The medical school dean: Understanding the development of a leader through Self- Determination Theory

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Exploring deans’ leadership experience may enrich our understanding of how they emerge, enact, and remain in administration. This study explores essential components of individual development and learning as outlined by Self-Determination Theory; that is, how deans develop autonomy in leadership, competency to lead, and a sense of belonging to medical schools. Semi-structured interviews were conducted with medical school deans in Riyadh city, Saudi Arabia. Participants were invited via email. Informed consent was secured. Interviews were conducted virtually, audio-recorded and transcribed. Data were analyzed using framework analysis. Five participants took part in the study. Eight themes were identified and in direct relation to the research questions:1) Leader’s autonomy: Defining autonomy and role negotiation), 2) Leader’s competency in leadership: Experience of mastery, influence of resources, formal leadership programs, and achievement of organizational goals), and 3) Sense of belonging: Interpersonal relationships and personal fulfillment. This study provides insights on the development of leaders in medical education at the granular level. Investment in developing deans as leaders and their teams through professional development programs may instigate transformational change for individuals and the executive leadership team, and if attention is paid to the leader as learner-in-context. Health sciences/Health care/Health policy Health sciences/Health care/Health care economics Leadership Leader Management Organizational culture Leadership Development Medical Education Academic Medicine Medical School Background Leadership research in the field of medical education remains central, mostly because of the ever-evolving responsibilities for medical school deans and the accountability-driven context they work in [ 1 – 3 ]. As a result, evidence-based practice in medical education leadership is crucial. The management of medical schools is of vital importance because of the massive contribution of medical schools to the healthcare workforce. The literature emphasizes the impact of leadership on the effectiveness of medical schools and undergraduate and postgraduate medical education quality [ 4 , 5 ]. Deans have a considerable potential in creating environments for faculty and learners that encourage excellence in education, scientific research production and translation, and community service. [ 6 , 7 ]. Research resulted in numerous works on leadership styles [ 8 ], leadership identity formation [ 6 ], and leadership development [ 9 ]. Less research is conducted on the leader-as-learner and how a leader learns to be a leader in their sociocultural context [ 10 ]. Leader and leadership development are essential. Professionals take on formal leadership positions in medical schools such as deans, vice-deans, heads of departments, and program directors based on interest and career ambitions [ 6 ]. While previous research explored the development of skills and styles amongst leaders [ 5 ], we do not fully know how they go about enacting their leadership role while also learning about leadership. Here we draw a distinction between development of a leader and leadership development . The former is concerned with the individual’s ability to lead, while the latter focuses on a process of development that involves and influences multiple people simultaneously [ 11 ]. In this study, attention is paid to these two concepts, not in how they are different but in how they are related. Individual leadership competencies can be developed overtime [ 12 ]. They can develop through mentoring, focused reflection and personal development [ 12 ], challenging assignments [ 13 ], and formal leadership development programs [ 9 ]. Most likely, a combination of these educational approaches can be utilized to prepare candidates and teams for their leadership roles [ 14 , 15 , 16 , 17 ]. To be mentored and to receive challenging assignments is not done individually but requires others, both seniors and juniors, to play a role. Therefore, Leader-as-learner is then not an individual undertaking but a relational and organizational process. Gap in the literature, study aim and research questions (RQs) Although a wealth of leadership literature exists in medical education, to the knowledge of the author, none explored the individual development of leaders through a Self Determination Theory (SDT) lens. The latter will enrich our understanding of leadership at the individual granular level. Moreover, although many studies have addressed leadership development by cataloging the experiences of leaders, in this study exploration of leader-as-learner is explored. As a result, our understanding of leadership development and how it should be addressed is deepened. In this study, the following research questions are explored: How do medical deans develop autonomy in their leadership? How do medical deans perceive competency in their leadership? How do medical deans experience relatedness in medical schools? Theoretical framework To orient this study, it is important to draw on a theoretical framework to organize thinking around the phenomenon at hand [ 18 ]. This study, as mentioned earlier, is principled by SDT [ 19 ]. This theory has a set of psychological mechanisms relating to the self, mainly that humans are growth-oriented, who are inclined to develop, and to do so within and in coherence with the larger social structure [ 20 ]. This growth can be encouraged or discouraged by internal or external factors. To continue to grow there is a need for autonomy, competence, and relatedness to others in the larger social context [ 21 ]. In SDT, a great emphasis is put on motivation to grow, such motivation can range from lack of motivation (amotivation), internal motivation and external motivation. External motivation can lead to internalizations of certain values. To remain internally motivated, the need for autonomy, competence, and relatedness must be satisfied. A high internal motivation e.g. aspiration for leadership leads to better understanding of leadership processes and higher satisfaction with the leadership experience [ 22 , 23 ]. Materials and Methods Study design The study is underpinned by social constructionism, whereby individuals construct and interpret realities based on their own experiences and interplay with others and the environment [ 24 ]. A qualitative research approach was utilized for this study, employing narrative inquiry, asking participants open-ended questions such as what does this concept mean to you? How did it influence you? The latter approach encourages understanding the human experience through the construction and reconstruction of narratives [ 25 , 26 ] thus affording the researcher an opportunity to understand the complexities of leader and leadership development. The study was conducted in accordance with the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of the College of Medicine, Imam Mohammad Ibn Saud Islamic University. Setting, data collection and participants The study was conducted in Riyadh, Saudi Arabia during the months of July - May 2022. Data were collected by semi-structured individual interviews. Interviews were expected to produce rich in-depth data. They were found appropriate because this study is concerned with meaning and does not aim to generalize the findings [ 27 , 28 , 29 ]. To be eligible for participation, participants must have at least 1 year work experience as a dean. The researcher contacted potential participants via e-mail invitation giving an overview of the research, eligibility criteria, and contact details of the researcher. To ensure the anonymity of those who wish to participate, they were asked to contact the researcher directly. The researcher then proceeded to personally contact the participants by phone, give an overview of the research and arrange for the interview. Interviews were 30–60 minutes long and were conducted in Arabic. They were audio-recorded and each recording was given a unique identifier to protect the identity of the participant and stored in a specific drive for the project. The semi-structured interviews were guided by an interview guide (Supplementary A) developed by the researcher based on the chosen theoretical framework and the literature review. Consent was sought at the beginning of the interview and participants were asked for verbal and written consent. Participants were ensured of their anonymity and right to withdraw at any time. Data analysis The portfolio of data generated were secured in three electronic folders. A folder for the interview transcripts, the text and its analysis, and the text translations. Quotes included in the article were translated from Arabic to English by the author (then back translated by a translator to ensure consistency) for the purpose of publication. Data from the text and interview transcripts were analyzed using framework analysis. Framework analysis is defined as "an analytical process which involves a number of distinct though highly interconnected stages" [30] (p. 177). The framework has five phases of analysis including: familiarization, identifying a thematic framework, indexing, charting, and mapping/interpretation. Results Five out of seven deans working in the capital Riyadh, Saudi Arabia took part in this study. Deans ages ranged from 42–53 years, the sample included both male and female participants, years served as a dean ranged 1–4 years. Eight themes were identified, two themes relating to RQ1: Defining autonomy and role negotiation; Four themes relating to RQ2: Experience of mastery, influence of resources, formal leadership programs, and Evidence of realizing organizational