Relation between Leadership Styles and Behaviors of Nurse Managers' and Organizational Commitment of Staff Nurses

Introduction

The complex and multi-faceted nature of modern healthcare requires nursing leadership professionals who can create effective intra-departmental and facility-wide systems of healthcare delivery, while leading a productive and efficient workforce. This allows for optimal patient care in any medical setting, from private hospitals and clinics to large medical centers and veteran’s administration hospitals. Nursing administration is a broad term that encompasses nursing professionals who are knowledgeable of leadership practices as they relate to the nursing profession (1).

Moreover, nursing manager and administrators have the responsibility to implement all of the nursing procedures in a healthcare environment. While administrators can communicate with patients, they will be more than likely manage a team of nurses who will work on the front lines interacting with the patients who are seen in the facility. As a managerial team member in the nursing department, and administrator, head nurse should ensure that the department is complying with laws and that the department is fully staffed (2).

Therefore, the most significant managerial function needed is leadership the dynamic force that stimulates, motivates and coordinates an organization. Leadership consists of interpersonal influence, exercised in a situation and directed by means of the communication process, toward the attainment of specific goals; it involves attempts by one person to affect the behavior of others in a situation (3).

Leadership, since its appearance in literature in the 19th century, has been attributed to quality in education, research and management (4). The central theme of leadership in health care revolves around the effectiveness of leadership in the improvement of the quality of care, client satisfaction, patient outcomes and financial performance (5).  Nursing requires leaders who are highly creative in their thinking, to be able to piece together multiple pieces of seemingly unrelated information, and test out new approaches in the pursuit of new meaning in support of nursing patient care. It will no longer be about the “nursing leader”; rather it will be about nursing leaders working with other health-related leaders and consumers (6, 7).

Leadership as a management function is mostly related to human resources and social interaction. It is the process of influencing a group of people towards achieving organizational goals (8). Leadership is the ability of a manager to influence, motivate, and enable employees to contribute toward organizational success (9).

Nurse managers as first-line leaders (head nurses) have a responsibility to induce changes in the clinical environment. Recently, this responsibility of nurse managers has become more important than ever due to demands for rationalization, cost cuttings, advancements in medical technology, and reduced lengths of hospital stay (10). Moreover, managers can utilize various leadership styles to lead and direct their employees including autocratic, bureaucratic, laissez-faire, charismatic, democratic, participative, transactional, and transformational leadership styles. There is no universal leadership style different leadership styles are needed for different situations. Effective leader must know when to exhibit a particular approach (11).

Furthermore, the efficient use of leadership styles is an essential ingredient of good leadership skills. Leadership styles are the various combinations of tasks and behaviors which motivate people towards the achievement of set goals. A critical leadership skill is the use of different leadership styles (12). Leadership styles are a combination of tasks and transaction behaviors that influence people in achieving goals (13).

For the past three decades, a pair of predominant leadership styles (transactional and transformational leadership) has received a significant amount of attention. Transformational leadership is a process in which “leaders and followers raise one another to higher levels of motivation and morality” (14). By implementing transformational leadership styles, subordinates feel empowered leading to organizational commitment and solving the employee morale problems which in turn lead to job satisfaction (15).

Transactional leadership starts with the idea that employees agree to obey their leader totally when they accept a job. The “transaction” is usually the organization paying the team members in return for their effort and compliance. The leader has a right to “punish”. The leader could give team members some control of their income/reward by using incentives that encourage even higher standards or greater productivity. Alternatively, a transactional leader could practice “management by exception” – rather than rewarding better work, the leader could take corrective action if the required standards are not met (16).

The laissez-faire leadership style is also known as the "hands-off'' style. It is one in which the manager provides little or no direction and gives employees as much freedom as possible. All authority or power is given to the employees and they must determine goals, make decisions, and resolve problems on their own (17).

So the efficient use of leadership styles is an essential ingredient of good leadership skills. Leadership styles are the various combinations of tasks and behaviors which motivate people towards the achievement of set goals. A critical leadership skill is the use of different leadership styles. Leadership styles are a combination of tasks and transaction behaviors that influence people in achieving goals (18).

