Health Related Quality Management Values and Key Principles of Communicative Leadership - Are They the Same?

Purpose: The purpose of this paper is to compare health related values within Quality Management with Key Principles of Communicative Leadership in order to see if Communicative leaders also promote healthy co-workers. Methodology/Approach: A literature review was conducted within the area of Communicative Leadership and within the values of health related Quality Management. The principles within Communicative leadership were compared with the underlying dimensions within the health related values ‘Leadership Commitment’ and Participation of everybody’. Findings: The analysis shows that the underlying dimensions within both of the health related Quality Management values ‘Participation of everybody’ and ‘Leadership commitment’ were related to some of the Key Principles of Communicative Leadership. Practical implications – The results can help Communicative Leaders to emphasize the Key Principles that also promote healthy co-workers. The results can also help leaders that already have healthy co-workers to increase leaders’ communication competence within organizations.


INTRODUCTION
Bringing in a more humane and effective practice into Quality Management provides beneficial effects on co-worker health (Lagrosen and Lagrosen, 2004).According to Axelsson (2000) the quality movement and the ergonomics movement have many fundamental similarities, for example the basic values these movements are built on.He maintains that the keywords shared between them are; "human needs, expectations, requirements, comfort, health, happiness, and satisfaction".This shows how both areas focus on the well-being of people, customers as well as co-workers, and how both areas assume that improvement for the individual can be carried over into advantages for the organization (ibid).Some studies have shown relationships between a company-wide implementation of quality and improved co-worker satisfaction, low co-worker turnover, in other words co-worker health, in addition to improved external customer satisfaction and financial results (Dahlgaard and Park Dahlgaard, 2003a;Dahlgaard and Park Dahlgaard, 2003b).The link between internal customer satisfaction, external customer satisfaction, and productivity has also been confirmed (Gronholdt and Martensen, 2001).
As several researchers emphasize, Quality Management has a strong participative component where every co-worker in the organization should be involved in the quality work (Sila and Ebrahimpour, 2002;Bergman and Klefsjö, 2010).This is well in line with research in the health field, where the demand-control-support model is a major finding which discusses the importance of the co-workers being able to control their own work situation (Karasek and Theorell, 1990).Co-worker participation has also shown to help improve both organizational outcomes (Eriksson et al., 2003;Hendricks and Singhal, 1996) and health outcomes (Karasek and Theorell, 1990).The co-workers' self-reported health, has shown to be correlated to the Quality Management values 'Leadership Commitment' and 'Participation of everybody' (Lagrosen, 2004).On the other hand, committed leadership can put more demands on co-workers.If the organization wants to do the best for its external customers, it must put demands on its co-workers which can lead to ill-health (Lagrosen, 2006).Wreder (2008) also found in her investigation that the value 'management commitment' was a supported value and conditional for the values 'co-worker involvement', focus on customer' and 'continuous development' when working with co-worker health.
Good communication skills are consistently listed as the most important quality necessary for organizational success by CEOs and other senior executives in all industries and countries (Barrett, 2006).The communication behaviour of leaders can provide co-workers with a sense of purpose, direction and identity (Miller and Monge, 1986;Fairhurst, 2001).Communicative leadership is a concept in use in Swedish business and private organizations, which relates to research findings on leadership communication that leads to higher levels of individual performance as a result of role clarity, co-worker commitment and engagement, (DeRue et al., 2011;Kozlowski and Bell, 2003;Morgenson et al., 2010).According to Berson and Avolio, (2004) face to face communication is important for co-worker awareness of strategic goals, which is related to leaders' openness, listening and careful articulation of strategic messages.Since Communicative Leadership seems to enhance the well-being of co-workers, the following question is interesting to investigate: Does Communicative Leadership influence co-worker health?
The purpose of this paper is to compare health related values within Quality Management with Key Principles of Communicative Leadership in order to see if communicative leaders also promote healthy co-workers.

