Nurses’ Perception of the Leadership Styles of their Nurse Managers in Riyadh region of Saudi Arabia

Introduction:

Leadership is the capacity to motivate other people to devote their best efforts toward the accomplishment of a goal, completion of a task, or actualization of a vision.¹ Ideas about leadership have evolved over the course of history based on the requirements of various groups of people and time.² A team whose leader is capable of instilling among team members a feeling of loyalty by way of shared aims, has high productivity, enhanced morale, and good satisfaction towards employment. This is because such a team works forward to achieve common objectives.³ In 1991, Bass and Avolio, introduced the theory of the “Full Range Leadership Model” which is considered a complete approach in covering various leadership styles.⁴ According to them, a leader can use a variety of leadership styles depending upon the situation in question, thereby making the model more inclusive.⁴ In general, this model contains three forms of leadership styles, namely transformational, transactional and laissez-faire leadership. 2

Transformational leadership style is characterized by leaders who inspire, motivate, and empower their followers to achieve their full potential.⁵ It is a leadership approach that focuses on elevating the aspirations and performance of individuals and teams by creating a positive and engaging work environment.⁶ Transformational leaders are known for their ability to inspire and stimulate their followers to surpass their own self-interests, for the greater good of the organization or team.⁷ Transformational leadership is further sub-divided into 4 domains, which include “idealized influence”, “individual consideration”, “intellectual simulation”, and “inspirational motivation”.8 Transformational leaders are capable of efficiently communicating to their employees about the significance of the group task, as well as the impact of every individual’s efforts on the group’s overall success.⁹

Transactional leaders focus on accomplishing the daily tasks by motivating their employees through systematic rewards and/or punishments (transactions).¹⁰ This form of leadership solely aims at completing specific portions of the task and hence it has been found synonymous with managerial leadership. However, evidence based studies have shown strained long-term relation and poor job satisfaction among employees working in an environment with prevalent transactional leadership style among managers.¹⁰ Transactional leadership style can be subdivided into the domains of “active management by exception”, “contingent reward”, and “passive management by exception”.11 In comparison to the transformational and transactional leadership styles, both of which are considered as hands-on leadership approaches, “Laissez-faire” leadership, is practiced as a hands-off approach.¹² Also known as delegative leadership, this style is characterized by limited supervision by managers and provides employees with a free-hand at decision-making. However, laissez-faire leadership style is regarded as more effective when managing a motivated and skillful set of staff members.¹²

Nursing staff comprise the largest group of managed workforce in hospitals and healthcare systems.³ They play a vital role in healthcare service delivery, and the ability of nurses to work and be managed as a team impacts their work environment. 13. The responsibilities handled by nurses in a hospital setting are both physically and psychologically demanding, whereby the leadership tenets of nurse managers play a critical role in ensuring high-quality service delivery to patients.¹⁴ Therefore, a conducive leadership between nurses and their nurse managers is necessary not only for fulfilling workplace requirements, but also for achieving optimal job satisfaction.¹⁵ In this context, the “Full Range Leadership Model” also applies to the field of healthcare, since each hospital or health institution relies on the management and leadership skills of nurse managers. The model can lend explanation to the leadership behaviors and practices of the nurse managers in every situation that they encounter.⁴ Thus, the efficiency of the nursing managers in handling the nursing staff could yield an enhanced positive outcome to both in nurse’s productivity and the patient satisfaction. 2

In any workplace setting, the use of appropriate leadership styles is a necessary component of effective leadership abilities.¹⁶ According to a recent study by Albagawi (2019), relationship-oriented leadership styles and particularly transformational leadership styles, are key to improving nurse satisfaction, promoting healthy work environments, and enhancing staff retention.¹⁷ Zaghini et al. (2019) examined the connection between the nurse managers’ styles of leadership to the quality of care rendered by nurses, as perceived by the patients.¹⁸ The study results revealed that when the nursing staff members were satisfied with the leadership styles of their managers, they did not feel burned-out and showed a positive outlook towards workplace relationships. In addition, the chances of committing errors or misbehavior at work reduced drastically to an extent that patients felt satisfied with the services they received from the nurses.¹⁸ In fact, nurses recognize the transformational leadership style of the nurse managers as extremely valuable, as it aligns with their professional values and promotes positive outcomes.¹⁹

