Introduction
A diverse range of third-sector organizations, principally nonprofit organizations (NPOs), includes entities contributing to cultural, educational, and healthcare fields. NPOs are usually tax-exempt because they work toward the public interest. Many combine advocacy with service provision, usually as their primary goal (Almog-Bar & Schmid, 2014). In the Italian context, organizations included in the third sector are those specifically dedicated to one or more activities of interest for the collectivity (law 117/2017).
The management of NPOs has been analyzed from several perspectives. These have included studies examining organizational dimensions and models (Martin-Perez et al., 2012; Rohim et al., 2019), human resource practices (Baluch, 2017; Baluch & Ridder, 2020; Bastida et al., 2018; Cooper et al., 2020; Walk et al., 2019), and leadership roles and leader efficacy (Alexander et al., 2011; Jaskyte, 2004; McMurray et al., 2013; Ortiz-Gomez, 2020; Schmid, 2008; Uzonwanne, 2015).
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In the debate about third-sector leadership, limited evidence exists about a specific category of NPOs: patient advocacy associations (PAAs). These are NPOs representing patients and citizens. PAAs have a variety of objectives, such as collecting and spreading information about specific pathologies, providing information-sharing platforms for patients and their relatives, broadening access to knowledge about care and treatment options, and defending the rights of patients and citizens. In their roles as representatives and third-party informers (Allmark & Klarzynski, 1992; Konke, 1982a, b; Morrison, 1991), PAAs may directly intervene or provide funding (Copp, 1986). The relevance of PAAs has increased due to their ability to enhance representation for patients in regional and national contexts and their involvement in healthcare planning. Moreover, PAA involvement within institutions has helped to highlight the importance of the rights and experiences of citizens and patients.
In Italy, PAAs have been present since the establishment of the National Health Service in 1978, which determined for the first time the need for patients, specially those more fragile (children, not self- sufficient, elderly), to be represented. The importance of PAAs in regional and national decision-making strategies has increased in recent years due to their involvement in the definition of policies, healthcare system evaluation, and the design of innovative clinical pathways (Vanara, 2008).
The role of PAAs in health policy decisions is well-known. However, few scientific contributions have examined PAAs, except Fernandez (2008), who described their failures; Hager (1999), who analyzed PAAs’ life cycle; Herlin (2015), who examined the role of the mission of PAAs; and Steinberg (2006), who reported PAAs’ efforts to compensate for governmental shortcomings. Additionally, contributions about PAA leaders’ roles, effects on goal achievement, and leadership styles are scarce, although leaders’ characteristics are among the factors that can determine organizational performance (Smart & Conant, 1994; Jadhav et al., 2015). Knowledge of PAA leadership characteristics and abilities is useful for regional and national policymakers to further increase their involvement in decision-making processes. The involvement of PAAs in healthcare policymaking is increasing, aiming to value the experiences of patients and citizens in healthcare policy debates. In Italy, the Ministry of Health and some regional health authorities have started systematically involving PAAs in projects and services, and some have begun to recognize accountability to PAAs regarding their networking activities. These processes begin from the individuation of leaders possessing the characteristics useful to allow them to catch and, consequently, adapt the organizational model to available opportunities and environmental limitations (Pfeffer & Salancik, 2003). Accordingly, successful organizations, comprising those operating in the advocacy context, tend to be the best adapted, depending on the choices and actions of their leaders (Chrobot-Mason et al., 2016; Lim et al., 2021; Yoshioka, 2017).
Differing from the for-profit context in which performance can be defined and measured more clearly, within the nonprofit context, particularly PAAs, exercising performance measurement is somewhat difficult. Generally, performance represents a multidimensional variable, useful to indicate the extent to which organization goals are achieved (McCloy et al., 1994). In the patient advocacy context, little agreement exists about how to measure performance, and accessing the information typically used for its measurement is difficult. However, literature (Cardone, 2009) and organizational practice converge in indicating that performance is not just service production or customer satisfaction but rather the value of the voluntary associations as custodians of unique and unrepeatable knowledge in the field of personal services. The role of the leader in building this value is evident (Smart & Conant, 2011; Morandi et al., 2021).
