sweep things under the rug or pre-tend it never happened. in.docx

sweep things under the rug or pre-
tend it never happened. in worship
services, take time to share with the
people how rich they are in god’s
grace rather than just telling them
how they should behave. in this sec-
tion of the book, the author does get
very specific on how to make sure
grace is shared publicly. Whether it is
in the worship service or dealing with
visitors as they walk in the door,
making sure people experience christ
is vital.
“Portable grace,” as Eclov calls it,
reveals how to minister outside the
walls of the church through hospital
ministry, death and grief, childbirth
visits, or home and work visitation.
One practical application that pastors
should hear is that one does not need
to be invited to go. As young pastors,
we usually do not go where we are
not invited, but the author recom-
mends challenging that thinking by
going proactively. i have taken this
advice, and it really has been a great
blessing for me and for those i’m
visiting.
Probably one of the most practical
chapters in the book is “March into

the Smoke.” When times are scary,
cloudy and daunting, a leader can
easily experience disorientation and
loss of focus. this section of the book
is for such pastors who are weary and
tired. it emphasizes the importance
of being healthy on the inside so that
you can take care of those on the out-
side. the pastor may project unre-
solved anger onto the congregation
without even realizing it. the things
he brings up are valid, but one thing
he is lacking is the how-to or even
the call to action for the pastor to get
help with anger or depression.
One concluding critique: in the
midst of his stories and encounters,
the author interjects his unique doc-
trinal understandings in the mix of
his stories and illustrations.
consequently, some of the conversa-
tions and interactions with others
would be very different if processed
in different faith tradition contexts.
the reader simply needs to filter and
adapt accordingly.
Pastoral Graces is a good book for
those who need encouragement. i
found the book to be helpful when it
comes to personal connections with
parishioners. As pastors, we can get
burned out and depressed, and feel
very much alone. this book is not a

fix-all, but it is a reminder that god
really does love us and care about us
as his messengers of grace. i cannot
say this book is for every pastor, but i
do recommend it for the young pas-
tors, new pastors, and discouraged
pastors who are on the verge of giv-
ing up. i believe the author accom-
plished what he set out to accom-
plish.
StEPhEN cArLiLE is a student in the Andrews
University Master’s of Pastoral Ministry extension
program and serves as church pastor of Adventist
Fellowship in tulsa, Oklahoma.
CHANGE LEADER:
LEARNING TO DO WHAT
MATTERS MOST
By Michael Fullan
San Francisco, CA: Jossey-Bass/Wiley
(2011)
Hardback, 172 pages
Reviewed by JORGE PEREZ
in Change Leader, Michael Fullan
argues for the importance of practice
as a learning tool for leaders, claim-
ing that it plays a more central role
than theory does in leading to effec-
tive change. he presents the case that
research and theory should be used
in the service of practice, and not the
other way around (pp. xii, xiii). this
last book in his trilogy on leadership

B O O K R E V I E W S T E P H E N C A R L I L E
THE JOURNAL OF APPLIED CHRISTIAN LEADERSHIP
PAGE 99
presents a seven-part solution to
change leadership which “places
practice front and center” and then
adds six other components of “com-
bining resolve, motivation, collabora-
tion, confidence, impact and ‘sim-
plexity’” (p. xiii). this book review
discusses these seven areas Fullan
proposes under the main theme that
practice is the way to create change.
For Fullan, experience is every-
thing. it is easy to appreciate that
through the chapters Fullan keeps
making a point that most good ideas
come from practice, either personal
or observed. Since most change ini-
tiatives fail, it makes leadership diffi-
cult because people are resistant to
experiencing change; people are
complicated and sometimes unman-
ageable (p. xiii). this is why the
author invites us in the book, again
and again, to look inside our prac-
tice, experiences, and ourselves.
hence, here i discuss Fullan’s con-
ception of seven core practices or
steps for today’s leaders that promise

to differentiate a powerful leader
from one that is merely competent.
the first step of the change
process is “Deliberate Practice.”
throughout the book, Fullan drives
home the evidence that practice-
driven leadership is most effective
because it lets practice, informed
by research and theory, become the
engine that brings change. theory is
not the driver as “practice is our best
bet for finding solutions” (pp. 155).
in short, deliberate practice drives
better practice. Fullan develops and
suggests that practice is a powerful
tool for change and elaborates on
how the brain works.
Elaborating further on the brain,
he explores recent discoveries on
how the brain learns in and from
practice. he discusses “unpredictable
inner drives,” “impressive empathy,”
“mirror neurons,” and “neuroplastic-
ity” to talk about how practice
changes brain processes. he argues
that “the best source of learning is
day-to-day practice because it is the
only experience that can engage and
reshape the brain” (p. 5). he suggests
that the framework presented (the
seven keys) is not an action plan, but
rather an instrument to promote
deliberate practice. in other words, in

exploring and adapting these seven
elements of change leadership we
could become leaders whose main
driver is experience.
the second step is about “Being
resolute.” in this section he reviews
the critical role of “impressive empa-
thy” (the ability to understand and
share the feelings of another) and
how change leaders combine impres-
sive empathy with moral purpose.
Fullan invites us to remember two
things: stay the course against all
odds and be empathetic when it
comes to antagonism. in the
process of adopting change, if this
is to occur, disagreements must
be resolved with resolution and
empathy. After all, values of resolute
leaders have a moral attribute, Fullan
says.
it is known that firm action is cru-
cial in change leadership, and at the
same time, in chapter 2 and through-
out the rest of the steps, the author
emphasizes the vital, if not indispen-
sable, role of impressive empathy—
empathy for those who disagree with
us. impressive empathy is important
because effective leadership must
involve and motivate people affected
by change. “Motivating people, after
all, is what change is about” (p. 48).

the third step deals with what
“Motivates the Masses.” in our busi-
ness environment, every leader is
expected to bring about change and
the big change problem is how to
engage people. two important asser-
tions by Fullan are that “change is
B O O K R E V I E W J O R G E P E R E Z
PAGE 100 Vol. 8, No. 2 FALL 2014
only a mirage unless people actually
experience the reality of improve-
ment” and that “helping people
accomplish something that they have
never accomplished before causes
motivation to increase deeply” (p.
52). in other words, “realized effec-
tiveness” is what motivates people.
the recent emphasis on change lead-
ership suggests that change is an
engine for moving masses that also
are looking for change. this is why
change leaders cannot achieve suc-
cess without the commitment and
collaboration of the group.
in the fourth step, “collaborate to
compete,” Fullan suggests that it is
vital for the change to occur to open
up the group to new ideas and com-
petition. this is what the author calls
“collaborative competition,” the yin-

yang of successful change. Fullan
invites us to build collaborative cul-
tures, and as effective change leaders
we must welcome both collaboration
and competition. he states that “the
effective change leader appreciates
both collaboration and competition
. . . for ongoing success you need to
collaborate and compete” (p. 97).
i resonate with Fullan when he
declares that change leaders shape a
philosophy of commitment and
sound competition. Furthermore, he
states, “if people become intrinsically
motivated, competition to do their
best comes naturally” (p. 98). in
short, a purposeful collaborative cul-
ture within the organization is the
key for change. After all, learning the
change process and how to influence
it is the job of the effective change
leader.
the fifth step, “Learning
confidently,” talks about the deter-
mination to learn as a vital compo-
nent to any leader of change. in this
step, it is important to note that only
by learning how to learn can we
become effective change leaders.
Fullan invites us, in this step, to do
four things in combination: to use
our brain, to cultivate a growth mind-
set in others and ourselves, to be

indispensable in the right way, and
to maintain a high level of confi-
dence. An old adage says that “a
text out of context is only a pretext;
context is everything.” this is what
change leaders do; they change con-
texts, according to Fullan. in fact, he
affirms that “change leadership is
about how to move individuals,
organizations, and systems into new
contexts” (p. 122). By learning, we
intentionally know what is going on
and what impact the change leader
is having.
Knowledgeable leaders of change
are able to admit and learn from mis-
takes. Fullan states that “only the
learners eventually become effective
change leaders” (p. 118). he further
admits that change leadership is
about changing context and that
“change leaders need to be explicitly
aware that this is the business they
are in” (p. 123).
regarding “impact,” the sixth
step, the author invites us to go out
of our way to get to know ourselves,
to be alert and mindful of our influ-
ence and power as change leaders.
Once again, we are reminded to use
our brain and to let practice drive
better practice. As change leaders,
we must be aware and competent of
our impact. this step is a good

reminder that leaders need to focus
on the task at hand, and avoid dis-
tractions, by becoming good at decid-
ing what not to do. Fullan makes
special emphasis on the importance
of knowing ourselves better in order
to admit our mistakes; align goals,
action, and feedback; establish a cli-
mate of opened and critical feedback;
focus on a few priorities; know our-
selves better; follow a checklist; and
celebrate success after it happens.
PAGE 101
All this is important because once the
leader identifies his or her shortcom-
ings, only a careful and intentional
checks and balances system will lead
to a successful change. the solutions
proposed by the author are rather
simple: work on your habits of the
mind and matching mechanisms.
Fullan confesses that what it takes
is “day-to-day leaders and managers
focusing on a small number of key
things, doing them well, and being
transparent about their practice and
progress. . . . it is simplexity itself”
(p. 150).

