Leadership and Healthcare Services Leadership and Healthcare Services

The reasons why organizations make changes in various fields, especially in their structure, include various changing situations such as globalization, increasing awareness in human rights and employee rights, developments in communication technologies, and changes in people’s expectations and demands. These changes in their structures have brought along changes in their management perspectives. In shaping the new management perspective which became a field of study which contains specialties, international competition has also played a major role as well as abovemen‐ tioned notions of globalization, human rights, and communication technologies. Organizations keeping up with the time and reaching success by achieving competitive superiority in their field of activity are closely related with being managed by real leaders and these leaders’ behaviors and attitudes. Competition in healthcare sector has increased as a result of raised awareness in the right of healthy life which is one of the fundamental rights of individuals and that their demands were developed in that direction. In addition to this, it is quite important that the leaders, who are able to guide people, have ethical leadership characteristics in order to set an example to especially people who follow them and show righteousness and honesty in their actions.


Introduction
In the rapidly changing world, it is inevitable for businesses, which assume an important role in producing products and services for people, to keep up with this change. Among the reasons why organizations make changes in various areas, primarily in their structures, are various diversifying circumstances such as globalization, raising awareness in human rights and therefore employee rights, advancement in communication technologies, and changes in people's expectations and demands.
Innovations in the structure of organizations have also brought along changes in the management perception. In addition to abovementioned concepts of globalization, human rights, and communication technologies, international competition has played an important role in shaping the new management perception which becomes a field of study with its own specialties. As a result of the organizations' approach in current practices, one of the outstanding fundamental concepts in management is leadership [1]. Due to changing social and economic conditions, it is stated that targets set for gaining advantage in this competition between organizations can be achieved under the management of leaders [2][3][4].
Competition in the healthcare sector has increased as a result of raising awareness of the public on healthy life right which is one of fundamental rights of individuals and their demands in that direction. One of the most important components of this sector, drug industry, constitutes an area in which this competition is quite high. Companies' operation in the drug industry requires administrators who can take them forward and lead them to gain competition advantage and meet the demand [5]. In addition, it is quite important that leaders, who have the ability to guide people, have ethical leadership qualities for setting an example for people who follow them and show the accuracy and honesty in their actions. When considered especially in terms of healthcare sector, it is important that administrators with leadership qualities exhibit ethical behaviors.
By mentioning leadership concept within the scope of this study, the history of the leadership and leadership in healthcare services is emphasized in this chapter. It is thought that the history of leadership and its improvement are important to understand the concept of the leadership and leadership in healthcare services. Therefore, the origin of the leadership is described before the leadership in healthcare services. In accordance with this purpose, a literature review was made in English and Turkish with the keywords "the definition of leadership, history of leadership, leadership approach(es), and leadership in healthcare."

Origin and history of the leadership
Leadership is a quite old phenomenon both conceptually and historically. It is considered that an Anglo-Saxon word lead which means road is the root of the word leader [6]. History of leader and leadership dates back to the days when people started to live in communities [7]. In addition, although studies on this subject have accelerated after the Industrial Revolution, leadership has been a subject which has drawn attention of every individual in the society since first ages and upon which various studies have been conducted since then [8,9].
Leadership and the concepts included therein, which were attributed to people who have influence on masses in the ancient times, were sometimes identified with various mythological deities. It is seen that communication merit of the leaders is correlated with Hermes, strategy development characteristic with Athena, renewal and regeneration traits with Demeter, and strength with Zeus [10]. Similarly, in Ancient Egypt, leadership perception is parallel with the god-king perception. It is also known that leadership concept was encountered in ancient China [11].
In various sources, there is information that various famous scientists have mentioned leadership in various forms throughout history. Furthermore, "first, do no harm" principle, which is accepted as one of the fundamental principles of leadership, is considered to be originated from Hippocrates' "primum non nocere" [12].
It is stated that Homer's Iliad and Odyssey contain various definitions of leadership concept. It is presumed that the term leadership was coined by Plato as "Ruling by wandering around" [13]. Xenophon's Cyropaedia is considered to be the first systematic book written on leadership. Moreover, another important work by the same author, Anabasis (The Fall of the Ten Thousand), contains significant information on effective and ethical leadership [12].
It is stated that Julius Caesar mentioned the characteristics that leaders should have in his speeches in the Roman Senate in 58-52 BC [14]. Furthermore, it is thought that the word leader has emerged for the first time in the 1300s. In addition to this, scripts about the British Parliament which include leadership concept were encountered in the early nineteenth century [15].
Leadership concept, which was perceived as an indicator or power and potency in the First and Middle Ages, started to be encountered more frequently in the twentieth century when democratic structures became widespread [16].
It is seen that the society's perception of a leader has focused on government or religion in the history; however, leadership concept mostly comes up in matters related to businesses today [10].

