Received: 15 November 2018 Revised: 3 April 2019 Accepted: 13 May 2019

DOI: 10.1111/jep.13204

ORIGINAL PAPER

Linking hospital culture to the training performance of

residents: The roles of leader‐member exchange and
transactional leadership style

Guangwei Deng Master, Ph.D. candidate1 | Di Zhao Master, Ph.D. candidate2 |

Jonathan Lio Doctor, Assistant professor3 | Xiaopeng Ma Doctor, Associate professor4 |

Liang Liang Doctor, Professor1 | Chenpeng Feng Doctor, Lecturer1

1
School of Management, Hefei University of
Technology, Hefei, China Abstract
2
School of Management, University of Science Background: Hospital culture is a crucial aspect of residents' training. However, the
and Technology of China, Hefei, China
3
mechanisms related to stakeholder culture (SC) and teacher‐resident interaction
Department of Medicine, University of
Chicago, Chicago, Illinois remain unclear. The study investigated the relationship between hospital culture
4
Department of General Surgery, The First and training performance of residents. Also, it explored the mediating effect of
Affiliated Hospital of University of Science and
teacher‐resident exchange and the moderating effect of the teacher's transactional
Technology of China, Hefei, China
leadership style within a Chinese context.
Correspondence
Dr. Chenpeng Feng, School of Management,
Methods: Based on stakeholder and leadership member exchange theories, we
Hefei University of Technology, No. 193, Tunxi constructed a composite model. Data were collected from 296 residents from five
Road, Hefei 230009, China.
Email: cpfeng@hfut.edu.cn
tertiary hospitals in China. Hierarchical moderated regression analyses were used to
test the hypotheses.
Funding information
Key Scientific and Technological Projects of Results: (a) Both the employee‐orientation culture (EOC) (β = .14, P ≤ .05) and
Anhui Province in China, Grant/Award Num- patient‐orientation culture (POC) (β = .47, P ≤ .001) in the hospital were significantly
ber: 1604a0802073; National Natural Science
Foundation of China, Grant/Award Number: related to residents' training performance. (b) Teacher‐resident exchange fully medi-
71601062; the Fundamental Research Funds ated the relationship between EOC and training performance and partially mediated
for the Central Universities, Grant/Award
Number: JZ2019HGTB0098; China Postdoc- the relationship between POC and training performance. (c) The moderating role of
toral Science Foundation, Grant/Award Num- transactional leadership style (TLS) in the relationship between EOC and leader‐
ber: 2017M620257
member exchange (LMX) (β = −.17, P ≤ .05) was negative; it was not significant in
the interaction between POC and TLS (β = .06, P > .1).
Conclusion: The results suggest that trainers should consider the value of multiple
cultures and ensure balance among stakeholders rather than focusing on a single one.
Furthermore, a positive interaction improves teacher‐student relationship and train-
ing performance. Most importantly, educational departments should pay attention
to establishing assessment tools, using rewards and incentives in residents' training.

K E Y W OR D S

hospital culture, teacher‐resident exchange, training performance, transactional leadership style

