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Leadership Case Studies

Here is a sample of three case studies from the book, Leadership Case Studies, that are most instructive and impactful to developing leadership skills.

Leadership Case Studies

For the past 30 years, I have conducted seminars and workshops and taught college classes on leadership.

I used a variety of teaching aids including books, articles, case studies, role-plays, and videos.

I recently created a book, Leadership Case Studies that includes some of the case studies and role-plays that I found to be most instructive and impactful.

Here is a sample of three case studies.

Peter Weaver Case Study

Peter Weaver doesn’t like to follow the crowd. He thinks groupthink is a common problem in many organizations. This former director of marketing for a consumer products company believes differences of opinion should be heard and appreciated. As Weaver states, “I have always believed I should speak for what I believe to be true.”

He demonstrated his belief in being direct and candid throughout his career. On one occasion, he was assigned to market Paul’s spaghetti-sauce products. During the brand review, the company president said, “Our spaghetti sauce is losing out to price-cutting competitors. We need to cut our prices!”

Peter found the courage to say he disagreed with the president. He then explained the product line needed more variety and a larger advertising budget. Prices should not be cut. The president accepted Weaver’s reasoning. Later, his supervisor approached him and said, “I wanted to say that, but I just didn’t have the courage to challenge the president.”

On another occasion, the president sent Weaver and 16 other executives to a weeklong seminar on strategic planning. Weaver soon concluded the consultants were off base and going down the wrong path. Between sessions, most of the other executives indicated they didn’t think the consultants were on the right path. The consultants heard about the dissent and dramatically asked participants whether they were in or out. Those who said “Out” had to leave immediately.

As the consultants went around the room, every executive who privately grumbled about the session said “In.” Weaver was fourth from last. When it was his turn, he said “Out” and left the room.

All leaders spend time in reflection and self-examination to identify what they truly believe and value. Their beliefs are tested and fine-tuned over time. True leaders can tell you, without hesitation, what they believe and why. They don’t need a teleprompter to remind them of their core beliefs. And, they find the courage to speak up even when they know others will disagree.

  • What leadership traits did Weaver exhibit?
  • If you were in Weaver’s shoes, what would you have done?
  • Where does courage come from?
  • List your three most important values.

Dealing with a Crisis Case Study

Assume you are the VP of Sales and Marketing for a large insurance company. Once a year your company rewards and recognizes the top 100 sales agents by taking them to a luxury resort for a four-day conference. Business presentation meetings are held during the morning. Afternoons are free time. Agents and spouses can choose from an assortment of activities including golf, tennis, boating, fishing, shopping, swimming, etc.

On day 2 at 3:00 p.m., you are at the gym working out on the treadmill, when you see Sue your administrative assistant rushing towards you. She says, “I need to talk to you immediately.”

You get off the treadmill and say, “What’s up?” Sue states, “We’ve had a tragedy. Several agents went boating and swimming at the lake. Randy, our agent from California died while swimming.”

(Background information – Randy is 28 years old. His wife did not come on the trip. She is home in California with their three children).

  • Explain what you would communicate to the following people.
  • Your Human Resources Department
  • The local police
  • The attendees at the conference (Would you continue the conference?)
  • How will you notify Randy’s wife?
  • If Randy’s wife and a few family members want to visit the location of Randy’s death, what would you do?
  • What are some “guiding principles” that leaders need to follow in a crisis situation?

 Arsenic and Old Lace Case Study

Review the YouTube video, “ I’ll show them who is boss Arsenic and Old Lace.”   

Background Information

The Vernon Road Bleaching and Dyeing Company is a British lace dyeing business. It was purchased in bankruptcy by the father/son team of Henry and Richard Chaplin. Richard has been acting as “Managing Director” which is the same as a general manager or president of a company.

The company has had 50-to-150 employees with 35-to-100 being shop floor, production employees. The company produces and sells various dyed fabrics to the garment industry.

Gerry Robinson is a consultant who was asked to help transform methods of conducting business to save the company.

Jeff is the factory manager.

  • What are Richard’s strengths and weaknesses as a leader?
  • What could Richard have done to make the problems of quality and unhappy customers more visible to the workforce?
  • What do you think Richard’s top three priorities should be for the next 12 months?
  • What could Richard have done to motivate the workforce?
  • Evaluate Jeff’s approach and effectiveness as a leader.

The book contains 16 case studies, four role-plays, and six articles. I hope you find some of the content useful and helpful in your efforts to teach leadership.

Click for additional leadership case studies and resources .

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HKS Case Program

The teaching cases in this section are designed to provoke critical thinking on various domestic and international leadership challenges. Students will find themselves in the shoes of leaders from many positions—whether it be in the nonprofit or public sectors—and will have to navigate the complex reality of what it means to be an effective leader.

Case - Operation Pufferfish: Building and Sustaining a Department of Neighborhoods and Citizen Engagement in Lansing, Michigan

Operation Pufferfish: Building and Sustaining a Department of Neighborhoods and Citizen Engagement in Lansing, Michigan

Publication Date: March 5, 2024

Lansing native Andi Crawford returned home and took over a mismanaged and outdated neighborhood grant program, revamping grant processes, bringing in new money and capacity, and expanding eligibility.This shift became just one element of a much...

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Charting a Course for Boston: Organizing for Change

Boston Mayor-elect Michelle Wu was elected on the promise of systemic change. Four days after her November 2021 victory—and just eleven days before taking office—she considered how to get started delivering on her sweeping agenda. Wu...

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More than a Contract: Black Self-Determination and People’s Assemblies in Jackson, Mississippi Epilogue

Publication Date: March 1, 2024

This epilogue accompanies HKS Case 2276.0. The Jackson People’s Assembly (JPA), a vehicle of “Black self-determination and autonomous political authority of the oppressed peoples and communities in Jackson,” launched the...

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More than a Contract: Black Self-Determination and People’s Assemblies in Jackson, Mississippi

The Jackson People’s Assembly (JPA), a vehicle of “Black self-determination and autonomous political authority of the oppressed peoples and communities in Jackson,” launched the political career of Chokwe Lumumba, a veteran...

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Mayor Curtatone’s Culture of Curiosity: Building Data Capabilities at Somerville City Hall Epilogue

Publication Date: February 21, 2024

This epilogue accompanies HKS Case 2255.0. A practitioner guide, HKS Case 2255.4, accompanies this case. For sixteen years, longer than any mayor in the city’s history, Mayor Joseph Curtatone has led his hometown of Somerville,...

