PHYSICIAN PERCEPTIONS OF LEADERSHIP EFFECTIVENESS .docx

PHYSICIAN PERCEPTIONS OF LEADERSHIP
EFFECTIVENESS
OF FRONT-LINE MANAGERS IN HOSPITALS
by
Renate G. Ilse
CHERYL ANDERSON, PhD, Faculty Mentor and Chair
HALEY CASH, PhD, Committee Member
RONALD DOWD, DrPH, Committee Member
Christy Davidson, DNP, Interim Dean, School of Nursing and
Health Science
A Dissertation Presented in Partial Fulfillment
Of the Requirements for the Degree
Doctor of Health Administration

Capella University
March 2015
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© Renate Ilse, 2015
Abstract
The purpose of this research study was to better understand the
factors that influence
physician perceptions of leadership effectiveness in front-line
managers. By contributing
to trust and respect of management, physician perceptions of
leadership effectiveness
have been linked to physician engagement and subsequently to

better organizational
performance and outcomes. Using qualitative research
methodology and face-to-face
interviews, this study found that hospital physicians ascribed
greater leadership
effectiveness to managers who had good communication skills,
managed conflict well
and who were able to get things done in their patient care areas.
While these behaviors
are also mentioned in leadership competencies used as an
organizational measure of
leadership effectiveness, a significant portion of managers’
formal role expectations
included activities that were not valued by physicians. Using
the adaptive leadership
model suggested by complexity theory, these findings were used
to propose specific
enabling leadership behaviors that could help increase physician
engagement and
physician perceptions of manager effectiveness. This study is
significant because
developing greater physician engagement has been shown to be
one of the most effective
strategies for improving general financial performance,

enhancing patient outcomes and
increasing organizational success in today’s highly competitive
healthcare environment.
These results offer an alternative to existing top-down efforts at
increasing physician
engagement and provide helpful information for organizations
that seek to increase
manager skills in building collaborative physician relationships.
While the research was
targeted on a specific hospital study site, these types of system
pressures are affecting all
hospitals in Canada and the United States and successful
implementation would set the
stage for broader adoption throughout the healthcare system.
iv
Dedication
This dissertation is dedicated to Remington, whose patience and

silent support
made this achievement possible.
v
Acknowledgments
Thank you to my family; your patience and support on my
journey made this
achievement possible, especially the endless hours you spent
listening to my ideas and
frustration and keeping things going while I studied and wrote.
Thank you to the
physicians at work, you know who you are, for listening,
supporting and providing
advice. Thank you to Sonia, for your unfailing support and
belief in me. A special thank
you to my mentor, Dr. Cheryl Anderson, for stepping up when I
needed you. Finally,
thank you to my committee members, Dr. Haley Cash and Dr.
Ronald Dowd; without
you this couldn’t have been done.

vi
Table of Contents
Acknowledgments v
List of Tables ix
CHAPTER 1. INTRODUCTION 1
Introduction to the Problem 1
Background of the Study 5
Statement of the Problem 8
Purpose of the Study 9
Rationale 10
Research Questions 11
Significance of the Study 11
Definition of Terms 13
Assumptions and Limitations 14
Nature of the Study 15
Organization of the Remainder of the Study 17
CHAPTER 2. LITERATURE REVIEW 18

Introduction to the Literature Review 18
Theoretical Framework 18
Physician Perceptions of Leadership Effectiveness in Hospital
Managers 25
Generic Qualitative Inquiry 34
Literature Review Summary 35
vii
CHAPTER 3. METHODOLOGY 36
Introduction to Chapter 3 36
Research Design 36
Generic Qualitative Research 39
Target Population and Sampling 40
Setting 42
Instrumentation/Measures 42
Data Collection 44

Data Analysis 46
Ethical Considerations 47
Chapter 3 Summary 49
CHAPTER 4. RESULTS 50
Site Description 50
Description of Sample 51
Research Methodology Applied to Data Collection and Analysis
52
Data Analysis Procedures 53
Major Themes 57
Other Comments and Observations 67
Factors Affecting Organizational Perception of Leadership
Effectiveness 68
Major Organizational Themes 69
Chapter 4 Summary 72
viii

CHAPTER 5. DISCUSSION, IMPLICATIONS,
RECOMMENDATIONS 73
Review of the Research Questions and Purpose 74
Summary of Results 74
Discussion of Results 77
Significance 84
Implications for Practice 85
Limitations 86
Recommendations for Future Research/Study 87
Conclusion 88
REFERENCES 90
APPENDIX A. STATEMENT OF ORIGINAL WORK 108
APPENDIX B. INTERVIEW GUIDE 110
ix

List of Tables
Table 1. Participant Demographic Overview 53
Table 2. Three Most Frequently Used Descriptive Words 55
Table 3. Three Most Important Factors in Influencing
Perception 57
Table 4. Presence of Major Theme in Participant Interviews 58
Table 5. Factors Affecting Organizational Perception of
Leadership Effectiveness 69
Table 6. Frequency of Descriptive Words in Leadership
Competency Tool 70
Table 7. Summary of Major Themes in Physician and
Organizational Factors 77
1
CHAPTER 1. INTRODUCTION
Introduction to the Problem
Physician engagement is one of the foremost health care
administration topics of the
decade. The recent literature is filled with calls for action and

descriptions of current engagement
initiatives (Clark, 2012; Daly, 2013; Denis, Baker, Black,
Langley, & Lawless, 2013; Dickson,
2012, Frattaroli, Webster, & Wintemute, 2013; Grimes, &
Swettenham, 2012; Johnson, 2014;
Kaissi, 2012aa; Milliken, 2014). Despite over three decades of
discussion and action, physician
engagement issues continue to headline at health care
conferences (Beckman, 2014; Dickson,
Reid, Van Aerde, 2014; Marino, & Faber, 2014; Riskind; 2014).
Improving the relationships
between hospital physicians and front-line managers represents
and unexplored opportunity for
meaningful improvement in physician engagement.
The concept of physician engagement developed out of the body
of evidence surrounding
employee engagement. Employee engagement has been widely
discussed in human resources
literature for years and has long been considered critical in
improving organizational
performance (Attridge, 2009; Gruman, & Saks, 2011; Kular,
Gatenby, Rees, Soane, & Truss,
2008; Macey, & Schneider, 2008; Robinson, Perryman, &
Hayday, 2004; Schaufeli, Salanova,

Gonzalez-Romá, & Bakker, 2002; Saks, & Gruman, 2011).
Although physicians typically are
not hospital employees, the increasingly intertwined fortunes of
hospitals and physicians have
resulted in growing interest in physician engagement as a means
to improve hospital
performance.
2
Physician engagement is important because, where physicians
are actively and
collaboratively engaged in hospital operations and performance
improvement, their organizations
perform better financially and have higher patient satisfaction,
better overall quality, higher
staff/physician satisfaction rates and lower staff/physician
turnover (Gosfield, 2010; Kaissi,
2012aa; Rice,, & Sagin, 2010). Physicians have been shown to
hold greater influence on hospital
operations than either administrators or other paramedical and
allied health professions
(Hamilton, Spurgeon, Clark, Dent, & Armit, 2008). Ultimately,

physicians attract patients to
hospitals and physicians drive utilization and cost (Armour et
al., 2001; Halpert, Pearson,
LeWine, & McKean, 2000; Paller, 2005).
For decades, the relationship between physicians, hospital
administrators and front-line
managers has been characterized by conflict, suspicion, lack of
collaboration and sometimes
outright hostility (Bettner, & Collins, 1987; Robinson, 2001).
Over the last few years the health
care system has been suffering from further deteriorating
relationships (Burns, Goldsmith, &
Muller, 2010; New Jersey Department of Health, 2008; Payton,
2012), fueled by stronger
competition, demographic shifts, reimbursement cuts and public
demands for accountability and
quality improvement (Carlson, & Greeley, 2010). Greater
regulation and escalating financial
pressures on both hospitals and physicians from the Affordable
Care Act has further increased
tensions (Beckman, 2011; Harbeck, 2011; Payton, 2012). This
continuing system pressure to
decrease costs and improve quality has highlighted the
importance of a positive relationship

between management and physicians and emphasized the need
for collaboration.
Despite discussions and interventions to increase physician
engagement that go back
more than twenty-five years (Bettner, & Collins, 1987), there is
still abundant recent literature
describing the ongoing crisis and the need for greater physician
engagement (Clark, 2012; Daly,
3
2013; Denis et al., 2013; Dickson, 2012, Frattaroli et al., 2013;
Grimes, & Swettenham, 2012;
Johnson, 2014; Kaissi, 2012aa; Milliken, 2014; Payton, 2012;
Sears, 2012), Past initiatives have
had variable and only limited effectiveness (Baker, & Denis,
2011); some efforts at physician-
hospital integration have worked in the short term, but there
have also been some spectacular
failures (Fraschetti, & Sugarman, 2009). It is clear there is still
considerable opportunity for new
and innovative ways of engaging physicians.
Most existing/published efforts aimed at improving physician

engagement have been
focused on building broad alignment between key physician
groups and the hospital, as well as
engaging physician leaders in the process of hospital
administration (Shortell et al., 2001). These
types of initiatives are most often high level, structural and
strategic, including system outreach,
monetary incentives, hospital-physician integration, physician
participation on strategic
committees, and stronger medical leadership infrastructure
(Buller, 2003; Carlson, & Greeley,
2010; Fralicx, 2012; Gosfield, 2010; Kaissi, 2012aa). People
most closely involved in these
initiatives are typically hospital board members, hospital
executives and senior medical
leadership representatives.
While strategic alignment is important, most of a hospital
physician’s daily interactions
occur with other direct care providers and front-line managers,
not with hospital board members,
hospital executives or even physician leaders. It is the behavior
of individual physicians that has
the major impact on quality and utilization for hospitals
(Hamilton et al., 2008; Paller, 2005) and

