The medical school dean: understanding the development of a leader through self-determination theory

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 Hitt and Tucker (2016), Leithwood (2001) and Muijs (2011). 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 health-care workforce. The literature emphasizes the impact of leadership on the effectiveness of medical schools and undergraduate and postgraduate medical education quality (McKimm and Lieff, 2021; Lieff, 2009). 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 (Lieff et al., 2012; Lieff and Yammarino, 2017). Research resulted in numerous works on leadership styles (Steinert et al., 2012), leadership identity formation (Lieff et al., 2012) and leadership development (Alwazzan and Al-Angari, 2020). Less research is conducted on the leader-as-learner and how a leader learns to be a leader in their sociocultural context (Kaur and Noman, 2020).

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 (Lieff et al., 2012). While previous research explored the development of skills and styles among leaders (Lieff, 2009), we do not fully know how they go about enacting their leadership role while also learning about leadership. Here, we draw a distinction between the 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 (Day, 2000). 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 over time (Ashford and DeRue, 2012). They can develop through mentoring, focused reflection and personal development (Ashford and DeRue, 2012), challenging assignments (Day and Dragoni, 2015) and formal leadership development programs (Alwazzan and Al-Angari, 2020). Most likely, a combination of these educational approaches can be used to prepare candidates and teams for their leadership roles (Pololi et al., 2009; Pololi and Evans, 2015; O'Neil, 2008; Sherk et al., 2009). 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.

In the literature, leadership has been extensively examined through multiple theoretical/conceptual frameworks. Classical trait perspectives focused on individual characteristics and behaviors. On the other hand, contingency theories gave special consideration to situational context to shape leadership effectiveness (Northouse, 2019; Fiedler, 1964). More recent leadership theories such as authentic and transformational leadership, emphasize values and influencing others, ultimately shaping organizational culture (Avolio and Gardner, 2005; Bass and Riggio, 2006). Health care and higher education contexts may be considered complex requiring more nuanced frameworks like the distributed leadership framework, this framework the interdependence and the need for collective responsibility (Spillane, 2005; Gronn, 2002). Collectively, the models highlight that leadership is not solely positional but an interpersonal process that is shaped by context.

In medical education, the complexity is increased because institutes may deliver education and research while simultaneously delivering clinical services. Previous works in medical education examined leadership practices (Frich et al., 2015), organizational culture (Mann, 2011) and leadership development in varying specialties (Straus et al., 2013). However, much of the produced research has focused on leadership behaviors and reporting leadership development interventional programs. Less has been published on how individuals develop leadership identities.

Progression of careers into leadership positions and role in academic medicine was also explored, demonstrating that leadership trajectories are not always linear and highly influenced by role expansion rather than deliberate career planning (Frich et al., 2015). Aspirations for leadership are shaped by perceived self-efficacy as well as feasibility, that is, how one balances leadership responsibilities with other professional and personal obligations (Mann, 2011). These qualities are highly important for medical school deans because deanship carries a high level of accountability and role ambiguity.

Formal as well as informal processes of leadership development have been studied in academic medicine. Formal approaches include structured leadership programs, executive education and fellowships aimed at developing leadership competencies. Such competencies include strategy building and execution, interpersonal skills and conflict management (Straus et al., 2013). Informal development happens through experiential learning, mentoring and peer communities of practice (Sambunjak et al., 2006; Wenger, 1998). Evidence suggests that the combination of formal and informal leadership approaches embedded within work contexts is most effective (Day, 2000). It is important to note that the availability of leadership development programs across institutions is variable and often costly. As a result, not everyone has access to such opportunities (Straus et al., 2013).

Fewer studies have conceptualized leadership development as an internal process, especially in medical education. Understanding why faculty members aspire to leadership and how they remain engaged is worthy of exploration. Self-Determination Theory (SDT) offers a framework by which we can examine leader development through core psychological needs: autonomy, competence and relatedness (Ryan and Deci, 2000). Examining leadership development through an SDT lens takes us beyond skills and behaviors, but a learner-centered and context-dependent process shaped by autonomy and personal agency, competence and growing mastery, and professional relationships and relatedness.

Although a wealth of leadership literature exists in medical education, to the knowledge of the author, none has explored the individual development of leaders through an SDT lens. The latter will enrich our understanding of leadership at the individual granular level. SDT is a theory of human motivation and development that posits three psychological needs: autonomy, competence and relatedness as essential for sustained motivation and learning. This theoretical lens was selected for the study because it provides a lens for understanding how individuals internalize their leadership roles and not only how they acquire managerial skills. Moreover, although many studies have addressed leadership development by cataloging the experiences of leaders, in this study, the 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 constructs of autonomy, competence and relatedness from SDT are drawn upon. They are defined as core psychological needs that shape leadership development and for the purposes of this study. Autonomy refers to the experiences of agency and self-endorsements in leadership role enactment. Competence is about the perception of effectiveness and mastery of leadership skills. Finally, relatedness refers to the experiences of connection and belonging one experiences within professional settings. These constructs were used as guides rather than predetermined categories imposed on participants. The following research questions were developed to explore how medical school deans self-describe and interpret their experience of autonomy, competence and relatedness in their leadership development:

To orient this study, it is important to draw on a theoretical framework to organize thinking around the phenomenon at hand (Deci and Ryan, 2008). SDT was chosen to guide this study because it is a well-established, empirically supported argument of the process by which individuals develop and maintain motivation, as well as internalize complex organizational roles such as the role of a leader. Opposite other leadership theories which focus on traits, styles or behaviors, SDT roots the leader as a learner-in-context. This makes the theory suitable for understanding how medical school deans come to develop as leaders and enact leadership roles over a period. The latter is the main objective of this, that is, not only how deans develop as leaders but also how they find meaning in their leadership (Deci and Ryan, 2008; Ten Cate, 2017; Kusurkar et al., 2011). 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 (Rees et al., 2023). 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 (Ten Cate et al., 2009).

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 internalization of certain values. To remain internally motivated, the need for autonomy, competence and relatedness must be satisfied. A high internal motivation, for example, aspiration for leadership leads to better understanding of leadership processes and higher satisfaction with the leadership experience (Bartholomew et al., 2011; Deci and Ryan, 2012).

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 (Edward et al., 2000). Social constructionism views knowledge and meaning as generated through social interaction and social context. As a result, leadership development is understood as a process that is socially constructed influenced by relationships, institutional roles and cultural expectations, rather than a group of traits. To that end, a qualitative research approach was used for this study, using 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 (Deci and Ryan, 2000; Crotty, 2003) thus affording the researcher an opportunity to understand the complexities of leader and leadership development particularly in relation to motivation, meaning-making and psychological need satisfaction 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.

In the Kingdom of Saudi Arabia, the landscape of medical education has undergone great transformation. Over the course of a decade, the number of medical schools surged from 5 institutions using traditional discipline-based curricula to over 40 medical schools featuring diverse curricular approaches. These approaches span the spectrum from traditional models to more progressive, problem-based and community-oriented programs. In addition to human capital, medical schools in Saudi Arabia provide medical services to society and produce scientific research. Therefore, medical school deans are expected to lead complex systems that hold a large responsibility. Medical schools can be categorized into governmental and private schools. Schools included in this study may be categorized into urban city-based schools. The schools vary in size, serving a student body of 500–2000 undergraduate medical students and use 150–400 faculty members in varying specialties, including clinical and basic science faculty. These schools operate within teaching hospital networks, as urban-based institutions, they function within highly regulated national accreditation standards and are embedded in the broader context of Saudi Arabia’s Health Transformation Program and Vision 2030 initiatives. Deans in these contexts typically oversee complex organizations that integrate training, clinical practice and research agendas.

The study was conducted in Riyadh, Saudi Arabia during the months of July–May 2022. It included two private school deans and three governmental school deans. 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 (Riessman and Quinney, 2005; Alwazzan, 2023; Crouch and McKenzie, 2006). To be eligible for participation, participants must have at least one year of work experience as a dean. Given access to resources and time, the study was limited to the capital city Riyadh where there are currently eight medical schools. In accordance with contemporary methodological practice, the aim of this qualitative study is to elicit rich, reflective accounts from participants’ leadership experiences. Generalizability and increased sample size were not an aim (Varpio et al., 2017).

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 min long and were conducted in English. 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 Material 1) 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 informed of their anonymity and right to withdraw at any time.

The portfolio of data generated was 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” (Ritchie and Spencer, 1994) (p. 177). The framework has five phases of analysis including: familiarization, identifying a thematic framework, indexing, charting and mapping/interpretation. Following initial coding and theme development by the author, a second reviewer with experience in qualitative research independently reviewed a subset of the audio transcripts, as well as the developed themes and definitions. The two reviewers met to discuss their independent findings. This process was done several times until both reviewers agreed on the final analysis. This iterative process increased analytic rigor.

Five out of eight deans working in the capital Riyadh, Saudi Arabia took part in this study. Deans’ ages ranged from 42 to 53 years, the sample included both male and female participants, years served as a dean ranged 1–10 years (see Table 1 for participant details)

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 (see Table 2 for theme definitions and mapping). Each theme is presented in the following sections and illustrative quotes are shared.

To increase depth, each theme is illustrated by multiple quotations from different participants. Quotes are presented as extended excerpts to show the substantive nature of the interview dialogue. Themes are categorizes according to the research questions of this study:

When asked “what is your understanding of autonomy in your leadership?”, participants conceptualized autonomy in three ways. First, autonomy related to decision-making is a necessary skill for the dean. This was viewed as the individual’s 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:

Another participant shared:

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:

Another participant shared a similar account:

These quotes illustrate how autonomy was experienced by deans as grounded in evidence and experience reinforming participants’ sense of self-efficacy and legitimacy as leaders.

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, but as entities contributing to the health-care workforce and influencers of the health economy:

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 fulfill their leadership role as dean and in turn learn, as one participant shared:

Another participant shared:

The previous quotes show how participants negotiated their roles and how that process shaped their autonomy. Role negotiation seems to be an active ongoing process requiring deans to construct meaning and seek balance.

