Leadership Styles in Health Crisis among Non-Governmental Hospital in Gaza Strip a Case Study: Al-Quds Hospital in Palestinian Red Crescent Society

For an organization to succeed, employees must work with an agreement to fulfill their aims. Because leadership includes a display of style or behavior by managers or supervisors while dealing with subordinates, leadership is one of the determining factors in employee behavior towards organizational goals Saeed et al. [1]. For many, leaders are not born but made. However, it is increasingly accepted that so as to be a good leader, one must have experience, knowledge, commitment, patience, and most importantly the skill of negotiating and working with others to fulfill aims. This is how good leaders are made, not born. Good leadership is developed during a never-ending process of self-study, education, training, and gathering of relevant experience Bass & Bass [2].

"The effect of the crisis on organizations and persons has been stronger than ever" Wang [3]. Leaders in organizations want to understand these words. They must have special skills, which will qualify them to lead, and resolve the potential crisis that may threaten the presence of their organizations. Houlihan (2007) illustrated that samples of these skills are the capacity to expect the natural response of employees and talk over with them a strategy to do the hard operation more efficient.

Its commentary offers that what leaders need to make to know the staff and participate in an obvious side of where the organization should be in the post-crisis future. In short, you need to build a mutual relationship. In addition, it is important to provide greater autonomy for employees and to view them as owners of organizations Collins [4]. This indicates that followers should be considered as responsible adults. Leaders want to confidence them to find their ideas and explore their inventive thinking in the potential to manage a crisis Harwati [5].

The expanding role of organizations, their size, and the complexity of their work, the diversity of internal relations, their correlation and their impact on the external environment are political, economic and social influences. These require continuous research and development, and this can only be achieved under conscious leadership Alnamr et al. [6]. Always, decisions are made to make an order, to explain a crisis management problem or to deal with many ineffective results.

More important is to make the correct decision that all persons understand and lead to perfect results. Accordingly, less management and more leadership are highly recommended to transact with or solve any problem or crisis Hassan & Rjoub [7]. The leadership style of hospital decision-makers and leaders - especially in times of health crisis - may play a main part in the crisis reaction process and the quality of health care provided, particularly in our situation in Palestine in general and in the GS in particular. Crisis and disasters are always close by the Israeli siege of the service sector for more than a decade, which included three harsh wars in 2008, 2012 and 2014. Hospitals were among the most suffering and continue to suffer Aljamal et al. [8].

Problem statement

The past decade (and currently), difficult years for the residents of the Gaza Strip and the health sector in particular as they facing much crisis, a crisis after another have exhausted citizens of the Gaza Strip. This crisis is disturbing the health sector and undoubtedly threatens the health services system and will have already serious and harsh effects that will cost the Palestinian patient his life. So, it is needed to prepare well to deal with this crisis and that there are good leaders of hospitals who can manage the health crisis and good response to any crisis surrounding them and draw lessons from the previous crises. So, the purpose of the study to discuss the leadership styles in health crisis management among health care providers at non- governmental hospitals in the Gaza strip.

General objective

The general objective of this study is to understand the leadership styles in health crisis management among healthcare providers at Al-Quds hospital in GS.

Specific objectives of the study

To describe the effectiveness of transformational leadership in health crisis management among health care providers at Al-Quds hospital in GS.

To identify the effectiveness of transactional leadership in health crisis management among health care providers at Al-Quds hospital in GS

To determine the effectiveness of charismatic leadership in health crisis management among health care providers at Al-Quds hospital in GS.

To identify the association between socio-demographic characteristics and leadership style in al-Quds hospital.

To provide recommendations and results to be taken during the management of the health crisis and disaster.

Strategy of the study

Based on the nature of the study and the goals that it looks for to realize, the researcher used the descriptive-analytical design, which is based on the study of the phenomenon as it exists in reality and is concerned as a precise description and expressed in qualitative and quantitative terms. This approach is not sufficient to collect information related to the phenomenon, but rather to analysis, linkage and interpretation to arrive at conclusions based on the proposed scenario to increase the knowledge of the subject.

