Quality - Module 3

366 Journal of the College of Physicians and Surgeons Pakistan 2016, Vol. 26 (5): 366-370

INTRODUCTION The healthcare organizations are a complex environ- ment with varied staff, services, consumers (patients or clients), etc.1 With time, the healthcare organizations are now transforming from hierarchically structured entities to networked organizations for meeting the consumers demands.2 Consequently, leaders' authority is changing and that has seen a change from transactional (TA) to transformational leadership style (TF).3

In the TA style, there are constructive and corrective types. In the corrective form, the leader works with individuals and/or groups, setting up and defining agreements or contracts to achieve specific work objectives, discovering individuals' capabilities, and specifying the compensation and rewards that can be expected upon successful completion of the tasks.4

While in the corrective form, the leader focuses on standards which relate to the task in two types. In its

passive form, it involves waiting for mistakes to occur before taking action; and in its active form, there is close monitoring for the occurrence of mistakes.4

The TF style consists of 4 major factors: idealized influence (attributes and behaviours), inspirational motivation, intellectual stimulation, and individualized consideration.4 In this style of leadership, the leaders tend to place followers' needs over their own needs.5 Transformational leaders influence the beliefs and attitudes of followers to align with theirs and then direct followers towards the attainment of greater organizational success".

Nurses are the backbone of medical care, hence the nursing leaders should build and maintain a healthy work environment that motivates and supports the nurses to reduce nurses turnover.7 It has been found that the nurses prefer to work in an environment which promotes social relationship and encourages partici- pation in decision-making, because it enhances their level of job satisfaction.8 Job satisfaction is vital to the critical care nurses and it has been found to have a strong correlation with organizational commitment and that the leadership style of head nurse effects the staff.9,10

The transformational leadership style has been rated higher by the nurses compared to transactional leadership style, and there were significant correlations between the perceived leadership style and organization

ORIGINAL ARTICLE

Effect of Leadership Styles on Job Satisfaction Among Critical Care Nurses in Aseer, Saudi Arabia

Fawaz Musaed M. Alshahrani1 and Lubna A. Baig2

ABSTRACT Objective: To evaluate the effect of transformational and transactional leadership styles of head nurses on the job satisfaction of staff nurses in critical care units (CCU) of a tertiary care hospital. Study Design: Cross-sectional study. Place and Duration of Study: Critical care units at Aseer Central Hospital (ACH), Abha, Saudi Arabia, from July to December 2012. Methodology: The multifactor leadership questionnaire (MLQ-5X) and job satisfaction survey with demographics were used. Staff nurses (N=89) reporting to 8 nurse leaders responded as per the requirements of MLQ-5X and also filled the job satisfaction survey. ANOVA, correlation coefficient (Pearson r) and multiple linear regression were used for analyses. Results: All nurse leaders demonstrated a combination of transactional (TA) and transformational (TF) style of leadership. Nurses working under leaders with a TF style demonstrated significantly (p < 0.05) higher job satisfaction. The operating conditions were related negatively to the style of leadership. Pay, fringe benefits and nature of work were not related to the style of leadership. The nurses were moderately satisfied with their work and 23% of the variation in nurses' job satisfaction could be explained by the head nurses 6 leadership facets with positive effect of professional support, intellectual motivation, management by correction and their laissez faire style. Conclusion: The study emphasized the importance of TF style of head nurses for increasing staff nurses' job satisfaction. It is suggested that nurse leaders should be trained in TF style of leadership and provided more support and training for effective management of CCU.

Key Words: Critical care units. Leadership style. Nurses. Job satisfaction.

1 Nursing, Directorate General of Health Affairs in Aseer, Ministry of Health, Saudi Arabia.

2 APPNA Institute of Public Health, Jinnah Sindh Medical University, Karachi.

Correspondence: Prof. Lubna A. Baig, Dean and Professor, APPNA Institute of Public Health, Jinnah Sindh Medical University, Karachi. E-mail: [email protected]

Received: March 05, 2015; Accepted: December 01, 2015.

outcomes which included: effectiveness, extra effort, and job satisfaction.11 Previous authors have found that the most important determinants of job satisfaction were recognition, technical aspects of supervision, work conditions, utilization of skills, pay and job advance- ment.12,13

There is a high turnover in critical care nursing in Saudi Arabia. Therefore, this study evaluated the type of leadership style (transactional and transformational) of the head nurses and its effect on the job satisfaction of the reporting nurses working in the CCU at ACH, Abha city, Saudi Arabia.