HEALTH RELATED QUALITY MANAGEMENT
Interest in the connection between Quality Management and health seems to have increased, and some authors in the quality area mention health or co-worker health in particular.The focus within Quality Management has been on external customer satisfaction and Continuous Improvements.The co-workers are however seen as internal customers by most quality researchers, thus their satisfaction and well-being have to be considered in quality work.Designing and improving a system in accordance with ergonomic principles can be seen as a quality issue in which the co-workers' requests for ergonomics are given a high priority (Axelsson, 2000).Deficiencies in information handling, management, work tasks, workplace design and motivation are important causes of poor quality (ibid) .The relations between quality management and co-worker health have also been discussed by Dolbier et al. (2001).They have documented the connection between psychologically unsatisfactory working environments and a high frequency of sickness (ibid).Developing a good working environment and work organization is related to increased workplace health and performance (Vinberg, 2006).Job satisfaction is affected positively by clear goals, goals that are realistic, and goals that are possible to evaluate (Arnetz, 2002).In other words, when the co-workers are well aware of the organization's goals and think that they can affect them they are more satisfied with their work.It is also important that people take pride in their organization, more pride gives higher job pleasure (ibid).Job pleasure is a comprehensive measure that shows the level of balance between co-workers and organizations (ibid).According to Lindberg (2006), there would be considerable gains for individuals, workplaces, and society if the number of co-workers suffering from physical and mental disorders could be reduced.
Studying successful organizations, Wreder (2008) found that leadership in the form of 'management commitment' was a supporting value and a prerequisite for Quality Management practices such as employee involvement, delegation and coaching when working with co-worker health.In addition, Bäckström, Larsson and Wiklund (2009) found that organizations that have achieved good co-worker health with low sickness absence through their conscious and well-structured work were also working according to Quality Management.There is also research which describes how Quality Management can be practiced to support health among co-workers and also what is of most importance within Quality Management, to influence co-workers' health (Bäckström, 2009;Lagrosen et al., 2010).The results show that the value 'Leadership Commitment' and the value 'Participation of Everybody' are important to support health among co-workers when Quality Management is practiced (Bäckström, 2009;Lagrosen et al., 2012).

COMMUNICATIVE LEADERSHIP
The concept of Communicative Leadership emerged in Sweden in the late 1990s in response to the more complex and changing business environment (Högström et al., 1999).Both public and private organisations have embraced the concept with reference to leaders who 'engage others in communication' during the past decade.Eriksen, (1997, p. 164), discussing Communicative Leadership in public institutions comments that: "A Communicative Leadership generally is characterized by greater openness and dialogue with the employees".Studies of what leaders and managers do at work illustrate that they spend 79 to 90 per cent of their time communicating every day (Mintzberg, 1973;Tengblad, 2006), however, the concept signifies that leaders who are "communicative" are not just communicating, which all organizational leaders and members do continuously, but that they are "good communicators" -thus, there is a competence aspect of the term, which implies that this communication competence can be developed.According to DeRue et al. (2011) and Tengblad (2006) communicative leaders have transformational characteristics that lead them to show respect for individual co-workers and engage them to act to strengthen the work group.Four central communicative behaviours of leaders: structuring, facilitating, relating, and representing; eight principles of communicative leadership, and a tentative definition of the concept have recently been presented, (Johansson, et al., 2014).A communicative leader is defined as someone who engages employees in dialogue, actively shares and seeks feedback, practices participative decision making, and is perceived as open and involved.
The four central leader communication behaviours can be related to outcomes on different levels.
At the manager-employee level, effective leader communication is associated with employees having role clarity, commitment to the organisation, and acting in an engaged manner toward their work assignments (DeRue et al., 2011;Jablin, 1979).At the unit level, effective leader communication is associated with work unit cohesion, the unit's belief in their abilities or confidence, and effective internal group operating processes.
As a result of role clarity, employee commitment, and engagement; communicative leadership leads to higher levels of individual performance (Derue et al., 2011;Kozlowski and Bell, 2003;Morgeson et al., 2010).As a result of unit cohesion, confidence, and effective group processes; communicative leadership leads to higher levels of performance at the unit level (DeRue et al., 2011;Morgeson et al., 2010).In a review of "effective" leadership behaviour, Yukl (2012) arrives at categories of central leader behaviours that display somewhat similar results, although in his review, the focus more generally downplays the importance of communication in constituting leadership interactions and processes.
The relevance of certain communicative leader behaviours is contingent upon the work setting -upon the demands for coordination within the unit and with other units, established patterns for production or task accomplishment, and unit or organizational culture to name just a few factors (Fairhurst, 2001;Jablin, 1979;Redding, 1972).Thus, the communicative behaviours can be used for analyses and evaluations of leaders' communication, which necessarily also integrates situational, cultural, and other contextual aspects.

