Perceived Leadership Styles among Key Medical Staff Stakeholders at Two Hospital Maternity Units Located in the Country of Mali: An Exploratory Study

PERCEIVED LEADERSHIP STYLES IN SIKASSO & KAYES MATERNITIES IN MALI
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Perceived Leadership Styles among Key Medical Staff Stakeholders at Two Hospital Maternity
Units Located in the Country of Mali: An Exploratory Study
By
Toutou Moussa Diallo
Exploratory Study
Doctor of Business Administration (DBA)
Doctoral Committee
Chair: Dr. Jonathan Green
Committee Member: Dr. Caroline Howard
Committee Member: Dr. Daniel Corcoran
School of Business Administration
Touro University Worldwide

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Abstract
This research project used the Multifactor Leadership Questionnaire adopted from Avolio &
Bass (1995, p.88-123). This instrument measures nine scales: five to capture transformational,
three to measure transactional, and one to reflect laissez-faire leadership styles, as well as three
to include leadership outcomes (Avolio & Bass 2004). It will help understand the impact of
perceived leadership styles among key medical staff stakeholders at two hospital maternity units
located in the country of Mali. Leaders were doctors, nurse practitioners, physicians assistants,
and residents. Subordinates were midwives, registered nurses, nurses, interns, nurse aides. In
Kayes, the number of leaders and subordinates were 6 and 29, respectively. Respective to
Sikasso, leaders were 8 and subordinates were 33. The study on 76 respondents, it was found that
perceptions of leadership from both leaders and subordinates were consistent with results
confirmed by Avolio & Bass (2004) and several other studies. Their contributions to this
research project played an important role in understanding the relationship between leadership
perceptions and organizational outcomes from both sites.

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Introduction
The purpose of this research study is to examine the perception of self-reported
leadership styles and preference for prioritization of health services among key medical staff
stakeholders at two regional hospitals located in Mali, on the African continent. Sikasso and
Kayes were selected to help understand perceived leadership styles in maternity units within
each regional hospital. Between the regional hospital Fousseyni Daou Maternity in Sikasso and
Kayes Regional Hospital Maternity, there were a total of 76 respondents between the two
hospitals. There were 41 participants were from Sikasso Regional Hospital and 35 from
Fousseyni Daou Regional Hospital in Kayes. The self-reported leadership styles among key
medical staff stakeholders were measured via the Multifactor Leadership Questionnaire (MLQ)
(Avolio and Bass, 1995).
There was a comparison of the perception of leadership styles between the perceived
leadership styles from the perspective of subordinates and from the self-report of hospital leaders
from two regional hospitals in Mali. Overall, this exploratory research project would provide
quantitative data on leadership styles expressed by healthcare leaders and experienced by
healthcare staff members between the two hospitals in Mali which is a sub-Saharan African
country.
Purpose of the Study
The purpose of this research project is to examine if there are any differences in the
perception of leadership styles in the two different hospitals and among medical hospital leaders
versus subordinate medical staff in Mali because there is very little published research on the
perception of leadership styles in hospital settings within the sub-Saharan country of Mali.
Various empirical studies done in healthcare settings outside of the country of Mali have

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highlighted the importance of transformational leadership in properly managing the healthcare
staff and provide quality care to patients. For example, research by Moon, Van Dam, & Kitsos
(2019) and Bass (1999), as Valentine (2019) cited, have highlighted that Transformational
Leadership is one of the most effective leadership styles utilized in the field of health services.
The closest study on leadership in a medical setting was done on emergency services in
Riyadh in Saudi Arabia (Leggio, 2013). This qualitative study was about how leadership is
learned among emergency medical services providers from multiple nations working in Riyadh,
kingdom of Saudi Arabia (Leggio, 2013).
Another study described a gap between the different roles (management vs. health care
provision) was because of communications between the different structures within the health
system (Seppey, Ridde, Touré, & Coulibaly, 2017). According to Seppey, Ridde, Touré, &
Coulibaly (2017), the gap existed between the operational (health agents) and the community
levels (ASACO and communes).
Furthermore, study done by Mathole, Lembani, Jackson, et al. (2018) described that
leadership is one of the key health systems factors affecting the performance of maternal health
services at facility level in two rural district hospitals in South Africa. The qualitative study
addressed a leadership development program but did not provide any information on leadership
styles using MLQ 5X model in maternity in Greater Accra Regional Hospital in Ghana. The
paper described that training nurses in management, communication, and leadership skills
successfully increased healthcare workers’ ability to identify and solve service delivery
challenges (Pfeiffer, Owen, Pettitt-Schieber, et al., 2019). A review of the literature indicates the
study of leadership in Mali hospital maternity units has not been previously studied. Few studies

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are similar as discussed though do not directly address the hospital leadership traits between the
hospital leaders and the hospital subordinate staff within this project.
Literature
Currently, there are a multitude of challenges facing people who manage healthcare
systems within the sub-Saharan African countries. Oleribe, Momoh, Uzochukwu, Mbofana,
Adebiyi, Barbera, Williams, and Taylor-Robinson (2019) described that the health care systems
need radical changes with innovative solutions in the prioritization and development of human
resources, budget allocation, and management. This cross-countries study comprised of
participants from 11 African countries along with some participants from Cuba and Portugal.
This study was conducted in two phases to encourage and engage research participants. During
the first phase, each group member identified key challenges facing healthcare services and
strategies to mitigate them in the African context. The groups then discussed and elaborated on
these issues in the second phase. Included were three distinct activities: 1) generating key
challenges, 2) generating key strategies/solutions, and 3) ranking the challenges and strategies.
Challenges and solutions were identified and ranked from 1-5, where 1 being the most important
and 5 being the least important (Oleribe, Momoh, Uzochukwu, Mbofana, Adebiyi, Barbera,
Williams, and Taylor-Robinson, 2019). The results of the research study indicated that the key
challenges highlighted by the sample of participants were inadequate human resources (ex.
doctors. nurses etc.) to deliver quality healthcare to patients (34.29%), inadequate budgets to
help provide health care services (30%), and poor healthcare leadership and management
(8.45%). On the other hand, Oleribe, Momoh, Uzochukwu, Mbofana, Adebiyi, Barbera,
Williams, and Taylor-Robinson (2019) also found through their research study that the highly
recommended solutions recommended by the sample of participants as part of the included