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Following the well-known model of Mouton and Blake (1964), one of the most popular leadership theories in public administration (Cho & Choi, 2018), and according to more recent contributions (Schmid, 2006; Couture & Harvey, 2021), to support their organizations, leaders must balance their efforts between two main areas: tasks and people. Attention to the task refers to leaders’ planning, managing, and organizing responsibilities, whereas attention to people refers to their abilities to motivate, involve, develop, be empathic to, and establish stable human relationships with workers.
To provide evidence about leadership traits in PAAs, we applied this model to a sample of PAA leaders. The decision to focus on the managerial grid model of Mouton and Blake was related to its usefulness in helping leaders to understand the direction of their efforts and improve their styles accordingly. The grid is based on sound theory, considerable research, and practical experience (Burke, 2017). As evidenced in Fig. 1, it separates two of the primary areas of management: personnel and production. It also provides a balanced style of management, useful for changing environments such as the third sector. The grid model provides a fundamental snapshot of individuals’ leadership styles, which is worthy of recognition.
Fig. 1
The Mouton and Blake Managerial Grid
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By assessing patient advocacy leaders’ traits through the Mouton and Blake managerial grid, we aimed to increase future success by developing initiatives for leaders and allowing them to build and plan specific training. Moreover, understanding their leadership styles may have crucial implications for the organizational climate and effectiveness.
As documented by the Hay Group (2016), almost 70% of the variance in organizational climate can be affected by leadership style, which is a critical determinant of employees’ actions toward the achievement of organizational goals (Saeed et al., 2014). These aspects are particularly relevant within PAAs, in which motivation and support are critical for employees and volunteers who are involved daily in challenging tasks (Nencini et al., 2016), helping people who are ill or in trouble.
This article first develops a theoretical background about leadership within the third sector. Next, we introduce the Mouton and Blake model. Finally, using the grid, we provide an assessment of the leadership styles of our sample. A discussion and implications conclude the paper.
Leadership and the Third Sector
In the field of organizational research, disagreement exists about how leadership styles should be categorized, with a notable distinction between the transactional leadership view and the charismatic leadership view. Researchers adopting the former perspective map factors that influence the effectiveness of the so-called motivational transactions between leaders and followers (e.g., Hersey and Balanchard, 1972). Meanwhile, the charismatic leadership perspective is based on emotional aspects of the relationship between leaders and followers (House, 1971) and addresses how leaders’ empathic relationships with their followers can motivate them to engage in activities surpassing their roles. Charismatic leaders, characterized by high self-confidence, clear vision, and unconventional behaviors, can act as change agents. They provide their followers with an image of goals while constantly increasing their motivation.
Within NPOs, leadership is critical for augmenting employee and volunteer engagement in socially useful activities, as well as for maintaining an overarching vision about the scope of the organization’s work and influencing specific organizational dimensions (Nencini et al., 2016). We revealed an ongoing debate following various perspectives. First, researchers have conducted studies focusing on the ability of leaders to create a vision. In Schmid’s view (2008, p. 181), “the real test of a leader [is] whether [they] can transmit that vision to followers… and mobilize their support.” According to this perspective, the role of the leader is to create an adequate and engaging organizational environment that facilitates the attainment of organizational goals. Leaders should be perceived by team members as effective, thus helping align all their efforts around clear tasks and objectives.
The literature has widely documented the connection between leadership effectiveness and group efficacy and performance (Chen & Lee, 2007; Jung & Sosik, 2003; Walumbwa et al., 2004). Leaders are asked to provide followers with the tools to manage themselves (Wageman, 2001). In the team-style approach, leaders provide more consultation than direction. Following the contingency model (Fiedler, 1964), due to the voluntary nature of work within PAAs, a participative style brings results that are more appreciated than authoritarian goals (Cho et al., 2018).
Consistent with Schmid’s perspective, in an analysis of a multisector healthcare alliance, Alexander et al. (2011) highlighted that leadership helps NPOs to establish and maintain partnerships among workers and volunteers and maintain a consensus regarding the organization’s mission, vision, goals, and strategies.