Setting of the study

The research was accomplished in Gaza stripe in Palestine, which comprises of five governorates: Rafah governorate, Khan Younis governorate, the mid-zone governorate, Gaza governorate, and Northern governorate. The study will be carried out in critical areas (emergency department, operating room, intensive care unit) at Al Quds Hospital of the PRCS.

Study period

The research was conducted four months from July 2019 to the end of October 2019.

The study population consisted of all healthcare providers include

1. Medical professionals.
2. Nurses (Nursing Manager, Nursing Supervisor, Head of Nursing department, staff nurse).
3. Paramedics (Anesthesia technicians, OR technicians).

1. The researcher used proportional census sample which include all health care provider as it was most appropriate sampling for this population which are health care providers who are working at critical area at hospital (emergency department, operating room, intensive care units) in Al-Quds, which is expected to provide a real population benchmark and a more representative sample without sampling errors.
2. The population of the study is 87 participants, the researcher distributed questionnaires to all populations to have more accurate results of the study the number of respondents was 82 out of 87 (response rate was 94.25%.), and that was higher than the sample size.

Inclusion criteria

All health care providers who are working in critical areas in Al- Quds hospital is qualified for choice in this study.

 The selected health care providers in critical areas were:

1. Medical Professionals.
2. Nurses
3. Paramedics (Anesthesia Technician and OR Technician).

In the current study, the researcher excluded all volunteers and trainers either from a physician, nurses, anesthesia technician and OR technician.

Secondary sources: The researcher used to the relevant Arabic and English books and references, articles, reports, researches and literature review that dealt with the subject of research, research and reading in different Internet sites.

Primary sources: To understand the analytical aspects of the research topic, the researcher sought to collect the initial data through the questionnaire as the main research tool, designed specifically for this purpose.

Data analysis was performed using SPSS Statistics

Socio-demographic characteristics of study participant

The study was conducted on 82 healthcare providers included in critical areas (ED, OR, ICU) and meet eligibility criteria at Al-Quds Hospital. The study sample consisted of 87 and the number of the responded sample was 82 who are healthcare providers work in Al-Quds Hospital, so the response rate was 94.25%.

Distribution of the participants’ perceptions according to their responses about transformational leadership

The distribution of the participants’ perceptions according to their responses about transformational leadership is presented in Table 1. When the healthcare providers have been asked about their estimation regarding the transformational leadership style, they showed that the total weighted mean for transformational leadership is 73.6%. this result consistent with the study Anwar [9]. The results revealed that the highest value among all leadership styles was transformational leadership. Bigger sample size and including all the key races in Kurdistan would provide support for further studies. And the results of the study Al Khajeh [10] showed that transformational leaders have a positive impact on organizational performance.

Table 1: General information of the respondents (n = 82).

However, charismatic leaders and transactions have a negative impact on organizational performance, because they do not provide opportunities and freedom for employees according to the results, the highest paragraph was number (5) "Leaders encourage people to think from a wider and broader perspective" with a weighted mean 78.2%, followed by the paragraph number (4) "Leaders communicate convincing values and goals" with a weighted mean 77.0%. We note that the highest paragraphs (5) and (4) talk about encouraging communication between leaders and employees, because almost all responsible leaders have higher degrees and this gives the leaders the ability to deal with all staff in times of crisis and brief them on emergency plans and training them. This is consistent with the Al Khajeh [10] study (2018), which says leadership style is the way people are directed, motivated and encouraged by a leader to achieve goals. While the lowest paragraphs number (1) "Leaders instill genuine pride in employees for being associated with them" with a weighted mean 69.0% followed by were number (3) "Leaders enjoy a high level of pride, respect, and trust" with weighted a mean 74.0%. Paragraphs (1) and (3) talked about the view of workers that they are not treated with a high level of pride and respect and this can be the result of long periods of work and stressful work during the crisis.

