Posted: September 27th, 2022

The impact of leadership on the quality of care for emergency medical services

The impact of leadership on the quality of care for emergency medical services in healthcare organizations in Saudi Arabia

A research proposal

Submitted for the degree of MSc.

Of healthcare management

Presented by

Abdulazeez Abdullah M Albaradei

Supervisor

Dr. Mohammed A. Almohaithef

Date

14/2/2022

Introduction

Studies connecting leadership with the quality of health organizations services are still rare. On the other hand many studies have shown that leadership has a great contribution to the performance of an organization. Therefore, this study will be utilized to develop a framework of service quality in health organizations which incorporates the role of leadership. The research will be based on a systematic review through a comparison of different studies in this field. Also, data will be collected by a systematic review on the perspective of the impact of leadership on health care quality in health organizations. But the basic is the formation of a systematic review through the comparison with the previous studies in this field. The results expected to show that there is effect of leadership on the quality of service.

Background

Effective leadership of healthcare professionals is critical for strengthening quality & integration of care. The requirement for elevated coordination in patient care & higher quality care at lower costs has made it essential for EMS agencies to have in-place quality control or quality enchantment programs that depend on key performance indicators to continuously monitor the system’s overall performance and the effectiveness of the various pre health organizations interventions. The IOM described quality as “the degree to what health services for individuals & populations elevate the likelihood of desired health outcomes and are consistent with recent professional knowledge” and showed six dimensions of quality care: a care that is safe, patient, timely, effective, efficient & equitable.(IOM,2006).

Factors that affect the level of service quality include human resources management, HR, organizational culture, leadership & others. Job satisfaction and organizational commitment allegedly played a role in determining the influence of leadership on the service quality. Leadership was one of different factor that mostly studied, but it is not clear how the leadership can affect the service quality. Evaluating quality of care is significant as patient satisfaction is discussed by the service quality. (Duggirala et al., 2008)

Quality criteria can be varied according to patient preference. It is therefore significant for health organizations to indicate the patient’s preferences so as to give quality patient care in line with expectations. The definition of service quality is the hope, desire, something that should be delivered by service providers, normative expectations, ideal standard, the desired service, and service levels known by consumers.

On the other hand, Leadership is a person’s ability to lead others, the ability to contribute to the achieve goals & organizational success. (Choi et al., 2006).also Blankenship described that leadership is the capability of a leader to arrive at the expected results. (Blankenship et al., 2010)

The Kingdom of Saudi Arabia is listed as the 14th largest country in the world with an area of 2, 2400,000 sq.km (Ewan et al., 2013).The health care as an organized structure began in 1926 in Mecca with the issuance of a decree establishing “health care department” by the first King of the country, King Abdul-‘Aziz which was one of the highest priorities to him. The development of Emergency medicine, as a specialty in Saudi Arabia is important. (Mufti et al., 2000) .The concept of Emergency medical services wasn’t strange to the Kingdom; it was brought firstly into the country by a charitable help society back which was the pre formation of SRCA.

Problem Statement

How leadership impact the quality of care for emergency medical services in healthcare organizations is not widely understood. The topic of how leadership in EMS is learned in different nations has not been well- discussed.

Within EMS publications, EMS professionals have described different styles or theories of leadership and applied the theories to the profession. There remains an elevate level of importance and interest in research to differentiate and substantiate EMS leadership. The critical nature of understanding how leadership affect the quality of EMS is not limited to one country, but is required internationally as the role of EMS during emergencies is a growing topic in international emergency medicine. Thus, the requirement for further understanding on leadership in EMS at the international level is recognized as an unmet requirement. (Brink et al., 2009)

Aims

This study aims to achieve the impact and the association among leadership and healthcare quality measures in Saudi Arabia organizations. To understand the nature of leadership work of the health organizations managers in order to examine their perceptions of the most essential roles, skills and training courses as health organizations managers. Also to identify the challenges, obstacles and issues facing health organizations leaders.

Objectives

The objectives of this study are the following:-

1-To investigate the strong influence of leadership on the quality of service of care for emergency medical services in healthcare organizations.

2-How the leadership can affect the service quality.

3-To determine the influence of leadership effectiveness on health-care service quality Care.

4-To determine whether there is a need to improve the quality of health.