92 © 2019 John Wiley & Sons, Ltd. w

7 ileyonlinelibrary.com/journal/jep J Eval Clin Pract. 2
7 020;26:92–1007.
DENG ET AL.
1 | I N T RO D U CT I O N
Most Chinese residents' training takes place in public hospitals, which
have always been required to adopt a patient‐oriented culture in the
management system. However, the frequent conflicts between doc-
tors and patients indicate that hospitals have practical difficulties in
establishing a safe and respectful environment. An employee‐oriented
culture has spread widely in medical organizations in recent years.1 In
the Chinese context, a stakeholder orientation is prevalent in hospi-
tals, and China is undergoing a major medical education reform in
the field of residents training standardization. As personnel who work
in the front line of clinical work, residents are also inevitably affected
by the stakeholder culture.2
Stakeholder theory indicates that the development of an organiza-
tion cannot be separated from the involvement of various stake-
holders. An organization should pursue its overall interest instead of
the interest of a particular entity.3 Stakeholder culture (SC) is defined
as a set of beliefs, values, and practices that are often utilized in solv-
ing stakeholder‐related problems, managing relationships with stake-
4
holders and emphasizing the balance of multiple subjects. Day
believes that an excellent organizational culture takes into account
the needs of employees and customers. Obviously, the main stake-
holders in the hospital are doctors and patients,5 and researchers
found that SC has played a prominent role in strengthening residency
training programmes and enhancing organizational performance.6-9
Chinese culture traditionally attaches a great amount of impor-
tance to interpersonal relationship. As the core relationship in the Chi-
nese organizational environment, the relationship between leaders
and subordinates plays a key role in organizational context and perfor-
10
mance. Therefore, the corresponding relationship between teachers
(leaders in departments) and residents (employees in departments)11,12
is also very relevant. We propose a model (see Figure 1) to understand
the underlying mechanisms of leader‐member exchange (LMX), also
called teacher‐resident exchange (TRX).
Several studies have demonstrated the influence of cultural and
contextual factors on the learning of residents.2,13 However, only a
few of them have focused on the moderating mechanism that links
SC to training performance from a contextual perspective, which is
an important aspect correlating SC and teacher‐resident interaction.
We aim at clarifying the effects of SC on the residents' training perfor-
mance by introducing another contextual condition called transac-
tional leadership style (TLS) as a moderator (see the section on
moderating effect). A Chinese public hospital is a typical managerial
organization; it has multiple levels and a stable and closed‐in environ-
ment. Because of the planned system and managerial mechanism,
93
which had worked for long‐term periods in the past, leaders in current
hospitals usually propose clear missions and requirements in order to
guide and stimulate subordinates in their efforts to accomplish their
tasks.14 This typical TLS has deeply influenced daily management in
hospitals, and it is still the most popular leadership style in the man-
agement of public hospitals.15
2 | THEORETICAL BACKGROUND AND
HYPOTHESES
2.1 | SC in hospitals and training performance of
residents
Although the operationalization of SC in the literature has been
debated, most researchers can recognize its employee‐ and
customer‐oriented components.16 Employee‐oriented culture indi-
cates that an organization treats its employees as an important organi-
zational asset and sees them as key partners on the way to success.17
Similarly, customer‐oriented culture is to put the customers' benefits
in the first place. The hospital culture should encompass the patient‐
oriented and physician‐oriented organizational cultures, which are
similar to the customer‐ and employee‐oriented cultures. Employee‐
oriented values define how the members of an organization should
interact and include employees' trust and empowerment.18 There is
a remarkable and positive correlation between resident‐oriented cul-
ture and improvement of training performance. The underlying logic19
is that if residents are expected to provide better services in
interacting with patients, the managers, such as the department direc-
tors, must provide better services to their subordinates and residents
in the first place. In this context, hospitals can train and give support
to residents at an organizational level. If they receive enough attention
and supports, the trend of residents' job burnout and turnover will be
minimized, and many counterproductive behaviours will be reduced,20
while the positive factors such as the increase of satisfaction, and
work input, will promote better residents' performances. The hospitals
with a strong resident‐oriented culture can fully meet the needs of
residents, and their training and relationship with the managers will
be more standardized. Therefore, the resident‐oriented culture can
positively influence residents' training performance.
The customer‐oriented culture is an essential aspect of successful
organizations.21 In public organizations, the relation between
customer‐oriented culture and organizational goals is developed in line
with the emotion and normative values that employees have towards
the public service.22 In public hospitals managed by the government,
FIGURE 1 Holistic hypothetical model
94
the patient‐oriented culture is an inherent requirement. The institute
that manages hospitals focuses on patients and considers the
