IOSR Journal of Nursing and Health Science (IOSR-JNHS)

e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 12, Issue 12 Ser. I (Nov – Dec. 2021), PP e10-e15

A SYSTEMATIC REVIEW PROTOCOL ON LEADERSHIP STYLES AND PATIENT-

CENTERED QUALITY HEALTHCARE DELIVERY IN HOSPITALS.

Bademosi A1, Tobin-West C.2

1
Department of Community Medicine, College of Medical sciences, Rivers State University Rivers state, Nigeria
1
Department of Community Medicine, College of Health Sciences, University of Port Harcourt Rivers state, Nigeria

ABSTRACT

Leadership has been extensively studied in a variety of fields including healthcare. Commonly used Leadership
theories including transformational Leadership and more recently, emotionally intelligent Leadership, have guided
health worker Leadership research and interventions, presumably due to their emphasis on relationships as the
foundation for effecting positive change or outcomes. The review will include all analytical observational studies with
no restriction to language and year of publication. A comprehensive search will be done in PubMed, Google Scholar,
Cochrane Library, and WHO Global Health Library, including databases of international conference proceedings.
Additionally, references of included studies will be searched. Search results will be managed in Rayyan, and data from
included articles extracted using standardized PROFORMA data collection form. Data will be narratively and
quantitatively synthesized. Random-effects meta-analysis will be carried out together with the appropriate sub-group
analysis. Results will be presented using forest plots. Publication bias will also be examined using funnel plots and
the Begg and Egger tests.This review will provide a comprehensive summary of the evidence on the effects of different
leadership styles on quality of healthcare reported by patients.

Keywords: Leadership, Style, Quality of Care, Patient Care, Outcomes

1. INTRODUCTION

Health care quality is a level of value provided by any health care resource, as determined by some measurement. As
with quality in other fields, it is an assessment of whether something is good enough and whether it is suitable for its
purpose. The goal of health care is to provide medical resources of high quality to all who need them; that is, to ensure
good quality of life, cure illnesses when possible, and to extend life expectancy. The health care organization
frequently offers services where there is often a face-to-face interaction with customers. This means that managers of
health care organizations should put a strategy in place that can ensure that employees are well motivated to provide
an excellent service encounter to their clients (the patients). The quality of care received by patients have been
associated with factors such as the quality of services delivered, outcome of treatment, availability of medical
equipment and the relationship with medical personnel during hospital visits (Khairunnisa & Nadjib, 2019; Sfantou
et al., 2017; Žibert & Starc, 2018). To ensure high quality care, there has to be direction, alignment and commitment
to a shared, holistic view of care that includes commitment to improving linkages with other providers and to achieving
system goals such as continuity of care. This in turn implies alignment across different parts of organizations, different
providers and other groups.

Patient Centered Care is fundamentally concerned with meeting patients’ needs, wants and or expectations by
respecting and integrating individual differences when delivering care. It consists of delivering care that meets with
the expectations, needs and wants of the patient and this conceptualization of Patient centered care relies upon
individual and contextual factors being accounted for by health care professionals. Effective clinical leadership has
been linked to a wide range of functions. It is a requirement of hospital care, including system performance,
achievement of health reform objectives, timely care delivery, system integrity and efficiency, and is an integral
component of the health care system(Mahmoud et al., 2019). In the context of healthcare, there is now general

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IOSR Journal of Nursing and Health Science (IOSR-JNHS)
e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 12, Issue 12 Ser. I (Nov – Dec. 2021), PP e10-e15

acceptance of the importance of engaging doctors in leadership roles, with recognition that deficiencies in medical
leadership can have a detrimental effect on patient care(Aghamolaei et al., 2014; Chapman et al., 2014).