5-To determine whether the efficacy of leadership has an impact on employee satisfaction.

Methods and Methodology

The systematic review will be designed & conducted in line with the published guidelines for reporting systematic reviews and meta-analyses. A systematic review of the leadership influence on the quality of healthcare will be performed. The review question is: “what is the impact of leadership in settings of healthcare & quality of care?” A systematic, comprehensive bibliographic search will be performed out in the National Library of Medicine (Medline) and EMBASE databases for the time between 2012–2021 in the PubMed interface.

Search terms that will be chosen from the USNML Institutes of Health list of Medical Subject Headings (MeSH) for 2015. The included MeSH terms are: “Leaders”; “Leadership”; “Managers”; “Management style”; “Leadership style”; “Organizational style”; “Organizational culture/climate”; “Leadership Effectiveness”; “Quality of healthcare”; “Patient outcome Assessment”; “Quality indicators, Healthcare”; “Healthcare quality, Access and Assessment”; and “Quality Assurance, Healthcare”. References that will be utilized by each identified study will also checked and involved in the study according to the eligibility criteria.

Five main inclusion criteria will be included:

• Papers published in peer-reviewed journal

• Papers written in the English language

• Papers published from 2012 to 2021 (focus on more recent knowledge)

• Human epidemiological studies

• Studies used a quantitative methodology reporting the leadership style and healthcare quality measures

Studies that do not meet the above criteria will exclude, while those that comply with the inclusion criteria will be listed and further reviewed.

Studies will be evaluated and appraised, Literature screening (a three-stage approach-exclusion by reading the title, the abstract, and the full text) and Data will be extracted systematically from each retrieved study, utilizing a predesigned standard data collection. The following information will be extracted from each one of the involved studies: authors, year of conduction, study design, subjects, country ,population, research purpose, leadership style definition, outcome definition, and major findings.

Conducting a systematic review about the influence of leadership on quality of healthcare inside and outside the health organizations.

14

A brief description of 10 related articles are shown on Table 1.

Main Findings

Outcome

Aim of the study

Main Study Characteristics

Country

Study’s Name

Author et al(year)

In the Makkah and Al Madinah Al Munawarah regions, the SRCA was well prepared to deal with MICs. The median score for Riyadh, the North Borders, the Eastern Region, Tabuk, Jazan, Hail, and Qasim was 3. A median score of 2 was assigned to the remaining regions. Some critical issues were not addressed in this study.

The findings back with prior research that found that EMS staff in Saudi Arabia lacked crisis management training. 22 Medical directors are major participants in MCI management, and they should set guidelines as well as engage in emergency preparedness planning. 23 The Saudi Red Crescent Authority needed EMS advisors who could oversee all EMS personnel’s daily operations and analyses crisis situations. The total median scores and the number of physicians in the center had a modest positive link in this study, indicating a lower personnel benchmark score. The second benchmark, and one of the most essential variables in incident management, was infrastructure.

To assess the mass casualty incident (MCI) preparedness of pre-hospital care providers in Saudi Arabia and to identify and highlight their strengths and weaknesses when responding to MCIs.

This cross-sectional descriptive quantitative analysis was conducted between January 2017 and 2018 and included all Saudi Red Crescent Authority (SRCA) general administration branches in 13 regions in Saudi Arabia. The modified version of the emergency medical specialists (EMS) incident response and readiness assessment (EIRRA) tool was used in this study.

Saudi Arabia

Assessing the pre-hospital care preparedness to face mass

casualty incident in Saudi Arabia

1.Alotaibi, & et al., (2019)

Paramedics respond to cardiac arrest emergencies on a regular basis, following carefully defined clinical protocols as they work together to resuscitate patients. The narratives offered a serve as key examples of how managers and employees respond to conflict. Deviance.

This article reports only two service interactions illustrating conflict in manager-worker relations, and is not representative of a full body of these interactions or incidents in street-level EMS. The stories presented here are not fact, but rather individually constructed interpretations of events. The results of managing for compliance versus managing for outcomes may be tremendously different, and the implications for individual patients may be great.