improvement of medical quality as its goal. Previous studies have dem-
onstrated that the patient‐oriented culture in public hospitals pro-
motes the performance of physicians.23 The success of medical
institutions, including the Mayo Clinic, is also determined by the core
value of putting the patient at the first place.24 A workplace environ-
ment with a patient‐oriented culture has a positive influence on the
personal accomplishment of health care employees.25 Once the
patient‐oriented culture in hospitals is deeply rooted, front‐line medi-
cal staff such as residents can actively participate and consciously
26
improve their ability in serving patients.
In short, organizations that pay attention to key factors (customer
and employee) usually have better performance than those that do not
have such organizational culture.27 Paying increasing attention to SC
can contribute to improve hospitals' performances and promote the
outputs of the residents.
H1a. A resident‐oriented culture in the hospital positively
influences the training performance of the residents.
H1b. A patient‐oriented culture in the hospital positively
influences the training performance of the residents.
2.2 | The mediating effect of TRX
Leaders can adopt different styles in treating their subordinates. Orga-
nizational relationships include high‐quality exchange relationships
and low‐quality exchange relationships.28 According to the study of
Graen and Uhl‐bien,29 high‐quality exchange relationships make sub-
ordinates feel trust, respect, and care towards their leaders, making
them feel more comfortable in their working environments. Under
these circumstances, residents have more opportunities to develop
themselves and their full potential, which makes them more likely to
take responsibilities for training goals and other tasks spontaneously
and to accept challenging jobs that could make them gain more tasks
and reputation. On the contrary, in low‐quality exchange relationships,
the motivations of residents are not generated by feelings of trust,
respect, or dedication and the level of care that they will give to the
patients will not be consistent.
We discussed TRX because the TRX relationship represents a
potential mediating mechanism in the relationship between SC and
performance. The existing literature has shown that contextual factors
30
influence high‐quality exchange relationship. SC provides a broader
cultural framework and optimal conditions for the formation of high‐
quality exchange relationships between clinical teachers with resi-
dents. Hospital cultures characterized by resident‐oriented values
put emphasis on the personal growth of residents in order to make
them feel fully respected, trusted, and supported by the faculties
and teachers. Correspondingly, residents will have more resources
and opportunities and access to more information and authorization.
On the other hand, a patient‐oriented culture puts patients' interests
first, which requires residents to focus always on patients' needs. By
DENG ET AL.
collecting and analysing feedback information on patients' needs, res-
idents could conduct response‐driven learning or adaptive adjustment.
Getting positive feedback from the patients, residents will be increas-
ingly more trusted and authorized to take on more responsibilities in
the next working steps.31 Thus, teachers and residents will gradually
establish a high‐quality exchange relationship through the continuous
accumulation of trust and positive feedback from patients.
The literature stated that TRX has an accurate predictive effect on
academic outcomes and trainees' achievements.32,33 During the train-
ing, high‐quality TRXs produce professional knowledge and experi-
ence and strengthen the efficiency of the communication between
teachers and residents, contributing to a better understanding of res-
idents' real ideas and practical difficulties. Special help and solutions
provided by the teachers are basic conditions for residents to get bet-
ter performances.6
H2a. LMX mediates the relationship between a resident‐
oriented culture and training performance of residents.
H2b. LMX mediates the relationship between a patient‐
oriented culture and training performance of residents.
2.3 | The moderating effect of TLS
Bass34 believes that the development of transactional leadership is
based on the LMX theory, wherein the exchange relationship between
leaders and subordinates is based on rewards or punishments. The TLS
in the Chinese context uses different strategies. On the basis of the
understanding of subordinates' needs, leaders clarify the requirements
and goals for a specific position, then stimulate employees and satisfy
their need.
The TLS is derived from the characteristics of China's traditional
culture.10 Many studies have proved that the TLS is prevalent in
public organizations in China,14,35 including public hospitals.15 Thus,
TLS is an inevitable organizational environment for resident training
in public hospitals. It is a mutual transactional process based on
conducting contractual obligations. Achieving resident‐oriented and
patient‐oriented cultures is the long‐term goal for SC hospitals. In
the process of standardized training, teachers complete the entire
training tasks by monitoring the learning process and controlling
the training outcomes.
The TLS works within the concrete organizational culture.36 In the
health field, organizational culture is closely related to leadership
behaviour.37 However, the widespread TLS in Chinese public hospi-
tals (Tu and Wang 2010) is contradictory to the SC orientation of cur-
rent residency training. For example, the punishment in TLS is
considered to be invalid, and Podsakoff38 argues that it influences
the team's development in a negative way. Bass and Avolio39 also
