The U.S. health care system is experiencing a three-pronged revolution involving policy, financial, and political strategies. National discussions of health care policy revolving around financial extremes and ineffectual outcomes are familiar to all and commonly addressed at the national and special interests level. Taking a high-power view, those same discussions are applied many times over on a micro-organizational scale from chief executive officers to physicians, nurses, and laboratory technicians. Along with hospitals and tributary stakeholders, pharmaceutical and medical device companies, too, are profoundly invested in the change management of our health care. Such sweeping change demands logistically nimble and adaptable followers teamed with emotionally intelligent leaders committed to transformational leadership.

Effective transformation is symbolic of harmonized leader-follower perspective and a shared organizational vision (Groves & LaRocca, 2011;Zagoršek, Dimovski, & Škerlavaj, 2009). In order to effect transformation at the individual and subsequently the organizational levels, leaders practice authentic leadership to inspire individual and collective organizational advancement. Leroy, Palanski, and Simons (2012) suggest the measure of an authentic leader is their degree of connectedness to their followers and ability to relate both their outlook and listen to their followers.  Gregory, Moates, and Gregory (2011) further elaborate taking the other’s point of view suggesting

“it would seemingly be difficult to have a transformational effect on the way an individual views the world without first being aware of the way that that individual does, in fact, view the world” (p. 810). 

Thus, transformational leaders must practice taking the other’s perspective before they can truly ensure common understanding and avoid reflexively responding (Gregory, Moates, & Gregory, 2011;Porter-O'Grady & Malloch, 2011).

Taking from the idiom “do unto others as you would have them do unto you”, transformational leaders lead by example.  Groves and LaRocca (2011) research suggest transformational leadership is strongly associated with deontological values “such that leaders’ strong beliefs in altruism, universal rights, and principles lay the groundwork for enacting the key motivational and inspirational behaviors that drive impressive leadership outcomes in organizations”(Groves & LaRocca, 2011 p. 522) Transformational management emphasizes five elements of leadership focused on individual followers and the larger corporate community: idealized attributes, idealized behaviors, inspirational motivation, intellectual stimulation, and individualized consideration (Groves & LaRocca, 2011 p. 512)  Leroy et al (2012) suggest leader behavioral integrity “as the perceived pattern of alignment between the leader’s words and deeds” (p. 256) directly correlates to follower commitment and valuation of their leader perception of authenticity and ability to ethically transform.  As a consequence, ethical leadership promotes a sense of meaningfulness which influences employee engagement and productivity (Hartog & Belschak, 2012 p. 38).  Followers are inspired by the ethicality of their leaders to emulate their actions and be held accountable (Groves & LaRocca, 2011;Hartog & Belschak, 2012;Wong & Laschinger, 2012;Zagoršek et al., 2009).  Transformational leaders foster organizational health and citizenship behavior through organizational learning, a shared mission, and person-environment fit (Ahmad, Veerapandian, & Ghee, 2011;Forest & Kleiner, 2011;Zagoršek et al., 2009).

Transformational leadership as evinced by authentic leaders and their influence on organizational citizenship behavior and corporate responsibility serves as the basis for review of the relevant literature. We will examine emotional intelligence and taking the other’s perspective as essential, interdependent leadership behaviors.  We will consider organizational culture from the perspective of organizational learning and information sharing, and person-environment fit.  Finally, I will synthesize my hybrid perspective of leadership based on the reviewed literature.

Transformational Leadership

Dyadic, the transactional leadership distinctive of the Newtonian era (Groves & LaRocca, 2011;Porter-O'Grady & Malloch, 2011), and still pervasive in many health systems, is by itself inadequate for the global and organizational demands of our evolving health care paradigm.  In our current health care state of affairs, it is now more imperative than ever we encourage consonance of expectations and authentic leadership.  Given the diversity and number of stakeholders, transformational leadership is vital for efficacious communication and collaboration.

James McGregor Burns is credited with introducing the concept of transformational leadership in his seminal research Leadership (1978)(Anand & UdayaSuriyan, 2010;Forest & Kleiner, 2011;Groves & LaRocca, 2011).  Transformational leadership facilitates effective, productive work environments through ethical leader behavior, which fosters organizational citizenship favorable to shared information and learning.  The transformational process elevates transactional, utilitarian leadership to embrace the intangible, human interaction qualities valuing as equally essential to organizational health and development as tangible measurements (Porter-O'Grady & Malloch, 2011; Zagoršek et al., 2009).