Leadership theories and approaches
The necessity to respond to complex questions such as globalization, diversifying labor, and financial crises; circumstances such as ethical dilemmas, promotion criteria, and increasing official; and social interest has increased the interest in leadership [17].
It is stated that more than 5000 studies have been conducted on leadership only in the twentieth century [13]. As a result of studies conducted on this matter, various theories were presented, and various approaches were determined with the purpose of providing an explanation for the traits of leaders such as leader behaviors and what type of leaders they are.
Fundamentally, leadership theories were presented as a result of studies which investigate leadership concept within the scope of diversities such as individual differences and situational traits [9]. In addition to these, various theories are also presented that leaders' behaviors and efficiency affect leaders' achievement [9,[18][19][20].
Leadership studies, which had focused on physical appearance or social status of the leader in the 1920s, have started to focus on various leadership approaches in time [21]. In these approaches, it was emphasized that the actions of the leaders are the factors which determine efficiency [22]. In the 1930s, the number of studies in which leadership behaviors have become prominent rather than leadership traits has increased [23,24]. These studies have accelerated when it was noticed that behaviors of the administrators will affect the behavior and performance of the employees and that followers tend to imitate the behaviors of the leader [25]. In these approaches which emphasize the importance of leaders exhibiting appropriate behavior in various circumstances for effective leadership, it is stated that leader behavior might be work or person oriented [22]. Ohio State and Michigan State Leadership Studies on leadership approaches in the 1950s have laid the foundation of many leadership approaches and caused that leadership studies in this field are accelerated [26]. However, the impact of modernization started to be seen in leadership studies in the 1990s. Unlike conventional leadership theories that emphasize rational stages, new approaches such as charismatic leadership and ethical leadership which are among the innovative theories and approaches which feature emotions and values started to emerge [23,27].
In leadership styles, leader's behaviors during human relations and studies are determinant. According to this, there are change-oriented, task-oriented, and relationship-oriented leadership types [26]. In addition to these, in various studies it is stated that guiding leaders have various styles to influence their followers. The expressions used to describe these styles are as follows: -Autocratic style: "I know the best for everyone's good." -Participative style: "We can decide together, but not everyone's vote is equal." -Opinion style: "We will continue to discuss until everyone agrees on a subject." -Laissez-faire style: "Do whatever you want" [22].
It is known that all theories and approaches regarding leadership are based on work or person orientation [20,24,26,28,29]. It is also emphasized that another common ground of all these approaches is the relationship between the leader and his/her followers [30]. However, differentiations were determined in the classification of theories and approaches which were discussed in numerous studies throughout history. Given the generally accepted classifications, these theories and approaches are investigated below.

Trait approach
This theory is based on the presumption that the reason why a person can be qualified as a leader in a certain group is the traits he/she has, and it is stated that the leader is differentiated from other members of the group by means of these traits [1].
The aim of trait approach is determined as to find the traits which make the leader effective and train new leaders in direction of these traits [15]. This approach emphasizes that being a leader varies according to personality, instincts, values, and abilities. It is stated that the factor which underlies the traits approach is the thought that people have leadership traits naturally [31].
In trait theory, it is also suggested that the physical qualities, social status, emotional nature, and speech skills of the person affect his/her leadership [21]. According to this theory, leadership is an inborn quality and people who have this quality manifest themselves under any circumstances [15].