the role of the front-line nurse manager is pivotal in creating
enabling environments for building
effective, productive and influential ongoing relationships with
medical staff (Kaissi, 2005;
McSherry, Pearce, Grimwood, & McSherry, 2012; Whiley,
2001). Improving physician-front-
4
line manager relationships represents an excellent opportunity
to further enhance physician
engagement.
There is considerable support in the literature about the
importance of front-line
managers in building collaboration and improving outcomes.
They bring organizational goals
and objectives to the front-line caregivers, shape behavior,
build engagement and remove
barriers (Cipriano, 2011; Grimes, & Swettenham, 2012). Front-
line managers are most often the
individuals responsible for enforcing hospital policies and
managing physician behavior on a
day-to-day basis. They must be able to engage physicians to

become willing “followers” who
support organizational goals as, in most cases, physicians are
not employees of the hospital and
cannot be forced into participation or compliance.
Leaders cannot lead unless they have willing and engaged
followers (Chaleff (2003).
Followers have specific expectations about how leaders should
behave and will typically choose
whether or not to accept leadership based on conformity to their
expectations, trust, perceived
leadership competence and believed worthiness of role and
power (Kenney, Schwartz-Kenney,
& Blascovich, 1996; Kaissi, 2012aa; Suderman, 2011).
Followership also increases in
proportion to the number of interpersonal interactions that are
seen as being positive and
meaningful (Bujak, 2003). Increasing positive interactions and
improving alignment between
physician expectations and leadership behavior could increase
physician engagement and
collaboration between physicians and managers.
Therefore it would be helpful to better understand what
physicians expect from front-line

managers, specifically, how they determine leadership
competence and what factors contribute to
their conscious and sub-conscious decisions to accept manager
influence. Then, if physician
5
expectations differ from organizational role definitions and
expectations of management
performance, efforts could be made to bridge that gap
Background of the Study
The fractured relationship between hospital administration and
physicians has had many
unfortunate consequences. Physicians are asking to be paid for
nonclinical duties they previously
did voluntarily; some are refusing to serve on hospital
committees, service the emergency
department or take call; some are limiting the number of
patients they will visit in a day; others
lie for patients on insurance and hospital billing claims; still
others are opening physician-owned
practices that directly compete with hospitals for market share –
all symptoms of lack of

physician engagement (Brown, 1983; Carlson, & Greeley, 2010;
Holm, 2008; Hunter, 2001;
Sade, 2012). Aside from the obvious financial and quality
implications of this behavior,
declining physician engagement across the broader health care
system has also been identified as
a key contributor to more physicians opting for early retirement
or reduced practice hours,
leading to increasing concerns over shortages of primary care
practitioners, surgical specialists
and hospitalists (Fraser, 2010; Sheldon, 2011; Voelker, 2009).
Without addressing the issue of
physician engagement, hospitals will not be able to meet current
and future performance
expectations.
Despite the conflicts, hospitals need physicians as they attract
patients to the hospital and
the physician is typically the only provider who can admit and
discharge patients, order tests,
dictate treatment and document the course of medical care for
many coding/billing purposes
(Kaissi, 2012a). Physicians may have obligations around
administrative/committee work,
teaching, and on-call coverage but ultimately do not pay to use

hospital facilities. They must
voluntarily comply with hospital policies and procedures. At the
same time, increased threat of
6
litigation/malpractice claims often result in higher costs from
defensive workups, more lab tests
and redundant diagnostic procedures (Baicker, Fisher, &
Chandra, 2007).
Hospitals have tried to break their dependence on physician
goodwill, by strengthening
utilization management policies, procedures and restricting
access to specific resources.
However, physicians then find ways to sabotage these rules and
regulations, increasing “stat”
orders and insisting on critical or defensive interventions
(Pfifferling, 2008). Managers,
following organizational direction, try to improve compliance,
but find themselves cajoling,
threatening and negotiating behavior changes and compliance
(Harris, 1977).These kinds of
behaviors are intrinsically dissatisfying and do not build
positive relationships.

In theory, good managers, as defined by the typical
competency-based frameworks used
in hospitals (NHCL, 2012) should be able to drive better
performance and greater compliance
from physicians. However, there is ongoing evidence that
experiences and personal connections
affect physician engagement (Kaissi, 2012aa) and that
willingness to follow a leader is ultimately
based on subjective world view (Bujak, 2003; Chaleff, 2003;
Kenney et al., 1996; Kaissi,
2012aa; Suderman, 2011) rather than traditional leadership
competencies.
“Good” Leadership and Physician Perspectives
“Good” leadership means different things to different people. At
the broadest level,
leadership is a process if influencing others to achieving
organizational goals and objectives
(Kruse, 2013). In addition to the virtually infinite different
subjective views on good leadership,
there are a multitude of formal definitions, theories and models,
including transformational
leadership, servant leadership, wise leadership, transactional
leadership and many more

(Kellerman, 2007; Mazyck, 2008; Nonaka, & Takeuchi, 2011;
Ramsey, 2003; Rolfe, 2011). In
health care, most organizations today have adopted the widely
supported National Center for
7
Healthcare Leadership (NCHL) model for assessing leadership
competencies (NCHL, 2012) and
use this, or some similar/related model, to guide and evaluate
leadership performance in
managers. The NCHL Model defines twenty-six competencies,
including communication,
financial management and human resources management,
grouped into the three domains of
transformation, execution and people.
While these usually accepted measures of front-line manager
effectiveness focus on
traditional leadership competencies including transformation,
execution and people skills
(DeOnna, 2006; NCHL, 2012; Ten Haaf, 2007), and the extent
to which managers can influence
employees and other stakeholders to work towards
organizational objectives (Cooper, &

Nirenberg, 2004), senior leaders throughout the health care
system suggest that physicians
appear to judge competence by a different measures than the
traditional leadership competencies.
Even physician executives, who are most likely to have
recognized leadership and management
training, have usually been through physician leadership
programs that heavily favor traditional
management skills such as financial management, conflict
resolution, business strategy, and
organizational behavior rather than soft skills and relationship-
building (Physician Leadership
Program. 2013; Preparing Physicians to Lead, 2013). Since
most physicians have no formal
education on the topics of leadership assessment and
management skills and interact with front-
line hospital managers and other administrators intermittently,
often transactionally, they make
their judgments about leader effectiveness based on incomplete
information and perception
rather than through any formal or validated performance
assessment tools.
Differing perceptions are significant because perception is the
process by which we

interpret and make meaning the world around us (Lindsay, &
Norman, 1977). Perceptions are
often subconscious, based on past experiences, values,
prejudices, self-interest and other
8
attitudes, and have been shown to be more important than
reality in the decision-making process
(Potgieter, 2011). In the absence of conflicting information, and
sometimes despite conflicting
information, perception invariably becomes reality in the mind
of the perceiver. Furthermore,
these perceptions and expectations may actually affect actual
manager performance (Inamori, &
Analoui, 2010; Livingston, 2009). Perceptions eventually
create their own reality.
With each manager-physician interaction, physicians
accumulate information that is
filtered through their perceptions about the
manager/organization and that affects the probability
of engagement and compliance with organizational goals and
objectives. If the factors

influencing physician perceptions differ from the traditional
leadership competencies, and/or
from the competencies that are encouraged and rewarded by the
organization, dissonance and
conflict may result (Kissick, 1995; Reay, & Hinings, 2009;
Waldman, & Cohn, 2007). Therefore,
understanding the factors that influence physician perceptions
of manager competence, and
hence physician engagement, could allow managers to modify
behavior to more effectively
influence physician engagement
Statement of the Problem
Hospitals today have an urgent need to find innovative
approaches to building physician
engagement. Existing efforts have not yielded sustainable
results and none address the essential
issue of daily physician-manager interactions at the front line
and the effectiveness of
physicians’ relationship with the front-line manager of the
patient care unit (Baker, & Denis,
2011; Fraschetti, & Sugarman, 2009). Better physician-manager
collaboration will improve
physician engagement and enhance organizational performance.

In the daily work on patient care units, physician compliance
and willingness to
acknowledge leadership and direction of management is related
to the extent that they
9
trust/respect manager leadership skills (Chaleff, 2003; Kenney
et al., 1996; Kaissi, 2012a;
Suderman, 2011). However, manager behaviors and
performance expectations are based on
competency frameworks that may not align with expectations of
physicians, whose world views
differ from those of administrators (Kaissi, 2012a; Klopper-Kes,
Meerdink, Van Harten, &
Wilderom, 2009; von Knorring, de Rijk, & Alexanderson, 2010;
Waldman, & Cohn, 2007).
Differing expectations lead to conflict and distrust (Kissick,
1995; Reay, & Hinings, 2009;
Waldman, & Cohn, 2007), minimizing physician engagement
and potentially manager
effectiveness. Although it has been shown that physicians and
administrators have different
world views and that they have different priorities at the front

line of patient care, there is little
evidence or research about what exactly they do view positively
in terms of manager behaviors
and activities. Gaining a better understanding of what manager
behaviors and activities
physicians value, will create an opportunity to improve
alignment between formal organizational
manager role expectations and physician perspectives.
Purpose of the Study
The purpose of this action research project was to determine
what factors influence
physician perceptions of leadership effectiveness in front-line
managers, which affected how
physicians decided whether or not to trust, accept leadership
from and collaborate with, front-
line managers. This purpose was relevant to current health care
system challenges because
physician perceptions of leadership effectiveness can be linked
to physician engagement and
subsequently to organizational efficiency and effectiveness.
First, an initial qualitative study, consisting of face-to-face
interviews of a sample group
of physicians was used to collect data on how physicians judge

effective leadership performance
in front-line managers in hospitals. Then, the results of these
interviews were compared against a
10
typical leadership competency model used by hospital
administrators to judge effective
leadership performance in front-line managers and analyzed
using a complexity theory lens.
Finally, based on the results of the above research, and using an
adaptive leadership model
suggested by complexity theory (Avolio et al., 2009, Uhl-Bien,
Marion, & McKelvey, 2007), a
specific intervention with leadership behavior changes was
proposed to help improve alignment
between physician and administrator perspectives.
Rationale
This action research was undertaken to find ways of improving
physician engagement at
the study site, a hospital in Ontario, Canada. The research
results were used to design an
intervention aimed at creating an enabling environment for

increasing alignment between
physician and administration expectations of leadership
behavior in front-line management, on
the premise that increased alignment would decrease physician
disengagement and improve
collaboration.
Since the target organization is facing massive system change
and incremental funding
reduction over the next three years (Ontario Health Coalition,
2012; Ontario Ministry of Health,
2012), improved collaboration and efficiency is critical to
organizational survival. In addition,
both the local health care region and Ontario as a whole are
suffering from ongoing and
potentially crippling physician shortages in many specialties
(Singh et al., 2010). Recruitment
and retention of internists, hospitalists and physician assistants
are all persistent challenges and
any initiative that improves competitiveness in this area is
helpful. Improved alignment in
perspectives should enable increased efficiency, better
outcomes and improved satisfaction for
staff and physicians (Accreditation Canada, 2010).