In contrast to transactional leadership characterized by functional ethicism, transformational leadership is concerned with moral obligations and follower rights (Groves & LaRocca, 2011).  Groves and LaRocca (2011) examine the difference between deontological ethical values (the theory or study of moral obligation)(Merriam-Webster, 2012a) characteristic of transformational leaders and teleological ethical values (a doctrine explaining phenomena by final causes) (Merriam-Webster, 2012b) distinctive of transactional leaders.  The intent of transformational leaders is follower influence by “changing [the] followers’ core attitudes and values” (Groves & LaRocca, 2011 p. 513) thereby affecting overall organizational transformation through cumulative leader-follower exchanges.

Conversely, transactional leaders, also described as utility leaders by Covey (1991), are as pragmatic as their followers. Leaders and followers seek a delicate balance of work output and equitable treatment ensuring both conundrums are in equilibrium (Covey, 1991).  Thus, transactional leaders maintain a functional relationship and contemplate ethics where “what is being done (the end) and the means employed to do it are morally legitimate” (Groves & LaRocca, 2011 p. 513).  By contrast, transformational leaders view followers as ends to the means(Groves & LaRocca, 2011).

While rooted in ethical constructs, transformational leadership is greater than merely a philosophical or theoretical exercise (Zagoršek et al., 2009).  Leadership behaviors and complementary organizational citizenship evince qualities characterized by transformational leaders (Ahmad et al., 2011; Forest & Kleiner, 2011; Groves & LaRocca, 2011).  Describing oneself as artful at achieving “buy-in” can either relate to transactional or transformational leadership.  Both transactional and transformational leaders are cognizant of their followers’ perspectives and overall tenor.  The intent with which one pursues the buy-in, however, differentiates between the two approaches.

Transactional leaders validate the legitimacy of outcomes by “managing outcomes and seeking behavioral compliance with practices that will maximize the mutual interests of both parties (Groves & LaRocca, 2011 p. 513).  Such reciprocal constructs are characterized by static input-output interchanges and prescribed conclusions that “are unlikely to generate strong beliefs in stakeholder perspective on CSR [corporate social responsibility]” (Groves & LaRocca, 2011 p. 511).  On the other hand, transformational leaders approach leadership as a moral consideration and operate from a cause-effect perspective.  Groves and LaRocca (2011) found transformational leaders inspire a collective vision and communal appreciation while encouraging followers to look beyond self-interest for immediate gratification and strive for organizational excellence (Groves & LaRocca, 2011).  Articulated by Forest and Kleiner (2011),

“…a custodian is an individual who upholds what is best for all people even if it may not be in their own interest to do so”(Forest & Kleiner, 2011 p. 258). 

Transformational leaders subscribe to a collaborative vision and exemplified mission statement (Forest & Kleiner, 2011) using “authentic empowerment strategies coupled with expert referent power” (Groves & LaRocca, 2011 p. 514).  Transformational leaders accept not every interaction or change is positive (Zagoršek et al., 2009).  Such leaders do not negotiate the field to achieve a preconceived goal while simultaneously striving to minimize negative follower impact.  Transformational leaders wholeheartedly champion a human-capital centered philosophy and navigate business culture from that frame of reference.

Authentic Leadership

Hartog and Belschak (2012) describe authentic leadership as: “acting fairly, promoting and rewarding ethical conduct, allowing follower voice, showing concern, demonstrating consistency and integrity, and taking responsibility for one’s actions” (p. 36). In contrast to Hartog and Belschak’s (2012) leadership characteristics, which more closely align with demonstrable behaviors, Leroy et al (2012) and Wong and Laschinger (2012) discuss four intrinsic authentic leader qualities.  Based on Walumbwa et al (2008), Leroy et al (2012) identify balanced processing, relational transparency, internalized moral perspective, and self-awareness (p. 256). Further elaborating, Wong and Laschinger (2012) expand on the four elements of an authentic leader.  Authentic leaders solicit follower perspective and feedback and formulate a cartogram of everyone’s viewpoint thereby exercising balanced processing (Wong & Laschinger, 2012). They avoid communication ambiguity and do not speak exclusively from their experience (Porter-O'Grady & Malloch, 2011). Rather, they engage their fellow conversationalist and encourage staff dialogue.  Relational transparency suggests leader sincerity and openness with followers while internalized moral perspective honors a leader’s moral compass complemented by a keen sensitivity to self-awareness (Wong & Laschinger, 2012).