goals; and two themes relating to RQ3: Interpersonal relationships and personal fulfillment. Each theme is presented in the following sections and illustrative quotes are shared. How do deans develop autonomy in their leadership? Defining autonomy When asked “what is your understanding of autonomy in your leadership?”, participants conceptualized autonomy in 3 ways. First, autonomy related to decision-making as a necessary skill for the dean. This was viewed as the individual ability to decide on one’s own. This is influenced by the magnitude of the decision that needs to be made and if the dean had prior experience. The need for competence in decision making refers to the sense of self-efficacy and belief in one’s ability to perform and make an impact. As the following participant shared: “My leadership shows in my ability to make difficult decisions and to be firm about it, the more experience I gain the further I can go with my decisions.” (Dean_1) Second, participants view their autonomy as it relates to supporting a decision with scientific evidence. As practicing physicians, deans often believed their scientific training and commitment to evidence-based practice, gave them more authority and enabled them as leaders, as one participant shared: “I’m highly trained with advanced degrees and I’m a highly published author in my field, my decisions are backed-up by my extensive training and experience. I don’t do things without reading extensively about it.” (Dean_2) Third, autonomy manifested as being self-determined to pursue goals and activities. Participants expressed a need for making decisions that are situated in the broader context, stating that medical schools are no longer seen as mere schools graduating practicing physicians, rather as entities contributing to the healthcare workforce and influencers of health economy: “We are not producing doctors; we are contributing to the economy. If you think of it this way you recognize that as a leader you must have great ambitions and goals for the school” (Dean_4) Role negotiation Participants also negotiated their professional versus personal roles as well as in-between their professional roles. Learner autonomy was often challenged by deans’ personal lives. Participants admitted to a compromise in one’s personal life to fulfil their leadership role as dean and in turn learn, as one participant shared: “To do this job I’ve sacrificed my personal life, my children must be more independent. Although I think there must be better models for work-life balance. I have colleagues whose solution is to leave the position to make time for their personal lives. I’m continuously looking for ways to balance, that is my responsibility as a leader to learn how to balance” (Dean_1) Another role negotiation that was appreciated in the data was the professional versus professional. That is, many participants spoke about their different professional roles, their roles as clinicians, teachers, researchers, and leaders. One participant shared: “I don’t spend much time in the clinic now that I’m the dean. I think this job is demanding and you must be ready for it and there are sacrifices you need to make. That is a decision I made to grow professionally. I don’t view it as a bad thing.” (Dean_3) How do medical deans perceive competence in their leadership development? Experience of mastery This theme considered participants’ abilities and experiences of mastery. Most of the data from junior deans focused directly on the internal conflict, the regulation of self-motivation to lead, and facing burnout. For example: “There are many demands. I’m overwhelmed most times, and I find difficulty in delegating to others” (Dean_1) Most participants spoke about situations where external parties influenced productivity and efficiency as a leader. “If we have support from senior leadership, we can achieve, if we don’t have the support, it is very difficult to accomplish anything” (Dean_2) Although some participants narrated situations where they were able to demonstrate competence, this demonstration was sometimes undermined by a lack of senior team members who provide a mentorship role, stating reticence in initiation of certain activities, as the following participant shared: “It is challenging to motivate everyone all the time. The vice-deans and the head of departments take on some of the responsibility for their own teams. I need a senior someone to motivate me too, to sign off on some of my plans. Some ideas, I leave because I’m thinking it is too small or too difficult.” (Dean_5) Others shared the challenge in demonstrating competence in the face of different organizational challenges: “In our schools we remain optimistic no matter the situation, but optimism is not always beneficial. You either have the knowledge and skills to preform or you don’t. At the end of the day there are performance indicators that we must meet.” (Dean_4) It was noticed that the more senior a leader is, the less talk there was on motivation to lead, whether internally or externally, rather on the ability to motivate others. “I don’t motivate myself, I motivate others, and others motivate me.” (Dean_2) Influence of resources In this theme participants spoke about the influence of resources on their competence such as: availability of material resources and the ability to recruit competent human capital. In terms of availability of resources one participant shared: “We are limited by resources; we don’t have enough to accomplish our desired goals. This demotivates me and those around me. In many ways I feel a responsibility to provide for my staff and their projects. As a leader who is constantly learning as I go, I find difficulty to thrive in a limiting environment” (Dean_2) In terms of human capital, one participant shared: “It is difficult nowadays to find people, competent people, who are willing to work in academics. Even when you are lucky to recruit them, it will be difficult to keep them in academics. This is one of the areas I need to develop in myself…human capital management” (Dean_3) Formal leadership programs Participants spoke about leadership training programs as a way to introduce themselves as potential leaders to their professional community, as one participant shared: “I knew I wanted to be the dean, so leadership development programs were a way to announce that, that I’m working on myself improving my knowledge and skills formally.” (Dean_3) Other participants spoke about leadership programs after the fact, serving as a catalyst for their growth, as one participant shared: “I became painfully aware of the skills I lacked when I took the job. As soon as a I realized, I looked around for workshops or something to orient me to my duties. There are some aspects I wasn’t aware of, financial management for example, you can find programs online.” (Dean_2) Evidence of realizing organizational outcomes The accomplishment of outcomes was prevalent across all participant narratives. Leaders linked their motivation to work and the ability to motivate others to competence and accomplishment of goals. For example: “Excellence is a choice. If you make that choice before you begin you will always be able to give fully and realize organizational goals.” (Dean_2) However, participants often described their unpreparedness to deal with the volume of employees, as the following participant shared: “It is surprising to me that my teaching role did not end but took a different shape. Both senior and junior staff, need constant mentoring. I need a crash course on how to mentor many people, I think that effects our bottom line” (Dean_5) How do medical deans experience relatedness in medical schools? Interpersonal relationships Participants spoke about the reciprocity among people when they felt a sense of connectedness and belonging. Positive interpersonal relationships nurtured a sense of security and caring. “I make an honest effort to get to know everyone I work with; I also make a point of inviting their families in reward ceremonies. I want them to celebrate their accomplishments with their family in addition to their professional family.” (Dean_5) Personal fulfillment Participants put great emphasis on certain feelings being a driving factor of success, as individuals and as an organization: Personal fulfillment, engagement, and quality of job performance were essential components of success. “I have my own ambitions for my development and career goals. My colleagues, and the university help me achieve them.” (Dean_4) Participants described job performance as directly related to a sense of belonging. “In my current role as dean I was able to connect with my vice-deans. I tried to build a team. They are my executive group. That makes me want to come to work that I’m supported by a leadership team.” (Dean_1) Finally, participants often referred to the larger macro context and the national and health transformation taking place in Saudi Arabia as a reason for increased belonging: “What we do in the medical college in directly related to Saudi Vision 2030. We have a duty to realize the Health Transformation Program and we come to work every day with this in our minds, how to contribute to the greater good” (Dean_5) Discussion This study adds to previous work on leadership in medical education, taking a granular view of medical school deans’ development within the Saudi Arabian context, examining their perceptions through a SDT lens. When speaking of their autonomy as learners, participants of this study highlighted the ability to make a decision, being evidence-based in their leadership practice, and being self-determined to pursue goals and activities as necessary skills. The results of this study show that deans prioritized leadership education and training, regarding it as a positive influencer and a reason for pursuing and remaining in leadership. To