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improving the healthcare training among health workers (29.69%), increasing budgets focused
for healthcare services (20.31%), and advocacy for political support and commitment to help
improve budgeting and support for improving healthcare services (12.31%).
Building off the finding by Oleribe, Momoh, Uzochukwu, Mbofana, Adebiyi, Barbera,
Williams, and Taylor-Robinson (2019) that poor healthcare leadership and management is the 3rd
highest concern among healthcare professionals located in Africa, and healthcare leadership is
described as one of the most influential factors in shaping organizational culture (Mathole,
Lembani, Jackson, Zarowsky, Bijlmakers, & Sanders, (2018). According to Ajmeera (2014),
healthcare management refers to the healthcare leadership and general management and
administration of hospitals, hospital networks, public health systems and or health care systems.
Healthcare leadership is one key component that the World Health Organization will focus to
emphasize and develop in the near future to help manage the limited health care resources in
developing countries (WHO, 2019). Leadership has been highlighted by the World Health
Organization (WHO) as essential for strengthening health systems and improving health
outcomes, and the WHO advocates for leadership development amongst health workers in low-
and middle-income countries (LMIC) (Pfeiffer, Owen, Pettitt-Schieber et al., 2019). The WHO
Framework proposes that good leadership and management at the operational level needs to have
a balance between four inter-related areas (WHO, 2007):
1. Ensuring an adequate number of managers at all levels of the health system,
2. ensuring managers have appropriate competences,
3. creating better critical management support systems, and
4. creating an enabling working environment.

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According to WHO 2007, better leadership and management cannot be achieved without
providing direction to, gaining commitment from partners and staff, facilitating change and
achieving better health services through efficient, creative and responsible deployment of people
and resources.
Cunninghan, Hazel, & Hayes (2020) describe that leadership in organizations influences
and facilitates individual and collective efforts to accomplish shared objectives. Researchers
have previously argued that leadership style manifested by a workplace leader can influence job
satisfaction and worker motivation among the subordinate employees (Aberese-Ako, Agyepong,
Dijk 2018). Motivated workers exhibit positive attitudes that ensure that work is done efficiently,
and quality care provided to clients (Aberese-Ako, Agyepong, Dijk (2018). To help provide
evidence for the impact of leadership skills upon the subordinate worker quality of work and
motivation, Aberese-Ako, Agyepong, Dijk (2018) conducted a study examining the impact of
leadership styles upon the mobilizing, influencing, inspiring, motivating and empowering of
subordinate health employees in two hospitals found in Ghana. Aberese-Ako, Agyepong, Dijk
(2018) found that hospital regulations and limitations in funding constrained a hospital leader’s
power and shaped their leadership styles in response to the needs of their subordinate healthcare
staff and corresponding patients. The workplace and environmental limitations on healthcare
leader created a diminished quality of health services provided towards patients, but when
healthcare leaders were able to work around the workplace and environmental constraints and
respond effectively to subordinate healthcare staff and patients’ needs, then the healthcare
leaders felt energized and motivated to work harder.
In a similar focus to the management skills of hospital leaders, Bakalikwira, Bananuka,
Kigongo, et al. (2017) conducted a study to examine the impact of hospital board governance

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and managerial skills or practices on the healthcare accountability across multiple hospitals in
Uganda. The focus of the study was hospital directors’ managerial skills or practices. The results
of the study showed a significant positive relationship between managerial competencies and
healthcare accountability. The study further finds that hospital board governance is not
significantly correlated with healthcare accountability among government hospitals.
Various empirical studies done in healthcare settings have highlighted the importance of
transformational leadership in properly managing the healthcare staff and provide quality care to
patients. For example, research by Moon, Van Dam, & Kitsos (2019 and Bass (1999) have
highlighted that Transformational Leadership is one of the most effective leadership styles
utilized in the field of health services. Moreover, a study of subordinate nurses in Malaysia found
that there was a strong relationship between job satisfaction and transformational leadership they
experienced from their nurse leaders as compared to experiencing a transactional
leadership (Aberese-Ako, Agyepong, & Dijk 2018). Shaughnessy, Griffin et al. (2018) also
conducted a study showing a significant positive relationship between transformational
leadership practices by nurse leaders and work engagement among subordinate nurses. The
research did reveal that differences in nurse leader educational attainment had an important
variable in properly implementing key leadership practices such as a shared vision, support for
innovation, and taking risks. Nyamtema, Urassa, & Roosmalen (2011) also reported that
insufficient implementation of evidence-based interventions in healthcare resource limited
countries was closely linked to a lack of national resources alongside the lack of effective
leadership skills.

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Transformational Leadership
Focusing specifically on a particular leadership style, previous research literature has
defined a Transformational leader as an individual who motivates followers to (1) move beyond
their self-interest, (2) commit themselves to organizational goals, and (3) perform beyond
expectations (Aberese-Ako, Agyepong, Dijk, 2018). Transformational leadership is based on
balanced exchanges, in which the focus is on producing efficiency by reinforcing negotiated
levels of performance (Aberese-Ako, Agyepong, Dijk, 2018). Other researchers have further
argued that the concept of transformational leadership is further defined as the degree to which
employees felt their supervisors idealized influence, inspired motivation, individualized
consideration, and were intellectual stimulating (Gong, Yaping, Jia-Chi Huang, and JiingLihFarh
2009). Transformational leaders additionally look to find the motives in followers to seek higher
needs and to fully engage the follower (Valentine, 2019)
Transactional Leadership
Valentine (2019) described that Bernard M. Bass in 1999 provided an overview of what
transactional leadership is through an example at Xerox’s Reprographic Business Group where
there was a shift in management style: “In the first step toward establishing management in
which managers take the initiative and show consideration for others, 44 specific, effective
management behaviors were identified. Two factors that characterize modern leadership were
found in many of these behaviors. One factor—initialing and organizing work—concentrates on
accomplishing the tasks at hand. The second factor—showing consideration for employees—
focuses on satisfying the self-interest of those who do good work. The leader gets things done by
making, fulfilling, promises of recognition, pay increases, and advancement for employees who
perform well. By contrast, employees who do not do good work are penalized. This transaction

