PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

Perceived Leadership Styles among Key Medical Staff Stakeholders at Two Hospital Maternity
Units Located in the Country of Mali: An Exploratory Study

By

Toutou Moussa Diallo

Exploratory Study

Doctor of Business Administration (DBA)

Doctoral Committee

Chair: Dr. Jonathan Green

Committee Member: Dr. Caroline Howard
Committee Member: Dr. Daniel Corcoran

School of Business Administration

Touro University Worldwide

DOI: 10.13140/RG.2.2.18270.51525

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PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

Abstract

This research project used the Multifactor Leadership Questionnaire adopted from Avolio &

Bass (1995, p.88-123). This instrument measures nine scales: five to capture transformational,

three to measure transactional, and one to reflect laissez-faire leadership styles, as well as three

to include leadership outcomes (Avolio & Bass 2004). It will help understand the impact of

perceived leadership styles among key medical staff stakeholders at two hospital maternity units

located in the country of Mali. Leaders were doctors, nurse practitioners, physicians assistants,

and residents. Subordinates were midwives, registered nurses, nurses, interns, nurse aides. In

Kayes, the number of leaders and subordinates were 6 and 29, respectively. Respective to

Sikasso, leaders were 8 and subordinates were 33. The study on 76 respondents, it was found that

perceptions of leadership from both leaders and subordinates were consistent with results

confirmed by Avolio & Bass (2004) and several other studies. Their contributions to this

research project played an important role in understanding the relationship between leadership

perceptions and organizational outcomes from both sites.

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PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

Introduction

The purpose of this research study is to examine the perception of self-reported

leadership styles and preference for prioritization of health services among key medical staff

stakeholders at two regional hospitals located in Mali, on the African continent. Sikasso and

Kayes were selected to help understand perceived leadership styles in maternity units within

each regional hospital. Between the regional hospital Fousseyni Daou Maternity in Sikasso and

Kayes Regional Hospital Maternity, there were a total of 76 respondents between the two

hospitals. There were 41 participants were from Sikasso Regional Hospital and 35 from

Fousseyni Daou Regional Hospital in Kayes. The self-reported leadership styles among key

medical staff stakeholders were measured via the Multifactor Leadership Questionnaire (MLQ)

(Avolio and Bass, 1995).

There was a comparison of the perception of leadership styles between the perceived

leadership styles from the perspective of subordinates and from the self-report of hospital leaders

from two regional hospitals in Mali. Overall, this exploratory research project would provide

quantitative data on leadership styles expressed by healthcare leaders and experienced by

healthcare staff members between the two hospitals in Mali which is a sub-Saharan African

country.

Purpose of the Study

The purpose of this research project is to examine if there are any differences in the

perception of leadership styles in the two different hospitals and among medical hospital leaders

versus subordinate medical staff in Mali because there is very little published research on the

perception of leadership styles in hospital settings within the sub-Saharan country of Mali.

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PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

Various empirical studies done in healthcare settings outside of the country of Mali have

highlighted the importance of transformational leadership in properly managing the healthcare

staff and provide quality care to patients. For example, research by Moon, Van Dam, & Kitsos

(2019) and Bass (1999), as Valentine (2019) cited, have highlighted that Transformational

Leadership is one of the most effective leadership styles utilized in the field of health services.

The closest study on leadership in a medical setting was done on emergency services in

Riyadh in Saudi Arabia (Leggio, 2013). This qualitative study was about how leadership is

learned among emergency medical services providers from multiple nations working in Riyadh,

kingdom of Saudi Arabia (Leggio, 2013).

Another study described a gap between the different roles (management vs. health care

provision) was because of communications between the different structures within the health

system (Seppey, Ridde, Touré, & Coulibaly, 2017). According to Seppey, Ridde, Touré, &

Coulibaly (2017), the gap existed between the operational (health agents) and the community

levels (ASACO and communes).

Furthermore, study done by Mathole, Lembani, Jackson, et al. (2018) described that

leadership is one of the key health systems factors affecting the performance of maternal health

services at facility level in two rural district hospitals in South Africa. The qualitative study

addressed a leadership development program but did not provide any information on leadership

styles using MLQ 5X model in maternity in Greater Accra Regional Hospital in Ghana. The

paper described that training nurses in management, communication, and leadership skills

successfully increased healthcare workers’ ability to identify and solve service delivery

challenges (Pfeiffer, Owen, Pettitt-Schieber, et al., 2019). A review of the literature indicates the

study of leadership in Mali hospital maternity units has not been previously studied. Few studies

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PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

are similar as discussed though do not directly address the hospital leadership traits between the

hospital leaders and the hospital subordinate staff within this project.

Literature

Currently, there are a multitude of challenges facing people who manage healthcare

systems within the sub-Saharan African countries. Oleribe, Momoh, Uzochukwu, Mbofana,

Adebiyi, Barbera, Williams, and Taylor-Robinson (2019) described that the health care systems

need radical changes with innovative solutions in the prioritization and development of human

resources, budget allocation, and management. This cross-countries study comprised of

participants from 11 African countries along with some participants from Cuba and Portugal.

This study was conducted in two phases to encourage and engage research participants. During

the first phase, each group member identified key challenges facing healthcare services and

strategies to mitigate them in the African context. The groups then discussed and elaborated on

these issues in the second phase. Included were three distinct activities: 1) generating key

challenges, 2) generating key strategies/solutions, and 3) ranking the challenges and strategies.

Challenges and solutions were identified and ranked from 1-5, where 1 being the most important

and 5 being the least important (Oleribe, Momoh, Uzochukwu, Mbofana, Adebiyi, Barbera,

Williams, and Taylor-Robinson, 2019). The results of the research study indicated that the key

challenges highlighted by the sample of participants were inadequate human resources (ex.

doctors. nurses etc.) to deliver quality healthcare to patients (34.29%), inadequate budgets to

help provide health care services (30%), and poor healthcare leadership and management

(8.45%). On the other hand, Oleribe, Momoh, Uzochukwu, Mbofana, Adebiyi, Barbera,

Williams, and Taylor-Robinson (2019) also found through their research study that the highly

recommended solutions recommended by the sample of participants as part of the included

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PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

improving the healthcare training among health workers (29.69%), increasing budgets focused

for healthcare services (20.31%), and advocacy for political support and commitment to help

improve budgeting and support for improving healthcare services (12.31%).