METHODOLOGY This quantitative cross-sectional study was conducted at the CCU of ACH in the southern region of Saudi Arabia. Licensed nurses, working under direct supervision of a head nurse with a minimum of 6 months experience in critical care units, were approached for data collection using convenience sampling.

Sample size calculated by RaoSoft with 95% confidence level, 10% margin of error, and 50% response distribution was 74 nurses. A total of 160 questionnaires were sent and 94 were returned with a response rate of 59%. In the analysis, the cases with missing information were deleted listwise.

Multifactor leadership questionnaire (MLQ-5X rater form with 45 items),16 and job satisfaction survey (JSS),14

were used after taking permission from the authors. Demographic questions were added on the job satisfaction form. A pilot study was done where the MLQ-5X Rater form and JSS questionnaire were given to 3 medical educationists and 3 CCU nurses for removing ambiguity or any other issue in the question- naires. The MLQ-5X form with 9 factor models has been validated in many organizations around the world.4

The reliability of MLQ-5X form, in this study was Cronbach's Alpha of 0.96.

JSS consists of 36 items which are written in both positive and negative formats and distributed in 9 facets. Each 4 items reflect one facet, the 9 facets are: pay, supervision, contingent rewards, operating procedures, promotion, fringe benefits, coworkers, communication, and nature of work,14 on a Lickert type agreement scale. The reverse scored items of MLQ-5X and JSS were transformed before data analysis stage. The internal consistency reliability of the JSS was Cronbach's Alpha of 0.81. The job satisfaction of participants was assessed through 9 facets on a scale from 1 - 6, with 6 being the highest. Mean responses of < 3 represents dissatisfaction; > 4 represents satisfaction; between 3 and 4 represents ambivalence.17

Formal approvals were obtained from College of Medicine Research Committee (COMRC) in King Saud

bin Abdul-Aziz University for Health Sciences in Riyadh, Saudi Arabia; King Abdullah International Medical Research Center (KAIMRC) in Riyadh, and Institutional Review Board (IRB) of the Saudi Ministry of Health in Riyadh and Aseer Central Hospital (ACH) in Abha before conducting the study. The consent from the head nurses (who worked in ACH critical care units during this study) was taken after IRB approval to allow for the staff nurses to measure their leadership styles by using multifactor leadership questionnaire.

Data was collected on the Nursing Education Activity Days (NEADs) in the CCUs at ACH. The purpose of the study was explained to the participants verbally during NEADs. The participants were informed that participation was voluntary, anonymous and filling of the questionnaire will be taken as consent. The researcher ensured the confidentiality of the participants by personal handling of all the data at all study stages.

Statistical Package for Social Sciences (SPSS) version 20 was used for data entering and analysis. Analysis of variance (ANOVA) with Post Hoc-Tukey HSD was used to identify the significant differences between TF and TA styles of head nurses. Multiple linear regression analysis was used for assessing the effect of 6 leadership factors in the MLQ-5X form on the job satisfaction of staff nurses.

RESULTS The number of respondents should be described here. Initially it gave an impression that 160 forms were distributed.

Participants’ nursing experience in critical care units at ACH varied from 6 months to 17 years and their age ranged from 22 to 58 years. Majority were females (98%, n=87) and married (57%, n=51). Seventy-nine percent (n=70) had a bachelor degree and 21% had a diploma of nursing. The majority of CCU nurses were doing 6 shifts in a week (94%, n=84), 84 were in 8-hour shifts and remaining in 12-hour shifts.

The mean score of TA style was higher than the mean score of TF; the mean score of nurses' job satisfaction was moderate. Leader 8 had the lowest mean score for TA and leader 7 had the highest mean score TA style and the lowest mean score for job satisfaction; leader 3 had the highest mean score for job satisfaction (Table I).

Leaders 5 and 8 were considered lowest in demonstrating transformational leadership behaviours as perceived by their nurses. There were statistically significant differences between 8 head nurses’ leadership styles; each head nurse demonstrated transformational and transactional leadership behaviours differently from other head nurses. The Post-Hoc-analysis identified significant differences for leader 5 for TA leadership styles with leader 7 (p=0.04) and leader 8 (p=0.02)

Effect of leadership styles on job satisfaction among critical care nurses in Aseer, Saudi Arabia

Journal of the College of Physicians and Surgeons Pakistan 2016, Vol. 26 (5): 366-370 367

and leader 8 with leader 1 (p < 0.01), leader 2 (p=0.01), leader 3 (p < 0.01), leader 4 (p=0.01), leader 6 (p < 0.01), and leader 7 (p < 0.01). For TF style: leader 5 was significantly different from leader 1 (p=0.02), leader 2 (p < 0.01), leader 3 (p < 0.01), leader 6 (p < 0.001), and leader 7 (p < 0.001) and leader 8 from leader 3 (p < 0.001), leader 6 (p < 0.001), and leader 7 (p < 0.001).

