by T.J. Hunt, MBA, RHIA, CHTS-IM
This article seeks to raise awareness of the leader-member exchange (LMX) theory of leadership and its potential benefit to the health information management (HIM) profession. A literature review that was conducted identified a leadership challenge for HIM practitioners. The review also provides examples of leadership definitions, and potential benefits of LMX to HIM professionals in leading people and influencing leaders in their organizations. The LMX concept may be an avenue to investigate in preparing future and current HIM professionals for leadership.
Keywords: leader-member exchange, leadership, education
The current healthcare environment is a rapidly changing and complex arena that increasingly requires the ability to manage and utilize data effectively for myriad purposes. The need to prepare health information management (HIM) professionals to lead the initiatives in which they are content experts has become increasingly apparent as well. This article seeks raise awareness of the leader-member exchange (LMX) theory as one potential method for improving leadership capabilities to meet this challenge. The Winter 2013 edition of Perspectives in Health Information Management focused on multiple aspects of leadership, including perspective,1 development,2 ethics,3 academics,4 and women in leadership.5 Although the increasing pace of change may be pushing the issue, the discussion regarding leadership in HIM content areas has been growing over time. The opportunity and need for HIM leadership has been expanding, and if credentialed HIM professionals do not take the opportunity to lead, someone else will.6 If there is an absence of HIM leadership, professionals from other disciplines will fill the leadership void and drive the initiatives that are truly best led by HIM experts.7 The last American Health Information Management Association (AHIMA) member survey indicated that respondents felt that the HIM profession is not the generator of change but a responder to change caused by external stakeholders.8 In addressing the need for leadership, reviewers of the survey results noted that “if this attitude frames the future roles and functions of HIM professionals, the profession as a whole may be relegated to an ancillary role in the new healthcare environment.”9 In seeking to prepare future HIM professionals and determine the focus of continuing education for the benefit of current professionals, a potential pathway in advancing leadership skill may be the idea of LMX.
The LMX theory of leadership was first introduced in 1975 regarding the vertical dyad of the supervisor-employee relationship in organizations. The theory has evolved since then; however, it continues to focus on the benefits of high-quality personal relationships between leaders and followers. The idea, which is seeing a resurgence of study as new generations of workers enter the workforce and more research is being pursued internationally, may be well worth revisiting. The objective of this article is to introduce the LMX concept and the benefits of LMX found in previous research to HIM professionals as a potential aid in meeting the stated leadership challenge. Leadership as a concept is introduced, and the benefits of high-quality relationships for both leaders and followers that could assist in advancing the influence of HIM practitioners in organizations are presented. A literature review was conducted to investigate the benefits found in previous research on this concept. Literature spanning 1975 through 2011 from North America, Europe, and Asia regarding LMX in multiple disciplines was examined. Content for the literature review was obtained by multiple methods. Scholarly articles from the electronic databases ProQuest, OCLC FirstSearch, EBSCOhost, and Gale were searched, as were textbooks regarding LMX studies. A multitude of peer-reviewed scholarly studies regarding LMX from around the world were found, although none addressed both LMX and HIM. The LMX studies selected for inclusion were on topics regarding benefits to both leaders and followers, from authors significant to the theory development, and ones thought to be generalizable to HIM practitioners. Overall, little peer-reviewed literature regarding any theory or method of leadership specifically in the HIM profession was found to exist; thus this study identified a need for further scholarly work to build the body of knowledge. Studies included original research in peer-reviewed journals, as well as meta-reviews and textbook chapters. The LMX-7 instrument measuring the self-perceived quality of leader-member relationships from both employee and supervisor perspectives was utilized in most studies and is discussed later in this article.
No single universal leadership style or method has been agreed upon in academics or industry.10 The study of leadership had challenges early on that still exist today: “Always, it seems, the concept of leadership eludes us or turns up in another form to taunt us again with its slipperiness and complexity. So we have invented an endless proliferation of terms to deal with it . . . and still the concept is not sufficiently defined.”11 Although many different definitions of leadership exist, most include the central aspects of a relationship, influence, and a common goal.12 Examples of these definitions include the following:
- an influence relationship among leaders and followers who intend real changes and outcomes that reflect their shared purposes;13
- a relationship that induces followers to pursue joint purposes that represent the motivations of both leaders and followers;14 and
- a process whereby an individual influences a group of individuals to achieve a common goal.15
Similarly, one definition of a leader is a person who sees a vision, takes action toward the vision, and mobilizes others to become partners in pursuing change—regardless of title or position.16
To prepare future HIM professionals and assist those currently in the workforce, the topic of leadership and leaders must move past definitions and begin to focus on methods.17 One potential avenue could be focusing on relationship building, as is discussed in the LMX theory, to lead employees and influence administrators.