Building off the finding by Oleribe, Momoh, Uzochukwu, Mbofana, Adebiyi, Barbera,

Williams, and Taylor-Robinson (2019) that poor healthcare leadership and management is the 3rd

highest concern among healthcare professionals located in Africa, and healthcare leadership is

described as one of the most influential factors in shaping organizational culture (Mathole,

Lembani, Jackson, Zarowsky, Bijlmakers, & Sanders, (2018). According to Ajmeera (2014),

healthcare management refers to the healthcare leadership and general management and

administration of hospitals, hospital networks, public health systems and or health care systems.

Healthcare leadership is one key component that the World Health Organization will focus to

emphasize and develop in the near future to help manage the limited health care resources in

developing countries (WHO, 2019). Leadership has been highlighted by the World Health

Organization (WHO) as essential for strengthening health systems and improving health

outcomes, and the WHO advocates for leadership development amongst health workers in low-

and middle-income countries (LMIC) (Pfeiffer, Owen, Pettitt-Schieber et al., 2019). The WHO

Framework proposes that good leadership and management at the operational level needs to have

a balance between four inter-related areas (WHO, 2007):

1. Ensuring an adequate number of managers at all levels of the health system,

2. ensuring managers have appropriate competences,

3. creating better critical management support systems, and

4. creating an enabling working environment.

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PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

According to WHO 2007, better leadership and management cannot be achieved without

providing direction to, gaining commitment from partners and staff, facilitating change and

achieving better health services through efficient, creative and responsible deployment of people

and resources.

Cunninghan, Hazel, & Hayes (2020) describe that leadership in organizations influences

and facilitates individual and collective efforts to accomplish shared objectives. Researchers

have previously argued that leadership style manifested by a workplace leader can influence job

satisfaction and worker motivation among the subordinate employees (Aberese-Ako, Agyepong,

Dijk 2018). Motivated workers exhibit positive attitudes that ensure that work is done efficiently,

and quality care provided to clients (Aberese-Ako, Agyepong, Dijk (2018). To help provide

evidence for the impact of leadership skills upon the subordinate worker quality of work and

motivation, Aberese-Ako, Agyepong, Dijk (2018) conducted a study examining the impact of

leadership styles upon the mobilizing, influencing, inspiring, motivating and empowering of

subordinate health employees in two hospitals found in Ghana. Aberese-Ako, Agyepong, Dijk

(2018) found that hospital regulations and limitations in funding constrained a hospital leader’s

power and shaped their leadership styles in response to the needs of their subordinate healthcare

staff and corresponding patients. The workplace and environmental limitations on healthcare

leader created a diminished quality of health services provided towards patients, but when

healthcare leaders were able to work around the workplace and environmental constraints and

respond effectively to subordinate healthcare staff and patients’ needs, then the healthcare

leaders felt energized and motivated to work harder.

In a similar focus to the management skills of hospital leaders, Bakalikwira, Bananuka,

Kigongo, et al. (2017) conducted a study to examine the impact of hospital board governance

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and managerial skills or practices on the healthcare accountability across multiple hospitals in

Uganda. The focus of the study was hospital directors’ managerial skills or practices. The results

of the study showed a significant positive relationship between managerial competencies and

healthcare accountability. The study further finds that hospital board governance is not

significantly correlated with healthcare accountability among government hospitals.

Various empirical studies done in healthcare settings have highlighted the importance of

transformational leadership in properly managing the healthcare staff and provide quality care to

patients. For example, research by Moon, Van Dam, & Kitsos (2019 and Bass (1999) have

highlighted that Transformational Leadership is one of the most effective leadership styles

utilized in the field of health services. Moreover, a study of subordinate nurses in Malaysia found

that there was a strong relationship between job satisfaction and transformational leadership they

experienced from their nurse leaders as compared to experiencing a transactional

leadership (Aberese-Ako, Agyepong, & Dijk 2018). Shaughnessy, Griffin et al. (2018) also

conducted a study showing a significant positive relationship between transformational

leadership practices by nurse leaders and work engagement among subordinate nurses. The

research did reveal that differences in nurse leader educational attainment had an important

variable in properly implementing key leadership practices such as a shared vision, support for

innovation, and taking risks. Nyamtema, Urassa, & Roosmalen (2011) also reported that

insufficient implementation of evidence-based interventions in healthcare resource limited

countries was closely linked to a lack of national resources alongside the lack of effective

leadership skills.

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PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

Transformational Leadership

Focusing specifically on a particular leadership style, previous research literature has

defined a Transformational leader as an individual who motivates followers to (1) move beyond

their self-interest, (2) commit themselves to organizational goals, and (3) perform beyond

expectations (Aberese-Ako, Agyepong, Dijk, 2018). Transformational leadership is based on

balanced exchanges, in which the focus is on producing efficiency by reinforcing negotiated

levels of performance (Aberese-Ako, Agyepong, Dijk, 2018). Other researchers have further

argued that the concept of transformational leadership is further defined as the degree to which

employees felt their supervisors idealized influence, inspired motivation, individualized

consideration, and were intellectual stimulating (Gong, Yaping, Jia-Chi Huang, and JiingLihFarh

2009). Transformational leaders additionally look to find the motives in followers to seek higher

needs and to fully engage the follower (Valentine, 2019)

Transactional Leadership

Valentine (2019) described that Bernard M. Bass in 1999 provided an overview of what

transactional leadership is through an example at Xerox’s Reprographic Business Group where

there was a shift in management style: “In the first step toward establishing management in

which managers take the initiative and show consideration for others, 44 specific, effective

management behaviors were identified. Two factors that characterize modern leadership were

found in many of these behaviors. One factor—initialing and organizing work—concentrates on

accomplishing the tasks at hand. The second factor—showing consideration for employees—

focuses on satisfying the self-interest of those who do good work. The leader gets things done by

making, fulfilling, promises of recognition, pay increases, and advancement for employees who

perform well. By contrast, employees who do not do good work are penalized. This transaction

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PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

or exchange—this promise and reward for good performance, or threat and discipline for

poor performance—characterizes effective leadership. These kinds of transactions took place in

most of the effective 44 leadership behaviors identified at Xerox's RBG. This kind of leadership,

which is based on transactions between manager and employees, is called "transactional

leadership” (p. 20).

