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Role Centralization Among Medical Directors Essays

TITLE
Chapter 2: Literature Review
I.      Role Centralization Among Medical Directors
Medical directors are influential figure in every health care setting. The influences of this core position extend to wide-scale and multi-level practices of the hospital care management. In fact, the 21st century has acquired a different stereotype in terms of college health medical director’s leadership influences in the health care setting. According to Talbott and Hales (2001), most health care institutions have expanded the roles of medical directors, especially in terms of hospital policy legislation, external and internal transactions, hospital main and subsidiaries supervision, and most of all, personnel evaluation (p.85). With the expansion of their roles, both administrative and managerial positions of the ideal hospital setting have revolved around the core position of medical director. Under such circumstances, the position of medical directors has been eyed for leadership competencies and maximization of role functionalities. As supported by Nash (1994), role competencies of medical directors are essential determinants of leadership influences among other sub-positions and multi-faceted administrative roles in the hospital setting.  Ideally, medical directors are considered core administration in the health care institution (p.78).
According to the 1987 study of Brown and McCool wherein perceptions of health care leaders towards the position of medical directors are assessed, they have proposed that leadership qualities and competencies of hospital heads greatly influence the various hospital functionalities, such as rendition of care, hospital staffs’ improvement, organizational productivity, etc. According to Reid and Silver (2002), the position of medical directors primarily emphasizes the collaborative philosophies of care and hospital management since the essentials of the role is to actually direct overall hospital systems (p.132). The centralization of medical director’s role justifies the need for appropriate competencies and leadership qualities considering the positions influential part in the collaboration with the overall hospital care team. However, according to Shortell and Kaluzny (2000), leadership and management is essentially not the key role of medical directors; rather, the clinical position is oriented mainly in facilitating centralization of every position present in the health care setting (p.110). Collaborative role of the medical director as the essence of their function, and acts as the central role overseer of other role functions essential to care delivery, hospital management and clinical functioning; hence, by role and function principles, medical director can actually influence the subsidiary roles of the health care setting.
               i.   Roles of Medical Directors
The roles of the medical directors identifies the scope of their function and duties in order to best explain their influence in the overall hospital functioning. According to Pompei and Murphy (2006), roles of the medical directors can be further categorized in three functionalities: (1) as an administrator, (2) as the clinical head, and (3) as the general overseer. Each role function is handled by higher level of competencies and strict leadership qualities (see Sect. III) in order to direct their influence towards the overall hospital function. The role of medical director lies in its collaborative and discursive nature oriented in health setting organization, maintenance and development.
According to the study made by Goldsmith (1994) wherein group of medical directors developed a comprehensive enumeration of the role’s functions and tasks, the first three important perceived functions of medical directors are administrative functions (e.g. coordination of policies and procedures), organizing and ensuring adequate medical coverage, and overseeing care delivery (p.85). Roles of medical directors influence the hospital management, the physicians and nursing staffs present or related to the work and professional environment. Leadership competencies among medical directors are measured in the role functions among these medical directors.
          ii.       Defining Traits and Competencies of Medical Directors
According to Brown (1994), leadership traits of medical directors are directly related to the performances and appropriate functioning of their role (p.145). As supported by Goldsmith (1994), the increasing regulatory requirements and rapidly growing patient demographics, medical directors are beginning be confronted by greater responsibility of organizing medical care and coordination of medical services (p.104). According to Barnett and Mayer (1992), virtually every organization redefines the position and roles of medical director as an important key factor in meeting the standards of care being delivered to the patients (p.58). Quality implementations of care, maintenance of credentials, and adherence to regulatory implementations are some of the most defining character of medical director’s competencies (Barnett and Mayer 1992; Goldsmith 1994).
However, Brown (1994) and Ottensmeyer and Keys (1994) emphasized communication skills as the primary trait requisite of an ideal college health medical director. Undoubtedly, the extension of medical directors’ participation and function in the hospital settings greatly expand their influence towards hospital key personnel and health care delivery system, especially the nursing department.
