week 5 Mini Assignment

Leadership styles’ influence on the quality of nursing care

Aladeen Alloubani King Hussein Cancer Centre, Amman, Jordan

Laila Akhu-Zaheya Department of Nursing,

Jordan University of Science and Technology, Irbid, Jordan Ibrahim Mubarak Abdelhafiz

Faculty of Medicine, University of Tabuk, Tabuk, Saudi Arabia, and M. Almatari

Department of Nursing, University of Tabuk, Tabuk, Saudi Arabia

Abstract Purpose – The purpose of this paper is to investigate managers’ leadership styles, from the perspective of registered nurses, and its effects on the quality of nursing care in both the private and public healthcare sectors. An additional aim is to assess the relationship between leadership styles and particular organisational outcomes. Design/methodology/approach – The sample for this quantitative research study was comprised of 400 respondents, among which 50 were nurse managers, 150 were staff nurses and the remaining respondents were patients. Two questionnaires were used in this study: the multi-factor leadership questionnaire (MLQ) 5X short and a patient satisfaction with nursing care quality questionnaire (PSNCQQ). Findings – A positive correlation was found between the transformational leadership style with leadership outcomes and the quality of nursing care (r ¼ 0.811**, 0.759**, 0.789** and 0.877** for extra effort, job satisfaction, leader effectiveness and quality, respectively). Practical implications – Although the sample study was extensive, a possible limitation is that the research utilised convenient sample who are working in the private and public healthcare sectors thus limiting the generalisability of the study. Originality/value – This study was proposed as a baseline for upcoming studies in areas of education, nursing practice, research and quality. Moreover, this study was expected to be imperative to the hospital’s management, in order to improve the current level of leadership, education models and advancement programs for the healthcare sector’s senior staff. Keywords Leadership, Quality healthcare, Quality management, Patient satisfaction, Nursing quality Paper type Research paper

Background Leadership style has vital importance in the quality of nursing care in hospitals. The leadership styles, adopted by nurse managers, are expected to affect patients’ care (Sfantou et al., 2017). Nurse managers as a unit/ward leader, have various roles, including the ability to properly supervise staff nurses, organising workflow and training both junior nurses and nursing students. In addition, they guarantee a high quality of nursing healthcare for patients (Alloubani, 2016; Huber, 2017); however, the leader role of nurses is not exclusive to the managerial role. Though all successful leaders have one common characteristic. They focus on influencing people around them, with the goal of ensuring that optimum performance is achieved from the resources in the organisation. It is the leaders in an

International Journal of Health Care Quality Assurance Vol. 32 No. 6, 2019 pp. 1022-1033 © Emerald Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-06-2018-0138

Received 4 May 2017 Revised 23 September 2017 11 January 2018 8 June 2018 8 August 2018 Accepted 31 August 2018

The current issue and full text archive of this journal is available on Emerald Insight at: www.emeraldinsight.com/0952-6862.htm

The authors hereby certify that this material, which we now submit for your Journal is entirely our own work and there is “No conflict of interest has been declared by author(s)”. Received no specific grant from any funding agency in the public, commercial, or non-for-profit sectors, or support in the form of equipment or other assistance. The authors would like to thank Manar Saleh (University of Houston; Teacher, Houston Independent School District) for her valuable assistance and support in editing and revising this manuscript.

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organisation who determine the culture, motivation, tolerance and values in an organisation. Leadership styles change and shape the institutional strategies, including their effectiveness and execution.

The role and effectiveness of leaders and leadership styles, particularly in healthcare facilities were highlighted in the literature (Denhardt et al., 2013). Previous studies concerning leaders and leadership styles have led many to accept the foundational knowledge and concepts identified by Bass (1985). Bass conceptualised three main leaders and leadership styles, referred to as the transformational leadership style, the transactional style and the laissez-faire style (Gençer and Samur, 2016).

The Bass theory was very important as it provided a theoretical base for leadership styles. The theory provided creative and rigorous ideas of structuring a purposeful, tentative and a systematic view in the healthcare sectors. This is what now enables systematic inquiry in the nursing care practice, which helps in the capability of acquiring knowledge that would improve patients’ care.

