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The relationship between hospital managers' leadership style and effectiveness with passing managerial training courses.

Background: Effective leadership that rises from managerial training courses is highly constructive in managing hospitals more effectively. This study aims at investigating the relationship between leadership effectiveness with providing management training courses for hospital managers. Methods: This was a cross-sectional study carried out on top and middle managers of 16 hospitals of Iran University of Medical Sciences. As a sample, 96 participants were selected through census method. Data were collected using leadership effectiveness and style questionnaire, whose validity and reliability were certified in previous studies. Pearson correlation coefficient and linear regressions were used for data analysis. Results: Leadership effectiveness score was estimated to be 4.36, showing a suitable status for managers' leadership effectiveness compared to the set criteria. No significant difference was found between leadership effectiveness and styles among managers who had passed the training courses with those who had not (p>0.05). Conclusion: Passing managerial training courses may have no significant effect on managers' leadership effectiveness, but there may be some other variables which should be meticulously studied.


Introduction
Effective leadership plays a crucial role in organizational success that is linked to organizational effectiveness (1)(2)(3). Organizational effectiveness is defined as an extent to which an organization reaches its goals. Nowadays, researchers believe that measuring effectiveness requires consideration of multiple criteria which evaluate the various organizational duties based on different characteristics (4).
The necessity of motivational factors for an appropriate organizational output among healthcare organizations and the problem of educational standards have made the leadership more complicated. This issue has not reduced the responsibilities of hospital middle-managers who are expected to perform at the level of top managers (5).
Studies show that the hospital middlemanagers have been increasingly playing an important role in the hospitals. Therefore, measuring the effectiveness trend of their leadership is essential (5). Effective leadership is a leadership in which the leader has the ability to lead an individual or a group of individuals towards the organizational goals (6). In addition, it is an indispensable factor in creating cooperation and sympathy among the staff. Hence, effective leaders are those who can bring people with different ideas and thoughts under the same umbrella (7).
Literature review show little operational information regrading leadership effectiveness in the healthcare sector. Bass et al., found that poor selection and recruitment policies lead to lack of effective leaders in healthcare organizations, especially hospitals (8).
A huge part of hospitals in Iran are either general or specialty that deliver therapeutic, educational, and research services simultaneously and are considered as teaching hospitals. The specific model of services delivery in these hospitals has given them a new identity, and therefore, it is necessary to pay sufficient attention to their context and conditions.
There are some data and statistics in researches which prove that most of the hospital managers lack enough leadership effectiveness. Most of these studies show that hospital managers tend to use autocratic leadership style whereas the existence of a dominant style can not necessarily be the best one in the variable and complicated environment (9)(10)(11). Furthermore, studies have revealed that many of the nursing managers do not use the essential managerial skills completely and appropriately (10,12). As Cohen pointed out, unfortunately hospital managers have not been enabled to perform leadership and supportive behaviors which are essential to motivate hospital personnel (13). In another qualitative study by Dehghan Nayeri et al., they stated that nurses link the their own productivity and their nursing team to their managers' management knowledge. Thus, they believed that holding managerial training workshops is important for all nursing managers, especially head nurses (14). In addition, Al shuaiby reported that not having enough managerial knowledge and information is an obstacle for effective leadership of the managers (15).
As mentioned above, many studies have been conducted on the relationship between leadership effectiveness with various variables, but its relationship with managerial trainings, especially in hospitals, has been overlooked. This study aims at investigating the relationship between leadership ef-fectiveness with providing management training for hospital managers.

Methods
This was a descriptive-analytic as well as a cross-sectional study which was conducted on top and middle managers of 16 hospitals of Iran University of Medical Sciences. The statistical community included all chief executive officers (CEO), chief financial officers (CFO), chief human resource officers (CHRO), chief information officers (CIO), chief nursing officers (CNO), and chief operating officers (COO) who were, in total, 96 participants. Sampling was done through census method due to the limited number of the statistical community.
Data were collected using a multifactor leadership questionnaire (MLQ) which contained demographic information, leadership style questions, and effective leadership questions in Likert scale. Demographic information included age, sex, education, managerial or other type of work experience along with the main variable of the study which was having management degree or passing managerial courses. The validity and reliability of the questionnaire were previously certified in a study in 2013 (16). Participants were explained about the objective of the study and were assured about the confidentially of their information.
Data were entered into SPSS Version 22 and were analyzed using descriptive statistical techniques as well as inferential techniques such as Pearson correlation coefficient and linear regressions (p>0.05). Paired t-test was used to determine the correlation between leadership effectiveness and triple leadership styles of the managers with passing managerial and leadership courses.