Leadership styles and skills reportedly have a considerable influence on the quality of services available in every
healthcare setting. Styles of leadership can be categorized into three types that are Laissez-Faire Leadership,
transactional leadership and transformational leadership (Emelumadu & Ndulue, 2012; Sfantou et al., 2017).
Leadership has been extensively studied in a variety of fields including healthcare. Commonly used Leadership
theories including transformational Leadership and more recently, emotionally intelligent Leadership, have guided
health worker Leadership research and interventions, presumably due to their emphasis on relationships as the
foundation for effecting positive change or outcomes(Aghamolaei et al., 2014; Mulenga et al., 2018). The key role of
a leader is to encourage his followers to accomplish a common goal. It has been reported that the styles of leadership
can be categorized into three types that are Laissez-Faire Leadership, transactional leadership and transformational
leadership(Ahmed & Abbasi, 2014). A proficient transformational leader aims to put in line the needs and aspirations
of followers with the desired goals of the organization. In doing so, a transformational leader is able to foster the
follower’s commitments towards the organization and encourages them to surpass their expected performance
(Sivanathan & Fekken, 2002), (Miia, et al. 2006), (Bass & Riggio, 2006). While The most prominent aspect of
transactional leadership is that such leaders focus more on the basic physical and security needs of their followers
(Bass, 1985). Therefore, the relationship among the leaders and followers in this type of leadership style is based on
the principal of returning rewards or incentives in response to appreciable performances of employees (Bass & Avolio,
1993a), Bass & Avolio (1993b). The international importance of interest in leadership is clear and evident in private
and public healthcare organizations. There have been a series of policy papers asserting the importance of improving
public services through the further development of leadership skills. As one of the most important public service
organizations, healthcare organizations rely on well- understood and highly developed leadership. This is important
to improve the quality of healthcare, as well as organizational processes. Consequently, leadership is seen as central
to progressing organizational productivity and capacity in healthcare(Alloubani et al., 2014). Where health service
staff report they are well-led and have high levels of satisfaction with their immediate supervisors, patients report that
they, in turn, are treated with respect, care and compassion (Dawson et al, 2011). Overall, the data suggest that when
health care staff feel their work climate is positive and supportive, as evidenced by coherent, integrated and supportive
people management practices, there are low and declining levels of patient mortality. These associations are consistent
across all the domains of health care - acute, mental health, primary care and ambulance. Relational approach to
leadership contributes to healthy work environments through support, open and honest communication and trust.
Managers who are concerned about the well-being of their staff, listen to and acknowledge their input, respond openly
and truthfully to concerns, and act on values that support exemplary patient care are more apt to garner healthcare
workers’ trust. Trustworthy managers inspire healthcare workers’ commitment and pride in work which may be
demonstrated in willingness to engage in new practices, voice patient issues, and make suggestions for workplace
changes (Wong & Cummings 2009). Leaders who create opportunities for meaningful dialogue with healthcare
workers to resolve care issues that risk patient safety and then follow through on staff suggestions for improvement
role model their commitment to patient care.

To gain a comprehensive appreciation of the underlying evidence linking leadership styles and patient-centered quality
healthcare delivery in hospitals, there is a need to synthesize all studies published on the topic to date, without any
language, time, and contextual restrictions. In doing so, there is a need to undertake a comprehensive search of the
underlying literature in which both formal databases are searched, as well as searching the grey literature. Furthermore,
there is a need to include a wide range Leadership styles, the quality of care administered and patient-centered
treatment outcomes that have been studied in previous primary studies. Previous systematic reviews have failed in at
least on one of these aspects. Therefore, by considering all these perspectives, the current systematic review aims to
identify, critically appraise, and synthesize the evidence from previous studies investigating the association leadership
styles and the quality of care in hospitals

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IOSR Journal of Nursing and Health Science (IOSR-JNHS)
e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 12, Issue 12 Ser. I (Nov – Dec. 2021), PP e10-e15

2. METHOD

The method used in developing this protocol is based on the Preferred Reporting Items for Systematic reviews and
Meta-analysis Protocols (PRISMA-P) guidelines(Moher et al., 2016).