UNDERLYING DIMENSIONS OF HEALTH RELATED QUALITY MANAGEMENT
The underlying dimension of the health related Quality Management values 'Leadership Commitment' and 'Participation of Everybody' regarding the relation to co-worker health was examined by Lagrosen and Bäckström (2005) and Lagrosen et al. (2010).In these studies, it was pointed out that integrity, presence and communication, empathy and continuity are underlying dimensions of the health related Quality Management value 'Leadership Commitment'.Development, being informed and influence were found to be the underlying dimensions of the health related Quality Management value 'Participation of Everybody'.These dimensions were also found to be established methodologies, leadership behaviours, values and practices in successful organizations that have achieved good workplace health environment, such as; excellence in leadership, good work environment, co-worker health and co-workership, along with improved profitability, (Bäckström, 2009).
'Integrity', deals with the manager's own characteristics such as independence, trustworthiness and fairness, (Lagrosen et al., 2010).'Presence and Communication' implies that the managers practice visible leadership and communicate clearly and distinctly.'Empathy' implies that the managers must show awareness and concern and must be alert to the needs of the co-workers and understand their situation.'Continuity' means that the manager should stay in the same position for a long time.A frequent change of manager is considered negative since building up trust can take quite a while to establish and a high turnover among the employees makes cooperation more difficult (ibid).In the extracted underlying dimensions 'Development', both skills and personal development are included.'Influence', is about co-workers' possibility to influence their own work situation.The third and last dimension is 'Being informed' and considers communication in general and especially getting enough information (ibid).

PRINCIPLES OF COMMUNICATIVE LEADERSHIP
Eight key principles of Communicative Leadership emerge from research, which can guide the research on development of leaders' communication competence within organisations, (Johansson, et al., 2014).These principles can also aid in assessments of leaders when matched with requirements of work design and context (ibid).
1) Communicative leaders coach and enable employees to be self-managing.
In enacting this first principle, leaders seek to delegate authority over decisions.Some teams or units are functionally self-managing while others increase their responsibilities.
Communicative leaders a) adopt a coaching persona, b) provide employees with compelling rationales for their job design as well as individuals and unit objectives, and c) seek their input when solving problems and making decisions.
2) Communicative leaders provide structures that facilitate the work.
Communicative leaders a) create workable structures and processes that enable employees to accomplish their work, b) are responsive to feedback on unit structures and operations, and demonstrate a willingness to change.
Communicative leaders convey priorities, ensure understanding of shortterm objectives and long-term aims, and follow up to see if assistance is needed.They set expectations, for example for quality, productivity, and professionalism.Leaders collaborate with employees to set high performance goals as well as determine how work will be evaluated.
4) Communicative leaders are approachable, respectful, and express concern for employees.
Communicative leaders are willing to listen, receive questions or complaints, and share appropriate information in a truthful and adequate manner.At all times, leaders treat employees with respect.They consider the needs and aspirations of individuals and looks after the unit's welfare.
5) Communicative leaders actively engage in problem solving, follow up on feedback, and advocate for the unit.Problems concerning personnel, work and strategy are rarely resolved quickly.Yet, communicative leaders pass on information and take on decision responsibilities.Leaders actively seek and share information with employees and same-and higher level managers to address issues.
Laissez-faire or passive managing is a danger for the unit and organization.There are three warning signs: (a) failure to be in a problemsolving mode; (b) not being responsive to employees' and others' complaints or observations related to productivity, personnel, or customer concerns; and (c) not keeping employees appraised of actions-in-progress.
6) Communicative leaders convey direction and assist others in achieving their goals.
Communicative leaders understand and convey to employees how their unit contributes to the organisation's overall objectives.They often engage their employees in daily conversation, relating unit actions to the larger scheme.
Visionary and charismatic leaders may be inspiring, but research does not yet support these qualities as part of communicative leadership.
7) Communicative leaders actively engage in framing of messages and events.
Communicative leaders are aware that their framing of organisational objectives, processes and events are important to others and influence their sensemaking, communication behaviours and actions.They consciously plan and seek feedback on their framing.
8) Communicative leaders enable and support sensemaking.
Communicative leaders know that communication is an interactive process.They recognise that other organisational actors continuously make sense of information, events and behaviour of leaders and employees -both verbal and non-verbal.In keeping with this knowledge, they engage in dialogue, use stories and narratives, and support sensemaking in formal and informal conversations, (Johansson, et al., 2013).