the last chapter, “Sustain
Simplexity,” provides an overview of
the above key steps solution. Fullan
reminds us to keep it simple and
“tackle complex problems without
feeling overwhelmed” (p. 152). this
chapter depicts Fullan’s change
Leaders Framework with the assump-
tion that if we understand the seven
keys of this framework we will
become better leaders. in this final
chapter, Change Leader reinforces
what it has been sharing throughout
the book, that practice, especially a
reflective experience, produces better
practice.
Using a combination of practice
and research theory obtained by his
consulting and teaching career,
Fullan presents throughout the chap-
ters a practical and rich picture of
how to become effective leaders of
change. he admits that most change
initiatives fail and throughout the
book he shows that we cannot force
people to change, that rewards do
not work or have short-lived impact,
and that inspiration is not enough.
What is very valuable is Fullan’s
assertion that his book provides pro-
tection against bad training because
it provides leaders of change with the
right reasons to learn from and trust
themselves.

in the final analysis, the author of
Change Leader reminds us that his
book is for the wise practitioner
rather than the abstract theorist. in
the last chapters, Fullan provides a
very practical way to know what
impact we are having as change lead-
ers. Leaders of change will be able to
learn to be effective by going out of
the way to know us better. he
acknowledges that the brain distorts
things, perceptive attention is being
diminished, information overloads
compromise our memory, and cogni-
tive impairment has become an epi-
demic along with the loss of empathy
and compassion. Fullan asks, What
does all this mean for us as leaders
of change? the proposed answer is
“use your brain; let deliberative prac-
tice drive better practice” and “be
aware and cognizant of your impact”
(p. 131). in short, be a learner.
this book is important for the
progress and growth of the leaders of
change as it presents and sustains all
along the 10-year rule: be a deliberate
and intentional learner and you will
master any field in 10 years. By shar-
ing and linking their own practices to
the seven elements suggested by
Fullan, leaders of change will move
to improve their effectiveness and
become better leaders. his argument

that to be an effective leader of
change we must go out of our way
to know ourselves and use our brain
is, pragmatically speaking, life
changing. the author presents deep
applied practice that is feasible for
anyone who wants to implement it.
this book has value for the leader
who is going through organizational
or team change and wants to make
sense of individual change manage-
ment first. Of all that Fullan offers, i
found step two, “Be resolute,” the
most valuable. in particular, impres-
sive empathy, the ability to under-
stand others who disagree with you,
is presented as a critical soft skill to
PAGE 102 Vol. 8, No. 2 FALL 2014
becoming an effective leader of
change. As a christian and leader, i
deeply agree with the emphasis and
critical role the author gives to being
impressively empathetic. As a
christian, i feel the responsibility to
“Love my neighbor as myself” and
“Whatever you wish that men would
do to you, do so to them.” in this,

Fullan asserts that “if you want to
have any chance of changing a nega-
tive relationship you have to give
other people respect before they have
earned it” (p. 32). it has been my
experience that there is no other way
to reach out to others, particularly
during the change process. Empathy
for others does exactly that.
What diminished the value of this
work for me was that even though
the author emphasizes the leader as a
learner, Fullan fails to go deeper into
exploring and putting together the
learning cycle of a leader. the author
establishes the relationship between
leadership and learning quite well.
however, the changeover from
“reflective doing” to theory is vague
and confusing. in several of the steps
and throughout the book, the learn-
ing cycle, which involves experience,
reflection, and theory, is not well pre-
sented or not presented at all, leaving
an immediate gap in understanding.
Since reflection is so central to the
learning cycle, a better effort could
have been made in establishing
reflection as connecting practice
(concrete experience) and (abstract)
theory. in addition, step seven,
“Sustain Simplexity,” reads more as a
conclusion rather than a valid step
and a part of the change solution.
this left me with a page-flipping

reaction to find more about
“Simplexity.”
Even with those apparent restric-
tions, i would recommend Change
Leader by Michael Fullan as an
esteemed reference in learning more
about ourselves as proactive leaders
and in particular leaders of change.
in conclusion, this volume pro-
vides us with a lot of common sense
and helps develop a new kind of
leader, a leader who values experi-
ence and reflective learning. By
understanding the seven-step change
process, leaders will become effective
and successful leaders of change in
their organizations. this book is full
of discernment and knowledge that
comes from someone with vast expe-
rience in the change process.
JOrgE PErEZ is an entrepreneur and owner of a
bilingual hispanic newspaper in Southwest Ontario.
he serves as President of the canadian Latin
American Association and is a Ph.D. student in the
Andrews University Leadership Program.
FOCUS: THE HIDDEN
DRIVER OF EXCELLENCE
By Daniel Goleman
New York, NY: Harper Collins (2013)
Hardcover, 312 pages

Reviewed by JORGE PEREZ
can a leader be fulfilled and pro-
ductive at the same time? goleman
thinks “Yes” and he makes his case
by placing attention, the elusive and
underappreciated mental faculty, in
the spotlight. in Focus: The Hidden
Driver of Excellence, he makes a case
for the science of attention as a deter-
minant skill for leaders, arguing that
such a state of awareness is linked to
excellence and a key to fulfillment
and success. “Leaders must pay more
attention to their attention, if they
want to increase it,” goleman says.
in his previous book, Emotional
Intelligence, goleman defines emo-
tional intelligence as self-awareness
and self-management—how we man-
age ourselves, and social skills, how
we manage our relationships.
PAGE 103
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International Journal of Human Resource Studies
ISSN 2162-3058
2012, Vol. 2, No. 2
www.macrothink.org/ijhrs 71
Millennials in the Workplace: A Conceptual Analysis of
Millennials’ Leadership and Followership Styles
Shih Yung Chou (Corresponding author)
HEB School of Business and Administration, University of the
Incarnate Word
4301 Broadway, CPO 394, San Antonio, Texas 78209, USA
Tel: 1-210-283-6482 E-mail: [email protected]
Accepted: March 29, 2012 Published: May 27, 2012
Doi:10.5296/ijhrs.v2i2.1568 URL:
http://dx.doi.org/10.5296/ijhrs.v2i2.1568
Abstract
The Millennial Generation in the workplace has received

increasing attention as it has been
shown that Millennials demonstrate different attitudes, values,
beliefs, and aspirations in the
workplace compared to the previous generations. Although a
number of studies have devoted
to the investigation of Millennials, the leadership and
followership styles exhibited by
Millennials at work has been largely neglected. Thus, the major
purpose of this article is to
develop a conceptual framework that explores Millennials’
leadership and followership styles
in the workplace. By examining Millennials in the context of
leadership and followership,
this article provides important theoretical and practical
implications.
Keywords: Millennials, Leadership, Followership
1. Introduction
With their entry to the workforce, the Millennial Generation has
received increasing scholarly
attention (Harris-Boundy & Flatt, 2010). According to Smola
and Sutton (2002), Millennials
are those born between 1979 and 1994 and have labeled the
Millennial Generation as

