Leadership and management are closely related terms that convey different but complementary aspects of the behavior associated with ensuring effective organizational performance. Bennis and Nanus make the distinction in this way: “Managers are people who do things right and leaders are people who do the right things” (p. 221).10 One implicit difference suggested by this characterization is that managers focus on efficiency and control, whereas leaders focus on the “big picture” (i.e., communicating a vision of the organization and inspiring and influencing people to invest in achieving it). Both perspectives and the associated activities of working managers and leaders at all levels are necessary to sustain effective, high-performance organizations. Although this applies to all complex organizations, it might be argued that in no sector of society is the need for visionary leadership and effective management of organizational resources more important than in health care in the 21st century.

One of the most obvious but surprisingly complex questions is: “What is leadership, actually?” A massive volume of literature in leadership theory and practice has attempted to address this question during the past century, including controlled social science research studies and more descriptive, intuitive narratives from practicing leaders and executive managers. Some researchers have concluded, on the basis of a lack of reliable findings about the nature of leadership in thousands of studies, that its usefulness as a research variable may no longer be warranted. Nonetheless, common wisdom among practicing managers would suggest that leaders do make a difference in influencing the satisfaction, motivation, and achievements of their followers and in effecting organizational outcomes—even if the effects of leadership alone on desired outcomes are difficult to measure reliably. Most working professionals would agree that, even if they are not absolutely certain about what makes leaders effective, they know that we need effective leaders, especially when we face difficult challenges, rapid change, and crises.

A thorough review of the themes and models of leadership developed during the past 75 years would go beyond the limits of this chapter. However, an overview of the key themes and approaches to leadership should be useful in demonstrating the direct relevance of HRM to leadership. One basic difference in the evolving models of management has been the distinction between those that focus on the characteristics of leaders independent of other factors affecting leadership and those that emphasize leadership as a set of relationships. The former is the “trait” approach, which is based on the assumption that leadership could be fully explained by identifying a cluster of personality and character traits that are necessary and sufficient for the leader to be effective. Stogdill’s11 meta-analysis of many such studies found that there was little correlation among the various sets of traits, although some characteristics (e.g., intelligence, initiative, and self-confidence) were frequently identified.

Beyond the lack of agreement about a common and sufficient core of traits was the recognition that different situations seemed to call for different kinds of leadership. For example, the ideal leader for handling a true crisis (i.e., effective decision making under fire) may not necessarily have the best qualities for gaining commitment to a pervasive and long-term process of organization change. This contingency approach to leadership recognizes that other variables in the leadership situation or context are likely to influence the leader’s behavior and effectiveness. Among the variables identified in research studies using this model are the nature of the task, the expectations and maturity of followers, and the stability of the environment.¹² One implication of a contingency approach to leadership is recognizing that what it takes to be an effective leader all depends on the situation the leader faces.

The fact that the nature of followers is recognized by the contingency approach as being an important variable suggests the importance of considering the relational nature of leadership. On one level, it is obvious that the concept of leadership entails that some others participate as followers. A credentialed health information manager might be an exceptionally competent and knowledgeable professional, but unless he or she has responsibility for directing the efforts of others, he or she is not a leader. So the aspect of relationship is inherent to a full understanding of leadership. This is also suggested by the leadership style approaches to leadership exemplified by the University of Michigan13 and Ohio State studies⁹ of leadership style or behavior. In both these classic studies, researchers attempted to determine which leadership styles were associated with effective group and organization performance. In these studies, two dimensions of leadership behavior were identified as characterizing different leadership styles: the Ohio State study identified these behavioral aspects as “initiating structure” and “consideration,” whereas in the Michigan State studies, the comparable dimensions were called “production orientation” and “employee orientation.” The first dimension focused on task behaviors and structuring and organizing work, whereas the second emphasized maintaining supportive relationships, especially between the leader (supervisor) and the followers (subordinates). These same dimensions are also the basis for the popular Managerial Grid, developed by Blake and McCanse,¹⁴ which describes five contrasting leadership styles (Figure 15-1).

A more sophisticated and dynamic approach to leadership is the situational leadership model developed by Hersey and Blanchard,¹⁵ which builds on the task behavior and relationship behavior vectors. However, this model also incorporates a situational variable, the maturity of followers, to suggest which leadership style might be most appropriate in a given situation. The quadrants on the charts (see Leadership Roles Matrix) correspond to four distinctive leadership roles: controller, coach, partner/colleague, and delegator. The effectiveness of these roles, in terms of individual and team satisfaction and productivity, will depend on the degree of team development and maturity of the followers (Figure 15-2).

Although by no means conclusive, the leadership style studies collectively suggest that effective leaders generally are those who exhibit both a high concern for productivity and for people. Fiedler’s12 research linking leadership behavior to similar dimensions suggested that a structuring style was more appropriate when the leadership situation was either very favorable or very unfavorable to the leader, whereas a more people-oriented behavior was more appropriate when the leader faced ambiguous circumstances. What seems clear is that over the long term, the leader must attend to both production and people concerns to continue to be effective.