METHODOLOGY
The research findings within the area of health related Quality Management and Communicative Leadership were studied and compared.The principles within communicative leadership were compared with the underlying dimensions within the health related values 'Leadership Commitment' and 'Participation of everybody'.This was conducted in a workshop with the researchers, where all the key principles and their descriptions were written on 'post-its' along with the underlying dimensions to the health related values 'Leadership commitment' and 'Participation of everybody' This was first done by each researcher by themselves.The 'post-its' were then read through and a discussion of identifying similarities was done.When consensus was found between the researchers the similarities were coded on commonly agreed upon 'post-its' for each key principle, underlying dimension and their descriptions.The analysis was then documented in tables.The analysis was then extracted on the level of dimensions and key principles.

HEALTH RELATED QUALITY MANAGEMENT DIMENSIONS VERSUS PRINCIPLES OF COMMUNICATIVE LEADERSHIP
The analysis of the underlying dimensions of the health related Quality Management value leadership commitment versus the key principles of communicative leadership is shown in Table 1.
Most of the underlying dimensions of the health related value 'Leadership commitment' are represented with key principles of the communicative leadership.The underlying dimension 'continuity' is the only one that did not have similarities to any key principle of communicative leadership.
All the underlying dimensions of the health related value 'Participation of everybody' are present in the key principles of communicative leadership (Table 2).The analysis also shows that six of eight key principles of leadership commitment are corresponding to the underlying dimensions that have been shown to create health among the co-workers.

CONCLUSIONS
The analysis on the level of dimensions and key principles shows that the key principles of Communicative Leadership are represented in all underlying dimensions of the health related Quality Management values 'Leadership commitment' and 'Participation of everybody' except for one: 'continuity', see Table 3. Hence it can be concluded that working according to the key principles of communicative leadership promotes co-worker health.

Influence
Being informed

Development
The underlying dimension 'Continuity' means that the manager should stay in the same position for a long time and the analysis shows that there is no relation between this dimension and any key principle of Communicative Leadership.
Table 3 also shows that key principle 6 and 7 not are related to any underlying dimension.Key principle 7 is about Communicative leaders actively engaging in problem solving, following up on feedback, and advocating for the unit.Key principle 6 is about Communicative leaders conveying direction and assisting others in achieving their goals.Thus, it can be concluded that these two communicative leadership key principles are not so important regarding coworker health.

DISCUSSION
The relationship between dimensions of health related Quality Management and Communicative Leadership stress the importance of leaders' communication for the well-being and health of co-workers.This is an important finding which can guide future research on communication related health effects in organizations.A practical implication of the findings is that Quality Management, HR and Communication departments need to consider which aspects of leaders' competence they emphasize in leadership programs.The findings will also be extremely useful when it comes to policies for recruiting or promoting leaders in an organization.We see a clear need to further discuss the communicative competence of leaders as an important factor which promotes healthy coworkers, and effective organizations.
It would also be interesting to further investigate the connection between health related Quality Management and Communicative Leadership for instance with empirical studies.Are leaders in successful organizations working according to both the health related Quality Management and Key Principles that are described in this paper?That would be an interesting question to dig deeper into.Maybe the health related Quality Management values could be extended with those key principles of Communicative Leadership that they did not have any relation with to arrive at a more completely Quality Management values.If so, would that influence the outcomes as engagement and performance?On the other hand the Key principles of Communicative Leadership could be extended with the 'missing' underlying dimension 'Continuity'.Would that provide a Communicative Leadership that increases health among co-workers since the other underlying dimensions of health related Quality Management was related to the key principles?A resulting question, will that provide external customer satisfaction and productivity?

Table 1 -
The analysis of the underlying dimension of the health related Quality Management value 'Leadership commitment' versus the description of the key principles of Communicative Leadership.

Table 2 -
The result of the analysis of the underlying dimension of the health related Quality Management value 'Participation of everybody' versus the description of the key principles of Communicative Leadership.

Table 3 -
Comparison of health related Quality Management dimensions versus key principles of Communicative Leadership.