11
If successful, the project results should be transferable to other
hospitals in the region and
province, since they are all facing similar challenges with
physician engagement and funding
reductions (Hutchinson, 2010; Ontario Health Coalition, 2012).
These types of pressures are also
being experienced elsewhere in Canada and the United States
(Carlson, & Greeley, 2010;
Dickson, 2012; Kaissi, 2011; Robinson, 2001) and so the
project has the potential to make a
broader contribution to health care administration.
Research Questions
Primary Research Question: How do hospital physicians judge
of front-line managers?
Secondary Research Question 1: How do physician perspectives
differ from those in a
current competency-based leadership effectiveness evaluation
model used by administrators?
Secondary Research Question 2: What intervention(s) could

improve alignment between
administrator and physician perceptions of leadership
effectiveness?
Significance of the Study
This action research study was pursued in order to find a new
opportunity for enhancing
organizational performance at the study site hospital, which
operates in an increasingly complex,
challenging and competitive environment. Managers at the
target organization, and in other
hospitals around the country, have being asked to provide
ongoing patient care services out of
shrinking budgets while meeting increasingly stringent quality
and reporting requirements. They
enforce hospital utilization policies and communicate
performance targets, mediating between
increasingly unhappy physicians and often disenfranchised
employees. But ultimately
physicians, not managers, drive utilization and demand, and
managers have no formal authority
over physician behavior.

12
Existing/published efforts to improve physician engagement in
supporting hospital goals
and objectives have focused on high level, strategic and
structural interventions (Bettner, &
Collins, 1987; Buller, 2003; Carlson, & Greeley, 2010; Fralicx,
2012; Gosfield, 2010; Kaissi,
2011). People involved in these initiatives are typically hospital
board members, hospital
executives and senior medical leadership. While strategic
alignment is important, most of a
hospital physician’s daily interactions occur with other direct
care providers and front-line
managers, not with hospital board members and executives. The
role of the front-line manager is
central in creating enabling environments and in building
effective ongoing and mutually
beneficial relationships with medical staff (McSherry et al.,
2012; Whiley, 2001).
Front-line manager complain about lack of physician
responsiveness, excessive physician
resource utilization, inadequate physician presence on inpatient
units and poor physician
communication with patient family members. Physicians, in

turn, chafe against what they see as
increasing regulation and obstructive bureaucracy, while
complaining about poor care
coordination, lack of communication restrictive policies and
excessive focus on money and
efficiency. Conversely, physicians are more visible on units
where they have positive
relationships with the coordinating front-line manager. They are
also more easily engaged in
supporting hospital targets and more willing to attend meetings
where they respect the
organizing manager, while allegedly ignoring meeting
invitations from others.
Gaining a better understanding of physician expectations of
front-line manager leadership
roles helped identify the gap between physician and
organizational expectations and evaluate if it
could be bridged by one or more of physician education,
improved communication,
modifications to manager role or more specialized manager
training. In addition to increasing
engagement, improved relationships between managers and
physicians will increase quality of

13
work life for both groups and improve collaboration, which in
turn will increase productivity and
enhance outcomes, customer satisfaction and patient safety
(Accreditation Canada, 2010;
Amabile, & Kramer, 2012).
Definition of Terms
Bundled payments set a reimbursement rate for an episode of
care rather than for
individual interventions (Burns, 2013; Draper, 2011).
Employee engagement means that employees exert discretionary
effort beyond the basic
requirements of the job and work to create additional value
without being asked (Kruse, 2012).
Followership means that leaders cannot lead without followers
and that leadership is a
relationship created actively by both the leader and followers
(Oc, & Bashshur, 2013).
Hospitalists are physicians who specialize in inpatient
medicine rather than in the typical
service lines of surgery, medicine, cardiology etc. (Wachter, &
Goldman, 1996).

Leadership Competencies: When a person is described as having
competency in a
specific field, they are stated to have the all of the required
knowledge, skill and judgment to
perform effectively in that field (Hollenbeck, McCall, & Silzer,
2006).
Physician Engagement means that physicians are actively
involved in the planning and
delivery of care and also in supporting the pursuit of
organizational objectives.
Physician-hospital integration refers to the process of devising
more formal and mutually
beneficial relationships between physicians and hospitals, such
as expanded hospitalist programs
or partnership agreements and professional service agreements.
Utilization management refers to the deliberate control of
resource consumption in
hospitals.
14
Value-based purchasing (or pay-for-performance) is an effort to
increase health care

system efficiency where hospitals are reimbursed based on how
well they meet predetermined
performance targets rather than by fee-for-service.
Assumptions and Limitations
This research was premised on a series of logical conclusions
which, while founded in
comprehensive literature review, still ultimately led to an
assumption about the validity of this
series of conclusions. This sequence began with evidence that
1) physician satisfaction was a
critical issue in health care today 2) that it was declining 3) that
existing engagement efforts have
had limited success and there was a need for novel approach 4)
that manager actions at the front
line were important in communicating organizational objectives
5) That physician attitudes
towards managers affected the extent to which physicians were
willing to listen to managers and
engage in activities related to organizational objectives 6) That
while there was evidence that
physician attitudes were based on different world view and
socialization from traditional
administrative views, there was little evidence about what

actual factors influence their
perceptions.
This researcher assumed that the factors influencing physician
perceptions of leadership
effectiveness of front-line managers were different from those
in traditional leadership
competency models and that these factors could be described,
measured and compared. The
study also assumed that a sufficient number of physicians would
volunteer to be interviewed and
that they would be truthful in their interviews.
Because of the subjective nature of qualitative research, this
project was subject several
limitations. Interviewees may not have been aware of their own
biases, prejudices and
perceptions about what constitutes leadership effectiveness.
Past and existing relationships
15
researcher / interviewee relationships and organizational
position may have influenced interview
responses and discussion. Despite assurances of anonymity,

interviewees may have felt inhibited
by concerns over confidentiality. Finally, this was an action
research project in which
organizational context is relevant and influential in interviewee
responses, which could be seen
as a limitation on the generalizability of the work.
Nature of the Study
This study was based on the conceptual framework provided by
complexity theory. In
complexity science scholars suggest that interdependence and
independent action exist
simultaneously and both rational and irrational behavior can
coexist (Cooksey, 2001). Through
the combination of many simple patterns and relationships,
there are infinite outcomes and
possible actions. Complexity science borrows from many other
disciplines, including biology,
sociology, computer science, economics, anthropology
(Zimmerman, Lindberg, & Plsek, 2009),
and studies how systems actually behave rather than how they
are expected to behave.
Complexity theory provided a relevant and helpful framework
for thinking about the

relationship between front-line managers and hospital
physicians. In complexity theory, the
hospital is viewed as a complex adaptive system (CAS) and
described as a set of relationships
between autonomous agents, with infinite interconnections and
the capacity to learn from
experience and alter behavior (Zimmerman et al., 2009). All of
these independent agents (such as
physicians and managers) act locally and independently,
according to their own plan and agenda.
In general, people do not all behave the same way when faced
with similar circumstances and
much of human behavior is not predictable or even explainable.
Even with many shared
experiences and agreed upon goals, people may choose different
actions.
16
Historically, leaders have been encouraged to try to influence
and control in order to
drive alignment towards a common vision (Marion, & Uhl-Bien,
2001). Complexity theory
holds that human behavior does not respond well to such efforts

at control because of the reality
of free choice/human agency and unexplained actions and
responses (Heylighen, 2006). When
faced with traditional efforts to drive alignment, these
stakeholders may respond by developing
coalitions to protect their own interests and visions however,
given the right set of enabling
circumstances, they can also act collaboratively, co-dependently
and supportively (Marion, &
Uhl-Bien, 2001).
Instead of aiming to control or direct, the role of an adaptive
leader is to support and
enable learning, creativity, and desired behavior in the complex
organizational system,
particularly in those functioning predominantly with knowledge
workers such as physicians
(Uhl-Bien et al., 2007). Adaptive leadership embraces the
evolutionary, creative and learning
activities that leaders must facilitate to stimulate collaboration.
Rather than being directive or
manipulative, adaptive leadership supports and coaches the
activities of the many free agents
comprising the system (Avolio et al., 2009; Uhl-Bien et al.,
2007).

