الفهرس 
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Abstract
Physicians are the central pillar of any heath care organization. It’s important for healthcare organization to recognize the importance of physicians’ well-being taking into consideration their different work setting and relationship to patients. In general, workers in the healthcare industry are very susceptible to psychological distress and despair. such as long hours, demanding patient loads, and administrative burdens. Leadership style plays a crucial role among various organization. In healthcare organizations transformational leadership is from the most preferred styles. Transformative leaders inspire their followers to see issues from new perspectives, offer support and motivation, share a vision, and arouse feelings of affiliation and emotion. Transformational leadership in healthcare organization has an impact on physicians’ well-being. This impact may be directly on wellbeing or may be through different mediators. from these mediators, distress in which physicians were exposed including their emotional stress and stress specific to physicians’ responsibilities. Another mediator was career purpose which demonstrated the meaning of their work. Finally, their cognitive flexibility which revealed the personality of physicians as their open mindedness and their ability to see different perspectives of things also affected physicians’ well-being.
Objective of the study:
This study aims to assess the transformational leadership style among physicians and physicians’ well-being at the Main University Hospital in Alexandria. Then to investigate the association between transformational leadership style and the overall physicians’ well-being.
Material and methods:
This was a cross-sectional study conducted at the Main University Hospital in Alexandria, Egypt. The sample size of 220 physicians was calculated using G-power software. The target population consisted of physicians (residents and academic staff) were randomly selected from different departments in the Main University Hospital. Physicians having working experience less than 6 months were excluded from the study. The main outcomes of this study were assessing the transformational leadership style and physicians’ wellbeing then assessing the influence of transformational leadership, distress, career purpose (meaning of their work) and cognitive flexibility on their well-being.
The data collection methods and tools included:
A pre-coded, predesigned, self-administrated questionnaire based on previously validated tools was used to gather the required variables. The questionnaire was composed of three sections, the first section comprised of the participated physicians’ sociodemographic characteristics (age, gender, marital status, educational level, job position, department, and years of work experience). The second section assessing their leaders’ transformational leadership style using global transformational leadership scale (GTL). The last section assessing participants’ wellbeing using two different tools, the first one WHO 5 wellbeing index which assessed their overall well-being, the second tool was physician wellness inventory (PWI) which composed of three scales: distress, career purpose (meaning of their work) and cognitive flexibility.
Results:
The study revealed the following main results:
1. Assessment of transformational leadership style among their leaders revealed that 66.4% reported their leaders with high transformational leadership behaviors (received a score above cut off point (≥21)) with a mean score of 23 ± 6.4.
2. Assessment of physicians’ wellbeing revealed that 51.4% of the physicians participating in the study rated lower scores (≤28) in WHO 5 wellbeing index questionnaire which indicative of depression. Only 17.3% from the participated physicians rated a higher score above the cutoff point (>50) which indicative of good well-being. While 31.4% reported a score from > 28 to ≤50 which reflected poor wellbeing with a mean score of 30.9 ± 19.1. Regarding physician wellness inventory, more than half of the participated physicians (61.4%) rated high career purpose. The same for their cognitive flexibility 78.2% had high cognitive flexibility. On the other hand, 64.5% of the participated physicians exposed to low (≤3) distress including emotional distress and stress specific to physicians’ responsibilities with a mean score of 2.88±0.58.
3. Assessment association between sociodemographic data, transformational leadership style and physicians’ wellbeing revealed that there was no statistically significant difference between different socio-demographic characteristics categories of the participated physicians and their well-being. There was a statistically significant difference between various departments in the hospital in concern with transformational leadership style used (p= 0.007). There was no statistically significant association between different socio-demographic characteristics categories of the participating physicians and their career purpose in Alexandria Main University Hospital. On the other hand, there was a statistically significant difference in their cognitive flexibility in concern with physicians’ gender (p=0.015) and with their postgraduate educational studies(p=0.049). There was a statistically significant difference in the stress they were exposed according to their gender (p=0.024).