Wong and Laschinger (2012) note authentic leaders “…draw on their life experiences, psychological capacities (i.e., hope, optimism, resilience, and self-efficacy), a sound moral perspective, and a supporting organizational climate to produce greater self-awareness and self-regulated positive behaviours” (Wong & Laschinger, 2012 p. 2). In turn, authentic leaders empower their followers through access to shared information, training, and professional opportunities (Wong & Laschinger, 2012). Based on a review of the literature, Wong and Laschinger (2012) report nursing performance outcomes and job satisfaction are enhanced when paired with authentic, transformational, and supportive leadership styles.  Wong and Laschinger (2012) suggest,

“involving staff in decisions and connecting those decisions to unit goals invites increased ownership of work results (Wong & Laschinger, 2012 p. 4).

Emotional Intelligence

Anand and UdayaSuriyan (2010) delineate emotional intelligence characteristics as “the capacity to effectively perceive, express, understand, and manage your emotions and the emotions of others in a positive and productive manner” (Anand & UdayaSuriyan, 2010 p. 65). Taken from Chen, Jacobs, and Spencer (1998), Anand and UdayaSuriyan’s (2010) report close to 90% of successful leadership is attributed to skillful emotional intelligence (p. 65).  A hallmark of practiced emotional intelligence is the ability of successful leaders to mange their emotions as well as navigate those of their followers (Anand & UdayaSuriyan, 2010). Just as followers are empowered through authentic leadership, leaders are similarly enabled through the self-reflective lens of emotional intelligence.  Leaders are more savvy to discern what they need and want as well as their followers and respond appropriately (Anand & UdayaSuriyan, 2010).  Emotional intelligence informs leaders how to manage their feelings and effectively “manage the moods and emotions of others” (Anand & UdayaSuriyan, 2010 p. 67).

Using a descriptive survey approach, Anand and UdayaSuriyan’s (2010) utilize a leadership practices inventory developed by Kouzes and Posner (1997) and consider modeling the way, challenging the process, inspiring a shared vision, encouraging the heart, and enabling others to act (p. 67). They found leadership executives greater than 45 years of age have significantly higher scores in encouraging the heart when compared to their younger counterparts (Anand & UdayaSuriyan, 2010).

Of note, Anand and UdayaSuriyan’s (2010) found younger leaders tend to engage in encouraging behaviors as organizational initiatives rather than individual followers. 

Anand and UdayaSuriyan’s (2010) also concluded professionally and non-professionally educated leaders have greater emotional intelligence than non-formally educated leaders though there was not a commiserate finding related to overall leadership practices.  Anand and UdayaSuriyan’s (2010) suggest awareness of self-regard allows leaders to more effectively “…read the individuals which make them to adopt according to the situation" (Anand & UdayaSuriyan, 2010 p. 69).

Other’s Perspective

Perception coupled with life’s experiences provides the framework for “the way we all interpret our experiences” Otara (2011 p. 21). Likewise, “in addition to mechanics of perception, it is also important to recognize every person has a unique frame of reference” and “interpretation…is dependent on many factors not directly related to the immediate situation” (Otara, 2011 p. 22) Otara (2011) suggests “habit, motivation, learning, specialization and social background” (Otara, 2011) contribute to interpretative determinations.

Continuing from Otara’s (2011) characterization of perspective taking, Gregory et al (2011) further define two methods of perspective taking.  The first owes its origin in developmental psychology and the influential minds of Piaget, Kohlberg, and Kegan who apply perspective taking as a personality construct characterized as core to the individual which they apply across all contexts (Gregory et al., 2011 p. 809). The second method considers perspective taking as a mental behavior situationally employed across various relationships (Gregory et al., 2011 p. 810). Gregory et al (2011) suggest,

“the basis of the argument for the relationship between perspective taking and transformational leadership is that transformational leadership requires the leader to influence the follower’s perceptions of reality” (p. 810) noting the implausibility of doing so without compensate knowledge of follower perspective and common ground.

Organizational Culture

Organizational culture is the cumulative shared learning, uniquely common values, and rituals of its constituents.  Ahmad et al (2011) note it “…is generally seen as a set of key values, assumptions, understandings, and norms that is shared by members of an organisation and taught to new members as correct”(p. 11).  It is the social infrastructure of an institution shaped by leader vision, follower commitment and citizenship behavior, and leader-follower exchanges.

