Original Associations between Leadership Style and Employee Resistance in a Healthcare Setting

Purpose: Health reform is forcing healthcare administrators to make rapid changes. A tendency to resist change can present problems for the leaders of health care organizations, including the large, not-for profit Catholic healthcare systems. The transformational leadership style has been shown to be positively correlated with change however, the relationship among leadership styles, employees’ behaviors, and motivation to change are still not well understood and require further study. Further, although Oreg’s Resistance to Change (RTC) approach has been researched in direct patient care areas, RTC research in non-patient settings is lacking. Methods: This study focused on the relationship of transformational leadership to RTC and if the relationships leaders’ have with subordinates’ influence change. A customized survey that included the Multifactor Leadership Questionnaire, RTC, and Leader Member Exchange (LMX 7) was emailed to 500 random individuals of various ages and races from three non-patient areas. Thirty leaders (included directors and managers) and 133 raters (those under the direction of a director or manager) responded. Results: The regression analysis showed a strong correlation between transformational leadership and RTC. Additionally, each of the variables from the LMX 7 section of the survey showed associations indicating the relationship leaders develop with their subordinates and leader transformational scores were positive. Conclusion: This study may contribute to the awareness of RTC and utilizing transformational leadership style to move change in a positive direction for a healthcare setting.


Introduction
Traditional law was first introduced in 1200 BC., which led to the first documentation of organizational change (Burke, 2011). Today, different approaches and theories are used by healthcare organizations to impact change. Change is often feared in healthcare organizations, which makes it even more difficult to occur. With the fast rate of change among healthcare organizations (Burke, 2011), it is important to discover a way to overcome resistance to it. Healthcare organizations are at risk of losing an average of $135 million dollars for every $1 billion invested (Langley, Smallman, Tsoukas, & Van de Ven, 2013).
For many years, leaders have served to overcome hurdles and lead organizations toward achievements.
Change occurs both in small increments and with leaps and bounds. Change is usually not incremental; it can be nonlinear (Burke, 2011). The health care industry is known for advancements to occur daily; therefore, preparation for change can be complicated at times. Health care usually follows an evolutionary change pattern, which involves organizational strategic planning and careful development; the mission acts as the primary entity making change (Burke, 2011). With change occurring rapidly and with reimbursement driving the healthcare organization to change, a leader's influence remains a factor.
According to Al-Swidi (2012), transformational leadership can improve employees' behaviors. There is, however, a gap in the association between a not-for-profit Catholic healthcare organization, transformational leadership, and the ability to motivate people to change.
According to Oreg (2003), four underlining factors are correlated with RTC: (a) routine seeking, (b) emotional reaction to imposed change, (c) short term focus, and (d) cognitive rigidity. Many leaders in healthcare face change; they handle it in different ways, using diverse theories. One such theory is called "transformational leadership", it was founded, in part, by Bass (1999). This type of leadership style has leaders working hand in hand with subordinates to identify the needed change and then creating a vision to guide the change. The founding theorist proposed that transformational leaders exhibited "superior leadership performance" (Bass, 1999, p. 21).
Transformational leadership is commonly practiced in business sectors other than health care, where it has been found to be beneficial. Transformational leadership is also a contributing factor in several vital change.

