Personal Leadership Portrait Paper

ORIGINAL RESEARCH published: 30 April 2015 doi: 10.3389/fpubh.2015.00073 Full-range public health leadership, part 1: quantitative analysis Erik L. Carlton 1* , James W. Holsinger Jr. 2 , Martha Riddell 3 and Heather Bush 4 1 Division of Health Systems Management and Policy, University of Memphis, Memphis, TN, USA, 2 Department of Preventive Medicine, University of Kentucky, Lexington, KY, USA, 3 Department of Health Management and Policy, University of Kentucky, Lexington, KY, USA, 4 Department of Biostatistics, University of Kentucky, Lexington, KY, USA Background: Workforce and leadership development are central to the future of public health. However, public health has been slow to translate and apply leadership models from other professions and to incorporate local perspectives in understanding public health leadership. Edited by: Will R. Ross, Washington University School of Medicine, USA Reviewed by: Marguerite Ro, Public Health – Seattle & King County, USA Sharyl Kidd Kinney, University of Oklahoma College of Public Health, USA Jo Ann Shoup, Kaiser Permanente Colorado, USA *Correspondence: Erik L. Carlton, Division of Health Systems Management and Policy, The University of Memphis, 128 Robison Hall, Memphis, TN 38152-3330, USA erik.carlton@memphis.edu Specialty section: This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health Received: 26 January 2015 Accepted: 13 April 2015 Published: 30 April 2015 Citation: Carlton EL, Holsinger JW Jr, Riddell M and Bush H (2015) Full-range public health leadership, part 1: quantitative analysis. Front. Public Health 3:73. doi: 10.3389/fpubh.2015.00073 Purpose: This study utilized the full-range leadership model in order to examine public health leadership. Specifically, it sought to measure leadership styles among local health department directors and to understand the context of leadership in local health departments. Methods: Leadership styles among local health department directors (n = 13) were examined using survey methodology. Quantitative analysis methods included descriptive statistics, boxplots, and Pearson bivariate correlations using SPSS v18.0. Findings: Self-reported leadership styles were highly correlated to leadership outcomes at the organizational level. However, they were not related to county health rankings. Results suggest the preeminence of leader behaviors and providing individual consideration to staff as compared to idealized attributes of leaders, intellectual stimulation, or inspirational motivation. Implications: Holistic leadership assessment instruments such as the multifactor leadership questionnaire can be useful in assessing public health leaders’ approaches and outcomes. Comprehensive, 360-degree reviews may be especially helpful. Further research is needed to examine the effectiveness of public health leadership development models, as well as the extent that public health leadership impacts public health outcomes. Keywords: public health leadership, multifactor leadership questionnaire, public health workforce development, transformational leadership, local health department, full-range leadership Full-Range Public Health Leadership Today’s public health leaders face increasingly complex challenges while being called on more and more to collaborate with and lead in the communities in which they live, work, and serve. Health care reform is transforming the entire health system, including public health. Public health agencies, tasked with basic care for the indigent and assurance of health standards for whole populations, have their budget appropriations cut so that they not only have reduced physical and medical resources, but also have fewer human resources to assign to meet those needs (1, 2). Those human resources – the public health workforce – are in the midst of significant upheaval. The retirement of Frontiers in Public Health | www.frontiersin.org 1 April 2015 | Volume 3 | Article 73 Carlton et al. Full-range public health leadership large numbers of highly experienced members of the public health workforce results in a dearth of practical knowledge as new staff members, when they can be hired, may not have similar educational or experiential backgrounds (3). Concern for what national health reform will mean for the public health organization and its employees is an issue (4, 5). Committed and effective leadership in public health has perhaps never been more important (6). The vital issues of today demand public health leaders who are as skilled and astute politically as they are at managing the technical and systemic aspects of public health (7, 8). Given this highly dynamic context, understanding and developing the leadership abilities of public health leaders is essential to meeting the demands of population health issues. In The Future of Public Health (9), the Institute of Medicine (IOM) suggested that without appropriate attention to workforce and leadership development, public health organizations would be ill prepared to fulfill the essential purposes of public health. By 2003, the IOM had published two additional reports, The Future of the Public’s Health in the 21st Century (10) and Who Will Keep the Public Healthy? (11). Both of these studies reiterated the workforce and leadership development themes identified 15 years previously: leadership training and development activities must be a priority for both governmental public health organizations and academic public health institutions. organizations and communities in transformational change processes that not only ensure, but also seek to improve the health and well-being of the public. These efforts frame a vision for public health leadership that currently prefers transformational, change-agent leaders. However, as Nicola (15) has pointed out, classic management functions – planning, organizing, leading, and controlling – remain vital to assuring the performance of public health organizations. Personal Leadership Portrait Paper