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or exchange—this promise and reward for good performance, or threat and discipline for
poor performance—characterizes effective leadership. These kinds of transactions took place in
most of the effective 44 leadership behaviors identified at Xerox's RBG. This kind of leadership,
which is based on transactions between manager and employees, is called "transactional
leadership” (p. 20).
As the name implies, transactional leadership is a style of leadership based on an
exchange or transaction that takes place between the leader and the follower in order for the
organization to reach its desired goals and objectives. Valentine (2019) explained that the first
scholar to highlight the differences between transactional leaders and transformational leaders
was James Burns. Valentine (2019) described that James Burns identified two basic types of
leadership (transactional and transformational), where transactional leaders are looking to
exchange one thing for another (jobs for votes or subsidies for campaign contributions) and
transforming (transformational) where leaders recognize and exploit an existing need or demand
of a potential follower.
Transactional leadership can be divided into three dimensions or components: contingent
reward, management by exception (active), and management by exception(passive) (Valentine,
2019). Out of these three components, contingent reward is the most effective because followers
receive incentives after they accomplish their task(s). Contingent reward is transactional when
these incentives are material (e.g., bonus), but can also be transformational when the incentive is
psychological in nature (e.g., praise) (Valentine, 2019).
Knowing that subordinates will make mistakes and not perform to expectation and
complete their goals and get their rewards is when management by exception (MBE) occurs.
Valentine (2019), suggested MBE, both active (MBEa) and passive (MBEp) as follows: MBEa

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refers to both monitoring performance and taking corrective action as necessary, where the focus
of MBEa is on setting standards and monitoring deviations from these standards; MBEp is even
less active (hence “passive”), where leaders intervene only when problems become serious.
MBEa can be associated with what is known as “micromanagement,” where supervisors/leaders
consistently check on progress, especially the smallest of details, to make sure that performance
is going as agreed upon.
Laissez-Faire
There is one other term to be defined that is associated with transactional leadership, and
that is laissez-faire leadership. Valentine (2019) described laissez-faire
Leadership as having an absence of leadership or an avoidance of leadership and is the most
inactive as well as the most ineffective form of leadership according to almost all research on the
style. Lewin, Lippitt, and White, Skogstad et al. (2007 as cited by Valentine, 2019) stated that
laissez-faire leadership represents a leadership style where the leader has been nominated
and physically occupies the leadership position, but where the leader has for the most part
abdicated from the responsibilities and duties assigned to him or her. This is a “hands-free” form
of leadership, but where the leader would still be held accountable for his or her actions.
To understand perceived leadership styles in Kayes and Sikasso maternity units, a full
range leadership testing framework using the 45 statements in the Multifactor Leadership
Questionnaire (MLQ 5X) from Avolio & Bass (2004, p 9-23) was adopted for the current
research project. This leadership framework in Figure 1 below is widely used in leadership
research study as evidenced in Avolio & Bass (1995, p5) and subsequent studies by Valentine
(2019), and Aberese-Ako, Agyepong, & Dijk (2018).

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Figure 1: Avolio & Bass’s Leadership Framework
Source: Avolio & Bass (2004, p. 9-23)
It was the basis for the comparison of the perceived leadership styles rated by hospital
leaders self-raters (ex. obstetric doctors, residents) and rated by hospital staff subordinates (ex.
registered nurses, midwives, interns, and matrone) in Kayes and Sikasso. This leadership
framework by Avolio & Bass (2004) has 9 factors listed below:
Factors 1-2– IDEALIZED INFLUENCE (Attributes & behaviors) indicates whether leaders hold
subordinates’ trust, maintain their faith and respect, show dedication to them, appeal to their
hopes and dreams, and act as their role model.
Factor 3– INSPIRATIONAL MOTIVATION measures the degree to which leaders provide a
vision, use appropriate symbols and images to help others focus on their work, and try to
make others feel their work is significant.
9 FACTORS

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Factor 4 – INTELLECTUAL STIMULATION shows the degree to which leaders encourage
others to be creative in looking at old problems in new ways, create an environment that is
tolerant of seemingly extreme positions, and nurture people to question their own values
and beliefs of those of the organization.
Factor 5 – INDIVIDUALIZED CONSIDERATION indicates the degree to which leaders show
interest in others’ well‐being, assign projects individually, and pay attention to those who
seem less involved in the group.
Factor 6 – CONTINGENT REWARD shows the degree to which leaders tell others what to do in
order to be rewarded, emphasize what you expect from them, and recognize their
accomplishments.
Factors 7-8 – MANAGEMENT‐BY‐EXCEPTION (Active (MBEA) & Passive (MBEP))
assesses whether leaders tell others the job requirements, are content with standard performance,
and are a believer in “if it aint broke, don’t fix it.”
Factor 9 – LAISSEZ‐FAIRE measures whether leaders require little of others, are content to let
things ride, and let others do their own thing.
Methodology
Participants
There was a total of 76 participants between the Fousseyni Daou Hospital Maternity
unit in Sikasso and Kayes Regional Hospital Maternity unit who participated in the research
project. There were 41 participants from Sikasso Regional Hospital and 35 from Fousseyni Daou
Regional Hospital in Kayes. The leadership hierarchy shown on Figure 2 below was used to help
define hospital leaders (ex. medical chief, obstetric doctors, residents) versus hospital
subordinate staff (ex. registered nurses, midwives, interns, and matrone).