Study Design
This study utilized three tools that were customized into one questionnaire but were first separately analyzed and then analyzed together. The first section of the questionnaire is the MLQ, focusing only on transformational leadership, which was redesigned (Bass & Avolio, 2003).
The questionnaire was web-based, and respondents were able to retrieve the survey through Mind Garden Transform MLQ 360 online survey. With a confidence level of 95% and a sample size of 500, the percentage was 50%, leaving the confidence interval at 4.38. Five hundred random associates (raters) and 85 random leaders were identified through human resources as current employees based on payroll status. The questionnaire contained a series of multiple-choice questions. The leader had three sections in the survey to answer.
The first section asks about demographics including age, gender, region, and race. The questionnaire consists of 37 questions in two sections. The first section of the questionnaire has 20 questions correlated to the leader and the raters their describing leadership style and focusing on transformational The second section contained 17 statements concerning a participant's overall beliefs and attitudes about change. The 17-item scale, Dispositional Resistance to Change (RTC), introduced by Oreg (2003) was used to measure resistance to change. The scale identifies four factors: (a) routine seeking, (b) emotional reaction, (c) short-term focus, and (d) cognitive rigidity. The respondents' answered on a 5-point scale from Strongly Disagree to Strongly Agree. Studies by Oreg and colleagues have shown that dispositional RTC affects occupational interests and choices (Oreg et al., 2009). Additionally, Oreg and Sverdlik (2011) demonstrated that the feelings toward the change agent correlated with the relationship between dispositional RTC and resistance towards change, meaning that change was only positive amongst employees who were positively oriented toward the change agent. Therefore, RTC is a valid resource for a resistance of change measurement. Most healthcare organizations are able to initiate change; however, it's the followers' resistance that remains the challenge.
In third section for the rater, respondents answered seven questions pertaining to his or her leader and the contributing variables that are crucial to consider during change. The main focus of LMX-7 is the unique relationship leaders cultivate with their followers (Schyns & Day, 2010). Consequently, the distinctive relationship between a leader and follower is the principal focus of concern. The rewards include better communication, emotional support, and higher roles. The associates (raters) answered www.scholink.org/ojs/index.php/rhs Research in Health Science Vol. 5, No. 2, 2020 Published by SCHOLINK INC.
seven questions on a scale from Rarely to Very often.

Setting and Participants
The population size consists of a random-sized group from three departments containing 500 associates and 85 leaders. Department type were defined as the department category in which each respondents was working as self-reported on the demographic survey. Department type categories included Information Management (including Health Informatics), Human Resources, and Patient Financial Services. The anonymity of participants were protected by non-association of email correspondence and generically labeling of respondents as "Leader" or "Rater". At the end of the data collection period, 158 respondents had submitted data, 30 leaders and 133 raters. Of the leaders, the data from five leaders were excluded from analysis because their raters did not respond.

Measures
Quantitative data was collected from the customized MLQ360 online Mind Garden's Transform™ questionnaire. This questionnaire enabled the researcher to make comparisons by linking leadership characteristics in a not-for-profit Catholic organization at a departmental level and the resistance to change among the employees in each of the three departments. Additionally, the questionnaire focused on (a) the context of employees' reactions to change and (b) leadership styles in a not-for-profit Catholic organization.

Data Collection
Three questionnaires were administered. Based on answers to the custom MLQ 360 online questionnaire answered the following questions: • How does leadership dictate changes that are orchestrated today in healthcare?
• What factors provided relevance in understanding change?
• What leadership style influences change in a healthcare organization?

Statistical Analysis
The integrated data gathered from the 20 questions focusing on transformational leadership were there is a variable relationship. In order to determine the frequency of the dependent variable and the standardized residuals, a histogram was used.