II.    Leadership Influences: Medical Directors and College Nursing Staffs
From the analysis of medical director’s role in the hospital and health care delivery system, another consideration of their importance and function is their influence among college nursing department. Defining the roles of a college health medical director as an interlinking position in the hospital justifies the influence it renders in the overall care delivery system. However, according to the survey study of Ottensmeyer and Keys (1994), medical director’s influence on nursing staffs is only considered as the 11th most important leadership traits (n=30; mean=5.50). Although, various studies (Brown, 1994; Goldsmith, 1994; Reid and Silver, 2002) indicate that leadership qualities of medical directors, such as communication skills, health care administrative function, etc, directly influence the care provision of nursing staffs towards their patients.
According to White and Truax (2007), the influence of medical directors’ administrative function in the delivery of care has always been channeled through the nursing staffs rendering the care (p.10). Medical director is responsible in ensuring the standards of medical care and overseeing of most care diversion, including nursing care management and quality improvement programs.
As supported by White and Truax (2007) and Talbott and Hales (2001), college health medical directors work closely with the nursing service department to ensure the delivery quality care standards (Turner and Hurley 2002 p.154). Hence, leadership traits and competencies are essential determinants in medical director’s core function.
             i.        College Health Services Nursing Staff
     College health nursing services is considered as one of the nursing sub-departments that primarily focuses on the health care needs and concerns of persons between the ages of 17 and 24 years (Turner and Hurley 2002 p.154). According to Hood, Leddy and Pepper (2005), college nursing services vary in size and scope and emphasize self-care and wellness among college patients (p.398). According to Turner and Hurley (2002), college health medical directors among college health settings are increasing its collaborative function and involvement with the collage nursing service staffs in order to accomplish the mission of college health nursing (p.154). College health medical directors and college nursing staffs are encourage to work collaboratively in order to facilitate health care roles prescribed by ANA (American Nursing Association) – advocacy, consultation, direct care, collaboration, research, education, management and leadership (Turner and Hurley 2002 p.154).
     Skills and credentials of both parties are critically examined and evaluated in order to justify competencies and leadership capacities. According to Turner and Hurley (2002) and Murray (2002), college health nurse manager and medical director must work collaboratively to ensure adequate staffing, budgeting and care delivery. In order for the nursing health care system to work effectively, various significant factors of college nursing services largely depend on the medical director’s role functionalities: (1) budgeting and program/supply financing, (2) policy provisions, (3) standards of care supervision, and (4) implementation of quality assurance and employee screening. Thus, the direct relationship between college health medical director and nursing staffs’ needs and service requisites in terms of health care delivery largely depend on the appropriate performance of duties and responsibilities on the part of the medical director (Turner and Hurley 2002 p.155).
           ii.        Perceived Influence of Medical Directors
     Leadership influences of college health medical directors on nursing staffs’ job satisfaction, retention, productivity and organizational structure are further explored from the nurse’s point of view. In a survey study conducted by the Joint Commission Resources (JCR 2004), nurses’ perceptions towards the leadership capacity of their medical directors have been evaluated. By examining 27 respondents (specifically, nursing heads of different departments) from four different hospital institutions in the United States, the top three perceived influences of medical directors to their nursing staffs are (1) the legislation of policies and structure of health care delivery (n=27; mean=3.60), (2) the boosting of nurses’ morale in delivery of care (n=27; mean=3.30), and (3) collaboration of nurse-physician work relationship in providing primary care modalities (n=27; mean=2.90).
     Meanwhile, the study of Rosenstein (2002) analyzes the impact of work-relationship between nurses and their medical directors as well as other physicians, especially in terms of nurse satisfaction and retention. The study surveys n=1200 respondents (nurses, physicians and medical director) in terms of the perceived influence of daily interactions between nurses and their medical head. According to the results of the study, nurses are more concerned to the work-force environment being fostered by this working atmosphere. In fact, most respondents (n=1200; c1=1044- 87%) acknowledges the direct link between the disruptive incapacity of their medical heads and nurses’ satisfaction/retention.