As the name implies, transactional leadership is a style of leadership based on an

exchange or transaction that takes place between the leader and the follower in order for the

organization to reach its desired goals and objectives. Valentine (2019) explained that the first

scholar to highlight the differences between transactional leaders and transformational leaders

was James Burns. Valentine (2019) described that James Burns identified two basic types of

leadership (transactional and transformational), where transactional leaders are looking to

exchange one thing for another (jobs for votes or subsidies for campaign contributions) and

transforming (transformational) where leaders recognize and exploit an existing need or demand

of a potential follower.

Transactional leadership can be divided into three dimensions or components: contingent

reward, management by exception (active), and management by exception(passive) (Valentine,

2019). Out of these three components, contingent reward is the most effective because followers

receive incentives after they accomplish their task(s). Contingent reward is transactional when

these incentives are material (e.g., bonus), but can also be transformational when the incentive is

psychological in nature (e.g., praise) (Valentine, 2019).

Knowing that subordinates will make mistakes and not perform to expectation and

complete their goals and get their rewards is when management by exception (MBE) occurs.

Valentine (2019), suggested MBE, both active (MBEa) and passive (MBEp) as follows: MBEa

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PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

refers to both monitoring performance and taking corrective action as necessary, where the focus

of MBEa is on setting standards and monitoring deviations from these standards; MBEp is even

less active (hence “passive”), where leaders intervene only when problems become serious.

MBEa can be associated with what is known as “micromanagement,” where supervisors/leaders

consistently check on progress, especially the smallest of details, to make sure that performance

is going as agreed upon.

Laissez-Faire

There is one other term to be defined that is associated with transactional leadership, and

that is laissez-faire leadership. Valentine (2019) described laissez-faire

Leadership as having an absence of leadership or an avoidance of leadership and is the most

inactive as well as the most ineffective form of leadership according to almost all research on the

style. Lewin, Lippitt, and White, Skogstad et al. (2007 as cited by Valentine, 2019) stated that

laissez-faire leadership represents a leadership style where the leader has been nominated

and physically occupies the leadership position, but where the leader has for the most part

abdicated from the responsibilities and duties assigned to him or her. This is a “hands-free” form

of leadership, but where the leader would still be held accountable for his or her actions.

To understand perceived leadership styles in Kayes and Sikasso maternity units, a full

range leadership testing framework using the 45 statements in the Multifactor Leadership

Questionnaire (MLQ 5X) from Avolio & Bass (2004, p 9-23) was adopted for the current

research project. This leadership framework in Figure 1 below is widely used in leadership

research study as evidenced in Avolio & Bass (1995, p5) and subsequent studies by Valentine

(2019), and Aberese-Ako, Agyepong, & Dijk (2018).

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Figure 1: Avolio & Bass’s Leadership Framework

9 FACTORS

Source: Avolio & Bass (2004, p. 9-23)

It was the basis for the comparison of the perceived leadership styles rated by hospital

leaders self-raters (ex. obstetric doctors, residents) and rated by hospital staff subordinates (ex.

registered nurses, midwives, interns, and matrone) in Kayes and Sikasso. This leadership

framework by Avolio & Bass (2004) has 9 factors listed below:

Factors 1-2– IDEALIZED INFLUENCE (Attributes & behaviors) indicates whether leaders hold

subordinates’ trust, maintain their faith and respect, show dedication to them, appeal to their

hopes and dreams, and act as their role model.

Factor 3– INSPIRATIONAL MOTIVATION measures the degree to which leaders provide a

vision, use appropriate symbols and images to help others focus on their work, and try to

make others feel their work is significant.

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Factor 4 – INTELLECTUAL STIMULATION shows the degree to which leaders encourage

others to be creative in looking at old problems in new ways, create an environment that is

tolerant of seemingly extreme positions, and nurture people to question their own values

and beliefs of those of the organization.

Factor 5 – INDIVIDUALIZED CONSIDERATION indicates the degree to which leaders show

interest in others’ well‐being, assign projects individually, and pay attention to those who

seem less involved in the group.

Factor 6 – CONTINGENT REWARD shows the degree to which leaders tell others what to do in

order to be rewarded, emphasize what you expect from them, and recognize their

accomplishments.

Factors 7-8 – MANAGEMENT‐BY‐EXCEPTION (Active (MBEA) & Passive (MBEP))

assesses whether leaders tell others the job requirements, are content with standard performance,

and are a believer in “if it aint broke, don’t fix it.”

Factor 9 – LAISSEZ‐FAIRE measures whether leaders require little of others, are content to let

things ride, and let others do their own thing.

Methodology

Participants

There was a total of 76 participants between the Fousseyni Daou Hospital Maternity

unit in Sikasso and Kayes Regional Hospital Maternity unit who participated in the research

project. There were 41 participants from Sikasso Regional Hospital and 35 from Fousseyni Daou

Regional Hospital in Kayes. The leadership hierarchy shown on Figure 2 below was used to help

define hospital leaders (ex. medical chief, obstetric doctors, residents) versus hospital

subordinate staff (ex. registered nurses, midwives, interns, and matrone).

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Figure 2: Hospital Leadership Hierarchy

Fousseini Daou Regional Hospital

Sikasso Regional Hospital Medical Chief
Medical Chief

Obstetric Obstetric
doctors doctors

Residents Residents

Midwives Midwives

Registered Registered
Nurses Nurses

Interns Interns

Martrone

In Kayes, the number of hospital leaders and subordinates were 6 and 29, respectively. In

Sikasso the distribution of participants is 8 Leaders and 23 subordinates. Based on the definitions

of hospital leaders versus hospital subordinate staff, there was a comparison perceived leadership

styles rated by hospital leaders self-raters (medical chief, obstetric doctors, residents) and as

rated by hospital subordinates (registered nurses, midwives, nurses, interns, and matrone) in

Kayes and Sikasso.

Instrument

There is one key measure used for this research study which is the Multifactor Leadership

Questionnaire. This standardized instrument collects and measures information on

transformational, transactional, and laissez-faire (Hemsworth, Muterera, &Baregheh, 2013).

