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Abstract

Given rapid changes in the health care landscape, nurse leaders need to be equipped with effective leadership skills. Those who are aware of their styles of working and its impact on their employees could adopt a better leadership style. The study aim was to assess the leadership styles of nurse leaders, as perceived by their employees. The secondary objectives were to explore differences between self-ratings and others’ ratings of leadership styles, as well as correlation between perceived leadership styles and organisational outcomes. A cross-sectional survey was conducted among registered nurses from four inpatient wards in an acute tertiary hospital in Singapore. Respondents were asked to complete a questionnaire that consisted of demographic questions, the Multifactor Leadership Questionnaire and the Organizational Commitment Questionnaire, as well as a Three-index item Questionnaire, to elicit turnover intention. A total of 111 completed surveys (37% response) were received. Overall, registered nurses reported that their nurse leaders exhibited both transformational and transactional leadership behaviours and, to a lesser extent, laissez-faire. Of interest was the finding that nurse leaders in this study tend to rate themselves higher than others rate them. The results implied a need to incorporate self-awareness elements in nursing leadership development programmes.

Keywords

Nurse leader job satisfaction organisation commitments staff retention transformational leadership

Introduction

Effective leadership in health care is crucial in improving and enhancing the effectiveness and efficiencies of health care systems.¹ Given global trends, such as ageing populations and rapid adoption of new technologies, the way in which health care is being delivered has changed substantially² in the last 10 years, which in turn brings a need for new ways of leading a health care team.

More specifically, transformational leadership, which refers to a leader’s ability to influence others towards attaining common goals,¹ was reported to increase job satisfaction among nursing staff.² Similarly, relational leadership styles that focus on creating positive relationships were associated with higher patient satisfaction, and reductions in patient mortality, medication errors, restraint use and hospital-acquired infections.³

Although there is a proliferation of literature on leadership styles of nurse leaders, there is a dearth of studies focused on nurse leaders in Singapore. On the one hand, given the influence of societal culture on leadership and employee commitment,⁴ it is of interest to evaluate leadership styles among nurse leaders in Singapore and its influence on organisational outcomes. On the other hand, given leniency and social desirability biases, self-ratings of one’s leadership may be overinflated, which in turn could result in poorer performance.⁵ Henceforth, it is important to examine the level of self-awareness of local nurse leaders to inform the design and implementation of leadership development programmes.

This study aimed to assess the leadership styles of nurse leaders as perceived by employees, that is, registered nurses under their charge. The secondary objectives were as follows.

To explore differences between nurse leaders’ self-rated leadership styles and their leadership styles as perceived by their employees.

To explore the correlation between perceived leadership styles and organisational outcomes, namely job satisfaction, organisational commitment and turnover intention.

Method and results

A cross-sectional survey was conducted among registered nurses from four inpatient wards in an acute tertiary hospital in Singapore. Data collection was carried out in April and May 2017. Employees were asked to complete a questionnaire that consisted of demographic questions, the Multifactor Leadership Questionnaire (5× short version) and the Organizational Commitment Questionnaire, as well as a Three-index item Questionnaire to elicit turnover intention. Nurse leaders from the four wards were asked to complete a demographics form as well as the Multifactor Leadership Questionnaire, as a self-rating.

The Multifactor Leadership Questionnaire is made up of five transformational (inspirational motivation, idealised influence (attributed), idealised influence (behaviour), intellectual stimulation, individualised consideration) three transactional (contingent reward, active management by exception, passive management by exception), one laissez-faire and three outcome sub-scales (extra effort, the effectiveness of leader’s behaviour, followers’ satisfaction with their respective leader).⁶ The reported internal consistency was above 0.70 for all scales, except for active management by exception, which was 0.63.⁶ The external validity of the Multifactor Leadership Questionnaire has also been established in previous studies conducted in health care organisations.^7–9 Each item is rated on a scale of 0 (not at all) to 4 (frequently, if not always). Ratings were summed and divided by the number of items in each sub-scale to derive average ratings.⁶ For this study, contingent reward and management by exception (active) are labelled transactional leadership, while management by exception (passive) and laissez-faire management are labelled passive and avoidant leadership, respectively.

The Organizational Commitment Questionnaire consisted of 15 items, of which six were negatively phrased, to elicit nurses’ level of affective commitment.¹⁰ A Likert scale rating was used, whereby 1 indicated ‘strongly disagree’ and 7 referred to ‘strongly agree’. The reliability of the tool is well established, with reported values between 0.82 and 0.93.¹¹ The validity of the tool was also established, with the demonstration of a positive association between commitment and intention to leave an organisation.¹²

The Three-index item Questionnaire¹³ sought information on intention to quit by asking respondents to rate their level of agreement with the three items: ‘I will actively look for a new job in the next year,’ ‘I often think about quitting,’ and ‘I will probably look for a new job in the next year.’ Similarly, a Likert scale rating was used, where 1 referred to ‘strongly disagree’, and 7 referred to ‘strongly agree’.