Another research perspective focuses on the relationship between leadership styles and decision-making approaches, demonstrating the existence of such a relationship and its significance. Together, effective leadership and decision-making allow NPOs to maximize the potential of employees, empowering them and engaging subordinates in decision-making processes, thereby improving organizational output (Uzonwanne, 2015).
Ortiz-Gomez et al. (2020) revealed that servant leadership can augment effective worker engagement. Having effective worker engagement is a particularly significant dimension for social organizations caring for people in difficult circumstances. Aboradaman et al. (2020) proposed a model in which work engagement mediates the effects of transformational and transactional leadership simultaneously on affective commitment and organizational citizenship behavior among NPO employees. In a comparative analysis of the effects of charismatic and transactional leadership in NPOs, McMurray et al. (2013) presented a theoretical model of relationships among leadership, organizational climate, and workplace innovation, wherein leadership had a greater direct effect on organizational climate than on workplace innovation. Specifically, they suggested that the individual support provided by charismatic leadership and the contingent punishment related to a transactional style of leadership are key predictors of workplace innovation.
Finally, the relationship between leadership and organizational culture in third-sector organizations has been analyzed (Jaskyte, 2004). The authors suggested that leader effectiveness depends first on the comprehension of organizational culture and secondly on direct management and applying fixes. The quintessential importance of leaders in influencing culture may be mediated through a variety of actions, such as rewards, attention to employees, reactions to crises, recruitment, and the criteria used for employee and volunteer selection and promotion.
Other important contributions have been provided about how leadership traits, experience, and skills are fundamental to allow leaders to fulfill the entrepreneurial and managerial tasks necessary for the survival of their organizations (Cummings, 1988; Lim et al., 2021). Dula et al. (2020) argued that organizational performance is responsive to the gender composition of a managerial board. In general, women leaders tend to present a style more associated with charismatic leadership (Eagly et al., 2003; Martin, 2015; Pounder & Coleman, 2002; Trinidad & Normore, 2005; Vinkeburg et al., 2011), whereas men tend to be transactional leaders. Additionally, compared to men, women leaders have been reported to be more inclined to seed the development of empathy and communication in the workplace and among coworkers (Britton, 2000; Eagly, 2007; Prouteau et al., 2010).
The optimal leadership style depends on the objectives, culture, goals, and human resources associated with particular organizations. Thus, success depends on mutual adaptation to the current organizational life cycle phase and the use of leadership approaches and behaviors required for that phase (Schmid, 2008).
In sum, third-sector-specific literature provides an ongoing debate about leadership, thus testifying to its importance for the organizations operating here. However, we found a lack of contributions aimed at empirically assessing leadership styles particularly within PAAs. To fill this gap, using the Mouton and Blake managerial grid, we explored for the first time the leadership styles adopted in a sample of PAA leaders, with the specific aim to provide a picture of their maturity and offer such leaders a valuable self-assessment tool.
Leadership Models: Mouton and Blake’s Managerial Grid
The Second World War motivated the pursuit of studies seeking to determine the best leadership style. Differing from previous theories of leadership that focused on the analysis of personality and traits, the majority of this war-motivated research stressed the importance of leaders’ behaviors (e.g., Mann, 1959; Stodgill, 1948). As that line of work revealed a strong relationship between leadership behaviors and group performance, researchers were driven to more deeply explore the existence of specific styles with a positive impact on workers (Kreitner & Kinicki, 2004).
Notably, Mouton and Blake (1964) developed a now-famous managerial grid model in which leadership style desirability is judged based on positive outcomes, such as performance, morale, job satisfaction, and well-being. The managerial grid model has two main leader-function dimensions: concern for tasks and concern for people.
The model is represented by a grid (Fig. 1), with concern for tasks as the x-axis and concern for people as the y-axis, each axis ranging from 1 (low) to 9 (high). Of the five leadership styles identified, impoverished-style (e.g., 1:1) leaders are characterized by a low concern for both tasks and people, an interest in preserving their job or seniority, and a self-preservation drive to protect themselves by avoiding getting into trouble. Such leaders avoid assuming responsibility for mistakes, and they are very prone to delegate and then disappear. Because they lack interest in task accomplishment as well as in the maintenance of relationships with coworkers, they may avoid power struggles and give their employees great freedom.