     The findings of the study suggest the establishing of quality nurse-physician relationship (medical directors and hospital executives) in order to improve nurse recruitment, productivity and retention. As supported by the study of Lane (1998), medical director’s competencies and management skills greatly affect the issuance of health care delivery of the nurses in ever health care institution. With the help of ACPM (American College of Preventive Medicine), findings suggest the direct link between core competencies of medical directors and the performance of the nursing staffs.
III.  Leadership Behaviors and Qualities Among Health Care Practitioners
Leadership behaviors among higher health care role, such as the medical directors, are important requisites that influence the direction of health care management in order to establish and achieve the institutional goals. According to Resnick (2005), the formal leadership within any setting includes key individuals who are involved with identifying and implementation of ways to meet the organization’s goals and objectives (p.5). As supported by Swansburg (1995), appropriate leadership traits and qualities among hospital executives (medical or hospital directors) empower and motivate their constituents, such as nursing staffs and personnel, in order to foster autonomy, decision-making, and participatory management (p.320).
     According to the survey study conducted by Brown (1994), the perceived competencies and leadership traits that medical director should possess include (1) persuasiveness, (2) people-oriented attitude, (3) confident, (4) proactive, (5) team player and (6) quality-oriented. Leadership behaviors comprise of leadership traits and competencies. Key formal leadership positions in health care delivery system need to possess virtue of skill, attitude, or longevity, tend to influence the attitudes and performance of others within the facility (Resnick, 2005 p.5).
i.       Defining Leadership Competencies
According to JCR (2007), leadership competencies greatly vary in every institution’s culture and social perception on positional qualifications and needs (p.16). There is no exact definition that explains the concept of leadership competencies. Evidently, the studies of Lane (1998), Brown (1994), Ottensmeyer and Keys (1994) and Rosenstein (2002) reveal different views of leadership competencies. Although, there are significant points of relationship that link the definition of leadership competencies within the studies mentioned.
Roussell and Swansburg (2006) summarize the idea of leadership competencies by categorizing it into (1) professional core competencies, (2) emotional core competencies and (3) positional core competencies (p.30-32). Professional core competencies deal with the (1) capacity of the individual to initiate and maintain organizational structure, (2) provide administrative role and function, and (3) legislate and implement standards of quality care delivery. Meanwhile, emotional core competencies deal with the intrinsic leadership characters present in the individual, which specifically include (1) self-awareness, (2) self-assessment, (3) self-confidence, and (3) self-control. Lastly, positional core competencies include mostly the required qualifications of a given role/position, which include (1) intellectual and physical efficiency, (2) sufficient and related profession experiences and credentials, and (3) capacity to handle people (Roussell and Swansburg 2006 p.30-32). Leadership competencies are the defining characters of every executive, such as the medical director, that influence the direction of any organization (Pompei and Murphy 2006 p.121).
ii.     Medical Director’s Leadership Traits
Meanwhile, according to Brown (1994), leadership competencies are defined greatly by the intrinsic leadership traits present in an individual. Furthermore, Resnick (2005) and Swansburg (1995) consider these traits as essential defining characteristics that influence the outcome performance of subordinates, such as nursing staffs, directed by the executive, such as the medical director. In the study of Ottensmeyer and Keys (1994), they have conducted surveys among senior care leaders to explore the desirable traits of an effective medical director. Out of 30 interviewed medical leaders from different specializations, the results reveal the medical director’s “concern to the quality of care” (n=30; mean=5.96) as the most important trait, while “prioritized paper work” (n=30; mean=2.20) is the least important trait considered. The interviewed leaders have identified communication and interpersonal skills (n=30; mean=5.80) as the most important qualities needed for the role of medical director.