Distribution of the participants’ perceptions according to their responses about transactional leadership

The distribution of the participants’ perceptions according to their responses about transactional leadership is illustrated in Table 2. When the healthcare providers have been asked about their estimation regarding the transactional leadership style, they showed that the total weighted mean for transformational leadership is 73.60%. According to the results, the highest paragraph was number (9) "Leaders prefer to work within the system and to minimize the variation of the health organization" with a weighted mean 76.40%, followed by the paragraph number (4) "Leaders are available when they are needed" with a weighted mean 76.0%.

Table 2: Distribution of the participants’ perceptions according to their responses about transformational leadership item.

N: number of subjects & SD: standard deviation.

While the lowest paragraphs were number (7) "Leaders immediately responding to urgent questions" with a weighted mean 69.06%, followed by the number (6) "Leaders do forgive mistakes easily" with a weighted mean 72.0%. This result agrees transactional leadership more effective, the study by Longe [11] revealed that transactional leadership style has a positive impact on organizational performance. Transactional leadership helps create the context in which organizational and human capacities are maximized and maintained, where employees are always able to deliver tangible and intangible rewards. This leadership style, in particular, helps create an ideal environment for performance and also demonstrates an attractive vision that promotes overall organizational performance Longe [11].

And study Obeidat [12] The results illustrated out that there is a lack of administrative qualifications for clinicians and seems difficult to apply the transformational style in Jordanian hospitals due to the fear of responsibility and bad distribution of power and authority among clinicians. Transactional and trait theory was the dominant styles in these hospitals. And Kirilina [13] It was found that in both enterprises transactional style, autocratic behavior and task-orientation of leadership prevailed. On the other hand, according to the research conducted by Sofi & Devanadhen [14], disagree transactional leadership more effective or not empowers imagination and development among the workers and thus, the workers don't perform as per the desires of the organization.

Distribution of the participants’ perceptions according to their responses about charismatic leadership

Table 3 illustrated the distribution of the participants’ perceptions according to their responses about charismatic leadership. When the healthcare provider has been asked about their estimation regarding the charismatic leadership style, they showed that the total weighted mean for charismatic leadership is 74.0%. According to the results, the highest paragraph was number (8) "Leaders have a vision of successful future for their followers" with a weighted mean 77.40%, followed by the paragraph number (1) "Leaders gather followers through dint of personality and charm, rather than any form of external power or authority" with a weighted mean 76.40%. While the lowest paragraphs were number (2) "Leaders are effective in representing employees to a higher authority" with a weighted mean 72.20% and paragraph number (6) "Leaders show a sense of power and confidence" with a weighted mean 72.4%. AL Jamal study (2018).

Table 3: Distribution of the participants’ perception according to their responses about transactional leadership.

The finding There were statistically significant differences between charismatic leadership style and job description in favor of the nurses and more effective and motivate staff during a crisis. and Hasan & Rjoub [10]. The results showed that the highest value among all leadership styles was charismatic leadership. The study demonstrates that charismatic leadership has to turn out to be rigorous in the latest decades and that firms' growth usually requests modifying during crisis time. And Ojokuku et al. [15] the results of their research indicate that charismatic leadership has a negative relationship with organizational leadership. It does not motivate and motivate staff enough to restore the expected performance.

Distribution of the participants’ perceptions according to their responses about crisis management item

Table 4 illustrated the distribution of the participants’ perceptions according to their responses about crisis management items. When the healthcare provider has been asked about their estimation regarding crisis management items, they showed that the total weighted mean for crisis management is 74.8%. According to the results, the highest paragraph was number (10) "The Leaders remain steadfast in the field of work during the crisis" with a weighted mean 77.40%, followed by the paragraph number (8) "Leaders can build and maintain good relations with employees at the time of crisis" with a weighted mean 76.80%.

Table 4: Distribution of the participants’ perceptions according to their responses about charismatic leadership item.

N: number of subjects & SD: standard deviation.