Generation Y, Nexters, and the Nexus Generation (e.g.,
Barnard, Cosgrove, & Welsh, 1998;
Burke & Ng, 2006; Zemke, Raines, & Filipczak, 2000).
Meanwhile, this article uses
“Millennials” to describe this generation in order to be
consistent with the literature and
public press. Despite their popularity in the literature and public
press, Millennials have
received much concern and speculation. For instance, it is
argued that Millennials are
self-important, impatient, and disloyal (Hill, 2008; Howe &
Stauss, 2007; Jacobson, 2007). In
addition, it is suggested that Millennials are ambitious, value
organizational training and
ISSN 2162-3058
2012, Vol. 2, No. 2
development, prefer meaningful work, and seek for personal
fulfillment on the jobs (Hauw &
Vos, 2010; Loughlin & Barling, 2001; Rawlins, Indvik, &
Johnson, 2008). Although a

number of studies have devoted to the study of Millennials in
the workplace, the leadership
and followership styles exhibited by Millennials have not
received much attention Millenials
are not all in the workforce. Therefore, this article strives to
address this gap by exploring
Millennials’ leadership and followership styles in the
workplace.
To add crucial knowledge to the analysis of Millennials as
leaders and followers, this article
evaluates how Millennials’ leadership style is shaped by their
work attitudes, beliefs, and
values and how Millennials behave as followers in the
workplace. Specifically, we apply
Lewin, Lippitt, and White’s (1939) theory of leadership styles,
which has been the foci of
leadership research and modern management (Deutsch, 1992;
Wolf, 1973), and Kelley’s
(1992) theory of followership as it has been suggested to be one
of the most important
contributions in the followership literature (Blanchard,
Welbourne, Gilmore, & Bullock,
2009).

The remainder of this article is organized as follows. In the
second section, we provide a brief
literature review on Millennials in the workplace with the
emphasis on their work values,
attitudes, and behaviors. Next, we briefly discuss Lewin et al.’s
(1939) theory of leadership
and Kelley’s (1992) theory of followership. This is followed by
our theoretical arguments and
propositions. In the fourth section, we discuss the implications
for theory and managerial
practice. The final section concludes this article with a brief
summary.
2. Literature Review
2.1 Millennials in the Workplace
As Millennials are the newest individuals to the workforce,
there is an increasing discussion
on Millennials in the workplace from various perspectives. For
instance, drawing upon an
economic model, Barkin, Heerman, Warren, and Rennhoff
(2010) analyzed the impact of
obesity on lifetime earnings for the Millennial generation and
predicted that obese Millennial
women and men in the U.S. earn an average of $956 billion and
$43 billion less than

non-obese Millennial women and men. In their study of
Millennials in teams, Harris-Boundy
and Flatt (2010) showed that Millennials demonstrate higher
levels of individualism than
collectivism. Hershatter and Epstein (2010) explored ways that
the Millennial generation
approach the world of work and suggested that Millennials
integrate technology into their
lives and expect accommodations by organizations based upon
their experiences, needs, and
desires. In their empirical study of the effect of generation on
work attitudes, Kowske, Rasch,
and Wiley (2010) found that Millennials have higher levels of
overall company satisfaction
and satisfaction with job security, recognition, and career
advancement than Generation Xers
and Baby Boomers. Myers and Sadaghiani (2010) discussed
Millennials workplace
expectations, communication styles, and relationships with team
and organizational members.
Specifically, these researchers suggested that Millennials work
well in team settings, are
motivated by significant tasks, prefer open and frequent
communication, and comprehend

communication technologies. In their field study of the
Millennial generation, Ng, Schweitzer,
and Lyons (2010) discovered that Millenials emphasize
individualism, seek for career
ISSN 2162-3058
2012, Vol. 2, No. 2
advancement and skill development, and ensure a meaningful
and satisfying life outside of
work.
Despite the amount of research on Millennials in the workplace
has dramatically increased,
two important research areas still need to be addressed.
Specifically, with their entry to the
workforce, what leadership style do Millennials exhibit? In
addition to their leadership style,
what is the type of followership style exhibited by the
Millennial generation? To answer these
questions, I apply the theory of leadership styles developed by
Lewin et al. (1939) and the

theory of followership developed by Kelley (1992). In the
following sections, Lewin et al.’s
(1939) theory of leadership and Kelley’s (1992) theory of
followership are briefly discussed.
2.2 Lewin’s Theory of Leadership Styles
As the concept of leadership covers a wide range of aspects, it
has been defined in various
ways. For instance, Fiedler (1967) defined leadership as the
individual who is given the task
of directing and coordinating task-relevant group activities and
who carries the primary
responsibility for performing these activities in the group.
Stogdill (1974) suggested that
leaders initiate and maintain the structure in expectation and
interaction. Pfeffer and Salancik
(1975) claimed that leadership refers to a leader’s task and
social behaviors. Bryman (1992)
defined leadership as an individual’s ability to guide followers
toward common goals.
Because leadership has been defined in several ways, leadership
styles have been developed
based upon different dimensions such as decision-making
distribution and the relationship

between a leader and a follower (Ismail & Ford, 2010). Among
various theories of leadership
styles, the study conducted by Lewin and his colleagues is one
of the most important and
influential social psychological leadership theories (Liden &
Antonakis, 2009; Marrow, 1969;
Wolf, 1973). Specifically, Lewin, Lippitt, and White conducted
an experimental study in
1939 that examined leadership behavior based on the
distribution of decision-making
authority between a leader and a follower, and discovered that
leadership styles can be
described in three patterns: autocratic, participative, and
laissez-faire style.
Autocratic leadership occurs when a leader makes decisions
without asking for subordinates’
opinions and suggestions and therefore subordinates have no
influence on the
decision-making process (Yukl, 2002). As autocratic leadership
style constrains subordinates’
inputs in decisions and exhibits little respect for subordinates’
opinions and values (Bass,
1990), a number of previous studies have demonstrated the
negative outcomes of autocratic

leadership style such as negative emotions experienced by
subordinates (e.g., De Cremer,
2007), passive-aggressive behavior exhibited by leaders (e.g.,
Johnson & Klee, 2007), low
satisfaction and motivation demonstrated by subordinates (e.g.,
De Cremer, 2006), and
burnout experienced by subordinates (e.g., De Hoogh & Hartog,
2009).
Participative leadership style is demonstrated when a leader
allows followers to contribute in
decision-making process (Kaufman, 2001). Thus, participative
leaders consult with
subordinates, ask subordinates’ suggestions, and take
subordinates’ ideas into consideration
when making decisions (Chen & Tjosvold, 2006). Given the
joint influence on decision
making, previous studies have shown various positive outcomes
of the participative
leadership style such as increased subordinates’ motivation
(e.g., Locke & Latham, 1990),
ISSN 2162-3058

2012, Vol. 2, No. 2
commitment (e.g., Yammarino & Naughton, 1992), satisfaction
(e.g., Smylie, Lazarus, &
Brownlee-Conyers, 1996), and reduced turnover (e.g., Spector,
1986).
Laissez-faire leadership describes those leaders who are
reluctant to influence or give
directions to subordinates and subordinates thus have
considerable freedom in deciding their
actions (Deluga, 1990). Because laissez-faire leaders avoid
exercising leadership functions,
they avoid making decisions, hesitate in taking actions, and are
absent when needed (Judge &
Piccolo, 2004).
2.3 Kelley’s Theory of Followership
According to Howell and Costley (2001), followership refers to
an interactive role that an
individual plays that complements the leadership role, and is as
important as the leadership
role in determining group and organizational performance.
Although leaders would not be
existent without followers (Hollander, 1993), followership is

still an understudied discipline
(Mushonga & Torrance, 2008) because it is usually associated
with negative connotations
(Bjugstad, Thach, Thompson, & Morris, 2006). Meanwhile,
Kelley (1992) claimed that
followers are those individuals who are courageous and honest,
and who cooperate to
accomplish goals without competing for leadership or power.
Based upon the definition of
followership, Kelley further conceptualized followership using
two behavioral dimensions:
critical thinking and active engagement. Specifically, followers
with high levels of critical
thinking are independent and critical thinkers, willing to be
creative and innovative, and
willing to offer criticism regardless of the consequences
(Mushonga & Torrance, 2008).
Meanwhile, followers who have high levels of active
engagement often take initiatives,
assume ownership, and actively participate in performing their
jobs (Blanchard et al., 2009).
Moreover, high actively engaged followers go above and beyond
their job requirements and
exert effort to accomplish goals (Kahn, 1990; Rothbard, 2001),