Country club–style leaders (e.g., 1:9) are characterized by attentiveness to worker comfort and security because they view these issues as essential to obtaining higher levels of performance. They tend to be friendly but not necessarily productive. Country club–style leaders tend to use rewards to maintain discipline but also encourage goal accomplishment. These leaders prefer not to punish workers or use power to propel goals for fear of damaging relationships with workers.
Middle-of-the-road-style leaders, who have midlevel scores for both dimensions (e.g., 5:5), are categorized as those who try to balance company goals and workers’ needs. These leaders pay attention to both people and production. Moreover, they hope to achieve suitable performance but do not fully satisfy production aims or people’s needs.
Authoritarian-style leaders show high scores in the task dimension with a low score in the concern for people dimension (e.g., 9:1). They view employees’ needs as unimportant. Authoritarian leaders expect performance in return for wages and tend to use rules and punishments to achieve company goals without much room for cooperation, collaboration, or debate. When something goes wrong, authoritarian leaders tend to focus on who is to blame rather than exactly what went wrong and how to prevent it. They are intolerant of perceived dissent, making it difficult for their subordinates to contribute or develop.
Finally, team-style leaders are those who obtain high scores for both dimensions (e.g., 9:9). Team-style leaders are attentive to both production and people, encouraging teamwork and commitment among employees, who consider themselves constructive contributors to the company. Coworkers are highly involved and fostered by team-style leaders to more fully reach their potential, as both team members and individuals. Team-style leaders encourage workers to reach team goals as effectively as possible. Typically, team-style leaders form and lead high-performance teams.
Although Mouton and Blake’s managerial grid model represents just one of the available leadership style assessment tools, it provides a self-assessment tool for leaders to help them to improve their style (Burke, 2017). Some studies have employed the grid to evaluate the effectiveness of leadership types in different contexts, such as academia (Cho & Choi, 2018), whereas other scholars have documented the usefulness of this tool (Holta & DeVore, 2005). Mouton and Blake’s managerial grid has also been employed for organizational development purposes by consulting firms assisting government, business, and third-sector organizations (Rainey, 2003). Thus, we elected to use Mouton and Blake’s managerial grid model in our assessment of PAA leaders.
Data and Methodology
The data employed in the present study were collected by a survey aimed at exploring the organizational characteristics of PAAs and the leadership profiles of their leaders. It was sent through the SurveyMonkey platform to 300 Italian PAA leaders, who were asked to respond regarding their own characteristics and the organizational features of their associations. Additional contacts were made in the following months by email and telephone. Before being administered to the entire sample, the questionnaire was validated by a scientific committee and a focus group.
The questionnaire was composed of three sections. Section 1 aimed at exploring the personal information of the leaders: age, gender, tenure, networking activities, and training paths. The latter were differentiated into “training on the job,” which refers to the acquisition of the technical skills useful to physically develop work (Jacobs, 2003), and “graduate training programs,” (Wong, 1996) pertaining to the acquisition of theoretical knowledge and the behavioral competencies necessary to successfully cover a job role. Finally, the level—national or regional—of the leader’s association was identified.
Section 2 was used to determine each respondent’s leadership profile, following Mouton and Blake’s managerial grid scale. We proposed 16 items, each answered on a 9-point Likert scale, wherein “1” indicated a low agreement and “9” high agreement. The mean scores for each dimension were calculated and used to obtain grid coordinates, with the resulting position indicating the respondent’s leadership style.
Section 3 consisted of a checklist of 22 managerial, relational, and strategic competencies. The respondents were asked to indicate their level of confidence with each listed competency on a 5-point Likert scale, wherein “1” and “5” represented low and high confidence, respectively. A standardized 0–100% index was then obtained for each respondent by summing their Sect. 3 responses and dividing by the maximal score of 110.