To investigate the interactions between street-level personnel and formal authority figures during emergency medical service provision. The findings show that there are both instances of compliance and disobedience to managerial directives. When the patient’s clinical demands were generally obvious and the directions’ consequences were sufficiently congruent with the paramedic’s preconceived conceptions of acceptable response, compliant behavior was evident. When a patient’s positive outcomes were contingent on disobeying orders, there was a clear deviation from managerial directives.

Contributions to theory and practice are reviewed, as well as future research directions.

Qualitative methods (Gilboy, 1992; Maynard-Moody and Musheno, 2003; Newman, Guy, and Mastracci, 2009; Sandfort, 2000; Vinzant and Crothers, 1998), mixed methods (Oberfield, 2010; Riccucci, 2005), and quantitative experimental studies have all been used in empirical research into the unique nature of street-level bureaucrats (Scott, 1997). This study provides a beginning examination of influence and discretion in frontline leader-worker interactions, both of which are essentially subjective concepts. As a result, for this investigation, an interpretative methodological base is acceptable This exploratory study use narrative analysis to capture multiple interconnected, complicated, and mostly unexplored ideas as they arise in frontline EMS practitioners’ actual actions (Yin, 1994). The narrative of a street-level EMS worker caring for a patient in the face of physical, social, and clinical contingencies serves as the study’s unit of analysis. “Naturalistic ones [with] high time pressure, high information content and changing conditions” are how Klein, Calderwood, and Macgregor (1989) describe such settings (462). The researcher utilize tales in a similar way to Klein (1998), who observes that “stories include many different lessons and are valuable as a type of virtual experience for persons who did not witness the occurrence” (179)

International Review of Public Administrat-ion.

Leadership in Street-Level Bureaucracy: An Exploratory Study of Supervisor-Worker Interactions in Emergency Medical Services

2-Henderson&et al ., (2013)

A synthesizing argument has been spread based on a critical interpretative synthesis of literature that implies leadership is a social construct. There will be no one-size-fits-all solution that will work for everyone (Allio 2009). However, the research suggests that any leadership style has a basic balance of four elements: the leader, the follower, common objectives, and the situation. Individual paramedic leaders must evaluate how each of the aspects interacts with one another in order to be effective. It is stated that if the paramedic leader can achieve this, regardless of the style they use, they will be successful.

Leadership is a complicated topic that has been researched extensively over time.

Its significance in the development of successful and efficient organizations has been debated and re-examined several times. This has resulted in a plethora of study aimed at determining the best way to effective leadership. Despite a lot of effort and effort, no one solution has been identified that gives an answer to this question; instead, a diverse set of approaches has been developed.

to help people transform; to Help them in become the best they can be, so that the organization and the individuals can work together to achieve their goals.

It had the potential to accomplish far more than had been anticipated. The model incorporated concern for ethics, norms, and meeting followers’ needs.

There appears to be a continual need for excellent leaders and good leadership to guide us out of our challenges in recent times. David Cameron (2011), for example, declared at the Conservative Party Conference in 2011: “I “In these challenging times, we require leadership to get our economy going and our society functioning. Leadership is effective.”

It is quite simple to talk eloquently about the virtues of leadership; for millennia, people have been studying and striving to do so. The problem is that, while leadership is a notion that most people intuitively grasp, defining what excellent leadership is or implies becomes extremely challenging (Crainer1998). Who decides when ‘leadership works,’ as Cameron put it? People, according to Northouse (2007)

Sheffield Hallam University

Understanding an alternative approach to paramedic leadership

3-Johnson, & et al.,( 2018)

The research revealed four significant elements regarding paramedics’ abilities to engage in leadership on the front lines of treatment. Table 2 provides an overview of these concepts. When the themes are examined, they appear to reflect the predecessors of shared leadership, shared leadership practices, and the structural circumstances that allow shared leadership to arise. Below, we’ll go through each concept in further depth.

Leadership is not recognized as a major competency of competency for all levels of paramedics in Canada. The lack of attention paid to leadership development among paramedics extends beyond Canada and is a global issue. Paramedic associations and organizations might consider implementing leadership modules as part of their core curriculum and training. Health care organizations may benefit from having a culture of shared leadership to bolster patient care.

Few empirical researches on shared leadership in health care settings have been conducted too far. Despite paramedics’ critical role in leading on the front lines of treatment, there are few studies of leadership in paramedicine.

We look at what it means to informally lead on the front lines of patient care using paramedics as an example, with a focus on paramedics responding outside of the hospital.