While it is clear that transformational leadership empowers nurses by involving them in autonomous decision-making and valuing their contributions,20 majority of the reported studies have focused predominantly on the behaviors and qualities of nurse managers without examining the nurses' perceptions of their leadership style. Although transformational leadership is reportedly the most prevalent leadership style among nurse managers, in Saudi Arabia,21 the views of nurses regarding this style of leadership of their nurse managers has not yet been evaluated. In order to bridge this paucity in research evidence, the present study aimed at exploring the level of nurses’ perception about the leadership styles of their nurse managers and the way it might be affected by demographic characteristics of the nurses, at a secondary cum tertiary level hospital and healthcare complex in Saudi Arabia.

Materials and Methods

Study setting, sampling frame and sample size

The present study utilized a quantitative, analytical, cross-sectional design. Ethical approval for the study was obtained from the Institutional Review Board (IRB) at King Fahad Medical City (IRB Log Number: 22-311E). This study was designed and conducted among nurses employed at King Fahad Medical City Hospital in Riyadh region of Saudi Arabia. This medical city comprises a large scale, multi-specialty, tertiary level hospital complex with affiliated secondary level healthcare centers, which cater to different strata of patients from the central region of Saudi Arabia. The study was conducted among a representative sample of nursing staff members employed at King Fahad Medical City, between August 2022 and December 2022. The sampling frame was determined after excluding nurses who were either undergoing training or were employed for a period less than one year. This included 1500 nurses who fulfilled the criteria of being employed as a bedside nurse, for more than one year in one of the hospitals at the medical city, irrespective of their demographic status. The sample size for the study was calculated using Steven Thompson formula,22 after assuming population size (N)=1500, probability (p)=50%, error proportion (d)=0.05, and confidence level at 95% (z)=1.96, as below.

Accordingly, a total of 306 nurses were needed for the current study, and a final sample size of at least 300 – 315 participants was targeted after overestimation. Study participants were recruited based on a convenience, random sampling methodology, wherein the questionnaires were sent to the entire population in question (N=1500) and the responses submitted within the deadline were to be included, until estimated sample size was achieved. Informed consent to voluntarily participate in the study was obtained as a part of the response and ethical consideration for anonymity of participants was maintained throughout.

Study Instrument

Questionnaires in the form an online survey were shared electronically through the nursing department and human resource administration of the institution. The conceptual framework for the study was devised to collect data about the independent demographic variables of participants (age, education, experience, gender and income) and testing its association with the dependent variable (nurses’ perception of the leadership styles of their nurse managers) (Fig.1).

[Fig.1 to be inserted here]

The survey instrument for data collection was designed as a self-administered, multifactorial leadership, questionnaire in English language, adapted from the validated tool, originally reported by Avolio and Bass in 1995.4 The present study instrument was made up of two parts (Figure 2). Part one included questions to collect demographic information of the participants. Part two comprised a questionnaire consisting of 21 closed ended items, which were used to assess the transformational (items 1-12), transactional (items 13-18) and laissez faire (items 19-21) leadership styles of nurse managers, as perceived by the nurses. Based on a five-point scale similar to the Likert scale, respondents were asked to rate for each one of the 21 items regarding how their nurse managers engaged in a particular leadership activity (0=not at all; 1=once in a while; 2=sometimes; 3=fairly often; and 4=frequently, if not always). During distribution, the order of the 21 questionnaire items were randomized to avoid response bias. In order to ensure internal consistency, validity and reliability of the study instrument, a pilot study was conducted among 40 nurses. The total Cronbach’s Alpha for the framed questionnaire items was 0.979, and this was considered adequate enough to prove its reliability, in order to measure the objectives of the study.

[Fig. 2 to be inserted here]

Statistical Analysis

The Statistical Package for Social Sciences software (IBM SPSS Statistics Version 26, IBM Corporation, Armonk, NY, USA) was used to analyze the data. Descriptive statistics including frequencies, means, and standard deviations (SDs), were calculated. In order to test statistical association between independent demographic variables and nurses’ perception about leadership styles of the nurse managers, either T-test (only for gender) or one-way ANOVA (for all other demographic variables) was conducted, depending upon the demographic factor having only two groups or more than two groups, respectively. Additionally, Tukey post-hoc test was done to compare between the groups, when one-way ANOVA showed statistical significance, which was assumed when “p-value” was less than 0.05 (p<0.05) for all statistical tests.