Results
We collected 140 filled surveys. After eliminating incomplete and illegible answers, the final sample consisted of 94 respondents with complete questionnaires. The representativeness of this sample was satisfactory given the lack of an official census of Italian PAAs.
Of the 94 leaders surveyed, the majority were women (N = 64; 68.1%), and the mean age of the sampled respondents was 55 years. Most had completed a master’s degree (N = 65; 69.1%). The most highly represented pathology focus areas of the represented PAAs were oncological (N = 25; 26.6%) and neurological diseases (N = 22; 23.4%). Other pathological areas represented included dermatological diseases and lymphatic system diseases (each represented by one PAA, 1.1% each). The majority of the respondents (N = 58; 61.7%) indicated that their PAAs did not exercise a caregiver function. Analysis of the personal development path of the respondents, based on the training courses attended, indicated that 31/94 respondents (32.9%) attended a graduate training program aimed at developing theoretical and behavioral competencies, and 19/94 (20.2%) attended training on the job aimed at developing more technical skills. Finally, 44 respondents (46.8%) did not complete any training activities.
According to the respondents’ grid coordinates, most were in the team-style leader quadrant of the managerial grid (N = 56; 59.7%; Fig. 2A). Most of the remaining respondents’ coordinates placed them in the country club–style leader quadrant (N = 12; 12.7%). Three additional leaders were on the cusp between the country club and team styles of leadership, and one was on the cusp between the team and authoritarian styles. The coordinates of two leaders (2.1%) placed them in the impoverished-style quadrant. The coordinates of one leader each indicated an exact middle-of-the-road style (5- concern for tasks, 5- concern for people) and one lands into the authoritarian style.
Fig. 2
A: Managerial grid plot of global assessment result of surveyed leaders. B: Managerial grid distribution of dimensional scores according to gender. C: Managerial grid distribution of dimensional scores according to education. D: Managerial grid distribution of dimensional scores according to involvementin networking activities
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Regarding gender distribution across leadership styles (Fig. 2B), women were highly represented in the country club–style quadrant, and the few leaders in the impoverished- and authoritarian-style quadrants were women. The middle-of-the-road leader was a man.
Concerning training paths (Fig. 2C), leaders in the team-style quadrant were equally likely to have had a graduate training program, a training-on-the-job program, or no training. The majority of the country club–style leaders indicated that they had not achieved specific training goals, including two who had completed graduate training programs and two who had completed training-on-the-job programs. The authoritarian-style leader attended a graduate training program, and the middle-of-the-road leader did not have any specific training path.
Regarding the distribution of leadership styles by networking activities (Fig. 2D), most of the team- and country club–style leaders indicated that they were involved in networking activities. The one authoritarian-style leader and the two impoverished-style leaders indicated that they did not have specific involvement in networking activities. The one middle-of-the-road leader did have specific involvement in networking activities.
The majority of the respondents had a relatively high concern for people (dimensional scores, 5–8), regardless of age. Only three respondents, all under 55 years old, had concern for people dimensional scores of less than 5. The majority of leaders had concern for tasks dimension scores under the mean score for team-style leaders (i.e., < 5).
Fig. 3
A: Conceren for people dimensional scores plotted by respondent age. B: Conceren for tasks dimensional scores plotted by respondent age. C: Managerial grid distribution of dimensional scores with respondents’ ages labelled
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The dimensional scores obtained are shown for each respondent in the managerial grid in Fig. 3C, with each respondent’s age labeled on their plotted data point. The two respondents in the impoverished-style quadrant were 38 and 49 years old, whereas the one respondent in the authoritarian-style quadrant was 27 years old. The respondents in the country club–style quadrant ranged in age from 39 to 70 years, and those in the team-style quadrant ranged from 29 to 76 years old.
All respondents had competency index levels in the range of 60–100% (Fig. 4A–C). All but three had concern for people dimension scores of between 5 and 8; three had concern for people dimension scores below 5 (Fig. 4A). Although the majority of the respondents also had concern for task dimension scores of between 5 and 8, 14 respondents had concern for tasks dimension scores of below 5 (Fig. 4B). Notably, a substantial portion of respondents with degrees of competency very near or at 100% had relatively high concern for tasks dimension scores (Fig. 4B).