The study performed semi structured interviews (Q&A) with 29 paramedics from central and eastern Canada’s emergency medical services. The goal of qualitative research is to gain a better understanding of the lived experiences of those who work on the front lines of patient care. The participants’ paramedicine experience ranged from 3 to 30 years, with 75.7 percent of men and 24.3 percent of women being questioned. We’re looking into the many types of leadership that occurs on the front lines of care, not only official or formal leadership positions, but the kind of leadership that paramedics conduct on a daily basis. The interviews were semistructured in the sense that we created questions before collecting data, but we changed them and asked various questions depending on the flow of the conversation.

Canada

Leading on the edge: The nature of paramedic leadership at the front line of care.

4-Danielle &et al., (2018)

In each round, all key competence statements received a majority vote, and all issues received more than the required 75 percent consensus. Between rounds, the degree of consensus increased, with a minimum rise of 0.2 percent for item 9, indicating the maximum level of consensus attainable. A response rate of 70% is considered the minimum acceptable rate for maintaining research rigour.

The first research to reflect the perspectives of important experts and stakeholders in Saudi EMS in order to develop an agreement on a core competence framework. The Delphi research met all of the criteria for majority, consensus, stability, and response rate. In Saudi Arabia, paramedics are expected to have certain fundamental competences. However, the findings of the study do not provide a definitive blueprint for the development of EMS courses. To build a full picture, more study and statistical modelling based on bigger samples is suggested.

To obtain agreement from a professional group on the desired core skills for EMS. In order to build a core competence framework for Saudi Arabian EMS, bachelor’s degree graduates in Saudi Arabia were recruited.

Expert views on essential competences for Saudi EMS Bachelor degree graduates were gathered using the Delphi technique. The instrument was written in English, and two native Arabic speakers were among the participants. Only 17 of the 20 expert potential participants decided to take part in the study. The whole survey was completed by all participants, and there were no responses to the optional open-ended question. Minimum, maximum, central tendency (mean), amount of dispersion (standard deviation), and number and percentage of replies to each of the question levels were all included in the statistical feedback report.

The demographic information was left out of the feedback report, which was confined to collective answers. According to Keeney’s advice, the adopted consensus level was 75%. (15). While all fundamental competencies are important,

Australia

Emergency medical services core competencies: a Delphi study.

5- Alshammari, Talal & et al., (2019).

Leadership effectiveness is an important tool for organizations in order to inspire, mobilize, communicate and motivate their followers. Quality of health care service relates to enhancing and enhancing health care services, increasing efficiency and reducing mistakes and costs. However, the findings revealed that leadership effectiveness was substantially connected with service quality (p 0.05). The correlation between the two variables, however, is quite poor (r = 0.103). The respondents rated leadership effectiveness, service quality, and overall service quality as good in Table 3. Patients were asked to rate HUSM’s overall service quality on a scale of 1 to 10, with 1 being the worst and 10 being the best (very high). The majority of responders (99.2%) were happy with the services, according to the results. Only a small percentage of people picked a scale lower than 5. (0.8) percent

In this study, the Spearman’s Rho Correlation analysis was used. The findings revealed that leadership effectiveness was substantially connected with service quality (p 0.05).relationship between leadership effectiveness and service quality is very weak.

To discover the impact of leadership effectiveness on the quality of health care service at

The university hospital in Kelantan, Malaysia.

The research was carried out at the “Hospital University Saints Malaysia” (HUSM), a teaching institution in Kubang Kerian, Kelantan, Malaysia. The questionnaire was distributed to in-patients and hospital workers by the researcher. The researcher visited with each in-patient and staff member individually to explain the study’s goal. The study employed a quantitative approach. A cross-sectional research approach was adopted in this study. It employed two sorts of survey instruments in this situation. The Leadership Practices Inventory (LPI) survey, designed by Jim Kouzes and Barry Posner, was used to assess leadership effectiveness among doctors, nurses, and administrators (2000). The study employed a commonly used questionnaire, the Consumer Assessment of Health Care Providers and Systems, or CAHPS, for the in-patient survey.

Malaysia.