better our understanding of the role of autonomy in learning to be a leader, educators and researchers must expand their thinking beyond the role of formal leadership training; that is, formal training may be utilized to expand an individual’s leadership competency but through experiential learning and through managerial assignments that increase in difficulty as the leader grows, as mentioned in the literature [ 13 ], may be a more effective means of learning. Moreover, autonomy is classified as a universal psychological need, that must be supported to enhance motivation and facilitate internalization [ 22 ] and in turn leadership components such decision-making and exercising influence become regulated behaviors. As the leadership development field continues to grow, SDT may be a suitable framework to explore the role of autonomy support and development in the area of role negotiation (professional versus personal) as well as professional role negotiation (clinician versus leader). That is, how one can achieve work-life balance. Neglecting this area may lead to loss of talent, as many qualified and promising candidates may self-exclude because of their perceived inability to achieve balance. This will give leader and leadership development a roadmap as it seeks to fulfil its goals in developing a better organizational culture and leadership experiences. According to the participants of this study, for deans to have more meaningful leadership experiences, motivational factors included internal, external, and a reciprocal type of motivation must be considered. More junior deans faced burnout and struggled to be internally motivated. This is aligned with SDT thinking, as the more novice a learner the more likely they need external motivation [ 21 ]. The external motivators identified in this study included material and human resources, as well as senior leadership support. These findings agree with previous leadership studies in academic medicine [ 4 , 5 ]. More senior deans had an appreciation that they themselves were a motivator to others and vice versa. This finding highlights the importance of giving team members the opportunity to contribute to the decision making, this may transition potential leaders from indirect on-the-job training or coaching to direct formal training. Leaders often feel the pressure to perform in their capacity as individual leaders who must be self-sufficient; that is leadership as acting independently and showing confidence for others to follow. However, recognizing that leadership is a group process, where the responsibility to achieve is a team effort, may increase motivation and sense of belonging amongst individuals and groups alike. The results of this study showed that National Health Transformation Program, gave participants a chance to relate to the larger national context, and as a result felt more empowered to engage in leadership. In relation to a higher purpose, participants’ opinions were of empowerment and transformation. Further studies are needed to explore leaders’ experiences of leading transformation. Such a form of leadership may be addressed in leadership programs; that is, development of learning communities i.e. leadership development programs where the primary objective is to encourage relatedness and build professional relationships that one can depend on and as a result motivation for transformation and organizational growth. Drawing on the concept of relatedness, an interpersonal orientation to leadership is needed. Established leaders can be mentors, coaches, or sponsors, providing career opportunities for potential leaders, guidance in navigating such opportunities, and contributing to meaningful career growth. Fostering such professional relationships has been associated with greater career satisfaction [ 14 , 15 , 31 ], thus increasing motivation for leadership and encouraging the development of self-regulation later. This leads to key considerations for the role of active professional relationship development and how such relationships can be fostered. Methodological strengths and limitations This study is strengthened by its originality, to the author’s knowledge it is the first study utilizing Self-Determination Theory to understand the development of leaders in academic medicine. The results are consistent with findings of other leadership development research. Although, this study sheds light on the complex interplay between leader’s autonomy, motivation to lead and leaders’ ability to motivate others and how that contributes to organizational culture, a larger sample size, that includes deans from other Saudi Arabian cities, is needed for the findings to be transferable to other contexts. Moreover, although the study shows a positive impression of leadership training programs, it does not measure actual outcomes or impact. As a result, the full effect of educational programs formal or informal cannot be determined. Implication for educational practice and policy Despite the methodological limitations of this study, the findings have several implications for educational practice and policy. First, at the individual level, leaders and candidates for administrative positions should be educated in their leadership roles. Leaders need to understand what role autonomy, competency, and relatedness play in their development as leaders and how to best cultivate these aspects while practicing leadership. Second, in terms of the organizational level, policies regarding leadership recruitment and development of leaders belonging to the medical school need to be developed. Such policies may foster better workplace culture that prioritizes leadership development that may lead to efficient and effective organizations. Implications for research Further qualitative and quantitative research are needed with expansion of the leader type such as heads of departments and program directors, in order to explore the generalisability of our findings beyond senior leadership (dean), as well as beyond the Saudi Arabian context. Further studies should aim to collect data from junior aspiring leaders in postgraduate training and who may have a different experience of leadership. Furthermore, researchers should evaluate the outcomes of interventions designed and implemented to improve leadership practice in medical education. As a result of this study, the use of Self-Determination Theory to understand the development of leaders in medical education and how this may inform the design of leadership development programs are recommended. Finally, this study shows that leadership is a relational process, therefore, more qualitative study designs are recommended to understand how professional relationships are initiated and nurtured overtime. Conclusions Leader and leadership development in Saudi Arabian medical education is vital for the growth of the healthcare sector. Using an SDT lens, this study presented several findings that may direct future studies and educational leadership programs. Understanding the leader-as learner including the development of their autonomy, competency, and sense of relatness may help us better prepare deans and motivate them for their leadership roles in medical schools, contributing to the quality of medical education and practice. Declarations Author’s Contributions: The author has read and agreed to the published version of the manuscript. Funding: This research received no external funding. Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of College of Medicine, Imam Mohammad Ibn Saudi Islamic University (protocol code 272/2022 and 1/7/2022)”. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. Data Availability Statement: The data presented in this study are available on request from the corresponding author. The data are not publicly available due to anonymity and protection of the participant privacy. The population of the study is limited, and participants may be easily identified. Acknowledgments: The author wishes to thank Dr Nouf Alharbi for her unwavering support. Competing interest: The author declares no conflict of interest. References Hitt, D.H. Tucker, P.D. Systematic review of key leader practices found to influence student achievement: A unified framework. Rev educ res . 86 (2):531-69 (2016). Leithwood, K. School leadership in the context of accountability policies. Int J Leadersh Educ . 4 (3):217-35 (2001). Muijs, D. Leadership and organisational performance: from research to prescription? Int J Educ Manag . 25 (1):45-60 (2011). https://doi.org/10.1108/09513541111100116 McKimm, J., Lieff, S.J. Medical education leadership. A Practical Guide for Medical Teachers, E-Book. 24 :429 (2021). Lieff, S.J. Perspective: The missing link in academic career planning and development: pursuit of meaningful and aligned work. Acad Med . 84 (10):1383-8 (2009). doi: 10.1097/ACM.0b013e3181b6bd54. PMID: 19881426. Lieff, S.J., Baker, L., Mori, B., Egan-Lee, E., Chin, K., Reeves, S. Who am I? Key influences on the formation of academic identity within a faculty development program. Med Teach . 34 (3):e208-15 (2012). doi: 10.3109/0142159X.2012.642827. PMID: 22364478. Lieff, S.J., Yammarino, F.J., How to Lead the Way Through Complexity, Constraint, and Uncertainty in Academic Health Science Centers. Acad Med . 92 (5):614-621 (2017). doi: 10.1097/ACM.0000000000001475. PMID: 28441672. Steinert, Y., Naismith, L., Mann, K. Faculty development initiatives designed to promote leadership in medical education. A BEME systematic review: BEME Guide No. 19. Med teach . 34 (6):483-503 (2012). Alwazzan, L., Al-Angari, S.S. Women's leadership in academic medicine: a systematic review of extent, condition and interventions. BMJ Open . 15(1):e032232 (2020). doi: 10.1136/bmjopen-2019-032232. PMID: 31948988; PMCID: PMC7044906. Kaur, A., Noman, M. Educational leadership and self-determination theory in collectivist cultures. 