4. Regarding correlation between global transformational leadership scale and WHO 5 wellbeing index scale, there was a statistically significant moderate positive correlation between transformational leadership scale using global transformational leadership and the overall psychological well-being using WHO 5 wellbeing index (r= 0.406,
p= 0.000).Regarding correlation between global transformational leadership scale and the other three scales of physician wellness inventory (career purpose, cognitive flexibility and distress), there was a statistically significant moderate positive correlation between transformational leadership using global transformational leadership scale and physicians’ career purpose (r= 0.350, p= 0.000), there was a weak positive correlation between transformational leadership scale and cognitive flexibility (r= 0.209, p= 0.002), there was a negative weak significant correlation between transformational leadership scale and distress scale (r=- 0.168, p= 0.013). On the other hand, regarding correlation between WHO 5 wellbeing index scale and the other three scales of physician wellness inventory ( career purpose, cognitive flexibility and distress), there was a statistically significant moderate positive correlation between total psychological wellbeing scale using WHO 5 well-being index and their career purpose scale (r= 0.546, p= 0.000), there was a statistically significant a weak positive correlation between total psychological wellbeing scale using WHO 5 wellbeing index and their cognitive flexibility scale (r= 0.335, p= 0.000) and there was a statistically significant negative weak correlation between total psychological well-being scale and distress scale (r= -0.338, p= 0.000).
5. Multiple linear regression analysis revealed that the dependent variable (the overall physicians’ well-being) was statistically significant regressed on predicators (transformational leadership, career purpose, cognitive flexibility, and distress). The independent variables were statistically significantly predicting overall physicians’ wellbeing (P < 0.001) indicating that the predicators under study had significant impact on overall physicians’ well-being. Moreover, that model explained 42.5% of the variability in the overall physicians’ wellbeing.
6. First Structural equational modeling (SEM) demonstrated that there was a direct and indirect (through mediators) relationships between transformational leadership and the overall physicians’ wellbeing in which the mediators in this model were career purpose, cognitive flexibility, and distress. This model was a statistically significant model (p<0.001). but this model revealed a poor fit to the data: AGFI, CFI, TLI were all below recommended level of 0.9 (0.441, 0.668, -0.105, respectively). However, the squared multiple correlation showed that 39.5% variation in the overall physicians’ well-being was accounted by transformational leadership, career purpose, cognitive flexibility, and distress.
7. Second structural equational modeling was conducted after removing cognitive flexibility variable from the mediators revealed a statistically significantly model (p=0.040). In addition to, this model revealed a better fit to the data indices: AGFI, CFI, TLI (0.905, 0.979, 0.874, respectively) than the first one. Furthermore, AGFI, CFI showed recommended level of 0.9. However, the squared multiple correlation showed that 40.5% variation in overall physicians’ well-being was accounted by transformational leadership, career purpose, and distress.
6.2. Conclusion:
Based on the results of the present study, the following may be concluded:
• High transformational leadership behavior was more frequently perceived by participating physicians among their leaders than low transformational leadership behavior with a mean score of 23 according to global transformational leadership scale.
• The greatest proportion of participated physicians working in Alexandria Main University Hospital rated their leader behavior in the dimensions of staff development, supportive leadership, empowerment, and innovative thinking “often” and dimensions vision, led by example and charisma “occasionally” according to global transformational leadership scale.
• The majority of the physicians participated in the study reported poor well-being and depression according to WHO-5 wellbeing index scale with a mean score of 30.9.
• Regarding WHO 5-index wellbeing items, greater percentages of physicians rated “some of the time” for feeling cheerful, in a good spirit, calm, relaxed, active, vigorous and their lives had been filled with things that interest them, while rated “at no time” for waking up feeling fresh and rested.
• Higher percentage of the participated physicians in the Alexandria Main University Hospital experienced meaningful work (high career purpose) with a mean score of 3.2 and high cognitive flexibility with a mean score of 3.56, while nearly third of the study sample in the hospital exposed to distress a mean score of 2.88 using patient wellness inventory.
• There were no statistically significant association between almost different categories of sociodemographic characteristics (age, years of experience, marital status, educational level, job position, title of the leader and department) and distress scale of physician wellness inventory. On the other hand, there was a statistically significant association between gender and distress scale according to physician wellness inventory.
• Female physicians had reported a higher cognitive flexibility than males and this was statistically significant using physician wellness inventory questionnaire. Regarding educational levels, there was a statistically significant between level of education and categories of cognitive flexibility using physician wellness inventory.
• Regarding correlation between global transformational leadership scale and WHO 5 index well-being scale, there was a statistically significant moderate positive correlation between transformational leadership scale using global transformational leadership and the overall psychological physicians’ well-being using WHO 5 wellbeing index.