The Impact of Leadership Effectiveness on the Quality of Health Care Service at Universiti Sains Malaysia Hospital (HUSM), Kubang Kerian, Kelantan, Malaysia

6-Abdul Rahman,Wan,(2017)

The number of patients transferred from the scene to the hospital for medical and trauma reasons differed significantly between male and female EMS users, according to the findings. For both sexes, basic support was significantly more prevalent on the scene than advanced care, with 551 men and 237 women receiving basic help compared to only eight male and four female patients receiving advanced treatment. Essential patient information for both male and female EMS users, as well as the event category “no medical care provided.” In the city, there were 295 (73.8%) male EMS users and 105 (26.3%) female EMS users. The urban group had a mean age of 42.75 years, whereas the rural group had a mean age of 39.72 years.

A number of important concerns were discovered after analyzing this cross-sectional dataset by both geographic area and gender. One of the most significant distinctions was that rural EMS users were more likely to have trauma-related situations that necessitated EMS transport, whereas medical reasons were more prevalent among urban EMS users. Men also used EMS at a substantially greater rate than women, and were more likely to be transferred to the hospital after a call. The current study did not have the resources to investigate the reasons underlying these findings, thus more research is needed to properly understand the results.

To provide a broad picture of how patients used prehospital EMS in the Riyadh region of Saudi Arabia, with a particular focus on any differences in patient behavior.

Acomparison between urban and rural settings There was no research in this field found in a literature search.

Only a few research outside the United States have been undertaken on this topic, according to Riyadh.

EMS results in urban and rural areas were examined in Europe and Australia. This piece is part of a larger project.

EMS performance in rural and urban settings is being investigated as part of a study project.

Saudi Arabian nationals.

The Saudi Red Crescent Authority EMS in the Kingdom of Saudi Arabia gathered emergency patient records (EPRs) over the course of a year, from January 1, 2017, to December 31, 2017. The initiative intended to concentrate on data from the Makkah administrative region, The Saudi Red Crescent Authority EMS in the Kingdom of Saudi Arabia gathered emergency patient records (EPRs) over the course of a year, from January 1, 2017, to December 31, 2017. The initiative intended to concentrate on data from the Makkah administrative region, which has the greatest population base and the highest rates of EMS transportation. Riyadh was chosen as the data source since it has the second-highest number of transferred cases. The 800-item dataset came from hardcopy EPRs generated after an EMS response to an emergency call-out. The data was manually transcribed once each hard copy was physically read. The files were chosen with the help of a Saudi Red Crescent supervisor using a computer-generated random number list. Statistics that are simple and descriptive

which has the greatest population base and the highest rates of EMS transportation. Riyadh was chosen as the data source since it has the second-highest number of transferred cases. The 800-item dataset came from hardcopy EPRs generated after an EMS response to an emergency call-out. The data was manually transcribed once each hard copy was physically read.The files were chosen with the help of a Saudi Red Crescent supervisor using a computer-generated random number list.

Saudi Arabia

Utilization of prehospital emergency medical services in Saudi Arabia: An urban versus rural comparison, : Journal of Emergency Medicine, Trauma and Acute Care.

7-Alanazy, A., et al.,(2021

Most respondents suggested that they thought clinical leaders had the skills and abilities to do their job. Most thought clinical leaders were involved in team work, the generation of new ideas, were great communicators and involved others appropriately. Most didn’t care where their experience was from or what sort of experience it was as long as they had valid road side experience. Most didn’t value research insights or qualifications. What mattered was that the values of the clinical leaders were matched by their actions and abilities.

It is hoped that with a better understanding of clinical leadership and how it is perceived by paramedics and ambulance officers, they will be able to play a more effective part in service improvement, impacting positively on pre-hospital care delivery. As well, a more effective understanding will be gained of how clinical leadership impacts on the effectiveness and delivery of pre-hospital care and how the ambulance service can bolster and support greater clinical leadership and service improvement.

To identify how clinical leadership is perceived by paramedics in the course of their everyday work and the effectiveness and consequences of the application of clinical leadership in pre-hospital care delivery.

A questionnaire (with a supporting information letter) was distributed via inservice training sessions to all St. John Ambulance operational staff in WA between February 2010 and November 2010 (n = 250). The methodological principals supporting the study are based on phenomenology. Analysis of the quantitative data was via SPSS software and qualitative data was analysed by spreadsheet and word documents.