2020, In Oxford Research Encyclopedia of Education. Oxford University Press. https://doi.org/10.1093/acrefore/9780190264093.013.592 Day, D.V. Leadership development: A review in context. Leadersh Q . 11 (4):581-613 (2000). Ashford, S.J. DeRue, D.S. Developing as a leader: The power of mindful engagement. Organ Dyn . 41 (2):146-54 (2012). https://doi.org/10.1016/j.orgdyn.2012.01.008 Day, D.V. Dragoni L. Leadership development: An outcome-oriented review based on time and levels of analyses. Annu Rev Organ Psychol. Organ Behav. 2 (1):133-56 (2015). Pololi, L., Conrad, P., Knight, S., Carr, P. A study of the relational aspects of the culture of academic medicine. Acad Med . 84 (1):106-14 (2009). doi: 10.1097/ACM.0b013e3181900efc. PMID: 19116486. Pololi, L.H., Evans, A.T. Group Peer Mentoring: An Answer to the Faculty Mentoring Problem? A Successful Program at a Large Academic Department of Medicine. J Contin Educ Health Prof . 35 (3):192-200 (2015). doi: 10.1002/chp.21296. PMID: 26378425. O'Neil, M.L. Human resource leadership: the key to improved results in health. Hum Resour Health. 6 :10 (2008). https://doi.org/10.1186/1478-4491-6-10 Sherk, K.E., Nauseda, F., Johnson, S., et al. An experience of virtual leadership development for human resource managers. Hum Resour Health. 7 :1 (2009). https://doi.org/10.1186/1478-4491-7-1 Rees, C., Alwazzan, L., Gordon, L. Theory in Health Professions Education Research. In Foundations of Health Professions Education Research: Principles, Perspectives and Practices: Rees, C.E., Monrouxe, L.V., O’brien, B.C., Gordon, L.J., Palermo, C., Eds.; Wiley-Blackwell: Hoboken, New Jersey, 2023. Ten Cate, T.J., Kusurkar, R.A., Williams, G.C. How self-determination theory can assist our understanding of the teaching and learning processes in medical education. AMEE guide No. 59. Med Teach . 33 (12):961-73 (2009). doi: 10.3109/0142159X.2011.595435. PMID: 22225433. Bartholomew, K.J., Ntoumanis, N., Ryan, R.M., Bosch, J.A., Thøgersen-Ntoumani, C. Self-determination theory and diminished functioning: The role of interpersonal control and psychological need thwarting. Pers soc psychol bull . 37 (11):1459-73 (2011). Deci, E.L., Ryan, R.M. Self-determination theory. In Handbook of theories of social psychology ; Lang, P.A.M., Kruglanskji, A.W., Higgins, E.T., Eds.; Sage Publications: London, UK, 2012; Volume 1, pp. 416-433. Edward, L., Deci, E.L., Richard, M., Ryan. The "What" and "Why" of Goal Pursuits: Human Needs and the Self-Determination of Behavior, Psychol Inq 11 :4, 227-268 (2000). doi: 10.1207/S15327965PLI1104_01 Deci, E.L., Ryan, R.M. The" what" and" why" of goal pursuits: Human needs and the self-determination of behavior. Psychol Inq . 11 (4):227-68 (2000). Crotty, M. The Foundations of Social Research: Meaning and Perspective in the Research Process. Sage Publications: New York, 2003. Riessman, C.K., Quinney, L. Narrative in Social Work: A Critical Review. Qual Soc Work , 4 (4), 391–412 (2005). https://doi.org/10.1177/1473325005058643 Alwazzan, L. Interviewing medical education leaders: methodological considerations for a Saudi Arabian context. In Culturally sensitive research methods for educational administration and leadership, 1 st edition. Samier, E.A, Elkaleh, E.S.; Routeldge: London, 2023. Crouch, M., McKenzie, H. The logic of small samples in interview-based qualitative research. Soc Sci Inf , 45 (4):483–499 (2006). https://doi.org/10.1177/0539018406069584 Denzin, N.K. Lincoln, Y.S. Introduction: The Discipline and Practice of Qualitative Research. In The SAGE Handbook of Qualitative Research , 5th edition. Denzin, N.K., Lincoln, Y.S. Thousand Oaks: SAGE Publications, 2009; pp.10. Patton, M. Qualitative Evaluation and Research Methods: Integrating Theory and Practice, 4th edition. Thousand Oaks: SAGE Publications, 2014. Ritchie, J., Spencer, L. Qualitative Data Analysis for Applied Policy Research. In Analyzing Qualitative Data, Bryman, A., Burgess, R., Eds., Routledge, London, 1994; pp. 173-194. https://doi.org/10.4324/9780203413081_chapter_9 Alwazzan, L. Physicians and academic leadership: Key considerations from a social identity perspective. In Educational administration and leadership identity formation , 1 st edition. Samier, E.A., Milley, P., Eds.; Routledge, London, 2020. Additional Declarations No competing interests reported. Supplementary Files LeadInterviewsScheduleV122.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3163079","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":219621202,"identity":"d52a9f1d-4b12-4fcf-b0c0-e7ebe730a17e","order_by":0,"name":"Lulu Alwazzan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIiWNgGAWjYBACPgYeIFkA5X0AYjZ2AlrYwFoMIBzGGSARZlK0MPOASUJa2M8eYPhhcFhevv/ws8c2v7bJ8zEzMH74mINHC09eAmOPwWHDxoZj5sa5fbcN25gZmCVnbsPnsBwDBh6D24zNjA1m0rk9txmBWtiYefFp4X9jwPjH4LZ9GzP7N2nLHhCDkBaJHANmoC2JPWw8ZtIMP24nEqHljcFhGYP/yTN4eMokextuJ7cxMzbj9Qs/f47hwzcVabbz+49vk/jx57bt/Pbmgx8+4tECAgfgLMY2MNmAXz0q+EOK4lEwCkbBKBgpAADZF0bZ7l1J1wAAAABJRU5ErkJggg==","orcid":"","institution":"imam mohammad ibn saud islamic university","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Lulu","middleName":"","lastName":"Alwazzan","suffix":""}],"badges":[],"createdAt":"2023-07-12 09:14:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3163079/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3163079/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":48758383,"identity":"c809b930-846f-488e-8abd-4978479b619b","added_by":"auto","created_at":"2023-12-25 04:52:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":393640,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3163079/v1/9a95a1f6-8155-493f-8d11-c448837359b0.pdf"},{"id":40359921,"identity":"a63e8d33-0d43-4203-9dde-d9c0b88ff36b","added_by":"auto","created_at":"2023-07-21 08:09:36","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":94541,"visible":true,"origin":"","legend":"","description":"","filename":"LeadInterviewsScheduleV122.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3163079/v1/06c843f266907befc4f0d4f6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The medical school dean: Understanding the development of a leader through Self- Determination Theory","fulltext":[{"header":"Background","content":"\u003cp\u003eLeadership research in the field of medical education remains central, mostly because of the ever-evolving responsibilities for medical school deans and the accountability-driven context they work in [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. As a result, evidence-based practice in medical education leadership is crucial. The management of medical schools is of vital importance because of the massive contribution of medical schools to the healthcare workforce. The literature emphasizes the impact of leadership on the effectiveness of medical schools and undergraduate and postgraduate medical education quality [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Deans have a considerable potential in creating environments for faculty and learners that encourage excellence in education, scientific research production and translation, and community service. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Research resulted in numerous works on leadership styles [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], leadership identity formation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], and leadership development [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Less research is conducted on the \u003cem\u003eleader-as-learner\u003c/em\u003e and how a leader learns to be a leader in their sociocultural context [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLeader and leadership development are essential. Professionals take on formal leadership positions in medical schools such as deans, vice-deans, heads of departments, and program directors based on interest and career ambitions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. While previous research explored the development of skills and styles amongst leaders [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], we do not fully know how they go about enacting their leadership role while also learning about leadership. Here we draw a distinction between \u003cem\u003edevelopment of a leader\u003c/em\u003e and \u003cem\u003eleadership development\u003c/em\u003e. The former is concerned with the individual\u0026rsquo;s \u003cem\u003eability\u003c/em\u003e to lead, while the latter focuses on a \u003cem\u003eprocess\u003c/em\u003e of development that involves and influences multiple people simultaneously [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In this study, attention is paid to these two concepts, not in how they are different but in how they are related.\u003c/p\u003e \u003cp\u003eIndividual leadership competencies can be developed overtime [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. They can develop through mentoring, focused reflection and personal development [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], challenging assignments [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], and formal leadership development programs [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Most likely, a combination of these educational approaches can be utilized to prepare candidates and teams for their leadership roles [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. To be mentored and to receive challenging assignments is not done individually but requires others, both seniors and juniors, to play a role. Therefore, \u003cem\u003eLeader-as-learner\u003c/em\u003e is then not an individual undertaking but a relational and organizational process.