According to Nash (1994), clinical credibility (n=30; mean=5.70), ego strength (n=30; mean=5.63), concern about quality (n=30; mean=5.55), being a team player (n=30; mean=5.53), and having a clear philosophy of managed care (n=30; mean=5.43) are other characteristics frequently identified as important for a medical director (p.78). Medical directors are empowered through the extension of their authority over clinical care in order to possess wider administrative and management duties and investment of non-clinical time in collaboration with other members of clinical management team.
iii.   College Nursing Staff Performance
From the earlier sections, most studies (Brown, 1994; Nash, 1994; Ottensmeyer and Keys, 1994) and authors (Resnick, 2005; Swansburg, 1995) have concluded that leadership qualities and competencies of the medical director can influence the productivity and work performances of nursing staffs. However, from college nursing staff point of view, there are indeed diversified components being affected the leadership of medical directors. According to Ottensmeyer and Keys (1994), performance components affected by the leadership of the medical director vary accordingly. Meanwhile, JCR (2007) adds that the effects of medical director’s leadership competencies to nursing staffs’ performance vary according to the workplace setup and the cultural backgrounds of the institutional atmosphere.
From the nursing staffs’ point of view (Brown, 1994; Ottensmeyer and Keys, 1994; Nash, 1994; Lane, 1998), leadership in higher position (e.g. medical director) can affect their overall performance through the following ranked components: (1) communication and interaction relationships between nurse-medical directors, (2) philosophy mandated by the organization, (3) role modeling of the medical directors, (4) professional backgrounds and qualifications, (5) policy adherence and implementation by the leaders. According to Brown (1994), nurse respondents have rated communication and interpersonal skills as the number one influence to the nurse’s work-performances and productivity. As supported by Nash (1994), nurses are able to obtain morale boosts and psychosocial motivation through appropriate nurse-physician interaction.
 As mentioned in the study of George et al. (2002) and supported by earlier studies of Brown (1994) and Ottensmeyer and Keys (1994), four main components of nursing performance are being affected by the leadership of hospital executives, particularly the medical director:
1.     Nurses’ job satisfaction in terms of the working atmosphere and sufficient work-profits
2.     Retention policies and qualifications obtained by the nursing service staffs
3.     Productive rendering of primary care interventions and health management services
4.     Professional commitment of the nurses to the health care institution or organization
The influence of clinical leadership has been clearly demonstrated in setting practice patterns and determining group norms of practice styles (Brown, 1994 p.153). As for the study, the four criteria, particularly (1) job satisfaction, (2) retention, (3) productivity and (4) commitment, are utilized as the evaluators of leadership effects on nurses’ staff performances. According to Lugon and Walker (2001), medical directors of the hospitals are the key influential figure that imposes the profession culturalism and modifies the working atmosphere among nurses (p.135). College health service nurse staffs largely depend on the management and administration of medical directors in various ways, such as the (1) imposition of institutional policies providing the scopes and limitations of their duties and responsibilities, (2) the provision of criteria of evaluation, (3) standards and protocols of quality health care services, and (4) setting of retention, qualification criteria and recruitment policies (Turner and Hurley, 2002 p.154). Hence, leadership competencies among medical directors greatly affect various components of college nursing profession as supported by the factors mentioned above.
IV.    Leadership and Management in Hospital Setting
The role of College Health medical directors and college health nurses are interdependent and related in various ways. Leadership and management imposed and performed by the medical director influence the working atmosphere of the nursing service. Medical directors are confronted by specific tasks, namely (1) policy legislation, (2) maintenance of quality health care services, (2) staffing and supply budgeting, (3) fostering and establishing nurse-physician relationships, and (4) organizing hospital structure. According to Lugon and Walker (2001), the NHS (National Health Service) Modernization Agency Leadership Centre provides a Medical Directors Development Framework, which describes the qualities, behaviors, skills and knowledge required for senior medical roles. Various elements of the medical director’s role described are the following (p.135):
a.    Corporate responsibility – shared responsibility for strategic direction across the trust and for driving forward the national and local agenda for healthcare development
b.    Leadership across the trust – ability to translate vision into action
c.    Managing services and information – ability to interpret and manage disparate and complex information
d.    External relationships – ability to successfully manage the diverse range of relationships
College Health Medical directors possess definite leadership role in extending support among clinical and nursing service staffs, especially in managing the quality of services (Lugon and Walker 2001 p.135). Meanwhile, college health nursing and the implementation of their health goals as well as the emphasis on health promotion, health education, and prevention largely depend on the work-setting or hospital environment modified by the administration of executive positions, such as the medical director.