While transformational leadership qualities enable public health leaders to engage communities in efforts to improve population health, the full range of leadership qualities, including technical and managerial acumen, is necessary not only to lead change but also to effectively attend to general and regular organizational tasks and responsibilities should not be overlooked. To that end, leadership may have discipline-specific requirements unique to public health. Rather than assume that leadership qualities, characteristics, and processes are universal to all professions, public health agencies would benefit from a better understanding of the skills and competencies required for successful public health leadership. Purpose The purpose of this study was to examine the full range of leadership styles among local health department directors in Kentucky. Specifically, this portion of the study quantitatively explores: (1) the leadership styles of local health department directors and their perceptions of organizational outcomes, (2) the sub-components of each style contributing to the overall leadership style of local health department directors, and (3) whether there is any relationship between leadership styles and specific county health outcomes. We posited that while leadership styles would vary, the predominant leadership style, and the one most closely correlated with positive leadership outcomes, would be the transformational leadership style. Personal Leadership Portrait Paper

Public Health Leadership Development Efforts Since the initial IOM report, public health practice and academic organizations have focused increasingly on public health leadership development. These efforts include the development of state, regional, national, and international public health leadership institutes, the formation of a national public health leadership development network, and the development of public health leadership competency frameworks for both educational and practice settings. These efforts shape the development of public health leaders now and into the future. To assist in the shaping of future public health leaders, the Association of Schools and Programs of Public Health (ASPPH) has developed core competencies for individuals obtaining Master of Public Health (MPH) (12) or Doctor of Public Health (DrPH) (13) degrees. Both models delineate specific competencies necessary for public health students to evince in order to achieve their leadership potential. Further, both models define leadership in terms of creating a shared vision, combined with notions of motivating others, galvanizing organizational and community resources to address public health problems, and utilizing the best strategies and practices to enhance service and solve problems. Finally, both models highlight the potential of public health graduates to lead organizations and communities, with the competence to influence others, establish a shared vision, and accomplish the mission of public health. Further, leadership competencies are not the purview of ASPPH alone. The Core Competencies for Public Health Professionals (14) include leadership and systems thinking skills. Clearly, leadership competence is on the agenda for current and future public health workforce efforts. The overarching theme of public health leadership literature and public health leadership development efforts is the need for highly skilled and well-educated leaders capable of galvanizing Frontiers in Public Health | www.frontiersin.org Method This study used the multifactoral leadership questionnaire (MLQ), developed by Avolio and Bass (16). The 45-item MLQ is among the most commonly used and validated measures of fullrange leadership styles (16–23), and has been shown to be an effective tool in leadership development (24, 25). The MLQ measures three general leadership styles – transformational, transactional, and passive-avoidant – and nine sub-types (see Table 1), as well as outcomes of leadership. Personal Leadership Portrait Paper

Each of the individual leadership components in the MLQ, including the leadership outcomes, yields a raw score between 0 and 4. These scores are translated into percentiles based on national norms for self-reported data provided with the MLQ instrument. Licenses to use the MLQ were purchased. The MLQ was combined with demographic variables and distributed electronically to local public health directors using Qualtrics. Using a consensus-driven sampling approach, this study identified local health directors as potential subjects by interviewing key state and university public health leaders. Specifically, one paragraph, literature-based (i.e., theory-driven) descriptions of transformational and transactional leadership styles were given to an expert group of individuals well-acquainted with potential study participants. These individuals were independently asked to 2 April 2015 | Volume 3 | Article 73 Carlton et al. Full-range public health leadership TABLE 1 | Brief definitions of leadership types and sub-types and outcomes of leadership. Leadership type Definition/characteristics Transformational leadership Transformational leaders influence and change followers’ awareness of what is important, providing a greater vision of themselves and the opportunities and challenges of their environment. They are proactive and strive to optimize individual, group, and organizational development, and innovation. They influence associates, coworkers, and followers to strive for higher levels of performance and higher moral and ethical standards Idealized influence attributes (IIA) Idealized attributes include: instilling pride in others, going beyond self-interest for the good of the group, acting in ways that build others’ respect, and displaying a sense of power and confidence Idealized influence behaviors (IIB) Idealized behaviors include: talking about important values and beliefs, specifying the importance of having a strong sense of purpose, considering the moral and ethical consequences of decisions, and emphasizing the importance of having a collective sense of mission Inspirational motivation (IM) These leaders behave in ways that motivate others by providing meaning and challenge to their followers’ work. Enthusiasm and optimism arouse individual/team spirit. Personal Leadership Portrait Paper