Hypothesis Tests
Looking at the results from the analysis, it is observed that almost in all the cells have values that represents correlation between variables considered. For the importance of this study, each correlation coefficient was further subjected to significant test in other to identify only the significant correlation coefficients and to avoid misinterpretation of the whole data. Pearson correlation, which can range in size from -1.00 to +1.00. The power of the association of the variables is determined by this test (Gujarati, 2003). A correlation of 0 indicates no relationship, while 1.0 indicates a perfect positive correlation and -1.0 indicates a perfect negative correlation. implies that the correlation is significant at α = 0.01, and showed higher correlation with RTC 11, "Often, I feel a bit uncomfortable even about changes that may potentially improve my life", resulted at -.227. In addition to MLQ question 8, a higher correlation resulted at α = 0.01 was recognized with MLQ question 11, "I act in ways that build others' respect for me", and RTC question, "Often, I feel a bit uncomfortable even about changes that may potentially improve my life.  change. An analysis of overall resistance to change was performed by comparing the mean RTC scores of leaders and raters in Table 3. there's going to be a significant change regarding the way things are done at work, I would probably feel stressed. The model is significant with P-value 0.039 < α = 0.05.
In regression, the total sum of squares helps express the total variation of the y's. The regression sum of squares is the variation attributed to the relationship between the x's and y's. The sum of squares of the residual error is the variation attributed to the error. By comparing the regression sum of squares to the total sum of squares, you determine the proportion of the total variation that is explained by the regression model (R2, the coefficient of determination possible. Table 4 showed the model is significant with p-value 0.039 < α = 0.05 because all p-values were greater than .05, this test shows that this data provide substantial evidence that individuals are not resistance to change unless change occurred significantly at work.  Table 8. Cognitive rigidity has the highest mean and its' mean significantly differs from that of other subscales. Emotional reaction also has a mean next to Cognitive rigidity, nevertheless, it differs from cognitive rigidity as well from other subscales. Routine seeking has a mean 3rd in ranking when compared in descending order. Its mean is different from the mean observed for other subscales. And finally, Short-term focus has the lowest mean value. In conclusion, from the result of the analysis, there is a significant difference between the observed means for the subscales.  Note. Means for groups in homogeneous subsets are displayed. Since group sizes are unequal, the harmonic mean of the group sizes was used. Type 1 error levels are not guaranteed. The regression equation is simpler if variables are standardized so that their means are equal to 0 and standard deviations are equal to 1, for then b = r and A = 0. Detailed regression results can be seen in Table 9. From the model summary table, the criteria to be considered is Adjusted R2, as it adjusted for any variable added or removed from the model. A total of 20 models were reviewed at the end of the analysis using backward elimination method. Model 15 has the highest Adjusted R2, even though the value is 0.069, therefore we are going to consider it as the best model. Table 10 includes detailed information about this model. The Dependent Variable: I generally consider changes to be a negative thing was analyzed against constant MLQ Predictors: I talk optimistically about the future, I spend time teaching and coaching, I specify the importance of having a strong sense of purpose, I consider each individual as having different needs abilities and aspiration from others, I go beyond self-interest for the good of the group, and I act in ways that build others respect for me. results. The results of the regression equation is RTC1 = 2.094 + 0.289 (MLQ4) -0.298 (MLQ11). We can therefore conclude that MLQ4 , I consider each individual as having different needs abilities and aspiration from others and MLQ11, I act in ways that build others respect for me does have positive results and could assist in to RTC question, I generally consider changes to be a negative thing, to become a positive influential factor.

LMX 7 Data Analysis
To find the answer to H02, There is no relationship between relationships leaders develop with their subordinates and leader transformational scores, the following analyses were conducted. Using the LMX 7 questionnaire, the total score was calculated for each respondent. Additionally, the MLQ questionnaire consisted of using the five leadership style scale in consideration were: Individual Consideration, Intellectual Stimulation, Idealized Influence (Behavior), Inspirational Motivation, and Idealized Influence (Attributes). Each of these have been related to transformational leadership style.
The average was then calculated for each of the five scales. This process was done to come up with a concise and valid analysis. Having made these modifications, the variables in question became quantitative and could easily be analyzed using Pearson's correlation coefficient to test for the presence of association among the variables. Below is a list of finding that was gathered using the LMX 7 questionnaire: 1. There is an association between relationships leaders develop with their subordinates and individual consideration with a correlation value of 0.902, p<.000. Meaning that the higher the relationship leaders develop with their subordinates, the higher individual consideration.

There is an association between relationships leaders develop with their subordinates and Intellectual
Stimulation with a correlation value of 0.869, p<.000. Which implies the higher the relationship leaders develop with their subordinates, the higher Intellectual Stimulation becomes.
3. Also, there is an association between relationships leaders develop with their subordinates and relationship leaders develop with their subordinates, the higher inspirational Motivation.