Another role negotiation that was appreciated in the data was the one between different professional roles. That is, many participants spoke about their different professional roles, their roles as clinicians, teachers, researchers and leaders. One participant shared:

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:

Another participant shared:

The quotes illustrate competence as a developmental process, where gradual learning takes place rather than being immediate.

Most participants spoke about situations where external parties influenced productivity and efficiency as a leader:

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:

Others shared the challenge in demonstrating competence in the face of different organizational challenges:

Another participant shared:

These accounts show competence as performance oriented and constrained by the setting.

It was noticed that a senior leader talked less about the motivation to lead, whether internally or externally, rather on the ability to motivate others.

In this theme, participants spoke about the influence of resources on their competence such as the availability of material resources and the ability to recruit competent human capital. In terms of the availability of resources, one participant shared:

In terms of human capital, one participant shared:

Participants spoke about leadership training programs as a way to introduce themselves as potential leaders to their professional community, as one participant shared:

Another participant shared:

Leadership programs operated for some as mechanisms of identity formation and not just sites of skill acquisition. Moreover, they increased the feeling of legitimacy in leadership.

Other participants spoke about leadership programs after the fact, serving as a catalyst for their growth, as one participant shared:

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 the accomplishment of goals. For example:

However, participants often described their unpreparedness to deal with the volume of employees, as the following participant shared:

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:

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:

Another participant shared:

Participants described job performance as directly related to a sense of belonging.

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:

Another participant shared:

These quotes illustrate the relatedness to a broader level, where motivation is not only interpersonal but also alignment with national goals and collective identity.

This study takes a granular view of medical school deans’ development within the Saudi Arabian context, examining their perceptions through an SDT lens, emphasizing autonomy, competence and relatedness as central psychological processes shaping professional growth. 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 used 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 (Day and Dragoni, 2015), may be a more effective means of learning. The themes of defining autonomy and role negotiation show how deans internalized leadership roles while balancing clinical, teaching and research responsibilities. These findings align with SDT’s construct of autonomy as a self-motivated action rather than mere independence. This underscores that leadership development involves meaning-making and alignment with personal values rather than mere positional authority.

Competence emerged as a process shaped by personal learning efforts as well as institutional support. Participant’s mastery of leadership reflected growing confidence and capability in managing complexity. Resources and formal leadership programs carry an important structural and educational support in fostering leadership effectiveness. The theme of realizing organizational goals shows that competence was experienced through realized outcomes. These findings suggest that leadership development is more sustainable when leaders perceive themselves as capable and supported in meeting institutional needs.

Relatedness was illustrated through interpersonal relationships and personal fulfillment because of contributing to the broader organizational mission. This underscores that leadership is a socially embedded process. Fulfillment is linked to feelings of belonging and alignment with national goals. This supports SDT’s principle that relatedness is essential to motivation.

These findings together demonstrate that leadership development among medical school deans can be understood as a process of psychological need rather than a set of generic leadership behaviors and skills. 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 (Pololi et al., 2009; Pololi and Evans, 2015), 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.

This study is strengthened by its originality; to the author’s knowledge it is the first study using SDT 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 leaders’ autonomy, motivation to lead and leaders’ ability to motivate others and how that contributes to organizational culture, several limitations must be taken into consideration when interpreting the findings. First, the sample was based on convenience sampling and included a small number (n = 5). A larger sample size, which includes deans from other Saudi Arabian cities, is needed for the findings to be transferable to other contexts. Second, participants were drawn from a single city, which may limit the transferability of the findings to medical school deans working in other regions and health-care systems. Third, time and access to the resources available for this research were constrained, both in terms of time and funding. As a result, the decision was made to streamline the analysis process to ensure the completion of the study within the specified constraints. 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.

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 a better workplace culture that prioritizes leadership development, which may lead to efficient and effective organizations. The experiences described by those who took part in this study highlight that leadership ability within the dean role is not simply a function of seniority, but rather a developmental process shaped by institutional settings. As a result of this insight, specific areas where intentional intervention can ensure this developmental process are crucial. In addition to practice, the results of this study have implications for policy. There is a need for structured, system-level investments in leadership development with medical education. At a macro/policy level, findings of this study support the need for integration of formal leadership development frameworks into institutional strategies. Moreover, at a societal level, the study findings support fostering reflective and human-centered leadership cultures within medical education, encouraging institutions to recognize the individual and relational dimensions of leadership. Supporting leaders as a result can lead to improved healthier organizational cultures, where teachers and learners can thrive.

Further qualitative and quantitative research is needed with expansion of the leader type such as heads of departments and program directors, to explore the generalizability of the 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 SDT to understand the development of leaders in medical education and how this may inform the design of leadership development programs is 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 over time.

Leader and leadership development in Saudi Arabian medical education are vital for the growth of the health-care 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 relatedness 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.

This research received no external funding.

The author has read and agreed to the published version of the manuscript.

The following supporting information can be downloaded at: Supplementary Material A: interview guide.

Informed consent was obtained from all subjects involved in the study.