The success or failure of proper organizations, nations and other social units has been largely credited to the nature of their leaders and manager leadership style (19). Moreover, as explained in manufacturing companies, leadership is really a process for impacting on others commitment toward recognizing their full potential in achieving goals, vision with passion and integrity (20).

Organizational commitment is a common phenomenon which has been extensively addressed by many researchers worldwide due to its importance to the organization (21). In the meantime, over the past two decades, organizational commitment was the dominant job attitude that has been the center of researchers' attention (22). Today, healthcare organizations are challenged by the lack of commitment from nurses and doctors due to their choices to leave the organization (23).

Commitment is defined as the psychological bond that is characterized by the members’ feeling of attachment, obligation, and loyalty to a given organization. Commitment also describes the level of employees’ acceptance of the organization’s goals and the willingness they have to work towards these goals (23, 24).

Organizational commitment shows the psychological attachment of an employee to the organization (25). According to Meyer and colleagues (2002) there are three types of organizational commitment: affective, continuance and normative commitment. Affective commitment relates to an employee’s emotional attachment to the organization and its goals. Continuance commitment shows cognitive attachment between an employee and his or her organization because of the costs associated with leaving the organization. Finally, normative commitment refers to typical feelings of obligation to remain with an organization (26).

Thus, leadership of managers plays a critical role in employees ‘job satisfaction and commitment (27, 28). The achievement of organizational goals largely depends on managers and their leadership behavior and styles. The use of a particular leadership behavior by manager affects both job satisfaction and productivity and commitment of the employees (29). 

Significance of the study

Manger function as a leader and act on cement commitment of staff in the future, nurses' manger can set an example by personally welcoming whoever walks through the door or asks about joining the organization or initiative.  Ask questions and get nurses know, and make them feel valued.  That not only gives people a good feeling about the effort and encourages them to become involved, but it also provides the basis for developing a relationship that helps nurse manger function as a leader and acts to cement commitment in the future (30).

Nurses today work in an environment that overflows with unique challenges and opportunities, yet they tend to be over-controlled but grossly uninspired. There is an increasing need for leadership that inspires followers to aspire for a common greater good in a supportive environment is provided by leadership style (31).  The role of leadership is to ultimately accomplish outcomes for organizations through influencing others (31).

Moreover, during my work in Health Insurance Hospital, it was observed that some nurses in hospital have negative commitment to their units, and desires to leave work. And by the speaking with nurses, they expressed the negative feeling from their manger; due to their manger leadership style, and behaviors when deal with them. Thus, it is crucial to determine the relation between leadership styles and behaviors of nurse managers which can play an instrumental role in promoting organizational commitment of nurses working in health care settings.

Aim of the study

The aim of the current study is to investigate or to determine relation between leadership styles and behaviors of nurse managers and organizational commitment of staff nurses

Research questions

-          Is there a relation between leadership styles of nurse managers and organizational commitment of staff nurses?

-          Is there a relation between leadership behaviors of nurse managers and organizational commitment of staff nurses?

-          Is there a relation between leadership behaviors and leadership styles among head nurses?

Subjects and methods

Research design:

Descriptive correlational research design was used to achieve the aim of the current study.

Setting:

The study was conducted in Health Insurance Hospital Minia governorate.

Subjects:

Study subject was included all nurse managers (head nurses) and staff nurses in Health Insurance Hospital departments (n=255), divided as (17 nurse managers + 238 staff nurses)

Data collection tools:

Data was collected by using three tools as follows:

Tool (І): Leadership Styles Questionnaire, it was included two parts as follows:  

Part 1: Demographic data sheet which was attached with tools to get information among nurse mangers. It was included: gender, age, residences, years of experience, years of experience in current department, unit, and head nurse code.