Grounded by self-reflection and awareness, transformational leaders practice authentic leadership typified by a willingness and discipline to take the other’s perspective as a cornerstone of emotional intelligence.  By virtue of their holistic approach, transformational leaders effectually engage, foster and energize followers in the change process enhancing organizational community.

Organizational Learning

Zagoršek et al (2009) posit organizational learning is central to an organization’s “sustainable competitive advantage” and is a quintessential driver of “corporate performance” (Zagoršek et al., 2009).

According to Zagoršek et al (2009) and borrowed from Huber (1991), organizational learning can be described as four constructs: (1) information acquisition; (2) information distribution; (3) information interpretation; and (4) organizational memory (p. 146). Organization learning potentiates learner behavioral changes and cognitive understanding (Zagoršek et al., 2009).

Information acquisition through internal and external networking is essential to learning augmented by formal sharing of information through organizational training (Zagoršek et al., 2009). Organizations have at their disposal various information distribution mechanisms (Zagoršek et al., 2009). Key to organizational learning is effective distribution of the corporate message coupled with effective conveyance (Zagoršek et al., 2009).  Further, organization members must have tools to appropriately interpret the information (Zagoršek et al., 2009). Mass internal distribution of information as with e-memos only addresses prescribed explication of organizational sharing (Zagoršek et al., 2009). Interactive tools must also be utilized such as video conferencing, periodic meetings with the president, and intranet updates with flexibility for staff feedback (Zagoršek et al., 2009). Zagoršek et al (2009) reason “if no behavioural or cognitive changes occur, organizational learning has not in fact happened and the only thing that remains is unused potential for improvement”(Zagoršek et al., 2009 p. 146).

In their research, Zagoršek et al (2009) found leadership influences all four constructs of the learning process with the greatest affect on behavioral changes and cognitive understanding.  Zagoršek et al (2009) assert,

it [leader influence] affects them [followers] through the previous information-processing phases of the organizational learning process. By facilitating or impeding information processing in an organization, leaders encourage or impede changes in the mentality or behaviour of organizational members in order to address changes in the internal or external business environment. However, leaders also influence changes in behaviour and cognition directly, over and above the indirect influence through information processing phases(Zagoršek et al., 2009 p. 158).

Zagoršek et al (2009) advise leaders must promote learning at all levels and encourage diversity of learning.  Leaders must be cognizant of their influential impact on learning and organizational performance, strive for an active organizational learning approach characterized by dynamic, facilitated information sharing(Zagoršek et al., 2009).

Organizational Citizenship Behavior

Yoon and Zhi-Wei (2011) examine organizational citizenship behavior (OCB)

“defined as individual behavior that is beneficial to the organization” through “behavior that is discretionary, not directly or explicitly recognized by the formal reward system, and that in the aggregate promotes the effective functioning of the organization” (Yoon & Zhi-Wei, 2011 p. 106). 

The trialists consider OCB from the viewpoint of virtual communities and draw parallels with traditional, brick and mortar organizational communities.  They study five fundamentals of organizational citizenship behavior:altruism, conscientiousness, sportsmanship, courtesy, and civic virtue and posit all elements, separately and taken as a whole, impact social capital (Yoon & Zhi-Wei, 2011 p. 106).  Yoon and Zhi-Wei (2011) further delimit social capital by suggesting “…social interaction ties, trust, norm of reciprocity, identification and shared goals influence members' knowledge-sharing intentions and knowledge quality in virtual communities” (Yoon & Zhi-Wei, 2011 p. 106). Finding its genesis in social interaction ties, norm of reciprocity, and shared member knowledge and goals, social capital stems from internal and external networking focused on social connections with individuals, organizations, communities, and societies (Yoon & Zhi-Wei, 2011). Discussed by Zagoršek et al (2009), information acquisition contributes to organizational learning and facilitates behavioral changes and cognitive learning.  Yoon and Zhi-Wei (2011) suggest social capital is essential to an “organization's effectiveness, efficiency, and overall performance” noting “some scholars also suggest that OCB is a key mechanism for creating social capital” (Yoon & Zhi-Wei, 2011 p. 106).  In the virtual community, Yoon and Zhi-Wei (2011) did not find trust to be central to knowledge sharing and OCB.  They explain this finding suggesting trust is necessary in risky situations, while people do not typically find the virtual environment risky (Yoon & Zhi-Wei, 2011). Also, peculiar to the virtual environment, Yoon and Zhi-Wei (2011) found the norm of reciprocity did not have a significant impact on OCB.  They reason “online-based interactions maybe generalized rather than dyadic, and direct reciprocity is not necessary for sustaining collective action (Yoon & Zhi-Wei, 2011 p. 113). Similar to the norm of reciprocity, the trialists found shared goals did not have a significant impact on knowledge-sharing intention (Yoon & Zhi-Wei, 2011 p. 113). Yoon and Zhi-Wei (2011) infer virtual communities are typically voluntary and thus would not be benefited through knowledge-sharing.