Complexity theory has been used to describe and explain many
phenomena in health care
systems and hospitals, including unexpected consequences of
government interventions (Reece,
2008), differential leadership success in hospitals (Ford, 2009),
adaptive interventions in primary
care (Litaker, Tomolo, Liberatore, Stange, & Aron, 2006),
planning physician governance
(Lindberg, Herzog, Merry, & Goldstein, 1998) and hospital
change management (Dattée, &
Barlow, 2010). It has also been used in dissertation research to
look at the impact of
environmental change on hospitals (Penprase, 2007). In the case
of front-line leadership in
hospitals, complexity theory suggests that an adaptive leader
could facilitate alignment of goals
17
and that the organization could create enabling structures that
also support collaboration among
free agents (Uhl-Bien et al., 2007; Zimmerman et al., 2009).
In summary, complexity theory is founded on a viewpoint that

reality is subjective,
changing and relational. Meaning is created out of the complex
relationships among people and
between people and the environment. As such, complexity
theory will well support dissertation
research that is aimed at better understanding the perceived
reality of physicians and managers as
it relates to the leadership effectiveness of front-line managers
in hospitals.
Organization of the Remainder of the Study
The remainder of this research study includes sections on the
literature, methods, analysis
and discussion. Chapter 2 presents an aggregation of the
relevant current literature related to the
research and theoretical framework. Chapter 3 provides details
of the qualitative research
methodology and study design. Chapter 4 describes the results
of the study and the analysis of
the data. Finally, chapter 5 includes discussion of the results,
limitations, conclusions, and
recommendations for future research.

18
CHAPTER 2. LITERATURE REVIEW
Introduction to the Literature Review
This dissertation focused on the relationship between physicians
and front-line managers
in hospitals. This relationship is important because it affects not
only the extent to which hospital
physicians are present and engaged at point of care, but also the
probability that they are willing
to follow the leadership of the manager and support
organizational objectives. The research
specifically addressed physician perceptions of leadership
effectiveness in front-line managers.
The review of the relevant literature begins with a brief
discussion of generic qualitative
inquiry and then presents a more detailed review of the
theoretical framework used in
interpreting interview responses and suggesting an action
research intervention. This is followed
by a comprehensive review of the current knowledge about
perceptions of leadership and the

leader-follower relationship of front-line leaders and
physicians. The section is completed by a
discussion on the need for further research as presented in this
dissertation study.
Theoretical Framework
Complexity science was the theoretical framework used in
discussing the physician
interview results and in proposing an intervention to build
alignment between physician and
organizational views on leadership behavior. Complexity theory
was selected because it is
broadly applicable to the current state of healthcare where
multiple stakeholders are experiencing
disruptive changes, competing priorities and paradoxical
incentives, yet must collaborate to
19
optimize their own position. This section of the literature
contains a review of some of the
foundational thinking in complexity theory, a discussion of how
complexity theory particularly
applies to healthcare and then an explanation of how complexity
theory suggests leaders can be

more effective.
Complexity science challenges the linearity that permeates
much traditional economic,
management and systems theory, where systems are viewed as
the sum of their parts and end
results are predictable outcomes of a series of prescribed steps
(The Physical World, 1998).
Linear models assume that there is an inherent order to things,
that the world largely progresses
in an expected sequence, and that a specific amount of one
variable produces a relatively
proportional amount of change in the other (Brettel, Greve, &
Flatten, 2011). As an alternative,
complexity science draws from many different theories and
disciplines, studying patterns of
relationships, self-organizing behavior, surprising outcomes and
unintended consequences
(Zimmerman et al., 2009). In the economic and then leadership
contexts, this difference is
important because, in linear models, leaders can reasonably
expect that particular leadership
inputs, including the active application of traditional theory,
rewards, coaching, planning and

analysis, will produce desired level of employee behavior and
system response. In complexity
theory this is not the case and studies of complex adaptive
systems suggest alternate behaviors.
Complex adaptive systems are the cornerstone of the research
and literature in
complexity science. By definition, complex adaptive systems
are open and dynamic, containing a
wide variety of components or agents that are interconnected
and interdependent (Beinhocker,
1997). Each of the components, agents or groups of agents acts
independently, according to self-
interest and based on a specific knowledge set and personal
circumstances, but is influenced by
the behavior of other agents; any central control is illusory, as
outcomes and consequences are
20
ultimately determined by the connections, conflicts and
collaborations of the many independent
agendas (Beinhocker, 1997; Zimmerman et al., 2009). The range
of possible outcomes is infinite,
not only because of the variety of possible interactions, but

because the system and agents learn
from experience and demonstrate evolutionary and emergent
behavior (Beinhocker, 1997; Uhl-
Bien et al., 2007; Zimmerman et al., 2009). The characteristics
of complex adaptive systems,
especially the combination of independent behavior but
interdependent outcomes, suggest that
enabling behavior and mutual interests can be more effective
than attempts to control – and this
thinking can be applied to hospitals.
In complexity theory, the hospital is viewed as a complex
adaptive system (Best, Saul, &
Willis, 2013; Zimmerman et al., 2009). The independent agents
in hospitals that are most often
cited include physicians and managers, however may include
any stakeholder group with both
independence of action and agenda as well as interconnected
outcomes, such as patients, staff,
unions, governments, insurers, and many other stakeholders.
(Zimmerman et al., 2009).
Managers, physicians and staff act locally and independently,
according to their own plan and
agenda but, given the right set of enabling circumstances, have
demonstrated collaborative and

codependent actions for mutual benefit (Best et al., 2013;
Dickson, 2012; Zimmerman et al.,
2009). This evidence suggests that front-line managers could
use enabling behaviors to facilitate
mutually beneficial outcomes with physicians and other
stakeholder groups in their areas and has
been further studied in complexity leadership theory.
Historical Leadership Teaching
Existing knowledge and teachings on leadership dates back to
the industrial age, founded
in the work of the classical theorists such as Taylor, Weber and
Fayol (Chalcraft, 2009) and
originated at a time that was characterized mass production,
departmentalization, standardized
21
education, hierarchical organizations and economies of scale
(Drucker, 1998). These scientific
theories of management were succeeded by post-bureaucratic,
systems theories that advocated a
more situational and transformative leadership approach in the
flattened organizations and team-

based environments of the late 20th century (Ledlow, &
Coppola, 2011). However, in the
complex working environments of the 21st century knowledge
economy, information, innovation
and flexibility are the key drivers of success (Uhl-Bien et al.,
2007), and traditionally accepted
leadership skills and activities do not provide sufficient
explanation or direction. Many business
leaders and scholars, including renowned leadership scholar
Henry Mintzberg, have concluded
that traditional leadership thinking and training is falling short
of what is needed and is not
providing the right direction to today’s managers (Thompson,
2008). This is particularly true in
healthcare where continuing upheaval and disruptive change has
created a burning need for new
ideas and new solutions (Begun, Zimmerman, & Dooley, 2003;
Beinhocker, 1997). These gaps
between traditional leadership theories and the ongoing
disruptive changes in healthcare in
healthcare have catalyzed the development of complexity
leadership theory.
Traditional leadership theory assumes that there is an inherent
order to things, that the

business planning progresses in an expected sequence, and that
managerial cycles can be
established to achieve organizational goals (Uhl-Bien et al.,
2007). Leaders are expected to find
ways to motivate followers and to direct them in performing
effectively and efficiently (Zaccaro,
& Klimosky, 2001). Founded in a linear and mechanistic
approach, most leadership theories are
prescriptive and predictive through group functioning models,
strategic planning approaches, and
performance management systems, and are aimed at exerting
control on the natural tendency
towards system disorder (Ford, 2009). Even human relations
models of transformational
leadership focus on inspiring employees to buy into the
organizational vision and to building
22
commitment to achieving organizational goals (Bass, 1985;
Huxham, & Vangen, 2000). These
models focus on the predictable and controllable aspects of
management at a time when health

care is increasingly unpredictable (Uhl-Bien et al., 2007) and
organizations can instead work on
building capacity for learning, creativity and adaptability
(McKelvey, & Boisot, 2003). This is
unpredictability is particularly relevant to the current state
tension between hospitals and
physicians.
Complexity Science and Leadership Theory
Complexity science is a relatively recent concept through which
scholars attempted to
address the disorganized realities of living and leading in the
knowledge era. In the world of
complexity science, interdependence and independent action
exist simultaneously and both
rational and irrational behavior coexist (Cooksey, 2001).
Today’s health care organizations meet
the previously described criteria of complex adaptive systems.
They demonstrate highly
complex, diverse organizations with multiple interconnected
elements that function both
independently and collaboratively. The system has evolved into
its present state in a relatively
short period as a result of multiple mergers, alliances and
adaptations to market forces and

legislation. They exhibit self-organizing behavior in
organizational sub-culture, advocacy
groups, physician practice groups and ad hoc interdisciplinary
teams (Begun et al., 2003; Best et
al., 2013; Zimmerman et al., 2009). The larger health care
system is composed of smaller
complex adaptive systems (hospitals, governments etc.), which
are, in turn, composed of even
smaller ones (physician groups, family health teams, unions,
committees), and all of these
systems evolve both in a mutual and interdependent way
(Zimmerman et al., 2009). This
complex adaptive structure has many implications for healthcare
leaders.
23
A fundamental reality of healthcare today is that there is little
direct authority or control
over the many agents. At the highest level, complexity theory
suggests leaders embrace
uncertainty and change and that instead of aiming to control or
direct; the goal of leadership

