Empowerment and Leader-Member Exchange Quality in Physicians

Leadership development contributes to the culture of safety through engagement and empowerment of frontline healthcare workers.(1,2) Empowerment behavior in physicians directly correlates to higher degrees of safety and quality in healthcare organizations.(3) Empowerment behavior also has been directly correlated to the quality of the relationship between the leader and the team member across several industries.(4,5) However, the effect has only been studied in direct reporting relationships and has not been studied through the lens of the relationship between a physician and other clinical team members in a team-based care environment.

Many physicians work in an interprofessional environment where other members of the healthcare delivery team do not report directly to the physician. For the purposes of this discussion, the referent leader-follower dyad, where the follower is not a direct report of the leader, will be the focus due to the commonality of this type of relationship in the interprofessional healthcare team. In that paradigm, the physician who heads the clinical team is referred to as the leader, and others on the team are referred to as team members.

Widanti defines empowerment as “the organizational process employees of the organization at every hierarchy are given to make decisions in terms of their work assignments and responsibilities.”(6) The degree to which empowerment occurs can be difficult to measure because of intention versus perception. For example, a leader may intend to give autonomous control to a team member, but the team member may not feel autonomous in their decision-making. Empowerment behaviors are the external manifestations of empowerment that can be seen and measured through the Empowering Leadership Scale.(7) Behaviors may be displayed as shared decision-making, psychological empowerment, or mutually beneficial relationships.(8)

Shared decision-making is fostered by a leader who includes team members in the process as a mechanism to encourage autonomous function. Psychological empowerment is the result of team members gaining authority through power sharing with the leader and motivational and development support from the leader.(9) Mutually beneficial relationships develop when the leader and team member both gain power and authority because of the dyadic relationship. Measuring autonomy and development support is made possible through surveying the team member on multiple factors that relate to decision-making authority and the leader’s actions to help develop the team member in their role.(10)

Leader-member exchange (LMX) quality refers to the interpersonal relationship between leader and team member.(5) High-quality LMX relationships have been associated with improved safety and quality in healthcare.(11) Trust appears to be a mediating variable in the association, which results in increased intention to report patient safety events, increased employee engagement, and higher levels of proactive involvement in the organization.(4) LMX quality can be measured by asking team members about the respect, loyalty, affect, and contribution their leader shows toward their development.(5) Higher levels in each of the four dimensions indicates a stronger trust relationship between each team member and the leader.

An association between empowering behavior in leaders and LMX quality has been identified in direct reporting relationships across several industries, including healthcare.(4) The association has not previously been studied in interprofessional healthcare teams with a physician leader who has a referent leadership role on the team.

In this study, we evaluate empowerment behavior in physicians and the role that LMX quality may play in the physician’s ability to engender empowerment in members of their interprofessional clinical teams. Determining the role LMX quality plays in empowerment behavior may help in the development of physicians as leaders of interprofessional teams and may help increase quality and safety in healthcare delivery.

Methodology

We performed a quantitative non-experimental correlation study to determine the relationship between empowerment behavior in physicians and LMX quality between physicians and their clinical team members. The recruiting and informed consent processes were approved by an academic institutional review board. Data were collected from 113 participants at 15 academic medical centers in the United States. Participants included physicians who led interprofessional teams and their team members. Empowerment behavior was measured through the Empowering Leadership Scale (ELS).(10) LMX quality was measured using the Multidimensional Leader-Member Exchange Survey (LMX-MDM).(12)

Recruitment involved nonprobability convenience sampling of physicians using two national networks of health system leadership. Physicians were asked to complete a demographics survey and the Myers-Briggs Type Indicator assessment and then identify up to 10 team members to receive an electronic survey about their work with the physician. A random sample of five team members from each physician received an invitation to participate.

Team members who provided informed consent completed online versions of the ELS and LMX-MDM assessments. ELS consisted of 18 questions in two domains: autonomy support and development support.(10) LMX-MDM consisted of 12 questions in four domains: respect, loyalty, affect, and contribution.(12) Both surveys used a 7-point Likert scale with a single averaged score for each survey. This methodology allowed participants to skip questions they were not comfortable answering.