Several studies have been conducted to identify leadership styles and behaviours (Kang et al., 2015; Loshali and Krishnan, 2013; Wilson, 2018). Huber (2017) defined the transformational leader as a pioneer who inspires supporters to perform at their maximum capacity after some time, by providing adjustment in recognition, and a sense of guidance; whereas, a transactional leader is a leader that has capacities in a caregiver role and is centred on the everyday operation. Transformational leadership was divided into five sub-categories, which included individual consideration, intellectual stimulation, inspirational motivation, idealised influence in behaviour and idealised influence in attributes. Transactional leadership (TAL) was comprised of contingent reward, management by exception active and management by exception passive.

The last leadership style is the laissez-faire style, which is considered a negative style of leadership. This style gives employees freedom of choice to independently find solutions to the raised problems, due to the frequent absence of their leaders.

In Jordan, the setting of the study, a widely respected and highly effective healthcare system is recognised as a model to other countries in the region and serves as an ideal setting for further research into nursing leadership (Alloubani et al., 2016). Still, there is a need to implement strategies that create opportunities to develop leadership in Jordan as well as the need to build institutions that can produce effective health managers and leaders. A majority of researchers have highlighted the role and effectiveness of leaders and leadership, particularly in healthcare facilities (Denhardt et al., 2013). In Jordan, there have been long debates over why private sector hospitals are more successful than public sector ones in providing more convenient services.

Aim This study aimed to investigate nurse managers’ leadership styles from the registered nurses’ perspective and to assess the effect of leadership styles on the quality of nursing care, as rated by patients. Moreover, the aim was to evaluate the relationship between leadership styles and particular organisational outcomes (job satisfaction, leader effectiveness, registered nurses’ enthusiasm to spend extra efforts).

Materials and methods Design and settings This study used a cross-sectional, descriptive and correlational design. The study was conducted at three private hospitals and three public hospitals in Jordan. The descriptive design of the study enabled descriptions of the phenomena of interest as they currently exist, without manipulation, and the cross-sectional design simultaneously simplifies interpretations of some subsets of the population with respect to the independent variables

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(Parahoo, 2014). A correlation design is efficient for gathering huge quantities of information concerning specific phenomena (Polit and Beck, 2016). In Jordan, a widely respected and highly effective healthcare system is recognised as a model for other countries in the region and serves as an ideal setting for further research into nursing leadership (Alloubani et al., 2016). The six largest hospitals among the private and public hospitals were approached.

Participants A convenience sampling method was employed. This method is very suitable for distinguishing correlations amongst different phenomena. In addition, the assumption connected with convenience sampling is that the members of the target population are comparable. That is, there would be no difference in the research results obtained from a random sample (Etikan et al., 2016). Moreover, the objective of convenience sampling is to collect information from participants who are readily available to the researcher, like recruiting providers attending a staff meeting for participation in the study (Palinkas et al., 2015).

The inclusion criteria included a nurse manager who was in charge of or responsible for at least three nurses, with a minimum of one-year experience as a manager in his/her current position, with 24-hour accountability and responsibility for operational processes. The nurses should have had at least one-year experience with the same manager. For the patients, the inclusion criteria were adult patients, above 18 years old, conscious and oriented.

Based on a medium-effect size for a two-tailed test with an α of 0.05 and a power of 0.8, the minimum number of participants needed was 364 participants. However, the study included 400 participants (50 nurse managers, 150 staff nurses and 200 patients from public and private healthcare sectors).

Ethical considerations The approval to conduct the study was obtained from the Institutional Review Board (IRB), the Ministry of Health and ethics committee within the public sector hospitals (Number: 2,954), as well as from each of the participating hospitals in the private sector. In addition, the approval to use the instrument was obtained from the author.

Instruments Two questionnaires were used in this study: The multi-factor leadership questionnaire (MLQ) 5X short and a patient satisfaction with nursing care quality questionnaire (PSNCQQ). MLQ is the most broadly recognised questionnaire to investigate and evaluate the level of one’s leadership style as transformational, transactional or laissez-faire (Sfantou et al., 2017; Avolio and Yammarino, 2013, Avolio, 2011).