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Mayor Curtatone’s Culture of Curiosity: Building Data Capabilities at Somerville City Hall Practitioner Guide

This practitioner guide accompanies HKS Case 2255.0. An epilogue, HKS Case 2255.1, follows this case. For sixteen years, longer than any mayor in the city’s history, Mayor Joseph Curtatone has led his hometown of Somerville,...

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Mayoral Transitions: How Three Mayors Stepped into the Role, in Their Own Words

Publication Date: February 29, 2024

New mayors face distinct challenges as they assume office. In these vignettes depicting three types of mayoral transitions, explore how new leaders can make the most of their first one hundred days by asserting their authority and...

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Mayor Curtatone’s Culture of Curiosity: Building Data Capabilities at Somerville City Hall

For sixteen years, longer than any mayor in the city’s history, Mayor Joseph Curtatone has led his hometown of Somerville, Massachusetts. The case begins in January 2020 when the mayor is looking ahead at his recently won,...

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Leadership in Moral Conflict Simone Veil and Abortion Reform in France

Publication Date: April 1, 2003

This case tells the 1974 story of a French health minister, Simone Veil, and her ultimately successful effort to liberalize France's abortion law. It serves as a vehicle for exploring leadership in a legislative setting, in this instance a...

Teaching Case - Fallen Idol? Aung San Suu Kyi & the Rohingya  Humanitarian Crisis

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Publication Date: January 25, 2024

This epilogue accompanies, "Fallen Idol? Aung San Suu Kyi & the Rohingya Humanitarian Crisis," HKS Case Number 2139.0. Soon after Myanmar’s longtime democracy crusader and opposition leader, Aung San Suu Kyi, was...

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Publication Date: December 12, 2023

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Leading Pension Reform in Rhode Island: Building Holding Environments to Achieve Change

In 2010, Rhode Island’s public employee pension system was on the verge of collapse: it was just 48% funded and represented a $4.7 billion liability – the largest such pension liability in the nation. For many state employees and...

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Cases in Leadership

Cases in Leadership

  • W. Glenn Rowe - Western University, Canada
  • Laura Guerrero - University of Houston, USA
  • Description

See what’s new to this edition by selecting the Features tab on this page. Should you need additional information or have questions regarding the HEOA information provided for this title, including what is new to this edition, please email [email protected] . Please include your name, contact information, and the name of the title for which you would like more information. For information on the HEOA, please go to http://ed.gov/policy/highered/leg/hea08/index.html .

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Supplements

Instructor Resource Site

Password-protected Instructor Resources include the following:

  • Editable, chapter-specific Microsoft® PowerPoint® slides offer you complete flexibility in easily creating a multimedia presentation for your course. Highlight essential content, features, and artwork from the book.
  • Chapter-specific discussion questions  help launch classroom interaction by prompting students to engage with the material and by reinforcing important content.  
  • Case Notes  providing summaries, suggested teaching strategies, and analyses of the cases.

Textbook is both engaging and informative. Your textbook meets both of these criteria.

The text is well-written and easy to understand. The authors have done a great job of explaining complex concepts in a clear and concise way. The text is also well-organized, which makes it easy for students to find the information they need.

NEW TO THIS EDITION: 

  • 14 new cases and 6 new articles have been added to reflect new and emerging issues in leadership. 
  • A new chapter on Followership helps students understand how to be effective followers.  
  • Coverage of newer leadership theories such as authentic leadership and servant leadership prepares students to thrive in today’s workplace. 
  • An extensively revised chapter on women and leadership reflects recent events in major organizations, such as Fox News, Google, and Uber, and includes new research and new statistics. 

KEY FEATURES: 

  • Real-world cases from around the world, including India, China, Canada, the United States, Brazil, South Africa, and Switzerland, illustrate the complex nature of leadership in organizations and help students apply concepts to a practical setting.
  • Concept summaries, discussion questions, and readings provide students with a solid framework for understanding key leadership theories.
  • The cases provide students with the opportunity to practice and hone skills , including the ability to analyze, make decisions, apply lessons learned, and plan and engage in oral communication.

Sample Materials & Chapters

Chapter 5: Followership

Chapter 8: Servant Leadership

For instructors

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Leadership and Ethics Case Studies

case study related to leadership

Hertz CEO Kathryn Marinello with CFO Jamere Jackson and other members of the executive team in 2017

Top 40 Most Popular Case Studies of 2021

Two cases about Hertz claimed top spots in 2021's Top 40 Most Popular Case Studies

Two cases on the uses of debt and equity at Hertz claimed top spots in the CRDT’s (Case Research and Development Team) 2021 top 40 review of cases.

Hertz (A) took the top spot. The case details the financial structure of the rental car company through the end of 2019. Hertz (B), which ranked third in CRDT’s list, describes the company’s struggles during the early part of the COVID pandemic and its eventual need to enter Chapter 11 bankruptcy. 

The success of the Hertz cases was unprecedented for the top 40 list. Usually, cases take a number of years to gain popularity, but the Hertz cases claimed top spots in their first year of release. Hertz (A) also became the first ‘cooked’ case to top the annual review, as all of the other winners had been web-based ‘raw’ cases.

Besides introducing students to the complicated financing required to maintain an enormous fleet of cars, the Hertz cases also expanded the diversity of case protagonists. Kathyrn Marinello was the CEO of Hertz during this period and the CFO, Jamere Jackson is black.

Sandwiched between the two Hertz cases, Coffee 2016, a perennial best seller, finished second. “Glory, Glory, Man United!” a case about an English football team’s IPO made a surprise move to number four.  Cases on search fund boards, the future of malls,  Norway’s Sovereign Wealth fund, Prodigy Finance, the Mayo Clinic, and Cadbury rounded out the top ten.

Other year-end data for 2021 showed:

  • Online “raw” case usage remained steady as compared to 2020 with over 35K users from 170 countries and all 50 U.S. states interacting with 196 cases.
  • Fifty four percent of raw case users came from outside the U.S..
  • The Yale School of Management (SOM) case study directory pages received over 160K page views from 177 countries with approximately a third originating in India followed by the U.S. and the Philippines.
  • Twenty-six of the cases in the list are raw cases.
  • A third of the cases feature a woman protagonist.
  • Orders for Yale SOM case studies increased by almost 50% compared to 2020.
  • The top 40 cases were supervised by 19 different Yale SOM faculty members, several supervising multiple cases.

CRDT compiled the Top 40 list by combining data from its case store, Google Analytics, and other measures of interest and adoption.

