¶ … Implanting Total Quality Management in healthcare: The critical leadership traits" by Nwabueze (2011), TQM is an increasingly critical part of ensuring cost-effective management of healthcare in the modern economic environment. However, there are often substantial institutional and personal obstacles to realizing its benefits. "TQM leadership is therefore about presence, and a process carried out within an organizational role that assumes responsibility for the needs and rights of employees who choose to follow the leader in achieving results" (Nwabueze, 2011, p.331). In the article, leadership in general is conceptualized as motivating people to do what you want them to do of their own free will without constant supervision and coercion and TQM in particular is a values-based system (Nwabueze, 2011, p.332). The concept of zero defects and continuous improvement must be instilled within all employees on a consistent basis throughout the organization and this requires a transformation of past ways of thinking. Such a transformation is, of course, more easily said than done and by surveying a 50 chief executive officers in British National Health Care System, Nwabueze (2011) attempted to better understand what leadership traits facilitated the use of TQM within healthcare organizations. Although the National Health Service is a single-payer, government-run and funded organization, cost containment is of paramount importance. Five traits are viewed as key in all theories of leadership: intelligence, knowledge, dominance, self-confidence, and creativity (Nwabueze, 2011, p.332). Nwabueze (2011) would also add courage: even though this is often thought of as a trait primarily confined to physically active leadership such as in the military, implementing a TQM program is often so far-reaching that considerable boldness is necessary to challenge the organizational paradigm. A leader must also be highly skilled both technically and interpersonally -- the leader must know what he or she needs to do and how to do it.

In his specific application of trait-based theory to the NHS, it is noted by the author that it an authoritarian style is likely to be particularly unhelpful to implement TQM directives. First and foremost, the NHS is a heavily bureaucratic organization and issuing categorical directives is not helpful in such a context. However, a purely situationally-based style of leadership which is self-adjusting based upon the needs of the organization is not necessarily beneficial, either. TQM is still a fairly standardized process and being cognizant of this fact is essential for the organization to thrive. It "continues both in wartime ... and peacetime," in other words, the emphasis is on staying the course, versus adjusting strategy to suit the needs of a down versus an up market (Nwabueze, 2011, p.334). The preferred modes of leadership, however, based upon Nwabueze's literature review, however, are transformational and/or visionary leadership that entirely reconfigure how members of the organization see themselves. "TQM is transformational in outlook in the author's opinion, requiring first and foremost, a transformation in managerial style, employee behavior and attitudes, systems, structures, processes, and skill sets" (Nwabueze, 2011, p.335). Visionary leaders inspire organizational members to rise up above political conflicts and make a substantive commitment to the organization's goals (Nwabueze, 2011, p.335). In short, they appeal to the employee's higher selves.

Although Nwabueze's article does not discuss the specific application of these principles to healthcare in much depth, it is easy to see why transformative and visionary philosophies might be particularly appealing for a healthcare entity. Whether for-profit or not-for-profit, healthcare organizations must be driven to serve the needs of the consumer, given that consumers are trusting the precious commodity of their healthy to the entity. A failure to ensure quality can have serious and lasting repercussions for the rest of the consumer's lifespan. In one of the specific examples used in the article that is pertinent to healthcare, the need for the TQM leader to embody the ideals of the organization is underlined: it is not simply enough to articulate goals such as timeliness, the leader himself must uphold them in practice or else the employees will not believe in his vision. In the specific survey of the 50 NHS executives, the leadership qualities which emerged as critical amongst effective leaders included being a "good communicator, a good commander, [being] "hands on," a "planner" "enthusiastic," "strong-minded" and a "good listener" amongst others (Nwabueze, 2011, p.339). Overall, these qualities suggest that TQM requires assertive leadership while still being sensitive to employee needs.

However, the article "Trait and behavioral theories of leadership: An integration and meta-analytic test of their relative validity" by Derue, Nahrgang, Wellman, & Humphrey (2011) questions whether viewing leadership as a trait-based dimension at all is helpful. Although it acknowledges...

