Overall, the results show no significant difference between the respondents’ occupational groups in their agreement with the questionnaire statements. This is contrary to previous research findings for Slovenian hospitals [12–15, 23–25], where statistically significant differences were established between occupational groups for comparable variables. Nevertheless, the results in this study have shown significant differences in the rate of agreement between leaders and employees, in agreement with previous research results.
Leaders were found to rate their active participation in employee development extremely highly, while the ratings of employees were significantly lower regarding the role of leaders in this field. Moreover, employee responses revealed that they were not familiar with the training and development programmes for the next four years, and not sufficiently included in them. The participating hospitals moderately encourage the culture of annual interviews, and moderately promote professional development, the acquisition of knowledge and skills, and their practical application. The needs for education and training required to facilitate work at a department are partially reflected in employees’ education needs. The results suggest that leaders are critical of the principal human resource management activity—personal training and development programmes—since they responded to this item with the lowest mean value. In general, human resource management in the participating hospitals is underdeveloped. Interestingly, other studies on human resource management “posit, although rarely directly test, that the hospital-level outcomes increase as a function of human resource management systems increasing employee participation behaviour .” It should be remembered, however, that the outcomes of clinical interventions in Slovenian health care are not yet systematically monitored, making it difficult to assess the impact of employee development on the quality of work.
Managers at the participating hospitals were reluctant to include employees in the decision-making and change-implementation processes. Moreover, the inclusion of employees in their development and the complex operations of an organization were low. According to Plsek , a health-care organization is a complex system that prioritizes interpersonal relations, structures, processes and models, the personalities of individuals, a high degree of flexibility, experimentation and searches for optimum solutions, the impact of non-linear change and the inclusion of the organization into the broader system. In their efforts to implement development and innovation strategies, health-care organizations often face the unconscious remains of Taylorism from the era of industrial management on the one hand, and constant disagreement between managers and doctors or between groups of health-care professionals on the other. This fact has been demonstrated by previous research results in Slovenian health care, especially for doctor–nurse relations [13, 15, 28]. Differences in opinion towards integrated patient care between doctors and nurses, and hierarchical doctor–nurse relationships have led to the formation of strong subcultures of doctors and nurses , as has been demonstrated by previous research [13–15, 21, 28] in Slovenia.
Surprisingly, the desire of employees to become actively involved in change implementation at their hospitals was low, even though leaders believe that employees have the opportunity for active involvement, a fact highlighting employee passivity. The passive role of employees in Slovenian hospitals was previously shown by Skela Savič et al. , establishing that hierarchy in Slovenian hospitals has been accepted and internalized by the employees and that employees do not desire changes in the organizational culture. Consequently, the readiness of employees to accept responsibility for change could be questioned. Kane-Urrabazo  has suggested that managers must put support systems and other mechanisms into place that encourage employees to empower themselves and to flourish, thus increasing their own effectiveness as well as that of the organization.
Leaders were predominately satisfied with their status and leadership roles in the hospital; employees’ satisfaction levels were much lower. Therefore, leaders should work towards the delegation of authority and recognition of personnel efforts; opportunities for promotion and job enrichment must be a part of hospitals’ human resources strategy [31, 32].
Areas where leaders could improve their performance include work-related problem solving and providing clear feedback on employees’ work. Participating employees were found to be insufficiently included in working teams, and their intellectual capital and experience were not fully tapped. In addition, employees’ satisfaction with their status and role in the hospital was low. Employees feel that their suggestions and wishes for professional development should be taken into account more; they also wish to be actively involved in the change-implementation process at the hospital. These results are congruous with those of Skela Savič and Pagon . Generally speaking, we can conclude that participating employees are only partially satisfied with their involvement, status and roles in the hospitals where they work. Indirectly, these results can be explained by previous research results on organizational culture in Slovenian hospitals, which was found to be directed predominately towards hierarchy, control and supervision [14, 15, 21]. Several international studies have demonstrated a positive correlation between organizational culture and employee satisfaction or the efficiency of an organization [33–37]. This is an important reason for managers and leaders to be aware of their contribution in establishing organizational culture. Managers and leaders in health care who create and manage organizational culture, build teamwork and lead the personal development of each employee must accept responsibility for the results of existing personal involvement and start to work on interprofessional collaboration within the organization and outside of it . Establishing good working teams within the micro-unit is a vital challenge for local leaders; managing the cultural diversity of professions is a central part of that challenge [5, 38].
Overall, leaders rated organizational motivation higher than did their employees, but the differences between the two groups for this set were not as pronounced as for the other sets. Organizational goals tend to be less clear to the employees than to the leaders, and the same holds true for the perceived synergy in an organization. Leaders and employees mostly agree that their intention is to perform the best possible work and slightly agree that optimism is present in the organization. A significant difference was established for satisfaction with working conditions, where employees were significantly less satisfied than leaders. A slight agreement was expressed with the idea that individuals working in the organization do not require external incentive to perform their work, and that the organization’s advantages are individual commitment, a sense of responsibility, loyalty and taking initiative. Lambrou et al.  have recognized that health-care professionals tend to be motivated more by intrinsic factors (e.g. meaningfulness of work, strong interpersonal relationships, respect), implying that this should be a target for effective employee motivation.
