Mental Health Team Leadership and Consumers’ Satisfaction and Quality of Life Patrick W. Corrigan, Psy.D. Sarah E. Lickey, A.M. John Campion, B.S. Fadwa Rashid, B.A.
Objective: The purpose of this study was to determine the association between leadership styles of leaders of mental health treatment teams and consumers’ ratings of satisfaction with the program and their quality of life. Methods: A multifactor model has distinguished three factors relevant to leadership of mental health teams: transformational leadership, in which a leader’s primary goal is to lead the team to evolving better programs; transactional leadership, in which the leader strives to maintain effective programs through feedback and reinforcement; and laissezfaire leadership, an ineffective, hands-off leadership style. Research has shown transformational leadership to be positively associated with measures of the team’s functioning, but the effects of leadership style on consumers is not well known. A total of 143 leaders and 473 subordinates from 31 clinical teams rated the leadership style of the team leader. In addition, 184 consumers served by these teams rated their satisfaction with the treatment program and their quality of life. Results: Consumers’ satisfaction and quality of life were inversely associated with laissez-faire approaches to leadership and positively associated with both transformational and transactional leadership. Moreover, leaders’ and subordinates’ ratings of team leadership accounted for independent variance in satisfaction ratings—up to 40 percent of the total variance. Conclusions: Leadership seems to be an important variable for understanding a team’s impact on its consumers. (Psychiatric Services 51:781–785, 2000)
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ental health and psychiatric rehabilitation programs can have a significant impact on the lives of persons with severe and persistent mental illness (1–3). These programs rely on interdisciplinary teams to provide services. Teams that work well together provide more satisfactory services to their clientele (4,5). To understand what elements of effective teamwork are relevant to services, researchers have examined relationships among a variety of staff
variables and consumers’ functioning, especially aggression. Results suggest that consumers’ hostility is associated with staff members who make critical statements (6), have poorly defined roles (7), and fail to be optimistic about innovative approaches to treatment (8). Effective leaders are essential for team members to function competently (9); unfortunately, relatively little research has examined the relationship between team leadership and staff per-
The authors are affiliated with the University of Chicago Center for Psychiatric Rehabilitation, 7230 Arbor Drive, Tinley Park, Illinois 60477 (e-mail,
[email protected]).
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formance on mental health teams. Organizational psychologists have studied a variety of models for understanding leadership that are relevant to this question. One particularly useful theory to arise out of this research is the multifactor model of leadership developed by Bass and colleagues (10–14), which distinguishes two sets of important skills. Leaders who demonstrate transformational leadership skills help team members transform programs to meet the ever-evolving needs of their clientele. Those with transactional leadership skills attend to the day-today tasks of the team that need to be completed to operate the program smoothly. Transformational goals are achieved through charisma, inspiration, intellectual stimulation, and consideration of the interests of individual staff members. Transactional goals are pursued using the strategies of goal setting, feedback, self-monitoring, and reinforcement. These effective styles have been contrasted to what has been shown to be a fundamentally ineffective approach to leadership—laissez-faire leadership. The laissez-faire leader is aloof, uninvolved, and disinterested in the day-today activities of the treatment team. The multifactor model was originally developed in business and military settings. Two subsequent studies, involving more than 1,000 staff working in human service settings, showed that independent groups of mental health staff (15) and rehabilitation staff (16) identified leadership factors that paralleled the transformational and 781
transactional leadership distinction. A third study showed that transformational leadership was positively associated with the organization’s culture and negatively associated with staff burnout on mental health teams (Corrigan PW, Lickey SE, Campion J, et al, unpublished data, 1999). Unfortunately, the positive impact of staff members’ leadership on consumers is not well known. One of the few studies in the literature suggested that mental health teams under strong managerial control serve consumers who report greater alienation from the staff (17). Positive effects of leadership on consumers’ satisfaction are not well documented. The purpose of the study reported here was to determine the relationship between transformational and transactional styles and consumers’ perspectives on their mental health programs. One way to measure the consumer’s perspective is by assessing satisfaction with the clinical program. Consumers’ satisfaction has been shown to be associated with positive perceptions about staff (18), perseverance in treatment (19), and selfreported treatment gains (20,21). An indirect way to assess consumers’ functioning is by evaluating their quality of life. People benefiting from psychosocial treatment programs report a higher quality of life (22,23). Moreover, consumers reporting higher treatment satisfaction tend to report a better quality of life (24). Earlier research suggests that cohesive teams with well-defined roles lead to less hostile and more therapeutic programs (4,6,25). Consequently, we expected that ratings of satisfaction and quality of life would be positively associated with active forms of leadership like transformational and transactional leadership; we expected laissezfaire leadership to be negatively associated with consumers’ satisfaction and quality of life. A leader’s style also depends on the eye of the beholder; leaders’ perceptions of their leadership style may differ from those of their subordinates. Hence, in this study, we contrasted leaders’ and subordinates’ perceptions of leadership style and their association with consumers’ satisfaction and quality of life. 782