A convenient sample of nurses from four inpatient wards was invited to participate in the study. The inclusion criteria were:

Had worked under the direct supervision of the named nurse leader for a continuous period of at least 6 months; and

Staff nurses, senior staff nurses and nurse clinicians.

The results of the questionnaires were analysed using Statistical Package for the Social Sciences (SPSS) Version 23. Correlation between leadership styles and organisational commitment or intention to quit was analysed using Spearman’s rho. The one-sample t test was used to compare the employees’ ratings with the nurse leaders’ self-rating scores.

A total of 111 completed questionnaires were collected from the employees (response rate: 37%). The majority (n = 93; 84%) were female, Chinese (n = 44; 40%) and between 26 and 30 years of age (n = 49; 44%) (Table 1). Only three out of four nurse leaders (75%) participated in the self-rating. Ward D’s nurse leader was not available during the period of data collection for this study.

Table 1.

Demographics of employees – registered nurses.

		N (%)
Sex	Male	18 (16%)
Sex	Female	93 (84%)
Race	Chinese	44 (40%)
	Malay	24 (22%)
	Indian	14 (13%)
	Other	29 (26%)
Age	20–25	12 (11%)
	26–30	49 (44%)
	31–35	27 (24%)
	36–40	11 (10%)
	41–45	7 (6%)
	46 and over	5 (5%)
Highest education qualification	Diploma	37 (33%)
	Advanced diploma	8 (7%)
	Degree	64 (58%)
	Other	2 (2%)
Place of work	Ward A (speciality)	60 (54%)
	Ward B (surgical)	17 (15%)
	Ward C (surgical)	13 (12%)
	Ward D (medical)	21 (19%)

Perceived leadership styles

Employees in Wards A, C and D reported that their nurse leaders displayed more transformational leadership behaviours than transactional, passive or avoidant behaviours (Table 2). In Ward B, employees gave their nurse leader the highest rating (mean score, 2.59) on the contingent reward.

Table 2.

Comparison between ratings by registered nurses and self-ratings by nurse leaders.

Leadership styles	Ward A (n = 60)				Ward B (n = 17)				Ward C (n = 13)				Ward D (n = 21)
	Self-rating	Rating by RN (mean)	One-sample t test	P	Self-rating	Rating by RN (mean)	One-sample t test	P	Self-rating	Rating by RN (mean)	One-sample t test	P	Rating by RN (mean)
Idealised influence behaviours	3.00	2.65	−4.094	<0.0001	2.75	2.19	−3.196	0.006	3.00	2.81	−1.0	0.337	2.38
Idealised influence attributes	3.25	2.75	−5.753	<0.0001	3.5	2.35	−6.486	<0.0001	3.75	2.96	−5.704	<0.0001	2.54
Inspirational motivation	3.00	2.76	−2.508	0.015	3.25	2.37	−4.987	<0.0001	3.25	2.92	−1.889	0.083	2.48
Intellectual stimulation	3.50	2.35	−12.896	<0.0001	3.5	2.22	−10.570	<0.0001	3.25	2.69	−3.928	0.002	2.27
Individual consideration	2.75	2.37	−3.728	<0.0001	4.00	2.10	−11.515	<0.0001	3.75	2.52	−8.297	<0.0001	2.18
Contingent reward	3.25	2.62	−7.329	<0.0001	3.50	2.59	−8.046	<0.0001	3.00	2.77	−1.477	0.165	2.45
Management by exception (active)	2.50	2.60	1.006	0.319	3.00	2.24	−4.478	<0.0001	2.00	2.92	6.743	<0.0001	2.18
Management by exception (passive)	1.00	1.06	0.550	0.584	0.25	1.16	4.192	0.001	1.00	1.10	0.750	0.468	0.95
Laissez-faire	0.50	0.61	1.103	0.274	1.00	1.04	0.215	0.832	2.00	0.60	−10.012	<0.0001	0.56
Leadership styles	Self-rating	Rating by RN (mean)	One-sample t test	P	Self-rating	Rating by RN (mean)	One-sample t test	P	Self-rating	Rating by RN (mean)	One-sample t test	P	Rating by RN (mean)
Extra effort	2.67	2.48	−1.815	0.075	3.33	2.33	−5.657	<0.0001	3.33	2.41	−4.765	<0.0001	2.02
Effectiveness	3.00	2.76	−2.475	0.0016	3.25	2.41	−5.374	<0.0001	3.25	2.71	−3.895	0.002	2.33
Satisfaction	3.00	2.69	−2.899	0.005	2.50	2.38	−0.621	0.543	3.50	2.81	−4.185	0.001	2.45

RN: registered nurse.

