Evaluating Preferred and Perceived Leadership Styles of Nurse Managers Employed in Teaching Hospitals Affiliated to Yasuj University of Medical Sciences

Introduction

Each organization is about meeting the needs of and providing services for people based on its objectives. Therefore, more attention to providing and increasing the quality of optimal services to communities requires the initial focus on management of organizations and assessment of the applied leadership style. After the recognition of the strengths and weaknesses of the leadership style, proper management techniques can be identified and selected with regard to the level of culture, mental maturity, and talent of the personnel.¹ Management is significantly important in hospitals as well, and success of a hospital depends on its suitable and effective management style.^2,3 Today, nurse managers are faced with novel challenges, which affect the treatment results. Therefore, in these organizations, the utmost attention is paid to providing standard care, the suitability of which must be confirmed by valid evidence. Given the fact that the main focus is on patient satisfaction reports, nurse managers have the main responsibility of guiding the staff toward the provision of high-quality care.^4,5

Several researchers have emphasized the importance of effective leadership in healthcare and the central role of nursing leadership. In general, nurses are the largest representatives of healthcare, play a major role in providing healthcare services, and their performance eventually affects the success of the organization^4–10 The main challenge of healthcare centers of the world is creating an organizational culture, which can improve the constant provision of high-quality, safe and compassionate healthcare services. Leadership is the most effective factor for creating organizational culture and ensuring the development of the required leadership behaviors, strategies and qualities.^4,11,12 Leadership in healthcare must go beyond the boundaries of each healthcare organization. As such, leaders must show influential behaviors and empowerment through effective communication with the staff so that they could cooperate and learn from each other.^4,13

Leadership style was defined in the early studies as consisting of two broad and independent behavior dimensions: one oriented to production and tasks, the other concentrated on employees and relations. Leadership styles have also been studied in relation to outcome criteria (productivity, motivation, morale, and staff turnover). More recently, a new leadership style focusing on change within the organization has been developed, called change-oriented leadership behavior, which is a combination of the three domains: Change, Production and Employee relations.^14–16

Representative behavioral components of the three domains are: planning, giving instructions, defining and explaining work requirements (production-oriented); considering subordinates as individuals, relying on subordinates, commanding respect, allowing subordinates to decide (employee-oriented); and offering ideas and proposing new projects, driving growth, liking discussion of new ideas and focusing on the future (change-oriented).¹⁴

In a new categorization, leaders are divided into two groups based on performance style, including interactive or task-oriented group, in which managers motivate the staff to achieve the determined goals and pay attention to their basic needs, and transformational group, which penetrates in the beliefs, values and goals of the staff and affects their perceptual changes for innovation, creativity and increased motivation by mental stimulation.^16,17 Leadership is a feature that is firmly established in social relationships, and the effectiveness of leadership is influenced by how subordinates view leaders as a role model.¹⁸ Furthermore, the nursing literature shows that those who are aware of their work styles and their impact on their employees can adopt a better leadership style.¹⁹ However, studies comparing leadership styles adopted by managers based on their employees’ attitudes are rare. The results of studies by Sellgren et al²⁰ and Zampieron et al¹⁸ showed that the mean scores of nurses’ preferences were higher than their real views in all domains. Use of improper leadership style can result in unfavorable outcomes, such as dissatisfaction with their job and workplace, lack of occupational motivation, burnout and turnover intentions.²¹ In research by Zaeemi et al,²² it was indicated that while nurse managers reported high application of task- and relational-oriented leaderships, the majority of personnel (79.8%) marked a low level of use of the mentioned leadership styles by managers. In this research, leadership styles of nurse managers lacked the necessary effectiveness. Results obtained by Akhtar Shojaei et al²³ demonstrated that staff and managers had different attitudes toward leadership style. In other words, while managers think that they have collaborative and counseling style, their staff think otherwise and regard their leadership to be autocratic.

With this background in mind, this study aimed to identify and compare the perceived and preferred perceptions of nurse managers and personnel toward nursing leadership styles in teaching hospitals of Yasuj, Iran, to better understand whether there is a gap between preferred and perceived leadership styles. The main goal of the research was to reflect the obtained data and provide the proper feedback to nurse managers in order to help recognize their own weaknesses and strengths, eliminate shortages and improve the performance quality of nurse managers.

Materials and Methods

This cross-sectional and analytical research was conducted to evaluate the leadership styles of nurse managers from the perspective of nurse managers and personnel. The research setting was the teaching hospitals of Yasuj, and sample population included all nurse managers (matrons, supervisors, head nurses) and all of the hospital staff (nurses and paramedics) employed in the evaluated hospitals (five hospitals). Inclusion criteria for nurse managers were a minimum of 6 months of work experience in one of the various hospital wards or nursing offices as nurse manager, and minimum academic degree of BSc in nursing. On the other hand, inclusion criterion of nurses was a minimum of 6 months of work experience in the current ward. However, nurses working at night or weekend shifts were eliminated due to being occupied during the presence of their managers, which turned them into unfavorable subjects for determining nurse managers’ leadership style. This study was approved by Yasuj University of Medical Sciences ethics committee, all participants provided written informed consent, and it was conducted in accordance with the Declaration of Helsinki.

