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CHAPTER 11Health Care Leadership Communication

For the purpose of this text, we are going to use the following as working definitions:

■ Contingency theory: A leader is determined by the situation and how well his or her style/skills match the current needs—identifying which behav-iors are best suited for a variety of contingencies

■ Leader–member exchange (LMX) theory: Leaders are not making decisions in order to impact followers, they are trying to collaborate with followers; the communication between a leader and his or her followers

■ Leadership: The ability of one person to persuade a team and/or organi-zation to accomplish agreed-upon goals

■ Path–goal theory: A theory based on how leaders persuade followers to accomplish goals

■ Situational approach: Leaders adapt their approaches based on the situation, including their employees’ skills and knowledge

■ Skills approach: A management style that is leader focused, not personal-ity driven, but talents and skills can be learned

■ Styles approach: A management style that is leader focused, not personality driven, and highlights leaders’ behaviors and how their communication impacts followers based on the context

■ Team leadership: Leaders working within teams to accomplish goals

■ Trait approach: A management style that is leader-centric and emphasizes that certain people are born with explicit personality traits that make them leaders; with this approach, leaders are born, not made

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■ T R A I T S , S K I L L S , A N D S T Y L E S

Health care leadership in the 21st century has evolved in countless ways. In America, for most of the country’s history, patients and other providers viewed physicians as the leaders in health care delivery. Whether it was in their private offices, at the hospital bedside, or in health care administrative roles—physicians were perceived as the central figures in patient care. And although physicians continue to be critically important to the current interprofessional health care team system—U.S. health care takes much more of a group—than an individual- centric approach. Consequently, U.S. health care moves to more collaborative communication goals (patients, intra- and interprofessional teams, organizations) in order to improve patients’ outcomes. Therefore, the examples in prior decades of physicians’ and other providers’ autocratic, paternalistic lead-ership communication (with patients, providers, and administrators) needs to be supplanted by a more collaborative, supportive, and engaging style in pro-vider–provider, provider–patient, and provider– organization communication.

Early in the 20th-century, leadership was thought to be primarily based on inborn traits. Leaders were believed to have unique personality qualities and characteristics that separated them from others and were the reason for their leadership roles. However, as more research was done, it became obvious that leadership was not some type of genetic predisposition that limited who could be a potential visionary/manager, but instead was based on a wide variety of factors that could be learned (socially, academically, and/or professionally). As you can imagine, if indeed leaders had to born with the skills, knowledge, and abilities needed to persuade followers and create new opportunities—this chapter would be unnecessary and very few Americans would be considered leaders. However, the trait approach has identified some key traits or charac-teristics that may be important for successful leaders, including:

■ Knowledge

■ Self-assurance

■ Persistence

■ Honesty

■ Amiability

Although these traits are important for leaders to possess in varying degrees, it is obvious that most of these are personal values that are devel-oped or intelligence that includes both education and experience—but not things humans are uniquely born with. As you know from your own lives— leadership occurs in diverse ways. It is important to understand that leaders can be assigned (appointed or elected) as in the chief of surgery, or the surgical intensive care unit nurse manager, and so forth. Or they can emerge, based on their behaviors, skills, and communication, to assume a leadership role. For example, there could be an interprofessional team assigned to create the content for a hospital’s new electronic medical record (EMR). And although

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there may, or may not be, a leader appointed to direct this team, it would not be uncommon for a member of the team, through his or her efforts, intellect, and communication, to emerge as the person the team actually views as its leader and seeks direction and feedback from.

The question for health care providers who will be working in teams—but also at various times with patients, families, and peers as leaders—is how do effective leaders communicate and persuade followers to accomplish shared goals? As you may have surmised from the title of this chapter—the key to accomplishing leadership goals as well as team and organization goals is always effective communication. Regardless of the tasks, problems, needs, or goals, if more than one person is working to accomplish them—persuasive/collaborative interpersonal and team communication are going to be critical. Therefore, potential health care provider leaders need to understand the differ-ences and benefits of various communication skills and styles.