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eGap in the literature, study aim and research questions (RQs)\u003c/h2\u003e \u003cp\u003eAlthough a wealth of leadership literature exists in medical education, to the knowledge of the author, none explored the individual development of leaders through a Self Determination Theory (SDT) lens. The latter will enrich our understanding of leadership at the individual granular level. Moreover, although many studies have addressed leadership development by cataloging the experiences of leaders, in this study exploration of leader-as-learner is explored. As a result, our understanding of leadership development and how it should be addressed is deepened. In this study, the following research questions are explored:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow do medical deans develop autonomy in their leadership?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow do medical deans perceive competency in their leadership?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow do medical deans experience relatedness in medical schools?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eTheoretical framework\u003c/h2\u003e \u003cp\u003eTo orient this study, it is important to draw on a theoretical framework to organize thinking around the phenomenon at hand [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This study, as mentioned earlier, is principled by SDT [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This theory has a set of psychological mechanisms relating to the self, mainly that humans are growth-oriented, who are inclined to develop, and to do so within and in coherence with the larger social structure [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This growth can be encouraged or discouraged by internal or external factors. To continue to grow there is a need for autonomy, competence, and relatedness to others in the larger social context [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn SDT, a great emphasis is put on motivation to grow, such motivation can range from lack of motivation (amotivation), internal motivation and external motivation. External motivation can lead to internalizations of certain values. To remain internally motivated, the need for autonomy, competence, and relatedness must be satisfied. A high internal motivation e.g. aspiration for leadership leads to better understanding of leadership processes and higher satisfaction with the leadership experience [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThe study is underpinned by social constructionism, whereby individuals construct and interpret realities based on their own experiences and interplay with others and the environment [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. A qualitative research approach was utilized for this study, employing narrative inquiry, asking participants open-ended questions such as \u003cem\u003ewhat does this concept mean to you? How did it influence you?\u003c/em\u003e The latter approach encourages understanding the human experience through the construction and reconstruction of narratives [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] thus affording the researcher an opportunity to understand the complexities of leader and leadership development. The study was conducted in accordance with the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of the College of Medicine, Imam Mohammad Ibn Saud Islamic University.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSetting, data collection and participants\u003c/h2\u003e \u003cp\u003eThe study was conducted in Riyadh, Saudi Arabia during the months of July - May 2022. Data were collected by semi-structured individual interviews. Interviews were expected to produce rich in-depth data. They were found appropriate because this study is concerned with meaning and does not aim to generalize the findings [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. To be eligible for participation, participants must have at least 1 year work experience as a dean.\u003c/p\u003e \u003cp\u003eThe researcher contacted potential participants via e-mail invitation giving an overview of the research, eligibility criteria, and contact details of the researcher. To ensure the anonymity of those who wish to participate, they were asked to contact the researcher directly. The researcher then proceeded to personally contact the participants by phone, give an overview of the research and arrange for the interview. Interviews were 30\u0026ndash;60 minutes long and were conducted in Arabic. They were audio-recorded and each recording was given a unique identifier to protect the identity of the participant and stored in a specific drive for the project. The semi-structured interviews were guided by an interview guide (Supplementary A) developed by the researcher based on the chosen theoretical framework and the literature review. Consent was sought at the beginning of the interview and participants were asked for verbal and written consent. Participants were ensured of their anonymity and right to withdraw at any time.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe portfolio of data generated were secured in three electronic folders. A folder for the interview transcripts, the text and its analysis, and the text translations. Quotes included in the article were translated from Arabic to English by the author (then back translated by a translator to ensure consistency) for the purpose of publication. Data from the text and interview transcripts were analyzed using framework analysis. Framework analysis is defined as \"an analytical process which involves a number of distinct though highly interconnected stages\" [30] (p. 177). The framework has five phases of analysis including: familiarization, identifying a thematic framework, indexing, charting, and mapping/interpretation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFive out of seven deans working in the capital Riyadh, Saudi Arabia took part in this study. Deans ages ranged from 42\u0026ndash;53 years, the sample included both male and female participants, years served as a dean ranged 1\u0026ndash;4 years. Eight themes were identified, two themes relating to RQ1: Defining autonomy and role negotiation; Four themes relating to RQ2: Experience of mastery, influence of resources, formal leadership programs, and Evidence of realizing organizational goals; and two themes relating to RQ3: Interpersonal relationships and personal fulfillment. Each theme is presented in the following sections and illustrative quotes are shared.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eHow do deans develop autonomy in their leadership?\u003c/h2\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eDefining autonomy\u003c/h2\u003e \u003cp\u003eWhen asked \u0026ldquo;what is your understanding of autonomy in your leadership?\u0026rdquo;, participants conceptualized autonomy in 3 ways. First, autonomy related to decision-making as a necessary skill for the dean. This was viewed as the individual ability to decide on one\u0026rsquo;s own. This is influenced by the magnitude of the decision that needs to be made and if the dean had prior experience. The need for competence in decision making refers to the sense of self-efficacy and belief in one\u0026rsquo;s ability to perform and make an impact. As the following participant shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;My leadership shows in my ability to make difficult decisions and to be firm about it, the more experience I gain the further I can go with my decisions.\u0026rdquo; (Dean_1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSecond, participants view their autonomy as it relates to supporting a decision with scientific evidence. As practicing physicians, deans often believed their scientific training and commitment to evidence-based practice, gave them more authority and enabled them as leaders, as one participant shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I\u0026rsquo;m highly trained with advanced degrees and I\u0026rsquo;m a highly published author in my field, my decisions are backed-up by my extensive training and experience. I don\u0026rsquo;t do things without reading extensively about it.\u0026rdquo; (Dean_2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThird, autonomy manifested as being self-determined to pursue goals and activities. Participants expressed a need for making decisions that are situated in the broader context, stating that medical schools are no longer seen as mere schools graduating practicing physicians, rather as entities contributing to the healthcare workforce and influencers of health economy:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;We are not producing doctors; we are contributing to the economy. If you think of it this way you recognize that as a leader you must have great ambitions and goals for the school\u0026rdquo; (Dean_4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eRole negotiation\u003c/h2\u003e \u003cp\u003e Participants also negotiated their professional versus personal roles as well as in-between their professional roles. Learner autonomy was often challenged by deans\u0026rsquo; personal lives. Participants admitted to a compromise in one\u0026rsquo;s personal life to fulfil their leadership role as dean and in turn learn, as one participant shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;To do this job I\u0026rsquo;ve sacrificed my personal life, my children must be more independent. Although I think there must be better models for work-life balance. I have colleagues whose solution is to leave the position to make time for their personal lives. I\u0026rsquo;m continuously looking for ways to balance, that is my responsibility as a leader to learn how to balance\u0026rdquo; (Dean_1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother role negotiation that was appreciated in the data was the professional versus professional. That is, many participants spoke about their different professional roles, their roles as clinicians, teachers, researchers, and leaders. One participant shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I don\u0026rsquo;t spend much time in the clinic now that I\u0026rsquo;m the dean. I think this job is demanding and you must be ready for it and there are sacrifices you need to make. That is a decision I made to grow professionally. I don\u0026rsquo;t view it as a bad thing.