which in turn lead to positive
outcomes such as increased job satisfaction, organizational
commitment, and decreased
turnover (Salanova, Lorens, Cifre, Martinez, & Schaufeli, 2003;
Schaufeli & Bakker, 2004).
Based upon the characteristics of followers who demonstrate
different levels of critical
thinking and active engagement, Kelley developed a four-
quadrant followership model that
describes four styles of followership including alienated,
conformist, passive, and exemplary
followers. According to model, alienated followers are those
who have a healthy skepticism
of the organization. Conformist followers are those who
actively do their tasks and follow
orders. Passive followers are those who require constant
direction. Exemplary followers are
characterized as being independent and innovative, and being
able to understand how to work
and interact with others in organizations.
The brief review of Lewin et al.’s theory of leadership styles
and Kelley’s (1992) theory of
followership styles has shown the behavioral characteristics of
each of the leadership and

followership styles exhibits. In the following section, I provide
my theoretical arguments and
positions on the leadership and followership styles exhibited by
Millennials at work.
3. Theoretical Framework and Propositions
3.1 Leadership Style Exhibited by Millennials
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2012, Vol. 2, No. 2
Millennials in the workplace have been discussed and
researched by previous studies from
two major perspectives. A first research stream focuses on
Millennials’ work attitudes and
values. Although consistent findings have not been shown in the
literature, it has generally
been demonstrated that Millennials focus much on the social
aspect of work such as having
friendly coworkers and interesting work environment (Ng et al.,
2010). Similarly, in their

empirical study of medical students’ motives, Borges, Manuel,
Elam, and Jones (2010) found
that Millennials have greater social needs, tighter peer bond,
and stronger team orientation
than Generation Xers. The focus of social aspect at work,
however, does not result in
Millennials’ lack of effort in the workplace. Specifically,
Millennials are found to be
hard-working, responsible, team-oriented, and altruistic (Elam,
Stratton, & Gibson, 2007;
Gloeckler, 2008). Alsop (2008) supported this view by noting
that Millennials’ altruistic
behavior is mainly influenced by their families and friends. It is
also because of their
team-oriented mindset, Millennials tend to demonstrate an
inclusive management style where
immediate feedback is emphasized (Lowe, Levitt, & Wilson,
2008). Additionally, Millennials
have been found to demonstrate higher levels of self-esteem and
assertiveness than previous
generations (Twenge & Campbell, 2001) and to be
extraordinarily confident of their abilities
(Harris-Boundy & Flatt, 2010). These characteristics have also
been found by Trzesniewski

and Donnellan (2010). Specifically, Trzesniewski and
Donnellan revealed that Millennials
tend to have high levels of self-esteem and external locus of
control compared to previous
generations in a study of high school birth cohort.
A second research stream discusses Millennials’ communication
style. According to previous
research, Millennials not only seek for frequent, positive, and
open communication in the
workplace constantly but also gather and share information
readily (e.g., Gursoy, Maier, &
Chi, 2008; Hill 2002; Howe & Strauss, 2007; Tapscott, 1998;
Marston, 2007; Martin, 2005;
Zemke et al., 2000). From this perspective, one can expect that
Millennials, as leaders, will
utilize a two-way communication approach and emphasize the
importance of having
reciprocal relationships with subordinates. Meanwhile, the
leadership literature has suggested
that participative leadership involves including subordinates in
decision making, asking for
subordinates’ suggestions, and discussing organizational issues
with subordinates (Chen &
Tjosvold, 2006). Thus, when linking Milllennials’ workplace

attitudes, beliefs, values, and
communication style with leadership styles, it is expected that
Millennials will demonstrate
high levels of participative leadership style. This suggests the
first proposition:
Proposition 1: Millennials will demonstrate high levels of
participative leadership style in
the workplace.
3.2 Followership Style Exhibited by Millennials
When examining the communication style of Millennials,
previous studies have found that
Millennials expect to communicate with their supervisor openly
and frequently (Gursoy et al.,
2008; Martin, 2005) and to maintain strong relationships with
supervisors (Jokisaari & Nurmi
2009; Martin 2005). Moreover, Alsop (2008) and Gursoy et al.
(2008) suggested that
Millennials prefer to work with others as they perceive working
in groups is interesting.
However, Millennials also expect to express their thoughts,
ideas, and opinions and are not

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2012, Vol. 2, No. 2
intimidated by others because of lack of experience and status
(Myer & Sadaghiani, 2010).
Furthermore, Millennials often demonstrate high levels of need
for achievement, trust in their
organizations, and desire for organizational systems that
support and develop them
(Hershatter & Epstein, 2010; Howe & Strauss, 2003; Myer &
Sadaghiani, 2010).
According to Kelley’s (1992) followership model, it is
suggested that exemplary followers
play a crucial role in determining organizational success
because they are independent,
innovative, and willing to question leadership. In other words,
exemplary followers
constantly engage in critical and independent thinking
(Mushonga & Torrance, 2008). Given
that Millennials prefer to express their thoughts, ideas, and
opinions freely and frequently
(Myer & Sadaghiani, 2010), one can expect that Millennials will
demonstrate the

characteristics of exemplary followership style in the
workplace.
Moreover, it is suggested that exemplary followers often engage
in questioning their leaders’
decisions (Mushonga & Torrance, 2008). In other words,
exemplary followers might not
consider their statuses, titles, or experience when disagreeing
with their leaders. Furthermore,
Bjugsad et al. (2006) claimed that exemplary followers work
well with others and are always
available to those who interact with them. Given that
Millennials perceive working in groups
to be interesting (Alsop, 2008; Gursoy et al., 2008), one can
expect that Millennials will
demonstrate the characteristics of exemplary followership style
in the workplace. This
argument supports the second proposition:
Proposition 2: Millennials will demonstrate high levels of
exemplary followership style in
the workplace.
4. Discussion
This article has intended to describe the leadership and
followership styles exhibited by the

Millennial generation in the workplace. The purpose is to
provide organizations and
managers an understanding of Millennials in the contexts of
leadership and followership.
Given that this aspect has been largely neglected by previous
studies, this article provides
several important implications for theory and managerial
practice. In the following sections,
implications for theory and practice are presented.
4.1 Implications for Theory
We believe that the investigation of Millennials’ leadership and
followership in the workplace
extends the prior research on Millennials’ in two major ways.
First, to our best knowledge,
this article is one of the first few studies that extend Lewin et
al.’s (1939) leadership style
theory to the Millennial generation. Specifically, because
Millennials will continue to enter
the workforce until around 2022 (Hershatter & Epstein, 2010),
this article provides additional
insight into the understanding of Millennials as leaders in the
workplace as previous research
on Millennials focuses much on their attitudes, values, beliefs,

and aspirations in the
workplace rather than on how Millennials behave as leaders.
In addition to discussing Millennials’ leadership style, this
article provides important
contribution to the followership literature by adding the newest
generation of the workforce
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2012, Vol. 2, No. 2
into the literature. Given that followership is an important but
understudied field (Blanchard
et al., 2009), this article offers a theoretical basis for future
theoretical and empirical
followership research.
4.1 Implications for Practice
If the propositions offered by this article are validated by future
empirical research, the
framework could have important practical implications. First,
understanding Millennials’

leadership style may provide insight into designing a work
environment where leadership
effectiveness is maximized, which in turn fosters individual,
group, and organizational
performance. For instance, we have claimed that Millennials
will demonstrate a participative
leadership style in the workplace. Thus, organizations can
facilitate leadership effectiveness
by removing organizational barriers such as organizational
structure and levels as they have
been suggested that organizational levels is one of the factors
that influence leadership style
(Mintzberg, 1980; Yukl, 2002).
Second, by understanding the followership style exhibited by
Millennials, organizations and
managers are able to manage Millennials work performance
more effectively. For example,
the leader-member exchange (LMX) theory (Dansereau, Graen,
& Haga, 1975) has suggested
that leadership effectiveness is the result of the quality of the
dyadic relationship between
leader and follower and the quality of this relationship is
determined by the negotiation
between a leader and follower (Graen & Scandura, 1987; Graen