Statisticssolutions.com (nd) described the Multifactor Leadership Questionnaire (MLQ) as one

of the most widely established instruments in measuring transformational leadership. This

instrument has previously shown to being reliable in evaluating leadership ability and behaviors,

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follower reactions and situational attributes. There are 45 questions in total on a 5-point Likert

Scale. According to Statisticssolutions.com (nd), Bass’s MLQ Manual shows strong evidence of

validity. It is a reliable tool that measures leadership ability and behavior in organizations and

organizational studies; analyzes leadership approaches and the ways in which the test resonates

with and conflicts with particular approaches (Statisticssolutions.com, n.d.). The survey for the

current research project examined the responses on the transformational leadership subscales of

the Multifactor Leadership Questionnaire (MLQ-5X) between the hospital leaders (ex. Fousseini

Regional Hospital Medical Chief and Sikasso Regional Hospital Medical Chief) versus hospital

subordinate staff (ex. Obstetric Doctors, Residents, Anesthesiologists, Registered Nurses etc.).

Please see Table 1 below which highlights 5 facets of Multifactor Leadership Questionnaire

(MLQ-5X) Rater Form.

To provide more historical context on the instrument, Avolio& Bass in 1985

conceptualized their first leadership model that had 7 factors and charisma, inspirational,

intellectual stimulation, individualized consideration, contingent reward, management by

exception, and laissez-faire leadership (as cited in Avolio, Bass, & Jung, 1999). Considering

shortcomings in previous research on leadership styles and a new interest in testing the new

paradigm of transformational and transactional leadership, Avolio and Bass (1998) further

developed the full range of leadership traits. The full range model of leadership traits was

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developed to broaden the range of leadership styles (transformational, transactional, and laissez-

faire) typically investigated in the field (Avolio & Bass, 1991).

As stated earlier, this research project used the Multifactor Leadership Questionnaire

adopted from Avolio & Bass (1995, p.88-123). This instrument measures nine scales: five to

capture transformational leadership, three to measure transactional leadership, and one to reflect

a laissez-faire leadership style (Avolio & Bass 2004).

The Multifactor Leadership Questionnaire (MLQ5X) is a scientific evidence-based

leading survey instrument that assesses leadership (Batista-Foguet,Esteve & van Witteloostuijn,

2021). This instrument was created to test Bass and Avolio’s conceptual framework of leadership

(Batista-Foguet,Esteve & van Witteloostuijn, 2021). This instrument has been used in several

studies to correlate organizational behavior (Avolio & Bass, 1995). A quantitative study that

captures several leadership styles in a single measurement and incorporates a range of nine

scales: five to capture transformational, three to measure transactional, and one to reflect laissez-

faire leadership styles, as well as three to include leadership outcomes (Avolio & Bass 2004,

Batista-Foguet, Esteve & van Witteloostuijn, 2021, and Valentine 2019). Lowe, Kroeck, &

Sivasubramaniam (1996), Judge, & Piccolo (2004), & Valentine (2019) confirmed its

effectiveness and validity. It is a reliable tool that measures leadership capacity and behavior in

organizations and organizational studies (Statisticssolutions.com, nd). It is important to note that

MLQ is not designed to encourage labeling a leader as transformational or transactional. Rather,

it is more appropriate to identify a leader or group of leaders as (for example) “more

transformational than the norm” or “less transactional than the norm” (Avolio & Bass, 1995,

p.124).

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Recruitment Strategy

Letters were sent to the chief medical doctors in Kayes and Sikasso for their approval.

They sent their approval letters (Appendix C) to meet Touro University Worldwide Institutional

Review Board’s requirements. Along the way, another exceptional individual Yaya Togo, who is

a health economist and researcher, provided support in the areas of doing research in Mali and

how to use Kobotoolbox for data collection. The health economist and researcher volunteered his

time in doing face to face meeting with the researcher in understanding MLQ 5X. The health

economist and researcher signed an agreement with Mindgarden.com before translating the

questionnaire and he did not change the context (Appendix H). A translated copy was sent to

Mindgarden.com for approval. Mr. Togo found another person to translate the research proposal

and consent form. Mr. Togo also helped recruit two data collectors in Kayes, who happened to

be medical doctors.

After Touro University Worldwide IRB approval, a French version of the research

proposal had to be submitted to the Faculty of Medicine in Bamako. To be able to do any

research in Mali, an external researcher has to go through an approval process to perform his or

her research study. The review board in Mali and the Professor helping sponsor the research

project acknowledged that leadership study is needed in maternity units. The ethics committee

made recommendations that needed to be addressed before a second submission. The paper had

to be bound (relure in French) as a book for submission. Three weeks later the research proposal

was approved. Then a reconnect to the chief medical doctors for research project logistics in each

region was made. Both chiefs are the primary leaders of the maternity units. They coordinated all

research activities in their maternity units and took the survey as well. The data collection for

this research project with the sample of participants was via face-to-face data collection in a

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large conference room. Data collectors helped collect data by using tablets and the investigator

used her phone and laptop for gathering responses.

Ethical Considerations

Bryman & Bell (2011) identified areas of ethical concerns that may arise in conducting

research on an organization. In order to abide by ethical regulations of research, recruitment

letters were given to each participant (Appendix A) and consent was obtained from all

participants (Appendix B), no matter their level of engagements and job titles. The Touro

University Worldwide Ethical Principles & Guidelines for Research Involving Human Subjects

was strictly adhered (Appendix C) and explained below.

Risks

There are no risks associated with this study because it is not a medical research where

participants may be exposed to adverse effects of drugs. Participants are not from a protected

class (e.g., Pregnant women or minors) for the purposes of this project. Survey questions may

cause participant minor discomfort.

The Expedited Review involves human subjects completing the 45 question Multifactor

Leadership Questionnaire (MLQ-5X) and demographic questions, onsite in a room dedicated for

the participants to complete the survey. Participants are answering survey questions that might

cause discomfort.

If a participant was uncomfortable or chooses to withdraw from the study, the participant

notified the researcher face to face that they choose to withdraw. Any withdrawn participant

information was immediately destroyed, and participation terminated.