• Regarding correlation between global transformational leadership scale and the other three scales of physician wellness inventory (career purpose, cognitive flexibility and distress), there was statistically significant moderate positive correlation between transformational leadership using global transformational leadership scale and physicians’ career purpose, there was a weak positive correlation between transformational leadership scale and cognitive flexibility, there was a negative weak significant correlation between transformational leadership scale and distress scale.
• Regarding correlation between WHO 5 wellbeing index scale and the other three scales of physician wellness inventory (career purpose, cognitive flexibility and distress), there was a statistically significant moderate positive correlation between total psychological physicians’ well-being scale using WHO 5 wellbeing index and career purpose scale, there was statistically significant a weak positive correlation between total psychological well-being scale using WHO 5 well-being index and cognitive flexibility scale and there was statistically significant negative moderate correlation between total psychological physicians’ well-being scale using WHO 5 wellbeing index and distress scale.
• Using multiple linear regression model for examining impact of multiple variables (transformational leadership behaviors using global transformational leadership scale, career purpose, distress, and cognitive flexibility according to physician wellness inventory) on physicians’ well-being according to WHO 5 wellbeing index. The dependent variable (physicians’ well-being) was significantly regressed on predicator variables of transformational leadership, career purpose, cognitive flexibility, and distress. The model explained 42.5% of the variability in the overall physicians’ well-being. Coefficients were further assessed to a certain the influence of each of the factors on well-being. There was a significantly positive impact of transformational leader ship on overall well-being and there was a significantly positive impact of career purpose on overall well-being. Additionally, there was a statistically significantly negative impact of distress on well-being. On the other hand, there was no statistically significant positive impact of cognitive flexibility on wellbeing.
• Regarding the first structural equational modeling, the overall model was statistically significant. Furthermore, 39.5% variation in physicians’ well-being was accounted for transformational leadership, career purpose, cognitive flexibility, and distress. Transformational leadership style has an impact on physicians’ psychological well-being directly and through different mediators (career purpose, cognitive flexibility, and distress). the impact of Transformational leadership on Cognitive flexibility was positive and significant. Also, the impact of Transformational leadership on career purpose was positive and significant. Moreover, the impact of Transformational leadership on distress was negative and significant. On the other hand, the impact of cognitive flexibility on Overall wellbeing was positive and non-significant. the impact of Career purpose on Overall wellbeing was positive and significant and finally the impact of Distress on Overall wellbeing was negative and significant.
• Regarding the second structural equational model after removing cognitive flexibility construct from the mediating effect and the overall theoretical model. This model revealed a better fit to the fit indices like AGFI, CFI, TLI than the first one. Also, increasing in the squared multiple correlation in which 40.5% variation in overall physicians’ well-being was accounted by transformational leadership, career purpose, and distress. Moreover, all paths comprising the second mediated model were significant. The impact of Transformational leadership on distress was negative and significant. Also, the impact of Transformational leadership on Career purpose was positive and significant. Moreover, the impact of Transformational leadership on overall well-being was positive and significant. On the other hand, the impact of distress on Overall wellbeing was negative and significant, and finally the impact of Career purpose on Overall wellbeing was positive and significant.
6.3. Recommendation:
Based on the study findings and conclusions the following can be recommended:
• Leadership development programs should be implemented on regular basis in the Main University Hospital targeting mainly residents and head departments.
• Culture of positive transformational leadership style should be disseminated throughout all leaders in the university hospital and within healthcare professionals. For physicians and their companies to achieve wellbeing and a sense of balance between their personal and professional lives, a change in culture is necessary.
• Leadership behavior of managers and residents should be assessed and taking into consideration opinion of subordinates of physicians and other healthcare professionals.
• Goal setting treatments are another way that organizations can increase the long-term sustainability of these transformational behaviors. Thus, annual developmental assessments for managers and supervisors, such managerial skills surveys and 360-degree feedback instruments, can incorporate transformational training. This facilitates the control of interventions and allows firms to be sufficiently efficient and cost-effective to improve employee well-being.
• Stress management programs for physicians (mainly residents) and psychological consultation should be developed and regularly monitored on continuous basis to relieve and reduce their stress which accordingly affect their wellbeing.
• Sources of stress facing physicians should be investigated and mitigated.
• Regular monitoring of healthcare workers’ well-being should be applied.
• Further research to determine the cause behind the overwhelming poor physicians’ well-being.
• Further research to determine the cause behind the susceptible physicians’ emotional stress and stress related to their work responsibilities.