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Figure 2: Hospital Leadership Hierarchy
In Kayes, the number of hospital leaders and subordinates were 6 and 29, respectively. In
Sikasso the distribution of participants is 8 Leaders and 23 subordinates. Based on the definitions
of hospital leaders versus hospital subordinate staff, there was a comparison perceived leadership
styles rated by hospital leaders self-raters (medical chief, obstetric doctors, residents) and as
rated by hospital subordinates (registered nurses, midwives, nurses, interns, and matrone) in
Kayes and Sikasso.
Instrument
There is one key measure used for this research study which is the Multifactor Leadership
Questionnaire. This standardized instrument collects and measures information on
transformational, transactional, and laissez-faire (Hemsworth, Muterera, &Baregheh, 2013).
Statisticssolutions.com (nd) described the Multifactor Leadership Questionnaire (MLQ) as one
of the most widely established instruments in measuring transformational leadership. This
instrument has previously shown to being reliable in evaluating leadership ability and behaviors,
Fousseini Daou Regional Hospital
Medical Chief
Obstetric
doctors
Residents
Midwives
Registered
Nurses
Interns
Martrone
Sikasso Regional Hospital Medical Chief
Obstetric
doctors
Residents
Midwives
Registered
Nurses
Interns

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follower reactions and situational attributes. There are 45 questions in total on a 5-point Likert
Scale. According to Statisticssolutions.com (nd), Bass’s MLQ Manual shows strong evidence of
validity. It is a reliable tool that measures leadership ability and behavior in organizations and
organizational studies; analyzes leadership approaches and the ways in which the test resonates
with and conflicts with particular approaches (Statisticssolutions.com, n.d.). The survey for the
current research project examined the responses on the transformational leadership subscales of
the Multifactor Leadership Questionnaire (MLQ-5X) between the hospital leaders (ex. Fousseini
Regional Hospital Medical Chief and Sikasso Regional Hospital Medical Chief) versus hospital
subordinate staff (ex. Obstetric Doctors, Residents, Anesthesiologists, Registered Nurses etc.).
Please see Table 1 below which highlights 5 facets of Multifactor Leadership Questionnaire
(MLQ-5X) Rater Form.
To provide more historical context on the instrument, Avolio& Bass in 1985
conceptualized their first leadership model that had 7 factors and charisma, inspirational,
intellectual stimulation, individualized consideration, contingent reward, management by
exception, and laissez-faire leadership (as cited in Avolio, Bass, & Jung, 1999). Considering
shortcomings in previous research on leadership styles and a new interest in testing the new
paradigm of transformational and transactional leadership, Avolio and Bass (1998) further
developed the full range of leadership traits. The full range model of leadership traits was

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developed to broaden the range of leadership styles (transformational, transactional, and laissez-
faire) typically investigated in the field (Avolio & Bass, 1991).
As stated earlier, this research project used the Multifactor Leadership Questionnaire
adopted from Avolio & Bass (1995, p.88-123). This instrument measures nine scales: five to
capture transformational leadership, three to measure transactional leadership, and one to reflect
a laissez-faire leadership style (Avolio & Bass 2004).
The Multifactor Leadership Questionnaire (MLQ5X) is a scientific evidence-based
leading survey instrument that assesses leadership (Batista-Foguet,Esteve & van Witteloostuijn,
2021). This instrument was created to test Bass and Avolio’s conceptual framework of leadership
(Batista-Foguet,Esteve & van Witteloostuijn, 2021). This instrument has been used in several
studies to correlate organizational behavior (Avolio & Bass, 1995). A quantitative study that
captures several leadership styles in a single measurement and incorporates a range of nine
scales: five to capture transformational, three to measure transactional, and one to reflect laissez-
faire leadership styles, as well as three to include leadership outcomes (Avolio & Bass 2004,
Batista-Foguet, Esteve & van Witteloostuijn, 2021, and Valentine 2019). Lowe, Kroeck, &
Sivasubramaniam (1996), Judge, & Piccolo (2004), & Valentine (2019) confirmed its
effectiveness and validity. It is a reliable tool that measures leadership capacity and behavior in
organizations and organizational studies (Statisticssolutions.com, nd). It is important to note that
MLQ is not designed to encourage labeling a leader as transformational or transactional. Rather,
it is more appropriate to identify a leader or group of leaders as (for example) “more
transformational than the norm” or “less transactional than the norm” (Avolio & Bass, 1995,
p.124).

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Recruitment Strategy
Letters were sent to the chief medical doctors in Kayes and Sikasso for their approval.
They sent their approval letters (Appendix C) to meet Touro University Worldwide Institutional
Review Board’s requirements. Along the way, another exceptional individual Yaya Togo, who is
a health economist and researcher, provided support in the areas of doing research in Mali and
how to use Kobotoolbox for data collection. The health economist and researcher volunteered his
time in doing face to face meeting with the researcher in understanding MLQ 5X. The health
economist and researcher signed an agreement with Mindgarden.com before translating the
questionnaire and he did not change the context (Appendix H). A translated copy was sent to
Mindgarden.com for approval. Mr. Togo found another person to translate the research proposal
and consent form. Mr. Togo also helped recruit two data collectors in Kayes, who happened to
be medical doctors.
After Touro University Worldwide IRB approval, a French version of the research
proposal had to be submitted to the Faculty of Medicine in Bamako. To be able to do any
research in Mali, an external researcher has to go through an approval process to perform his or
her research study. The review board in Mali and the Professor helping sponsor the research
project acknowledged that leadership study is needed in maternity units. The ethics committee
made recommendations that needed to be addressed before a second submission. The paper had
to be bound (relure in French) as a book for submission. Three weeks later the research proposal
was approved. Then a reconnect to the chief medical doctors for research project logistics in each
region was made. Both chiefs are the primary leaders of the maternity units. They coordinated all
research activities in their maternity units and took the survey as well. The data collection for
this research project with the sample of participants was via face-to-face data collection in a

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large conference room. Data collectors helped collect data by using tablets and the investigator
used her phone and laptop for gathering responses.
Ethical Considerations
Bryman & Bell (2011) identified areas of ethical concerns that may arise in conducting
research on an organization. In order to abide by ethical regulations of research, recruitment
letters were given to each participant (Appendix A) and consent was obtained from all
participants (Appendix B), no matter their level of engagements and job titles. The Touro
University Worldwide Ethical Principles & Guidelines for Research Involving Human Subjects
was strictly adhered (Appendix C) and explained below.
Risks
There are no risks associated with this study because it is not a medical research where
participants may be exposed to adverse effects of drugs. Participants are not from a protected
class (e.g., Pregnant women or minors) for the purposes of this project. Survey questions may
cause participant minor discomfort.
The Expedited Review involves human subjects completing the 45 question Multifactor
Leadership Questionnaire (MLQ-5X) and demographic questions, onsite in a room dedicated for
the participants to complete the survey. Participants are answering survey questions that might
cause discomfort.
If a participant was uncomfortable or chooses to withdraw from the study, the participant
notified the researcher face to face that they choose to withdraw. Any withdrawn participant
information was immediately destroyed, and participation terminated.
Procedure
During the information session for both leaders and subordinates, they had time to ask