should be to support and enable learning, creativity, and
adaptation in the complex
organizational system, particularly those functioning
predominantly with knowledge workers
(Uhl-Bien et al., 2007). This means that the leaders need to
understand new frameworks of
thinking about work and leadership and then develop specific
new leadership skills to function
effectively in this environment.
The Role of the Leader in Complex Adaptive Systems
In describing the desirable leadership behaviors, complexity
theory borrows from post-
heroic leadership literature where the leader is a facilitator or
catalyst rather than driver of
behavior (Denis et al., 2013; Fletcher, 2004; Ford, & Ismail,
2006). Successful post-heroic
leaders are those who can encourage, enable, facilitate, support
and generally create conditions
under which collaboration happens and positive emergent
behavior results (Fletcher, 2004; Yukl,
1999). Successful relationships between stakeholders are those
founded in mutual influence
instead of control (Bradford, & Cohen, 1998). Clearly these
kinds of behaviors require very

different skill sets and new thinking. These kinds of behaviors
and required skills have been
adopted into complexity leadership theory.
More specifically, Uhl-Bien et al. (2007) describe adaptive and
enabling leadership as
overarching functions required in complex adaptive systems.
Adaptive leadership refers to
evolutionary, creative and learning activities in which leaders
must engage as these activities
emerge naturally from interactions within the complex adaptive
system. Rather than being
directive or manipulative, adaptive leadership supports and
facilitates the desirable relationships
24
and activities of independent agents within the system. Adaptive
leadership is required in work
groups, meetings, boardrooms and at the front line. An example
of adaptive leadership is
engaging others in brainstorming and “what if” scenario
analysis, as well as fostering
interprofessional collaboration (Avolio et al., 2009). As the

leader adapts to the situation and
stakeholders of the day and assesses the current requirement,
the leader can then focus on
enabling the desired actions and outcomes.
Enabling leadership then works as a catalyst which helps
adaptive functions flourish.
Enabling leadership also creates the appropriate organizational
conditions to foster adaptive
relationships and facilitates the flow of knowledge and
creativity from adaptive structures (Uhl-
Bien et al., 2007). An example of enabling leadership is
working to remove bureaucratic
obstacles as well as barriers to participation and openness
(Avolio et al., 2009). In addition to
these overarching functions, complexity leadership theorists
suggest three required behaviors for
leaders in organizing, following vision and influencing (Uhl-
Bien et al., 2007). Details of these
specific behaviors are as follows:
-organization by
recognizing and exploiting the
unpredictable nature of the complex adaptive organizations in
health care. They must

be able to harness the full potential of employees, partners,
physicians, customers and
all other stakeholders.
red by their vision, but allow
that vision to evolve as
the system evolves. By providing vision and boundaries, leaders
can allow employees
and potential collaborators to act based on their experience and
co-evolve with the
system.
25
lly, because leaders have limited influence on change
processes, leaders should
focus energy and attention where they can influence effectively.
They must learn to
confront the bases of conflict between stakeholder groups in a
changing organization
and to see them as opportunities rather than obstacles.
This new framework of thinking about relationships and
leadership behaviors presents new
opportunities for addressing the relationship between physicians

and front-line managers.
The Utility of Complexity Theory
Complexity leadership theory provides a useful framework for
analyzing physicians’
perspectives on leadership in front-line managers,
acknowledging that physicians and managers
have different views and goals that sometimes conflict, but
ultimately they are dependent on
each other for success. Complexity leadership theory has been
broadly applied in healthcare
leadership literature and suggests improved collaboration and
outcomes (Best et al., 2013;
Zimmerman et al., 2009). Ultimately, the manager’s role as
leader is to adapt to the changing
views and needs of multiple stakeholders and to create an
enabling environment in which all
stakeholders can realize a measure of success. By better
understanding those physician views and
needs, specifically their perspectives and expectations from
front-line managers, leaders could
engage physicians more effectively in mutually beneficial
behaviors.
Physician Perceptions of Leadership Effectiveness in Hospital
Managers

There is little direct research and existing literature about
physician perceptions of
leadership effectiveness in hospital managers, however
inferences can be made from related
literature. This this section discusses the general role of
perception in determining effective
leadership, specific evidence that physicians are more engaged
when the manager is a credible
and effective leader, previous research on physician
perspectives on managers as leaders, and
26
finally related research demonstrating differences in perceptions
of leadership effectiveness
between different stakeholder groups.
The Role of Perception in Determining Effective Leadership
Much of healthcare leadership research has been focused on
identifying the most
important leadership skills and competencies; that is, it is
leader-focused. Examples include
transformational leadership and authentic leadership (Avolio et
al., 2009). However, there is also

substantial and more general leadership research that is
follower-focused, specifically examining
the quality of the relationship between the would-be leader and
potential followers (Hall, &
Lord, 1995; Howell, & Hall-Merenda, 1999; Kellerman, 2007;
Liden, Wayne, & Stillwell, 1993;
Rentsch, & Hall, 1994; Suderman, 2012). This research on
implicit leadership suggests that the
actual knowledge, skills and behaviors of a leader are less
important than follower and other
stakeholder expectations of how the leader should behave
(Schyns, 2006; Schyns, & Schilling,
2010). This type of research aligns well with the complexity
theory approach to relationships that
are both independent and interdependent.
Implicit leadership research has demonstrated that both social
and leadership perceptions
are developed quickly and consistently according to the
expectations and beliefs of the perceiver
(Liden et al., 1993; Lord, & Maher, 1991; Murphy, & Zajonc,
1993). People quickly evaluate the
environment and the would-be leader against their own pre-
existing belief structure in ways that

may have little to do with objectively measured leadership
competencies. Based on these rapid
and usually subconscious assessments, individuals make long-
lasting conclusions, & decisions
about worthiness of followership (Hall, & Lord, 1995; Howell,
& Hall-Merenda, 1999;
Suderman, 1012). Rentsch, & Hall (1994) showed that members
of the same work groups
develop similar schemas for assessing leadership (intra-group
consistency). This view is
27
corroborated by research on actual leadership evaluations that
demonstrated strong intra-group
agreement (Bradley, Allen, Hamilton, & Filgo, 2008). There is
also evidence that different
groups develop different schemas (inter-group inconsistency)
and definitions on leadership
(Shertzer, & Schuh, 2004) and that these schemas can lead to
constraining beliefs about
leadership (Astin, & Astin, 2000). While this research seems
generally applicable to health care,
there is also confirmation through applied healthcare leadership

research.
Specific healthcare research studies have provided empirical
evidence on the impact of
perception. The research supported the notion that perceptions
of leadership effectiveness can be
different from actual effectiveness, as measured by traditionally
accepted evaluation methods
such as leadership competency assessments (Klopper-Kes,
Siesling, Meerdink, Wilderom, & van
Harten, 2010). Based on this evidence, understanding the
perceptual framework of physicians in
relation to front-line manager effectiveness is important.
Evidence Linking Physician Engagement to
Leadership Effectiveness in Managers
Administrators/managers are central in building physician
engagement in hospitals
(Dickinson, & Ham, 2008) and their effectiveness depends on a
variety of factors including the
individual experiences of physicians with managers and
personal connections established within
the organization. These experiences affect physician perceptions
about managers, including trust,
understanding and respect (Kaissi, 2012a), which in turn affect

physician alignment, willingness
to cooperate with others and engagement in shared activities
(Montgomery, 2001; Trybou,
Gemmel, & Annemans, 2011). The type and scope of the
relationship between physicians and
administrators has emerged over time as a result of the structure
and evolution of hospitals and
formalized healthcare systems.
28
Historically, as soon as there was separation of administrative
and clinical functions in
the hospital environment, it meant that physicians had to be able
to trust that managers would be
effective in overseeing hospital operation and patient care, and
that they would not interfere with
physician autonomy in their clinical domain (Kaissi, 2005).
Over the past two decades much has
changed in the physician-organization relationship and full
physician autonomy over clinical
decisions no longer exists; today, because of accountability and
efficiency requirements,

hospitals increasingly have become involved in the clinical
domain, engaging in
utilization/quality management and implementation of evidence-
based protocols (Orland, 2011;
Wagner, Gulácsi, Takacs, & Outinen, 2006). Physicians must be
able to trust that managers will
only interfere reasonably and appropriately in clinical decisions
- which is perhaps more difficult
than staying out of the clinical domain entirely.
While physician trust in hospital management is affected by the
extent to which they
respect managers and believe they are able to effectively carry
out their duties, it is also affected
more generally by leadership power (Hospital Check-up Report,
2007; Kaissi, 2012a). Since, in
most cases, managers have little or no hierarchical power over
physicians, they need to rely on
other sources of power to elicit physician collaboration, such as
referent and knowledge power
(Fuqua, Payne, & Cangemi, 1997; Isosaari, 2011). This once
again supports the need for
physician trust and respect of the manager’s leadership.
While the existing evidence around the importance of trust,
respect, and referent power is

considerable, little research exists on how physicians actually
decide whether a manager is an
effective leader and how they come to trust, respect and support
the manager. In an ideal world,
there would be good alignment between organizational and
physician expectations, evaluations
and conclusions. Hospitals would hire, train, evaluate and retain
excellent managers and
29
physicians would support these managers. However, continuing
reports about the conflicted
relationships between physicians and hospital administration as
well as their sometimes
conflicting goals suggests this is not the case (Burns et al.,
2010; Payton, 2012; Robinson, 2002).
Research into the quality of the physician-manager relationship
is helpful in further
understanding what has contributed to this fractured
relationship.
Existing Research on the Quality of Physician-Manager
Relationships

General research about differences between manager and
physician culture and world
view provides additional helpful information in predicting lack
of alignment between physician
and organizational perspectives of leadership effectiveness in
managers. In general, the body of
research around physician-manager relationships
overwhelmingly reports that physicians have
broadly negative feelings towards hospital managers in general
(Alexander, Brewer, &
Livingston, 2005; Bujak, 2003; Edwards, 2003; Klopper-Kes et
al., 2009; Klopper-Kes,
Meerdink, Wilderom, & van Harten, 2011; O'Hare, & Kudrle,
2007). These unfavorable views
have been attributed to the four key areas of negative
stereotypes, cultural differences,
conflicting goals and changes in health system incentives and
societal expectations.
Negative stereotypes. As a group, physicians have been found to
hold stereotypical
views of hospital managers as being low in social status,
uniformed, uninterested in physician
needs and not worthy of the amount of power they wield
(Edwards, 2003; Klopper-Kes et al.,