Behavioral approach
The majority of the studies on effective leadership consist of studies on determining behaviors [29]. This approach investigates what causes the efficiency of the leader, how to cope with problems, how to notice opportunities, and how to overcome pressure [31].
Behavioral leadership theories included followers as well as the leader himself/herself and tried to describe the leadership process based on the leader's behaviors toward his/her followers' behavioral approach; the main idea that the leader's behaviors exhibited in the leadership process which affect the success was emphasized [1].
One of the most important differences between this approach and trait approach is that it has been suggested that leadership behaviors can be acquired by means of training [15]. However, the difficulty in determining which behavior category is more significant for leaders is considered to be one of the most frequently encountered problems in this approach [29]. Another problem of the behavioral leadership theories arises due to the fact that no scale which can describe behaviors completely is developed yet although many scales have been developed within the scope of these theories [25,32,33].

Situational approach
In this approach which investigates the factors affecting the leadership process, fundamental situational variables are classified as: -Qualities of the followers -Qualities of the division where the leader works -Organizational structure and qualities of the external environment [31]

Other approaches regarding leadership
With the acceleration of studies on leadership, a number of various leadership theories have been suggested as studies on trait approach, behavioral approach, and situation approach which date back to the 1920s did not suffice.
These forms of leadership which can also be classified as alternative approaches, and leadership styles may be listed under various topics such as autocratic leadership, democratic leadership, charismatic leadership, transactional leadership, and transformational leadership. Furthermore, ethical leadership which has been frequently coming up recently has a significant place among leadership approaches. In addition to these leadership styles, it is known that there are other leadership styles such as authentic leadership which is considered to have similarities with ethical leadership, servant leadership which aims to serve its followers, and paternalistic leadership which is based on protecting the inferior [5,16,34,35]. These leadership styles can be described as follows:

Autocratic leadership
In autocratic leadership, which is a type of leadership in which all the authority is granted to the leader, the inferior have no voice and all decisions are made by the leader; it is necessary that the leader is also quite strong and intelligent in order that all these conditions are fulfilled [15]. In this type of leadership where the leader is willing to share his/her authority with the followers, followers are informed about various matters and their suggestions are taken into consideration [15].

Charismatic leadership
It is stated that this type of leadership is quite correlated with extroversion [36,37]. Charismatic leader ensures that his/her followers act in the direction he/she desires and contributes in increasing their performance by means of charismatic traits which mean attraction [1]. In addition to that, these leaders are known to have high self-confidence and inspire trust in their surroundings [5]. Furthermore, it is proven that these types of leaders are the mostly preferred leaders among university students as a result of studies conducted [15].

Transactional leadership
It is a type of leadership which prefers various rewarding methods to increase the achievement of the employees [38]. It is also stated that sanctions are implemented on employees, and some kind of exchange takes place between the leader and his/her followers when the objective is not acquired in interactive leadership where the tasks of the employees are stated clearly [5,15]. This exchange is expressed as some kind of trade between the leader and the employees [38].

Transformational leadership
It is known that it is important for these leaders who can realize the change and renewal that the organizations need make their followers accept their vision in order to achieve the required performance [1]. These leaders who perform activities such as supporting the improvement of the employees and making effort to bring forward their creativity are the leaders who believe that change is indispensable [5,15]. It is known that transformative leaders who do not give up against criticism take their employees' happiness into consideration as well as innovation and increasing performance [38,39].
In this type of leadership, concerns such as ensuring justice and order become prominent. These leaders who give importance to ensuring that their employees acquire a vision also aim to increase the trust of the inferior in the leader by making some changes in the organization culture. Transformative leaders are also open to criticism and consider criticism as an opportunity to improve themselves [38].