There is relationship between relationships leaders develop with their subordinates and Idealized
Influence (Attribute) with a correlation value of 0.883, p<.000. Which implies the higher the relationship leaders develop with their subordinates, the higher Idealized Influence (Attributes) becomes.
Since the hypothesis states that "there is no correlation between relationships leaders develop with their subordinates and leader transformational scores" one can only reject this if there is a significant relation between the variables "relationships leaders develop with their subordinates and leader transformational scores". From the above table, there is a correlation coefficient between LMX 7 total scores and the Five Leadership style scales in consideration. It is observed that all LMX 7 total scores correlate significantly with all the Five Leadership style scales, we therefor can reject the null hypothesis "there is no relationship between relationships leaders develop with their subordinates and leader transformational scores" and conclude that there is relationship between relationships leaders develop with their subordinates and leader transformational scores. The data can be found in Table 12.

Study Limitations
A strong correlation exists between transformational leadership and resistance to change. However, after additional analysis utilizing ANOVA and multivariate regression, the adjusted R2 remained low. A low R2 value is not necessarily negative. Since this study is predicting human perceptions, the low R2 scores may still be considered relevant. The overall sample size was 153; however, only 25 leaders were evaluated regarding transformational leadership style. Additionally, the independent and dependent variables in this study were associates' and leaders' opinions rather than their actual behaviors. The study did not verify participation in change management nor did it address actual aspects that frame a person's leadership style. Ultimately, the study measured the values that the individuals ascribed to the respective research areas. Leadership and management are both culturally-constrained. Religion, social customs, politics, values, and the environment can influence leadership and management. The product of working in a healthcare setting is a rapidly changing environment. Thus, the culture of a specific setting may also change. An organization may establish its cultural norms and values, but that does not mean each individual participates. This factor may lead to a bias since culture is sometimes misunderstood in a healthcare setting. To offset this, a randomized sample of 500 was utilized to establish some variance with the answers provided. In contrast, the results might not apply to all healthcare settings because of cultural differences. External factors can also influence leaders and management styles. Economic restraints, specified policies, interventional relations, and climate conditions are just a few of the operational circumstances in which leaders have to operate. Each individual can thrive and function effectively in certain situations. These factors were not evaluated in this research. Therefore, in order to raise the leader's efficiency, changing the situation or perhaps placing the right individual in a given situation can change and predict the needed outcome or result. This study, focused on a Not-for-profit healthcare organization. To ensure validity, the study should be repeated in other healthcare settings.
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Conclusion
The evidence produced in this study indicates that transformational leadership style can influence resistance to change in a healthcare setting. Furthermore, the quality of relationships leaders create with their subordinates is positively correlated with transformational leadership. Utilizing transformational leadership style as training mechanism could improve the implementation of changes and help leaders function well in a rapidly changing healthcare setting. Leadership and healthcare change management have faced many obstacles and change throughout the years. The tools needed to implement change in a healthcare setting have been researched, but finding a solid solution remains a challenge. This study addressed the ways a leader can mark the course using transformational leadership. Leaders are constantly striving for methods to identify the correct course of action when change is necessary. Just recognizing a need for change is not enough. Leaders need to support the change and work toward the goals of the change. However, as humans, it is natural to have resistance to change (Oreg, 2003). This study provided evidence that transformational leadership is essential when conquering resistance to change. Transformational leadership has characteristics that encompass change. In general, influencing individuals' attitudes, events, behaviors, and choices comes easily to transformational leaders. These leaders are good at switching perspectives. For example, subordinates that value constancy and steadiness may perceive organizational change as a danger and therefore resist it. Whereas individuals that desire stimulation and rejuvenation may interpret it as an opportunity and will more than likely welcome it. Therefore, leaders' values inspire the goals they assign and the outcomes that they will reward (Oreg & Berson, 2009 Vol. 5, No. 2, 2020