Results

A total of 312 responses were received from the participating nurses within the sample collection deadline, among which 12 responses were eliminated due to incompleteness of response data. Therefore, the final study sample for statistical analysis was determined at 300 nurses. Descriptive data showed that 79.3% of the participants were women, and with respect to age distribution, majority of the nurses were in the age group of 31-40 years (48.7%), followed by those who were 30 years or younger (22%). While nurses aged 50 years or older comprised 18.3% of the sample, those between 41 and 49 years were the least (11%). Approximately, 76.3% of the participants had a bachelor’s degree; 15.7% had a diploma; and 8.0% had a master’s degree or higher. While 60.7% of the study group were married and 35.0% were single, based on their income, those who earned between 5000 Saudi Riyals (SAR) and less than 10000 SAR constituted 59.3% of the study sample followed by those earning 10000 SAR or more (33.0%). Most of the nurses belonged to the outpatient department (33.3%) followed by medical (24%), daily care (12.3%), pediatric (10.7%), surgical (8.7%), emergency (6%), ICU/NICU (3.3%) and obstetrics (1.7%) departments (Table 1). The overall mean scores based on nurses’ perception for each leadership style, its domains, and the corresponding questionnaire items are given in Table 2. Furthermore, the predominantly perceived leadership style utilization among nurse managers was found to be transformational (64.04%) followed by transactional (63.83%) and laissez-faire (62.08%) styles (Table 2).

[TABLE 1 to be inserted here]

[TABLE 2 to be inserted here]

Within transformational leadership style, nurses perceived that “idealized influence” was highly utilized by their nurse managers (65.75%) and the next was “inspirational motivation” (65.16%). In comparison, only 63.66% and 61.58% of the nurses felt that “intellectual stimulation” and “individual consideration” were utilized, respectively. For the transactional leadership style, while 63.25% nurses felt the utilization of “contingent reward” by nurse managers, 64.41% felt that they were being “managed by exception”. On the whole, laissez-faire leadership was seeming least utilized by nurse managers, and was reportedly perceived by only 62.08% of the nurses. The aforementioned patterns were also observed while assessing the transformational leadership practice domain scores. The nurses perceived that “idealized influence” was the most commonly used style by their nurse managers, with a mean score of 7.89. In comparison, “intellectual stimulation” was the least commonly used style with a mean score of 7.39. Interestingly, the highest mean score for “idealized influence”, was observed in the item, “Makes others feel good to be around me”. However, in the “inspirational motivation” domain, the highest mean score was observed in two items: “Expresses with a few simple words what we could and should do” and “Helps others find meaning in their work”. Meanwhile, the highest mean score for “individual consideration” was observed in the items “Provides others with new ways of looking at puzzling things” and “Helps others develop themselves”. (Table 2)

Analyzing, the transactional leadership practice domains, it was found that the nurses perceived that “management‐by‐exception” was the most commonly used style by their nurse managers with a mean score of 7.73. This was followed by contingent reward with a mean score of 7.45. Among the contingent reward domain, the highest mean score was observed in the item “Provides recognition/rewards when others reach their goals.” Whereas, in “management‐by‐exception”, the highest mean score was observed in the item “Is satisfied when others meet agreed‐upon standards”. Finally, the laissez‐faire leadership practice domain had a mean score of 7.19 as perceived by the nurses, and the highest mean score was observed in the item “Is contented to let others continue working in the same ways always”. (Table 2)

One-way ANOVA for statistical association between the demographic variables and nurses’ perception about their nurse managers’ leadership styles, revealed significant differences (p<0.05) only for age and marital status when comparing transformational and transactional leadership styles (Table 1). For both the above leadership styles, Tukey post-hoc test showed that the statistically significant difference was observed between nurses in the age group of 31-40 years and those aged 50 years or older. Similarly, with respect to marital status, the significant difference was observed between married and single nurses, in their perceptions about the transformational and transactional leadership styles of their managers. There was no significant difference in the mean score of the nurses’ perception of the laissez‐faire leadership styles, for any of the demographic variables.