Ausralia

Perceptions of clinical leadership in the St. John Ambulance Service in WA

8- Stanley, D., Cuthbertson, J., & Latimer, K. (2012)

The National Institute for Health and Care Excellence (NICE, or the Institute) provides guidance to the National Health Service in England on the clinical and cost effectiveness of selected new and established technologies. According to NICE, the expression for health effects should be in QALYs. The EQ 5D is their preferred measure for health-related quality of life in adults.

This article reports on one of the few RCTs undertaken regarding CP. Among its unique features, the participant group presented a great challenge for the caregivers in attempting to conserve quality of life and reduce utilization of acute care facilities as well as LTC institutions. Where other studies have concentrated on the use of medics in the home to address acute issues and attempt to provide local care rather than transport to ERs, our study focussed on regular visitation and monitoring to alleviate the trajectory of chronic disease.

to determine whether communityparamedicine services (the intervention through home visits) would have a positive economic impact through influencing self-perceived qualityof life and determining a monetized value.

In addition to the rural setting in Renfrew, this study included new CP service provision and participation in the urban areas of Hastings County, Ontario. Paramedics from the Quinte Emergency Medical Services detachment in Belleville received the same supplemental training and were coached by the Renfrew CP prior to commencing home-based practice.

A total of 200 eligible clients (120 for Hastings and 80 for Renfrew) were recruited in early 2015 and randomly assigned to either the intervention group (receiving community paramedicine services) or the control group (receiving conventional treatment). All of these clients had used a Paramedic Service ambulance to go to a hospital emergency room (ER) three times or more in the preceding year, and had one or more of the following chronic conditions: chronic obstructive pulmonary disorder, congestive heart failure, diabetes, hypertension or stroke.

Eastern Ontario.

Conserving Quality of Life through Community Paramedics

9- Ashton, C., Duffie, D., & Millar, J. (2017).

Transformational leadership style has significant influence and positive toward employee performance.

This gives the meaning that transformational leadership style has a direct role to improve performance to be

generated at organization.

1) Transformational leadership style with its indicator which used are: the influence of ideal, intellectual

stimulation, leader behavior, consideration of individual has significant influence and positively to

motivation. With significant stage (0.000). Transformational leadership style has direct role to increase

motivation that will produce by employees to organization.

2) Transformational leadership style has significant influence and negative towards Burnout. With

significantly stage of (0.007). This thing showed that transformational leadership style has great capability to

prevent Burnout. Direct influence more strong than indirect influence. This proved that variable intervening

that mediates variable transformational leadership style with burnout cannot neglect.

to describe and analyze the

influence of transformational leadership styles, motivation, burnout, and job satisfaction and employee

performance. The unit of analysis is nursing paramedic at a hospital in Malang Raya.

This explanatory research is a kind of resarch that try to explain relationship among variables through

hypothesis test. Unit of analysis in this research is paramedics of Malang hospitals. Research population is

Malang hospitals that consist of Malang Regency, Malang City and Batu Malang City. It takes 6 hospitals at

Malang Raya area.Sampel of this research is nurse paramedics that use as responden. Sample size using Slovin

formula with 5% of galad precision. Base on calculation with Slovin formula get 105 people as sample size.

Indonesia

The Influence of Transformational Leadership Style, Motivation, Burnout

towards Job Satisfaction and Employee Performane

10- Risambessy, A., & et al., (2012).

Hypothesis

The way in which the leadership affect the quality of care for emergency medical services in health organizations.Leadership influence in Saudi Arabia organizations on the health care quality.

Excepted results

The results expected to show that there is strong influence of leadership on the quality of healthcare. This study expected to found that there is a difference in leadership approach among doctors, nurses and paramedics inside & outside the health organizations. Among doctors, charisma is a significant aspect of leadership, but among nurses, supportive approach is more important. And effect on health-related outcomes differs according to the different leadership types.

Time line

Start in February 2022 and expected to finish in May 2022

References

1. Institute of Medicine, Emergency Medical Services at a Crossroads, The National Academies Press, Washington, DC, USA, 2006.