Part 2: Multifactor Leadership Questionnaire 5X:

 This tool developed by Bass & Avolio (2004) ⁽³²⁾ and was adopted to measure the nurse managers' leadership styles and translated into Arabic. It was consisting of transformational, transactional, and laissez-faire leadership styles with nine subscales as: five subscales for transformational (Idealized Influence (attribute), Idealized Influence (behavior), Inspirational Motivation, Intellectual Stimulation, and Individualized Consideration), three subscales for transactional (Contingent Reward, Management-by-Exception- active, and Management-by-Exception- passive) and one Laissez Faire.  

Participants were asked to judge the extent to which they view their head nurses engaged in specific behaviors measured by the MLQ. The MLQ Form 5X is self-scoring and used 27 items to measure the nine subscales (3 items for each).  The items was rated using a 5-point Likert scale labeled as (0 = not at all, 1 = once in a while, 2 = sometimes, 3 = fairly often, 4 = frequently, if not always). The scoring system was calculated according to the sum of each style items. High score was showing high effectiveness of leadership style perception while low score was implying low effectiveness perception in the scale.

Tool (ІІ) – Leadership Behavior

This tool developed by Strange & Mumford (2002) ⁽³³⁾ and was adopted by the researcher to assess nurse manager’s leadership behaviors, and translated into Arabic. It includes 26 items divided to 4 domains as follows: leader’s encouragement and support to subordinates (13 items); leader’s clarification of vision to his/her subordinates (8 items); consistency of leader’s behavior with his/her vision (5 items); and leader’s persuasiveness in convincing subordinates to accept his/her vision (4 items). Each items was measured using five-point Likert scale (1 = strongly disagree, 2= disagree, 3 = neutral, 4 = agree, and 5= strongly agree).

The scoring system was according to the higher score of leaders' behaviors domain. The higher score of behavioral domain items indicated high level of behavior and low score indicated low level on behavioral domain.

Tool (ІІІ) - The Organizational Commitment of the Staff Nurses Questionnaire, it was included two parts as follows:  

Part 1: Demographic data sheet was attached with tool to get information among staff nurses. It was included: gender, age, residences, years of experience, years of experience in current department, certificate, and unit.

Part 2: The Organizational Commitment of the Staff Nurses scale

This tool developed by Meyer et al. (1993) ⁽³⁴⁾ and was adopted by the researcher to assess organizational commitment of staff nurse. It included 18 items divided to 3 factors of organizational commitment (affective, continuance, and normative). Each factor included 6 items and was measured using five-point Likert scale (1= strongly disagree, 2= disagree 3= neutral, 4= agree, 5 = strongly agree). Four items are negatively worded. The scoring system was ranged from 18 to 90, the higher score indicates higher level staff nurses commitment to the organization and low score indicates low commitment.

Validity of the tools:

Tools were tested for the content validity by a jury of 5 experts in the field of Nursing Administration and a necessary modification was done. The jury composed of two Assistant Professors from Faculty of Nursing, Minia University and three Assistant Professors from Faculty of Nursing, Assuit University. Each of the expert panel was asked to examine the instrument for content coverage, clarity, wording, length, format and overall appearance.

Reliability of the tools

Reliability of the tools was performed to confirm consistency of tools. The internal consistency measured to identify the extent to which the items of the tools measure the same concept and correlate with each other by Cronbach’s alpha test; the reliability of the tools were leadership styles (α=0.889), leadership behavior (α=0.874), and organizational commitment (α=0.791).

Pilot study:

A pilot study was conducted on 10% of participants as (2) of head nurse and (24) of staff nurse to ascertain the clarity, comprehensiveness and applicability of the tools as well as to estimate the appropriate time required to fill the questionnaire. Based on pilot study there was no modification done, and it was added to final results.

Study procedure:       

• Written approvals were obtained from administrative authorities (Faculty dean, Vice dean for teaching and student affairs, Director of Health Insurance Hospital, Nursing Director of Health Insurance Hospital, and head of departments of the Health Insurance Hospital) after explaining the purpose of the study.
• The questionnaires were distributed to all the participants after explaining the purpose and process of data collection. Questionnaires were directly administered and supervised by the researcher with the assistance of head nurse for each department.
• Participants were given from 15 minute to 30 minute to answer the questionnaires. They were allowed to discuss with researcher any item that needs more clarification. 
• The data collection was performed all head nurses and staff nurses of health insurance hospital during the period of 6 months from the beginning of September 2018 to February 2019. 