Although there are a variety of theories related to the most beneficial leader-ship skills, it seems clear that they all share several key components, including:

1. Personality/humanism

2. Knowledge/judgment

3. Vision/communication

One of the skills that have been identified as important for effective leaders is the ability to work well with others and participate with them in accomplishing goals. This humanist aspect of leadership is important to developing interpersonal relationships and trust with members/followers, but needs to also be supported by the person’s knowledge (education and experience) as well as his or her ability to analyze information and make necessary decisions. However, depending on the role, context, and goals, a leader may need to have a vision for others to follow, but regardless, the leader’s success and effectiveness will depend on his or her leadership and interpersonal communication skills. But, in addition to the role traits and skills play in leadership, the communication styles a leader adapts will also be important to his or her success.

Reflection 11.1. Consider someone in your life you consider an effective and/or successful leader (parent, professor, professional) and try to identify what specifically (traits, styles, and/or skills) about his or her behaviors contributed to his or her leadership. Why?

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Although traits and skills are predominantly about a leader’s personality, values, knowledge, visions, and social abilities—leadership style is focused more on communication behaviors. For example, as discussed earlier in this chapter and others, the use of a paternalistic/authoritarian communication approach to health communication is one of the styles leaders can use to try to persuade fol-lowers/patients/peers/other providers. Consequently, a leader who uses a pater-nalistic style is focusing on giving orders and therefore the result becomes the major emphasis for both leader and follower(s). An opposite style is much more focused on followers and their needs, but the task/goal becomes secondary. One of the most collaborative styles for health care providers to consider is a team management approach that focuses on interdependence, with relationship build-ing, goal attainment, and shared respect between leader and followers. However, there are other leadership communication theories for health care providers to understand and potentially apply in their various roles, situations, and/or teams.

■ C O N T I N G E N C Y , P A T H – G O A L , A N D L M X   T H E O R I E S

As health care professionals who are likely leaders in many different contexts (family, intraprofessional, interprofessional, etc.), it is important to not just rec-ognize that individual characteristics are important to effective leadership; inter-personal, cultural, and organizational theories are also useful. For example, you likely know someone who possesses many of the traits, styles, and skills that have been identified as important for leadership—and yet the individual was not as successful as expected.

Contingency TheoryAt its most basic, contingency theory is about identifying the most appropriate leader for a specific context. In health care, for example, contingency theory sug-gests that there are certain situations in which just because a person has a specific title, degree, and/or license—he or she may not be the ideal person to be the leader. This can be seen in 21st- century health care administra tion, where many of the senior administrators/leaders in hospitals and other health care systems are not physicians, nurses, and so forth. As the context for health care organizational

Reflection 11.2. Can you see the distinction between contingency theory and situational theory? Try to recall an example for each, whether in your life, in history, or the media, and discuss how it applies to these different theoretical approaches to leadership.

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leadership has evolved from primarily a clinical context to a more business-model approach—leadership has changed as well.

It is important to recognize that using a contingency-theory approach, leaders would be appointed or chosen based on their abilities to either focus on a goal(s) versus interpersonal relationship development. Therefore, by recognizing a leader’s strength in task completion or interpersonal devel-opment, based on the situation—the most effective leader can be deter-mined. Consequently, where previously any leader with certain traits, skills, and styles was felt to be a potential leader in any context, contingency the-ory points out that to be most successful it is very important to match a leader’s strengths to a situation’s needs/demands. Therefore, a leader is not expected to be universally the ideal choice for every context. Thus, a non-provider chief executive officer (CEO) of a health care system may be the best leader administratively, but clearly not the best leader in a clinical crisis (e.g., mass casualties from a motor vehicle accident [MVA]) in the hospi-tal’s emergency department (ED). The importance of contingency theory for health care professionals is that it should remind you that based on the context a leader may need to be selected, appointed, or emerge who has the most appropriate task or relational traits, skills, and styles to address the situation—regardless of his or her title, degree, and so forth. Although this book will not go into detail about the differences between contingency and situational theories, the major distinctions are that in situational leadership, the leader seeks to align his or her approach to the followers’ abilities based on the context. For example, a chief nursing officer (CNO) might choose to be more authoritarian in a situation that included many newly graduated RNs, versus another contex in which more experienced RNs were dealing with a similar problem but need more collaboration and support, rather than instructions or orders. As you can see, contingency theory is primarily focused on the leader’s skills/styles as they relate directly to the circum-stances. Whereas the situational approach links the leader’s choices not just to the context, but to his or her followers’ abilities and commitments. Just as these two theories provide differing perspectives for health care providers to use in determining the best leadership approach to follow so too does path–goal theory.