& Uhl-Bien, 1995). Since the
negotiation is initiated by the leader and reciprocated by the
follower, organizations and
managers need to ensure that Millennial followers perceive the
initial contribution from their
leaders so that they are able to experience a more satisfying and
high quality LMX
relationship, which in turn may improve Millennial followers’
performance, satisfaction, and
work attitudes. Given that Millennials prefer to express their
thoughts, ideas, and opinions
freely and frequently (Myer & Sadaghiani, 2010), high quality
LMX can be obtained, for
example, by using a two-way communication approach such as
offering open forum
discussions.
In addition to ensuring the quality of the leader-member
relationship, organizations and
managers can improve leadership effectiveness by matching
right leadership style to
Millennials’ followership style. Specifically, it is suggested that
a leader’s effectiveness is
greatly influenced by the followers’ permission (DePree, 1992).
Because Millennials tend to

demonstrate high levels of self-esteem and assertiveness and to
be extraordinarily confident
of their abilities (Harris-Boundy & Flatt, 2010; Twenge &
Campbell, 2001), a delegating
leadership style as suggested by Bjugstad et al. (2006) may be
used so that Millennial
followers are able to experience high levels of responsibility,
work meaningfulness, and
personal fulfillment on the jobs, which in turn may lead to high
levels of leadership
effectiveness and organizational performance.
5. Limitations and Future Research Suggestions
By exploring leadership and followership styles exhibited by
the Millennial generation at
work, this article provides a new perspective on understanding
Millennials in the workplace.
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2012, Vol. 2, No. 2

Although this article intends to explore this new perspective, it
is not without limitations.
A first limitation is related to the discussion of leadership
styles. Specifically, there are many
important leadership theories such as the contingency model of
leadership (Fiedler, 1967),
path-goal theory of leadership (House, 1971; House & Mitchell,
1974), vertical dyad linkage
theory (Dansereau, et al., 1975), transformational leadership
theory (Bass, 1985), etc.
Although this article applies Lewin et al.’s (1939) theory of
leadership styles, which has been
a major theoretical base for many studies that investigated
different leadership styles (Eagly
& Johannesen-Schmidt, 2001; Rosenbaum & Rosenbaum, 1971),
future research that applies
other leadership theories is still needed in order to expand our
understanding of Millennials in
the context of leadership.
When examining leadership and followership styles of the
Millennial generation in the
workplace, this article focuses mainly on the attitudes, values,
beliefs, and aspirations of
Millennials in the workplace identified by previous research.

However, it has also been
shown that individual and organizational factors could affect
leadership and followership
styles exhibited. For example, Valliant and Loring (1998)
examined the relationship between
leadership styles and personality and found that personality
traits such as self-control and
tolerance significantly affected an individual’s leadership style.
Moreover, it has been
suggested that organizational culture could influence leadership
styles in the organization
(Lok & Crawford, 2004; Ogbonna & Harris, 2000). Although
the primary objective of this
article is to take the first step and investigate Millennials’
leadership and followership styles
in the workplace, future studies that include micro- and macro-
level variables are still needed
to strengthen the framework offered by this article. Despite the
potential limitations, this
article provides important implications for theory and
managerial practice.
6. Conclusion
We have sought to explain the leadership and followership
styles of the Millennial generation.

As this perspective has not been explored by previous studies,
this article provides important
implications for theory and managerial practice. By
understanding Millennials’ leadership
and followership styles in the workplace, organizations and
managers are able to structure a
workplace where performance is maximized.
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RESEARCH ARTICLE
The need for strong clinical leaders –
Transformational and transactional
leadership as a framework for resident
leadership training
Barbara Saravo
1
, Janine Netzel
2
, Jan Kiesewetter

1*
1 Institut für Didaktik und Ausbildungsforschung in der
Medizin, Klinikum der Ludwig-Maximilians-Universität
München, Munich, Bavaria, Germany, 2 Center for Leadership
and People Management, Ludwig-
Maximilians-Universität München, Munich, Bavaria, Germany
* [email protected]
Abstract
Background
For the purpose of providing excellent patient care, residents
need to be strong, effective
leaders. The lack of clinical leadership is alarming given the
detrimental effects on patient
safety. The objective of the study was to assess whether a
leadership training addressing
transactional and transformational leadership enhances

leadership skills in residents.
Methods
A volunteer sample of 57 residents from postgraduate year one
to four was recruited across
a range of medical specialties. The residents took part in an
interventional controlled trial.
The four-week IMPACT leadership training provided specific
strategies for leadership in the
clinical environment, addressing transactional (e.g. active
control, contingent reward) and
transformational leadership skills (e.g. appreciation,
inspirational motivation).
Transactional and transformational leadership skill performance
was rated (1) on the Per-
formance Scale by an external evaluator blinded to the study
design and (2) self-assessed

transformational and transactional leadership skills. Both
measures contained items of the
Multifactor Leadership Questionnaire, with higher scores
indicating greater leadership skills.
Results
Both scores were significantly different between the IMPACT
group and the control group.
In the IMPACT group, the Performance Scale increased 15% in
transactional leadership
skill performance (2.10 to 2.86) (intervention effect, 0.76; 95%
CI, 0.40 to 1.13; p < .001,
eta
2
= 0.31) and 14% in transformational leadership skill
performance (2.26 to 2.94) (inter-
vention effect, 0.68; 95% CI, 0.27 to 1.09; p < .001, eta2 =
0.22). The self-assessed transac-
tional skills revealed a 4% increase (3.83 to 4.03) (intervention

effect, 0.20; 95% CI, 0.08 to
0.33; p < .001, eta2 = 0.18) and a 6% increase in
transformational leadership skills (3.54 to
3.86) (intervention effect, 0.31; 95% CI, 0.02 to 0.40; p< .001,
eta2 = 0.53).
PLOS ONE | https://doi.org/10.1371/journal.pone.0183019
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Citation: Saravo B, Netzel J, Kiesewetter J (2017)
The need for strong clinical leaders –

Transformational and transactional leadership as a
framework for resident leadership training. PLoS
ONE 12(8): e0183019. https://doi.org/10.1371/
journal.pone.0183019
Editor: Mirjam Körner, University of Freiburg,
GERMANY
Received: October 6, 2016
Accepted: July 28, 2017
Published: August 25, 2017
Copyright: © 2017 Saravo et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and

reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: The dataset
underlying our results is publicly available from the
Open Data LMU Repository. The DOI for our data is
10.5282/ubm/data.109.
Funding: This work was funded by the
Förderprogramm für Forschung und Lehre
(FöFoLe) to JK by a grant to the Klinikum of the
Ludwig-Maximilians-Universität Munich. The
funder had no role in study design, data collection
and analysis, decision to publish, or preparation of

the manuscript.
https://doi.org/10.1371/journal.pone.0183019
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0183019&domain=pdf&date_stamp=2017-08-25
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https://doi.org/10.5282/ubm/data.109
Discussion and conclusions
These findings support the use of the transactional and
transformational leadership frame-

work for graduate leadership training. Future studies should
incorporate time-latent post-
tests, evaluating the stability of the behavioral performance
increase.
Introduction
There is currently a consensus that young physicians are in need
of training in how to be effec-
tive leaders[1–5]. Medical residents take on various leadership
responsibilities in their daily
clinical work. For instance, they negotiate care plans, teach
medical trainees, balance diverging
perspectives in multiprofessional teams, while providing
effective, safe delivery of care[5, 6].
Residents’ leadership skills are not facilitated enough [5]. This
is surprising, given the body of
evidence that highlights the association between effective

leadership and the improvement of
medical care in fields such as teamwork[7–9],
communication[3] and patient safety[10, 11].
Current perspectives on clinical leadership are not precisely
conceptualized. Existing con-
cepts mainly reflect traditional understandings of the leader-
follower relationship, focusing on
individual behaviors and positional power[12]. As physicians in
training usually do not hold
formal authority and their leadership roles are not clearly
defined[13], a distinct approach in
framing the concept of leadership is needed[6]. Through a more
precise concept of leadership,
specific leadership behaviors could be identified and trained.
A vast number of leadership theories have been established in
the organizational literature