Methods As part of a large, multiyear investigation of factors that enhance leadership, 68 teams providing services to persons with severe and persistent mental illness participated in the Midwest mental health team leadership study. At the time the data were gathered (January 1996 to July 1997), these teams included more than 200 leaders and 600 subordinates serving consumers. The teams worked in state hospitals and community mental health programs, providing psychopharmacological and psychosocial treatments for adults with serious and persistent mental illness. Teams ranged in size from nine to 41 members. Community-based teams provided skills training, supported employment services, assertive community treatment, and drop-in services. Data were collected from three levels of participants: team leaders, who provided perceptions of their leadership style; subordinates, who rated their leader; and consumers, who reported their satisfaction with services and quality of life. Team leaders were defined as individuals who have direct responsibility and who supervise a group of staff that provides clinical or rehabilitation services to persons with severe mental illness. This definition excludes central administrators and persons who lead ancillary services. Data from consumers
Teams were asked to select at random three to five current consumers in the program to provide information about their satisfaction with the program and their quality of life; 184 consumers agreed. Consumers were administered the 42-item Patient Satisfaction Scale (PSS) (26). Previous research suggests that consumers’ feedback on satisfaction with treatment is frequently confounded by a halo effect (“I liked all of the treatment”) or a devil effect (“I liked none of the treatment”) (27). To minimize these effects, consumers were instructed to rate PSS items by comparing their current treatment program to a program in which they had previously participated, using a 7point, better-than–worse-than scale, with 7 indicating the best treatment ever, 6 indicating that their current treatment was much better than the
other treatment, and so forth. Ratings on the scale are summed into an overall satisfaction score, with higher scores indicating more satisfaction with treatment. Previous research has shown the overall score to have satisfactory reliability, construct validity, and sensitivity to the effects of program change (26,28). Of the various measures of quality of life, the subjective component of Lehman’s Quality of Life Interview (QOLI) (22) was selected for the study because it has been tested and replicated with the largest sample of persons with severe mental illness. The measure comprises 17 items about domains of independent living to which subjects respond on a 7-point scale, with 7 indicating delighted and 1 indicating terrible. An overall quality-of-life index is determined by summing the 17 items; higher scores represent better quality of life. The QOLI has been shown to have satisfactory parallel-form reliability, internal consistency, and differencescore reliability (29,30). Moreover, when the QOLI was used with three independent research samples, the QOLI index of subjective quality of life was shown to correlate with objective quality of life (30). Data from leaders and subordinates
Leaders and subordinates completed the Multifactor Leadership Questionnaire (MLQ) (31). Leaders were instructed to rate 44 items representing leadership skills according to “how you think your subordinates view you” (31). Subordinates were instructed to judge individual items in terms of “how frequently it fits your supervisor.” Items are rated on a 5-point frequency scale, with 1 indicating frequently if not always and 5 indicating not at all; lower scores represent greater endorsement of a scale’s construct. The MLQ has been widely investigated and shown to have excellent internal consistency, test-retest reliability, and construct validity (31). Results of factor analyses have shown that the MLQ yields eight reliable factors. Transformational leadership is represented by four factor scales: charisma, inspiration, intellectual stimulation, and consideration of the interests of individual staff members.
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Three scales represent transactional leadership: contingent reward, active management-by-exception, and passive management-by-exception. Leaders who use contingent reward regularly reinforce staff for accomplishing job goals. In active management-by-exception, leaders are vigilant for errors and ready to provide guidance. In passive management-by-exception, leaders provide feedback only when differences from the standard are blatantly manifest. Higher summed scores on the relevant factors indicate less endorsement of transformational and transactional leadership styles. The final factor, nonleadership, is called laissez-faire. High scores on this factor represent less laissez-faire leadership. Data analyses
Most teams in this study had more than one leader who worked closely with the team. Moreover, team members closely interacted, and they had a collaborative impact on consumers. Hence, the relationship between leader, subordinate, and consumer is not well construed as unidirectional or one-to-one. As a result, the unit of analysis for this study was the team and not the individual, a strategy consistent with organizational research on leadership (32). Mean scores for leaders, subordinates, and consumers for each dependent variable were determined for each team. Individual teams were included in the study only if data were provided by leaders, subordinates, and consumers. Thirty-one of the 68 teams met this criterion. These teams consisted of 143 leaders, 473 subordinates, and 184 consumers. Differences between leaders and subordinates were determined using paired t tests. Pearson product-moment correlations were used to examine associations between leaders’ and subordinates’ ratings of leadership and consumers’ ratings of satisfaction and quality of life. To determine whether leaders’ and subordinates’ ratings independently accounted for variance in consumers’ ratings, a stepwise multiple regression was conducted.
Results Most teams had more than one leader; leaders commonly included a lead psychiatrist, charge nurse, and a PSYCHIATRIC SERVICES
clinical manager. The mean±SD age of the leader sample was 47.9±5.1 years. Of the 143 leaders, 101 (70.7 percent) were women. A total of 117 leaders (81.8 percent) were European American and 26 (18.2 percent) were from other groups, including African American, Latino, and Asian American. They had diverse educational backgrounds: 12 leaders (8.4 percent) had completed high school, 25 (17.5 percent) had completed some college, 30 (21 percent) had an associate’s degree, 31 (21.7 percent) had a bachelor’s degree, 27 (18.9 percent) had a master’s degree, and 18 (12.6 percent) had a doctoral degree. Leaders worked a mean±SD of 13± 5.9 years in the field. Consumers’ satisfaction and qualityof-life ratings were not significantly correlated with demographic characteristics of leaders. The mean±SD age of the 473 subordinates was 42.5±7.4 years, and 338 (71.4) were women. This group was not significantly different from the group of leaders in age or gender, nor did they differ significantly from the leaders in ethnic backgrounds. A total of 391 subordinates (82.7 percent) were European American, and 82 (17.3 percent) were from the other groups listed above. Overall educational levels were significantly lower among subordinates than among leaders (p