Differences between self-ratings and others’ ratings

In the three wards where the nurse leaders provided self-rating scores, the leaders tended to rate themselves higher in the domain of transformational leadership (Table 2). The differences were statistically significant (P < 0.05) across all sub-scales in Wards A and B. In Ward C, the differences were statistically significant for the sub-scales of idealised influence-attributed, intellectual stimulation and individualised consideration.

In the domain of transactional leadership, registered nurses from all three wards reported lower ratings in contingent rewards, as compared with the leaders’ self-rated scores, with the difference being significantly different in Wards A and B. Registered nurses from Ward B reported statistically significant lower ratings (mean, 2.59) for management by exception (active) as compared with their nurse leader (self-rated score, 3.5); while registered nurses from Ward C gave higher ratings (Table 2).

Differences in ratings for laissez-faire leadership styles were not significant in Wards A and B. However, in Ward C; registered nurses gave their nurse leaders significantly lower scores (mean, 0.60 versus a self-rated score of 2.00) in the laissez-faire domain.

With regards to leadership outcomes, nurse leaders consistently rated themselves higher than registered nurses. The differences were statistically significant (P > 0.05), except for the sub-scale of extra effort in Ward A and the sub-scale of satisfaction in Ward B (Table 2).

Correlation between perceived leadership styles and organisational outcomes of job satisfaction, organisational commitment and turnover intention

As illustrated in Table 3, transformational leadership demonstrated positive, significant and strong correlations with extra effort (r = 0.704–0.895), effectiveness (r = 0.644–0.941) and satisfaction (r = 0.693–0.882). Conversely, the strength of positive correlations between transactional leadership and outcomes was weaker.

Table 3.

Correlation between perceived leadership styles and organisational outcomes.

Leadership style	Ward A (n = 60)			Ward B (n = 17)			Ward C (n = 13)			Ward D (n = 21)
	Rating by registered nurse (mean)			Rating by registered nurse (mean)			Rating by registered nurse (mean)			Rating by registered nurse (mean)
Transformational	12.88			11.24			13.90			11.85
Transactional	5.21			4.82			5.69			4.63
Passive or avoidant	1.67			2.21			1.69			1.52
OCQ	4.88			4.55			5.13			4.59
TIQ	3.97			3.80			2.77			4.08
	Correlation with EE	Correlation with EFF	Correlation with SAT	Correlation with EE	Correlation with EFF	Correlation with SAT	Correlation with EE	Correlation with EFF	Correlation with SAT	Correlation with EE	Correlation with EFF	Correlation with SAT
Transformational	0.735**	0.704**	0.755**	0.382	0.644**	0.693**	0.810**	0.770**	0.393	0.895**	0.941**	0.882**
Transactional	0.570**	0.475**	0.472**	0.393	0.511*	0.618**	0.715**	0.875**	0.550	0.532*	0.622**	0.555**
Passive or avoidant	0.091	−0.197	−0.325*	−0.321	−0.608**	−0.536*	0.247	−0.114	−0.220	−0.286	−0.392	−0.208
	Correlation with OCQ		Correlation with TIQ	Correlation with OCQ		Correlation with TIQ	Correlation with OCQ		Correlation with TIQ	Correlation with OCQ		Correlation with TIQ
Transformational	0.204		−0.368**	0.207		0.057	0.594*		−0.443	0.393		−0.61**
Transactional	0.211		−0.272*	0.134		0.016	0.674*		−0.427	0.576**		−0.53*
Passive or avoidant	−0.131		0.081	−0.570*		0.079	−0.236		−0.188	−0.375		0.289

Correlation significant at 0.05 level.

Correlation is significant at 0.01 level.

EE: extra effort; EFF: effectiveness: OCQ: Organizational Commitment Questionnaire; SAT: satisfaction; TIQ: Three-index item Questionnaire.

Transformational leadership was significantly positively correlated with organisational commitment in Ward C but not in other wards. On the contrary, transformational leadership was significantly negatively correlated with turnover intention in Wards A, C and D.

Transactional leadership correlated positively with organisational commitment in Wards C and D; and correlated negatively with turnover intention in Wards A, C and D.

Passive or avoidant leadership correlated negatively with organisational commitment in Ward B; otherwise, its relationship with commitment and turnover intention was not significant.

