbook of leadership: A survey of theory and research. New York: The Free Press. 67 University of Ghana http://ugspace.ug.edu.gh Bass, B. M., & Avolio, B. J, (1993). Transformational Leadership and Organizational Culture. Public Administration Quarterly. Vol. 17(1): pp 112-122. Bass, R, & Avolio, R (2004). MLQ multifactor leadership questionnaire. (3rd ed.). Redwood City, CA: MindGarden, Inc. Bass, B. M., Jung, D. I., Avolio, B. J., & Berson, Y. (2003). Predicting unit performance by assessing transformational and transactional leadership. Journal of Applied Psychology. VOL 88(2): pp 207-218 Bass, B. M., Avolio, B. J., & Goodheim, L. (1987). Biography and the assessment of transformational leadership at the world-class level. Journal of Management. Vol 13(1): pp 7-19. Bass, B. M. (1985). Leadership and performance beyond expectation. New York: Free Press Bass, B. M., & Avolio, B. J. 1990. The implications of transactional and transformational leadership for individual, team, and organizational development. In R. W. Woodman & W. A. Pasmore (Eds.), Research in organizational change and development. Vol 4: pp 231-272. Bass, B. M. (1990). From transactional to transformational leadership: Learning to sharethe vision. Organizational Dynamics. pp 19-31 Bass, B. M. 1995. Theory of transformational leadership redux. Leadership Quarterly. Vol 6: 463-478 Bass, B. M. (1997). Personal selling and transactional/transformational leadership. Journal of Personal Selling and Sales Management. Vol 17(3): pp 19-28 Blake, R. R., & Mouton, L. B. (1964), ―Breakthrough in Organization Development,‖ Harvard Business Review, 42 (6), 133-155. Bradley, E. H., Pallas, S., Bashyal, C., Curry, L., Berman, P., (2010). Health, Nutrition and Population (HNP). Discussion Paper Developing Strategies for Improving Health Care Delivery: A User’s Guide to Concepts, Determinants, Measurement, and Intervention Design. The International Bank for Reconstruction and Development. Braithwaite, J., Hyde, P., & Pope, C, (2010). Culture and climate in health care organizations. London: Palgrave MacMillan. Brown, A. (1995). Organisational Culture. (2nd ed). Pitman Publishing. pp. 9, 33, 176. Burns, J. M. (1978). Leadership. New York: Harper and Row. Buttell, P., Hendler, R., & Daley, J. (2007). Quality in Healthcare: Concepts and Practice. The Business of Health-Care. 68 University of Ghana http://ugspace.ug.edu.gh Carney, M. (2006). Understanding organisational culture: the key to successful middle manager strategic involvement in health care delivery? Journal of Nursing Management, Vol. 14, pp. 23‐ 33. Curry, L., Lauren Taylor, L., Guey-Chi Chen, P., & Bradley, E. (2012). Experiences of leadership in health care in sub-Saharan Africa. Human Resources for Health. Vol 10: pp 33 Elarabi, H. M., & Johari, F. (2014). The impact of human resource management in healthcare quality. Asian Journal of Management Sciences and Education. Vol 3(1) Esena, R. K. (2013). Managing for Quality in Health Care: Quality Improvement Issues in Ghana‘s Community-based Health Planning and Services Concept. Journal of Scientific & Innovative Research. Vol 2(2). Derue, D. S., Nahrgang, J. D., Wellman, N., & Humphrey, S. E. (2011). Trait and behavioral theories - of leadership: An integration and: meta‐analytic test of their relative validity. Personnel Psychology. Vol 4(1): pp 7-52. De Savigny, D., & Adam, T. (2009). Systems thinking for health systems strengthening. Alliance for Health Policy and Systems Research, Geneva: World Health Organization. Drafke, M. (2009). The human side of organisations. (10th ed). Upper Saddle River, NJ: Prentice-Hall. Donabedian, A. (1990). The Quality of Care: How Can It Be Assessed? Journal of the American Medical Association. Vol 260: 1743–48 Dunham-Taylor, J. (2000). Nurse executive transformational leadership found in participative organizations. Journal of Nursing Administration. Vol 30: pp 241-50. French, R., Rayner, C., Rees, G. & Rumbles, S. (2009). Organizational behaviour. West Sussex: Wiley. Ghana Statistical Service (2010). Population Census. GSS-Ghana Gobah, F.K., & Zhang, L. (2011). National Health Insurance Scheme in Ghana: Prospects and challenges: A cross-sectional evidence. Global Journal of Health Science. Vol 3(2). Goetsch, D., & Davis, K. (2011). Quality Management for Organizational Excellence: Introduction to Total Quality. Upper Saddle River, NJ: Prentice Hall. Gronfeldt, S., & Strother, J. B. (2006). Service Leadership: The Quest for Competitive Advantage. SAGE. Hersey P, Blanchard KH. (1969). Management of organizational