Unravelling the role of leadership in motivation of health workers in a Moroccan public hospital: a realist evaluation

OBJECTIVES: This study aimed at opening the black box of the relationship between leadership and motivation of health workers by focusing on a high-performance hospital in Morocco. DESIGN: We adopted the realist evaluation approach and used the case study design to test the initial programme theory we formulated on the basis of a scoping review on complex leadership. We used the Intervention-Context-Actors-Mechanism-Outcome Configuration as a heuristic tool to identify plausible causal configurations. SETTINGS: Since 2000, the Ministry of Health in Morocco initiated many reforms in the frame of the governmental deconcentration process called ‘advanced regionalisation’. The implementation of these reforms is hampered by inadequate human resource management capacities of local health system managers. Yet, the National ‘Concours Qualité’, a national quality assurance programme implemented since 2007, demonstrated that there are many islands of excellence. We explore how leadership may play a role in explaining these islands of excellence. PARTICIPANTS: We carried out a document review, 18 individual interviews and 3 group discussions (with doctors, administrators and nurses), and non-participant observations during a 2-week field visit in January–February 2018. RESULTS: We confirmed that effective leaders adopt an appropriate mix of transactional, transformational and distributed leadership styles that fits the mission, goals, organisational culture and nature of tasks of the organisation and the individual characteristics of the personnel when organisational culture is conducive. Leadership effectiveness is conditioned by the degree of responsiveness to the basic psychological needs of autonomy, competence and relatedness, perceived organisational support and perceived supervisor support. Transactional and overcontrolling leadership behaviour decreased the satisfaction of the need for autonomy and mutual respect. By distributing leadership responsibilities, complex leaders create an enabling environment for collective efficacy and creative problem solving. CONCLUSIONS: We found indications that in the Moroccan context, well-performing hospitals could be characterised by a good fit between leadership styles, organisational characteristics and individual staff attributes.