The facet of nature of work had the highest mean score (M = 4.47 ±0.89), followed by promotion (M + 3.29, ±1.05), contingent reward (M = 2.87 ±1.07), fringe benefits (M = 2.64 ±0.99), and the facet of operating conditions had the lowest mean score (M = 2.45 ±0.76).

There was a significant difference in nurses' job satisfaction: each head nurse had different level of staff nurses' job satisfaction compared to other head nurses. On Post Hoc analysis using Tukey HSD, nurse leader 1 had significantly higher job satisfaction compared to leader 7 (p=0.02) and leader 3 had significantly higher job satisfaction compared to leader 2 (p=0.009), leader 5 (p=0.01), leader 7 (p=0.001), and leader 8 (p=0.02).

There were significant strong positive correlations between transformational leadership style and extra effort, effectiveness and satisfaction (Table II). Multiple Linear Regression analysis identified that 4 leadership factors (Model 1) together can explain 23% variance in job satisfaction of nurse (R2 = 23%) with a p-value of 0.001. (Tables III and IV).

DISCUSSION The key findings of this study were that, the majority of the head nurses demonstrated transactional leadership style. Pay, fringe benefits and nature of work were not related to the style of leadership. The nurses working under leaders with higher transformational style of leadership had more job satisfaction compared to nurses working under leaders with higher scores on transactional style of leadership. Organizational out- comes were better with transformational style of leadership.

In this study, most of the head nurses demonstrated TA style of leadership compared to the transformational style of leadership, reinforcing the findings of previous studies.4 Most of the head nurses involved in this study were more concerned with efficient processes and in ‘what will work’ rather than in ‘what is true’.15 Such results are different from the findings of Omer.11 The differences could be because it was conducted at the National Guard Health Affair Hospital which has invested heavily in the development of its personnel.

Nurses in this study were moderately satisfied with their work environment, which is in congruence with the findings of Al-Ahmadi.12 Henceforth, the nurses' job

Fawaz Musaed M. Alshahrani and Lubna A. Baig

368 Journal of the College of Physicians and Surgeons Pakistan 2016, Vol. 26 (5): 366-370

Table I: Leadership style of head nurses and job satisfaction of staff nurses.

Leadership Styles (scale from 1-5 with 5 highest) Job Satisfaction (scale from 1-6)

Leaders Transactional Leadership (TA) Transformational Leadership (TF)

Mean SD Mean SD Mean SD

Leader (1) 3.76 0.49 3.36 0.45 3.71 0.44

Leader (2) 3.74 0.62 3.38 0.72 3.23 0.60

Leader (3) 3.65 0.62 3.68 0.45 3.81 0.43

Leader (4) 3.50 0.55 3.28 0.48 3.53 0.52

Leader (5) 3.41 0.33 2.51 0.77 3.14 0.55

Leader (6) 3.72 0.14 3.99 0.38 3.73 0.33

Leader (7) 4.24 0.56 3.87 0.30 2.91 0.30

Leader (8) 2.57 0.78 2.69 0.65 3.14 0.49

Total 3.58 0.68 3.32 0.72 3.40* 0.57

p-value <.000 <.000 <.000

*Mean response of 3 or less represents dissatisfaction; Mean response of 4 or more represents satisfaction; Mean scores between 3 & 4 are ambivalence (17).

Table II: Relationship between organizational outcomes and perceived transactional and transformational leadership styles.

Organization Transformational Transactional outcomes Leadership style Leadership style

Extra effort r 0.77 0.63

Sig. 0.001** 0.001**

Effectiveness r 0.77 0.55

Sig. 0.001** 0.001**

Satisfaction r 0.78 0.50

Sig. 0.001** 0.001**

** P-value < 0.01.

Table III: Multiple linear regression models for variables predicting job satisfaction (n = 94).

Model R2 Adjusted R2 R2 Change Sig. F Change

1 0.230 a 0.176 0.23 0.001**

2 0.225 b 0.181 - 0.004 0.49

a & b, predictors (leadership factors); R2, the proportion of variance in the dependent variable; Adjusted R2, the proportion of variance in the population. ** p-value < 0.01.