In the quasi-experimental study of Blanzola, Lindeman and King (2004) conducted in a U.S Navy hospital, nursing core competencies – involving assessment of self-confidence, self-awareness, work satisfaction, productivity and task proficiency – of nurses working in a properly organized hospital setting scored higher than the controlled group, who are placed in an uncomfortable and unstructured organization simulated by the researchers. According to Turner and Hurley (2002), college nursing health services are in need of critically formulated administrative considerations with regards to their budget requirements, staffing conditions, and current policies being implemented within their scope of specialty (p.155). The next section further explains the needs of college health service nurses.
                i.     Policy Legislation
College health nurses are confronted with various issues of policy inconsistencies and non-implemented quality assurance standards. According to the American College Health Association (ACHA), college health nursing staffs require networking resources, modification and further legislation of standards of care, and formulation of policies oriented to the benefits of the said nursing specialization. According to Turner and Hurley (2002), the medical director is responsible for addressing and enacting towards the work issues of the subordinate professions, such as nursing staffs, health care personnel, etc(p.158). The American Nurses Association (ANA) has cited policy issues concerning the need for further legislation of higher executives in every hospital institutions. These cited issues are the current policy concerns of not only college health service staffs, but also the nursing body as a whole.
ANA policy issues are as follows (Hitchcock, Schubert and Thomas, p.438):
a.  Health care reforms
b.  Medicaid reform and Medicare restructuring with prescription drug benefits
c.  Patient-nurse ratio among college nursing specialization
d.  Recruitment and standard policies
Policy legislation is an important function in the part of the medical director; however, Turner and Hurley (2002) emphasize the need in considering the role flexibilities and policy adaptation with regards to the dynamic nature of college health nurse staffs (p.158). Furthermore, in the context of the framework for college health nursing practice, such as health promotion, specific disease protection, case management, early diagnosis, prompt treatment to limit and prevent disability and rehabilitation, must be adaptive and related to the nature of policy legislation (Turner and Hurley 2002 p.157). Furthermore, since medical directors are crucial figure of college health service policy promulgators, it is important to consider the absolute implementation of every policy formulated. According to Lugon and Walker (2001), college health nursing staffs are also expected to participate in policy formulations accordingly, and depending on the perceived needs of the nursing core department.
              ii.     Maintenance of Quality Health Care Services
The maintenance of quality health care delivery is also one of the important requisite of college health nursing services. Medical directors are tasked to uphold and ensure the standards of care being delivered to patients. According to Rosentein (2002), Reid and Silver (2002) and Swansburg (1995), college health medical directors should possess adequate knowledge and strategic procedures in order to implement quality assurance policies in every health care services rendered to every patient. Furthermore, Shortell and Kaluzny (2000) added that the management and administrative capacity of the medical director should well fit in the dynamic and changing environments of health care needs and potential demographics.
Although, maintenance of care does not entirely depend on the college health service nurses, still, according to Murray (2002), nurses are considered as the extension of health service maintenance and quality assurance and, therefore, needs to be well equipped in the possible changes of patient needs and health requirements (JCH, 2007; Garko, 1992). The role of medical directors is to act as the primary overseer in supervising the subunits (college health nurses) according to the delivery of care, evaluation of performances, setting of qualification standards, and recruitment policies implemented in workforce standards.
            iii.     Staffing and Supply Budgeting
One of the concerns confronting the college health staff nurses is the insufficiency of professional and licensed nurses rendering specialization in the field of college health nursing and services. According to Turner and Hurley (2002), the ratio between patient and college health nurses accounts to 10:2 in a survey conducted by ANA in 1999 when the ideal ratio of patient-nurse is 1:1 for intensive care units and 2:1 for ward departments (p.157). Staffing is an important concern that tests the leadership skills and competencies of the medical director, which also influence the overall health care delivery of any given health care facility.