Path–Goal TheoryAs the name implies, a path–goal approach to leadership relies on a leader identifying the most appropriate style to use to persuade his or her followers to attain a shared goal. Path–goal theory focuses on a leader helping subor-dinates understand the organization’s/team’s goal, helping followers deter-mine the best path to attaining it, using his or her role to minimize or eliminate any obstructions, and collaborating with the team as needed for a successful outcome. The role of motivator is key for leaders who utilize a path–goal approach to problem solving/goal attainment, and so forth. Some of the

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specific behaviors needed by leaders for path–goal theory, based on their followers’ needs and the task/goal include:

■ Giving orders or specific instructions

■ Providing support and encouragement

■ Collaborating/participating

Consequently, in a hospital, for example, a leader using path–goal theory might need to be more autocratic in communicating with members exactly how to reach a goal of 100% for the unit’s handwashing—“Be sure to wash your hands before you enter every patient’s room and when you leave; there will be mon-itors watching you.” Or, with a different group, the leader might choose to be more encouraging and supportive—“I know you can help us reach our 100% handwashing goal because you are committed to patient safety and our success.” Finally, the leader might decide to collaborate with a team based on their charac-teristics to help identify a way to reach the goal—“I would like to work with you all to develop a plan that will help us assure we reach our 100% handwashing goal; together we can make it a reality.”

As you can see from these examples, in path–goal theory leaders are not just focused on the outcome, but on analyzing their followers/subordinates to deter-mine the best leadership styles and skills to use to motivate them to succeed. This move toward leadership that addresses not just organizational problems, tasks, and goals, but analysis of the subordinates as well, contributes to another import-ant leadership concept—LMX theory.

LMX TheoryCompared to the theories described earlier, LMX theory is focused on the communication between a leader and his or her followers/subordinates. One of the key elements in LMX theory is the understanding of moti-vated teams versus nonmotivated groups. By identifying those subordinates

Reflection 11.3. Have you ever worked in a group or on a team where some members would do anything to help achieve the shared goals, but others were not as motivated? If so, who did you identify with in the group/team—those who were motivated or not motivated? Why? How did your choice impact the group/team’s outcome, as well as your perceptions of working with that group/team? If you have not been in such a situation, how would you hypothesize it might impact a leader’s communication behaviors to have motivated and unmotivated subordinates?.

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who are motivated and willing to do what is needed regardless of role/job descriptions, leaders can develop more effective interpersonal communica-tion and relationships with those who are motivated to help them attain goals, complete tasks, and solve problems.

As you may have surmised, one of the realities of LMX theory is that those who are in motivated groups not only get more interactions with organizational leaders, but also tend to be identified and promoted to become future leaders. Consequently, LMX theory provides a way not just for current leaders to behave, but a plan to help prospective leaders demonstrate their interest, commitment, and contributions to the organization, its leaders, and its goals. Suppose you were a hospital unit manager and of the 20 employees under your leadership, five are always willing to accept new tasks, help solve problems, or fill in when other members are unavailable. Who are you more likely to want to work with when you have a problem or a new goal to accomplish, the five motivated members, or those who are not? Similarly, when asked by your supervisor who you would recommend for a promotion to a leadership position, does it not make perfect sense based on an LMX approach that the recommendation will come from the motivated group, even if that person might have less seniority than a member of the unmotivated group? Therefore, LMX theory helps leaders identify followers who may be best equipped to help problem solve, complete tasks, and attain goals based on their motivation, but also be the best choice for future leadership roles within the organization. However, in addition to LMX, path–goal, situational, and contingency theories—it is critically important for health care providers and professionals to understand the differences and ben-efits associated with team leadership theory.

Team Leadership TheoryAs we have discussed throughout this text, U.S. health care delivery is predominantly based on a team approach—even within a private practice setting there is often an intraoffice team as well as various interoffice teams (e.g., consultants, service providers, even institutions). Consequently, one of the most important leadership theories for health care professionals is team leadership. However, team leadership does not exist in a vacuum—therefore, a team leader needs to understand the previously discussed theories, traits, skills, and styles and utilize them appropriately based on the context, team members, and goals. In addition, effective team leaders need to be continu-ally monitoring both the context they are functioning in as well as the team’s progress toward an intended outcome/goal. Some of the specific activities that team leaders need to focus on include:

■ Assuring goal understanding

■ Strategizing for success

■ Encouraging shared decision making

■ Providing information and/or materials to help the team accomplish a task/goal

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■ Communicating interpersonally with members

■ Managing conflict

■ Exemplifying the commitment, ethical behavior, and excellence that is expected from members

As these actions illustrate, team communication is both dyadic and group focused. Team leaders need to develop interpersonal relationships with their members, but also be able to communicate effectively with all members in order to assure there is not a feeling of favoritism or bias. As discussed in Chapter 9, team communication is critical to 21st-century U.S. health care and how team leaders choose to use their interactions with the group and individ-ual members will determine in large part how the team performs and whether tasks/goals are effectively accomplished and patient care enhanced. Clearly, because the purpose for most health care teams, whether intra- or interpro-fessional, are task, problem solving, and/or goal related—a team leader needs to carefully assess the situation, his or her team members, and the outcome that is needed. However, as important to health care as team leadership and team communication are, understanding the role of women and leadership in health organizations is also vital.

Women and LeadershipAlthough it may seem odd to single out women and leadership, there are a number of reasons why this is important to understand:

1. More women than ever before are working in U.S. health care today.

2. Increasingly, there are greater numbers of female versus male providers (MD/DO, RN, advanced practice registered nurse [APRN], physician assistant [PA], etc.) graduating every year from U.S. health professions programs.

3. Important distinctions in leadership behaviors are based on sex and gender.

4. Almost always, more women are working as health care providers in U.S. health care delivery institutions than are males.

5. Inaccurate misperceptions exist regarding the stereotype of an American female leader.

It has been shown that women leaders tend to be more collaborative than males; however, there does not appear to be any significant difference in the sexes when it comes to interpersonal and task-related styles. And the two sexes seem equally effective in leadership roles. Therefore, with increasing numbers of female health care providers in all professions/disciplines, it is important for peers to understand the realities about women in health care leadership and ignore inaccurate stereotypes.

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Female health care provider leaders need to be assessed like their male counterparts, on their results and ability to motivate followers and attain orga-nizational goals. Although it is a sad truism in 21st-century America, that even though women are earning more academic degrees than males, they con-tinue to be paid less for the same job as their male counterparts. For example, according to Cain Miller (2016) in the New York Times, “Women who are sur-geons earn 71% of what men earn” (para. 3). However, this disparity between modern health care professionals based on sex is not limited to salaries. According to Torrieri (2014), “women account for 73% of medical and health services managers, but only account for 18% of US hospital CEOs” (para. 1). This inequity is hard to believe; however, for U.S. female health providers it is no less a reality.

From a leadership communication perspective, female health care profession-als must understand the current situation and recognize how increasing leader-ship by women can only serve to enhance the opportunities for others. Similarly, although female providers might analyze the data presented earlier and hypoth-esize that using masculine-gendered behaviors (aggression, independence, competitiveness, etc.) would be the path of least resistance to higher leadership positions—a reassessment of interpersonal relationships, health, and leadership communication realities would be very helpful. For example, feminine-gendered individuals, regardless of sex, are generally more collaborative, participative, and nurturing. These feminine-gendered skills/styles are exactly what have been rec-ommended in numerous leadership theories. Consequently, rather than trying to be like male leaders in their communication behaviors, health provider females who seek leadership roles need to focus on mentors whom they view as most effective, regardless of the leader’s sex. And they need to recognize the impor-tance of choosing the right leader ship approach based on the context, members, goals, and tasks. With more women successful in leadership roles across all differ-ent types of organizations, will the barriers to female leadership begin to dissolve and stereotypes be forgotten? Women health care providers are in the majority and, with continued effort and effective interpersonal, organizational, team, and leadership communication, they will assume the leadership roles they deserve.

Reflection 11.4. Recall a female leader in your life (mother, coach, professor, manager, etc.). How did her communication impact your perceptions of her as a leader? How did it affect the group’s work and/or goal attainment? What are some differences in her leadership style and that of a male leader in your life?

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R e f l e c t i o n s ( a m o n g t h e p o s s i b l e r e s p o n s e s )

11.1. Consider someone in your life you consider an effective and/or successful leader (parent, professor, professional) and try to identify what specifically (traits, styles, and/or skills) about his or her behaviors contributed to his or her leadership. Why?