Ethical leadership
Matters related to ethics are encountered in various fields today from health to education and from technology to sports. Recently, problems in social life, politics, and business world have caused that the trust in leaders and administrators is diminished. Especially, the scandals which surfaced due to the ethical violations of the people in administrative positions have played an effective role in bringing forward the ethics in terms of administration. Thus, the relationship between the leader and ethics started to be discussed frequently [11,25,31,34,40,41].
It is known that ethics is a factor which is included among the rules which regulate both business life and private life and it has two fundamental objectives. First of these objectives is what it takes to be a good person, and the second one is what the rules to determine and restrict the behaviors of individuals are. Each attitude and behavior has an aspect which can be evaluated ethically. Ethos, which means character in Greek, defines the attitudes and behaviors of man. In ethical administration concept, the relationship between ethics and division of the sources, rights, opportunities, and even communication included in the administration is brought forward [42].
In order to create a successful leader identity, ethics is considered as an indispensable factor [12]. In the ethics of leadership, people who use their power in direction of ethical concerns come to mind [43]. Although ethical behavior which is a part of leadership is also required for ethical organization, it is not sufficient alone. Ethical leadership is required for this [22]. Ethical leadership may be defined as "The demonstration of normatively appropriate conduct through personal actions and interpersonal relationships, and the promotion of such conduct to followers through two-way communication, reinforcement, and decision-making" [44]. Ethical leaders are assigned to create values and ethical awareness, define authority and responsibility, adapt to participative and democratic administration, be honest and reliable, and briefly be just in all attitudes and behaviors [42].
Today it is unarguably accepted that leader behaviors are taken as example by the followers, and ethical values that leaders should have for expanding ethical behaviors especially in private businesses are important [11,31,40,41,[45][46][47]. Ethical rules of organizations also help shaping the behaviors of the leaders who work in these organizations [48,49].
All of the correct and good attitudes exhibited by the leader are studied within the scope of ethical leadership. This is emphasized in numerous studies on a broad scope from decisionmaking processes to relations with the followers and from the shareholders' interests to preserving the quality [25,40,44,[50][51][52]. It is stated that high or low levels of ethical values of the employees are mostly correlated with the ethical values of the leaders [53]. However, ethical values are considered to be a factor which would help leaders to exhibit relationship-oriented behaviors toward their inferior. Leaders who have such values avoid rude behavior toward their inferior and do not exhibit attitude which discredits the inferior [54].
As well as cultural values of the organization and the society, the impact of personal perception in developing an ethical attitude should not be neglected. As leaders' use of the power they have in a negative manner would harm the organization, it is necessary that leaders who use their power for the good-correct are assigned and supported in administrative levels [50,52,55]. The impact of behaviors of the individuals, who are required to have ethical leadership traits, such as accuracy, reliability, and being fair in expanding the ethical perception within the organization, should be taken into consideration. It should be remembered that organizations administrated by leaders with these traits will be more successful and effective [41,46,51,55].

Authentic leadership
Authentic leaders who are committed to their objectives with passion and make a great deal of effort to implement their values prioritize both their motivation and their employees' motivation [56].

Servant leadership
Leaders who prioritize and focus on their followers in organizations are described as servant leaders. With the increasing importance given to fundamental humanitarian values, this type of leadership started to draw attention. Servant leaders are distinct from other leaders as they prioritize human benefits in managing human resources [57].

Paternalistic leadership
Protecting the followers is the most significant characteristic of the paternalistic leadership, and these leaders also take their leadership traits outside the organization by trying to guide their followers in their private lives [5].

Strategic leadership
Although strategy is a concept used mostly for military organizations, it brought along strategic leadership concept in the 1960s which will also apply to the businesses. In strategic leadership, internal and external environments are analyzed correctly (suitable strategy is determined), and these are implemented in the right time. Strategic leaders are described as the people who are responsible for the strategic administration of the organization [42].