Eligibility Criteria

Study types

Studies to be considered in this review include analytical observational studies: cohort studies, case-control studies,
cross-sectional studies, opinion papers, and other systematic reviews will be excluded

Participants: Hospital Leaders (Including; Medical and Administrative leaders)

Exposure/Subjects:Patients admitted at hospitals for more than 24 hours.
Duration: There will be no time restriction to the year of publications
Language:There will be no restrictions on the setting and language of published papers. We will translate articles
published in other languages than English, French, and Portuguese

Information source

Database searches

The following databases will be searched to extract relevant studies: PubMed, Google Scholar, Cochrane Library, and
WHO Global Health Library. We will also search databases of the proceedings of international conferences, such as
ISI Conference Proceedings, Citation Index via Web of Knowledge and ZETOC (British Library), and contact authors
who have previously published on the topic. We will also explore the reference lists of included studies to identify
more eligible studies

Search strategies
The search strategy will be performed using resources that enhance methodological transparency and improve the
reproducibility of the results and evidence synthesis. In this sense, the search strategy will be elaborated and
implemented prior to study selection, according to the PRISMA-P checklist as guidance (Moher et al., 2015).
Additionally, using the Population, Intervention, Comparison, Outcome and Study design (PICOS) strategy
(Cochrane, 2008). The guiding question of this review in order to ensure the systematic search of available literature
will be: ‘what is the relationship between clinical leadearship styles and quality of care in hospitals’ Studies will be
retrieved from the following databases: PubMed, Google Scholar, Cochrane Library, and WHO Global Health Library.
There will be no restriction regarding the language to avoid the reduce the yield of appropriate articles and also
generalizability. In addition, the reference section in the studies returned by the above search was scrutinized for
additional relevant articles.
Initially, the existence of controlled descriptors (such as MeSH terms, CINAHL headings, PsycINFO thesaurus and
DeCS-Health Science Descriptors) and their synonyms (key words) will be verified in each database. The search terms
will be combined using the Boolean operators (Lefebvre et al., 2008) ‘AND’ and ‘OR’. Subsequently, a search strategy
combining MeSH terms and free-text words, such as “Hospital” “Quality of Care” “Leadership style” “treatment
outcome” “patient care” will be used. In order to locate the quasi-experimental studies. In order to locate the clinical
trials and experimental studies, a filter after the PICOS search strategy will be added to include the following terms:
AND (randomized controlled trial OR randomized controlled trials as topic OR controlled clinical trial OR clinical
trial OR nonrandomized controlled trials).

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IOSR Journal of Nursing and Health Science (IOSR-JNHS)
e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 12, Issue 12 Ser. I (Nov – Dec. 2021), PP e10-e15

Study selection
The articles retrieved from all the databases will be exported to Endnote, where de-duplication will be undertaken.
Afterward, the articles will be exported to Rayyan, a web-based interface that facilitates collaboration among
reviewers, where screening of the papers for eligibility will be undertaken. The titles and abstracts of all papers will
be screened independently by at least two reviewers with a third reviewer arbitrating any disagreements that are not
resolved by discussion. Following the title and abstract screening, the reviewers will independently screen the full-
text of potentially eligible studies. Efforts will be made to translate studies found in any language other than English,
French, and Portuguese. Where data or information are missing, we will contact authors of respective studies to
request additional information.

Data collection and Data Items

Data will be extracted using a PROFORMA data collection form which will include four domains: (1) identification
of the study (article title; journal-title; authors; country of the study; language; publication year. (2) methodological
characteristics (study design; study objective or research question or hypothesis; sample characteristics, e.g., sample
size, sex; age, race; acute and/or chronic diagnoses; groups and controls; stated length of follow-up; validated
measures; statistical analyses, adjustments; (3) main findings and (4) conclusions. We will pilot and revise the data
extraction form using a couple of studies before its is used for all the the studies. The extraction will be done
independently by at least two reviewers, and where there are discrepancies, a third reviewer will arbitrate.

Outcomes and prioritizations

As primary outcomes, we will consider objectively measured leadership styles, quality of care assessment, treatment
outcomes and patient-reported satisfaction on quality of care.