behavior. Upper Saddle River, NJ: Prentice Hall 69 University of Ghana http://ugspace.ug.edu.gh Institute of Medicine (1990). Medicine: A strategy for quality assurance. Washington, D. C, National Academy Press. Institute of Medicine (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press Institute of Medicine (IOM). (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC. Jabnoun, N., & Rasasi, A. L. (2005). Transformational leadership and service quality in UAE hospitals. Managing Service Quality, 15 (1), 70-8 Jacobs, R., Mannion, R., Davies, H. T. O., Harrison, S., Konteh, F., & Walshe, K. (2013). The relationship between organizational culture and performance in acute hospitals. Journal of Social Science & Medicine. Vol 76: 115-125 Jamal, A., McKenzie, K., & Clarke, M. (2009). The impact of health information technology on the quality of medical and health care: A systematic review. Journal of Health Information Management. Vol 38(3). James, D. (2003). Back to the future - Enduring traits in leadership. Retrieved from Management Today. Judge, T. A., & Bono, J. E. (2004). Personality and transformational and transactional leadership: A meta-analysis. Journal of Applied Psychology, 89(5), 901-910. Juran, J. M. (1951). Quality control handbook. New York: McGraw-Hill: 37-41 Kabashiki, I. R., & Moneke, N. I. (2014). The impact of the use of health information and communication technology on health care delivery in Mannitoba Canada. Journal of Hospital Administration. Vol 3(6). Kabene, S. M., Orchard, C., Howard, J. M., Soriano, M. A., & Leduc, R. (2006). The importance of human resources management in healthcare: A global context. Human Resource for Health. Vol 4(20). Kearsey, K. (2003). Your work your health: whether patient or health care provider: a healthy workplace is key to wellbeing. Registered Nurse Journal. Vol. 15(1): pp 16‐19 Khan, M. A. (2011). Total quality management and organizational performance-moderating role of managerial competencies. International Journal of Academic Research. Vol 3(5): pp 453-458. Kleinman, C. (2004). The relationship between managerial leadership behaviors and staff nurse retention. Vol 82: pp 2-9. Kouzes, J. M., & Posner, B. J. (2002). Leadership challenge (3rd ed.). San Francisco: Jossey-Bass 70 University of Ghana http://ugspace.ug.edu.gh Kouzes, J. M. & Posner, B. Z. (2007). The leadership challenge. (4th ed). San Francisco: Jossey-Bass. Kunaviktikul, W et al. (2008). Nurse staffing and adverse patient outcomes. Chiang Mai University Journal. Vol 7 (1): pp 59-72 Laschinger, H., & Finegan, J. (2005). Using empowerment to build trust and respect in the workplace: A strategy for addressing the nursing shortage. Nursing Economics. Vol 23: pp 6-13. Lashinger, H., Finegan, J., & Wilk, P. (2009). Context matters: The impact of unit leadership and empowerment on nurses' organizational commitment. Journal of Nursing Administration. Vol 39: p 228-235. Leplege, A., Gzil, F., Cammelli, M., Lefeve, C., Pachoud, B. & Ville, I. (2007, November). Person- centredness: Conceptual and historical perspectives. Disability and Rehabilitation. Vol 29(20- 21): pp 1555-1565 Lord, R. G., De Vader, C. L., & Alliger, G. M. (1986). A meta-analysis of the relation between personality traits and leadership perceptions: An application of validity generalization procedures. Journal of Applied Psychology, 71(3), 402-410 Lowe, K. B., Kroeck, K. G., & Sivasubramaniam, N. (1996). Effective correlates of transformational and transactional leadership: A meta-analytic review of the MLQ literature. The Leadership Quarterly. Vol 7(3) Luthans, F. (2005). Organizational Behavior. Boston, MA: McGraw-Hill Irwin. Luzinski, C. (2011). Transformational leadership. Journal of Nursing Administration. Vol 41(12): pp 501-512 Mann, R. D. (1959). A review of the relationship between personality and performance in small groups. Psychological Bulletin, 56, 241–270 Marriner-Tomey, A. (1993). Transformational leadership in nursing. St. Louis: Mosby. McGuire, E., & Kennerly, S. (2006). Nurse Managers as transformational and transactional leaders. Nurse Economics, 24,179-185. McKinnies, R., Collins, S., Collins, K. S. & Matthews, E. (2010). Lack of performance: The top reasons for terminating healthcare employees. Journal of Management. Vol 32(3). Mead N. Bower P. (2002). Patient-centered consultations and outcomes in primary care: A review of the literature. Patient Educational Counsel. Vol 48: pp 51–61 71 University of Ghana http://ugspace.ug.edu.gh Miller, K., Riley, W. & Davis, S. (2009). Identifying key nursing