Traits of the leader and importance of the leadership
Carrying the organization to the future and increasing the ability to make innovations have become situations which are demanded from administrators more than fulfilling their tasks [58]. Realizing important factors for an organization such as achieving the desired success and ensuring the motivation of the employees will be possible by means of implementing innovative administration approaches [48].
Since leaders are an indispensable factor of successful operation of organizations, these people are also needed for increasing the organizational commitment of the employees [11,20]. Thus, it is ensured that employees remain within the organization and work eagerly [59].
Various descriptions have been made to explain the importance of leaders for organizations. In leadership practices, behaviors of the leaders in organizations are associated with the training of actors by directors or producers to improve their abilities in theatrical plays. Example elements within organizational culture such as god, hero, mother, judge, servant, and soldier can be turned into universal characters such as CEO, executive, secretary, customer, manager, and sales representative [10].
Leaders who want to manage the change should exhibit different behaviors rather than conventional leadership approaches. For the first time in history, today, four different generations [Silent Generation, baby boomer generation, X generation, and Y generation] started to work in organizations simultaneously. For that reason, leaders are expected to exhibit behaviors which comfort to the four generations [45].
As a result of studies on the traits that leaders should have, various qualifications have been presented. It is known that various leadership traits had been determined in ancient times. One of those is the five elements that Cicero has determined in relation to leadership [60]. These elements are listed as follows: -People like leaders.
-People respect leader's traits and perspective.
-Leader completely believes that he/she can meet the requirements of people.
-People are afraid of the leader's power.
-People expect to benefit from the leader's administration materially [60].
When discussing the leadership concept, cultural differences should also be taken into consideration [61], because it is known that expectations and characteristics of people raised in different cultures are different as well. For example, while Americans say that personal traits are more important in leadership, Japanese emphasize the importance of skills and behaviors [33]. On the other hand, leadership in the Chinese is influenced by Confucian, Daoist, and Mohist principles as specified in ethical leadership. In that direction, various rules such as the importance of non-selflessness of the leaders, the necessity of certain hierarchic order, and job descriptions have influenced the leadership behaviors in this culture, and furthermore, it is accepted that leadership is a process developed naturally by means of the existence of the followers [62].
However, it is also stated that leadership behavior is also affected by other various factors. Among these factors are elements such as working time, education, age, and task performed [5]. Furthermore, there are studies which indicate that there are gender-based differences in leadership behavior as well [11,[63][64][65][66].
A study investigating the gender-based differences in leadership contains information that men are more disciplined in daily activities and women have more ability to manage the sensitive relations within teams [65]. In addition to that, in another study investigating the gender factor in leadership, it is stated that women are mostly person-oriented leaders and men are task-oriented leaders; however, some leadership behaviors are not affected by gender variable [64].
In some studies, age is considered as a factor which affects the leadership styles. In Kearney's study which investigates the impact of leaders' age on their relationship with the employees, it is stated that the relationship is more positive when the leader is older than the employees, but there is no difference when the age of the leader is close to the average age of other employees [67]. In addition, a study in England emphasized that older leaders are more participative than younger leaders [68].
Besides all these studies, it is also known that there are studies which investigate whether the leadership traits are genetic information passed down on generations [69].