The MLQ is comprised of 45 items; 36 items measure and evaluate key leadership styles and effectiveness behaviours and nine items measure leadership outcomes. All questions are measured using a five-point Likert scale (4 ¼ frequently, if not always; 3 ¼ fairly often; 2 ¼ sometimes; 1 ¼ once in a while and 0 ¼ not at all). For the leadership styles, the total range score between 0 and 144, with the higher score indicates high behaviour related to leadership style. However, for the leadership outcomes the total range score from 0 to 36, with the higher score indicates higher satisfaction, extra efforts nurses can provide and more leader effectiveness. Earlier studies have demonstrated a significant connection between individual and organisational achievement (Tsuno and Kawakami, 2015; Nielsen and Daniels, 2012). The MLQ 5x is the latest version and has been reviewed numerous times (Antonakis and House, 2014).

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The construct validity was established whereby the factor loading ranges between 0.62 and 0.91 (Felfe and Schyns, 2004; Lee et al., 2011). For the reliability it was α¼ 0.94, indicating a high level of internal consistency (Churchill, 1979). For the MLQ subscales, the transformational subscales showed reliability range between 0.86 and 0.9; for the transactional, it was ranged between 0.70 and 0.80, while for the laissez-faire Leadership it was 0.8 (Avolio et al., 1995).

The PSNCQQ derived from the patient judgement of hospital quality (PJHQ) questionnaire. A multidisciplinary study team at the hospital corporation of America established the original PJHQ tool (Meterko et al., 1990). Questions were derived from a broad literature review, focus groups and a content analysis of patients’ exact responses to questions about the quality of the hospital.

The PSNCQQ has 22 items planned to assess patients’ satisfaction with the general quality of care through the hospital stay, overall nursing care quality and intention to recommend the hospital to your friends. A five-point Likert scale ranging from poor to excellent is used for each question of the PSNCQQ. There are two ways to score the PSNCQQ. For overall outcomes, the scores for all questions can be computed and averaged to yield a single assessment for each participant. For comprehensive feedback and more “actionable” outcomes, item means and standard deviations can be calculated. Another way is to calculate the percentage of “strongly agree” answers for each question. These outcomes can be employed to track changes over time or to assess the impacts of quality enhancement initiatives.

Cronbach’s α reliability assessments for the PSNCQQ is 0.97. Item total correlations are high, ranging between 0.61 and 0.89. Reliability estimates are similar across diverse hospital categories (public, private, teaching). This proposes that patients in different types of hospital systems are interpreting the questions on the PSNCQQ in a consistent way (Laschinger et al., 2005). In this study, Cronbach’s α was 0.89 in the private healthcare sector and 0.87 in the public healthcare sector.

Data collection procedure Data were collected using the questionnaire distributed to the nurse managers, staff nurses and patients. According to Parahoo (2014), questionnaires are resourceful tools for data collection on the aspects of clients or employees. They are also valuable in data collection relating to knowledge, opinions, values, attitudes, perceptions and behaviours for both employees and clients.

Frequent visits were made to various departments in the study hospitals by the investigators. The researcher explained the purposes and significance of the study to the prospective participants and invited them to participate. Participants were assured that participation was voluntary. They were also informed that they could withdraw from the study at any time and had the right to ask for clarification.

Upon their (nurse managers, nurses and patients) agreement to participate in the study, written informed consent was obtained from the participants. Nurse managers and nurses were provided with the questionnaire including the cover letter with instructions to complete the questionnaire. Once completed, they were instructed to return the questionnaire to designated, secure boxes within five days. The boxes were placed in various admissions offices at the hospital sites. For the patients, the PSNCQQ, including the cover letter was distributed. The researcher(s) explained the questionnaire items for the patients and remained with them during the completion of the questionnaire. Also, participants were assured that the gathered data were only for the purposes of the research. Moreover, confidentiality and anonymity of the collected information were assured and maintained.