All of this year’s Top 40 cases are available for purchase from the Yale Management Media store .

And the Top 40 cases studies of 2021 are:

1.   Hertz Global Holdings (A): Uses of Debt and Equity

2.   Coffee 2016

3.   Hertz Global Holdings (B): Uses of Debt and Equity 2020

4.   Glory, Glory Man United!

5.   Search Fund Company Boards: How CEOs Can Build Boards to Help Them Thrive

6.   The Future of Malls: Was Decline Inevitable?

7.   Strategy for Norway's Pension Fund Global

8.   Prodigy Finance

9.   Design at Mayo

10. Cadbury

11. City Hospital Emergency Room

13. Volkswagen

14. Marina Bay Sands

15. Shake Shack IPO

16. Mastercard

17. Netflix

18. Ant Financial

19. AXA: Creating the New CR Metrics

20. IBM Corporate Service Corps

21. Business Leadership in South Africa's 1994 Reforms

22. Alternative Meat Industry

23. Children's Premier

24. Khalil Tawil and Umi (A)

25. Palm Oil 2016

26. Teach For All: Designing a Global Network

27. What's Next? Search Fund Entrepreneurs Reflect on Life After Exit

28. Searching for a Search Fund Structure: A Student Takes a Tour of Various Options

30. Project Sammaan

31. Commonfund ESG

32. Polaroid

33. Connecticut Green Bank 2018: After the Raid

34. FieldFresh Foods

35. The Alibaba Group

36. 360 State Street: Real Options

37. Herman Miller

38. AgBiome

39. Nathan Cummings Foundation

40. Toyota 2010

22 Cases and Articles to Help Bring Diversity Issues into Class Discussions

Explore more.

  • Course Materials
  • Diversity, Equity, and Inclusion

T he recent civic unrest in the United States following the death of George Floyd has elevated the urgency to recognize and study issues of diversity and the needs of underrepresented groups in all aspects of public life.

Business schools—and educational institutions across the spectrum—are no exception. It’s vital that educators facilitate safe and productive dialogue with students about issues of inclusion and diversity. To help, we’ve gathered a collection of case studies (all with teaching notes) and articles that can encourage and support these critical discussions.

These materials are listed across three broad topic areas: leadership and inclusion, cases featuring protagonists from historically underrepresented groups, and women and leadership around the world. This list is hardly exhaustive, but we hope it provides ways to think creatively and constructively about how educators can integrate these important topics in their classes. HBP will continue to curate and share content that addresses these equity issues and that features diverse protagonists.

Editors’ note: To access the full text of these articles, cases, and accompanying teaching notes, you must be registered with HBP Education. We invite you to sign up for a free educator account here . Verification may take a day; in the meantime, you can read all of our Inspiring Minds content .

Leadership and Inclusion

John Rogers, Jr.—Ariel Investments Co.

—by Steven S. Rogers and Greg White

Gender and Free Speech at Google (A)

—by Nien-hê Hsieh, Martha J. Crawford, and Sarah Mehta

The Massport Model: Integrating Diversity and Inclusion into Public-Private Partnerships

—by Laura Winig and Robert Livingston

“Numbers Take Us Only So Far”

—by Maxine Williams

For Women and Minorities to Get Ahead, Managers Must Assign Work Fairly

—by Joan C. Williams and Marina Multhaup

How Organizations Are Failing Black Workers—and How to Do Better

—by Adia Harvey Wingfield

To Retain Employees, Focus on Inclusion—Not Just Diversity

—by Karen Brown

From HBR 's The Big Idea:

Toward a Racially Just Workplace: Diversity efforts are failing black employees. Here’s a better approach.

—by Laura Morgan Roberts and Anthony J. Mayo

Cases with Protagonists from Historically Underrepresented Groups

Arlan Hamilton and Backstage Capital

—by Laura Huang and Sarah Mehta

United Housing—Otis Gates

—by Steven Rogers and Mercer Cook

Eve Hall: The African American Investment Fund in Milwaukee

—by Steven Rogers and Alterrell Mills

Dylan Pierce at Peninsula Industries

—by Karthik Ramanna

Maggie Lena Walker and the Independent Order of St. Luke

—by Anthony J. Mayo and Shandi O. Smith

Multimedia Cases:

Enterprise Risk Management at Hydro One, Multimedia Case

—by Anette Mikes

Women and Leadership Around the World

Monique Leroux: Leading Change at Desjardins

—by Rosabeth Moss Kanter and Ai-Ling Jamila Malone

Kaweyan: Female Entrepreneurship and the Past and Future of Afghanistan

—by Geoffrey G. Jones and Gayle Tzemach Lemmon

Womenomics in Japan

—by Boris Groysberg, Mayuka Yamazaki, Nobuo Sato, and David Lane

Women MBAs at Harvard Business School: 1962-2012

—by Boris Groysberg, Kerry Herman, and Annelena Lobb

Beating the Odds

—by Laura Morgan Roberts, Anthony J. Mayo, Robin J. Ely, and David A. Thomas

Rethink What You “Know” About High-Achieving Women

—by Robin J. Ely, Pamela Stone, and Colleen Ammerman

“I Try to Spark New Ideas”

—by Christine Lagarde and Adi Ignatius

How Women Manage the Gendered Norms of Leadership

—by Wei Zheng, Ronit Kark, and Alyson Meister

Is this list helpful to you? What other topics or materials would you like to see featured in our next curated list? Let us know .

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COURSE DESIGN

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case study related to leadership

Leadership Case Studies

Paul Thornton

Paul Thornton

case study related to leadership

Paul B. Thornton

For the past 30 years, I have conducted seminars, workshops, and taught college classes on leadership.

I used a variety of teaching aids including books, articles, case studies, role plays, and videos.

I recently created a book, Leadership Case Studies that includes some of the case studies and role-plays that I found to be most instructive and impactful.

Here is a sample of three case studies. 

Gil Ramos Case Study

Gil Ramos accepted an appointment as the new principal of Smithfield Vocational School in July 2012. At the time, approximately 620 students attended Smithfield.

He knew he was in for the biggest challenge of his career.

Ramos had 10 direct reports including eight academic department heads, one assistant principal, and an administrative assistant. He had been in the education field for the past 18 years. Ramos had spent eight years as a teacher and the last 12 years in various administrative roles at three different high schools.

During the interview process and speaking informally with people in the community he heard various comments about the school including:                      

Ramos also learned that each of Smithfield’s 12 vocational programs, were funded through Chapter 74 (Massachusetts Vocational Technical Education Regulations). The law required each vocational program to have an advisory committee of 7-to-10 industry leaders from the region. However, most of the educational programs had no advisory committee or, at best, one that was barely functioning.