Human resource management can and should provide support to the operating manager to enhance his or her efforts in both domains. For example, effective employee recruitment and selection and job analysis processes can be useful tools in task structuring, whereas diversity management training can enhance the manager’s relational skills. Even a significant investment in the HRM function cannot guarantee effective leadership in the specific case, but without effective HRM processes, the manager may be at a distinct disadvantage. It could be argued that the more effective and efficient the HRM technical functions are, the more time and energy the manager should invest in his or her relationship-building activities with employees and peers.

Another useful perspective on leadership is that provided by Burns in his historical and psychological analysis of leadership.16 Burns contrasts two aspects or types of leadership: transactional and transformational. Transactional leadership refers to those behaviors associated with the more routine and continuing exchanges of effort and commitment between managers and employees in carrying out the business of the organization and sustaining effective working relationships. The transformational role of the leader refers to the visionary, motivational, and charismatic aspects of leadership. The transformational leader is able to articulate a vision of the organization’s future, to convince followers that they have a stake in the achievement of that vision, and to achieve commitment to change (personal and organizational) as not only inevitable but also beneficial both to the organization and to the employee’s self-interest. Schein¹⁷ focuses on the role of the leader as a change agent transforming organizational cultures by destroying dysfunctional ones and stimulating cultures supportive of growth and innovation. Hunt and Conger¹⁸ cite Tosi’s insistence that these aspects of leadership are complementary and necessary: “Supporting most successful charismatic/transforming leaders is their ability to effectively manage (transact with subordinates) the day-to-day mundane events that clog most leaders’ agendas. Without transactional leadership skills, even the most awe-inspiring transformational leader may fail to accomplish his or her intended mission.” Rohrer¹⁹ has proposed a third dimension, translational leadership, that allows for the effective communication of the charismatic vision into practice at the operating level, and that this aspect of leadership is an especially important responsibility of the middle manager as the key liaison between executive management and the first-line supervisory and operating staff. From this perspective the HRM director can be viewed as playing a “translational” role in establishing, communicating, and helping to implement HRM policies and procedures that support the strategic direction and goals of the health care organization.

Although not necessarily recognized as an HRM responsibility, the development of ethically responsible managers and leaders has profound implications for HRM. A justification for serious consideration of the ethical dimension of leadership, specifically in health care, is expressed by Darr20: “For the health services manager, a personal ethic is a moral framework for relationships with employees, patients, organization, and community. In these relationships, the manager is not, and cannot be, a morally neutral technocrat. The manager is a moral agent” (p. 1). What follows from Darr’s claim is that all managerial behavior—at least all activity that is relational rather than purely technical—must be considered from an ethical or moral perspective. This also entails that ethical decision making is complicated by the fact that the manager must consider his or her decisions in terms of the interests of various constituency groups. Burns’s¹⁶ theory of transformational leadership also places the ethical dimension at the core of leadership in that it is rooted in individual, organizational, and societal values. He contends that “transforming leaders ‘raise’ their followers up through levels of morality” (p. 426). He notes that transformational leaders are more concerned about “end values” such as justice and equality, whereas transactional leaders focus more on modal (means) values such as honesty and fairness. Characteristic of both types of leadership is the leader’s role in serving a common purpose that transcends individual needs and interests of the leader and the followers.

Normative ethics may be defined as the science or art of determining principles, rules, and guidelines for right conduct (i.e., how one should behave responsibly in the community). For example, the preamble to the American Health Information Management Association (AHIMA) Code of Ethics (2004) states²¹:

Northouse22 adds two other values critical to leadership that are certainly worth consideration: honesty and building community. A compelling argument could be made that honesty or truth telling is a bedrock value on which all others are founded. Certainly our entire social fabric and the stability and integrity of our organizational culture depends on the assumption that most people, most of the time, are telling the truth as they see it. Without this ethical foundation, we could not make any reliable assumptions about the link between intentions, speech, and behavior of ourselves or of those with whom we interact. Honesty is not only the best policy ethically; it is the only reasonable basis for group behavior, organizational effectiveness, and managerial decision making in the long run.

If honesty is seen as a necessary precondition for ethical behavior, community building may be viewed as an outcome of ethical leadership. Northouse²² argues that ethical leadership requires a community-oriented perspective. “Transformational leaders and followers begin to reach out to wider social collectivities and seek to establish higher and broader moral purposes . . . An ethical leader is concerned with the common good—in the broadest sense” (p. 316). Implicit in this statement is that ethical leaders will attempt to align their actions to the extent possible with the good of the community and broader society. For example, the board of directors and executive management team of a hospital should consider the impact of a potential relocation of the facility from the urban core to a growing suburb on both communities affected.

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