Unravelling the role of leadership in motivation of health workers in a Moroccan public hospital: a realist evaluation

Abstract

ObjectivesThis study aimed at opening the black box of the relationship between leadership and motivation of health workers by focusing on a high-performance hospital in Morocco.DesignWe adopted the realist evaluation approach and used the case study design to test the initial programme theory we formulated on the basis of a scoping review on complex leadership. We used the Intervention-Context-Actors-Mechanism-Outcome Configuration as a heuristic tool to identify plausible causal configurations.SettingsSince 2000, the Ministry of Health in Morocco initiated many reforms in the frame of the governmental deconcentration process called ‘advanced regionalisation’. The implementation of these reforms is hampered by inadequate human resource management capacities of local health system managers. Yet, the National ‘Concours Qualité’, a national quality assurance programme implemented since 2007, demonstrated that there are many islands of excellence. We explore how leadership may play a role in explaining these islands of excellence.ParticipantsWe carried out a document review, 18 individual interviews and 3 group discussions (with doctors, administrators and nurses), and non-participant observations during a 2-week field visit in January–February 2018.ResultsWe confirmed that effective leaders adopt an appropriate mix of transactional, transformational and distributed leadership styles that fits the mission, goals, organisational culture and nature of tasks of the organisation and the individual characteristics of the personnel when organisational culture is conducive. Leadership effectiveness is conditioned by the degree of responsiveness to the basic psychological needs of autonomy, competence and relatedness, perceived organisational support and perceived supervisor support. Transactional and overcontrolling leadership behaviour decreased the satisfaction of the need for autonomy and mutual respect. By distributing leadership responsibilities, complex leaders create an enabling environment for collective efficacy and creative problem solving.ConclusionsWe found indications that in the Moroccan context, well-performing hospitals could be characterised by a good fit between leadership styles, organisational characteristics and individual staff attributes.

The effect of leadership on public service motivation: a multiple embedded case study in Morocco

“…In table 3, we present a summary of the perspectives of staff on the leadership and management practices. We present in the first column the key summary data derived from the initial exploratory case study (NHMH Hospital) and detailed in Belrhiti et al 88…”

“…We applied the steps of the realist research cycle85 87 to structure our study: (1) eliciting the initial programme theory, (2) designing the study, (3) carrying out the data collection, (4) analysing the data and (5) synthesis. We refer to our paper reporting on a case study of leadership for more details on the realist approach 88…”

“…Our scoping review of complex leadership62 allowed us to elicit an initial programme theory (PT) on the relationship between leadership and motivation. It was further developed through a first exploratory case study (coded NHMH) (see Belrhiti et al 88), and this led to the initial PT that is the starting point of this study:…”

“…As we described before,88 the underlying theories used to build our above-mentioned programme theory rely on two mechanisms that have shown to be important in explaining the complex relationship between leadership and motivation89–91: (1) the satisfaction of basic psychological needs, based on self-determination theory92 (see box 1), and (2) perceived supervisor support and perceived organisational support89 90 93 (see box 2).…”

“…Figure 1 shows our programme theory (PT) and the complex relationship between leadership, individual motivation and organisational characteristics (organisational culture and climate, mission and goals, and degree of responsiveness to basic psychological needs) 88. The quality and type of staff motivation (extrinsic vs autonomous motivation, including PSM and intrinsic motivation) depends on the degree of autonomy support by leaders, and consequently their perceived supervisor support (which in itself is increased by transformational and distributed leadership and reduced by laissez-faire and transactional leadership).…”