A Leadership Approach for the HIM Profession
Just as there is no universal definition or approach to leadership, there has not been one common approach to leadership accepted and utilized by HIM practitioners, educators, and researchers. Few leadership theories have been published regarding the HIM profession specifically. This review is not intended to recommend one leadership method or theory exclusively, but to bring attention to the need for leadership preparation as well as the need for further investigation into directions to pursue in strengthening leadership in the HIM profession. AHIMA has previously suggested some ideas regarding leadership models for various HIM topics (such as data content standards, legal health records, ICD-10-CM/PCS implementation) based on the Independence, Influence, and Initiative process.18 Additional theories have also been suggested in the existing literature. Applying the Bowen theory of family relationships dealing with the intersection of multiple human relationships, not only a leader-follower dyad, has been suggested, along with integrating systems-based leadership, Kotter’s change management steps, and universally accepted project management principles.19 Johns has suggests Kouzes and Posner’s exemplary leadership model and stresses the idea of leadership development.20 With no universal method defined or prescribed, investigating leadership development focused on methods of earning incremental influence (influence beyond that contained in a role-specified situation)21 through mutual trust, respect, and obligation on an individual basis using LMX may be a worthwhile endeavor.
The LMX leadership theory emphasizes the leadership process of interactions between leaders and followers. It asserts that leaders have a unique relationship with each follower, rather than one leadership style or method applied to everyone.22 Leadership on a dyadic level refers to effective relationships between a leader and individual followers based on mutual trust, respect, and commitment.23 In this way, LMX theory is different from most other theories of leadership, which focus only on the leader’s activities or on the situation and environment. Building individual personal relationships with high levels of mutual trust, respect, and commitment shared by both parties provides demonstrable benefits to both leaders and followers.
Instead of focusing on one style of leader or on defined situations, LMX is a flexible and individual-based theory. This direction of leadership study draws from more than 35 years of research, including worldwide evidence from multiple cultures that may be useful in the creation of HIM curricula and standards that could be utilized in domestic or global settings. This effort would support the recent grant AHIMA received from the US Department of Commerce24 to develop content that can be applied domestically and globally to increase health information management and technology standards and education worldwide.
Benefits for Leaders
Leaders with high-quality LMX relationships with individuals in their teams have been found to experience multiple benefits. These benefits include positive group performance,25 increased self-efficacy of followers,26 and employees who take more initiative, attempt to exercise leadership to make the work unit more effective, take risks to accomplish missions, build networks and extend capabilities, influence others by doing something extra, and work to get their leader promoted.27 Their employees also show a lower turnover intention and higher job satisfaction28 and display more positive employee citizenship behaviors.29 Overall, leaders engaging in these high-quality relationships have teams with higher subordinate satisfaction, greater employee organizational commitment, better job performance of their units, and lower turnover.30
Benefits for Followers
Focusing on relationships between leaders and followers also has benefits for those without specific supervisory responsibilities, and for those in middle management who also report to an administrator. Research has found benefits in increased influence and job satisfaction. Those with high-quality LMX relationships with their supervisors experience greater access to organizational resources from leaders31, 32 and receive more work-based benefits than those reporting poor-quality relationships.33 They also experience more rapid career progression34, 35 and higher perceived organizational influence of the employee by others.36 More complex and responsible roles are assigned to employees with higher levels of mutual trust, respect, and obligation in the relationship with their supervisor.37 Overall, results of studies suggest that followers’ high-quality relationships with their leader can affect the entire work experience in a positive manner, including performance and affective outcomes.38
Concerns and Questions
Concerns and drawbacks to this leadership approach have been identified over the life span of research on the topic. Contextual and situational factors outside of the member-follower dyad can influence relationships. Forces such as organizational culture and practices, type of work,39 location, length of assignments, and number of team members that must form relationships40 can affect LMX. Others suspect that LMX is related more to satisfaction with the leader than to the actual quality of the exchange relationship41 and argue that a more accurate dyad-based model would take into account the ability of resource investment and exchange of each party. If one has little to offer, the exchange is limited to a weak one.42 Graen43 admits that the process is time-consuming because of the need to build a relationship between each specific member and leader, and the leader may be unable to give equal attention to all followers.44 Concerns regarding organizational justice have been raised,45 and the theory has been criticized for being descriptive rather than prescriptive,46 thus limiting its implementation by practitioners.