Generally, you may have been able to recognize the role that the leader’s knowledge, personality, communication, and collaborative style played in his or her success. Often, we identify someone as an effective leader if we feel that we have a relationship with that person—not just as one of many working on a project, but someone he or she knows and cares about on some level. We are more open to persuasion and efforts to reach goals if we feel valued and that everyone is sharing in the work, but also when we are recognized for our con-tributions. Finally, most Americans prefer collaborative, rather than authorita-tive leadership styles—we want to be part of something, not just ordered to do things. And this participative approach leads to a sense of individual and team ownership of the shared tasks, problem solving, and goal.

11.2. Can you see the distinction between contingency theory and situational theory? Try to recall an example for each, whether in your life, in history, or the media, and discuss how it applies to these different theoretical approaches to leadership.

One historical example would be General George S. Patton. In World War II, General Patton was known as a very authoritarian leader. He used a very masculine-gendered, independent, aggressive, and competitive approach to persuading/commanding his troops. When General Dwight D. Eisenhower appointed General Patton to his leadership post we can hypothesize that it was in part related to contingency theory—the U.S. tank battalions were getting beaten by the Germans—a leader with charisma and confidence was needed to take charge of the situation. Only a few years later, when the war was over and the context was different, General Patton was removed from his post for being too independent and aggressive in his comments to the press. Consequently, we can see how contingency theory helps us understand how different contexts call for different leaders and/or leader-ship skills and styles.

11.3. Have you ever worked in a group or on a team where some members would do anything to help achieve the shared goals, but others were not as motivated? If so, who did you identify with in the group/team—those who were motivated or not motivated, and why? How did your choice impact the group/team’s outcome, as well as your perceptions of working with that group/team? If you have not been in such a situation, how would you hypothesize it might impact a leader’s communication behaviors to have motivated and unmotivated subordinates?

Based on the situation, members’ motivations play a major role in leadership behaviors. As LMX theory suggests, when some members choose to do just

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11 Health Care Leadership Communication 205

the bare minimum of work and seem less invested in the task, problem- solving effort, and/or goal—it is likely they will not be perceived as moti-vated employees/teammates and consequently the organizational leader will pay less attention to them and more to those who are enthusiastic and committed. Consequently, the motivated members will be given more oppor-tunities for input into the decision-making and goal-attainment efforts, as well as frequently identified as ideal leadership candidates when organizational opportunities arise.

11.4. Recall a female leader in your life (mother, coach, professor, manager, etc.). How did her communication impact your perceptions of her as a leader? How did it affect the group’s work and/or goal attainment? What are some differences in her leadership style and that of a male leader in your life?

Female leaders, like males, can choose to communicate using either masculine- or feminine-gendered behaviors. And regardless of their sex they would be wise to decide which communication approach is needed based on the con-text, members, and goal. However, because female leaders have been shown to be more collaborative and participative in their leadership styles, it would not be surprising if that is what you observed in many of your experiences. Often, leaders who are not directive, but participative in their communication with members, are perceived as being more interpersonal and relational in their style and may verbally or nonverbally encourage others to behave simi-larly. Among the differences in leadership that you might have observed were more listening and nurturing communication behaviors by feminine-gendered leaders, as well as the aforementioned efforts to collaborate and participate in tasks, problem solving, goal attainment, and so forth. As with the trait approach that focused on leaders being born with the needed leadership characteristics, skills, and styles, it is important to avoid the U.S. stereotypical view of males being more appropriate in leadership roles than females. Again, there is no evidence to support that genetic differences between the sexes make one more suitable for leadership than the other. Avoid stereotypes in both your views of what makes a successful and effective leader and your openness to leadership, regardless of the individual’s sex or gender. Instead of stereotyping, use his or her behaviors, ethics, and outcomes to inform your analysis.

S k i l l s E x e r c i s e

In an organization (family, academic, or professional) or team in which you are an active member, analyze a current or recent task and/or goal that your teammates/family were assigned to successfully accomplish. Focus your analysis on the lead-er’s (yours if you were the leader) communication behaviors and how he or she tried to persuade members to complete the task/goal. What leadership theory, styles, traits, and skills did you see as being most beneficial (from leader and

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follower perspectives)? How did the context for the group/team effort impact leadership and followers behavior? In what ways did the sex and/or gender (of both the leader and followers) affect the effort and outcome? From this analysis, how will you consider your own health care leadership choices?