Panera Bread Case Study

Ron Shaich, the former CEO of Panera Bread, believes there are two essential requirements of operating any successful business: discovery and delivery.

  • Discovery refers to the actions taken to identify new products and services that customers will want to buy.
  • Delivery refers to the actions taken to deliver products and services in the most efficient way. 

Every few months, Panera Bread demonstrates discovery by announcing the addition of a few new items on their menu.

In addition, they periodically demonstrate delivery by implementing a new process that makes it easier to place and/or pick up an order.

Each action, discovery and delivery, requires a different focus and set of skills. The discovery process requires collaborating and brainstorming to come up with new products and services. 

The delivery process involves flowcharting, measuring, analyzing, and simplifying processes and procedures to improve efficiency. 

In addition to “discovery and delivery” leaders must engage in a number of related activities such as:  

  • Action and reflection
  • Giving and receiving feedback
  • Discussing facts and feelings
  • Focusing on the present and future
  • Talking and listening

What is the right ratio? Of course, it depends on the situation. The right ratio doesn’t mean a 50-50 split. Each situation is unique and requires proper analysis to determine the most effective ratio to use. 

  • What are the consequences of focusing too much on discoveryand not enough on delivery?
  • What are the consequences of focusing too much on delivery and not enough on discovery?
  • What factors should leaders consider when trying to find the right ratio or balance between two related activities?   

Urban Meyer Case Study

Read the short book, Leadership Case Studies—The Motivational Techniques of Urban Meyer.

Go to YouTube and watch the video, “Ohio State Leadership Case Study.”

  • What are his top three leadership traits?
  • According to Meyer, what traits do coaches need to build trust with their players?   
  • What are the major actions he takes to build a winning team?
  • What new insights did you learn about leadership from this case study?

The book contains 16 case studies, 4 role-plays, and 6 articles. I hope you find some of the content useful and helpful in your efforts to teach leadership.

________________________________________________________________________  

Paul B. Thornton is an author and speaker. His latest e-books include:

  • Leadership-Perfecting Your Approach and Style-($1.99) Amazon Kindle. 
  • Leadership Case Studies-($4.99) Amazon Kindle.

He has produced 28 short YouTube videos on various management and leadership topics.  

He can be contacted at [email protected] .

The Ethical Leadership Case Study Collection

The Ted Rogers Leadership Centre’s Case Collection, developed in collaboration with experienced teaching faculty, seasoned executives, and alumni, provides instructors with real-life decision-making scenarios to help hone students’ critical-thinking skills and their understanding of what good leaders do. They will be able to leverage the theories, models, and processes being advanced. Students come to understand that workplace dilemmas are rarely black and white, but require them to think through and address competing claims and circumstances. Crucially, they also appreciate how they can, as new leaders and middle managers, improve decisions by creating realistic action plans based on sound stakeholder analysis and communication principles. These case studies are offered free of charge to all instructors.

group of students at a round table during the Top 200 Program summit

Cases come in both long and short forms. The long cases provide instructors with tools for delving deeply into subjects related to a variety of decision making and organizational development issues. The short cases, or “minis,” are quick in-class exercises in leadership.

For both the long cases and the minis, teaching-method notes are provided, which include not only recommended in-class facilitation methods, but also grading rubrics, references, and student feedback.

Testimonials

“I have been invited to judge the Leadership Centre’s Annual Ethical Leadership National Case Competition since its inception. Each year, competitors are given a Centre’s case to analyze and present. These cases are like nothing else. They bring the student into the heart of the situation. To excel, students must not only be able to cogently argue the options, but also demonstrate how to implement a decision based on a clear-eyed stakeholder analysis and an understanding of the dynamics of change.” Anne Fawcett, Special Advisor, Caldwell Partners
“I have worked with the Ted Rogers Leadership Centre to both develop and pilot test case materials. Feedback consistently shows that the Centre’s cases resonate with students, providing them with valuable learning experiences.” Chris Gibbs, BComm, MBA, PhD, Associate Professor
"As a judge in the recent national Ted Rogers Ethical Leadership Case Competition, I was very impressed with the quality of the case study prepared by the Leadership Centre. It was brief but well-composed. It exposed the students to ethical quandaries, of the sort they may well face in their business careers. It not only tested their reasoning, but it challenged them to develop a plan of action when faced with incomplete information and imminent deadlines.” Lorne Salzman, Lawyer

We value your feedback

Please inform us of your experience by contacting Dr. Gail Cook Johnson, our mentor-in-residence, at [email protected] .

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Leadership Effectiveness in Healthcare Settings: A Systematic Review and Meta-Analysis of Cross-Sectional and Before–After Studies

Vincenzo restivo.

1 Department of Health Promotion, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE) “G. D’Alessandro”, University of Palermo, Via del Vespro 133, 90127 Palermo, Italy

Giuseppa Minutolo

Alberto battaglini.

2 Vaccines and Clinical Trials Unit, Department of Health Sciences, University of Genova, Via Antonio Pastore 1, 16132 Genova, Italy

Alberto Carli

3 Santa Chiara Hospital, Largo Medaglie d’oro 9, 38122 Trento, Italy

Michele Capraro

4 School of Public Health, Vita-Salute San Raffaele University, Via Olgettina 58, 20132 Milan, Italy

Maddalena Gaeta

5 Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Via Forlanini 2, 27100 Pavia, Italy

Cecilia Trucchi

6 Planning, Epidemiology and Prevention Unit, Liguria Health Authority (A.Li.Sa.), IRCCS San Martino Hospital, Largo R. Benzi 10, 16132 Genoa, Italy

Carlo Favaretti

7 Centre on Leadership in Medicine, Catholic University of the Sacred Heart, Largo F. Vito 1, 00168 Rome, Italy

Francesco Vitale

Alessandra casuccio, associated data.

Data will be available after writing correspondence to the author.