Data analysis The Statistical Package for Social Science (SPSS) SPSS®-PC version 21 for Windows was utilised for data analysis. For all statistical analyses, the significance level was set at 0.05.

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Data analysis included both inferential and descriptive analyses. Descriptive statistics based on the level of measurement (frequencies, percentages, means and standard deviations) were used to characterise the demographic features and background of the participants, as well the MLQ scale scores.

An independent sample t-test was used to examine the variation between nurse managers’ perceptions and the nurses under their supervision perception of the leadership style(s), as well as to find differences in leadership style(s) as perceived by nurse managers and nurses with respect to gender. A one-way analysis of variance (one-way ANOVA) was used to examine variations in leadership style(s) as perceived by nurse managers and nurses with respect to age, marital status, work experiences, and level of education. Cronbach’s α was used to find the internal consistency of both questionnaires.

Results The study’s findings explained the perception of the participants (nurse managers and nurses) in terms of the leadership styles and leadership outcomes (job satisfaction, leader effectiveness and extra effort). Additionally, the study findings revealed the patients’ perception of the quality of nursing care.

Participant demographics characteristics The total number of participating nurse managers and registered nurses was 200. In total, 96 (48 per cent) were males and 104 (52 per cent) were female. Moreover, 115 (57.5 per cent) of the participants were married and 85 (42.5 per cent) were single. Participants were divided into three age groups with the highest number of participants (108, 54 per cent) being in the 22−30 age group. Additionally, participants were divided according to their years of nursing experience with the highest number of participants (67, 33.5 per cent) having between 1 and 5 years of experience. Table I shows detailed participants’ demographic characteristics.

The quality of nursing care in both healthcare sectors In relation to the overall levels of the quality of nursing care, a total of 200 patients participated in the study. An independent sample t-test was used to evaluate the relationship between leadership styles and patients’ perception of the quality of nursing care. A significant difference was observed between the participants from the public sector (M ¼ 1.95; SD ¼ 0.88) and private sector (M ¼ 4.12; SD ¼ 0.82) (t ¼ 22.5, po0.001) (Table II).

Variables Frequency %

Gender Male 96 48 Female 104 52

Marital status Single 85 42.5 Married 115 57.5

Age (years) 22–30 108 54 31–40 73 36.5 o40 19 9.5

Experiences (years) 1–5 67 33.5 6–10 65 32.5 11–15 40 20 16–20 15 7.5 o20 13 6.5

Table I. Demographic characteristics of Participants (nurse managers and registered nurses)

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For nurses perceptions of leadership style, the results revealed significant differences between the participants in public (M ¼ 1.91; SD ¼ 0.48) and private hospitals (M ¼ 2.58, SD ¼ 0.35); (t ¼ −11.24, po0.001) (Table III).

Leadership styles subscales in private and public healthcare sectors For the MLQ, the results revealed that for the transformational leadership style, the mean and SD were (2.97, 0.54), (1.37, 0.58) for the private and public hospitals, respectively, which was significant (t ¼ 38.6, p ¼o0.001).That is the participants in the private hospitals prefer the transformational style more than public hospital. For the TAL style, the mean and SD were (2.10, 0.60), (3.14, 0.49) for the private and public hospitals, respectively, which was significant (t ¼ 48.5, p ¼o0.001) and this would indicate that participants in the public hospitals prefer the TAL style. While, for the laizzes-faire leadership style, the mean and SD were (1.19, 0.93), (1.23, 0.83) for the private and public hospitals, respectively, which was significant (t ¼ 31.7, p ¼o0.001). Table IV shows detailed results of the leadership style scales and subscales.

For the leadership outcomes, the result revealed significant differences between private and public hospitals in terms of leader effectiveness (t ¼ 37.1, p ¼o0.001), extra efforts (t ¼ 31.9, p ¼o0.001) and nurses’ satisfaction (t ¼ 29.6, p ¼o0.001). Table IV shows detailed results of the leadership outcomes. For the patients’ perception of the quality of nursing care, the results revealed also a significant difference between private and public hospitals (t ¼ 22.5, p ¼o0.001).