Quality assessment
The quality assessment and risk of bias of selected studies will be undertaken using the Effective Public Health
Practice Project tool (EPHPP) (https://www.ephpp.ca/quality-assessment-tool-for-qualtitative-studies). At least two
reviewers will independently appraise the quality and potential for risk of bias in all included studies, and a third
reviewer will arbitrate any disagreement. In addition to its global rating, the EPHPP tool provides a rating of studies
across six domains (selection bias, study design, confounders, blinding, data collection method, and withdrawals and
dropouts), enabling more detailed assessment of the strength and weakness of individual studies. Each domain will be
graded as low, moderate, and high and the combination of grading across the domains will be used to derive the global
grading.

Data Synthesis

Both narrative and quantitative synthesis of data retrieved from included studies will be performed. A narrative
description of all studies will be carried out with emphasis on population characteristics, study design, type of
exposure, and type of outcome. The quantitative synthesis will involve meta-analysis to statistically combine the
estimates across the included studies judged to be clinically and methodologically comparable. Considering that
results from included studies may be influenced by factors such as study design, geographic setting, methods of
statistical analysis, and data quality, the random-effects meta-analysis will be employed in spooling results across
studies. Possible heterogeneity between the studies will be quantified using the I2 statistic, which is a measure (range
0-100%) used to quantify the proportion of variance in the pooled estimates attributable to differences in estimates
between studies included in the meta-analysis [Error! Reference source not found.-Error! Reference source not
found.]. Subgroup analyses will be performed based on study design, leadership styles, treatment outcome and quality
of care assessment. Estimates from the individual studies may be presented in different forms (e.g., risk ratio, hazard
ratio, incidence rate ratio or odds ratio); therefore, hazard ration (HR), incidence rate ration (IRR) and odds ratio (OR)
estimates will be converted to risk ratios using the recently proposed formula as shown below in order to ensure
uniformity in measure of effect estimates[22]

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IOSR Journal of Nursing and Health Science (IOSR-JNHS)
e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 12, Issue 12 Ser. I (Nov – Dec. 2021), PP e10-e15

(a) RR ≈ IRR;

(b) RR ≈ HR or OR (if outcome is < 15% by the end of follow-up);

1 − 0.5√𝐻𝑅
(c) RR ≈ √𝑂𝑅 or (if outcome is ≥ 15% by the end of follow-up)
√ 1
1 − 0.5 𝐻𝑅

Sensitivity analysis will be done to explore the source of heterogeneity based on the quality of risk of bias. We will
address any publication bias by examining funnel plots and estimated using Begg and Egger tests [Error! Reference
source not found.,24]. Stata Statistical Software (Release 16; StataCorp LP., College Station, TX, USA) will be used
for the analysis.

Registration and reporting

This study will be registered on PROSPERO. We will report according to the PRISMA guidelines for reporting of
systematic reviews and MOOSE guidelines for observational epidemiological systematic reviews

References

Aghamolaei, T., Eftekhaari, T. E., Rafati, S., Kahnouji, K., Ahangari, S., Shahrzad, M. E., Kahnouji, A., & Hoseini,
S. H. (2014). Service quality assessment of a referral hospital in Southern Iran with SERVQUAL technique:
Patients’ perspective. BMC Health Services Research, 14(1), 322. https://doi.org/10.1186/1472-6963-14-322

Ahmed, Z., & Abbasi, K. (2014). The Impact of Leadership Styles on Innovation in the Health Services. Public
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Alloubani, A., Almatari, M., & Musa Almukhtar, M. (2014). Review: Effects of Leadership Styles on Quality of
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Mahmoud, A. B., Ekwere, T., Fuxman, L., & Meero, A. A. (2019). Assessing Patients’ Perception of Health Care
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López, A., Gil-González, D. M., Altman, D. G., Booth, A., … Whitlock, E. (2016). Preferred reporting items
for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Revista Espanola de

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Nutricion Humana y Dietetica, 20(2), 148–160. https://doi.org/10.1186/2046-4053-4-1

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Ethics approval and consent to participate: Not applicable

Consent for publication: Not applicable

Availability of data and materials: Not applicable

Competing interests: All the authors declare none

Funding: None

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