As supported by Resnick (2004), staffing and organization of workforce units in any given health care institutions are part of the overseer and managerial roles of the medical director (p.87). Meanwhile, according to Pompei and Murphy (2006), staffing conditions in every given hospital unit can greatly affect the status of nursing care delivery, especially the psychological response of the nursing staffs to the working atmosphere, satisfaction levels, and the overall health care productivity (p.44). Therefore, staff adequacy as manifested by appropriate patient-nurse ratio in college health service units is an essential consideration in satisfying and establishing efficient working environment.
In a study conducted by Aiken, Smith and Lake (1994), adequate staffing in a nursing unit actually decreased the rates of mortality from 7.7% (9 deaths per 1000 medicare discharges) to 4.6% with 95% confidence interval. According to the findings of the study, the main contributing factor in the decrease of mortality rating is the organization of nursing staffs and health care delivery measures initiated by the hospital executives. In addition, Cho, Ketefian, and Barkauskas (2003) support this claim through their study involving the relationship of adequate staffing to the decrease of case morbidities and mortality rates in the hospital unit. In the result of the study, the 10% increase in nurse-patient proportion has decreased the odds of complications (e.g. pneumonia, pressure sores, etc.) from 8.9% to 9.5%.
Meanwhile, in consideration of budgeting and appropriate supply management have also been linked to the productivity, job satisfaction, and efficiency of nursing tasks among college nurse health services. Medical director’s leadership capacity influences the trends of work efficiency rendered by staff nurses through policies and procedural implementations that concern supply and budgeting tasks. In a study conducted by Karuza and Katz (1994), they found out that one of components that can affect care delivery among staff nurses is the adequacy of supplies and facilities present in the working environment. The policy of the institutions legislated by the hospital executives, mainly the medical director, influence the availability of supplies and budget usage over the entire institution. Thus, medical director’s administrative competencies can directly affect nursing service efficiency through staffing, budgeting and supply management.
              iv.     Fostering and Establishing Nurse-Physician Relationships
Communication and interaction are the main concerns and considered qualifications of an ideal medical directors as perceived by the nurses interviewed by in the study of Brown (1994), Nash (1994) and Ottensmeyer and Keys (1994). According to the perceptions of these surveyed nurses, the collaborative and communication competencies of the medical director do affect the efficiency and delivery of not only the nursing care services but also the entire health care delivery system. As supported by Lugon and Walker (2001), the role of the medical director in a health care setting or college health service units is oriented in a collaborative nature; hence, communication skills and establishing of interactive relationship are essential components in delivering quality care to the patients and establishing adaptive working environment among the nursing staffs. In a more recent study of Disch et al.(2001), collaborative team work and improvement of working relationships between nurse-physicians and nurse-hospital executives are essential preventive conditions directly affecting the quality of care delivered to patients and job satisfaction being felt by both parties.
According to Hood, Leddy and Pepper (2005) leadership capacities and competencies of the medical director are entirely reflected by the overall functioning of the overall health care association and interaction (p.125). The delivery of care depends in the functioning of the staff, while the morale and the working conditions of the nursing staffs are greatly influence by the working atmosphere influenced by the physician and health care executives. As supported by Taylor and Taylor (1994) the responsibilities of the medical director are not only directed to the nurse staffs, but also to the clinicians or physicians responsible for the delivery of medical care (p.583). Hence, both work-force components of the college service units are handled by the medical director’s administrative and managerial strategies. Job satisfaction, productivity, retention and organizational commitment of the college health nurse staffs are correlated to the relational component and the working atmosphere between the physicians and the nurses. Meanwhile, managerial and administrative roles of the medical director affect both positions (nurse-physician) as well as their service provision (Taylor and Taylor, 1994 p.583).