Private sector Public sector M SD M SD t p

Transformation leadership style 2.979 0.547 1.375 0.581 38.6 o0.001 Intellectual stimulation 2.967 0.621 1.282 0.661 33.5 o0.001 Inspirational motivation 2.995 0.632 1.440 0.817 32.4 o0.001 Individual consideration 2.966 0.666 1.352 0.747 31.3 o0.001 Idealised influence (behaviour) 2.937 0.635 1.432 0.648 34.1 o0.001 Idealised influence (attributed) 3.030 0.651 1.367 0.683 33.2 o0.001 Transactional leadership style 2.109 0.608 3.143 0.498 48.5 o0.001 Contingent reward 2.607 0.773 3.110 0.627 41.6 o0.001 Management-by-exception (active) 2.340 0.888 3.237 0.562 41.9 o0.001 Management-by-exception (passive) 1.380 0.872 3.082 0.666 31.0 o0.001 Laizzes-faire 1.195 0.935 1.237 0.837 31.7 o0.001 Leadership outcomes 2.970 0.540 1.757 0.753 46.5 o0.001 Effectiveness 3.042 0.605 1.952 0.810 37.1 o0.001 Extra effort 2.870 0.638 1.700 0.893 31.9 o0.001 Satisfaction 2.975 0.668 1.455 0.979 29.6 o0.001 Quality of nursing care 4.124 0.825 1.950 0.885 22.5 o0.001

Table IV. Comparing leadership

styles subscales, leadership outcomes

and quality of nursing care between

private and public health sectors

Variables F % M SD t p

Sectors Public 100 50 1.910 0.487 −11.243 o0.001 Private 100 50 2.584 0.349

Table III. t-test analysis for

nurse managers and registered nurses

regarding their sectors

Variables F % M SD t p

Sectors Public 100 50 1.950 0.885 22.5 o0.001 Private 100 50 4.124 0.825

Table II. t-test analysis for patients regarding

their sectors

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Cronbach’s α (reliability analysis) Reliability analysis showed that the internal consistency of the MLQ and PSNCQQ were 0.90 and 0.88, respectively.

Correlations between leadership styles subscales, leadership outcomes and quality of nursing care Table V depicted the correlation matrix amongst the transformational leadership, TAL, laissez-faire leadership, and their substyles with leadership outcomes and the quality of nursing care using Pearson’s product-moment correlation. There was a significant positive relationship among the transformational leadership subscales and effectiveness, extra effort, satisfaction and the quality of nursing care (r ¼ 0.85**, 0.78**, 0.75**, 0.81** and 0.87** at p-valueo0.001), respectively. Moreover, all transformational leadership subscales were significantly positively correlated with effectiveness, extra effort, satisfaction and the quality of nursing care.

Adversely, the overall TAL was found to have a significant negative correlation with effectiveness, extra effort, satisfaction and quality (r ¼ −0.26**, −0.32**, −0.38 and −0.22**

Leadership style Leadership outcomes Effectiveness

Extra effort Satisfaction

Quality of nursing care

Transformational leadership (TRL)

Pearson Correlation

0.856** 0.789** 0.759** 0.811** 0.877**

p-value o0.001 o0.001 o0.001 o0.001 o0.001 Intellectual stimulation IS Pearson

correlation 0.797** 0.729** 0.714** 0.752** 0.775**

p-value o0.001 o0.001 o0.001 o0.001 o0.001 Individual consideration IC Pearson

correlation 0.779** 0.697** 0.716** 0.737** 0.748**

p-value o0.001 o0.001 o0.001 o0.001 o0.001 Inspirational motivation IM Pearson

correlation 0.819** 0.774** 0.698** 0.780** 0.795**

p-value o0.001 o0.001 o0.001 o0.001 o0.001 Idealised influence – behaviour IIB

Pearson correlation

0.804** 0.743** 0.702** 0.772** 0.802**

p-value o0.001 o0.001 o0.001 o0.001 o0.001 Idealised influence – attributed IIA

Pearson correlation

0.800** 0.741** 0.713** 0.747** 0.785**

p-value o0.001 o0.001 o0.001 o0.001 o0.001 Transactional leadership (TAL)