In Nwabueze (2011), no real distinction between traits and behaviors are made, although the emphasis is clearly upon traits -- it is assumed that visionary leaders, for example, will embody such values as being good listeners and communicators as a matter of course. While Nwabueze discusses certain theories that might be conceptualized as behaviorally based, he does not distinguish them from character-based contrast.
In contrast, Derue (et al. 2011) attempts to synthesize what the authors consider opposing paradigms that have more in common than the current literature might suggest. For example, in the case of the contrast of behaviors between transactional versus transformative leaders, it notes that transactional leaders may be more authoritarian and less relational in their trait-based orientations than transformative leaders. Character leads to certain types of behavior and behavior reveals character. A leader might advocate a visionary approach in words but not actually embody this in his actions. As well as breaking down leadership literature into a character-based versus a trait-based distinction, Derue (et al. 2011) also note that certain studies have focused more on leadership effectiveness in a group versus individual situation and this perspective can influence which traits are deemed more significant.

Such lack of integration of behavior versus trait-based theories is problematic, given the complexity of leadership. Focusing on one component of leadership to the exclusion of others can result in an unbalanced perspective. "Considering that leader traits such as gender and personality are often discussed in terms of the behaviors associated with those traits, the idea that leader behaviors mediate the relationship between leader traits and effectiveness seems especially plausible" (Derue et al. 2011, p. 12). Integration of studies is especially essential given that various traits and behaviors may be interrelated. In "meta-analyses on the relationship between intelligence and personality suggest that Extraversion and Openness to Experience are related to intelligence," even though the Big Five concept of personality traits conceptualizes them as separate entities (Derue et al. 2011, p. 12).

Of the specific hypotheses used by Derue (et al. 2011), hypothesis one is that "task competence" has a "stronger, positive relationship with task performance dimensions of leadership effectiveness than leaders' demographics or interpersonal attributes" while hypothesis two is that of so-called character-based traits "interpersonal attributes" or the leaders' actions with subordinates are far more important than more abstract, character-based dimensions (p.15). It is further hypothesized that competency at tasks and interpersonal skills will have a higher positive association with effectiveness as a leader versus demographic aspects such as gender (Derue et al. 2011, p. 15).

The formulating of the hypotheses of the Derue (et al. 2011) article is thus very different from Nwabueze (2011), given that it takes the form of a scientific hypothesis, versus a more general literature reviews. Subsidiary hypotheses also emphasize the importance of relationally-oriented and change-oriented leadership traits, which are hypothesized as more effective than passive, hands-off leadership methods, and an idea that is commensurate with Nwabueze's emphasis on the need for firm leadership that is not situationally-based (Derue et al. 2011, p. 18). Overall, eleven hypotheses were offered by Derue (et al. 2011) -- the proliferation of these is specifically intended to prove the interrelated nature of a multitude of leadership theories and that a failure to integrate them is a weakness of the literature. A meta-analysis of existing studies was deployed and the authors "created a comprehensive list of codes for the variables reported across all studies. The studies were divided among the authors who then coded the meta-analytic estimates for the variables of interest from each study" (Derue et al. 2011, p. 26).

Overall, a meta-analysis is considered to offer higher-quality evidence versus a single study of the type offered by Nwabueze (2011). Yet the findings were not dissimilar to Nwabueze (2011)'s study of 50 NHS professionals. It was determined that "conscientiousness was the most consistent trait predictor of leadership effectiveness. Within the behavioral paradigm, transformational leadership was the most consistent predictor across the criteria. Other behaviors contributed to effectiveness, but their relative validity was contingent on the particular outcome of interest" (Derue et al. 2011, p. 37). In other words, a transformational, visionary approach emerged as a great asset to leadership and conscientiousness and consistency, versus a situational, case-by-case approach to leadership emerged as a superior strategy. Unlike Nwabueze (2011),…