believe that exception management has a negative impact on satisfac-
tion and performance, especially when leaders are not proactive in
taking action or only set standards after problems have happened.
As mentioned above, resident‐oriented culture and patient‐oriented
culture both emphasize respect. If a resident physician makes a
DENG ET AL.
mistake or violates working standards, then the resident is going to be
punished and criticized. It obviously goes against the value of respect.
More seriously, the negative management of clinical teachers often
appears when residents' performance is poor or serious mistakes
occur in medical activities. If the standards have not been clearly illus-
trated before, then residents could not only fail in accomplishing their
goals but also have more complaints from subordinates to their
40
supervisors. Also, this phenomenon is not conducive for building
an efficient, high‐quality teacher‐resident relationship. Then, accord-
ing to Matey,41 clinical teachers who adopt the TLS only focus on
the completion of tasks and performances but rarely interact with
residents, which is detrimental to the formation of a positive culture.
H3a. The negative effect of a resident‐oriented culture
on LMX is moderated by TLS.
H3b. The negative effect of a patient‐oriented culture
on LMX is moderated by TLS.
3 | SAMPLE SELECTION AND VARIABLE
MEASUREMENT
3.1 | Samples and procedures
In August 2017, we distributed a questionnaire survey to the resi-
dents; the individuals of the sample source were considered based
on the first list published by the National Health and Family Planning
Commission in China. We then selected five tertiary hospitals (only
such hospitals were qualified for the training) from the south‐east
region and the central region. These target units were chosen because
of the high medical conditions prevalent in the south‐east region and
the middle medical conditions prevalent in the central region. The first
batch of hospitals was approved to be residential training bases, and
they began training residents in 2015. We contacted the staff of the
physician management office and informal resident organizations via
phone, fax, or social networking platforms (eg, QQ or WeChat). After
we received approval from their department, we immediately
approached hospitals with residents not only to obtain relevant infor-
mation about the residents but also to encourage the residents to
complete the survey.
During the investigation, anonymity and confidentiality of the data
were required. The residents were contacted and invited to participate
in the study. Paper‐based questionnaires were distributed to the par-
ticipants on site and were collected on the spot. The residents were
informed of the purpose of the survey and the procedures on how
to answer the questionnaire. Residents from the internal medicine,
surgery, paediatric, obstetric, community medicine, ICU, emergency,
and psychiatric departments were all involved in this investigation. A
total of 400 questionnaires were distributed, and 296 were collected
(74% response rate). Of these, 49 questionnaires were discarded
because of missing data. The demographic profiles of the 247 valid
participants are presented in terms of the following demographic var-
iables: gender, age, education, and hospital level.
95
3.2 | Variable measurement
Questionnaires that had been translated into modern Mandarin by
professional translators were used for the purpose of collecting data.
The translated versions had been verified and back‐translated into
English by independent translators before data collection to ensure
accuracy of meaning. Residents were asked to express their level of
agreement with each statement on a Likert scale ranging from
1 = strongly disagree to 5 = strongly agree.
3.2.1 | Resident‐orientation culture or
patient‐orientation culture
They were measured with Tsui's scale.20 Six items each were adapted
to assess resident‐orientation culture or patient‐orientation culture. A
sample item is respectively “Concerning for the individual develop-
ment of residents.” Example items for patient‐orientation culture are
“Sincere patient service” and “The profit of the patient is emphasized
extremely.”
3.2.2 | Transactional leadership style
To assess TLS, the questionnaire developed by Podsakoff et al42 was
used. The scale is composed of two subscales: a four‐item contingent
reward behaviour scale and three items contingent punishment scale,
including “My teachers always give me positive feedback when I per-
form well.”
3.2.3 | LMX (teacher‐resident exchange)
We adapted the 12‐item LMX scale proposed by Liden and Maslyn43
to measure TRX. Sample items include “I like my supervisor very much
as a person” and “My supervisor is a lot of fun to work with.”
3.2.4 | The performance of residents
In order to help assess resident performance during training, the
Residency Affair Committee of the Pediatric Residency Program of
the University of Padua (Italy) administered a Resident Assessment
Questionnaire (ReAQ). The ReAQ consists of 20 items that assess
the competence of residents' habitual and judicious use of communi-
cation, knowledge, technical skills, clinical reasoning, feelings, and
values.44 It could be used for self‐evaluation or for hetero evaluation.
In fact, previous research has shown that using the ReAQ for self‐
evaluations is more severe and reliable than the evaluations made
by faculty.44 It should be noted that entrustability scales are
valuable assessment tools and should be more widely adopted.45,46
Nevertheless, considering that residents' perceived performance bet-
ter suits the model logic and purpose of this research, scales should
be filled by residents, and we choose ReAQ instead of entrustability
scales.
96 DENG ET AL.