Procedure

During the information session for both leaders and subordinates, they had time to ask

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questions as well as in private session if they chose to do so. When participants were willing to

voluntarily participate in the survey, participants (1) received a recruitment letter, (2) signed a

consent form and then (3) proceeded to take the offline survey on tablets.

Data confidentiality

All the responses were kept strictly confidential and were only seen by authorized

members of designated staff at Touro University Worldwide, and Professor Teguete, field

supervisor at the Teaching Hospital Grabriel Touré. Researcher will store data in a safe

storage for a minimum of 3 years. All data files will be stored securely in a locked file

cabinets in Professor Teguete office at the Teaching Hospital Gabriel Touré. Researcher

will produce various types of reports or papers for publication, as well as a de-identified

data file for use by other researchers or the general public. If the research plan calls for

destruction of documents or electronic files after 3 years after the project has been

completed, all paper files or CDs with PII will be shredded and any electronic files on

memory drives, PCs, laptops and file servers will be permanently deleted.

Research Hypotheses

Based on the participant roles, hospital locations and the leadership ratings (via

Multifactor Leadership Questionnaire, MLQ5X) collected for the current research project, the

following research hypotheses were examined in the subsequent statistical analyses.

Null Hypothesis 1 (HO1): There is no difference in the ratings of medical professional

leadership styles between the two hospitals located in Sikasso and Kayes in the country of Mali.

Alternative Hypothesis 1 (Ha1): There is a difference in the ratings of medical professional

leadership styles between the two hospitals located in Sikasso and Kayes in the country of Mali.

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Null Hypothesis 2 (HO2): There is no difference in the ratings of medical professional

leadership styles between the medical leaders and subordinate medical staff.

Alternative Hypothesis 2 (Ha2): There is a difference in the ratings of medical professional

leadership styles between the medical leaders and subordinate medical staff.

Null Hypothesis 3 (HO3): There is no interaction in the ratings of medical professional

leadership styles between the variables of hospital location (Sikasso versus Kayes) and hospital

role (medical leader versus subordinate medical staff.

Alternative Hypothesis 3 (Ha3): There is an interaction in the ratings of medical professional

leadership styles between the variables of hospital location (Sikasso versus Kayes) and hospital

role (medical leader versus subordinate medical staff).

Table 2 below summarizes the various variables (i.e., the participant roles, hospital

locations and the leadership ratings (via Multifactor Leadership Questionnaire, MLQ5X)

collected for the current research project that was analyzed and presented in the results section.

Table 2: Hospital Role (Medical Leaders versus Subordinate Medical Staff) and

Hospital Location (Kayes versus Sikasso) in relation to Leadership traits (via the

Multifactor Leadership Questionnaire, MLQ5X)

Hospital Medical Leaders Hospital Subordinate Medical

Staff

Kayes • Transformational • Transformational

Leadership total Score
• Transactional
Leadership total score
• Passive Avoidant total
Score
• Idealized Influence
Idealized Behaviors
• Inspirational
Motivation-IM,
Leadership total Score
• Transactional
Leadership total score
• Passive Avoidant total
Score
• Idealized Influence
Idealized Behaviors
• Inspirational
Motivation-IM,

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PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

• Intellectual • Intellectual
Stimulation-IS, Stimulation-IS,
• Individual • Individual
Consideration-IS, Consideration-IS,
• Contingent Reward- • Contingent Reward-
IC, IC,
• Management by • Management by
Exception Active- Exception Active-
MBEA, MBEA,
• Management by • Management by
Exception Passive- Exception Passive-
MBEP, MBEP,
• Laissez-Faire-LF Laissez-Faire-LF

Sikasso • Transformational • Transformational

Leadership total Score Leadership total Score
• Transactional • Transactional
Leadership total score Leadership total score
• Passive Avoidant total • Passive Avoidant total
Score Score
• Idealized Influence • Idealized Influence
Idealized Behaviors Idealized Behaviors
• Inspirational • Inspirational
Motivation-IM, Motivation-IM,
• Intellectual • Intellectual
Stimulation-IS, Stimulation-IS,
• Individual • Individual
Consideration-IS, Consideration-IS,
• Contingent Reward- • Contingent Reward-
IC, IC,
• Management by • Management by
Exception Active- Exception Active-
MBEA, MBEA,
• Management by • Management by
Exception Passive- Exception Passive-
MBEP, MBEP,
• Laissez-Faire-LF • Laissez-Faire-LF

Results

For this research project, a five-point Likert Scale was used for the MLQ 5X

questionnaire to examine the relationship between the two regional hospitals’ maternities in their

21
PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

leadership styles. The rating scales for leadership items were Not at all = 0, Once in a while =

1, Sometimes = 2, Fairly often = 3, and Frequently, if not always = 4. As stated earlier, the total

number of respondents were 76 as detailed in Table 3.

Table 3: Between subjects factors

What hospital do you work in? N
Fousseyni Daou Hospital of Kayes
Type of Respondent Leader 6
Subordinate 29

What hospital do you work in? Fousseyni Daou Hospital of Kayes 35

What is your occupation (title)? Anesthetist 2
Area bloc 5
Licensed Nurse Practitioner 1
Matronne 1
Medical Doctor Specialist 3
Midwife 10
Registered Nurse 6
Resident 6
Stagiaire 1
Regional Hospital Sikasso
Type of Respondent Leader 8
Subordinate 33

What hospital do you work in? Regional Hospital Sikasso 41

What is your occupation (title)? Anesthetist 5
Area bloc 3
Medical Doctor Specialist 5
Midwife 20
Registered Nurse 5
Resident 3

In the Sikasso regional Hospital location, participants comprised of 15 males and 26

females. In the Kayes regional hospital location, participants comprised of 16 males and 19

females. MLQ Scoring Key was used to group items by scale and calculated the averages by

22
PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

scale from Avolio and Bass (1995). KoboCollect, a free statistical instrument from Harvard

University, easily dissected the 9 factors by items and region.

The Findings

Results of 2-way Multivariate Analysis of Variance (MANOVA) in Table 4 showed that

there was no significant multivariate main effect for Hospital Location, Wilks Lambda=0.734,

F(12,61)=1.556, p=0.129. Therefore, Null Hypothesis 1 was accepted, and Alternative

Hypothesis 1 is rejected.