To work efficiently in healthcare organizations and optimize resources, team members should agree with their leader’s decisions critically. However, nowadays, little evidence is available in the literature. This systematic review and meta-analysis has assessed the effectiveness of leadership interventions in improving healthcare outcomes such as performance and guidelines adherence. Overall, the search strategies retrieved 3,155 records, and 21 of them were included in the meta-analysis. Two databases were used for manuscript research: PubMed and Scopus. On 16th December 2019 the researchers searched for articles published in the English language from 2015 to 2019. Considering the study designs, the pooled leadership effectiveness was 14.0% (95%CI 10.0–18.0%) in before–after studies, whereas the correlation coefficient between leadership interventions and healthcare outcomes was 0.22 (95%CI 0.15–0.28) in the cross-sectional studies. The multi-regression analysis in the cross-sectional studies showed a higher leadership effectiveness in South America (β = 0.56; 95%CI 0.13, 0.99), in private hospitals (β = 0.60; 95%CI 0.14, 1.06), and in medical specialty (β = 0.28; 95%CI 0.02, 0.54). These results encourage the improvement of leadership culture to increase performance and guideline adherence in healthcare settings. To reach this purpose, it would be useful to introduce a leadership curriculum following undergraduate medical courses.

1. Introduction

Over the last years, patients’ outcomes, population wellness and organizational standards have become the main purposes of any healthcare structure [ 1 ]. These standards can be achieved following evidence-based practice (EBP) for diseases prevention and care [ 2 , 3 ] and optimizing available economical and human resources [ 3 , 4 ], especially in low-industrialized geographical areas [ 5 ]. This objective could be reached with effective healthcare leadership [ 3 , 4 ], which could be considered a network whose team members followed leadership critically and motivated a leader’s decisions based on the organization’s requests and targets [ 6 ]. Healthcare workers raised their compliance towards daily activities in an effective leadership context, where the leader succeeded in improving membership and performance awareness among team members [ 7 ]. Furthermore, patients could improve their health conditions in a high-level leadership framework. [ 8 ] Despite the leadership benefits for healthcare systems’ performance and patients’ outcomes [ 1 , 7 ], professionals’ confidence would decline in a damaging leadership context for workers’ health conditions and performance [ 4 , 9 , 10 ]. On the other hand, the prevention of any detrimental factor which might worsen both team performance and healthcare systems’ outcomes could demand effective leadership [ 4 , 7 , 10 ]. However, shifting from the old and assumptive leadership into a more effective and dynamic one is still a challenge [ 4 ]. Nowadays, the available evidence on the impact and effectiveness of leadership interventions is sparse and not systematically reported in the literature [ 11 , 12 ].

Recently, the spreading of the Informal Opinion Leadership style into hospital environments is changing the traditional concept of leadership. This leadership style provides a leader without any official assignment, known as an “opinion leader”, whose educational and behavioral background is suitable for the working context. Its target is to apply the best practices in healthcare creating a more familiar and collaborative team [ 2 ]. However, Flodgren et al. reported that informal leadership interventions increased healthcare outcomes [ 2 ].

Nowadays, various leadership styles are recognized with different classifications but none of them are considered the gold standard for healthcare systems because of heterogenous leadership meanings in the literature [ 4 , 5 , 6 , 12 , 13 ]. Leadership style classification by Goleman considered leaders’ behavior [ 5 , 13 ], while Chen DS-S proposed a traditional leadership style classification (charismatic, servant, transactional and transformational) [ 6 ].

Even if leadership style improvement depends on the characteristics and mission of a workplace [ 6 , 13 , 14 ], a leader should have both a high education in healthcare leadership and the behavioral qualities necessary for establishing strong human relationships and achieving a healthcare system’s goals [ 7 , 15 ]. Theoretically, any practitioner could adapt their emotive capacities and educational/working experiences to healthcare contexts, political lines, economical and human resources [ 7 ]. Nowadays, no organization adopts a policy for leader selection in a specific healthcare setting [ 15 ]. Despite the availability of a self-assessment leadership skills questionnaire for aspirant leaders and a pattern for the selection of leaders by Dubinsky et al. [ 15 ], a standardized and universally accepted method to choose leaders for healthcare organizations is still argued over [ 5 , 15 ].

Leadership failure might be caused by the arduous application of leadership skills and adaptive characteristics among team members [ 5 , 6 ]. One of the reasons for this negative event could be the lack of a standardized leadership program for medical students [ 16 , 17 ]. Consequently, working experience in healthcare settings is the only way to apply a leadership style for many medical professionals [ 12 , 16 , 17 ].

Furthermore, the literature data on leadership effectiveness in healthcare organizations were slightly significant or discordant in results. Nevertheless, the knowledge of pooled leadership effectiveness should motivate healthcare workers to apply leadership strategies in healthcare systems [ 12 ]. This systematic review and meta-analysis assesses the pooled effectiveness of leadership interventions in improving healthcare workers’ and patients’ outcomes.

2. Materials and Methods

A systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement guidelines [ 18 ]. The protocol was registered on the PROSPERO database with code CRD42020198679 on 15 August 2020. Following these methodological standards, leadership interventions were evaluated as the pooled effectiveness and influential characteristic of healthcare settings, such as leadership style, workplace, settings and the study period.

2.1. Data Sources and Search Strategy

PubMed and Scopus were the two databases used for the research into the literature. On 16th December 2019, manuscripts in the English language published between 2015 and 2019 were searched by specific MeSH terms for each dataset. Those for PubMed were “leadership” OR “leadership” AND “clinical” AND “outcome” AND “public health” OR “public” AND “health” OR “public health” AND “humans”. Those for Scopus were “leadership” AND “clinical” AND “outcome” AND “public” AND “health”.

2.2. Study Selection and Data Extraction

In accordance with the PRISMA Statement, the following PICOS method was used for including articles [ 18 ]: the target population was all healthcare workers in any hospital or clinical setting (Population); the interventions were any leader’s recommendation to fulfil quality standards or performance indexes of a healthcare system (Intervention) [ 19 ]; to be included, the study should have a control group or reference at baseline as comparison (Control); and any effectiveness measure in terms of change in adherence to healthcare guidelines or performances (Outcome). In detail, any outcome implicated into healthcare workers’ capacity and characteristics in reaching a healthcare systems purposes following the highest standards was considered as performance [ 19 ]. Moreover, whatever clinical practices resulted after having respected the recommendations, procedures or statements settled previously was considered as guideline adherence [ 20 ]. The selected study design was an observational or experimental/quasi-experimental study design (trial, case control, cohort, cross-sectional, before-after study), excluding any systematic reviews, metanalyses, study protocol and guidelines (Studies).