[14]. However, the medical community is facing the challenge
of identifying appropriate con-
cepts, and of adjusting them to the complex clinical
environments in order to design target-
oriented training programs. For graduate medical education, it
has been recommended to
base leadership training programs on established best
practices[5, 15].
A few attempts in developing resident leadership training have
been made. However, as has
been found in a current review on leadership training in
undergraduate medical education
[15], most programs vary greatly in aligning the curricula with
competencies. Also, existing
studies rarely associate outcomes to the interventions[16, 17].
Leadership programs for resi-
dents mostly adhere to broad dimensions, such as

confidence[18], communication skills[3],
emotional intelligence[19], or postgraduate careers[20] and
organizational leadership[21]. To
date, there is no systematic, evidence-based knowledge about
effective strategies to cultivate
outstanding, strong leaders in residency.
In this article, we introduce the Full Range Leadership Model
(FRLM)[22] into resident lead-
ership training. It is the best empirically studied and most
significant leadership framework in
organizational literature and has been successfully implemented
in several fields of application
[23–27]. First efforts have been made to empirically test the
model in medicine, however these
have primarily addressed nursing leadership[28, 29] and
hospital management[30–32].
According to the authors of the FRLM[33], a specific set of

leadership components is neces-
sary for effective leadership: a large portion of transformational
leadership, higher levels of
transactional leadership and a minimum of passive leadership.
Transformational leadership
refers to leaders with an appealing vision for their team who
intellectually stimulate others in a
way that is demanding and appreciative of the individual needs
of the team members[14].
Transactional leaders exert influence on followers based on
exchanging benefits for outstand-
ing performance and response to their self-interests when they
have achieved defined goals
[34]. In contrast to transformational and transactional
leadership, Bass[35] defines leaders
Transformational and transactional leadership training for
residents

August 25, 2017 2 / 13
Competing interests: The authors have declared
that no competing interests exist.
who do not take charge of their leadership role as passive
leaders. These three components of
leadership are conceptualized as different levels of activity a
leader can display, with passive
leadership as the least active form of leadership[36]. For
example, passive leaders avoid inter-
vening when mistakes are made and do not execute managerial
functions[37]; especially in
high-stakes organizations like medical care, passive leadership
can have harmful consequences
[38]. On the contrary, transactional leaders reinforce their
leadership by exercising active con-

trol when problems arise. Given the detrimental effects of
passive leadership, we consider
transactional and transformational leadership a crucial part of
clinical leadership, where
patient safety is among the highest of priorities.
Transformational and transactional leadership
are conceptualized as two distinct, yet interrelated components
of leadership behavior[39].
Therefore, leadership programs should address both components
alike.
We argue that, for ensuring high-quality delivery of care and for
maximizing clinical pro-
ductivity, physicians are expected to formulate clear
expectations, set high standards and moti-
vate team members to make strides to meet specified
requirements. If, for example, followers

get a feeling of involvement and are rewarded for making good
efforts, they are more likely to
be eager to achieve the goals that have been set. A clinical
leader should both have the capacity
to be transformational and transactional, but always be able to
exert active control when
needed.
Prior research has found positive effects of transformational and
transactional leadership
on several outcomes, such as enhanced satisfaction[40], the
willingness of followers to generate
extra effort[41], and increased performance[27].
While prior research showed that transformational, transactional
and passive leadership are
applicable in evaluating leadership styles in residents[42] and
senior physicians[43], so far, no

study has examined whether the model is suitable to guide
resident leadership training and
advance clinical leadership.
Gabel[13] particularly calls for training programs for informal
leaders addressing transfor-
mational leadership. In our four-week IMPACT leadership
training for residents, we explicitly
tied those transformational and transactional leadership skills to
the curriculum that are most
relevant for everyday clinical practice. The training curriculum
included the acquisition of key
leadership knowledge, application of practical leadership skills,
and simulation-based role-
plays representing real performance situations of inpatient
teams.
Objectives

We hypothesize that over the course of the IMPACT training,
(1) residents’ performance of
transformational and transactional leadership skills as rated by
an external evaluator will
improve, (2) self-assessed transformational and transactional
leadership skills will increase,
and (3) residents’ knowledge on leadership will expand.
Methods
Sample
For organizational reasons we split the IMPACT training group
into four cohorts, with each
cohort consisting of 10–15 persons. Cohort one and two took
part in the IMPACT leadership
training program in February/March 2015 and cohort three and
four in August/September
2015. All residents at our institution were eligible for

enrollment in the study. Participation
was voluntary and free of charge. For inclusion in the study,
residents had to be 1) affiliated to
one of the clinics of the university hospital, 2) in residency
training for up to four years, and 3)
willing to participate in all four consecutive training sessions.
57 residents were included in the
study, representing a range of specialties: internal medicine,
pediatrics, surgery, psychiatry,
residents
August 25, 2017 3 / 13
anesthesiology, neurology, radiology, gynecology, dermatology
and ophthalmology. Exclusion

criteria were 1) affiliation to an institution other than a
university hospital, 2) in residency
training for more than four years, 3) not committing to
participation in all training sessions.
According to these criteria, six applicants had to be excluded
from study entry. Participants of
the control group (n = 23) were recruited via email listings
between cohort two and three, after
all available positions for the IMPACT group had been
assigned.
Training procedure
The training design and procedure was based on and adapted
from a leadership training for
final year medical students[44, 45]. The IMPACT leadership
training was conducted over four
consecutive weeks, with two-and-a-half hour sessions once a
week after clinical duties. To

ensure instructional training efficiency, we relied on the same
three instructors across all train-
ing cohorts. Instructors either came from a leadership training
background (JN) or a medical
education background (BS, JK).
We designed the training in four modules. Module one
introduced leadership theory,
focusing on transactional and transformational leadership and
reflection on the residents’
leadership role within their clinical team. Module two tested the
participants’ leadership
behavior in one of four standardized five-minute scenarios in a
simulation-based environ-
ment. The scenarios were carried out with professional actresses
who were specially trained
and functioned as nurses within the role-plays. Female actresses

were chosen for role-plays
representing daily practice in German hospitals where the
majority of nurses is female[46].
The scenarios originated from a critical incident study[44], were
randomly assigned to the
residents and were recorded on video for later evaluation. Given
the positive effects of feed-
back on training transfer[26, 47], we integrated a half-hour one-
on-one feedback session
between modules two and three; based on the recorded role-
plays, physicians reflected their
leadership performance together with their instructor. Module
three comprised practicing
communication techniques explicitly tied to transactional and
transformational leadership.
Module four tested the participants in another standardized
scenario within the simulation-

based environment. Actresses and scenarios were evenly
distributed over module two and
module four.
At intervals of four weeks, participants of the control group
filled out two online question-
naires containing the same self-assessment scales as those of the
IMPACT group and received
a manuscript regarding clinical leadership. All participants of
the control group received €40
in compensation after completion.
Study design and setting
This study was a single-institution repeated measurement
controlled trial at a large university
hospital during the year 2015 involving several different clinics
of various medical specialties.
The primary outcome was transactional and transformational

leadership skill performance
as assessed by an external evaluator, the secondary outcome
self-evaluated transformational
and transactional leadership skills, and leadership knowledge.
In the training group (IMPACT
group), the primary and secondary outcomes were tested in a
pre-post design. Measurement
took place before the training and four weeks after the first
training session.
In the control group, only the secondary outcome was assessed
pre-to-post-test within a
four week interval, as residents of the control group did not
receive any role-play intervention.
Ethical approval for the study was obtained from the ethical
committee of the Ludwig-Max-
imilians-University (LMU) Munich. Prior to the training, all
residents gave their written

informed consent in study participation.
residents
August 25, 2017 4 / 13
Outcome measures
For the 12-item Performance Scale (measuring the primary
outcome), we designed items that
represented target behaviors for transactional and
transformational clinical leadership. For
instance, target behaviors for transactional leadership were
tested by statements such as ‘The
physician gave positive feedback for good performance’;
transformational leadership was

assessed by items like ‘The physician talked about the goals
that have been set in an encourag-
ing way.’. An external evaluator, who was blinded to the
assignment and specially trained to
assess (i.e. video coding), rated the primary outcome. The
evaluator rated the recorded role-
plays on a five-point Likert scale (range, 1 = strongly disagree
to 5 = strongly agree). Examples
for the ratings and corresponding leadership skills (i.e. target
behaviors) are presented in
Table 1. Rating quality was ensured by a ten percent inter-rating
(ICC = 0.92).
The 40-item Leadership Scale (assessing the secondary
outcome) includes three subscales:
transactional, transformational and passive leadership,
containing items of the German ver-
sion of the Multifactor Leadership Scale[48], a valid tool to