2. Duggirala, M., Rajendran, C., Anantharaman, R.N. (2008). Patient-Perceived Dimensions of Total Quality Service In Healthcare, Benchmarking: An International Journal, Vol. 15 No. 5, Pp. 560-583

3. Choi, J.H. (2006). The Relationship Among Transformational Leadership, Organizational Outcomes, And Service Quality In The Five Major NCAA Conferences, A Record Of Study, Submitted To The Office Of Graduate Studies Of Texas A&M University, In Partial Fulfillment Of The Requirements For The Degree Of Doctor Of Education

4. Blankenship, S.L. (2010). The Consequences of Transformational Leadership And/or Transactional Leadership In Relationship To Job Satisfaction And Organizational Commitment For Active Duty Women Serving In The Air Force Medical Service, A Dissertation, School Of Business And Entrepreneurship, Nova Southeastern University

5. Brink, P., Back-Petterson, S., & Sernert, N. (2012). Group supervision as a means of developing professional competence within pre-hospital care. International Emergency Nursing, 20, 76 – 82.

6. Ewan W. Anderson, Liam D. Anderson. An Atlas of Middle Eastern Affairs. New York, Routledge; 2 edition (Oct 28, 2013)

7. Mufti, Mohammed Hassan, S., (2000). Healthcare Development Strategies in the Kingdom of Saudi Arabia. New York: Springer

8. Yin, R.K. (1994). Case study research: Design and methods, London, Sage Publications

9. Sekaran, U. (1992). Research Methods for Business : A Skill Building approach, Second Edition, John Wiley & Sons Inc., USA

10. Alanazy, A., Wark, S., Fraser, J., & Nagle, A. (2021). Utilization of prehospital emergency medical services in Saudi Arabia: An urban versus rural comparison. Journal Of Emergency Medicine, Trauma And Acute Care, 2020(2). doi: 10.5339/jemtac.2020.9

11. Alotaibi, Khalaf & Higgins, Isabel & Chan, Sally & Al otaibi, Khalaf & Chan, Sally. (2018). Original Article Nurses’ Knowledge and Attitude toward Pediatric Pain Management: A Cross-Sectional Study. Pain Management Nursing. 1-12.

12. Henderson, Alexander & Pandey, Sanjay. (2013). Leadership in Street-Level Bureaucracy: An Exploratory Study of Supervisor-Worker Interactions in Emergency Medical Services. International Review of Public Administration. 18. 7-23. 10.1080/12294659.2013.10805237.

13. Johnson, D., Bainbridge, P., & Hazard, W. (2018). Understanding an alternative approach to paramedic leadership. Journal Of Paramedic Practice, 10(8), 1-6. doi: 10.12968/jpar.2018.10.8.cpd2

14. Wan Abdul Rahman, Wan Afezah. (2017). The Impact of Leadership Effectiveness on the Quality of Health Care Service at Universiti Sains Malaysia Hospital (HUSM), Kubang Kerian, Kelantan, Malaysia. International Review of Social Sciences. 5. 407-415.

15. Alanazy, A., Wark, S., Fraser, J., & Nagle, A. (2021). Utilization of prehospital emergency medical services in Saudi Arabia: An urban versus rural comparison. Journal Of Emergency Medicine, Trauma And Acute Care, 2020(2). doi: 10.5339/jemtac.2020.9

16. Alshammari, Talal & Jennings, Paul. (2019). Emergency medical services core competencies: a Delphi study. Australasian Journal of Paramedicine. 16. 10.33151/ajp.16.688.

17. Sfantou, D., Laliotis, A., Patelarou, A., Sifaki- Pistolla, D., Matalliotakis, M., & Patelarou, E. (2017). Importance of Leadership Style towards Quality of Care Measures in Healthcare Settings: A Systematic Review. Healthcare, 5(4), 73. doi: 10.3390/healthcare504007

18. Risambessy, A., Swasto, B., Thoyib, A., & Astuti, E. S. (2012). The influence of transformational leadership style, motivation, burnout towards job satisfaction and employee performance. Journal of Basic and Applied Scientific Research, 2(9), 8833-8842.

19. Ashton, C., Duffie, D., & Millar, J. (2017). Conserving quality of life through community paramedics. Healthc Q, 20(2), 48-53.

20. Stanley, D., Cuthbertson, J., & Latimer, K. (2012). Perceptions of clinical leadership in the St John Ambulance Service in WA. Response, 39(1), 31-37.

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