Moreover, there was a significant multivariate main effect for Type of Respondent, Wilks

Lambda=0.676, F(12,61)= 2.436, p=0.012. Thus, Alternative Hypothesis 2 was accepted, and

Null Hypothesis 2 is rejected. Finally, there was also no significant multivariate interaction for

the interaction of Hospital Location and Type of Respondent, Wilks Lambda=0.776, F(12,61)=,

p=0.161. Therefore, Null Hypothesis 3 was accepted, and Alternative Hypothesis 3 is rejected.

Table 4: Multivariate Test for both hospitals and type of respondents

Effect Value F Hypothesis Error Sig. Partial Noncent. Observed

df df Eta Parameter Powerc
Squared

Intercept Pillai's 0.948 93.167b 12.000 61.000 0.000 0.948 1117.999 1.000
Trace
Wilks' 0.052 93.167b 12.000 61.000 0.000 0.948 1117.999 1.000
Lambda
Hotelling's 18.328 93.167b 12.000 61.000 0.000 0.948 1117.999 1.000
Trace
Roy's 18.328 93.167b 12.000 61.000 0.000 0.948 1117.999 1.000
Largest
Root
Hospital Pillai's 0.234 1.556b 12.000 61.000 0.129 0.234 18.667 0.754
Trace
Wilks' 0.766 1.556b 12.000 61.000 0.129 0.234 18.667 0.754
Lambda
Hotelling's 0.306 1.556b 12.000 61.000 0.129 0.234 18.667 0.754
Trace
Roy's 0.306 1.556b 12.000 61.000 0.129 0.234 18.667 0.754
Largest
Root

23
PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

TypeofRespondent Pillai's 0.324 2.436b 12.000 61.000 0.012 0.324 29.229 0.940
Trace
Wilks' 0.676 2.436b 12.000 61.000 0.012 0.324 29.229 0.940
Lambda
Hotelling's 0.479 2.436b 12.000 61.000 0.012 0.324 29.229 0.940
Trace
Roy's 0.479 2.436b 12.000 61.000 0.012 0.324 29.229 0.940
Largest
Root
Hospital * TypeofRespondent Pillai's 0.224 1.470b 12.000 61.000 0.161 0.224 17.638 0.724
Trace
Wilks' 0.776 1.470b 12.000 61.000 0.161 0.224 17.638 0.724
Lambda
Hotelling's 0.289 1.470b 12.000 61.000 0.161 0.224 17.638 0.724
Trace
Roy's 0.289 1.470b 12.000 61.000 0.161 0.224 17.638 0.724
Largest
Root
a. Design: Intercept + Hospital +
TypeofRespondent + Hospital *
TypeofRespondent
b. Exact statistic

c. Computed using alpha = .05

The multivariate tests in Table 5 show that there are statistically significant differences

between the higher medical leaders (M=3.66) ratings compared to subordinate medical staff

(M=2.94) ratings on the dependent variable of the Individualized Consideration subscale of the

MLQ, F(1,72)=6.36, p=0.014. Moreover, there are statistically significant differences between

the higher medical leaders (M=3.64) ratings as compared to subordinate medical staff (M=3.04)

ratings on the dependent variable of the Contingent Reward subscale of the MLQ, F(1,72)=5.62,

p=0.02. Next, there are statistically significant differences between the lower medical leaders

(M=0.73) ratings and subordinate medical staff (M=1.19) ratings on the dependent variable of

the Management by Exception Passive subscale of the MLQ, F(1,72)= 6.294, p=0.014. Also,

there are statistically significant differences between the lower medical leaders (M=0.46) ratings

and subordinate medical staff (M=1.00) ratings on the dependent variable of the Laissez-Faire

subscale of the MLQ, F(1,72)= 4.198, p=0.044.

24
PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

There are statistically significant differences between the higher medical leaders

(M=16.8) ratings and subordinate medical staff (M=14.65) ratings on the dependent variable of

the Transformational leadership scale on the MLQ, F(1,72)= 4.123, p=0.046. There were also

statistically significant differences between the lower medical leaders (M=1.2) ratings and

subordinate medical staff (M=2.19) ratings on the dependent variable of the Laissez-Faire

leadership scale on the MLQ, F(1,72)= 6.936, p=0.01

Table 5: Tests of Between-Subjects Effects

Source Dependent Variable Type III Sum of df Mean Square F Sig.
Squares
Corrected Model Idealized Attributes 2.924a 3 0.975 1.276 0.289
Inspirational Motivation 3.344b 3 1.115 1.78 0.159
Intellectual Stimulation 4.897c 3 1.632 2.619 0.057
Individualized Consideration 10.885d 3 3.628 4.226 0.008
Contingent Reward 4.097e 3 1.366 1.89 0.139
Management by Exception Active .934f 3 0.311 0.422 0.738
Management by Exception 6.023g 3 2.008 5.303 0.002
Passive
Laissez Faire 7.958h 3 2.653 3.996 0.011
Extra Effort 4.143i 3 1.381 1.687 0.177
Effectiveness 2.479j 3 0.826 1.459 0.233
Satisfaction 2.884k 3 0.961 1.561 0.206
Transformational 107.898l 3 35.966 2.977 0.037
Transactional 6.847m 3 2.282 0.93 0.431
Laissez-Faire 26.822n 3 8.941 6.006 0.001
Intercept Idealized Attributes 389.626 1 389.626 510.001 0
Inspirational Motivation 458.171 1 458.171 731.882 0
Intellectual Stimulation 493.642 1 493.642 791.959 0
Individualized Consideration 489.49 1 489.49 570.141 0
Contingent Reward 502.256 1 502.256 695.114 0
Management by Exception Active 415.773 1 415.773 563.537 0
Management by Exception 39.997 1 39.997 105.642 0
Passive
Laissez Faire 24.154 1 24.154 36.382 0
Extra Effort 493.223 1 493.223 602.582 0
Effectiveness 489.425 1 489.425 864.296 0
Satisfaction 501.888 1 501.888 814.742 0
Transformational 11147.703 1 11147.703 922.806 0
Transactional 1831.976 1 1831.976 746.383 0
Laissez-Faire 126.315 1 126.315 84.859 0