These results confirm the hypothesis that leaders should consider different aspects of job satisfaction for different employees, because job satisfaction predictors vary according to individuals. Krogstad et al.  found the most common predictors of job satisfaction to be good leadership, professional development, good communication and support from the immediate superior. Low motivation leads to the insufficient transfer of knowledge, the underutilization of available resources, and weak health-care system performance [40, 41]. Organizational motivation levels can be attributed directly to the actions of respondent leaders . Leaders should be inspiring and motivate employees to work better ; they should have a clear self-image based primarily on successful achievement of past goals; they should be decisive and committed to their work ; and they should use the transformational leadership style to significantly increase employee motivation [43, 45].
Multiple linear regression analyses revealed that employment position was the crucial predictor for the four examined variables, all of which can be significantly explained by leaders and their actions, a fact that underscores the importance of leadership in hospitals. Similar results were obtained by Krogstad et al. . For personal involvement, a positive correlation was established for the explanatory variables “area of employment” (health-care providers or health administration) and “level of education”, which means that a higher level of education increased the level of agreement with the statements on leader–employee relationship. By contrast, level of education correlated negatively with motivation: respondents with a lower level of education rated motivation lower.
The predictive power of leadership was demonstrated for all variables. A previous study by Skela Savič et al.  demonstrated that teamwork was the key predictor of personal involvement in change-implementation processes, making leaders’ education, training and career development crucial . In fact, Sellgren et al.  established that employees desire a leader with a clearer leadership style than the leader personally deems appropriate, that employees desire leaders to adopt a more active leadership role, and to be clearer in work-related instructions. These factors should be considered when selecting health-care leaders, and when planning their continuous professional development.
In interpreting the results of this research, it is important to note that leaders in Slovenian health care are primarily selected for their professional merit and often have little experience in leadership, which means that leadership styles are frequently outdated, as has been demonstrated by previous research [16, 17, 24]. When implementing improvements in Slovenian health-care system leadership, it should not be forgotten that researchers [47, 48] have pointed to a close correlation between the quality of treatment and leadership in health care. Employees will not support change-implementation processes in their working environment unless they play an active role in these processes. This emphasizes the role of leaders, who should include individuals in change-implementation processes, because that is an important predictor for successful functioning of a health-care system. These results have shown low levels of employee participation in change-implementation processes, resulting in moderate employee satisfaction with status and role at the hospital.
These results clearly demonstrate that Slovenian hospitals lack a comprehensive career-development system—the percentage of leaders who have participated in postgraduate education programmes is low, and the most frequently attended training and education programmes were those from their own professional fields. A higher participation of health-care leaders in quality-implementation programmes over the last seven years is the result of a systematic programme launched by the Ministry of Health for comprehensive quality implementation in Slovenian hospitals, under which the Ministry and other health-care associations organized training and education programmes. The results for participation of leaders at other training and education programmes relevant for middle management reveal a participation rate of less than 40%, indicating a non-systematic nature for achieving knowledge goals in those areas relevant for quality middle-management work (vision, strategy, employee leadership, change implementation, organization of work processes, comprehensive quality management, health-care funding, etc.) Education is an important factor for organizational development. Research conducted by Skela Savič et al.  in nine Slovenian hospitals has shown that leadership performance in participating hospitals correlated with the type and extent of previous training and education programmes for leaders and employees. In hospitals where only leaders participated in training and education programmes, employees tended to rate their leadership with lower mean scores than they did in other hospitals, emphasizing the fact that employees, too, require the knowledge and skills to understand their leaders’ instructions, to participate in teamwork, and to understand the change-implementation process. These results showed that leaders received significantly more training and education than employees, and that health-administration leaders received significantly more education and training in health-care system management, leadership, employee development and health-care funding than did health-care leaders. Education of employees in Slovenian hospitals is still not perceived as a necessary investment for improving work processes, and the education of leading health-care workers in management skills is still not high enough.
This study’s results demonstrate a clear gap between leaders and employees. When interpreting the results, we need to keep in mind that almost all Slovenian hospitals are state owned and that the state is, in fact, responsible for their administration by appointing directors. Moreover, state representatives are members of supervisory boards of each state-owned hospital, which undoubtedly plays a major role in the management of hospitals and has an important effect on leader–employee relationships. Another important issue is that health-care employees are part of the public sector, whose salaries include payments from the Health Insurance Institute of Slovenia and voluntary health insurance companies for services provided. The “public-servant” status results in an extremely rigid payment system with limited room for manoeuvre concerning personnel motivation. Additionally, the “public-servant” status allows limited opportunities for changes in the hierarchical structure of a hospital. In terms of health-care policy, it is extremely important that the state, as the owner of hospitals, take responsibility for the existing situation, described previously in other Slovenian studies [12–17, 21, 23–25, 28].
As with any survey, the issue of representative sampling presents itself. The questionnaire was distributed to all leaders of participating hospitals, who were selected with a purposive sample. The employee sample was cross-sectional, purposive, and used quota sampling. Possibly more concerning is the response rate, and, speculatively, the opinions of those who chose not to participate in the research [49–51]. We believe, however, that the response rate data have been appropriately presented . Although response rates in participating hospitals differed widely, the purpose of this research was not interhospital comparison but situation assessment for all hospitals. Future in-depth research is required on the impact of middle management for the performance and efficiency of health-care organizations and the health-care system as a whole. The data were collected at the start of the global recession in Slovenia. We suggest that new studies be conducted in the future to measure the impact of austerity measures in 2012 and 2013 on the performance and efficiency of middle management on health-care organizations in Slovenia.