Discussion

High-quality medical care received by patients, depends on competent nurses and their managers. Nurses’ perception about their managers’ leadership styles could influence their capacity to provide quality care, and also their knowledge and attitudes towards healthcare delivery.^{9, 23, 24} The outcomes of the present study results are expected to provide insights into how nurses view different types of leadership. Data on the nurses’ preference and characteristics of the different leadership styles may be used to educate nurse leaders to accomplish future goals of excellence, which is pertinent in the case of Saudi Arabia, as it has outlined definitive healthcare goals as part of its vision 2030 objectives.

In the present study, transformational leadership was the most commonly used leadership practice, followed by transactional leadership and laissez-faire leadership. According to Asamani et al.,25 transformational leadership has positive effects on various outcomes, including employee satisfaction, engagement, commitment, performance, and organizational effectiveness.²⁵ Similarly, the current results are also consistent with those reported by another study in a cohort of nurses from Qatar, wherein transformational leadership accounted for the vast majority of leadership styles, followed by transactional leadership.²⁶ Because transformational leaders make use of domains such as “idealized influence”, “inspiration and motivation”, “intellectual stimulation”, and “individualized consideration”, the results of their efforts are of a higher quality than those of the efforts by other leaders.²⁷ Transformational leaders inspire individuals to achieve goals that are previously thought to be unachievable and to surpass their expectations in the process.²⁸ Findings similar to the present study were reported by Andri and Darti (2021), who found that the nurses’ performance is positively affected by inspiration and motivation.²⁹ Similarly, Naseem et al. (2019) from Pakistan, found that the transformative type of leadership encourages work satisfaction among the nurses resulting in improvement of their performance.³⁰

The second most perceived leadership style among nurse managers by nurses, as evidenced in this study, was the transactional leadership, with the domains “contingent reward” and “management-by-exception”. Based on a study conducted in Saudi Arabia, Albagawi et al. (2017) reported comparable findings and demonstrated that nurse managers more often used transformational leadership followed by transactional leadership and laissez-faire leadership only sometimes.¹⁷ The findings of the present study are also comparable to those of the study by Goh et al. (2018), wherein, registered nurses perceived nurse leaders in their workplace to exhibit transformational and transactional leadership behaviors in preference to laissez-faire leadership behaviors.³¹ Similar coherent findings are reported in the research conducted by Hayati et al. (2022) among Saudi Arabian nurses, who believed their supervisors used transformational and transactional leadership styles more often than passive-avoidant leadership styles, such as the laissez-faire style.³² The present findings also indicate that leaders who adopt a transformational style promote increased work satisfaction among nursing staff compared with leaders who used a transactional style. This corroborates the findings of earlier researches which revealed that a transparent and two-way approach to communication affected the level of job satisfaction experienced by workers. 3

Transformational leaders spend most of their time instructing and coaching nurses.¹ They concentrate on improving nurses’ existing strengths, offer guidance for nurses’ professional and personal development, treat their subordinates as individuals, and listen to their concerns and questions.²⁸ Nurses are able to work more effectively and exert more effort toward accomplishing their objectives when this management strategy is used.³³ This conclusion is consistent with the findings of several previous studies that the adoption of the transformational leadership style has the greatest influence on the performance indicators of healthcare systems. 30. One of the inherent strengths of the present study was its ability to identify nurses’ perception about nurse managerial leadership styles, from nurses with different strata of age, experience and departmental exposure. Although this study was limited by its ability of reporting findings from one particular geographical region (Saudi Arabia), the outcomes would be valid enough to be extrapolated globally considering the universal nursing standards being implemented by healthcare institutions worldwide.

Conclusion

Based on the outcomes of the present study, nurses who participated reported that their nurse leaders predominantly exhibited transformational leadership, followed by transactional leadership, and only minimally a laissez-faire leadership attribute. Furthermore, the participant nurses identified the transformation leadership style and more specifically its domains “idealized influence” and “inspirational motivation” as the most prevalent and preferred leadership styles to be managed with. The current findings not only enable potential future healthcare leaders, to learn how their staff nurses perceive their leadership styles, but would also encourage them to incorporate them in their continuing professional leadership policies, procedures and practices.

Legends for figure and tables

Fig 1. Conceptual Framework of the Study (Self-Developed Model)

Fig 2. Study instrument – questionnaire

Table 1: Demographic characteristics of the participants and its association with nurses' perception about the leadership style of nurse managers.

Table 2: Mean scores and level of utilization for each leadership style, its domains and corresponding questionnaire items for the nurse managers, as perceived by the nurses.

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