Video Discussion ExerciseAnalyze the video

■ Patch Adams (1998)

Interactive Simulation ExercisePagano, M. (2015). Communication case studies for health care professionals: An

applied approach (2nd ed.). New York, NY: Springer Publishing Company.

■ Chapter 9, “I’ve Got the License, So We’re Doing It My Way” (pp. 91–100)

Health Care Issues in the MediaThe costs of health carehttps://www.youtube.com/watch?v=iEXkKV3kbb8

Women as hospital CEOshttp://www.healthcaredive.com/news/why-women-account-for-just-a- fraction-of-hospital-ceos/337822

H e a l t h C o m m u n i c a t i o n O u t c o m e s

Leadership communication is critical to the success of 21st-century providers, teams, and organizations. However, to be effective and successful health care leaders and professionals need to understand that certain personality traits are important to possess, but a leader does not have to be born with them. Traits, like leadership skills and styles, can be learned from family, peers, mentors, academ-ics, and life experiences. However, based on the theoretical approach to lead-ership chosen, a leader may need to utilize a variety of traits, skills, and styles depending on the context, task, problem, goal, and his or her followers/members.

Contingency theory, for example, requires leaders to be chosen or appointed based on the task, problem to be solved, and/or goal. Therefore, it is goal driven, with the choice of leader relating to his or her expertise, skills, styles, and education most appropriate for the context. In contrast, situational the-ory is more follower focused in that the leader tries to align his or her style with the members’ abilities in order to address the situational goal. In con-trast, path–goal theory is leader focused and suggests that to attain a goal the leader needs to identify the most effective way to motivate his or her members/ followers, remove obstacles, and support their efforts. Using a different focus, LMX theory seeks to use the followers’ motivations as the lens for a leader to

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use in determining which members to focus his or her communication toward. Therefore, a leader who uses LMX theory, in order to accomplish tasks, solve problems, generate ideas, and attain goals, seeks to identify the most motivated members of the organization or team and work primarily with them to com-plete the assignment/goal. In addition, LMX theory provides an opportunity for an organization/team to identify potential future leaders based on their level of motivation and efforts.

Although each of these theories has potential for health care provider lead-ers, team leadership may be the most commonly used form in day-to-day health care delivery. Because so much of 21st-century health care is done in team envi-ronments, intra- and interprofessionally, leadership in health care organizations generally falls into two distinct, but interdependent macroteams: administrative and clinical. However, team leadership theory is applicable to both and generally includes one of the other theoretical perspectives based on the leader, members, tasks, and so forth. Based on team leadership theory, a leader needs to be very communication-centric (interpersonal and team) and analyze both the goal and his or her teammates to provide understanding, motivation, and feedback, but also to offer support, conflict management, ethical behaviors and a collaborative, participative environment for the maximum sharing of information, ideas, and solutions. Finally, especially in modern health care organizations, it is important to note the increasing roles and numbers of women in all health professions and the need to concomitantly expand their leadership roles—both clinically and administratively. Consequently, stereotypes of female professionals need to be avoided and gendered communication behaviors, regardless of a person’s sex, need to be analyzed to determine the ideal leader for the task, problem, situation, team, and goal. By understanding the various leadership theories dis-cussed in this chapter you should be able to identify not only the best choice for you as a future leader, but also understand that leadership is not dependent on a person’s genes (inherited traits and/or sex), but on how an individual uses his or her education and life experiences to develop the necessary personality characteristics, skills, and styles of a successful and effective leader.

■ R E F E R E N C E S

Cain Miller, C. (2016, January 15). How to bridge that stubborn pay gap. New York Times. Retrieved from http://www.nytimes.com/2016/01/17/upshot/how-to-bridge-that-stubborn-pay-gap.html?_r=0

Torrieri, M. (2014). Why women account for just a fraction of hospital CEOs. Retrieved from http://www.healthcaredive.com/news/why-women -account-for-just-a-fraction-of-hospital-ceos/337822

■ B I B L I O G R A P H Y

Aronson, E. (2001). Integrating leadership styles and ethical perspectives. Canadian Journal of Administrative Sciences, 18(4), 244–256.

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Avolio, B., & Locke, E. (2002). Contrasting different philosophies of leader motivation: Altruism versus egoism. Leadership Quarterly, 13, 169–191.

Graeff, C. (1997). Evolution of situational leadership theory: A critical review. Leadership Quarterly, 8(2), 153–170.

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