Some of the questions concerning LMX have been addressed through further research, and others remain. Studies continue to seek new insights to add to the body of knowledge regarding LMX, investigating avenues to give a more prescriptive picture of how practitioners can implement LMX theory and improve leader-follower relationships. Some avenues include making decisions in a procedurally fair manner that would increase trust and be accepted by the different followers.47 More research incorporating the importance of the leader’s perspective of LMX48 has also added to data that previously focused only on followers’ perceptions, which gave the impression that satisfaction with the leader, as opposed to trust, obligation, and respect, was driving results. Trust and relationships are not dependent on satisfaction or on people liking one another personally; they are based on understanding one other. To gain this understanding, relationships are crucial.49 Although certain aspects of workplace relationships can be defined and measured, and practical benefits and outcomes have been replicated in studies, the process of developing relationships is still not concrete. A specific guide to the process of relationship building has not been identified, which is viewed as a continuing weakness of the theory. Contextual forces also continue to be factors that most leadership theories must take into account, and these questions continue to be researched.
Developing LMX Quality
The ability to work successfully with different people has been found to have a relationship with LMX, which would be expected. The LMX-7 instrument, developed by Graen and Uhl-Bien and found to be reliable and valid, and similar variations have been used to measure LMX in 85 percent of LMX studies since 1999.50 This instrument employs seven questions that can be answered from a leader or follower perspective on a five-point Likert scale:51
- Do you know where you stand with your leader/follower; do you usually know how satisfied your leader/follower is with what you do?
- How well does your leader/follower understand your job problems and needs?
- How well does your leader/follower recognize your potential?
- Regardless of how much formal authority your leader/follower has built into his or her position, what are the chances that your leader/follower would use his or her power to help you solve problems in your work?
- Regardless of the amount of formal authority your leader/follower has, what are the chances that he or she would “bail you out” at his or her expense?
- I have enough confidence in my leader/follower that I would defend and justify his or her decision if he or she were not present to do so.
- How would you characterize your working relationship with your leader/follower?
In light of the questions in the LMX-7 instrument regarding building trust, respect, and a sense of obligation between people, it makes sense that communication is a large part of high-quality LMX relationships.52 Communication apprehension was found to have a strong negative relationship with LMX quality and be a negative predictor of LMX quality.53 Other potential pieces of building trust, mutual obligation, and respect in a leader-follower relationship include level of emotional expresson,54 emotional intelligence,55 the identification of leader-follower similarities,56 empathy,57 and support, recognition, and inclusion.58 These factors that have been found to be related to high-quality LMX relationships may be useful tools for HIM professionals to leverage in the workforce, whether in leading a team or working with direct supervisors.
Much of the information presented above seems intuitive; certainly those with better relationships would benefit as a leader and a follower. Formal HIM degree programs and continuing education offerings must cover many clinical, technical, and administrative topics. In preparing HIM professionals to succeed in the workplace, it may be important to focus not only on technical competency but also on components of building mutual trust, respect, and commitment in interpersonal relationships and leadership. Interpersonal skills such as communication, inclusion, empathy, support, and recognition, although they do not provide a step-by-step guide, have been found to help both leaders and followers build beneficial workplace relationships. Focusing on LMX could be an asset for HIM professionals when leading a HIM department, a team of remote employees, or a project implementation, or when seeking to influence the direction of the healthcare organizations in which they work. Evidence in multiple cultures suggests that high-quality LMX relationships are beneficial for individual career advancement and success in any role, and may benefit the professional workforce as a whole domestically and internationally. An awareness of the potential benefits of the LMX concept in HIM may support further inclusion of or attention to this theory in formal degree and continuing education offerings.
T.J. Hunt, MBA, RHIA, CHTS-IM, is an associate dean and assistant professor of health information management at Davenport University College of Health Professions in Grand Rapids, MI.
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T.J. Hunt, MBA, RHIA, CHTS-IM. “Leader-Member Exchange Relationships in Health Information Management.” Perspectives in Health Information Management (Spring 2014): 1-8.