V.      Influences of Leadership in College Nurses’ Work Performances
From the discussions mentioned prior to this section, various forms of indirect and direct influences of the medical director’s leadership competencies towards College health nurse staffs’ work performances have been shown. Diversities and extensions of the roles of the medical director have allowed these effects in various categories of nursing work performances. The perceptions of the college health nurses in their job satisfaction are influenced by the policy legislation, staffing conditions, and monetary benefits obtained by these nurses in exchange to their specialized health care rendition (Taylor and Taylor, 1994 p.583; Resnick, 2004 p.87). Meanwhile, retention is indirectly influenced by the capacity of the hospital executives to implement quality assurance protocols, legislate appropriate and needed policies, and maintain proper job description (Lugon and Walker 2001). On the other hand, productivity of the college nurse staffs largely depend on the working environment, interactive conditions between nurses and physicians, team collaboration among health care team, and appropriate staffing and placement of workforce (Cho, Ketefian, and Barkauskas 2003; Shortell and Kaluzny 2000). Lastly, organizational commitment involves the overall satisfaction of the nurses in the hospital environment and working conditions.
                            i.     Job Satisfaction
Job satisfaction among these nurses related to the medical director’s leadership competencies depend to the following attributes: (1) capacity of the medical director to properly organize the staffing structure of the nurse servicing staffs, (2) appropriately legislate needed policies protecting the job description and specialization coverage of the nurses in a college health servicing facility, and (3) provide appropriate monetary benefits proportionate to the working conditions, standards of services offered and the credential status of the college nurse staffs employed (Turner and Hurley 2002 p.144). In a survey conducted by Advisory Board’s Nurse Executive Center (2004; cited in Contino, 2004), perceived job satisfaction of nurses has been evaluated into three components: (1) collaborative role of nurses in health care and policy legislation, (2) relationship among executives and physicians, and (3) working conditions (e.g. concerns with staffing, patient-nurse ratio, etc.). In the study, 84% of the respondents have indicated the collaborative function of nurses with the hospital executive as the primary concern imposed to the higher leaders (e.g. medical director). Meanwhile, 43% for relationship in the workforce environment, and 16% for working conditions have considered these factors as the second and third concerns affecting their job satisfaction.
                          ii.     Retention
Retention is another component being contributed by the managerial and administrative role of the medical director through the channels of (1) policy legislations governing the standard protocols of the college health care hospital, (2) recruitment qualifications, and (3) quality assurance protocols being implemented in the health care setting. Due to the rising concerns of the college health service nurses (e.g. staffing conditions, monetary concerns in other areas, etc.), the medical director is confronted by legislative concerns and issues inclined to the better benefits of the specialized nursing field, which is college health service provision. According to the study conducted by Ribelin (2003), 46% (n=425) of the interviewed nurses have left their positions due to the leadership style and strategies being implemented by their medical head or director.
According to the conclusion of Ribelin’s (2003) findings, retention of nurse staffs also depend on the working environment and relational conditions present in the hospital environment. As supported by the study of Brown (1994), nurses even perceived the communication qualification of the medical director as the number one trait of leadership, which implicate appropriate interaction and communication towards the subordinates (e.g. nurse staffs).
                        iii.     Productivity
The component, productivity, comprises a diverse and multi-faceted criterion that pertains to a broader scope of performance outcome. In terms of medical director’s leadership competencies and its effect on nursing service productivity, such category is said to be influenced by (1) workforce environment (Ottensmeyer and Keys, 1994), (2) nurse-higher executive relationship (Brown, 1994), (3) adequate staffing and supplies/ facilities provision (Turner and Hurley 2002 p.144), and (3) leadership styles utilized by the medical director (Ribelin 2003). Considering the broad criterion of college nurse performance productivity, the component narrows down in the working environment of the hospital institution being managed by the hospital director.