and team behaviours to achieve high reliability. Journal of Nursing Management, Vol. 17 No. 2: pp. 247‐55 Ministry of Agriculture (2012). Profile of Volta Region. Ministry of Agriculture Report, 2012 Ministry of Health. (2009). Health Statistical Year Book. Ghana: Ministry Of Health Mosadeghrad, A. M. (2014). Factors influencing healthcare service quality. International Journal of Health Policy Management. Vol 3: pp 77–89. Mseleku, T. (2007). A policy on quality in health care for South Africa. National Department of Health, Pretoria. Neill, M., & Saunders, N. (2008). Servant leadership: Enhancing quality of care and staff satisfaction. Journal of Nursing Administration. Vol 38: pp 395-400. Northouse, P. G. (2001). Leadership: Theory and practice (2nd ed). Thousand Oaks, Calif: Sage Publications. Northouse, P.G. (2003) Leadership: Theory and Practice (3rd Edition). London: Sage Publications Ltd Northouse, P. G. (2010). Leadership theory and practice. (5th ed). Los Angeles: SAGE. Offei, A., Bannerman, C., & Kyeremeh, K. (2004). Health care quality assurance manual for sub- districts. Ghana Health Service. Ofori-Okyere, I., & Aboagye, P. (2015). An evaluation of HR strategies for developing quality healthcare in district hospitals in Ghana. International Journal of Business and Marketing Management. Vol 3(1): pp 16-30 Owusu-Bempah, G., Amoako, D., Frempong, R., & Assampong, E. (2013). Preventing procurement corruption in the health sector of Ghana: A factor and principal component analysis. European Journal of Business and Management. Vol.5 (1): pp 89. Oyeyemi, S. O., & Wynn, R. (2014). Giving cell phones to pregnant women and improving services may increase primary health facility utilization: A case-control study of a Nigerian project. Reproductive Health. Vol 11 (8). Peersman G, Rugg D, Erkkola T, Kiwango E, Yang J (2009). Are the investments in national HIV monitoring and evaluation systems paying off? Journal of Acquire Immune Deficiency Syndrome. Vol 52: pp 87-96 Politis, J. D. (2002). Transformational and transactional leadership enabling (disabling) knowledge acquision of self-managed teams: The consequences for performance. Leadership and Organisation Development Journal. Vol 23(3/4): pp 186-197. 72 University of Ghana http://ugspace.ug.edu.gh Purvanova, R., Bono, J. & Dzieweczynski, J. (2006). Transformational leadership, job characteristics, and organizational citizenship performance. Human Performance. Vol 19: pp 1-22. Radwin, L. E., Cabral, H. J. & Wilkes, G. (2009). Relationships between patient-centered cancer nursing interventions and desired health outcomes in the context of the health care system. Research in Nursing and Health. Vol (32): pp 4-17. Ratnamiasih, I., Govindaraju, R., Prihartono, B., & Sudirman, I. (2014). The Influence of Leadership and Organizational Control on Hospital Service Quality. Australian Journal of Basic and Applied Sciences. Vol 8(14): pp 40-44 Robbins, S. P. (2001). Organisational behavior (9th ed). Upper Saddle River, N. J: Prentice Hall. Russell, R. F., & Stone, G. A. (2002). A review of servant leadership attributes: developing a practical model. Leadership and Organization Development Journal. Vol. 23(3): pp.145 – 157 Safari, A., & Sabouri, R. (2014). Studying the relationship between leadership styles and applying principles total quality management. Indian Journal of Scientific Research. Vol 3(1): pp 391-399 Sakyi, E. K., Atinga, R. A., & Adze F. A. (2012) "Managerial problems of hospitals under Ghana's National Health Insurance Scheme", Clinical Governance: An International Journal. Vol. 17 (3): pp.178 – 190 th Saunders, M., Lewis P., & Thornhill A. (2009) Research Methods for business student. (4 ed). Pearson education limited Sellgren, S., Ekvall, G., & Tomson, G. (2006). Leadership styles in nursing management: Preferred and perceived. Journal of Nursing Management. Vol 14: pp 348-355 . Spendlove, M. (2007). Competencies for effective leadership in higher education. International Journal of Educational Management. Vol 21(5): pp 407-417. Sridhar, D. (2009). Post-Accra: Is there space for country ownership in global health? Third World Quarterly. Vol 30: 1363-1377 Stineman, M. G., Kurz, A. E., Kelleher, D. & Kennedy, B. L. (2008). The patient‘s view of recovery: An emerging tool for empowerment through self-knowledge. Disability and Rehabilitation. Vol 30(9): pp 679-688. Stogdill, R. M. (1948). Personal factors associated with leadership: A survey of the literature. Journal of Psychology, 25, 35–71. Thomas, M. (2006). The complete CEO: The executive’s guide to constant peak performance. West Sussex: Capstone. 