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questions as well as in private session if they chose to do so. When participants were willing to
voluntarily participate in the survey, participants (1) received a recruitment letter, (2) signed a
consent form and then (3) proceeded to take the offline survey on tablets.
Data confidentiality
All the responses were kept strictly confidential and were only seen by authorized
members of designated staff at Touro University Worldwide, and Professor Teguete, field
supervisor at the Teaching Hospital Grabriel Touré. Researcher will store data in a safe
storage for a minimum of 3 years. All data files will be stored securely in a locked file
cabinets in Professor Teguete office at the Teaching Hospital Gabriel Touré. Researcher
will produce various types of reports or papers for publication, as well as a de-identified
data file for use by other researchers or the general public. If the research plan calls for
destruction of documents or electronic files after 3 years after the project has been
completed, all paper files or CDs with PII will be shredded and any electronic files on
memory drives, PCs, laptops and file servers will be permanently deleted.
Research Hypotheses
Based on the participant roles, hospital locations and the leadership ratings (via
Multifactor Leadership Questionnaire, MLQ5X) collected for the current research project, the
following research hypotheses were examined in the subsequent statistical analyses.
Null Hypothesis 1 (HO1): There is no difference in the ratings of medical professional
leadership styles between the two hospitals located in Sikasso and Kayes in the country of Mali.
Alternative Hypothesis 1 (Ha1): There is a difference in the ratings of medical professional
leadership styles between the two hospitals located in Sikasso and Kayes in the country of Mali.

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Null Hypothesis 2 (HO2): There is no difference in the ratings of medical professional
leadership styles between the medical leaders and subordinate medical staff.
Alternative Hypothesis 2 (Ha2): There is a difference in the ratings of medical professional
leadership styles between the medical leaders and subordinate medical staff.
Null Hypothesis 3 (HO3): There is no interaction in the ratings of medical professional
leadership styles between the variables of hospital location (Sikasso versus Kayes) and hospital
role (medical leader versus subordinate medical staff.
Alternative Hypothesis 3 (Ha3): There is an interaction in the ratings of medical professional
leadership styles between the variables of hospital location (Sikasso versus Kayes) and hospital
role (medical leader versus subordinate medical staff).
Table 2 below summarizes the various variables (i.e., the participant roles, hospital
locations and the leadership ratings (via Multifactor Leadership Questionnaire, MLQ5X)
collected for the current research project that was analyzed and presented in the results section.
Table 2: Hospital Role (Medical Leaders versus Subordinate Medical Staff) and
Hospital Location (Kayes versus Sikasso) in relation to Leadership traits (via the
Multifactor Leadership Questionnaire, MLQ5X)
Hospital Medical Leaders Hospital Subordinate Medical
Staff
Kayes • Transformational
Leadership total Score
• Transactional
Leadership total score
• Passive Avoidant total
Score
• Idealized Influence
Idealized Behaviors
• Inspirational
Motivation-IM,
• Transformational
• Transactional
Score
Idealized Behaviors
• Inspirational
Motivation-IM,

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• Intellectual
Stimulation-IS,
• Individual
Consideration-IS,
• Contingent Reward-
IC,
• Management by
Exception Active-
MBEA,
• Management by
Exception Passive-
MBEP,
• Laissez-Faire-LF
• Intellectual
Stimulation-IS,
• Individual
Consideration-IS,
IC,
• Management by
Exception Active-
MBEA,
• Management by
Exception Passive-
MBEP,
Laissez-Faire-LF
Sikasso • Transformational
• Transactional
Score
Idealized Behaviors
• Inspirational
Motivation-IM,
• Intellectual
Stimulation-IS,
• Individual
Consideration-IS,
IC,
• Management by
Exception Active-
MBEA,
• Management by
Exception Passive-
MBEP,
• Transformational
• Transactional
Score
Idealized Behaviors
• Inspirational
Motivation-IM,
• Intellectual
Stimulation-IS,
• Individual
Consideration-IS,
IC,
• Management by
Exception Active-
MBEA,
• Management by
Exception Passive-
MBEP,
Results
For this research project, a five-point Likert Scale was used for the MLQ 5X
questionnaire to examine the relationship between the two regional hospitals’ maternities in their

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leadership styles. The rating scales for leadership items were Not at all = 0, Once in a while =
1, Sometimes = 2, Fairly often = 3, and Frequently, if not always = 4. As stated earlier, the total
number of respondents were 76 as detailed in Table 3.
Table 3: Between subjects factors
What hospital do you work in? N
Fousseyni Daou Hospital of Kayes
Type of Respondent Leader 6
Subordinate 29
What hospital do you work in? Fousseyni Daou Hospital of Kayes 35
What is your occupation (title)? Anesthetist 2
Area bloc 5
Licensed Nurse Practitioner 1
Matronne 1
Medical Doctor Specialist 3
Midwife 10
Registered Nurse 6
Resident 6
Stagiaire 1
Regional Hospital Sikasso
Type of Respondent Leader 8
Subordinate 33
What hospital do you work in? Regional Hospital Sikasso 41
What is your occupation (title)? Anesthetist 5
Area bloc 3
Medical Doctor Specialist 5
Midwife 20
Registered Nurse 5
Resident 3
In the Sikasso regional Hospital location, participants comprised of 15 males and 26
females. In the Kayes regional hospital location, participants comprised of 16 males and 19
females. MLQ Scoring Key was used to group items by scale and calculated the averages by