According to According to the American College Health Association (ACHA), college health nursing staffs are oriented primarily by the policies (inclusive of health service limitations, specialty considerations and responsibilities) legislated by the hospital executives, primarily by the nursing director and the medical director. In such condition, medical director’s leadership competencies, and capacity to assess and plan appropriative interventions addressing the needs and requisites of the college nurse staffs can vastly affect the productivity among nursing service outcomes.
                          iv.     Organizational Commitment
Lastly, organizational commitment of the college health service nurses is an important factor in the maintenance of a well-functioning college health care group. In response to this issue, the college health medical director needs to consider significant interventions (e.g policy legislation fostering nurse’s commitment, increasing monetary benefits, etc.) that can influence organizational commitment among the subordinate health care members. According to the findings in the study of Lok and Crawford (1999), organizational commitment among nurses is largely dependent in two components: (1) nurses’ trust in the organization and the administration behind it, and (2) suitable and appropriate working conditions present in the health care institution. Meanwhile, Laschinger, Finegan and Shamian (2001) have observed that commitment among nurse staffs are also affected by the empowerment (see empowerment theory) and culture of professionalism fostered by the higher roles, such as the medical director of the hospital institution. In a non-experimental design, random sample of 412 nurse staffs have been evaluated based on their commitment, work attitudes and productivity. In their findings, test results suggest relevant relationship between the nurses’ perception of organizational commitment, empowerment and work attitudes, and the managerial and administration being led by the hospital leaders.
VI.    Evaluation of Nursing Staff’s Leadership Qualities
In evaluating the perceptions of the college health service nurses’ in terms of the influence of leadership competencies of medical directors to the work performance (four components: (1) job satisfaction, (2) retention, (3) productivity and (4) organizational commitment), descriptive study utilizing survey methodology can be used to gather these data. In Brown’s (1994) study, the respondents have undergone a series of questionnaires and interviews in order to gather perceptions of ideal leadership traits that can be used as basis of qualifications for the role of medical director. Meanwhile, Ottensmeyer and Keys (1994) have also utilized a descriptively designed survey procedures in order to gather the perceptions of the staff nurses pertain to the ideal leadership traits and competencies of a medical director. These studies are the illustration of some of the evaluation strategies utilized by the previous researchers in an effort of determining the perceptions of the respondents.
Meanwhile, studies of Nash (1994), Laschinger, Finegan and Shamian (2001), Turner and Hurley (2002), Lugon and Walker (2001), JCR (2007), Lane (1998) and others mentioned have indicated how these perceived traits and qualities affect the work performances and functioning of the nurses in the college health nursing facility. In order to evaluate the effects of leadership competencies, traits and qualities of the medical director to the work performances of the college health service nurse staffs, specific fields should be utilized as the basis of evaluation, particularly (1) job satisfaction, (2) retention, (3) productivity and (4) organizational commitment. Previous studies mentioned in the latter portion of the review have evaluated these criteria through descriptively designed survey with open-ended questionnaires aimed at obtaining the perceptions of the nurse staffs (respondents).
According to the studies of Brown (1994), Ottensmeyer and Keys (1994) and Nash (1994), evaluating the perception of nursing staffs regarding to appropriate leadership qualities can vary depending on the work environment’s culture, and the prevailing issues and concerns in a given health care institutions. Despite of the perception studies done by previous literatures, leadership qualities and traits of a medical director are still considered subjective outcomes of research procedure and have been validated according to the prevailing trends of working atmosphere in every respondent setting. Meanwhile, from the literatures reviewed, the findings suggest that leadership styles, competencies and qualities can indirectly and directly affect the work performance of nurses related to the institution governed by its leaders.

VII.  References
Aiken, L. H., Smith, H. L., & Lake, E. T. (1994, August). Lower Medicare Mortality among a Set of Hospitals Known for Good Nursing Care. Journal for Medical Care, 32, 771-787.
Barnett, A. E., & Mayer, G. G. (1992). Ambulatory Care Management and Practice. New York, U.S: Jones & Bartlett Publishing.
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