25
PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

Type of Respondent Idealized Attributes 0.25 1 0.25 0.327 0.569

Inspirational Motivation 0.86 1 0.86 1.374 0.245
Intellectual Stimulation 1.976 1 1.976 3.17 0.079
Individualized Consideration 5.46 1 5.46 6.36 0.014*
Contingent Reward 4.061 1 4.061 5.62 0.02*
Management by Exception Active 0.138 1 0.138 0.187 0.666
Management by Exception 2.383 1 2.383 6.294 0.014*
Passive
Laissez-Faire 2.787 1 2.787 4.198 0.044*
Extra Effort 1.016 1 1.016 1.241 0.269
Effectiveness 0.239 1 0.239 0.422 0.518
Satisfaction 0.7 1 0.7 1.137 0.29
Transformational 49.802 1 49.802 4.123 0.046*
Transactional 5.697 1 5.697 2.321 0.132
Laissez-Faire 10.325 1 10.325 6.936 0.01*
Hospital Idealized Attributes 1.322 1 1.322 1.73 0.193
Inspirational Motivation 0.313 1 0.313 0.5 0.482
Intellectual Stimulation 0.817 1 0.817 1.311 0.256
Individualized Consideration 0.502 1 0.502 0.585 0.447
Contingent Reward 0.004 1 0.004 0.006 0.938
Management by Exception Active 0.158 1 0.158 0.214 0.645
Management by Exception 1.494 1 1.494 3.947 0.051
Passive
Laissez Faire 0.18 1 0.18 0.271 0.604
Extra Effort 0.215 1 0.215 0.263 0.61
Effectiveness 0.029 1 0.029 0.052 0.821
Satisfaction 0.064 1 0.064 0.104 0.748
Transformational 11.294 1 11.294 0.935 0.337
Transactional 0.11 1 0.11 0.045 0.833
Laissez-Faire 2.711 1 2.711 1.821 0.181
Type of Respondent * Idealized Attributes 0.03 1 0.03 0.039 0.844
Hospital
Inspirational Motivation 1.945 1 1.945 3.106 0.082
Intellectual Stimulation 0.27 1 0.27 0.434 0.512
Individualized Consideration 1.351 1 1.351 1.574 0.214
Contingent Reward 0.005 1 0.005 0.008 0.931
Management by Exception Active 0.679 1 0.679 0.921 0.341
Management by Exception 0.123 1 0.123 0.324 0.571
Passive
Laissez Faire 1.867 1 1.867 2.812 0.098
Extra Effort 0.952 1 0.952 1.163 0.284
Effectiveness 1.017 1 1.017 1.796 0.184
Satisfaction 1.47 1 1.47 2.386 0.127
Transformational 8.655 1 8.655 0.716 0.4
Transactional 0.563 1 0.563 0.229 0.633
Laissez-Faire 2.946 1 2.946 1.979 0.164

26
PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

Error Idealized Attributes 55.006 72 0.764

Inspirational Motivation 45.073 72 0.626
Intellectual Stimulation 44.879 72 0.623
Individualized Consideration 61.815 72 0.859
Contingent Reward 52.024 72 0.723
Management by Exception Active 53.121 72 0.738
Management by Exception 27.26 72 0.379
Passive
Laissez Faire 47.801 72 0.664
Extra Effort 58.933 72 0.819
Effectiveness 40.771 72 0.566
Satisfaction 44.353 72 0.616
Transformational 869.776 72 12.08
Transactional 176.722 72 2.454
Laissez-Faire 107.175 72 1.489
Total Idealized Attributes 690.438 76
Inspirational Motivation 782.813 76
Intellectual Stimulation 814 76
Individualized Consideration 788.563 76
Contingent Reward 812.438 76
Management by Exception Active 742.563 76
Management by Exception 126.125 76
Passive
Laissez Faire 117.5 76
Extra Effort 846.444 76
Effectiveness 846 76
Satisfaction 856.5 76
Transformational 18175.313 76
Transactional 3071.625 76
Laissez-Faire 440 76
Corrected Total Idealized Attributes 57.93 75
Inspirational Motivation 48.417 75
Intellectual Stimulation 49.776 75
Individualized Consideration 72.7 75
Contingent Reward 56.121 75
Management by Exception Active 54.055 75
Management by Exception 33.283 75
Passive
Laissez Faire 55.76 75
Extra Effort 63.076 75
Effectiveness 43.25 75
Satisfaction 47.237 75
Transformational 977.674 75
Transactional 183.569 75
Laissez-Faire 133.997 75

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PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

a R Squared = .050 (Adjusted R Squared = .011)

b R Squared = .069 (Adjusted R Squared = .030)
c R Squared = .098 (Adjusted R Squared = .061)
d R Squared = .150 (Adjusted R Squared = .114)
e R Squared = .073 (Adjusted R Squared = .034)
f R Squared = .017 (Adjusted R Squared = -.024)
g R Squared = .181 (Adjusted R Squared = .147)
h R Squared = .143 (Adjusted R Squared = .107)
i R Squared = .066 (Adjusted R Squared = .027)
j R Squared = .057 (Adjusted R Squared = .018)
k R Squared = .061 (Adjusted R Squared = .022)
l R Squared = .110 (Adjusted R Squared = .073)
m R Squared = .037 (Adjusted R Squared = -.003)
n R Squared = .200 (Adjusted R Squared = .167)
*p<0.05 significance

Avolio & Bass (2004, p. 12) described that transformational leadership had the strongest

and most positive impact whether outcomes were measured subjectively or objectively. The

same pattern of leadership is also supported by Aberese-Ako, Agyepong, & Dijk 2018,

Shaughnessy, Griffin et al. (2018), and Valentine (2019).

Implications of Findings for the Profession

Results showed that there are no differences on ratings of leadership between the 2

locations. However, there are differences in ratings between medical leaders and subordinates

from both locations where medical leaders self-reported higher ratings on Individualized

Consideration, Contingent Reward, Transformational leadership scale as compared to

subordinate medical personnel. Also, medical leaders have self-reported lower ratings on

Management by Exception Passive, Laissez-Faire subscale, Laissez-Faire leadership scale from

both locations. These findings could spur new research and gain further insight on the medical

leadership practices in maternity units in Mali.