The leaders’ interventions followed Chen’s leadership styles classification [ 6 ]. According to this, the charismatic leadership style can be defined also as an emotive leadership because of members’ strong feelings which guide the relationship with their leader. Its purpose is the improvement of workers’ motivation to reach predetermined organizational targets following a leader’s planning strategies and foresights. Servant leadership style is a sharing leadership style in whose members can increase their skills and competences through steady leader support, and they have a role in an organization’s goals. The transformational leadership style focuses on practical aspects such as new approaches for problem solving, new interventions to reach purposes, future planning and viewpoints sharing. Originality in a transformational leadership style has a key role of improving previous workers’ and healthcare system conditions in the achievement of objectives. The transactional leadership style requires a working context where technical skills are fundamental, and whose leader realizes a double-sense sharing process of knowledge and tasks with members. Furthermore, workers’ performances are improved through a rewarding system [ 6 ].

In this study, the supervisor trained the research team for practical manuscript selection and data extraction. The aim was to ensure data homogeneity and to check the authors’ procedures for selection and data collection. The screening phase was performed by four researchers reading each manuscript’s title and abstract independently and choosing to exclude any article that did not fulfill the inclusion criteria. Afterwards, the included manuscripts were searched for in the full text. They were retrieved freely, by institutional access or requesting them from the authors.

The assessment phase consisted of full-text reading to select articles following the inclusion criteria. The supervisor solved any contrasting view about article selection and variable selection.

The final database was built up by collecting the information from all included full-text articles: author, title, study year, year of publication, country/geographic location, study design, viability and type of evaluation scales for leadership competence, study period, type of intervention to improve leadership awareness, setting of leader intervention, selection modality of leaders, leadership style adopted, outcomes assessed such as guideline adherence or healthcare workers’ performance, benefits for patients’ health or patients’ outcomes improvement, public or private hospitals or healthcare units, ward specialty, intervention in single specialty or multi-professional settings, number of beds, number of healthcare workers involved in leadership interventions and sample size.

Each included article in this systematic review and meta-analysis received a standardized quality score for the specific study design, according to Newcastle–Ottawa, for the assessment of the quality of the cross-sectional study, and the Study Quality Assessment Tools by the National Heart, Lung, and Blood Institute were used for all other study designs [ 21 , 22 ].

2.3. Statistical Data Analysis

The manuscripts metadata were extracted in a Microsoft Excel spreadsheet to remove duplicate articles and collect data. The included article variables for the quantitative meta-analysis were: first author, publication year, continent of study, outcome, public or private organization, hospital or local healthcare unit, surgical or non-surgical ward, multi- or single-professionals, ward specialty, sample size, quality score of each manuscript, leadership style, year of study and study design.

The measurement of the outcomes of interest (either performance or guidelines adherence) depended on the study design of the included manuscripts in the meta-analysis:

  • for cross-sectional studies, the outcome of interest was the correlation between leadership improvement and guideline adherence or healthcare performance;
  • the outcome derived from before–after studies or the trial was the percentage of leadership improvement intervention in guideline adherence or healthcare performance;
  • the incidence occurrence of improved results among exposed and not exposed healthcare workers of leadership interventions and the relative risks (RR) were the outcomes in cohort studies;
  • the odds ratio (OR) between the case of healthcare workers who had received a leadership intervention and the control group for case-control studies.

Pooled estimates were calculated using both the fixed effects and DerSimonian and Laird random effects models, weighting individual study results by the inverse of their variances [ 23 ]. Forest plots assessed the pooled estimates and the corresponding 95%CI across the studies. The heterogeneity test was performed by a chi-square test at a significance level of p < 0.05, reporting the I 2 statistic together with a 25%, 50% or 75% cut-off, indicating low, moderate, and high heterogeneity, respectively [ 24 , 25 ].

Subgroup analysis and meta-regression analyses explored the sources of significant heterogeneity. Subgroup analysis considered the leadership style (charismatic, servant, transactional and transformational), continent of study (North America, Europe, Oceania), median cut-off year of study conduction (studies conducted between 2005 and 2011 and studies conducted between 2012 and 2019), type of hospital organization (public or private hospital), type of specialty (surgical or medical specialty) and type of team (multi-professional or single-professional team).

Meta-regression analysis considered the following variables: year of starting study, continent of study conduction, public or private hospital, surgical or non-surgical specialty ward, type of healthcare service (hospital or local health unit), type of healthcare workers involved (multi- or single-professional), leadership style, and study quality score. All variables included in the model were relevant in the coefficient analysis.

To assess a potential publication bias, a graphical funnel plot reported the logarithm effect estimate and related the standard error from each study, and the Egger test was performed [ 26 , 27 ].

All data were analyzed using the statistical package STATA/SE 16.1 (StataCorp LP, College 482 Station, TX, USA), with the “metan” command used for meta-analysis, and “metafunnel”, “metabias” and “confunnel” for publication bias assessment [ 28 ].

3.1. Studies Characteristics

Overall, the search strategies retrieved 3,155 relevant records. After removing 570 (18.1%) duplicates, 2,585 (81.9%) articles were suitable for the screening phase, of which only 284 (11.0%) articles were selected for the assessment phase. During the assessment phase, 263 (92.6%) articles were excluded. The most frequent reasons of exclusion were the absence of relevant outcomes ( n = 134, 51.0%) and other study designs ( n = 61, 23.2%). Very few articles were rejected due to them being written in another language ( n = 1, 0.4%), due to the publication year being out of 2015–2019 ( n = 1, 0.4%) or having an unavailable full text ( n = 3, 1.1%).

A total of 21 (7.4%) articles were included in the qualitative and quantitative analysis, of which nine (42.9%) were cross-sectional studies and twelve (57.1%) were before and after studies ( Figure 1 ).

An external file that holds a picture, illustration, etc.
Object name is ijerph-19-10995-g001.jpg

Flow-chart of selection manuscript phases for systematic review and meta-analysis on leadership effectiveness in healthcare workers.

The number of healthcare workers enrolled was 25,099 (median = 308, IQR = 89–1190), including at least 2,275 nurses (9.1%, median = 324, IQR = 199–458). Most of the studies involved a public hospital ( n = 16, 76.2%). Among the studies from private healthcare settings, three (60.0%) were conducted in North America. Articles which analyzed servant and charismatic leadership styles were nine (42.9%) and eight (38.1%), respectively. Interventions with a transactional leadership style were examined in six (28.6%) studies, while those with a transformational leadership style were examined in five studies (23.8%). Overall, 82 healthcare outcomes were assessed and 71 (86.6%) of them were classified as performance. Adherence-to-guidelines outcomes were 11 (13.4%), which were related mainly to hospital stay ( n = 7, 64.0%) and drug administration ( n = 3, 27.0%). Clements et al. and Lornudd et al. showed the highest number of outcomes, which were 19 (23.2%) and 12 (14.6%), respectively [ 29 , 30 ].