2009; Klopper-Kes et al., 2011; O'Hare, & Kudrle, 2007).
Individual manager competence can
be irrelevant as physicians, beginning with low expectations,
decide that a manager’s ongoing
efforts to advance organizational goals reinforce distrust and
the situation creates win-lose
relationships between managers and physicians (Alexander,
Brewer, & Livingston, 2005; Bujak,
2003, Edwards, 2003). With manager turnover, repeated
organizational restructuring and often
30
fleeting daily interactions, physicians may have little
opportunity to get to know managers as
individuals and can easily slide into basing their behaviors and
opinions on the archetype of a
bottom-line driven manager.
Cultural differences. Physicians and managers also have been
shown to have broad
cultural differences, which invariably produce opposing views
in daily activities as well as
interprofessional conflict (Kovner, Elton, & Billings, 2000).
Managers are conditioned into

hierarchical behavior, focusing on building collaboration and
valuing relationships/harmony.
These are activities that are fundamentally affiliative and
collectivist (Bujak, 2003; Degeling,
Kennedy, & Hill, 2001; Kaissi, 2005; O'Hare, & Kudrle, 2007).
Because of hospital planning
cycles and the requirement to engage many stakeholders,
managers also generally need to take a
long view; activities such as gaining consensus and acquiring
new equipment may take months
or years.
The above hierarchical and collectivist management culture
characteristically clashes
with the entrenched expert and far more individualistic culture
found in physician groups,
complete with expectations of clinical autonomy, immediate
action and reductionist decision-
making (Kaissi, 2005; Waldman et al., 2003). This expert
culture has been found to contribute to
a physician view of managers as intellectually weak, without
any common educational
background, true professional status or solid evidence-based
training. Managers are further

viewed as lacking in respect for individual physician expertise,
competency and skills (Cejka
Search, 2013). With such conflicting belief systems, differing
expectations and conflicting
behaviors can be anticipated.
Goals and objectives. The manager-physician differences
continue in the most basic
professional goal of each group, most often cited as physicians
pursuing the good of the
31
individual patient compared to managers aiming to serve the
best interests of patients as a group,
including setting priorities and allocating scarce resources
(Bujak, 2003). In addition, because
managers are often involved in work that superficially appears
to have little to do with the daily
activities of physicians and front-line patient care, they are
sometimes perceived as uninterested
in patient welfare and good clinical outcomes (Edwards, 2003).
The resulting and seemingly
inevitable conflicts are further exacerbated by continuing
system changes.

System changes. Ongoing health reform and health system
pressures often seem to
naturally pit administration and physicians against each other.
First, heath care funding reform
forces managers to focus on driving efficiency and cost
containment. Since physicians
ultimately drive utilization and resource use, these efficiency
initiatives often impinge on
physician autonomy (Beckman, 2011; Gosfield, 2010; Grimes,
& Swettenham, 2012). Increased
regulation and demands for accountability also result in
management pressuring physicians about
evidence-based care, performance metrics, appropriateness and
value (Degeling, Maxwell,
Kennedy, & Coyle, 2003). Consumerism, including the broad
societal movement to improve
patient experience, adds to these pressures (Klopper-Kes et al.,
2010). Finally, physicians
themselves are demanding shorter work hours and resisting
efforts to involve them in
committees and hospital driven improvement initiatives, again
placing managers and physicians
at odds. Without some way of finding common ground, these
differences appear irreconcilable.

Research on Perceptions of Leadership Effectiveness from
Related Fields
Applied research on perceptions of leadership effectiveness in
related contexts can
provide helpful information supporting the idea that physicians
and hospital administration
would have different perspectives. This research includes
evidence that followers ultimately
interpret behavior based on self-interest (Kellerman, 2007) and
that their perceptions of
32
leadership effectiveness may differ by hierarchical position,
gender, culture and the quality of
leader-follower relationship. In particular, the literature related
to manager vs. nonmanagers
perspectives is relevant.
Qualitative research has shown that, in studying hierarchical
differences, managers may
have substantially different perceptions about leadership
effectiveness when compared to
nonmanagers (Muchiri, Cooksey, Milia, & Walumbwa, 2011;

Pulakos, Schmitt, & Chan, 1996).
In addition, analysis of leadership perceptions as measured in
360-degree feedback and other
multi-rater environments also found broad lack of agreement
across stakeholder groups. While
managers at all levels principally value vision, supportive
leadership and integrity,
nonmanagement employees rank leadership behaviors that
demonstrate fairness, equality and
honesty more highly (Muchiri et al., 2011; Pulakos et al., 1996).
Since physicians would fall into
the nonmanagement category in the organizational hierarchy,
again, conflicting expectations are
inevitable.
Applied Research on the Impact of Culture on Leadership
Perceptions
As presented earlier, physicians and managers occupy different
cultural contexts leading
to fundamentally different world views. In addition to this
specific situation, several researchers
have demonstrated that culture can generate broad differences
in perceptions of leadership
effectiveness. Yan (2005) found generalized cultural differences
in perceptions about leadership

across key dimensions such as power distance (acceptance of
power inequities), uncertainty
avoidance, individualism/collectivism, and fatalism across
cultures. Yancey, & Watanabe (2009)
found some cultures value personality in evaluating leadership
as compared to others that value
skills and knowledge. Ford, & Ismail (2006) also demonstrated
significant differences across a
variety of cultures. Holt, Bjorklund, & Green (2009)
demonstrated that perceptions about good
33
leadership varied by cultural background, age and education.
Therefore, the anticipated probable
impact of these physician-manager cultural differences is
supported by more general research on
the impact of culture.
In addition to general research, it is also possible to extrapolate
from other industries,
including the military, to healthcare (Kaissi, 2012b). The
military, which has its own set of
beliefs and artifacts, has existing research results that are

relevant in demonstrating the impact of
culture on leadership perception. Specifically, Hinchman,
Magone, Marshall, & Stoddard (2009)
administered a leadership perception survey developed by
Kouzes, & Posner (2007) to military
personnel at a training facility. They found statistically
significant differences in 13 of the 20
surveyed characteristics of admired leaders when comparing the
results of military personnel to
the general population in the original survey (Hinchman et al.,
2009). These types of ongoing
differences in perceptions of leadership can also be extrapolated
from research into the impact of
gender on perception.
Muchiri et al. (2011) demonstrated that men and women judge
differently. Gender stereotyping has been shown plays a role in
influencing leadership
perceptions when analyzing perceived leadership planning and
foresight (Pratch, & Jacobowitz,
1996). As physicians are more apt to be male while hospital
administrators are more apt to be
female (Global Health Observatory Data Repository, 2014), this
research is relevant and

provides additional support.
Finally, the familiarity in the relationship between physicians
and managers can also be
considered. Research has demonstrated that the physical and
metaphorical distance in the
relationship between the observer and the leader also impacts
observer perception of leadership
performance and subsequent ratings (Howell, & Hall-Merenda,
1999; Lord, Brown, Harvey, &
34
Hall, 2001). Personal observation has shown that physician-
manager interactions on patient care
units are often fleeting and superficial, with little time for true
familiarization; similarly,
physician and manager offices are rarely co-located. Both
situations support continues
incongruence in views.
In summary, there is little direct research into how physicians
decide to trust managers, or
how they decide if managers are effective leaders, but much
supporting evidence has been

extracted from related relevant research. Expectations have been
shown to be important in
perceptions of effective leadership and the research
overwhelmingly suggests that physicians, as
a group, and hospital administration would have fundamentally
different expectations and
therefore perceptions of leadership effectiveness.
Generic Qualitative Inquiry
In research where there is no intent to investigate ethnographic
phenomena, to do detailed
case investigations or to develop a theory as a result of the
research, generic or noncategorical
qualitative inquiry is an accepted approach (Caelli, Ray, & Mill,
2003; Merriam, 1998;
Sandelowski, 2000; Thorne, Kirkham, & MacDonald-Emes,
1997). In generic qualitative
inquiry, researchers are not guided by an established set of
philosophical assumptions, but
instead seek to understand the social reality constructed by a
group of individuals (Merriam,
1998) in this case, the perspectives of hospitals physicians on
leadership effectiveness in front-
line managers.

Caelli et al. (2003) and Merriam (1998) suggest that to
maintain rigor in generic
qualitative research, the inquiry must contain theoretical
positioning by establishing a lens
through which the data are examined and interpreted. This
dissertation research is approached
through a complexity theory lens. They go on to describe
analysis of data that identifies recurring
35
patterns, themes, categories, or factors that pervade the data and
correlate with the theoretical
framework. This approach is used throughout this dissertation
research.
Literature Review Summary
This chapter provided a summary of the research and existing
evidence that is relevant to
this study. The research showed that physician perceptions of
leadership effectiveness in front-
line managers are important because favorable perceptions can
lead to greater physician
engagement which, in turn, can generate improved collaboration

and greater probability of
favorable outcomes for both organization and other stakeholder
groups. There is a broad body of
relevant and related research about physician views on
administrators, evidence of cultural and
perceptual differences between stakeholder groups, and research
on how leadership perceptions
can be influenced by the specific evaluation schema of the
perceiver; however, to date, there has
been no specific research on how physicians judge leadership
effectiveness and what factors
generate favorable perceptions. Complexity theory was shown
to provide a helpful interpretive
lens that fits well with the unpredictability and multiple
stakeholder agendas that exist in
healthcare today and provides a useful framework for
suggesting improvements. Generic
qualitative inquiry was shown to be applicable in this situation.
This study will add specific new
leadership knowledge that may serve as a foundation for
improved physician engagement and
collaboration.