Person-environment Fit

Ahmad et al (2011) juxtaposes person-environment (P-E) fit and organizational commitment in their synthesis and suggests P-E is an equally variable determinate of organizational commitment as are other factors rather than merely a fixed indicator of outcome.  P-E suggests behavioral and social dynamics must be considered in tandem with organizational environment (Ahmad et al., 2011). Thus, followers’ perspective and their individualized narrative cannot be considered in isolation separate from the larger organizational context (Ahmad et al., 2011). Ahmad et al (2011) encourage, “managers need to pay attention to not only their organisational culture such as training, rewards, teamwork and communication, but to also ensure that they are aimed towards improving the fit between individuals and their work environment (p. 11). Ahmad et al (2011) suggest leaders “look beyond the simple bivariate relationships between P-E fit and job outcomes” (p. 11) and uncover the larger P-E fit of organizational values and leader style.  Similarly, organizational values and leader style must be contemplated from the follower’s perspective to ensure congruous fit (Ahmad et al., 2011). “In essence, P-E fit embodies the premise that attitudes, behaviour and other individual level outcomes result not from the person or environment separately, but rather from the relationship between the two” (Ahmad et al., 2011 p. 12).

Personal Leadership Approach

While I cannot say I have ever worked for a transformational leader or such a visionary organization, I am persuaded transformational leadership exemplified by authentic qualities is not simply an academic pursuit.  Perhaps my conviction of soul overcomes my pessimistic side and allows for optimism.  Surely, health care providers appreciate our fork-in-the-road and welcome moral, patient, and follower-centered leadership as part of our new path.  I sincerely hope so.  There is no time like the present for change.

By way of example, I was recently speaking with a colleague regarding former hospital administrators who were perturbed because three elderly patients adamantly refused to accept admission to the hospice service nor would they sign a do-not-resuscitate (DNR) form.  The reason administration was so concerned- frequent re-admissions negatively impact their Medicare benchmark rates and reimbursement.  Sadly, yet typical, they were focused on the patients failing to agree to choose one of the two offered options.  Aside from the ethical presentation, administration failed to ask the bigger questions.  First and foremost, whywere the patients refusing? I have worked with so many patients who declined to sign a DNR when discussing with the physician but later discussed with me and were much relieved to sign one.  They were utterly confused by the intent of the DNR, and the many options.  It is not absurd to understand patients feel like they are signing a death warrant with they sign a DNR because we, in health care, so often fail to take the other’s perspective and expect emotional maturity from ourselves.

While the literature is replete with examples of increased social responsibility and commitment, enhanced job satisfaction, and improved job performance under transformational leaders, in practice it is much less taxing and easier to utilize transactional leadership to direct a vision rather than laboriously invest in persuasion with the very real possibility of failure.  Furthermore, many followers are not prepared for transformational leadership. Transactional leadership may not be sensitive to one’s personhood, but we have so insulated ourselves from self-reflection and feedback, dyadic leadership offers minimal engagement and ample room for commentary.  Transformational leadership, on the other hand, demands committed self-reflection, awareness and follower commitment.  It is easy to laud morality and ethics until they must be practiced.

For my part, I will strive for authenticity and take the other’s view.  Perhaps others will be inclined to do the same, or perhaps not. Ultimately, the tenets of transformational leadership speak to the ethics of conscious that require honesty, fairness, and justness, which I am, compelled to honor.


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About The Author

Hannah Thomas has spent the past 23 years in project and program management, working in biotech and healthcare. She received her Masters of Science in Clinical Research Administration from the George Washington School of Medicine & Health Sciences. Hannah has managed projects guiding clinical research and examining patient care. She works to bring big-data, analytics, and critical thinking to solving systemic and programmatic problems.

Hannah Thomas
Hannah Thomas has spent the past 23 years in project and program management, working in biotech and healthcare. She received her Masters of Science in Clinical Research Administration from the George Washington School of Medicine & Health Sciences. Hannah has managed projects guiding clinical research and examining patient care. She works to bring big-data, analytics, and critical thinking to solving systemic and programmatic problems.

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