Table IV: Leadership factors that have an effect on job satisfaction.

Model (1)

a. Predictors Std. Beta Sig.

Professional support 0.46 0.007**

Idealized influence - 0.08 0.49

Intellectual motivation - 0.29 0.02*

Management-by-correction (active) - 0.25 0.06

Management-by-correction (passive) - 0.22 0.04*

Laissez faire 0.31 0.01**

Std. Beta, the standardized coefficient; * p-value < 0.05, ** p-value < 0.01.

satisfaction in Saudi Arabia necessitates more exploratory studies. Nurses were not satisfied with the head nurses who demonstrated transactional leadership style. This could be because of the effect of transactional leadership approach on the job satisfaction. This is in line with previous studies suggesting that a two-way communication and leadership approach can affect employees' satisfaction.8,9

Those head nurses who were perceived as demons- trating the corrective passive behaviour of management for solving problems generated higher levels of dissatisfaction among their staff nurses. It is likely that the demonstration of such passive behaviours by the leader is perceived as lack of effectiveness in the leadership roles. Therefore, nurses may feel un- supported by their head nurse, especially in a stressful environment as critical care units. Thus, staff nurses prefer to have transformational leaders versus transactional leaders in their units. This result supports that the transformational leadership style was preferred more than transactional leadership style.16

The organizational outcomes (effectiveness, extra effort and satisfaction) had strong associations with the transformational leadership behaviour more than transactional leadership, which is in congruence with the Bass et al. study.16 The transactional leadership style of the head nurses provides a basis for effective leadership. But when the head nurses augment their transactional leadership behaviour with transformational leadership, the staff nurses become more effective and put in extra efforts to achieve organizational goals. These findings are in line with several previous studies which indicated that the transformational leadership approach was the strongest predictor of the organizational outcomes.4,6,11,16

The results of the multiple linear regression analysis indicated that 23% of the variation in nurses' job satisfaction was explained by the head nurse's transformational and transactional leadership styles. The results support the conclusion that there are nurse's job satisfaction dimensions other than salary and incentive that predict the intention to stay.13 This also reflects that job satisfaction is a complex variable, affected by several factors (situational or personnel). Therefore, leaders, educators and researchers in the nursing field should try to identify those variables which are not accounted for in the present study.

The critical care units have a stressful environment due to complexity which is reflected in the acuity of cases, variety of healthcare givers and variety of procedures.1 It needs full commitment from nurses to optimize the delivery of healthcare services. In units where the head nurses continually urge or encourage nurses to search for new ideas or methods of performing their job may have detrimental effects on nurses' job satisfaction. It

creates ambiguity and tends to raise conflict among the nurses. In this study, the authors found a negative effect of intellectual motivation on nurses' general job satisfaction. Therefore, these results did not support the use of Keats notion that related to creativity in such critical area.17 It was about the phenomenon of negative capability, as it is a state in which a person is capable of being in a state of uncertainties, mysteries, doubts, without any irritable reaction after fact and reason. Future research studies in other branches of nursing field as nursing education and nursing management as well as nursing critical and general care might help to explore the effect of the creativity in the Saudi nursing context.

The findings of this study revealed that nurses in the critical care units need an active leader instead of passive manager. The head nurse should be orientated towards building capacity in anticipation of unforeseen challenges.18 Therefore, our results indicated that there was a drop in nurses' job satisfaction when the head nurse failed to interfere until problems become serious. Such findings support Goleman's argument that the leaders who seek an excellence in leadership should have strengths in the emotional intelligence competencies.19

It has been found that nurses' job satisfaction has a strong association with the organizational commitment.9

These results show that nurses were satisfied with nature of work meaning that the general environment of ACH was good. However, they were dissatisfied with the operating conditions, fringe benefits and contingent rewards. Thus, it demands from the hospital's nursing director, planning committees department and human resources department, to make new strategic plans to raise the level of satisfaction among nurses.

In this study, we considered only the effect of the leadership approach on nurses' job satisfaction. It might be valuable to investigate other dimensions of the job satisfaction. In addition, the results of this study should be interpreted taking into consideration that we only had evaluations on 8 nursing leaders from a government hospital.