Pearson correlation

−0.344** −0.266** −0.325** −0.383** −0.225**

p-value o0.001 o0.001 o0.001 o0.001 o0.001 Contingent reward CR Pearson

correlation −0.011 0.033 −0.032 −0.049 0.077

p-value 0.881 0.646 0.653 0.494 0.13 Management-by exception- active MBEA

Pearson correlation

−0.213** −0.141* −0.241** −0.223** −0.147**

p-value 0.002 0.047 0.001 0.002 o0.001 Management-by-exception- passive MBEP

Pearson correlation

−0.520** −0.446** −0.446** −0.565** −0.444**

p-value o0.001 o0.001 o0.001 o0.001 o0.001 Laissez-faire LF Pearson

correlation −0.033 −0.040 0.008 −0.063 −0.014

p-value 0.645 0.574 0.912 0.376 0.386 Notes: *,**Correlation is significant at the 0.05 and 0.01 levels (two-tailed)

Table V. Correlation coefficient among leadership outcomes and quality of nursing care with leadership styles

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at p-valueo0.001). Indeed, the correlations between management by exception passive and all the dependent variables had the most negative correlation amongst all the TAL substyles and dependent variables (r ¼ −0.44**, −0.44**, −0.56** and −0.44 at p-valueo0.001). Additionally, the relationship amongst the laissez-faire leadership style and dependent variables was negative and insignificant (r ¼ −0.03 at p-valueo0.645).

Predictors of nursing care quality Multiple regression analysis showed the model anticipated a sizeable proportion of variance in quality of nursing care (F ¼ 68.65, po0.001). The R2 for the model was 0.51, and adjusted R2 was 0.50. Table VI shows the unstandardised regression coefficients (b), standard error, standardised regression coefficients (β) and t-statistics for each variable.

Discussion The aims of this study were to investigate nurse managers’ leadership styles from the registered nurses’ perspective, as well as to assess the effect of leadership style on the quality of nursing care as rated by patients. Moreover, the aim was to evaluate the relationship between leadership styles and particular organisational outcomes (job satisfaction, leader effectiveness and registered nurses’ enthusiasm to spend extra efforts).

Our results revealed both transformational and TAL styles were the most used leadership styles by nurse managers, which corroborates the debate that leaders are both transactional and transformational (Bass and Bass, 2008). However, the results of the current study showed transformational leadership was the preferred style among managers in the private sector. This finding is consistent with previous studies, which also found that transformational leadership was dominant (Abdelhafiz et al., 2016; Bryman, 2013; Tsuno and Kawakami, 2015). The transformational leaders are more inspirational and provide intellectual stimulation. The transformational leaders look at the satisfaction and creativity of followers. However, this finding is inconsistent with Vinkenburg et al. (2011), who said the transformational leadership was more frequently used by leaders in the public sector than those working in the private sector.

The findings of the current study indicated a significant positive correlation between transformational leadership style and particular organisational outcomes, such as job satisfaction, leader effectiveness, registered nurses’ enthusiasm to spend extra efforts and the quality of nursing care. Therefore, this would support the argument the transformational leadership style was positively correlated with the organisational consequences (Abualrub and Alghamdi, 2012; Casida and Parker, 2011). Transformational leadership is incredibly significant to recent work and modern organisations (Avolio and Yammarino, 2013).

According to Tsuno and Kawakami (2015), transactional leaders, set goals for their followers and thus the focus is on task completion. In the current study and among the TAL substyle, the findings revealed contingent reward was the highest score, indicating that reward is important for nurses’ achievement. This is supported by Lowe et al. (2013), which contended that contingent rewards fostered a positive relationship with employees’ perceptions of work. Nurse managers’ use of contingent reward supports the efficiency of the TAL. The study results revealed in the public healthcare sector, the contingent reward was

Predictors B β t p

Transformational leadership (TRL) 0.56 0.48 8.37 o0.001 Transactional leadership (TAL) −0.52 −0.34 −5.93 o0.001 Laissez-faire LF 0.07 0.05 1.09 0.277 Notes: R2 ¼ 0.51; adjusted R2 ¼ 0.50; F ¼ 68.65; po0.001

Table VI. Predictors of nursing

care quality

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the major substyle than even the transformational leadership style. This is consistent with previous study, which found a strong presence of contingent rewards (Yang et al., 2011).