23
scale from Avolio and Bass (1995). KoboCollect, a free statistical instrument from Harvard
University, easily dissected the 9 factors by items and region.
The Findings
Results of 2-way Multivariate Analysis of Variance (MANOVA) in Table 4 showed that
there was no significant multivariate main effect for Hospital Location, Wilks Lambda=0.734,
F(12,61)=1.556, p=0.129. Therefore, Null Hypothesis 1 was accepted, and Alternative
Hypothesis 1 is rejected.
Moreover, there was a significant multivariate main effect for Type of Respondent, Wilks
Lambda=0.676, F(12,61)= 2.436, p=0.012. Thus, Alternative Hypothesis 2 was accepted, and
Null Hypothesis 2 is rejected. Finally, there was also no significant multivariate interaction for
the interaction of Hospital Location and Type of Respondent, Wilks Lambda=0.776, F(12,61)=,
p=0.161. Therefore, Null Hypothesis 3 was accepted, and Alternative Hypothesis 3 is rejected.
Table 4: Multivariate Test for both hospitals and type of respondents
Effect Value F Hypothesis
df
Error
df
Sig. Partial
Eta
Squared
Noncent.
Parameter
Observed
Powerc
Intercept Pillai's
Trace
0.948 93.167b
12.000 61.000 0.000 0.948 1117.999 1.000
Wilks'
Lambda
0.052 93.167b
12.000 61.000 0.000 0.948 1117.999 1.000
Hotelling's
Trace
18.328 93.167b
12.000 61.000 0.000 0.948 1117.999 1.000
Roy's
Largest
Root
18.328 93.167b
12.000 61.000 0.000 0.948 1117.999 1.000
Hospital Pillai's
Trace
0.234 1.556b
12.000 61.000 0.129 0.234 18.667 0.754
Wilks'
Lambda
0.766 1.556b
12.000 61.000 0.129 0.234 18.667 0.754
Hotelling's
Trace
0.306 1.556b
12.000 61.000 0.129 0.234 18.667 0.754
Roy's
Largest
Root
0.306 1.556b
12.000 61.000 0.129 0.234 18.667 0.754

24
TypeofRespondent Pillai's
Trace
0.324 2.436b
12.000 61.000 0.012 0.324 29.229 0.940
Wilks'
Lambda
0.676 2.436b
12.000 61.000 0.012 0.324 29.229 0.940
Hotelling's
Trace
0.479 2.436b
12.000 61.000 0.012 0.324 29.229 0.940
Roy's
Largest
Root
0.479 2.436b
12.000 61.000 0.012 0.324 29.229 0.940
Hospital * TypeofRespondent Pillai's
Trace
0.224 1.470b
12.000 61.000 0.161 0.224 17.638 0.724
Wilks'
Lambda
0.776 1.470b
12.000 61.000 0.161 0.224 17.638 0.724
Hotelling's
Trace
0.289 1.470b
12.000 61.000 0.161 0.224 17.638 0.724
Roy's
Largest
Root
0.289 1.470b
12.000 61.000 0.161 0.224 17.638 0.724
a. Design: Intercept + Hospital +
TypeofRespondent + Hospital *
TypeofRespondent
b. Exact statistic
c. Computed using alpha = .05
The multivariate tests in Table 5 show that there are statistically significant differences
between the higher medical leaders (M=3.66) ratings compared to subordinate medical staff
(M=2.94) ratings on the dependent variable of the Individualized Consideration subscale of the
MLQ, F(1,72)=6.36, p=0.014. Moreover, there are statistically significant differences between
the higher medical leaders (M=3.64) ratings as compared to subordinate medical staff (M=3.04)
ratings on the dependent variable of the Contingent Reward subscale of the MLQ, F(1,72)=5.62,
p=0.02. Next, there are statistically significant differences between the lower medical leaders
(M=0.73) ratings and subordinate medical staff (M=1.19) ratings on the dependent variable of
the Management by Exception Passive subscale of the MLQ, F(1,72)= 6.294, p=0.014. Also,
there are statistically significant differences between the lower medical leaders (M=0.46) ratings
and subordinate medical staff (M=1.00) ratings on the dependent variable of the Laissez-Faire
subscale of the MLQ, F(1,72)= 4.198, p=0.044.

25
There are statistically significant differences between the higher medical leaders
(M=16.8) ratings and subordinate medical staff (M=14.65) ratings on the dependent variable of
the Transformational leadership scale on the MLQ, F(1,72)= 4.123, p=0.046. There were also
statistically significant differences between the lower medical leaders (M=1.2) ratings and
subordinate medical staff (M=2.19) ratings on the dependent variable of the Laissez-Faire
leadership scale on the MLQ, F(1,72)= 6.936, p=0.01
Table 5: Tests of Between-Subjects Effects
Source Dependent Variable Type III Sum of
Squares
df Mean Square F Sig.
Corrected Model Idealized Attributes 2.924a 3 0.975 1.276 0.289
Inspirational Motivation 3.344b 3 1.115 1.78 0.159
Intellectual Stimulation 4.897c 3 1.632 2.619 0.057
Individualized Consideration 10.885d 3 3.628 4.226 0.008
Contingent Reward 4.097e 3 1.366 1.89 0.139
Management by Exception Active .934f 3 0.311 0.422 0.738
Management by Exception
Passive
6.023g 3 2.008 5.303 0.002
Laissez Faire 7.958h 3 2.653 3.996 0.011
Extra Effort 4.143i 3 1.381 1.687 0.177
Effectiveness 2.479j 3 0.826 1.459 0.233
Satisfaction 2.884k 3 0.961 1.561 0.206
Transformational 107.898l 3 35.966 2.977 0.037
Transactional 6.847m 3 2.282 0.93 0.431
Laissez-Faire 26.822n 3 8.941 6.006 0.001
Intercept Idealized Attributes 389.626 1 389.626 510.001 0
Inspirational Motivation 458.171 1 458.171 731.882 0
Intellectual Stimulation 493.642 1 493.642 791.959 0
Individualized Consideration 489.49 1 489.49 570.141 0
Contingent Reward 502.256 1 502.256 695.114 0
Management by Exception Active 415.773 1 415.773 563.537 0
Passive
39.997 1 39.997 105.642 0
Laissez Faire 24.154 1 24.154 36.382 0
Extra Effort 493.223 1 493.223 602.582 0
Effectiveness 489.425 1 489.425 864.296 0
Satisfaction 501.888 1 501.888 814.742 0
Transformational 11147.703 1 11147.703 922.806 0
Transactional 1831.976 1 1831.976 746.383 0
Laissez-Faire 126.315 1 126.315 84.859 0