They articulate a compelling vision of the future and expressing confidence that goals will be achieved Intellectual stimulation (IS) These leaders stimulate their followers’ efforts to be innovative and creative by questioning assumptions, reframing problems, and approaching old situations in new ways. They re-examine critical assumptions, seek differing perspectives when solving problems, get others to look at problems from many different angles, and suggest new ways of looking at how to complete assignments Individual consideration (IC) These leaders pay attention to each individual’s need for achievement and growth. Individual differences in terms of needs and desires are recognized. These leaders spend time teaching and coaching and help others to develop their strengths Transactional leadership Transactional leaders focus on constructive (contingent reward) and corrective (management-by-exception) transactions, by defining expectations and promoting performance to achieve these levels. These leadership styles are among the core “management” functions in organizations Contingent reward (CR) These leaders clarify expectations and offer recognition when goals are achieved. These leaders provide others with assistance in exchange for their efforts, discuss in specific terms responsibility for achieving performance targets, make clear what one can expect to receive when performance goals are achieved Management-by-exception: active (MBEA) This style of leadership implies closely monitoring for deviances, mistakes, and errors and then taking corrective action as quickly as possible when they occur. These leaders focus attention on irregularities, mistakes, exceptions, and deviations from standards Passive-avoidant leadership Passive leaders do not specify agreements, clarify expectations, or provide goals and standards to be achieved by followers. It is a style typified as being more passive and reactive Management-by-exception: passive (MBEP) Passive leaders fail to interfere until problems become serious, waiting for things to go wrong before taking action. They show a firm belief in “if it ain’t broke, don’t fix it” Laissez-Faire (LF) Laissez-faire leaders avoid getting involved when important issues arise, are often absent when needed, avoid making decisions, and delay responding to urgent questions identify approximately five to seven effective local health department directors who possessed qualities of either transformational leadership or transactional leadership. Passive-avoidant leadership is also referred to as “non-leadership” in the full-range leadership literature. For this reason, we sought to sample only leaders thought to possess one of the two primary leadership styles – transformational and transactional. A group of 15 transformational directors and 15 transactional directors were identified from which a sample of 10 directors from each leadership style category was randomly selected. This random selection served to reduce sampling bias. Some of the health department directors declined participation in the study. While completion of the survey was voluntary, initial non-response initiated two additional attempts to solicit participation in order to maximize the response rate. Personal Leadership Portrait Paper

All surveys were administered electronically using Qualtrics, with links to the survey provided by email to the participants. Finally, as an incentive to participate, individual directors who elected to complete the survey received direct feedback in the form of a report that interpreted the results of survey, identifying leadership strengths, and suggesting potential growth areas. A final sample of 20 directors was identified and they were invited to participate in the quantitative phase of the study. The sample consisted of 10 directors perceived to be more Frontiers in Public Health | www.frontiersin.org transformational and 10 directors perceived to be more transactional. To encourage participation, the survey email was preceded by an email from the state commissioner for public health. The survey email was followed by up to two additional contacts inviting participants to complete the survey. Thirteen directors completed the survey for a 65% response rate. This included seven directors from the perceived transformational group and six from the perceived transactional group. Leadership Outcomes Transformational and transactional leadership are both related to the success of the group. Success, or outcomes of leadership, was measured with the MLQ through leaders’ self-reported skills at motivation, effectiveness in interacting at different levels of the organization, and perceived employee satisfaction with leaders’ methods of working with others. These include: extra effort (EE), effectiveness (EFF), and satisfaction with the leadership (SAT). EE may be defined as the extent to which leaders get others to do more than they expected to do, heighten others’ desire to succeed, and increase others’ willingness to try harder. Effective leaders are effective in meeting others’ job-related needs, in representing their group to higher authority, and in meeting organizational requirements. They lead groups that are effective. Leadership satisfaction 3 April 2015 | Volume 3 | Article 73 Carlton et al. Full-range public health leadership includes: using methods of leadership that are satisfying and working with others in a satisfactory way. TABLE 2 | Demographics (n = 13). Background information Analysis Gender Male Female The extent of transformational and transactional leadership styles and components of leadership styles reported by study participants was explored with descriptive statistics (e.g., means and SDs). Pearson bivariate correlation coefficients were calculated to measure relationships between variables of interest. Given the limited sample size, power analyses, as well as additional or more complex analyses, were not feasible. Finally, findings from the descriptive analysis were examined for any relationship to existing county-level data: Beale Codes, which measure relative population density on a rural-urban continuum, and the County Health Rankings (26), which rank counties based on health outcomes (mortality and morbidity) and health factors (health behaviors, clinical care, physical environment, and social and economic factors). Personal Leadership Portrait Paper

This study was approved by the University of Kentucky Institutional Review Board. 5 (38%) 8 (62%) Race White/Caucasian Black Other 12 (92%) 1 (8%) 0 (0%) Age 18–25 26–35 36–45 46–55 55 + Results Participant Demographics Thirteen local health directors completed the initial survey phase of the study. Complete demographics are provided in Table 2 below. Nearly two-thirds (62%) of participants were female and the majority (n = 12, 92%) were white. Participants were of varying ages. All participants had at least a bachelor’s degree. The majority (n = 11, 85%) classified their health departments as rural and the others (n = 2, 15%) classified their health departments as sub-urban. Personal leadership development was at least a moderate priority for participants. About a third of participants (n = 4, 31%) indicated that their own leadership development was a moderate priority. Just over two-thirds (n = 9, 69%) felt it was a high priority. Similarly, developing the leadership abilities of staff was also at least a moderate priority for participants. The results were identical. About a third of participants (n = 4, 31%) indicated that their own leadership development was a moderate priority. Just over two-thi ..Personal Leadership Portrait Paper