evaluate the FRLM. Before and
after four weeks of training, participants stated on a five-point
Likert scale (range, 1 = not at all
to 5 = frequently, if not always) the frequency with which they
exerted a certain leadership
behavior.
The nine-item multiple choice (measuring the secondary
outcome) knowledge test was
developed to examine leadership knowledge regarding
transformational and transactional
leadership. The test yields a composite mean score of 34.
A-priori, all scales were validated in a pilot study. Residents of
different fields of application
(e.g. anesthesia, surgery, radiology) were interviewed one-by-
one after filling out the scales of
the subjective measurement. Based on their ratings and

comments, we revised the Leadership
Scale as well as the multiple choice knowledge test thoroughly
and made changes where
necessary.
Data collection
Prior to the training, participants received a random pseudonym
as an identifier on data
sheets. Residents participating in the IMPACT group filled out
the Leadership Scale as well as
the knowledge test on-site before and after the training, and
were supervised by one of the
trainers at any time. Within an interval of four weeks,
participants of the control group filled
out these two tests, as well. However, data of the control group
were only obtained via online
assessment. As participants of the control group filled out the

tests at home or at their work-
place, supervision could not be established. The Performance
Scale was assessed by an inde-
pendent evaluator after modules two and four. The dataset
underlying our results is publicly
available from the data repository Open Data LMU (DOI:
https://doi.org/10.5282/ubm/data.
109).
Table 1. Example leadership skills of the performance scale by
leadership component.
Leadership component Leadership skill
Transactional leadership The resident. . .
• gave positive feedback for good efforts.
• made clear what the nurse can expect when she performs well.
• clarified who is responsible for defined tasks.

Transformational
leadership
• treated the nurse respectfully.
• encouraged the nurse to engage in overall goals of the clinical
team.
• formulated an appealing vision of what shall be achieved to
improve
patient care.
https://doi.org/10.1371/journal.pone.0183019.t001
residents
August 25, 2017 5 / 13

Statistical analysis
A sample size calculation was performed and it was found that a
sample size of 60 was needed
to provide 80% power to detect medium to large effects. Data
was entered into SPSS (version
23.0, SPSS Inc. Chicago, Illinois) for further analysis. We used
repeated measures ANOVA to
test for (1) the progression of externally rated leadership skills
and self-assessment of the lead-
ership scale as well as of the knowledge test, and (2) group
between control and IMPACT
group for the leadership knowledge test and self-assessment of
the leadership-scale. All analy-
ses were based on a 5% level of significance.

Results
Of 57 residents, 50 (88%) completed the training (m = 29.98
years; SD = 2.60), with 25 (50%)
female participants; 40 residents (70%) performed both role-
plays. Reasons for missing ses-
sions included clinical emergencies, unexpected changes in
rotation schedules, clinical exami-
nation of incoming refugees at the central station, or illness. 23
residents participated in the
control-group (n = 23; m = 29.13 years; SD = 2.53), with 18
(78%) female residents. All out-
come variables showed sufficient reliability, with a pre-test
Cronbach’s alpha of 0.55 (knowl-
edge test), 0.64 (transactional leadership) and 0.85
(transformational leadership) and a post-
test Cronbach’s alpha of 0.70 (transactional leadership), 0.81
(knowledge test) and 0.84 (trans-

formational leadership).
Performance scale
As hypothesized, after four weeks of training, the Performance
Scale increased 15% in transac-
tional leadership skill performance (2.10 to 2.86) (intervention
effect, 0.76; 95% CI, 0.40 to
1.13; P< .001, eta2 = 0.31) and 14% in transformational
leadership skill performance (2.26 to
2.94) (intervention effect, 0.68; 95% CI, 0.27 to 1.09; P< .001,
eta2 = 0.22). Table 2 presents
pre- and post-test means, standard deviations and mean changes
for leadership skill perfor-
mance. Graph C illustrates this effect in Fig 1.
Leadership scale
Expectedly, we found a significant increase in self-assessed
transactional and transforma-
tional leadership, as well as a significant interaction between

point of measurement and group,
indicating a substantial gain in both leadership components only
for the IMPACT group
(F(1,73) = 5.63, P< .02, eta2 = 0.07). The Leadership Scale
revealed a 4% increase in self-
Table 2. Descriptive statistics and mean changes for leadership
skill performance, divided into transactional and
transformational leadership.
Performance Scale External Rater n m SD mean change (95%
CI)
Transactional leadership
a
Pre-test to post-test 40 0.76 (0.40, 1.13)
Pre-test 40 2.10 0.75
Post-test 40 2.86 0.99

a
Pre-test to post-test 40 0.68 (0.27, 1.09)
Pre-test 40 2.26 0.88
Post-test 40 2.94 1.13
a Scale: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 =
agree, 5 = strongly agree; m = mean; SD = standard deviaton; n
= sample size; CI = confidence
interval
residents
August 25, 2017 6 / 13

assessed transactional skills (3.83 to 4.03) (intervention effect,
0.20; 95% CI, 0.08 to 0.33; P<
.001, eta
2
= 0.18) and a 6% increase in transformational leadership skills
(3.54 to 3.86) (inter-
vention effect, 0.31; 95% CI, 0.02 to 0.40; P< .001, eta2 =
0.53). The reported effects are consid-
ered to be excellent[49]. Mean scores for passive leadership
were low at baseline, both in the
IMPACT group (m = 1.87, SD = 0.55) and the control group (m
= 1.94, SD = 0.51). Graph A
and B illustrate this effect in Fig 1.
Knowledge test
Two cases had to be eliminated from further analysis as data
sets were not complete. Groups
differed significantly in a-priori (F(1,69) = 17.17, P< .001, eta2
= 0.20) and post-test leadership

knowledge (F(1,69) = 15.51, P< .001, eta2 = 0.19). Testing for
group differences for the leader-
ship knowledge test resulted in a significant effect for group
(F(1,69) = 22.26, P< .001, eta2 =
0.25), yet there was no significant increase in leadership
knowledge in any of the groups. In
Table 3, pre- to post-test findings of transactional,
transformational leadership, as well as lead-
ership knowledge are summarized.
Correlations between the scales
In line with prior studies[25, 50], the two subscales of the
leadership scale, transactional and
transformational leadership, correlated significantly (r = .60; P<
.05). Accordingly, passive
leadership showed negative, significant correlations to
transformational (r = -.49; P< .001)
and transactional leadership (r = -.52; P< .001).
Fig 1. Overview of the effect for the self assessed leadership
scale (graph A and B) and the performance

scale (graph C).
https://doi.org/10.1371/journal.pone.0183019.g001
residents
August 25, 2017 7 / 13
https://doi.org/10.1371/journal.pone.0183019.g001
Discussion
In this study, the four-week IMPACT leadership training was
designed to increase transforma-
tional and transactional leadership skills in residents of various
specialties. Transformational
leadership refers to the leader’s ability to motivate team
members to commit to a common

goal. Transactional leadership involves the practice of
exchanging benefits for excellent perfor-
mance. Taking into account that a comprehensive set of
leadership skills is necessary to meet
the complex demands of daily clinical practice[5], we based our
training on the Full Range
Leadership Model[22].
Previous studies on leadership trainings have mainly been
conducted in the organizational
setting, primarily focusing on the transformational leadership
component. The study by Abrell
et al.[26] can be considered as one of the most comprehensive
effort to train transformational
leadership in a long-term study design. In their study,
transformational leadership was as-
sessed by subordinates and leadership performance was rated by

leaders’ supervisors, showing
a significant improvement over time[26]. Abrell et al.[26]
incorporated feedback mechanisms
into their curriculum as well as theoretical sessions giving an
in-depth review of different
transformational leadership styles, such as ‘individual
consideration’ or ‘inspirational motiva-
tion’. To the best of our knowledge, there is no program
training transformational and transac-
tional leadership alike, neither in the organizational nor in the
medical field of application.
Existing leadership programs in graduate medical education,
such as the one by Awad et al.
[3], focus on broader communication skills. Awad et al.[3]
implemented a leadership training
for surgical residents over the course of 6 months. They aimed
at improving collaborative lead-

ership through fostering a communication style that is regarded
less commanding. Before and
after completion of the training, residents assessed self-
perceived alignment of the team, com-
munication and integrity. The authors were able to demonstrate
significant increases in these
Table 3. Improvement of transactional and transformational
leadership skills in the IMPACT group and changes in
leadership knowledge, as com-
pared to a control group.
IMPACT Group Control Group
Scale mean change
(95% CI)
m SD mean change
(95% CI)

m SD
Transactional leadership
a
Pre-test to post-test
c
0.20 (0.08, 0.33) 0.07 (0.10, 0.23)
Pre-test 3.83 0.48 3.79 0.47
Post-test 4.03 0.45 3.86 0.53
a
c
0.31 (.023, 0.40) 0.83 (0.08, 0.25)
Pre-test 3.54 0.38 3.53 0.48