Conclusions

Overall, registered nurses reported that their nurse leaders exhibited both transformational and transactional leadership behaviours and, to a lesser extent, laissez-faire. This is in congruence with that reported in a previous study conducted among nurses,¹⁴ whereby nurse leaders put greater emphasis on higher motivation development, and promoted followers’ motivation and positive emotions by providing an inspiring vision of the future (transformational leadership).⁶ Nurse leaders in this study also displayed contingent-reward behaviours, whereby they focused on clearly defined tasks and provided followers with rewards when such tasks were achieved.⁶

Of interest is the finding that nurse leaders in this study tend to rate themselves higher than others rate them. Previous studies have reported that over-estimators (i.e. leaders who rated themselves higher than others perceived them) tended not to be as effective as in-agreement and under-estimators.¹⁵ The results implied a need to incorporate self-awareness elements in nursing leadership development programmes. Self-awareness is crucial to good leadership and enables leaders to choose roles where they will succeed, as well as recognise how to build teams that complement their strengths.¹⁶

Like the study by Casida and Parker,¹⁴ we found strong significant correlations between transformational leadership and outcomes regarding extra effort, effectiveness and satisfaction. Except for the sub-scale of effectiveness in one ward, we found weaker correlations between transactional leadership and extra effort, effectiveness and satisfaction. Conversely, in our study, leadership traits did not correlate strongly with organisational commitment and turnover intention.¹⁷ This could be because of the relatively small samples sizes of Wards B and C. As this was a cross-sectional survey, we also could not determine the actual turnover rate. Nonetheless, this study provided an insight into the leadership styles of local nurse leaders and their self-awareness. Future studies should adopt a longitudinal design to elicit the influence of leadership styles and behaviours on actual organisational outcomes.

Footnotes

Acknowledgements

We thank the nurses who have given their time to participate in this study from the four study wards.

Declaration of conflicting interests

The authors declare that there is no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

References

Vesterinen

Suhonen

Isola

, et al. Nurse managers’ leadership styles in Finland. Nurs Res Pract 2012; 2012: 605379.

Choi

Goh

Adam

, et al. Transformational leadership, empowerment, and job satisfaction: the mediating role of employee empowerment. Hum Resour Health 2016; 14: 73.

Wong

Cummings

Ducharme

The relationship between nursing leadership and patient outcomes: a systematic review update. J Nurs Manag 2013; 21: 709–724.

Jackson

Meyer

Wang

XH.

Leadership, commitment and culture. J Leadersh Organ Stud 2013; 20: 84–106.

Atwater

Yammarino

FJ.

Does self-other agreement on leadership perceptions moderate the validity of leadership and performance predictions?

Pers Psychol 1992; 45: 141–164.

Avolio

Bass

Walumbwa

, et al. Multifactor leadership questionnaire: manual and sampler set. 3rd ed. Redwood City: Mind Garden, 2004, p. 110.

Asiri

Rohrer

Al-Surimi

, et al. The association of leadership styles and empowerment with nurses’ organizational commitment in an acute health care setting: a cross-sectional study. BMC Nurs 2016; 15: 38.

Abualrub

Alghamdi

MG.

The impact of leadership styles on nurses’ satisfaction and intention to stay among Saudi nurses. J Nurs Manag 2012; 20: 668–678.

Kanste

Miettunen

Kyngas

Psychometric properties of the Multifactor Leadership Questionnaire among nurses. J Adv Nurs 2007; 57: 201–212.

10.

Mowday

Steers

Porter

LW.

The measure of organizational commitment. J Vocat Behav 1979; 14: 224–247.

11.

Mowday

Steers

Porter

LW.

Employee–organization linkages: the psychology of commitment, absenteeism and turnover. New York: Academic Press, 1982, p. 253.

12.

Cooke

DK.

Discriminant validity of the organizational commitment questionnaire. Psychol Rep 1997; 80: 431–441.

13.

Mobley

Horner

Hollingsworth

AT.

An evaluation of precursors of hospital employee turnover. J Appl Psychol 1978; 63(4): 408–414.

14.

Casida

Parker

Staff nurse perceptions of nurse manager leadership styles and outcomes. J Nurs Manag 2011; 19: 478–486.

15.

Fleenor

McCauley

Brutus

Self-other rating agreement and leader effectiveness. Leadersh Q 1996; 7: 487–506.

16.

Martin

ES.

How self-awareness helps a physician become a leader. Clin Dermatol 2012; 30: 248–250.

17.

Green

Miller

Aarons

GA.

Transformational leadership moderates the relationship between emotional exhaustion and turnover intention among community mental health providers. Community Mental Health J 2013; 49: 373–379.