4 | D A T A A N A L Y S I S A N D RE S U L T S 4.2 | Hypotheses tests

4.1 | Reliability and validity
We first evaluated the reliability and validity of measurements using
confirmatory factor analysis (CFA). Table 1 shows the CFA results.
The reliability is reflected by internal consistency reliability, called
Cronbach's α value. As shown in Table 1, each multi‐item variable's
Cronbach's alpha value is higher than .7, which implies high internal
consistency.
The convergent validity is measured by Composite Reliability (CR)
and Average Variance Extracted (AVE). The acceptable value of CR is
higher than 0.7 and AVE is higher than 0.5. As shown in Table 1, the
CR values of each variable ranges from 0.90 to 0.94, and the
AVE values of each variable range from 0.51 to 0.73, which imply high
convergent validity.
The discriminant validity was tested by comparing the relationship
between the correlations among constructs and square root of the
AVE scores. Table 2 indicates that the square root of the AVE scores
for each construct is greater than the correlations among the con-
structs, thus confirming the discriminant validity.
TABLE 1 Evidence of reliability and convergent validity
All hypotheses were tested by hierarchical regression analyses via
SPSS 22. Bias‐corrected bootstrapping procedure developed by
Preacher and Hayes47 was adopted to further examine the mediating
role of LMX. To reduce multicollinearity problems, all independent
variables were standardized.
4.2.1 | Hospital culture and the residents' training
performance
To test the main effect, the control variables are first entered and then
independent variables. Results were presented in Table 3. As pre-
dicted, resident‐orientation culture in hospital was positively related
to training performance (β = .14, P ≤ .05, Model 4); POC in hospital
was positively related to training performance (β = .47, P ≤ .001,
Model 4). Results provided evidence to H1a and H1b.
4.2.2 | The mediating effect of LMX
H2a and H2b proposed that the effect of hospital culture (resident‐
orientation culture and patient‐orientation culture) on training perfor-
mance was mediated by LMX. To test the mediating role of LMX, we
adopted the procedures developed by Baron and Kenny48: (a) the
independent variable (ie, hospital culture) is significantly related to

Composite the dependent variable (ie, training performance) and the mediator
Variables Loading Cronbach's α Reliability AVE (ie, LMX), respectively; (b) the mediator (ie, LMX) is significantly
related to the dependent variable (ie, training performance); and
Resident‐orientation .75‐.87 .87 .90 .65
culture (c) the coefficient of the independent variable becomes smaller or

Patient‐orientation culture .78‐.91 .93 .94 .73 non‐significant when mediator is incorporated into the regression
equation.
LMX .65‐.90 .84 .94 .60
As shown in Table 3, first, resident‐orientation culture was
TLS .75‐.88 .69 .94 .71
positively related to LMX (β = .37, P ≤ .001, Model 2) and training
Performance .60‐.81 .91 .94 .51
performance (β = .14, P ≤ .05, Model 4); patient‐orientation culture
Note. LMX represents teacher‐resident relationship. was positively related to LMX (β = .19, P ≤ .05, Model 2) and

TABLE 2 Correlations of latent variables and evidence of discriminant validity

Variable Mean SD 1 2 3 4 5 6 7 8

1. Gender
2. Age 0.02
3. Education −0.06 0.18**
4. Resident‐orientation culture 3.11 0.73 −0.15* 0.09 −0.11 0.81
5. Patient‐orientation culture 3.68 0.64 −0.11 0.06 −0.13* 0.63** 0.85
6. LMX 3.50 0.53 −0.04 0.04 −0.08 0.48** 0.42** 0.77
7. TLS 3.60 0.41 0.19** 0.03 0.06 0.27** 0.31** 0.45** 0.84
8. Performance 3.62 0.44 0.02 0.09 0.00 0.42** 0.55** 0.48** 0.43** 0.71

Note: n = 245. The diagonal elements are the square root of AVE. LMX represents teacher‐resident relationship; TLS represents transformational leadership.
***P < .001;
**P < .05;
*P < .1.
DENG ET AL. 97

TABLE 3 Results of regression analysis for mediating effects

LMX Training Performance

Model 1 Model 2 Model 3 Model 4 Model 5 Model 6

Gender −0.05 0.03 0.02 0.10 0.05 0.09

Age 0.06 0.00 0.09 0.03 0.06 0.03
Education −0.09 −0.01 −0.01 0.08 0.03 0.08
Resident‐orientation culture 0.37*** 0.14* 0.03
Patient‐orientation culture 0.19* 0.47*** 0.42***
LMX 0.49*** 0.30***
R2 0.01 0.25 0.01 0.33 0.24 0.39
ΔR 2
0.01 0.24*** 0.01 0.32*** 0.23*** 0.07***
F 0.93 16.26 0.70 22.99 19.08 25.72
ΔF 0.93 38.81*** 0.70 55.95*** 73.57*** 26.88***

Note. LMX represents teacher‐resident relationship.