Ethical consideration:

a)       An oral consent was obtained from participants to collect the study data before data collection. After explanation of the purpose of the study, the privacy and confidentiality of the answers were guaranteed by the researcher.

b)       Each assessment sheet was coded and participants' names not appeared on the sheets for the purpose of anonymity and confidentiality.

c)       The participants were informed that their participation in the study was completely voluntary and there was no harm if they not participate in the study.

Statistical analysis:

Data entry was done using compatible personal computer. Statistical analysis done by using statistical package of social science (SPSS) version 25 and excel for figures. The content of each tool was analyzed, categorized and then coded. Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables, and means and standard deviations for quantitative variables. Statistical significance used at P value <0.05.

Results:

Table (1) Distribution of the personal data regarding to head nurses and staff nurses

Table (1): shows that more than half (58.8%) of head nurses age ranged from (20-30) years old. In relation to gender, all of them (100%) were females. Concerning to years of experience, more than three quarter (76.5%) had (1-10) years of experience; in relation to years of experience in the current job the majority of them (82.4%) had (1-10) years of experience. As regard to residence, the majority of them (84.1%) lived in urban areas.

Regarding personal data of staff nurses shows that less than three quarter (70.2%) of staff nurses age ranged from (20-30) years old with mean age (28.6+7.03). In relation to gender, more than three quarter of them (78.6%) were females. Concerning to years of experience, more than two third (70.6%) had (1-10) experience years, and in relation to years of experience in the current job the majority of the sample (85.3%) had (1-10) experience years. As regard to residence, about two third of them (65.5%) were lived in rural areas.

Table (2) Frequency distribution by percentage of staff nurses perception regarding their head nurses leadership style

Table (2) shows that highest percentage of the staff nurses perceived their head nurses had high level for transformational leadership style (63%) and its subscales (59.2%, 64.3%, 63.9%, 62.6%, and 63.4% respectively) as well as had high level for transactional leadership style (59.7%) and its subscales (60.9%, 72.3%, and 56.7% respectively); except the majority of the staff nurses perceived their head nurses had low level to lassie faire style (84.5%).

Table (3) Frequency distribution by percentage of head nurses perception regarding their leadership behavior

Table (3) shows that the highest percentage staff nurses perceived their head nurses had high level to all dimensions of leadership behaviors (59.7%, 57.4%, 76.5, and 58.8% respectively). Regarding total score of leadership behaviors, it was noted that more than half (58.8%) of staff nurses perceived their head nurses had high level of leadership behaviors and more than one third (39.9%) had moderate level.

Table (4) analysis of variance among head nurses and staff nurses regarding to leadership styles and leadership behaviors dimensions (n=255)

Table (4) shows that there are no statistical significance differences between head nurses perception to themselves about leadership styles and leadership behaviors; and staff nurses perception about their head nurses leadership styles and behaviors.

Table (5) Frequency distribution by percentage of staff nurses perception regarding organization commitment and its dimension

 Table (5) shows that the near the half (48.7%) of staff nurses had moderate level regarding affective commitment; while more than two third (70.6%, and 70.2%) had high level regardingcontinuance commitment and normative commitment. Regarding the total score of organizational commitment, it was noted that more than half (57.1%) had high level commitment and more than one third had (41.2%) moderate level 

Table (6) correlations between leadership styles, leadership behavior and organizational commitment

Table (6) there are positive correlations between transformational with transactional (r= 0.922, p=0.00); with leadership behavior (r=0.672, p=0.000) and with organizational commitment (r=0.302, p=0.000); also, there are positive correlations between transactional leadership style with leadership behavior (r=0.666, p=0.000) and with organizational commitment (r= 0.529, p=0.000); while no correlation between lassie-faire style and other styles as well as leadership behavior and organizational commitment.