3.2. Leadership Effectiveness in before–after Studies

Before–after studies ( Supplementary Table S1 ) involved 22,241 (88.6%, median = 735, IQR = 68–1273) healthcare workers for a total of twelve articles, of which six (50.0%) consisted of performance and five (41.7%) of guidelines adherence and one (8.3%) of both outcomes. Among healthcare workers, there were 1,294 nurses (5.8%, median = 647, IQR = 40–1,254). Only the article by Savage et al. reported no number of involved healthcare workers [ 31 ].

The number of studies conducted after 2011 or between 2012–2019 was seven (58.3%), while only one (8.3%) article reported a study beginning both before and after 2011. Most of studies were conducted in Northern America ( n = 5, 41.7%). The servant leadership style and charismatic leadership style were the most frequently implemented, as reported in five (41.7%) and four (33.3%) articles, respectively. Only one (8.3%) study adopted a transformational leadership style.

The pooled effectiveness of leadership was 14.0% (95%CI 10.0–18.0%), with a high level of heterogeneity (I 2 = 99.9%, p < 0.0001) among the before–after studies ( Figure 2 ).

An external file that holds a picture, illustration, etc.
Object name is ijerph-19-10995-g002.jpg

Effectiveness of leadership in before after studies. Dashed line represents the pooled effectiveness value [ 29 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ].

The highest level of effectiveness was reported by Weech-Maldonado R et al. with an effectiveness of 199% (95%CI 183–215%) based on the Cultural Competency Assessment Tool for Hospitals (CCATH) [ 39 ]. The effectiveness of leadership changed in accordance with the leadership style ( Supplementary Figure S1 ) and publication bias ( Supplementary Figure S2 ).

Multi-regression analysis indicated a negative association between leadership effectiveness and studies from Oceania, but this result was not statistically significant (β = −0.33; 95% IC −1.25, 0.59). On the other hand, a charismatic leadership style affected healthcare outcomes positively even if it was not statistically relevant (β = 0.24; 95% IC −0.69, 1.17) ( Table 1 ).

Correlation coefficients and multi-regression analysis of leadership effectiveness in before–after studies.

3.3. Leadership Effectiveness in Cross Sectional Studies

A total of 2858 (median = 199, IQR = 110–322) healthcare workers were involved in the cross-sectional studies ( Supplementary Table S2 ), of which 981 (34.3%) were nurses. Most of the studies were conducted in Asia ( n = 4, 44.4%) and North America ( n = 3, 33.3%). All of the cross-sectional studies regarded only the healthcare professionals’ performance. Multi-professional teams were involved in seven (77.8%) studies, and they were more frequently conducted in both medical and surgical wards ( n = 6, 66.7%). The leadership styles were equally distributed in the articles and two (22.2%) of them examined more than two leadership styles at the same time.

The pooled effectiveness of the leadership interventions in the cross-sectional studies had a correlation coefficient of 0.22 (95%CI 0.15–0.28), whose heterogeneity was remarkably high (I 2 = 96.7%, p < 0.0001) ( Figure 3 ).

An external file that holds a picture, illustration, etc.
Object name is ijerph-19-10995-g003.jpg

Effectiveness of leadership in cross-sectional studies. Dashed line represents the pooled effectiveness value [ 30 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ].

The effectiveness of leadership in the cross-sectional studies changed in accordance with the leadership style ( Supplementary Figure S3 ) and publication bias ( Supplementary Figure S4 ).

Multi-regression analysis showed a higher leadership effectiveness in studies conducted in South America (β = 0.56 95%CI 0.13–0.99) in private hospitals (β = 0.60; 95%CI 0.14–1.06) and in the medical vs. surgical specialty (β = −0.22; 95%CI −0.54, −0.02) ( Table 2 ).

Multi-regression analysis of leadership effectiveness in cross-sectional studies.

* 0.05 ≤ p < 0.01.

4. Discussion

Leadership effectiveness in healthcare settings is a topic that is already treated in a quantitative matter, but only this systematic review and meta-analysis showed the pooled effectiveness of leadership intervention improving some healthcare outcomes such as performance and adherence to guidelines. However, the assessment of leadership effectiveness could be complicated because it depends on the study methodology and selected outcomes [ 12 ]. Health outcomes might benefit from leadership interventions, as Flodgren et al. was concerned about opinion leadership [ 2 ], whose adhesion to guidelines increased by 10.8% (95% CI: 3.5–14.6%). On the other hand, other outcomes did not improve after opinion leadership interventions [ 2 ]. Another review by Ford et al. about emergency wards reported a summary from the literature data which acknowledged an improvement in trauma care management through healthcare workers’ performance and adhesion to guidelines after effective leadership interventions [ 14 ]. Nevertheless, some variables such as collaboration among different healthcare professionals and patients’ healthcare needs might affect leadership intervention effectiveness [ 14 ]. Therefore, a defined leadership style might fail in a healthcare setting rather than in other settings [ 5 , 13 , 14 ].

The leadership effectiveness assessed through cross-sectional studies was higher in South America than in other continents. A possible explanation of this result could be the more frequent use of a transactional leadership style in this area, where the transactional leadership interventions were effective at optimizing economic resources and improving healthcare workers’ performance through cash rewards [ 48 ]. Financing methods for healthcare organizations might be different from one country to another, so the effectiveness of a leadership style can change. Reaching both economic targets and patients’ wellness could be considered a challenge for any leadership intervention [ 48 ], especially in poorer countries [ 5 ].

This meta-analysis showed a negative association between leadership effectiveness and studies by surgical wards. Other research has supported these results, which reported surgical ward performance worsened in any leadership context (charismatic, servant, transactional, transformational) [ 47 ]. In those workplaces, adopting a leadership style to improve surgical performance might be challenging because of nervous tension and little available time during surgical procedures [ 47 ]. On the other hand, a cross-sectional study declared that a surgical team’s performance in private surgical settings benefitted from charismatic leadership-style interventions [ 42 ]. This style of leadership intervention might be successful among a few healthcare workers [ 42 ], where creating relationships is easier [ 6 ]. Even a nursing team’s performance in trauma care increased after charismatic leadership-style interventions because of better communicative and supportive abilities than certain other professional categories [ 29 , 47 ]. However, nowadays there is no standardized leadership in healthcare basic courses [ 5 , 6 , 12 ]. Consequently, promoting leadership culture after undergraduate medical courses could achieve a proper increase in both leadership agreement and working wellness as well as a higher quality of care. [ 17 ]. Furthermore, for healthcare workers who have already worked in a healthcare setting, leadership improvement could consist of implementing basic knowledge on that topic. Consequently, they could reach a higher quality of care practice through working wellness [ 17 ] and overcoming the lack of previous leadership training [ 17 ].