***P < .001;
**P < .05;
*P < .1.

training performance (β = .47, P ≤ .001, Model 4). Second, LMX was TABLE 4 Results of regression analysis for moderating effects
positively related to training performance (β = .49, P ≤ .001, Model
LMX
5). Third, when LMX was incorporated into the regression equation
Model 7 Model 8 Model 9 Model 10
in which training performance was dependent variable, the effect
of resident‐orientation culture on training performance (β = .03, Gender −0.05 0.03 −0.06 −0.07

Model 6) was not significant, the effect of patient‐orientation culture Age 0.06 0.00 0.01 0.03
on training performance (β = .42, Model 6) was smaller than that in Education −0.09 −0.01 −0.06 −0.07
Model 4, whereas LMX was still significantly correlated to training Resident‐orientation 0.37*** 0.31*** 0.31***
performance (β = .30, P ≤ .001, Model 6), indicating that LMX fully culture
mediated the relationship between resident‐orientation culture and Patient‐orientation 0.19* 0.10 0.10
training performance, partly mediated the relationship between culture
patient‐orientation culture and training performance. H2a and H2b TLS 0.35*** 0.34***
were supported. Resident‐orientation −0.17*
culture *TLS
Patient‐orientation 0.06
4.2.3 | The moderating effect of TLS culture * TLS
R2 0.01 0.25 0.35 0.38
H3a and H3b proposed that TLS moderated the relationship between
ΔR2 0.01 0.24*** 0.10*** 0.02*
hospital culture and LMX. Hierarchical moderated regression analyses
F 0.93 16.26 21.87 17.70
were conducted to test this prediction. First, control variables (ie, gen-
der and age) were plugged into equation, followed by independent ΔF 0.93 38.81*** 37.49*** 3.70*