Individual team member responses to the surveys were collated into a group average such that each physician had an average ELS score and an average LMX-MDM score. Group averages to assess leadership performance in team-based environments have been validated by Nowack and Mashihi as a mechanism to substantiate between and within group interrater reliability.(13) Demographic data on the team members provided a foundation for analyzing differences in longevity of the relationship team members had with the leader and to control for age, gender, and length of time in healthcare in the analysis.

We performed partial correlation analysis using Pearson’s correlation coefficient (r) for assessment of the relationship between ELS and LMX-MDM, two continuous variables. Empowerment behavior was the dependent variable, and LMX quality was the independent variable. Gender, age, tenure in leadership, length of time at the current employer, specialty of clinical practice, the physician’s Myers-Briggs Type Indicator result, and whether the physicians have had leadership training were captured and controlled in the analysis.

Results

Leaders’ demographics are presented in Table 1. Physicians in the leadership positions ranged in age from 35 to 68 years with a mode of 35 to 44 years of age. Sixty-five percent of the physician respondents were male, and half of the physicians received their medical training in one of the primary care fields of study. More than half of the respondents were in leadership positions for more than 10 years and had some form of leadership training. Despite longevity in leadership positions, 55% of the physician leaders had been with their present organization fewer than 10 years, and 75% had been in their current role fewer than five years.

Each leader had up to five team members complete the follower survey. Demographics of the team members completing the surveys were recorded with respect to their relationship with their leader (see Table 2). Twenty-four percent of the team members were the same age decile as their leader, and 59% were the same gender as the leader. Team members’ average length of time in their current position and with the leader were both 1–5 years. Team members’ average length of time with the organization was 6–10 years and their average length of time in healthcare was 11–15 years.

In-group measures to determine the degree of reliability within the respondents are presented as the average of the mean, standard deviation, variance, and range for each group of team members on the ELS and the LMX surveys. The ELS average score of 5.97+/-0.6775 and LMX average score of 6.3447+/-0.5770 represent approximately 20% variance between members of the group for each survey.

Partial correlation analysis using Pearson’s r between ELS and LMX-MDM determined a statistically significant relationship exists (r = 0.839, p = 0.005) when controlled for personality type of the leader, age of the leader, gender of the leader, length of time as a leader, the presence of leadership training, length of time in the current position, length of time at the current organization, and length of time as a physician (see Table 3).

Length of time as a physician demonstrated a statistically significant relationship with LMX-MDM (r = 0.553, p = 0.011), but the practical significance is unclear given the role the variable played in the analysis. Other relationships in the analysis did not rise to the level of significance. The linear relationship between ELS and LMX-MDM can be seen in Figure 1 (R squared = 0.370).

Figure 1. Relationship between ELS (empowering leadership survey) and LMX-MDM (multidimensional leader-member exchange survey)

Implications

The study results demonstrate that relationships are important in the development of physicians as clinical leaders of interprofessional teams. A strong association exists between LMX quality in the relationship of a physician with their team members and the empowerment behavior displayed by the physician. The relationship between empowerment of frontline healthcare workers and the safety and quality of care delivery in healthcare environments has been demonstrated through structural empowerment as a mechanism to enhance the culture of safety.(3) Leadership development correlates to outcomes in healthcare via enhanced engagement of frontline workers.(2) The importance of LMX quality in outcomes in a direct reporting relationship has been defined.(4) The results of this study provide further evidence of the importance of transferrable leadership skills in the development of physician-leaders.

Physicians who have higher-quality relationships with team members allow those individuals to perform with greater autonomy and are more likely to contribute to their professional development. The contribution to development enhances the psychological empowerment and trust experienced by the team member. That positive relationship translates into increased engagement and proactive involvement, such as increased intention to report patient safety events as they are identified. Findings from this study could be generalizable to all clinical environments and used in organizational development programs across the healthcare industry.

The limitations of this study include the relatively small sample size. The correlation between LMX quality and empowerment was strong, but associated characteristics could not be fully described in this study population. Further study to characterize the antecedents of a high-quality relationship is needed as well as identification of factors that may contribute to increased trust. Personality congruence between the leader and team members may contribute to the association between LMX and empowerment behavior and should be explored. Finally, replication of this study in different settings and reporting relationships will help to define the role employment structure plays in the relationship between empowerment behavior and relationship quality.

References

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