Leadership in healthcare services
Developments and changes which became widespread with globalization have taken effect in healthcare as well as many other fields [70]. Among the important developments in the field of healthcare in the last century, it is known that drug industry has contributed in improvement of human health and life quality significantly [71]. Drug industry which is one of the prominent sectors especially in terms of use of drugs has various roles such as developer, manufacturer, marketer, and seller in the healthcare sector [72].
Characteristics which distinguish healthcare sector from other sectors are: -Government which is the biggest buyer in many countries is the most important shareholder in the sector.
-Uncertainties in relation to diseases which are hard to predict.
A society with high level of health is accepted as an indicator of the country's strength [74]. Recent studies have revealed the importance of administration in healthcare sector. However, there is still discussion going on what type of administration should be implemented and which traits should the people who will work and lead in these authorities have [75].
There are some incentives to be implemented by organizations in order that leaders, whose administration and leadership traits might provide great benefits and whose mistakes might cause great loss as well, exhibit the correct behaviors. It is known that training activities are carried out intensively in order that especially healthcare professionals can improve themselves [76][77][78][79].
Leaders who work in healthcare services are required to show their visions with their behaviors, not with their words. If these leaders fail to adapt to change, employees cannot be expected to do so [80]. Administrators who work in the healthcare sector which is an indispensable field are required to improve themselves in terms of their abilities and be more sensitive and attentive than the leaders in other sectors [81]. With the increasing quality of life, the competition between the organizations which provide healthcare services has increased as well. For that reason, organizations need strong leaders to gain competitive advantage over each other [5].
There are both national and international studies on leadership within organizations and institutions operating in the healthcare sector. The common ground emphasized in most of these studies is that the values one has become more prominent when it comes to leadership in the field of health.
Whether in administrative staff or not, all healthcare professionals should render services without forgetting that each one of them is a leader. Leadership traits of these people have a meaning when combined with ethical principles. In that respect, it is seen that ethical leadership has a different significance for healthcare services. Among the studies which emphasize the importance of ethical leadership in healthcare services, various propositions are encountered [55]. Correlation between these propositions and healthcare services are as follows: -Relationship between ethical role modeling and ethical leadership: most of the experienced healthcare professionals also function as instructors. For that reason, it is important in terms of ethical leadership that they act in accordance with ethical rules without forgetting that their behaviors are monitored closely by their followers, patients, and patient relatives.
-Relationship between ethical leadership and an environment supports ethical behavior: since healthcare professionals are trained on ethical rules during their occupational training, they start working as fundamentally equipped in this matter. For that reason, they are more sensitive in understanding ethical and nonethical behavior in their environment than other occupations. This creates an environment which supports ethical behavior.
-Relationship between clarity, conscience, and ethical leadership that healthcare professionals are able to understand and be clear is quite important in terms of relations with both the students and patients as well as other healthcare professionals. Rendering a quality service and achieving good results will only be possible in this way. It is necessary to stick to ethical principles while doing so.
-Relationship between ethical leadership and using power for others' benefit: utility and no harm principles which are among the most important ethical principles which healthcare professionals comply with provide an indispensable guide for using the power they have in the right way. Thus, the trust between their followers and them is reinforced.
-Relationship between anxiety, fear, pressure, and ethical leadership: it is obligatory that healthcare professionals have the required knowledge and skills to practice their occupation correctly. Otherwise, they approach the cases with anxiety and fear and this results in mistakes. In addition, it is quite important that the healthcare professionals are objective and have the strength to resist to any negative pressure which they might encounter.
Among the studies on the place of leadership in healthcare sector are studies carried out by the National Health Service (NHS) in the United Kingdom. NHS within the Ministry of Health of the United Kingdom carries out various studies to investigate the innovations in healthcare services and increase efficiency by providing training to the healthcare sector administrators.
In that respect, Healthcare Leadership Model developed by NHS Leadership Academy describes leadership behavior in nine dimensions [82]. These dimensions are as follows: -Inspiring shared purpose: this dimension focuses on the impact of leadership on creating a shared value in which individuals working on different subjects will believe and which will inspire them. Determining the values to be considered in the service offered is evaluated within the scope of this dimension.
-Leading with care: the way that the emotions of coworkers are affected and the necessities toward focusing their energy on the work are emphasized within this dimension. Elements in relation to creating a safe environment which will ensure that everyone fulfills their task effectively to understand the characteristics and needs of the team are also included in this dimension.
-Evaluating information: as well as elements regarding development of new ideas and understanding what is going on, the importance of making evidence-based decisions which will be respected by various perspectives is also emphasized within this dimension.
-Connecting our service: in this dimension, the necessity that the leaders understand how the works by different groups are carried out becomes prominent, and the necessity of collaboration between these groups is also mentioned.
-Sharing the vision: the importance of sharing the vision which will ensure that employees believe in the work they carry out is explained in this dimension.
-Engaging the team: in groups where mutual respect is present, the factors related to the contributions that individuals will provide by presenting their ideas are among the subjects discussed in this dimension.
-Holding to account: in this dimension, the importance of employee's being aware of the responsibilities they undertake to achieve the purpose and ensuring the necessary freedoms in this process is included.
-Developing capability: since leadership is a factor which requires continuity, the importance of improving the abilities these people have is emphasized in this dimension.
In conclusion, competition in the healthcare sector has increased as a result of raising awareness of the public on healthy life right which is one of fundamental rights of individuals and their demands in that direction. For that reason, companies need administrators who can take them forward and lead them to gain competition advantage and meet the demand. In addition, it is quite important that leaders, who have the ability to guide people, have ethical leadership qualities primarily for setting an example for people who follow them and show the accuracy and honesty in their actions. When considered especially in terms of healthcare sector, it is important that administrators with leadership qualities exhibit ethical behaviors.