73 University of Ghana http://ugspace.ug.edu.gh Thompson, N. (2009). People skills. (3rd edition). New York: Palgrave Macmillan. Tubbs-Cooley, H. L., Cimioti, J. P., Silber, J. H., Sloane, D. M., & Aiken, L. H. (2013). An observational study on nurse staffing ratios and hospital readmission among children admitted for common conditions. Bio Medical Journal for Quality and Safety. Tyczkowski, B., Vandenbouten, C. & Reilly, J. (2015). Emotional intelligence (EI) and nursing leadership styles among nurse managers. Nursing Administration Quarterly. Vol 39 (2): pp 172- 180 Ukawa, N., Tanaka, M., Morishima, T., & Imanaka, Y. (2015). Organisational culture affecting quality of care: Guideline adherence in perioperative antibiotic use. International Journal of Quality Health Care. Vol 27(1): pp 37-45 Ulle, R. S., & Kumar, A. N. S. (2014). A Review on Total Quality Leadership in TQM Practices- Industrial Management and Organizations. International Journal of Emerging Research in Management &Technology. Vol.3 (5): pp 152-155 Van-den Boom, G. J. M., Nsowah-Nuamah, N. N. N., & Overbosch, G. B. (2004). Healthcare Provision and Self-medication in Ghana, (accessed via Web Archive) http://web.archive.org/web/20070625163825/http://www.saga.cornell.edu/images/vandenboom. pdf (accessed 30 October 2014) Verbeke, F., Karara, G., & Nyssen, M. (2013). Evaluating the impact of ICT tools on healthcare delivery in sub-Saharan hospitals. Studies on Health Technology Information. Vol 193 pp 520 - 534. Vriesendorp, P., De La Peza, L., Perry, C.P., Seltzer, J.B., O'Neil, M., Reimann, S., Gaul, N.M., Clark, M., Barraclough, A., Lemay, N., & Buxbaum, A. (2010). Health Systems in Action: An e- Handbook for leaders and managers. Cambridge: Management Science for Health. Waleed A. A. M., Charuwan, T., Wirin, K., & Krit P. (2014). Relationship between leadership behaviors and job satisfaction among nurses in hospitals of south Kordofan state, Sudan. Journal of Nursing Science. Vol 32. No 4 Weaver, S. J., Dy, S. M., & Rosen, M. A. (2014). Team-training in healthcare: A narrative synthesis of the literature. Bio Medical Journal for Quality and Safety. WHO (2010). Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. Geneva: WHO. World Health Organization (2007). Strengthening Health Systems to Improve Health Outcomes: WHO‘s Framework for Action. Geneva: World Health Organization. World Health Organization (2008). Health Metrics Network Framework and Standards for Country Health Information Systems. Geneva: World Health Organization. 74 University of Ghana http://ugspace.ug.edu.gh Yielder, J. & Codling, A. (2004). Management and leadership in the contemporary university. Journal of Higher Education Policy and Management. Vol 26(3): pp 315-328. Zandbelt, L. C., Smets, E. M. A., Oort, F. J., Godfried, M. H. & de Haes, H. C. J. M. (2007). Patient participation in the medical specialist encounter: Does physicians‘ patient-centred communication matter? Patient Education and Counseling. Vol 65: pp 396-406. 75 University of Ghana http://ugspace.ug.edu.gh APPENDICES UNIVERSITY OF GHANA BUSINESS SCHOOL (DEPARTMENT OF PUBLIC ADMINISTRATION AND HEALTH SERVICES MANAGEMENT) QUESTIONNAIRE FOR NURSES Dear Respondent, I am currently carrying out a study for the purpose of writing a thesis as a requirement for the award of MPhil in Health Services Management at University of Ghana Business School. The topic for the study is LEADERSHIP STYLE AND QUALITY HEALTHCARE DELIVERY. You have been selected to participate in this study due to the importance of your information. The information will be treated with utmost confidentiality. Please feel free and answer all the questions truthfully. Thank you very much. Section A: Background Information (Please tick as appropriate) 1. Age 20-29 years 30-39 years 40-49 years 50 years and above 2. Gender Male Female 3. Marital Status Single Married Other Specify…………….. 4. Higher education attained. Diploma/Certificate Degree Masters 5. Years spent in this organization: Less than 1 year 2-3 years Four years and above 6. Please specify your ward ............................... 