Only a few participants responded positively to the laissez-faire leadership style, showing a low interest in using it. The outcomes also presented a significant negative correlation existed between laissez-faire style and certain organisational outcomes. It is often not considered to be a leadership style at all (Easterby-Smith et al., 2012). Besides, laissez-faire leadership style seemed to be an unfavourable aspect style of leadership, which is also supported by other studies (Sfantou et al., 2017; Saeed et al., 2014).

Two important issues should be taken into consideration when adopting certain leadership styles, which are nurses’ retention and satisfaction while maintaining the quality of patient care. Nursing care and patient satisfaction are a significant concern in today’s competitive healthcare climate, which also set a high demand for established efficiency and public responsibility (Al-Abri and Al-Balushi, 2014). Satisfying patients’ expectations has always been significant to healthcare workers, and it has developed even more in current years. Over the previous decade, patients have taken a more active role in their treatment because of their interest in safety, cost, and quality of care. The quality of nursing care was found to be better in the private hospitals than in the public hospitals. This could be related to the staffing system and the ratio of nurses to that of patients. Patient satisfaction could be affected by leadership styles quality. In addition, in the private healthcare sector, there is a great concern about medical tourism. Thus, nurses and patients’ satisfaction is very important. All patients’ issues are treated within a stipulated time frame, according to their convenience, unlike in public hospitals where treatment can get delayed owing to technical issues and patient neglect.

Nurse manager leadership styles would impact patients’ outcomes and the entire organisation’s performance. Nurses play a vital role in healthcare organisations. Leaders’ management affects nurses’ performance and patients’ satisfaction. Patients’ satisfaction is one of the indicators of the quality of nursing care (Abusalem et al., 2013; Mari et al., 2018; Zamil et al., 2012). This is in terms of various aspects such as technical quality, the art of care, availability, physical environment, efficacy, and continuity (Nunes and Gaspar, 2016). Analysis of patient satisfaction becomes a tool that is significant in the organisation and the planning of care to respond to the patients’ needs by nurse managers. In the current study, patients’ satisfaction related to nursing care was better in the private sector than the public healthcare sector.

The positive findings related to the private healthcare sector can be replicated in the public sector. The public sector must strive to deliver the care to their patients as the private sector. For instance, the public organisations should avoid unnecessary long waits. It is known that the wait time for lab results – for example – is more in public than private healthcare sector and even dissatisfaction to the patients. In the public organisations, every nurse should learn how to handle and respond to the patients’ complaints and concerns in a professional manner.

Conclusion and implication The result of the current study has different implications for hospital administrators, nurse managers, education and research. For administrators, it’s important to take nurses perception and patient satisfaction into consideration when adopting any leadership style, which should be based on the institution vision, mission, values and philosophy. Additionally, nurse managers should understand the different leadership styles and be trained on the style which reflects the institution strategy. For education, clinical leadership practice and different leadership styles should be integrated into the nursing curriculum. In the clinical practice, nursing students should be trained on different leadership styles providing them with the pros and cons of each style and the expected impact on nurses and patients’ satisfaction. Regarding research, further studies should look at the cultural influence on adopting certain leadership styles among nurse managers.

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The transformational style of leadership is applied in the private healthcare sector, while TAL is more common in the public healthcare sector. This affects the quality of nursing care, which was found to be better in the private healthcare sector than in the public healthcare sector. Regardless of the perceived leadership styles, the various organisational outcomes that encompass a leader’s effectiveness, job satisfaction, the performance of employees and the quality of nursing care would be affected. Education for the leadership models for the senior staff in the healthcare sector is needed.

Although the sample study was extensive, a possible limitation is that the research utilised convenient sample who are working in the private and public healthcare sectors thus limiting the generalisability of the study.

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Corresponding author Aladeen Alloubani can be contacted at: [email protected]

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