\u0026rdquo; (Dean_3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eHow do medical deans perceive competence in their leadership development?\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003eExperience of mastery\u003c/h2\u003e \u003cp\u003eThis theme considered participants\u0026rsquo; abilities and experiences of mastery. Most of the data from junior deans focused directly on the internal conflict, the regulation of self-motivation to lead, and facing burnout. For example:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;There are many demands. I\u0026rsquo;m overwhelmed most times, and I find difficulty in delegating to others\u0026rdquo; (Dean_1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMost participants spoke about situations where external parties influenced productivity and efficiency as a leader.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;If we have support from senior leadership, we can achieve, if we don\u0026rsquo;t have the support, it is very difficult to accomplish anything\u0026rdquo; (Dean_2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAlthough some participants narrated situations where they were able to demonstrate competence, this demonstration was sometimes undermined by a lack of senior team members who provide a mentorship role, stating reticence in initiation of certain activities, as the following participant shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;It is challenging to motivate everyone all the time. The vice-deans and the head of departments take on some of the responsibility for their own teams. I need a senior someone to motivate me too, to sign off on some of my plans. Some ideas, I leave because I\u0026rsquo;m thinking it is too small or too difficult.\u0026rdquo; (Dean_5)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOthers shared the challenge in demonstrating competence in the face of different organizational challenges:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;In our schools we remain optimistic no matter the situation, but optimism is not always beneficial. You either have the knowledge and skills to preform or you don\u0026rsquo;t. At the end of the day there are performance indicators that we must meet.\u0026rdquo; (Dean_4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIt was noticed that the more senior a leader is, the less talk there was on motivation to lead, whether internally or externally, rather on the ability to motivate others.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I don\u0026rsquo;t motivate myself, I motivate others, and others motivate me.\u0026rdquo; (Dean_2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eInfluence of resources\u003c/h2\u003e \u003cp\u003eIn this theme participants spoke about the influence of resources on their competence such as: availability of material resources and the ability to recruit competent human capital. In terms of availability of resources one participant shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;We are limited by resources; we don\u0026rsquo;t have enough to accomplish our desired goals. This demotivates me and those around me. In many ways I feel a responsibility to provide for my staff and their projects. As a leader who is constantly learning as I go, I find difficulty to thrive in a limiting environment\u0026rdquo; (Dean_2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn terms of human capital, one participant shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;It is difficult nowadays to find people, competent people, who are willing to work in academics. Even when you are lucky to recruit them, it will be difficult to keep them in academics. This is one of the areas I need to develop in myself\u0026hellip;human capital management\u0026rdquo; (Dean_3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eFormal leadership programs\u003c/h2\u003e \u003cp\u003eParticipants spoke about leadership training programs as a way to introduce themselves as potential leaders to their professional community, as one participant shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I knew I wanted to be the dean, so leadership development programs were a way to announce that, that I\u0026rsquo;m working on myself improving my knowledge and skills formally.\u0026rdquo; (Dean_3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOther participants spoke about leadership programs after the fact, serving as a catalyst for their growth, as one participant shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I became painfully aware of the skills I lacked when I took the job. As soon as a I realized, I looked around for workshops or something to orient me to my duties. There are some aspects I wasn\u0026rsquo;t aware of, financial management for example, you can find programs online.\u0026rdquo; (Dean_2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eEvidence of realizing organizational outcomes\u003c/h2\u003e \u003cp\u003eThe accomplishment of outcomes was prevalent across all participant narratives. Leaders linked their motivation to work and the ability to motivate others to competence and accomplishment of goals. For example:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Excellence is a choice. If you make that choice before you begin you will always be able to give fully and realize organizational goals.\u0026rdquo; (Dean_2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, participants often described their unpreparedness to deal with the volume of employees, as the following participant shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;It is surprising to me that my teaching role did not end but took a different shape. Both senior and junior staff, need constant mentoring. I need a crash course on how to mentor many people, I think that effects our bottom line\u0026rdquo; (Dean_5)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eHow do medical deans experience relatedness in medical schools?\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eInterpersonal relationships\u003c/h2\u003e \u003cp\u003e Participants spoke about the reciprocity among people when they felt a sense of connectedness and belonging. Positive interpersonal relationships nurtured a sense of security and caring.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I make an honest effort to get to know everyone I work with; I also make a point of inviting their families in reward ceremonies. I want them to celebrate their accomplishments with their family in addition to their professional family.\u0026rdquo; (Dean_5)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003ePersonal fulfillment\u003c/h2\u003e \u003cp\u003eParticipants put great emphasis on certain feelings being a driving factor of success, as individuals and as an organization: Personal fulfillment, engagement, and quality of job performance were essential components of success.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I have my own ambitions for my development and career goals. My colleagues, and the university help me achieve them.\u0026rdquo; (Dean_4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants described job performance as directly related to a sense of belonging.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;In my current role as dean I was able to connect with my vice-deans. I tried to build a team. They are my executive group. That makes me want to come to work that I\u0026rsquo;m supported by a leadership team.\u0026rdquo; (Dean_1)\u003c/p\u003e\u003cp\u003eFinally, participants often referred to the larger macro context and the national and health transformation taking place in Saudi Arabia as a reason for increased belonging:\u003c/p\u003e\u003cp\u003e\u0026ldquo;What we do in the medical college in directly related to Saudi Vision 2030. We have a duty to realize the Health Transformation Program and we come to work every day with this in our minds, how to contribute to the greater good\u0026rdquo; (Dean_5)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study adds to previous work on leadership in medical education, taking a granular view of medical school deans\u0026rsquo; development within the Saudi Arabian context, examining their perceptions through a SDT lens. When speaking of their autonomy as learners, participants of this study highlighted the ability to make a decision, being evidence-based in their leadership practice, and being self-determined to pursue goals and activities as necessary skills. The results of this study show that deans prioritized leadership education and training, regarding it as a positive influencer and a reason for pursuing and remaining in leadership. To better our understanding of the role of autonomy in learning to be a leader, educators and researchers must expand their thinking beyond the role of formal leadership training; that is, formal training may be utilized to expand an individual\u0026rsquo;s leadership competency but through experiential learning and through managerial assignments that increase in difficulty as the leader grows, as mentioned in the literature [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], may be a more effective means of learning.