While the lowest paragraphs were number (3) "Leaders take proper actions to set up health and safety system and evaluate the risk management" with a weighted mean 72.0% and paragraphs number (7) "Leaders share information from managers to personnel and vice versa" and number (4) "Leaders depend on qualified and experienced workforces in crisis" with a weighted mean 72.6%. Alrazeeni [16] Participants believed that incorporating disaster courses into EMS curricula, along with hands-on training, would help prepare students for environmental management of disaster management. In addition, participants in the study reported that they were not readily responding to a catastrophic crisis that made them unsure of their ability to respond adequately to the catastrophic crisis. And study Al Banna [17] the finding illustrated the high qualifications of the employees and the high knowledge of the organizations plays an important role in crisis management.

And study (Abu El-Aish 2016) The study result that Gaza Strip organizations have crisis management systems, However, the main obstacle to the implementation or development of these systems is the lack of financial support finally Nqeirah [18]. This research develops an effective and efficient simulation-based decision-making tool that can be applied in real-time in the crisis management situations.

Distribution of the participants’ perceptions according to their responses about the total domains

Table 5 shows the distribution of the participants’ perceptions according to their responses about the total domains. The results showed that the weighted mean of all domains was 73.73%which means the participants agree about the total domain score. According to the results, the highest domain is domain number (3)"Charismatic leadership" with a weighted mean of 74.0%. On the other hand, the lowest domain was a number (1) "Transformational leadership" with a weighted mean of 73.6%and the domain number (2) "Transactional leadership" with a weighted mean of 73.6%.

Table 5: Distribution of the participants’ perceptions according to their responses about crisis management items.

N: number of subjects & SD: standard deviation.

Correlation between health crisis management and the predictor variables (leadership styles) in the participants’ P-value

Correlation between domains participants’ opinions regarding crisis management domain and three leadership styles domains showed Table 6. Pearson correlation test found that crisis management have a positive statically significant correlation with Transformational leadership (r=0.617 & P=0.000), transactional leadership (r=0.549& P=0.000), charismatic leadership (r=0.719 & P=0.000) and domain as total (r=0.808 & P=0.000). Also, the results showed there is a positive statically significant correlation with leadership styles (P<0.001).

Table 6: Distribution of the participants’ perceptions according to their responses about total domains.

N: number of subjects & SD: standard deviation.

Tables 7 & 8 showed multiple linear regressions to test effect of different leadership styles on crisis management at Al-Quds Hospital. Multiple linear regression was calculated to use other leadership styles domains as predictors for crisis management. A significant regression equation was found (F=38.775, P < 0.001) with an R2 of 0.599 and adjusted R2=0.583. The rank of leadership styles domains effect in crisis management according to t-test were charismatic leadership (t=5.860 & P=0.0.00) followed by transformational (t=2.299 & P=0.024) and transactional leadership (t=1.655 & P=0.102), respectively. Subjects’ predicted equation for crisis management (Y)=(0.766* Transformational leadership) + (0.131* Transactional leadership) + (0.482* Charismatic leadership) + 0.193.

Table 7: Correlation between health crisis management and the predictor variables (leadership styles).

*P≤0.05: Significant, P>0.05: Not significant & r: Pearson correlation.

Table 8: Multiple linear regressions to test effect leadership Style and health crisis management.

*P≤0.05: Significant, P>0.05: Not significant; r: Pearson correlation; r2: coefficient of determination value; SE: standard error & F: one-way ANOVA

The researcher used multiple linear regression analysis to find the most effective and suitable leadership style during health crisis management in order to manage the crisis (Table 9). It was found that the value of B for transformational leadership 0.193, P≤0.05 this indicated that transformational leaders are suitable and effective leaders during health crisis management at hospitals, accordingly the first research objective was supported which stated that ‘Transformational leaders are effective during a health crisis in hospitals’’. The value of B for charismatic leadership 0.482, P≤0.05 this indicated that charismatic leaders are suitable and effective leaders during health crisis management at hospitals, accordingly the second objective was supported which stated that ‘’Charismatic leaders are effective during a health crisis in hospitals’’. Finally, the value of B for transactional leadership 0.131, P<0.05 this indicated that transactional leaders are not suitable and ineffective leaders during health crisis management at hospitals, Consequently, it was inconsistent with the third objective, which stated that “transaction leaders are effective during the hospital health crisis”.