variable (ie, hospital culture). Then, the moderating variable (ie, trans- Note. LMX represents teacher‐resident relationship; TLS represents trans-
formational leadership) and the interaction of hospital culture and formational leadership.
TLS were successively entered in the quotation. The variance inflation ***P < .001;
factors (VIF) ranged from 1.150 to 1.770, which were below the cut‐ **P < .01;
off of 2.000, indicating that multicollinearity problem was not a major *P < .05.
issue in this study.
In line with H3a, results in Table 4 supported the moderating role
of TLS in the relationship between resident‐orientation culture and related to LMX when TLS was high rather than low. Accordingly,
LMX, because the interaction of resident‐orientation culture and TLS H3a was supported. However, the interaction of patient‐orientation
(β = −.17, P ≤ .05, Model 10) was negatively related to LMX. culture and TLS (β = .06, P > .1, Model 10) was not significantly related
Figure 2 showed that resident‐orientation culture was less positively to LMX, rejecting H3b.
98
FIGURE 2 Interaction effect of resident‐
orientation culture and transformational
leadership on leader‐member exchange (LMX)
5 | C O N C L U S I O N S A N D RE M A R K S
5.1 | Discussion
First, resident‐oriented culture and patient‐oriented culture are posi-
tively related to performance in this study. Furthermore, we also
found a positive relationship between SC and training performance.
Based on the stakeholder theory, resident physicians can obtain differ-
ent resources to improve their performance in training through
resident‐oriented culture and patient‐oriented culture. We believe
that resident physicians can improve their cognitive and clinical pro-
fessional skills through SC‐oriented cultures that can promote training
performance. Our empirical finding is a response to the importance of
13
different cultural factors in residency training proposed by Mi et al.
Hoff2 constructed a cultural orientation model and demonstrated its
usefulness when applied to the training outcomes of residents. Fur-
thermore, our finding contributes to understanding the effect of cul-
ture or contextual factors on the outcome of residency training by
adopting the SC concept, wherein TRX and leadership theory are uti-
lized in the same model.
Second, the results reveal that TRX serves as a fundamental pro-
cess. TRX is the basis of culture performance (ie, SC's influence perfor-
mance), and it fully mediates SC training performance. We identify the
relationship effect process through which SC relates to the training
performance of residents. Thus, the perspective of teacher‐resident
relationship provides additional explanations to medical vocational
training, thereby expanding the scope of the stakeholder theory. Many
other motivational variables linking the cultural context to the training
performance of residents have been found.
Third, we found support for our hypothesis that TLS moderates the
relationship between SC and TRX. Clinical teachers with TLS need to
make changes, for example, achieving goals of better exchange, paying
attention to the goal of residents' long‐term development, and creat-
ing a good atmosphere, especially reducing penalties. When teachers
adopt high TLS, the positive effect of employee‐oriented hospital cul-
ture on TRX is weakened, while when adopting low TLS, the positive
effect is stronger. Employee‐oriented hospitals with high TLS allow
DENG ET AL.
resident physicians to believe that they are members of the hospital
through effective rewards and establishing high‐quality supervisor‐to‐
subordinate relationships to achieve the training and settled goals.
Transactional teachers give specific assignments to guide and motivate
residents, satisfy their requirements actively, and give residents on‐time
feedbacks such as rewards mechanisms. Teachers decide whether to
give support to residents on different aspects, such as living and work-
ing, in order to facilitate high‐quality exchange relationship between
them. In certain cultural contexts in China, the power distances in most
organizations are relevant.49 Supervisors have the right to make the first
move in the supervisor‐subordinate relationships in hospitals, and their
leadership behaviour decides the development of the mutual relation-
ship between supervisors and subordinates.
5.2 | Practical implications
This study has some practical implications for residents' training in the
field of medical education. First, our findings suggest that residents'
training in hospitals should consider that SC might somehow deter-
mine performance outcomes and the mediating role of TRX. Thus,
training hospitals must be aware of the significance of SC. The impact
of the patient‐oriented hospital culture on residents' training can be
easily observed. Noting that occupational burnout is widespread
among health care professionals,20,50 the employee‐oriented culture
that respects and supports residents is even more important because
it makes residents more active. From the perspective of policy making
and practicing, this study is very significant. Our conclusion is that
supervisors should consider the value of both cultural orientations,
rather than pursuing just one of them.
Second, significant mediating effects indicate that the establish-
ment of high‐quality teacher‐student relationships is beneficial for
improving the residents' training performance, and it may even be a
prerequisite for their learning.51 High‐quality teacher‐student relation-
ships can be strengthened by taking actions, such as building mutually
respectful relationships, using rewarding mechanisms and recognizing
residents' progress. This interactive training relationship emphasizes
communication, learning, and the shaping of qualified physicians and
DENG ET AL.
teachers between both parties; it provides reciprocity and equity in
the relationship to promote the improvement of the teacher‐student
relationship on a higher level. At best, it would foster lifelong
52
mentor/mentee relationships.
Third, our findings indicate the importance of TLS that prevails in
the training of residents in the context of Chinese culture. Thus, edu-
cational departments should pay more attention to the establishment
of assessment tools for residents' training and give rewards to resi-
dents with good performance. In addition, we need to monitor more
closely teachers' negative behaviours to reduce them.
5.3 | Limitations and future research directions
This study has some limitations. First, residents' perceptions of vari-
ables, especially training performance, are collected by a self‐report
method. Despite the acceptance of this method in some studies,44
the problem of common method bias might arise. In our future
research, entrustability scales, which the ACGME uses for milestones
reporting,45,46 and self‐assessment methods need to be applied simul-
taneously to evaluate the performance. Second, the use of the cross‐
sectional data, rather than longitudinal data, may lead to the inade-
quacy of evidence for causation. Third, unmeasured exogenous vari-
ables may affect the relationship we studied. For instance, we have
selected only the most common TLS as the research variable, perhaps
ignoring the possibility of other compounds. Thus, for future research,
we can use objective assessment or external evaluation and encourage
researchers to evaluate changes in the effects of other exogenous fac-
tors and training performance practices over time. By adopting longi-
tudinal research designs, trainers are better able to recognize causal
effects in the training‐performance chain and assess the impact of
any intervention designed to improve resident performance.
CONFLICT OF INTEREST
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
FUND ING INF OR MATI ON
This research is supported by the Key Scientific and Technological
Projects of Anhui Province in China (No. 1604a0802073), National
Natural Science Foundation of China (No. 71601062), the Fundamen-
tal Research Funds for the Central Universities (JZ2019HGTB0098),
and China Postdoctoral Science Foundation (No. 2017M620257).
ORCID
Chenpeng Feng https://orcid.org/0000-0002-9224-9027
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How to cite this article: Deng G, Zhao D, Lio J, Ma X, Liang L,
Feng C. Linking hospital culture to the training performance of
residents: The roles of leader‐member exchange and transac-
tional leadership style. J Eval Clin Pract. 2020;26:92–100. https://
doi.org/10.1111/jep.13204