76 University of Ghana http://ugspace.ug.edu.gh SECTION B: Leadership Styles Using the following scale, please rate your immediate supervisor/ team leader by circling your choice on the following Not at all= 1 Once in a while= 2 Sometimes= 3 Fairly often= 4 Always= 5 My team leader/supervisor…………………………. Statements Not at Once in a Sometimes Fairly Always all while Often Provides me with assistance in exchange for my efforts Re-examines critical assumptions to question whether they are appropriate Fails to interfere until problem become serious Focuses attention on irregularities, mistakes, and deviations from standards Avoids getting involved when important issues arise Talks about his/her most important values and beliefs Is absent when needed Seeks differing perspectives when solving problems Talks optimistically about the future Instill pride in me for being associated with him/her Discusses in specific terms who is responsible for achieving performance targets Waits for things to go wrong before taking actions Talks enthusiastically about what needs to be accomplished Specifies the importance of having a strong sense of purpose Spends time coaching Makes clear what one can expect to receive when performance goals are achieved Shows that he/she is a firm believer in ―if it is not broken, ―don‘t fix it‖ 77 University of Ghana http://ugspace.ug.edu.gh Goes beyond self-interest for the good of the group Treats me as an individual rather than just a member of a group Demonstrates that problems must become chronic before taking action Acts in the way that builds my respect Concentrates his/her full attention on dealing with mistakes and complaints Consider the moral and ethical consequences of decision Keeps track of all mistakes Displays a sense of power and confidence Articulates a compelling vision of the future Directs my attention toward failures to meet standards Avoids making decisions Considers me as having different needs, abilities, and aspirations from others Gets me to look at problems from many different angles Helps me to develop my strengths Suggests new ways of looking at how to complete assignments Delays responding to urgent questions Emphasizes the importance of having a collective sense of mission Expresses satisfaction when I meet expectations Expresses confidence that goals will be achieved 78 University of Ghana http://ugspace.ug.edu.gh Section C: Quality Healthcare Practices Please indicate the extent to which you agree or disagree with the factors listed in the table below as factors contributing to quality healthcare practices in this establishment. You are kindly requested to rate your response according to the ratings below: 1= Strongly Disagree, 2= Disagree, 3= Neutral, 4 = Agree and 5= Strongly Agree. My supervisor ensures that........... Statements Strongly Disagree Neutral Agree Strongly Disagree Agree 1. I have enough knowledge on the service‘s definition of patient's needs. 2. I explain the effect of drugs and procedures to patients adequately 3. I consider the patients' views during drug administration. 4. I ensure the satisfaction of patients 5. Patient‘s complaints are used as input to improve upon service delivery 6. I ensure the confidentiality of patient records 7. Directional information is readily available to enable patient receive quality care 8. Training and education of nurses is held in high esteem 9. Management indicates what is expected for professional with respect to quality healthcare delivery 10. Regular monitoring is carried out to ensure professionals stick to commitment 11. Rewards and incentive packages are motivational enough 12. Systematic feedback is given to professionals about their performance 79 University of Ghana http://ugspace.ug.edu.gh 13. There is a good interpersonal relationship between professionals 14. Adequate equipment and logistics needed for work is supplied 15. There is enough safety measures put in place to protect workers 16. Opportunity is given to the workers to show their views and constructive critique 17. Medical treatment and interventions are carried out base on prescribed standards 18. There are standards governing attendant of patients under critical care 19. Prescribed standards for the utilisation of clinical equipment are followed 20. The health organisation‘s objectives are used as standards to measure the performance effectiveness. 21. We operate on a well structured computerised system rather than paper based 22. Health workers are adequately on the use of the information system 23. It is easy to access reliable internet services 24. Security and confidentiality of patient‘s and health worker‘s data is ensured on the information system 25. It is easy to communicate with other health workers through the information system 26. There is a clear mission that gives meaning and direction to our work 27. There is a clear strategy for the future 28. There is a widespread agreement about goals of this organisation 80