Educational activities targeting leadership styles of head nurses should be conducted regularly in all institutions and should emphasize the importance of two-way communication process and mutual trust between the leaders and the staff nurses. Future research could replicate our study and address the other dimensions that can affect nurses' job satisfaction. System workload and rewards should also be rearranged in innovative ways in order to help nurses feel satisfied, valued and may be enthused with a sense of purpose in their work. The 6 factor solution of the MLQ-5X form in the Saudi nursing context should be validated further.

Effect of leadership styles on job satisfaction among critical care nurses in Aseer, Saudi Arabia

Journal of the College of Physicians and Surgeons Pakistan 2016, Vol. 26 (5): 366-370 369

Fawaz Musaed M. Alshahrani and Lubna A. Baig

370 Journal of the College of Physicians and Surgeons Pakistan 2016, Vol. 26 (5): 366-370

CONCLUSION The study emphasized the importance of TF style of head nurses for increasing staff nurses' job satisfaction. It is suggested that nurse leaders should be trained in TF style of leadership and provided more support and training for effective management of CCU.

REFERENCES 1. Begun JW, Zimmerman B, Dooley K. Healthcare organizations

as complex adaptive systems. In: Mick SM, Wyttenbach M editors. Advances in healthcare organization theory. San Francisco: Jossey-Bass; 2003; p. 253-88.

2. Drucker P. The new realities. New York: Harper & Row; 1988.

3. Avolio BJ, Gibbons TC. Developing transformational leaders: a life span approach. In: Conger JA, Kanungo RN, editors. Charismatic leadership: The elusive factor in organizational effectiveness. San Francisco: Jossey-Bass; 1988; p. 276-308.

4. Bass B, Avolio B. Manual for multifactor leadership question- naire: Sampler set. 3rd ed. Redwood: Mind Garden Inc.; 2004.

5. Walumbwa FO, Avolio BJ, Gardner WL, Wernsing TS, Peterson SJ. Authentic leadership: development and validation of a theory-based measure. J Manag 2008; 34:89-126.

6. Horwitz IB, Horwitz SK, Daram P, Brandt ML, Brunicardi FC, Awad SS. Transformational, transactional, and passive- avoidant leadership characteristics of a surgical resident cohort: analysis using the multifactor leadership questionnaire and implications for improving surgical education curriculums. J Surg Res 2008; 148:49-59.

7. Sherman R, Pross E. Growing future nurse leaders to build and sustain healthy work environments at the unit level. OJIN: Online J Issues Nurs 2010; 15:325-30.

8. Campbell SL, Fowles ER, Weber BJ. Organizational structure and job satisfaction in public health nursing. Pub Health Nurs 2004; 21:564-71.

9. Al-Hussami M. Study of nurses' job satisfaction: The relationship to organizational commitment, perceived organizational support, transactional leadership, transformational leadership, and level of education. Eur J Sci Res 2008; 22: 286-95.

10. Mrayyan MT. Jordanian nurses' job satisfaction and intent to stay: Comparing teaching and non-teaching hospitals. J Prof Nurs 2007; 23:125-36.

11. Omer TY. Leadership style of nurse managers at the Saudi National Guard Hospitals [Dissertation]. United States: George Mason University; 2005.

12. Al-Ahmadi HA. Job satisfaction of nurses in ministry of health hospitals in Riyadh, Saudi Arabia. Saudi Med J 2002; 23: 645-50.

13. Zaghloul AA, Al-Hussaini MF, Al-Bassam NK. Intention to stay and nurses' satisfaction dimensions. J Multidiscipl Healthcare 2008; 2:51-8.

14. Spector P. Measurement of human service staff satisfaction: Development of the job satisfaction survey. Am J Commun Psychol 1985; 13:693-713.

15. McCall MW. Review of leadership and performance. In: Bass BM. Editor. Leadership and performance beyond expectations. Greensboro: John Wiley & Sons, Inc; 1986. p. 481-4.

16. Bass BM, Avolio BJ. Multifactor Leadership Questionnaire for research. Menlo Park, CA: Mind Garden Inc.; 1995.

17. French R, Simpson P, Harvey C. Negative capability: a contribution to the understanding of creative leadership. In: Sievers B, Brunning H, De Gooijer J, Gould L, editors. Psychoanalytic studies of organizations: Contributions from the international society for the psychoanalytic study of organizations. London: Karnac Books; 2009. p. 1-16.

18. Day DV, editor. Leadership development: a review in context. Pennsylvania: Elsevier Science Inc.; 2001.

19. Goleman D. Leadership that gets results. Harvard Business Review. 2000; p.1-15.