Table 9: Linear regression to find the most effective and suitable leadership Style during health crisis management.

The results of this study aim to discover the most effective leadership style between the three types (transformational, charismatic and transactional) in health crisis management. Several studies have shown that transactional leadership is the most effective in health crisis management between the three types of leadership style, as demonstrated by the Kirilina [13] study. Other studies, such as the Anwar [9] study, showed that transformational leadership is more effective in health crisis management than transactional leadership, whereas our study after analyzing the results shows that charismatic leadership is more effective in crisis management than transactional leadership and transformational leadership and this result consistent with study Hassan & Rjoub [7].

Leadership is one of the most researched social phenomena, with a wide range of definitions, parameters, and theories. Some of the parameters discussed in our model are general and may apply to emergency leadership especially medical ones; however, medical leadership has its uniqueness and complexity as discussed above. Regardless of their background, training, education, environment, and skills, each leader will use a different leadership style by creating, adopting and using a unique element within themselves. It must be recognized that the style of leadership depends not only on the personality of the individual but also on the environment in which the individual works and on the team, members concerned Shamir (2007). Regardless of which model is used, the most important factor for effective leadership is the interaction between personality, skills, and abilities, interacting with those who are being led and influencing the immediate surroundings. Effective leaders must have the ability to switch between leadership styles appropriate to different situations and adjust accordingly.

Finally, after studying leadership style in crisis and disaster management, the study shows that there is no single effective style for dealing with all crises and situations within the hospital. But we can deal with all types of styles during the crisis.

Leadership plays a vital role in many professions, particularly in challenging positions such as emergency medical service jobs. The reason for this study was to find the relationship between managers’ leadership styles and health emergency management. And to study the association between leadership styles and health crisis management in regard to sociodemographic characteristics among health care providers who are working at the critical departments at al-Quds hospital. The study was conducted on 82 healthcare providers included in critical areas (emergency department, operating room, intensive care units) and meet eligibility criteria at Al-Quds Hospital. 87 the total population of health care providers, 82 of them responded. So, the response rate was 94.25%. The majority of respondents were married (91.5%) and the not married were (8.5%), while neither divorcees nor widows were included in the study. Of married, 36.6% have less than 3 siblings, while 37.8% have 3-6 siblings and 25.6% have more than 6 siblings.

More than half of the participants’ (65.9%) hold bachelor qualification and the same result diploma and postgraduate studies 17.1% and about one-third of the respondents had a monthly income of 1500 - 2500 NIS, 35.4% of their monthly income was less than 1500 NIS, and 23.1% of the respondents had more than NIS 2500. One-third of respondents live in Gaza, followed by the Middle zone 36.6% and 19.5% from the North, while Khan Younis had the lowest number of our respondents 2.4%. Distribution of the participants according to the department where they work at the time of crisis OR respondents 40.2%, ICU 28.1% and ER 26% and Nursing director Head of dept. Medical director 4.9% from participants.

And the distribution of the participants according to Job description About half of the participants are nurses 47.6%, Physician 36.6%, Anesthesia technician 9.8, and OR technician 6.2%. Half of the participants had less than 10 years of experience, 39% had 11-20 years of experience, and only 11% had more than 20 years of experience. Distribution respondent according to received crisis management courses more than half of the participants’ do not receive crisis management courses and 43.9% received crisis management courses. Considering the importance of health crisis management in different professions, particularly in the challenging profession of a medical emergency, identifying factors that influence health crisis management is crucial.

Since the results of the present study indicate the positive influential role of charismatic leadership in making higher health crisis management among staff, it is suggested that the health sector policymakers should give the basis for implementing a charismatic leadership style to upgrade the health crisis management among of medical crisis staff. Leaders with such leadership criteria and capabilities should be preferentially chosen to coordinate and direct individuals in medical emergency services. Future studies in other sectors and regions could be considered to broaden the results for managers and policymakers in the region. According to the results of the research mentioned above, there is more to reveal the topic of leadership and crisis management in the Ministry of Health. Within the framework of the study results, the researcher suggests the following.

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