\u003c/p\u003e \u003cp\u003eMoreover, autonomy is classified as a universal psychological need, that must be supported to enhance motivation and facilitate internalization [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and in turn leadership components such decision-making and exercising influence become regulated behaviors. As the leadership development field continues to grow, SDT may be a suitable framework to explore the role of autonomy support and development in the area of role negotiation (professional versus personal) as well as professional role negotiation (clinician versus leader). That is, how one can achieve work-life balance. Neglecting this area may lead to loss of talent, as many qualified and promising candidates may self-exclude because of their perceived inability to achieve balance. This will give leader and leadership development a roadmap as it seeks to fulfil its goals in developing a better organizational culture and leadership experiences.\u003c/p\u003e \u003cp\u003eAccording to the participants of this study, for deans to have more meaningful leadership experiences, motivational factors included internal, external, and a reciprocal type of motivation must be considered. More junior deans faced burnout and struggled to be internally motivated. This is aligned with SDT thinking, as the more novice a learner the more likely they need external motivation [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The external motivators identified in this study included material and human resources, as well as senior leadership support. These findings agree with previous leadership studies in academic medicine [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. More senior deans had an appreciation that they themselves were a motivator to others and vice versa. This finding highlights the importance of giving team members the opportunity to contribute to the decision making, this may transition potential leaders from indirect on-the-job training or coaching to direct formal training. Leaders often feel the pressure to perform in their capacity as individual leaders who must be self-sufficient; that is leadership as acting independently and showing confidence for others to follow. However, recognizing that leadership is a group process, where the responsibility to achieve is a team effort, may increase motivation and sense of belonging amongst individuals and groups alike.\u003c/p\u003e \u003cp\u003eThe results of this study showed that National Health Transformation Program, gave participants a chance to relate to the larger national context, and as a result felt more empowered to engage in leadership. In relation to a higher purpose, participants\u0026rsquo; opinions were of empowerment and transformation. Further studies are needed to explore leaders\u0026rsquo; experiences of leading transformation. Such a form of leadership may be addressed in leadership programs; that is, development of learning communities i.e. leadership development programs where the primary objective is to encourage relatedness and build professional relationships that one can depend on and as a result motivation for transformation and organizational growth.\u003c/p\u003e \u003cp\u003eDrawing on the concept of relatedness, an interpersonal orientation to leadership is needed. Established leaders can be mentors, coaches, or sponsors, providing career opportunities for potential leaders, guidance in navigating such opportunities, and contributing to meaningful career growth. Fostering such professional relationships has been associated with greater career satisfaction [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e31\u003c/span\u003e], thus increasing motivation for leadership and encouraging the development of self-regulation later. This leads to key considerations for the role of active professional relationship development and how such relationships can be fostered.\u003c/p\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eMethodological strengths and limitations\u003c/h2\u003e \u003cp\u003eThis study is strengthened by its originality, to the author\u0026rsquo;s knowledge it is the first study utilizing Self-Determination Theory to understand the development of leaders in academic medicine. The results are consistent with findings of other leadership development research. Although, this study sheds light on the complex interplay between leader\u0026rsquo;s autonomy, motivation to lead and leaders\u0026rsquo; ability to motivate others and how that contributes to organizational culture, a larger sample size, that includes deans from other Saudi Arabian cities, is needed for the findings to be transferable to other contexts. Moreover, although the study shows a positive impression of leadership training programs, it does not measure actual outcomes or impact. As a result, the full effect of educational programs formal or informal cannot be determined.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eImplication for educational practice and policy\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eDespite the methodological limitations of this study, the findings have several implications for educational practice and policy. First, at the individual level, leaders and candidates for administrative positions should be educated in their leadership roles. Leaders need to understand what role autonomy, competency, and relatedness play in their development as leaders and how to best cultivate these aspects while practicing leadership. Second, in terms of the organizational level, policies regarding leadership recruitment and development of leaders belonging to the medical school need to be developed. Such policies may foster better workplace culture that prioritizes leadership development that may lead to efficient and effective organizations.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eImplications for research\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eFurther qualitative and quantitative research are needed with expansion of the leader type such as heads of departments and program directors, in order to explore the generalisability of our findings beyond senior leadership (dean), as well as beyond the Saudi Arabian context. Further studies should aim to collect data from junior aspiring leaders in postgraduate training and who may have a different experience of leadership. Furthermore, researchers should evaluate the outcomes of interventions designed and implemented to improve leadership practice in medical education. As a result of this study, the use of Self-Determination Theory to understand the development of leaders in medical education and how this may inform the design of leadership development programs are recommended. Finally, this study shows that leadership is a relational process, therefore, more qualitative study designs are recommended to understand how professional relationships are initiated and nurtured overtime.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eLeader and leadership development in Saudi Arabian medical education is vital for the growth of the healthcare sector. Using an SDT lens, this study presented several findings that may direct future studies and educational leadership programs. Understanding the leader-as learner including the development of their autonomy, competency, and sense of relatness may help us better prepare deans and motivate them for their leadership roles in medical schools, contributing to the quality of medical education and practice.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s Contributions:\u003c/strong\u003e The author has read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement:\u0026nbsp;\u003c/strong\u003eThe study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of College of Medicine, Imam Mohammad Ibn Saudi Islamic University (protocol code 272/2022 and 1/7/2022)\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement:\u0026nbsp;\u003c/strong\u003eInformed consent was obtained from all subjects involved in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e The data presented in this study are available on request from the corresponding author. The data are not publicly available due to\u0026nbsp;anonymity and protection of the participant privacy. The population of the study is limited, and participants may be easily identified.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e The author wishes to thank Dr Nouf Alharbi for her unwavering support.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest:\u003c/strong\u003e The author declares no conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHitt, D.H. Tucker, P.D. Systematic review of key leader practices found to influence student achievement: A unified framework. \u003cem\u003eRev educ res\u003c/em\u003e. \u003cstrong\u003e86\u003c/strong\u003e(2):531-69 (2016).\u003c/li\u003e\n\u003cli\u003eLeithwood, K. School leadership in the context of accountability policies. \u003cem\u003eInt J Leadersh Educ\u003c/em\u003e. \u003cstrong\u003e4\u003c/strong\u003e(3):217-35 (2001).\u003c/li\u003e\n\u003cli\u003eMuijs, D. Leadership and organisational performance: from research to prescription? \u003cem\u003eInt J Educ Manag\u003c/em\u003e. \u003cstrong\u003e25\u003c/strong\u003e(1):45-60 (2011). https://doi.org/10.1108/09513541111100116\u003c/li\u003e\n\u003cli\u003eMcKimm, J., Lieff, S.J. Medical education leadership. A Practical Guide for Medical Teachers, E-Book. \u003cstrong\u003e24\u003c/strong\u003e:429 (2021).\u003c/li\u003e\n\u003cli\u003eLieff, S.J. Perspective: The missing link in academic career planning and development: pursuit of meaningful and aligned work. \u003cem\u003eAcad Med\u003c/em\u003e. \u003cstrong\u003e84\u003c/strong\u003e(10):1383-8 (2009). doi: 10.1097/ACM.0b013e3181b6bd54. PMID: 19881426. \u003c/li\u003e\n\u003cli\u003eLieff, S.J., Baker, L., Mori, B., Egan-Lee, E., Chin, K., Reeves, S. Who am I? Key influences on the formation of academic identity within a faculty development program. \u003cem\u003eMed Teach\u003c/em\u003e. \u003cstrong\u003e34\u003c/strong\u003e(3):e208-15 (2012). doi: 10.3109/0142159X.2012.642827. PMID: 22364478.