26
Type of Respondent Idealized Attributes 0.25 1 0.25 0.327 0.569
Inspirational Motivation 0.86 1 0.86 1.374 0.245
Intellectual Stimulation 1.976 1 1.976 3.17 0.079
Individualized Consideration 5.46 1 5.46 6.36 0.014*
Contingent Reward 4.061 1 4.061 5.62 0.02*
Management by Exception Active 0.138 1 0.138 0.187 0.666
Passive
2.383 1 2.383 6.294 0.014*
Laissez-Faire 2.787 1 2.787 4.198 0.044*
Extra Effort 1.016 1 1.016 1.241 0.269
Effectiveness 0.239 1 0.239 0.422 0.518
Satisfaction 0.7 1 0.7 1.137 0.29
Transformational 49.802 1 49.802 4.123 0.046*
Transactional 5.697 1 5.697 2.321 0.132
Laissez-Faire 10.325 1 10.325 6.936 0.01*
Hospital Idealized Attributes 1.322 1 1.322 1.73 0.193
Individualized Consideration 0.502 1 0.502 0.585 0.447
Contingent Reward 0.004 1 0.004 0.006 0.938
Passive
1.494 1 1.494 3.947 0.051
Laissez Faire 0.18 1 0.18 0.271 0.604
Extra Effort 0.215 1 0.215 0.263 0.61
Effectiveness 0.029 1 0.029 0.052 0.821
Satisfaction 0.064 1 0.064 0.104 0.748
Transformational 11.294 1 11.294 0.935 0.337
Transactional 0.11 1 0.11 0.045 0.833
Laissez-Faire 2.711 1 2.711 1.821 0.181
Type of Respondent *
Hospital
Idealized Attributes 0.03 1 0.03 0.039 0.844
Individualized Consideration 1.351 1 1.351 1.574 0.214
Contingent Reward 0.005 1 0.005 0.008 0.931
Passive
0.123 1 0.123 0.324 0.571
Laissez Faire 1.867 1 1.867 2.812 0.098
Extra Effort 0.952 1 0.952 1.163 0.284
Effectiveness 1.017 1 1.017 1.796 0.184
Satisfaction 1.47 1 1.47 2.386 0.127
Transformational 8.655 1 8.655 0.716 0.4
Transactional 0.563 1 0.563 0.229 0.633
Laissez-Faire 2.946 1 2.946 1.979 0.164

27
Error Idealized Attributes 55.006 72 0.764
Inspirational Motivation 45.073 72 0.626
Intellectual Stimulation 44.879 72 0.623
Individualized Consideration 61.815 72 0.859
Contingent Reward 52.024 72 0.723
Management by Exception Active 53.121 72 0.738
Passive
27.26 72 0.379
Laissez Faire 47.801 72 0.664
Extra Effort 58.933 72 0.819
Effectiveness 40.771 72 0.566
Satisfaction 44.353 72 0.616
Transformational 869.776 72 12.08
Transactional 176.722 72 2.454
Laissez-Faire 107.175 72 1.489
Total Idealized Attributes 690.438 76
Inspirational Motivation 782.813 76
Intellectual Stimulation 814 76
Individualized Consideration 788.563 76
Contingent Reward 812.438 76
Management by Exception Active 742.563 76
Passive
126.125 76
Laissez Faire 117.5 76
Extra Effort 846.444 76
Effectiveness 846 76
Satisfaction 856.5 76
Transformational 18175.313 76
Transactional 3071.625 76
Laissez-Faire 440 76
Corrected Total Idealized Attributes 57.93 75
Inspirational Motivation 48.417 75
Intellectual Stimulation 49.776 75
Individualized Consideration 72.7 75
Contingent Reward 56.121 75
Management by Exception Active 54.055 75
Passive
33.283 75
Laissez Faire 55.76 75
Extra Effort 63.076 75
Effectiveness 43.25 75
Satisfaction 47.237 75
Transformational 977.674 75
Transactional 183.569 75
Laissez-Faire 133.997 75

28
a R Squared = .050 (Adjusted R Squared = .011)
b R Squared = .069 (Adjusted R Squared = .030)
c R Squared = .098 (Adjusted R Squared = .061)
d R Squared = .150 (Adjusted R Squared = .114)
e R Squared = .073 (Adjusted R Squared = .034)
f R Squared = .017 (Adjusted R Squared = -.024)
g R Squared = .181 (Adjusted R Squared = .147)
h R Squared = .143 (Adjusted R Squared = .107)
i R Squared = .066 (Adjusted R Squared = .027)
j R Squared = .057 (Adjusted R Squared = .018)
k R Squared = .061 (Adjusted R Squared = .022)
l R Squared = .110 (Adjusted R Squared = .073)
m R Squared = .037 (Adjusted R Squared = -.003)
n R Squared = .200 (Adjusted R Squared = .167)
*p<0.05 significance
Avolio & Bass (2004, p. 12) described that transformational leadership had the strongest
and most positive impact whether outcomes were measured subjectively or objectively. The
same pattern of leadership is also supported by Aberese-Ako, Agyepong, & Dijk 2018,
Shaughnessy, Griffin et al. (2018), and Valentine (2019).
Implications of Findings for the Profession
Results showed that there are no differences on ratings of leadership between the 2
locations. However, there are differences in ratings between medical leaders and subordinates
from both locations where medical leaders self-reported higher ratings on Individualized
Consideration, Contingent Reward, Transformational leadership scale as compared to
subordinate medical personnel. Also, medical leaders have self-reported lower ratings on
Management by Exception Passive, Laissez-Faire subscale, Laissez-Faire leadership scale from
both locations. These findings could spur new research and gain further insight on the medical
leadership practices in maternity units in Mali.
Previous research on leadership styles found evidence that leadership training and
resources can greatly improve the staff performance in medical settings, thus this research study