Previous research on leadership styles found evidence that leadership training and

resources can greatly improve the staff performance in medical settings, thus this research study

28
PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

examining leadership perception in maternity settings in Mali is a first step towards that long

term goal. Avolio & Bass (2004, p. 13) even recommended two tools to facilitate individual

leadership process. One is a notebook that helps expand transformational leadership qualities

among leaders. Leaders can develop a Leadership Development Plan (LDP) based on the results

of the MLQ reports. It contains developmental behaviors for each MLQ scale and item. The

other tool is the MLQ Training Full Range Leadership Binder. This binder aids the trainer in

developing workshop for teaching the Full Range Leadership model and how to use the MLQ to

create positive behavioral change for the organizational leader.

Limitations

Cleave (2017) and Dickinson (2014) described that close-ended questions have

limitations. They start with words, such as: Can, Did, Will, and Have. As such, Cleave (2017)

and Dickinson (2014) argue that the selection of words in the questions do not give respondents

the choice to truly voice their opinions. Closed questions collect quantitative data, and they give

the respondent a limited number of options to choose from. Closed questions are popular, as

quantitative data is easier to analyze than qualitative data.

Some of the identified limitations in the maternity units were availability of shift

employees on the same day of survey. Those who worked in overnight shift had difficulty filling

out forms and needing extra help by reading to them and explaining each statement in the

questionnaire. These respondents took longer to respond than those who work in the morning

shift.

The level of education and reading comprehension posed some problems. Those with

higher education, such as doctors, residents, midwives, and registered nurses completed the form

in less than 20 minutes. One doctor completed his form in less than 10 minutes. Those with

29
PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

reading comprehension were helped in explaining the statement in Bambara and French. Nurse

aides might have only a primary school level of education and needing more time to complete

questionnaire. It seems that it does not take these participants 30 minutes to answer the MLQ 5X

questionnaire.

There were difficulties also in understanding some of the statements. For leaders :

Statement 1 : « j’apport mon aide aux autres en échange de leurs efforts ». The word « échange »

or exchange confused 75 percent of the respondents because it does not conceptualize in the

Malian culture. Statement 14: “… sense aigu du but …” 60 percent were challenged with word

“aigu”. Investigator wrote down difficulties encountered and explained before participants took

the survey. Overall, data collectors documented all these challenges while participants were

taking the survey. Other statements that were outlined by leaders were items 3, 5, 7, 8, 12, 19,

23, 26, and 40. Statements that need attention in the subordinates’ section are adding a block area

workers can check. Furthermore, this important note listed below at the beginning of the

subordinates’ questionnaire was not understood by respondents. Subordinates’ respondents did

not know which statement to choose.

IMPORTANT (nécessaire pour le traitement) : lequel vous décrit le mieux ?

___ Je suis à un niveau organisationnel plus élevé que la personne que j’évalue.

___ La personne que j’évalue est à mon niveau organisationnel.

___ Je suis à un niveau organisationnel inférieur à celui de la personne que j’évalue.

___ Je ne souhaite pas que mon niveau organisationnel soit connu.

The box above is not relevant because respondents work at the same facility. The person

being evaluated is the chief medical doctor in each maternity.

30
PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

Conclusions

This research project was quite exploratory. The objective of the study was achieved. The

null hypothesis (HO2) was rejected, and the alternative hypotheses (Ha2) was supported which

reflected differences in the perceptions of leadership styles by medical leaders and the medical

subordinate/support staff. When comparing the to the norms for using the MLQ 5X

questionnaire, it could be concluded that Transformational leadership is utilized more than

Transactional leadership or Laissez-Faire leadership in both maternities wards. The corrected

total of leadership characteristics is: Transformational Leadership = 977.67, Transactional

Leadership = 183.57, and Laissez-Faire =134.

This research project helped identify leadership style perception between medical

maternity leaders and their subordinate medical maternity staff members in 2 hospitals in the

country of Mali. Though the MLQ (5X)’s 360 degrees capabilities can assess perceptions of

leadership effectiveness of team leaders, supervisors, manager, and executives from many

different levels of an organization as Avolio & Bass (2004), data collected from this research

project indicates no statistical significance in extra effort, effectiveness, and satisfaction.

This exploratory research project intended to tackle perceived leadership among medical

leaders and subordinate medical staff stakeholders in Kayes and Sikasso, where little or no study

previously been performed on the topic of leadership. Both leaders practiced mixed forms of

transformational and transactional leadership skills in both hospitals.

Recommendations

Overall, the study in Sikasso and Kayes went smoothly with the assistance the Chiefs of

the Maternities in collaboration with staff members, and assistance from data collectors.

Everyone was receptive of the study because not one like this has ever been done in Mali,

31
PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

especially in maternity units. Both directors from the hospitals want a follow-up study done that

may include the entire hospital.

If we intend to continue research at the national level in Mali, some of the statements in

the MLQ 5X Questionnaire need to be revised and adjusted to the level of understanding and

comprehension of most healthcare workers in Mali. While we are on the questionnaire, it is quite

important to have trained data collectors who understand the hospital system and KoboCollect

and be able to explain statements to respondents.

There is not much to recommend on self-reported leadership styles among leaders only to

report some of the concerns voiced in the subordinates’ ratings of their leaders in Sikasso.

One important thing that was noticed in Kayes is that titles change from department to

department even when they work as nurses. For example, nurse obstetrician (infirmiere

obstetrique-IO) is not the same or does not do the same job as regular nurse. Some of the

classifications were clarified in Kayes than in Sikasso. These classifications of titles need to be

included in the questionnaire of the maternity units and in the organization structure.

A follow-up qualitative research may answer some of the human experiences that were

not fully captured or covered this quantitative research project. Also, a follow-up leadership

training program recommended by Avolio & Bass (2004, p. 13) and a second study on some of

the identified limitations may help some medical leaders in improving leadership and

performances in their maternity units.

In closing, this research project could be the baseline for future studies. These

recommendations from the current research could also help maternity medical chiefs improve

their leadership styles that might lead towards further improvements in organizational outcomes.

32
PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

For example, medical leaders could continually encourage their subordinate medical staff

members to provide quality care and service towards their patients.

33
PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI

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