Fig. 4
A: Concern for people dimensional scores plotted according to respondents’ degrees of competency. B: Concern for tasks dimensional scores plotted according to respondents’ degrees of competency. C: Managerial grid distribution of dimensional scores with respondents’ degrees of competency labelled
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The distribution of respondents according to the two grid dimensions (concern for tasks and concern for people) is shown in Fig. 3C, with each respondent’s competency index score labeled. The one authoritarian-style leader had 60% competency. The two impoverished-style leaders had 63% and 89% competency index scores. The competencies of the country club–style leaders ranged from 63 to 89%. Notably, all respondents with competencies in the range of 90–100% were team-style leaders.
Discussion
Based on the knowledge that PAA leaders strongly influence employees and volunteers (Morandi et al., 2021; Smart & Conant, 2011) our study analyzed leadership styles among such leaders using Mouton and Blake’s managerial grid model.
The majority of the 94 surveyed PAA leaders could be categorized as team-style leaders. Their survey responses indicated that they encouraged teamwork in their PAAs and made strong efforts to enhance the commitment of employees and volunteers and their sense of contribution to the PAA, as individuals and as part of a team. The team-style leaders indicated that they encouraged their workers to reach team goals as effectively as possible.
Limited information in the literature regards how leadership style relates to organizational outcomes (Northouse, 2007). Notably, Cho et al. (2018) found that team-style leaders were more effective at reaching outcome goals than those employing other styles. In a study of leaders in the banking sector, Garg (2013) found that a healthy balance between concern for tasks and concern for people, consistent with a team style of leadership, led to positive results.
We found that team-style leadership propensity was independent of gender or age, but it was commonly related to involvement in networking activities and degree of competency. Engagement in networking may help to create and maintain a team spirit while facilitating the development of boundary-spanning collaborations. The sampled leaders tended to have high degrees of competency overall, but very high degrees of competency (> 90%) were only found in the team-style quadrant of the grid.
Only 12 respondents in our study showed a country club style of leadership, characterized by a strong interest in interpersonal relationships but a low interest in tasks. These leaders tend to think that performance can be enhanced by ensuring the security and comfort of workers and by relying on rewards while avoiding punishments. Although their styles are personable, they may not achieve superior performance. The majority of country club–style leaders in our sample were women, and many lacked a training path. Their friendly style can facilitate networking activities outside the PAA as well as within it. The age span of the country club leaders was broad, with a mean of almost 58 years. Most had high degrees of competency, with only a few having competency scores below 70%. Country club leaders tend to use their knowledge to manage the relational sphere rather than applying it to planning tasks and objectives.
Only two leaders in our study, both relatively young women (38 and 49 years old), had an impoverished style, with a low concern for both people and tasks. The degrees of competency of the two impoverished-style leaders in our sample were 60% and 89%. Notably, both indicated that they were not involved in networking activities, and neither had completed a specified training path. Their lack of interest in managing relationships internally was extended to an additional absence of external relationships.
Only one of the respondents in our sample, a 27-year-old woman, landed in the authoritarian style of leadership quadrant. She indicated that she was not involved in networking activities. She had attended a graduate training program, but her level of competency was only 60%. Based on this profile, she would be recommended to improve her abilities as a leader.
Our respondent cohort included exactly one leader, a 49-year-old man, with a precisely middle-of-the-road style of leadership, balancing middling scores of 5 in both dimensions. He indicated that he did not have a specific training path and was not involved in networking activities, but his degree of competency was high at 89%. Unfortunately, with neither dimension having a particularly high score, such a leader is unlikely to satisfy either production goals or people’s needs.
Our results have managerial and policymaking implications. First, the findings reveal a generally positive situation for Italian PAAs regarding leadership profiles. Most of the assessed leaders showed the team style of leadership, which researchers have previously found to be the most successful (Cho et al., 2018; Garg, 2013). We are pursuing follow-up studies aimed at evaluating how and to what extent leadership styles may affect PAA performance.