29
examining leadership perception in maternity settings in Mali is a first step towards that long
term goal. Avolio & Bass (2004, p. 13) even recommended two tools to facilitate individual
leadership process. One is a notebook that helps expand transformational leadership qualities
among leaders. Leaders can develop a Leadership Development Plan (LDP) based on the results
of the MLQ reports. It contains developmental behaviors for each MLQ scale and item. The
other tool is the MLQ Training Full Range Leadership Binder. This binder aids the trainer in
developing workshop for teaching the Full Range Leadership model and how to use the MLQ to
create positive behavioral change for the organizational leader.
Limitations
Cleave (2017) and Dickinson (2014) described that close-ended questions have
limitations. They start with words, such as: Can, Did, Will, and Have. As such, Cleave (2017)
and Dickinson (2014) argue that the selection of words in the questions do not give respondents
the choice to truly voice their opinions. Closed questions collect quantitative data, and they give
the respondent a limited number of options to choose from. Closed questions are popular, as
quantitative data is easier to analyze than qualitative data.
Some of the identified limitations in the maternity units were availability of shift
employees on the same day of survey. Those who worked in overnight shift had difficulty filling
out forms and needing extra help by reading to them and explaining each statement in the
questionnaire. These respondents took longer to respond than those who work in the morning
shift.
The level of education and reading comprehension posed some problems. Those with
higher education, such as doctors, residents, midwives, and registered nurses completed the form
in less than 20 minutes. One doctor completed his form in less than 10 minutes. Those with

30
reading comprehension were helped in explaining the statement in Bambara and French. Nurse
aides might have only a primary school level of education and needing more time to complete
questionnaire. It seems that it does not take these participants 30 minutes to answer the MLQ 5X
questionnaire.
There were difficulties also in understanding some of the statements. For leaders :
Statement 1 : « j’apport mon aide aux autres en échange de leurs efforts ». The word « échange »
or exchange confused 75 percent of the respondents because it does not conceptualize in the
Malian culture. Statement 14: “… sense aigu du but …” 60 percent were challenged with word
“aigu”. Investigator wrote down difficulties encountered and explained before participants took
the survey. Overall, data collectors documented all these challenges while participants were
taking the survey. Other statements that were outlined by leaders were items 3, 5, 7, 8, 12, 19,
23, 26, and 40. Statements that need attention in the subordinates’ section are adding a block area
workers can check. Furthermore, this important note listed below at the beginning of the
subordinates’ questionnaire was not understood by respondents. Subordinates’ respondents did
not know which statement to choose.
IMPORTANT (nécessaire pour le traitement) : lequel vous décrit le mieux ?
___ Je suis à un niveau organisationnel plus élevé que la personne que j’évalue.
___ La personne que j’évalue est à mon niveau organisationnel.
___ Je suis à un niveau organisationnel inférieur à celui de la personne que j’évalue.
___ Je ne souhaite pas que mon niveau organisationnel soit connu.
The box above is not relevant because respondents work at the same facility. The person
being evaluated is the chief medical doctor in each maternity.

31
Conclusions
This research project was quite exploratory. The objective of the study was achieved. The
null hypothesis (HO2) was rejected, and the alternative hypotheses (Ha2) was supported which
reflected differences in the perceptions of leadership styles by medical leaders and the medical
subordinate/support staff. When comparing the to the norms for using the MLQ 5X
questionnaire, it could be concluded that Transformational leadership is utilized more than
Transactional leadership or Laissez-Faire leadership in both maternities wards. The corrected
total of leadership characteristics is: Transformational Leadership = 977.67, Transactional
Leadership = 183.57, and Laissez-Faire =134.
This research project helped identify leadership style perception between medical
maternity leaders and their subordinate medical maternity staff members in 2 hospitals in the
country of Mali. Though the MLQ (5X)’s 360 degrees capabilities can assess perceptions of
leadership effectiveness of team leaders, supervisors, manager, and executives from many
different levels of an organization as Avolio & Bass (2004), data collected from this research
project indicates no statistical significance in extra effort, effectiveness, and satisfaction.
This exploratory research project intended to tackle perceived leadership among medical
leaders and subordinate medical staff stakeholders in Kayes and Sikasso, where little or no study
previously been performed on the topic of leadership. Both leaders practiced mixed forms of
transformational and transactional leadership skills in both hospitals.
Recommendations
Overall, the study in Sikasso and Kayes went smoothly with the assistance the Chiefs of
the Maternities in collaboration with staff members, and assistance from data collectors.
Everyone was receptive of the study because not one like this has ever been done in Mali,

32
especially in maternity units. Both directors from the hospitals want a follow-up study done that
may include the entire hospital.
If we intend to continue research at the national level in Mali, some of the statements in
the MLQ 5X Questionnaire need to be revised and adjusted to the level of understanding and
comprehension of most healthcare workers in Mali. While we are on the questionnaire, it is quite
important to have trained data collectors who understand the hospital system and KoboCollect
and be able to explain statements to respondents.
There is not much to recommend on self-reported leadership styles among leaders only to
report some of the concerns voiced in the subordinates’ ratings of their leaders in Sikasso.
One important thing that was noticed in Kayes is that titles change from department to
department even when they work as nurses. For example, nurse obstetrician (infirmiere
obstetrique-IO) is not the same or does not do the same job as regular nurse. Some of the
classifications were clarified in Kayes than in Sikasso. These classifications of titles need to be
included in the questionnaire of the maternity units and in the organization structure.
A follow-up qualitative research may answer some of the human experiences that were
not fully captured or covered this quantitative research project. Also, a follow-up leadership
training program recommended by Avolio & Bass (2004, p. 13) and a second study on some of
the identified limitations may help some medical leaders in improving leadership and
performances in their maternity units.
In closing, this research project could be the baseline for future studies. These
recommendations from the current research could also help maternity medical chiefs improve
their leadership styles that might lead towards further improvements in organizational outcomes.

33
For example, medical leaders could continually encourage their subordinate medical staff
members to provide quality care and service towards their patients.

34
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