\u003c/li\u003e\n\u003cli\u003eLieff, S.J., Yammarino, F.J., How to Lead the Way Through Complexity, Constraint, and Uncertainty in Academic Health Science Centers. \u003cem\u003eAcad Med\u003c/em\u003e. \u003cstrong\u003e92\u003c/strong\u003e(5):614-621 (2017). doi: 10.1097/ACM.0000000000001475. PMID: 28441672.\u003c/li\u003e\n\u003cli\u003eSteinert, Y., Naismith, L., Mann, K. Faculty development initiatives designed to promote leadership in medical education. A BEME systematic review: BEME Guide No. 19. \u003cem\u003eMed teach\u003c/em\u003e. \u003cstrong\u003e34\u003c/strong\u003e(6):483-503 (2012).\u003c/li\u003e\n\u003cli\u003eAlwazzan, L., Al-Angari, S.S. Women\u0026apos;s leadership in academic medicine: a systematic review of extent, condition and interventions. \u003cem\u003eBMJ Open\u003c/em\u003e. 15(1):e032232 (2020). doi: 10.1136/bmjopen-2019-032232. PMID: 31948988; PMCID: PMC7044906.\u003c/li\u003e\n\u003cli\u003eKaur, A., Noman, M. Educational leadership and self-determination theory in collectivist cultures. 2020, In Oxford Research Encyclopedia of Education. Oxford University Press. https://doi.org/10.1093/acrefore/9780190264093.013.592\u003c/li\u003e\n\u003cli\u003eDay, D.V. Leadership development: A review in context. \u003cem\u003eLeadersh Q\u003c/em\u003e. \u003cstrong\u003e11\u003c/strong\u003e(4):581-613 (2000).\u003c/li\u003e\n\u003cli\u003eAshford, S.J. DeRue, D.S. Developing as a leader: The power of mindful engagement. \u003cem\u003eOrgan Dyn\u003c/em\u003e. \u003cstrong\u003e41\u003c/strong\u003e(2):146-54 (2012). https://doi.org/10.1016/j.orgdyn.2012.01.008\u003c/li\u003e\n\u003cli\u003eDay, D.V. Dragoni L. Leadership development: An outcome-oriented review based on time and levels of analyses. \u003cem\u003eAnnu Rev Organ Psychol. Organ Behav.\u003c/em\u003e\u003cstrong\u003e2\u003c/strong\u003e(1):133-56 (2015).\u003c/li\u003e\n\u003cli\u003ePololi, L., Conrad, P., Knight, S., Carr, P. A study of the relational aspects of the culture of academic medicine. \u003cem\u003eAcad Med\u003c/em\u003e. \u003cstrong\u003e84\u003c/strong\u003e(1):106-14 (2009). doi: 10.1097/ACM.0b013e3181900efc. PMID: 19116486.\u003c/li\u003e\n\u003cli\u003ePololi, L.H., Evans, A.T. Group Peer Mentoring: An Answer to the Faculty Mentoring Problem? A Successful Program at a Large Academic Department of Medicine. \u003cem\u003eJ Contin Educ Health Prof\u003c/em\u003e. \u003cstrong\u003e35\u003c/strong\u003e(3):192-200 (2015). doi: 10.1002/chp.21296. PMID: 26378425.\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Neil, M.L. Human resource leadership: the key to improved results in health. \u003cem\u003eHum Resour Health. \u003c/em\u003e\u003cstrong\u003e6\u003c/strong\u003e:10 (2008). https://doi.org/10.1186/1478-4491-6-10 \u003c/li\u003e\n\u003cli\u003eSherk, K.E., Nauseda, F., Johnson, S., \u003cem\u003eet al.\u003c/em\u003e An experience of virtual leadership development for human resource managers. \u003cem\u003eHum Resour Health. \u003c/em\u003e\u003cstrong\u003e7\u003c/strong\u003e:1 (2009). https://doi.org/10.1186/1478-4491-7-1 \u003c/li\u003e\n\u003cli\u003eRees, C., Alwazzan, L., Gordon, L. Theory in Health Professions Education Research. In Foundations of Health Professions Education Research: Principles, Perspectives and Practices: Rees, C.E., Monrouxe, L.V., O\u0026rsquo;brien, B.C., Gordon, L.J., Palermo, C., Eds.; Wiley-Blackwell: Hoboken, New Jersey, 2023.\u003c/li\u003e\n\u003cli\u003eTen Cate, T.J., Kusurkar, R.A., Williams, G.C. How self-determination theory can assist our understanding of the teaching and learning processes in medical education. AMEE guide No. 59. \u003cem\u003eMed Teach\u003c/em\u003e. \u003cstrong\u003e33\u003c/strong\u003e(12):961-73 (2009). doi: 10.3109/0142159X.2011.595435. PMID: 22225433.\u003c/li\u003e\n\u003cli\u003eBartholomew, K.J., Ntoumanis, N., Ryan, R.M., Bosch, J.A., Th\u0026oslash;gersen-Ntoumani, C. Self-determination theory and diminished functioning: The role of interpersonal control and psychological need thwarting. \u003cem\u003ePers soc psychol bull\u003c/em\u003e. \u003cstrong\u003e37\u003c/strong\u003e(11):1459-73 (2011).\u003c/li\u003e\n\u003cli\u003eDeci, E.L., Ryan, R.M. Self-determination theory. In \u003cem\u003eHandbook of theories of social psychology\u003c/em\u003e; Lang, P.A.M., Kruglanskji, A.W., Higgins, E.T., Eds.; Sage Publications: London, UK, 2012; Volume 1, pp. 416-433.\u003c/li\u003e\n\u003cli\u003eEdward, L., Deci, E.L., Richard, M., Ryan. The \u0026quot;What\u0026quot; and \u0026quot;Why\u0026quot; of Goal Pursuits: Human Needs and the Self-Determination of Behavior, \u003cem\u003ePsychol Inq\u003c/em\u003e\u003cstrong\u003e11\u003c/strong\u003e:4, 227-268 (2000). doi: 10.1207/S15327965PLI1104_01\u003c/li\u003e\n\u003cli\u003eDeci, E.L., Ryan, R.M. The\u0026quot; what\u0026quot; and\u0026quot; why\u0026quot; of goal pursuits: Human needs and the self-determination of behavior. \u003cem\u003ePsychol Inq\u003c/em\u003e. \u003cstrong\u003e11\u003c/strong\u003e(4):227-68 (2000).\u003c/li\u003e\n\u003cli\u003eCrotty, M. The Foundations of Social Research: Meaning and Perspective in the Research Process. Sage Publications: New York, 2003. \u003c/li\u003e\n\u003cli\u003eRiessman, C.K., Quinney, L. Narrative in Social Work: A Critical Review. \u003cem\u003eQual Soc Work\u003c/em\u003e, \u003cstrong\u003e4\u003c/strong\u003e(4), 391\u0026ndash;412 (2005). https://doi.org/10.1177/1473325005058643\u003c/li\u003e\n\u003cli\u003eAlwazzan, L. Interviewing medical education leaders: methodological considerations for a Saudi Arabian context. In Culturally sensitive research methods for educational administration and leadership, 1\u003csup\u003est\u003c/sup\u003e edition. Samier, E.A, Elkaleh, E.S.; Routeldge: London, 2023. \u003c/li\u003e\n\u003cli\u003eCrouch, M., McKenzie, H. The logic of small samples in interview-based qualitative research. \u003cem\u003eSoc Sci Inf\u003c/em\u003e, \u003cstrong\u003e45\u003c/strong\u003e(4):483\u0026ndash;499 (2006). https://doi.org/10.1177/0539018406069584\u003c/li\u003e\n\u003cli\u003eDenzin, N.K. Lincoln, Y.S. Introduction: The Discipline and Practice of Qualitative Research. \u003cem\u003eIn The SAGE Handbook of Qualitative Research\u003c/em\u003e, 5th edition. Denzin, N.K., Lincoln, Y.S. Thousand Oaks: SAGE Publications, 2009; pp.10.\u003c/li\u003e\n\u003cli\u003ePatton, M. Qualitative Evaluation and Research Methods: Integrating Theory and Practice, 4th edition. Thousand Oaks: SAGE Publications, 2014.\u003c/li\u003e\n\u003cli\u003eRitchie, J., Spencer, L. Qualitative Data Analysis for Applied Policy Research. In Analyzing Qualitative Data, Bryman, A., Burgess, R., Eds., Routledge, London, 1994; pp. 173-194. https://doi.org/10.4324/9780203413081_chapter_9\u003c/li\u003e\n\u003cli\u003eAlwazzan, L. Physicians and academic leadership: Key considerations from a social identity perspective. \u003cem\u003eIn Educational administration and leadership identity formation\u003c/em\u003e, 1\u003csup\u003est\u003c/sup\u003e edition. Samier, E.A., Milley, P., Eds.; Routledge, London, 2020.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Leadership, Leader, Management, Organizational culture, Leadership Development, Medical Education, Academic Medicine, Medical School","lastPublishedDoi":"10.21203/rs.3.rs-3163079/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3163079/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eHow a dean develops in context is crucial for our understanding of medical school administration. Exploring deans\u0026rsquo; leadership experience may enrich our understanding of how they emerge, enact, and remain in administration. This study explores essential components of individual development and learning as outlined by Self-Determination Theory; that is, how deans develop autonomy in leadership, competency to lead, and a sense of belonging to medical schools. Semi-structured interviews were conducted with medical school deans in Riyadh city, Saudi Arabia. Participants were invited via email. Informed consent was secured. Interviews were conducted virtually, audio-recorded and transcribed. Data were analyzed using framework analysis. Five participants took part in the study. Eight themes were identified and in direct relation to the research questions:1) Leader\u0026rsquo;s autonomy: Defining autonomy and role negotiation), 2) Leader\u0026rsquo;s competency in leadership: Experience of mastery, influence of resources, formal leadership programs, and achievement of organizational goals), and 3) Sense of belonging: Interpersonal relationships and personal fulfillment. This study provides insights on the development of leaders in medical education at the granular level. Investment in developing deans as leaders and their teams through professional development programs may instigate transformational change for individuals and the executive leadership team, and if attention is paid to the leader as learner-in-context.\u003c/p\u003e","manuscriptTitle":"The medical school dean: Understanding the development of a leader through Self- Determination Theory","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-07-21 08:09:27","doi":"10.21203/rs.3.rs-3163079/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fa70d90c-358e-475b-9f6e-dffb7f91b71f","owner":[],"postedDate":"July 21st, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":23360608,"name":"Health sciences/Health care/Health policy"},{"id":23360609,"name":"Health sciences/Health care/Health care economics"}],"tags":[],"updatedAt":"2023-12-25T04:44:18+00:00","versionOfRecord":[],"versionCreatedAt":"2023-07-21 08:09:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3163079","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3163079","identity":"rs-3163079","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}