Results
Ninety-six participants including hospital presidents, managers, administrative, and financial heads as well as educational supervisors took part in this cross-sectional study. Of the participants, 57.4% (n=55) were male and the rest were female. On average, the managers aged 44 years and had 6.1 years of work experience. Other demographic information is presented in Table 1.
According to the findings, the average score of transformational, transactional, and laissez-faire leadership styles was 4.34, 3.74, and 2.42, respectively. Therefore, the transformational style was the dominant style among the studied managers.
Moreover, the leadership effectiveness score was estimated to be 4.36, showing that the studied managers had a proper leadership effectiveness compared to the determined criteria. Table 2 provides more information on quantitative variables of the study.
The results of the present study revealed no significant correlation between these variables (p>0.05). In other words, no significant difference was observed between leadership effectiveness and triple leadership styles among managers who had passed some managerial courses with those who had not (Table 3). In addition, our results revealed that age, marital status, organizational position, job conditions, and education of the participants had no major effect on their leadership effectiveness (p>0.05). On the contrary, a significant relationship was observed between transformational leadership style with managers' work experience (p=0.009, r=0.282). In other words, the more the managers' work experience, the higher their score of transformational leadership style, which is the main predictor of leadership effectiveness.

Discussion
According to the findings of this study, the leadership effectiveness score was estimated to be 4.36, indicating a suitable status for managers' leadership effectiveness compared to the determined criteria. Effective leadership has a huge impact on organizational success (1). Studies have indicated that hospital middle managers have been increasingly playing an important role in the hospitals. Therefore, measuring the trend of leadership effectiveness in the health sector is absolutely necessary (5). Moreover, organizational success depends on effective leadership, and this is a key point in any organization, especially hospitals (6). Bass et al. pointed out that poor selection and recruitment policies result in not having enough effective leaders in healthcare organizations (8).
Effective leadership plays a vital role, particularly at the time of specific events and interventions in a cyclic process, where a relationship exists between internal organizational roles, responsibilities, external environment, community, and specific moral characteristics of leadership (17). Effective leaders are also moral leaders and are known for their interests, attitudes, and capacities in accepting critiques and paying simultaneous attention to the performance of their staff (18).
In addition, the results of the current study revealed a significant correlation between transformational and transactional leadership styles with leadership effectiveness. The correlation coefficient between leadership effectiveness with the former and latter styles was 51 and 21%, respectively. Hence, a significant relationship exists between transformational leadership style of the hospitals' middle managers of Iran University of Mecical Sciences with their leadership effectiveness.
Xirasagar et al. proposed an assumption in 2005 in which they stated that leaders with transformational style are more effective than those following other leadership styles; our findings are in agreement with their assumption. Moreover, they indicated that applying transformational style in healthcare organizations will result in improved health services and will control the costs (19). Furthermore, in a study conducted by Gabbert et al. on the relationship between transformational leadership style with having high performance among hospital managers, they found that this type of leadership style obtained higher scores and was directly correlated with leaders' high performance (20). Our findings were also in line with those of Gabbert's study. Moreover, Haldman in 2002, reported that transactional leadership style is positively correlated with leadership effectiveness and managers' high performance (21). Accord- ing to Bolz, reaching a framework for effectiveness development is possible when organizations base their leadership on that framework (22).
Hospital middle managers can have a high performance if they use a mixture of both transformational and transactional styles. In addition, they should be aware that relying solely on these styles may have unintended and undesirable consequences (23). For instance, transactional leadership without ideal inspiration and paying attention to individuals can reduce their satisfaction, morale, and efforts, and will negatively affect their performance. On the other hand, exclusive emphasis on interactive leadership (rewarding and punishment) will finally prevent from creativity and productivity of the hospital personnel. Therefore, reduced ability of hospital administrative managers in solving healthcare problems is a twenty-first-century issue (24). Transactional leadership may be useless if hospital middle managers lack enough resources for rewarding their personnel.
Although no relationship was found between receiving managerial trainings with leadership effectiveness in the present study, there have been some conflicting results in other studies. According to Bass et al., transformational leadership should be taught to all members of the organizations to positively affect their performance (25). Previous studies on military sets and business institutions have revealed that training can improve transformational and transactional leadership (26,27). Researchers have also reported that teaching these styles to organizational members can increase leaders' effectiveness as well as personnel satisfaction (28).
Patients' satisfaction and effective use of human resources reflect the existence of a successful and effective leadership (29). Results of a study carried out by Purcell et al. indicated that managers claimed that before passing managerial training courses they were not familiar with their roles and responsibilities and did not know what they should do when holding such positions.
They also mentioned that such courses ought to empower them to improve the clinical competency of their nurses (30). Furthermore, Swearing believes that such trainings are necessary to improve leaders' effectiveness, and that its effect on hospital should be monitored continuously (31). Other studies have also linked effective leadership to leadership development programs (32).

Conclusion
It seems that determining the exact relationship between having managerial trainings with leadership effectiveness requires careful consideration of the available moderating variables as well as having more samples. The current study revealed that providing managerial trainings may not affect the leadership effectiveness of the managers, but it is worth knowing that there may be some other variables which affect this relationship.