36
CHAPTER 3. METHODOLOGY
Introduction to Chapter 3
This chapter describes the research approach, design, sampling,
analysis and other
methodological information relevant to this research. High
quality manager-physician
relationships contribute to physician engagement and are
critical to quality, effectiveness and
efficiency in hospitals (von Knorring et al., 2010) and so the
researcher selected a generic
qualitative, descriptive, research design in order to gain an
understanding of how physicians
judge leadership effectiveness in front-line managers. The
researcher interviewed hospital
physicians about the perceptions, opinions and feelings they had
experienced about the
leadership of front-line managers with whom they had worked
over the course of their careers.
Research Design
Qualitative Research
This dissertation used qualitative research design. Qualitative

research is widely used in
healthcare research and characterized by the following common
features (Campbell, 2014;
Creswell, 2003; Holloway, 1997; Sandelowski, 2004):
1. Through qualitative research, investigators try to better
understand the experiences,
thinking, attitudes and/or behaviors of a target group.
2. Qualitative research aims to interpret, understand and explain
patterns of behavior
that have been observed in a specific situation or culture.
37
3. Instead of measuring and quantifying, qualitative research
typically describes
observations in words, identifying connections and common
themes.
4. Qualitative research is also most often exploratory and open-
ended, approached from
the perspective of the target population and allowing the
patterns to emerge naturally
instead of constructing bounded approaches that limit
participant comments.

This dissertation study followed this general qualitative design
and used open ended questions
with physicians as the target population.
Qualitative research has been described as an appropriate choice
in specific situations
where quantitative research is not possible and other factors
favor more generalized inquiry
(Campbell, 2014; Creswell, 2003; Curry, Nembhard, & Bradley,
2009; Krasner, 2001;
Sandelowski, 2004; Westbrook, 1994). These factors include:
1. The research question is an effort to understand how or what,
with an emphasis on
understanding and describing rather than on identifying and
measuring specific
relationships between variables.
2. The goal is to explore the topic in a general way, as opposed
to developing a theory.
3. The researcher wants to develop detailed insight and
understanding of a specific
phenomenon or worldview.
4. There is little existing research on the topic. Qualitative
research is usually a first step

that is applied in situations where there is little existing
research and data about the
subject and can be very helpful in generating a model or
hypothesis for further study
by other methods.
5. The researcher wishes to gain an understanding of behavior
in the subjects’ natural
setting, free of any artificial influences or contrived
circumstances. Qualitative
38
research is most often naturalistic, that is, it studies behavior
and thinking in the
participants’ natural environment rather than in a laboratory or
some other
manufactured environment.
6. Instead of trying to determine absolute truth, naturalistic
qualitative research is
focused on the truth as perceived by the participants and
influenced by their world
view. Most often, qualitative research uses interviews or focus
groups to collect

participant thoughts and experiences.
7. The researcher has a specific interest in and personal
relationship with the topic of
study, rather than simply conducting objective analysis. The
interviewer is a part of
the study environment.
8. The researcher has sufficient time for field research and
thematic analysis of the
resultant data.
9. Both the reviewers of the research and the participants in the
study are open to
qualitative research design.
10. The researcher wishes to approach the study as a learner
rather than as an expert.
All of these described circumstances are highly relevant to this
research. In this
dissertation, the researcher wished to understand how
physicians determine effective leadership
in front-line managers. The goal was to explore the topic
generally and to learn what factors
influence physicians in their determination of leadership
effectiveness and understand how the
physician worldview affects their judgment. There is little

published research on how hospital
physicians decide if a front-line manager is an effective leader.
Stakeholder behavior in hospitals
is highly contextual and therefore studying behavior in the
actual environment is preferable. The
researcher is actively employed in the study site and wishes to
learn more about physician-
39
manager relationships. Finally, qualitative research is widely
used and supported in healthcare
services research (Bradley, Curry, & Devers, 2007).
Generic Qualitative Research
This dissertation research used a generic qualitative approach.
Generic qualitative
research is often simply referred to as qualitative research, but
to distinguish it from other forms
of qualitative research it has also been called basic descriptive
research, noncategorical research,
interpretive description and exploratory research (Merriam,
1998; Sandelowski, 2000; Thorne et
al., 1997). It is different from other specific qualitative

approaches, such as phenomenology,
grounded theory and ethnography, in its simplicity (Thomas,
2006). This simplicity made it
attractive for a beginning examination of the relatively
unexplored relationship between hospital
physicians and frontline managers.
Generic qualitative research is used where the researcher
desires to develop a
straightforward, first level description of the target population
perspectives without any intention
of developing a theory or rules of behavior, or of having to
resort to complex philosophy or
technical language (Thomas, 2006). General qualitative
research is becoming increasingly
common in healthcare as clinicians and administrators seek to
answer elegant and useful
questions, but have neither the time nor formal research
background to develop highly theoretical
approaches (Caelli et al., 2003). It provides a general and
practical approach to examining real-
world problems in a healthcare setting (Cooper& Endecott,
2007) and lends itself to easy
understanding by nonacademic readers. This current study
addressed the real world problem of

hospital physician engagement by exploring their perspectives
on frontline managers and
suggesting alternative leadership approaches.
40
Target Population and Sampling
The target population for this research study consisted of
physicians currently working in
the selected acute care hospital and who have daily interactions
with front-line managers. The
initial goal was to recruit 6-8 participants, however nine
physicians eventually participated in this
study. This sample size is supported in qualitative research
projects where the inquiry is
relatively narrow in scope, the topic clear, the interviewees are
a homogeneous and articulate,
and where the interview is focused on gaining a better
understanding of a specific phenomenon
rather than generalizing to a large population or testing a
hypothesis (Crouch, & McKenzie,

2006; Dworkin, 2012; Mason, 2010; Morse, 2000).
The research drew volunteers from the full-time physicians with
current privileges at a
hospital in Ontario, Canada. Site permission was obtained for
use of organizational resources,
communication systems, contact lists and attendance at
meetings . The initial plan was to recruit
participants through signs posted in the doctors’ mailroom ,
verbal presentations and handouts at
physician meetings and, if necessary, specific e-mail
solicitations for participants. However, the
researcher began participant recruitment during the summer
months, by which time all
department and medical advisory committees were on summer
hiatus, making presentation to
these groups impossible. Also, despite a two month-long
posting of the research study
recruitment poster in physician areas, no volunteers came
forward to participate. The successful
method for recruiting participants was the internal e-mail
solicitation method. Personally
addressed e-mails sent out to staff physicians yielded ten
qualified volunteers; however, one
physician withdrew from the study prior to data collection.

In order to ensure they had had significant experience with the
physician/manager
relationship and had had sufficient time to develop opinions on
manager effectiveness,
41
prospective participants were screened to establish they had
been practicing in a hospital setting
for at least three years. Any doctors who did not regularly visit
patient care area with front-line
managers were excluded. Doctors with sole reporting through
the surgical program, where the
researcher is employed, were also excluded from participation
in order to avoid any perceived
conflict of interest. Most of the recruitment conversations were
conducted electronically,
however if a prospective participant asked for any clarification
of further explanation, a follow
up telephone conversation was initiated.
After obtaining preliminary agreement, qualified prospective
participants were provided
with a detailed consent form for private review prior to

conducting an interview. During both the
process of soliciting volunteers and of obtaining consent, it was
made clear that participation was
entirely voluntary and that failure to participate would in no
way affect any future access to
hospital resources. On finding out that the interviews were to be
recorded, one participant
subsequently withdrew consent and did not follow through on
the interview. This left nine
participants from the original 10 volunteers. The final sample
population included men and
women, physicians and surgeons, and also represented a variety
of cultures and medical
specialties. The interviewed doctors were all very experienced,
had each been in practice for over
ten years, and had worked at this organization for at least four
years each.
Confirmed, qualified volunteers were scheduled for a face-to-
face interview that was
recorded using a digital audio recorder. Participants were asked
to verbally confirm that they had
read and signed the consent form and that they were aware that
the conversation was being
recorded. They were also informed that they would be e-mailed

an interview transcript for
review, at which time they could withdraw from the study
and/or add/delete comments.
42
Setting
This dissertation research was conducted at a community
hospital in Ontario, Canada.
The organization consists of two campuses, several community-
based mental health clinics and a
walk-in clinic. This facility was selected because the researcher
is employed there as program
director of surgery. As with most hospitals today, managers at
this organization continue to be
challenged with shrinking budgets and increasing accountability
for documenting and improving
the quality of care. The health system in which the organization
operates is increasingly
competitive as mergers and program divestments threaten
traditional internal and external
relationships. As physicians drive costs through their control of

lab tests, imaging tests,
prescribing and length of stay, physician engagement is
increasingly important on maintaining
competitive position. As noted earlier in this dissertation, the
organization is facing massive
system change and incremental funding reduction over the next
three years (Ontario Health
Coalition, 2012; Ontario Ministry of Health, 2012), improved
collaboration and efficiency is
critical to organizational survival. In addition, both the local
health care region and Ontario as a
whole are suffering from ongoing and potentially crippling
physician shortages in many
specialties, reinforcing the need for physician engagement and
retention.
Initial site permission was obtained from the CEO in 2013 and
updated in spring of 2014.
Permission was also sought from the organizational research
ethics board (REB). This committee
provided a waiver for research with academic purposes.
Instrumentation/Measures
This qualitative research was conducted through individual,
face-to-face interviews using