Although very few studies have included in a meta-analysis examined in private healthcare settings [ 35 , 38 , 40 , 41 , 42 ], leadership interventions had more effectiveness in private hospitals than in public hospitals. This result could be related to the continent of origin, and indeed 60.0% of these studies were derived from North America [ 38 , 41 , 42 ], where patients’ outcomes and healthcare workers’ performance could influence available hospital budgets [ 38 , 40 , 41 , 42 ], especially in peripheral healthcare units [ 38 , 41 ]. Private hospitals paid more attention to the cost-effectiveness of any healthcare action and a positive balance of capital for healthcare settings might depend on the effectiveness of leadership interventions [ 40 , 41 , 42 ]. Furthermore, private healthcare assistance focused on nursing performance because of its impact on both a patients’ and an organizations’ outcomes. Therefore, healthcare systems’ quality could improve with effective leadership actions for a nursing team [ 40 ].

Other factors reported in the literature could affect leadership effectiveness, although they were not examined in this meta-analysis. For instance, professionals’ specialty and gender could have an effect on these results and shape leadership style choice and effectiveness [ 1 ]. Moreover, racial differences among members might influence healthcare system performance. Weech-Maldonado et al. found a higher compliance and self-improvement by black-race professionals than white ones after transactional leadership interventions [ 39 ].

Healthcare workers’ and patients’ outcomes depended on style of leadership interventions [ 1 ]. According to the results of this meta-analysis, interventions conducted by a transactional leadership style increased healthcare outcomes, though nevertheless their effectiveness was higher in the cross-sectional studies than in the before–after studies. Conversely, the improvement by a transformational leadership style was higher in before–after studies than in the cross-sectional studies. Both a charismatic and servant leadership style increased effectiveness more in the cross-sectional studies than in the before–after studies. This data shows that any setting required a specific leadership style for improving performance and guideline adherence by each team member who could understand the importance of their role and their tasks [ 1 ]. Some outcomes had a better improvement than others. Focusing on Savage et al.’s outcomes, a transformational leadership style improved checklist adherence [ 31 ]. The time of patients’ transport by Murphy et al. was reduced after conducting interventions based on a charismatic leadership style [ 37 ]. Jodar et al. showed that performances were elevated in units whose healthcare workers were subjected to transactional and transformational leadership-style interventions [ 1 ].

These meta-analysis results were slightly relevant because of the high heterogeneity among the studies, as confirmed by both funnel plots. This publication bias might be caused by unpublished articles due to either lacking data on leadership effectiveness, failing appropriate leadership strategies in the wrong settings or non-cooperating teams [ 12 ]. The association between leadership interventions and healthcare outcomes was slightly explored or gave no statistically significant results [ 12 ], although professionals’ performance and patients’ outcomes were closely related to the adopted leadership style, as reported by the latest literature sources [ 7 ]. Other aspects than effectiveness should be investigated for leadership. For example, the evaluation of the psychological effect of leadership should be explored using other databases.

The study design choice could affect the results about leadership effectiveness, making their detection and their statistical relevance tough [ 12 ]. Despite the strongest evidence of this study design [ 50 ], nowadays, trials about leadership effectiveness on healthcare outcomes are lacking and have to be improved [ 12 ]. Notwithstanding, this analysis gave the first results of leadership effectiveness from the available study designs.

Performance and adherence to guidelines were the main two outcomes examined in this meta-analysis because of their highest impact on patients, healthcare workers and hospital organizations. They included several other types of outcomes which were independent each other and gave different effectiveness results [ 12 ]. The lack of neither an official classification nor standardized guidelines explained the heterogeneity of these outcomes. To reach consistent results, they were classified into performance and guideline adherence by the description of each outcome in the related manuscripts [ 5 , 6 , 12 ].

Another important aspect is outcome assessment after leadership interventions, which might be fulfilled by several standardized indexes and other evaluation methods [ 40 , 41 ]. Therefore, leadership interventions should be investigated in further studies [ 5 ], converging on a univocal and official leadership definition and classification to obtain comparable results among countries [ 5 , 6 , 12 ].

5. Conclusions

This meta-analysis gave the first pooled data estimating leadership effectiveness in healthcare settings. However, some of them, e.g., surgery, required a dedicated approach to select the most worthwhile leadership style for refining healthcare worker performances and guideline adhesion. This can be implemented using a standardized leadership program for surgical settings.

Only cross-sectional studies gave significant results in leadership effectiveness. For this reason, leadership effectiveness needs to be supported and strengthened by other study designs, especially those with the highest evidence levels, such as trials. Finally, further research should be carried out to define guidelines on leadership style choice and establish shared healthcare policies worldwide.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/ijerph191710995/s1 , Figure S1. Leadership effectiveness by leadership style in before after studies; Figure S2. Funnel plot of before after studies; Figure S3. Leadership effectiveness in cross sectional studies by four leadership style; Figure S4. Funnel plot of cross-sectional studies; Table S1. Before after studies included in this systematic review and meta-analysis; Table S2. Cross-sectional studies included in this systematic review and meta-analysis. All outcomes were performance.

Funding Statement

This research received no external funding.

Author Contributions

Conceptualization, V.R., A.C. (Alessandra Casuccio), F.V. and C.F.; methodology, V.R., M.G., A.O. and C.T.; software, V.R.; validation, G.M., A.B., A.C. (Alberto Carli) and M.C.; formal analysis, V.R.; investigation, G.M., A.B., A.C. (Alberto Carli) and M.C.; resources, A.C. (Alessandra Casuccio); data curation, G.M. and V.R.; writing—original draft preparation, G.M.; writing—review and editing, A.C. (Alessandra Casuccio), F.V., C.F., M.G., A.O., C.T., A.B., A.C. (Alberto Carli) and M.C.; visualization, G.M.; supervision, V.R.; project administration, C.F.; funding acquisition, A.C. (Alessandra Casuccio), F.V. and C.F. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Ethical review and approval were waived for this study due to secondary data analysis for the systematic review and meta-anlysis.

Informed Consent Statement

Not applicable.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Overview of the leadership exchange theory, case study: xyz corporation, impact on organizational effectiveness, recommendations for improvement.

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