Another implication of the study regards how training paths can help improve leadership styles. Currently, universities and other institutions agree that patient advocacy leaders may acquire managerial skills through training path attendance. Thanks to this assessment, we may provide specific indications about how to develop their leadership approach. For example, leaders who have fallen into the impoverished-style quadrant know that if they want to move to the team-style quadrant, they must more clearly understand the role of people within the organization they lead while simultaneously focusing better on how to reach organizational tasks. Additionally, human resource management content can be useful to increase leaders’ attention to people, and training courses dedicated to strategy and planning could be helpful to better focus and accomplish tasks.
Although team-style leadership emphasizes collaboration and inclusiveness, these attributes are not necessarily the most archetypical traits of team-style leaders. Regardless, the team leadership style encourages people to reach goals while working to strengthen interpersonal bonds within and beyond their organizations. It can be distinguished from other styles by its facilitation of democratic involvement. This approach encourages inter-individual interactions (Bai, 2001). Under democratic leadership, initiatives circulate widely to produce outcomes with the involvement of many stakeholders rather than only organization leaders. Team-style leaders share the democratic leadership characteristics of focusing attention simultaneously on both goals and people, including attending to people’s needs and their willingness to contribute to decision-making processes. Therefore, we believe that the team style of leadership is well-suited to the PAA context.
Limitations
This study provides a thus far unique assessment of PAA leaders’ styles but has several limitations. First, our sample consisted of just 94 respondents. However, considering the lack of an official list of PAAs in Italy, we can consider our sample acceptable at this stage. Second, because we only surveyed leaders of PAAs in Italy, how well our findings could be generalized to other countries is unknown. Future international collaborations may enable us to expand our research into other national contexts. The third limitation regards Mouton and Blake’s managerial grid methodology, which has been criticized as being more suitable as a counseling tool than a scientific one. However, this tool has been used previously to inform the development of training programs and in the development of academic studies.
Another limitation is that leadership traits were self-assessed, with the risk of social desirability bias (Podsakoff et al., 2003). However, as discussed by Posner and Kues (1988) and Turrentine (2001), the higher risk in leadership trait self-assessment, compared to peer observation, is obtaining underrating results. This was not the case for our sample, for which the majority of ratings fell into the high–high quadrant.
Finally, we identified team-style leadership as the style optimal to the needs of PAAs. However, we are aware of the possible differences that can emerge in changing our unit of analysis, such as considering for-profit organizations or service-providing NPOs. Due to their different contexts, constraints, aims, and needs, the optimal leadership style may be modified. Further investigations involving leaders from these different contexts may allow us to compare and discuss the emerging results.
Despite these limitations, this work provides different contributions. For organization studies, it provides new empirical evidence about the use of Mouton and Blake’s managerial grid, contributing to the existing debate. We also contribute to the leadership literature by offering a picture of the leadership traits possessed by patient advocacy leaders, scarcely explored until now.
Finally, we contribute to the debate on public organizations by offering a profile of patient advocacy leaders, who are critical to the motivation and support of employees and volunteers involved daily in representing patients’ needs and helping them in dealing with their pathologies. The picture that emerges is that the majority of the surveyed leaders were team-style leaders, thus providing a positive perspective for PAA development. Furthermore, we provide a starting point for operative interventions aimed at improving and sustaining organizations dedicated to the protection and representativeness of vulnerable patients and citizens.
Acknowledgements
Authors acknowledge Dr. Teresa Petrangolini (Director of Patient Advocacy Lab- Altems) and Dr. Eugenio Di Brino (Altems Advisory) for all the helpful suggestions.
Declarations
Conflict of Interest
No financial or other relationships that might lead to a conflict of interests are present.
Informed Consent
All participants were asked to sign a written informed consent, in accordance with applicable Italian data protection law. If participant did not sign the written consent, the session ended automatically; consequently, the approval of an ethics committee was not required. Italian legislation (D.lvo 24.6.2003, n.211, “attuazione della direttiva 2001/20/CE”) indicates that ethics approval is not required for anonymous interviews/questionnaires.
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