an interview guide developed by the principal investigator with
input from Capella staff at the
Dissertation Colloquium (see Appendix B). This interview guide
was field tested though
43
interviews with five individuals with relevant credentials: two
physicians with leadership
responsibilities and three hospital administrators with formal
leadership training.
Field Testing
The purpose of field testing was to identify any potential
problems with the interview tool
such as confusion about the meaning of the questions or
misinterpretation of individual terms or
concepts (Brancato et al., 2006; Scheuren, 2004). The testers
were asked to consider:
1. Whether the instructions were clear in explaining the type of
information needed
2. Whether the questions flowed well and led to natural
elaboration by the interviewee
3. Whether the questions generated helpful and appropriate
types of information

considering the research questions and the overall goal of the
research
4. Whether the questions would elicit individual perspectives on
leadership
effectiveness
5. Whether the interviews could reasonably be completed within
a targeted 60 minutes,
based on market research evidence that physician willingness to
complete/participate
drops by two-thirds beyond sixty minutes (Maciolek, & Palish,
2009)
6. Whether they prospective participants could reasonably be
expected to discuss the
stated topics openly and honestly, given the insider position of
the researcher
Each expert confirmed the appropriateness and utility of
interview questions. They all
stated that they believed the instrument would accomplish the
study goals and that they had no
concerns about interviewee participation or openness.
Interviewers were also asked for specific
suggestions for improvement. One tester suggested an
additional clarifying question, which was

eventually incorporated into the interview guide.
44
Data Collection
Data collection commenced after receiving the appropriate
approvals from both the
Capella Institutional Review Board and the study hospital
Research Ethics Board as well as
completing the Pre-Data Collection Conference call.
Participants were recruited and screened as
described in the sampling section of this chapter and then
booked for a face-to-face interview
with the researcher. Initially there were ten volunteers but one
withdrew on hearing that the
interviews would be recorded and only nine interviews were
scheduled. The participants were
offered the option of meeting in the researcher’s office, the
participant’s office or a separate
meeting room. Three chose to be interviewed in their own
offices and the remainder selected the
researcher’s office.

The Interviews
The interview guide was designed to generate physician
opinions and perspectives on
front-line manager leadership effectiveness. At the beginning of
the interview session, each
participant was asked if they had any questions and the digital
recorder was turned on. The
researcher also took notes throughout the interview to document
any items that needed
clarification or exploration later in the session. Before
commencing the actual interview, the
researcher requested verbal confirmation that the participant
understood and had signed the
consent form, and that they were aware of being recorded. The
researcher then provided a brief
review of the study methodology, including restating that the
purpose of the interview was to
understand how physicians judged leadership effectiveness in
managers, specifically front-line
managers in hospitals. For the purpose of this interview, and for
clarification and consistency,
participants were provided with a written definition of
leadership as follows: “The process of

45
social influence in which one person can enlist the aid and
support of others in the
accomplishment of common tasks or organizational goals”
(Chemers, 2000, p27).
The actual interview commenced with a grand tour question
regarding a participant’s
general experiences with and opinions about leadership in front-
line managers. This was
followed with in-depth probing around their specific
experiences with managers they deemed to
be good or bad leaders. Participants were asked to identify
specific incidents, experiences and
interactions or that caused them to consider a manager as either
a good or bad leader and to share
their beliefs and opinions on the subject.
Initially, some of the participants struggled to differentiate
between leadership and
management; however, they were repeatedly brought back to the
definition provided at the
beginning of the interview. The interviewees were all highly
engaged in the topic and

commented that they enjoyed the reflective process and personal
insight that was stimulated by
the interview. While the interviews were scheduled for 60
minutes each, most physicians
answered the questions thoroughly in around 45 minutes.
At the end of the interview, participants were thanked for their
participation and were
informed that the interviews would be transcribed and sent to
them by hospital e-mail for their
review. Again, they were reminded that they could add or delete
comments at that time, or
withdraw from the study if they desired. The recording was
stopped at that point.
From interview to interview there was a high level of repetition
of comments and
consistency in the perceptions and opinions expressed by the
participants; after five or six
interviews it became apparent that there were diminishing new
insights offered up. After nine
interviews, there was definite saturation in interview results and
this confirmed that the planned
sample size provided was sufficient (Dworkin, 2012; Mason,
2010; Morse, 2000; O’Reilly, &

46
Parker, 2012). The entire process of interviewing the nine
participants took over two months due
to recruiting delays and difficulty scheduling interviews and
mutually agreeable times.
Transcribing and Validating the Interview Output
All interviews were recorded on a digital audio recorder. The
files were downloaded to a
secure laptop. The electronic file was labeled with a unique
identifying number and was
uploaded by file number only to secure cloud storage for
retrieval by a research assistant. The
research assistant had previously signed a confidentiality
agreement and required specific access
permission for each file retrieval. The original recording was
retained on the secure laptop,
stored only by unique identifying number. The key for the
identifying numbers was stored
separately in a locked filing cabinet.
The research assistant returned completed transcripts to the
researchers secure hospital e-

mail. Once the transcripts were received back from the
transcriptionist, the researcher reviewed
them for accuracy by comparing them to the original audio
recording and handwritten notes
taken at the interview. Any comments or references that
specifically identified the participant,
the hospital or a specific manager were removed. Final
transcripts were sent to the individual
participants for review and confirmation. All participants
confirmed that the transcript was
acceptable and did not request any changes. Final copies were
printed and stored securely with
the relevant handwritten notes for later analysis.
Data Analysis
The interviews, interview transcripts and accompanying notes
were reviewed using
general qualitative analysis techniques. These techniques are
inductive and aimed at coding and
interpreting the participant comments (Saldaña, 2009). They
included listening to each interview
as a whole, reviewing each interview as text, reviewing each
interview for first order themes,

47
reviewing each interview for clustering of themes, reviewing
the interview set for overall
themes, developing a taxonomy for describing the results, and
then describing overarching
themes (Hycner, 1985; Morrissette, 1999, Thomas, 2006).
Specific analysis was done for
frequency of occurrence of descriptive words (Baptiste, 2001).
Each interview was reviewed
repeatedly for less obvious connotations, subtext and metaphors
that could be important in
understanding perspective. Any areas that were emphasized or
repeated by an individual
participant were also highlighted. Initially, the researcher had
planned to use a computerized data
analysis software package; however, the small sample size and
high degree of consistency
among participant responses made this unnecessary.
In the case of this research study, the desired output was a set
of factors or characteristics
describing how physicians judge leadership effectiveness. These
factors will be examined in the
discussion portion of the thesis, comparing them to factors

presented in the leadership
competency model used in evaluating managers at the research
site for performance appraisal
purposes.
Ethical Considerations
This dissertation research followed the Capella University best
practice guidelines for the
protection of human research study participants (Capella, 2013;
U.S. Department of Health and
Human Services, 1979). The research qualified as low risk and
received research ethics waiver
from the study hospital Research Ethics Board and was deemed
Exempt by the Capella
Institutional Research Board.
General Ethical Considerations
All participants were provided with a detailed description of the
planned research and
interview expectations and then were given the opportunity to
ask questions before agreeing to
48

participate. Consent was obtained in writing and participants
were informed they could withdraw
at any time. During the consent process, participants were
informed that, in addition to
publishing as part of the professional dissertation, the overall
results would potentially be:
ers
Participants were also reassured that no one would know who
had been interviewed in the
study and that they could not be specifically identified in the
publication in any specific way.
The research invited volunteers from the approximately 500
physicians with privileges at
the study hospital. Although all the participants ended up being
recruited via e-mail, signs were
initially posted in the physician mailroom and all eligible
physicians had an opportunity to
volunteer. All required policies on recordkeeping, safeguarding
data, preserving privacy and
anonymizing the results were followed. Prospective participants

were reassured that any
participation or nonparticipation would not affect their status or
current/future access to
resources. Interviews were conducted in private and any
identifiable comments were anonymized
or removed from the transcripts. All physician interview results
were aggregated and in no way
attributed to specific individual respondents.
Ethical Implications Related to the Researcher
This dissertation research project was undertaken as an insider.
While the researcher’s
insider status and personal credibility facilitated access,
recruitment and organizational support
for the project, it was important to reassure participants about
confidentiality. Although the
interview topic was low risk and nonthreatening, it was deemed
safer to exclude physicians with
49
a sole resource dependence through the researcher’s surgical
program in order to avoid any
potential perception of conflict of interest.

Ethical Implications Related to the Broader Organization
The researcher undertook research on a topic that could have
implications for
administrator and physician relationships and which also could
affect individual working
relationships (Moore, 2007). In any organization there are
always people who resist change to
the status quo, usually because of fear about loss of power,
influence, comfort or other desirable
state (Piderit, 2000). Therefore, it was important to get
stakeholder buy-in up front and
throughout the project, managing relationships so as to mitigate
this sort of risk. Throughout the
research process, the CEO, physician and administrative leaders
were kept apprised of the
project and offered an opportunity to ask questions and
comment.
Chapter 3 Summary
This chapter presented a detailed description of the research
design choice, sampling,
instrumentation, data collection, analysis and other
methodological information. In this
dissertation research, the investigator used a generic qualitative

approach in to gain a better
understanding of hospital physicians’ perceptions of leadership
effectiveness in front-line
managers. Minor adjustments to planned recruitment strategies
and data analysis were needed,
however overall data collection and analysis proceeded well and
provided a considerable amount
of very consistent and helpful information for further study.
50
CHAPTER 4. RESULTS AND ANALYSIS OF DATA
Introduction to Chapter 4
Chapter 4 describes and analyzes the results of the physician
interviews that were
conducted in order to better understand physician perspectives
on leadership effectiveness in
front-line managers in hospitals. The interview recordings,
interview transcripts and
accompanying notes were examined using general qualitative
analysis techniques in order to
produce a set of factors that affect physician perceptions of
leadership effectiveness. Specifically,

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