Post-test 3.86 0.31 3.61 0.40
Knowledge test
b
d
0.6 (-1.17, 1.29) -1.09 (-2.96, 0.77)
Pre-test 26.48 2.67 22.95 4.32
Post-test 26.54 4.19 21.86 5.28
a Scale: 1 = not at all, 2 = once in a while, 3 = sometimes, 4 =
fairly often, 5 = frequently.
b Scale: Multiple choice format, maximum achievable score =
34
c Significance level: p < .01
d Significance level: p>.30
m = Mean, SD = Standard Deviaton, CI = confidence interval.

residents
August 25, 2017 8 / 13
areas; however, training effects in terms of leadership
performance such as improved team
interactions have not been evaluated.
Our results go beyond prior research in different ways: First,
unlike in the study by Abrell
et al.[26], we not only tested for transformational leadership
skills but also for transactional
leadership skills in a pre-post design. Second, for the first time,
the two leadership components

were trained in a group of residents, extending external validity
of the proposed leadership
model to the medical education area of application. Overall, our
results indicate that the
FRLM is well suited for empirically testing leadership skills in
residents of a wide spectrum.
Third, we built upon first attempts to test the model in the
medical context[42, 43] by provid-
ing a targeted, multimethod, structured training curriculum to
improve resident leadership.
Fourth, the different evaluation data modalities we applied
(self-assessment, evaluation of per-
formance) expand existing studies that have not evaluated the
behavioral component of
leadership.
We provided evidence that both distinct leadership components
laid forth in the model are

applicable for displaying significant increases in residents’
leadership performance. For exam-
ple, at the end of the training, residents were able to show
appreciation for good efforts (trans-
formational leadership skills) and make clear who is responsible
for specific tasks (transactional
leadership skills). Interestingly, residents scored higher in self-
assessed transactional leadership
at baseline than in transformational leadership. They did change
significantly in both leader-
ship components, yet remained higher mean scores for
transactional leadership also after
training was completed. We believe this reflects the unique
requirements of the clinical setting
where fostering and sustaining patient safety is among the
highest of priorities. In their every-
day clinical practice, residents might feel more obliged to
intervene and exert active control in

order to prevent medical errors, thus exhibiting more
transactional leadership behaviors.
Our results further suggest that four weeks of training seem to
be a good starting point to
effectively train leadership skills in residents across a wide
range of specialties.
A control group did not increase in self-assessed leadership
skills. It is remarkable that a
substantial gain in both leadership components was
demonstrated by video coding of simula-
tions from an external evaluator perspective and by subjective
data, as well. The increase in
leadership skills from two different, independent perspectives
supports the applicability of the
leadership model for graduate medical education.
We controlled for a possible confounding effect of passive
leadership at baseline, as this

most ineffective leadership component is considered to
attenuate the effect of transformational
leadership on safety[38]. Consistent with previous studies[33,
42], mean scores for passive
leadership were low in both groups.
Limitations
Randomization and blinding between groups were not complete,
as the participants were
aware of which group they would be assigned to when applying;
a selection bias can thus not
be ruled out. However, this is somewhat ameliorated by the low
and not differing scores
between IMPACT group and control group as regards the
leadership scale. For the knowledge
test, there was no significant change in the two groups. Item
difficulty for the pre-test measure

might have been too high, resulting in low values of cronbach’s
alpha at pre-test. In contrast,
high values for cronbach’s alpha at post-test might be explained
by increasing knowledge
through the training. Apart from that, high standard deviations
for mean scores for pre- and
post-test might reflect a high range in leadership knowledge
among the participants. A rede-
sign of our knowledge test in terms of discriminatory power
analysis might be beneficial in
order to detect significant changes in residents’ leadership
knowledge. In addition, both
residents
August 25, 2017 9 / 13

groups differed significantly in leadership knowledge at
baseline and after the training. We
traced this finding back to the different data acquisition
modalities (on-site assessment versus
unsupervised online assessment) and different levels of
motivation. Unsupervised data collec-
tion also poses the problem of participants potentially
consulting textbooks or the internet in
order to gain better test results. For preventing potential
confounding effects generated by
data collection modalities, we suggest that future research
should incorporate on-site data
acquisition also for the control group. Passive leadership was
only assessed prior to the training
by the participants themselves. Since self-assessment is prone to

self-serving biases, future
studies should examine passive leadership also from an external
perspective. As this study was
a single-institution controlled trial, the degree of transferability
could be enhanced by recruit-
ing residents from different institutions. It must be noted,
however, that our participants came
from a wide range of specialties, and the proportion of female
to male residents was balanced,
indicating that the generalizability of our findings is not
completely limited. Overall, our study
would have benefited from a larger sample size, especially in
the control group. However, the
effect sizes for the group comparisons were extraordinarily
high[49], raising questions as to
the benefit of larger sample sizes.

Conclusions
Our study is the first to establish and design a training format
for the clinical setting based on
the transactional and transformational leadership approach,
going beyond previous research
in a number of ways. First, we illustrated the feasibility of the
proposed leadership framework
for the clinical environment by providing evidence for support
of this model. Second, we
included a number of strong design elements, such as the use of
a control group, and an out-
comes assessment based on the performance rating by an
external evaluator, as opposed to
self-assessment. Third, in the following we provide best
practice strategies for leadership pro-
grams specifically tailored for residents: As it is known that
transactional and transformational

leadership can have both a protective impact on patient
safety[10, 11] and a positive effect on
teamwork[7–9], medical institutions should establish resident
leadership training drawn to the
transactional and transformational framework. To ensure
behavioral change, curricula should
embed simulation-based practices, addressing transactional and
transformational behaviors
alike. Programs including one-on-one feedback can guide the
way to individual high-quality
leadership performance. Future studies should examine the
implementation of the behavioral
changes in daily clinical work, potentially incorporating
leadership training as a starting point
for mentoring programs within specialties[51]. We recommend
building upon the target

behaviors which we tied to transactional and transformational
leadership skills in the perfor-
mance assessment. We suggest to evaluate the stability of the
increased leadership performance
by conducting a time-latent post-test of the behavioral
component in further studies. In order
to expand upon the promising findings of our study, a research
network for clinical leadership
could prove beneficial for researchers to catalyze the design and
evaluation of programs.
Acknowledgments
We are grateful to the following individuals, who participated
and were compensated for par-
ticipation in this study:
Research assistants: Sabrina Reif (Ludwig-Maximilians-
Universität Munich)

Actresses: Eva-Maria Kerp, Tamara Mayer (Klinikum der
Universität)
Independent evaluators: Christian Strobel (Ludwig-
Maximilians-Universität Munich),
Hannah Freienstein (Ludwig-Maximilians-Universität Munich)
residents
August 25, 2017 10 / 13
We thank all resident physicians who participated in the study.
Participants of the control
group receives honoraria for their contributions.
Author Contributions
Conceptualization: Barbara Saravo, Janine Netzel, Jan

Kiesewetter.
Data curation: Barbara Saravo, Janine Netzel, Jan Kiesewetter.
Formal analysis: Barbara Saravo, Jan Kiesewetter.
Funding acquisition: Barbara Saravo, Jan Kiesewetter.
Investigation: Barbara Saravo, Janine Netzel, Jan Kiesewetter.
Methodology: Barbara Saravo, Janine Netzel, Jan Kiesewetter.
Project administration: Barbara Saravo.
Supervision: Barbara Saravo, Jan Kiesewetter.
Validation: Barbara Saravo, Janine Netzel, Jan Kiesewetter.
Writing – original draft: Barbara Saravo, Janine Netzel, Jan
Kiesewetter.
Writing – review & editing: Barbara Saravo, Janine Netzel, Jan
Kiesewetter.
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