In this research, subjects were selected through stratified random sampling. In total, 45 participants were selected from nurse managers (matrons, supervisors, head nurses) and 315 subjects were selected from the nursing staff. The data collection tool was the change, production, employee (CPE) model questionnaire, which was designed and validated by Arvonen and Ekvall in 1991 and 1994, respectively. The reliability of this questionnaire was tested with Cronbach’s alpha with coefficients between 0.86 and 0.94²⁴ and its validity has been revealed in several large studies.^14,15 In the first stage, the technical validity of the questionnaire was determined. For this purpose, the questionnaire was translated into Farsi after receiving the permission of the author. In the next stage, the questionnaire was translated back to the original language by another translator and the content was again reconciled with the original questionnaire. The validity of each item on the questionnaire was assessed by several nursing faculty members, but no changes were made to the original questions. To determine the reliability of the questionnaire, a pilot research was conducted on three nurse managers and 30 personnel. It should be noted that these individuals were excluded from the main study. In addition, the reliability of the questionnaire was confirmed at Cronbach’s alpha with coefficients between 0.9 and 0.91. This research tool has two perceived and preferred forms, comparison of which can determine the preferred and perceived leadership styles of nursing managers from their own perception and the viewpoint of their staff (nursing personnel).

This questionnaire has 30 items and is scored based on a four-point Likert-scale (completely disagree =1, disagree =2, agree =3, completely agree =4). In addition, negative items are scored reversely. The questionnaire evaluates the viewpoint of nurse managers and their personnel (nursing staff) from three aspects of change/development, production/commitment/structure, and employees/relations. Each aspect contains 10 items, and the score range for each area is 10–40. Higher scores of each aspect are interpreted as greater importance of that area. Items relating to Production involved the following: plans carefully, gives clear instructions, is very precise about plans being followed, defines and explains the work requirements. Items related to Change concerned aspects such as: recommends new ways to do things, pushes for growth, initiates new projects, thinks about the future, likes to discuss new ideas. Employee-related items involved: shows regards for subordinates as individuals, stands up for his/her subordinates, relies on subordinates, allows subordinates to decide.¹⁴ The CPE questionnaire was selected in the present research to assess the leadership style of managers from three fundamental dimensions. Data analysis was performed in SPSS version 21 using independent t-test to compare mean scores of the perceived and preferred viewpoints.

Results

From 360 questionnaires distributed among the managers and employees (45 completed by managers and 315 filled by nursing staff), 296 (94%) and 45 (100%) completed questionnaires were received from the nursing staff and nurse managers, respectively. According to the results, the majority of nurse managers were female (68.9%), and the rest were male 31.1%. Most of the nurse managers (42.2%) were within the age range of 36–45 years and had work experience of 11–15 years. In terms of level of education, 88.9% of the nurse managers had a BSc degree. Moreover, most of the nursing staff (84.4%) were female, and the remaining were male (15.2%). In addition, 99.6% of the nursing personnel had a BSc degree, and most of them were within the age range of 26–35 years. Most (60.8%) of the nursing personnel had work experience of 1–5 years (Table 1).

Table 1 Demographic Characteristics of the Participants

According to the results, the highest mean score of perceived perception of nurse managers was related to the area of employees (17.20), whereas the highest score of preferred viewpoint of nurse managers was associated with production (18.25). On the other hand, while the lowest mean score of perceived viewpoint of nurse managers was related to the area of production (15.02), the lowest mean score of preferred perception was related to the area of employees (17.40). Furthermore, the highest mean score of perceived viewpoint of nursing personnel was related to the area of employees (18.60), whereas the highest mean score of preferred perception of nursing staff was associated with the area of employees (19.36). On the other hand, the lowest mean score of perceived viewpoint of the nursing staff was related to the area of production (16.45), and the lowest score of preferred perception of the nursing personnel was associated with the area of production (17.30). Mean scores of various aspects of perceived and preferred viewpoints of nursing staff and nurse managers regarding leadership styles of nursing managers are presented in Table 2.

Table 2 Mean Values for Preferred and Perceived Nurse Manager Leadership Styles

Results demonstrated a statistically significant difference between the preferred perception of nursing managers and the staff in all areas (P<0.01). In addition, comparison of mean scores of perceived and preferred viewpoints of nursing managers indicated that the mean score of preferred perception was higher, compared to the perceived viewpoint. Meanwhile, no significant difference was observed in these subjects regarding the area of employees (P=0.1). Results of the present study were also indicative of a significant difference between the perceived and preferred perceptions of the nursing staff in all areas (P<0.01). In addition, scores of preferred perception of the nursing staff were higher, compared to the perceived viewpoint. Moreover, comparison of the perceived perception of the nursing personnel and managers showed that the mean scores of perceived perception of nurses were higher, compared to managers. In general, the nursing staff had a more positive perception of the leadership style applied by the nursing managers. Furthermore, a significant difference was observed between the managers and staff in all areas of perceived perception (P<0.01).

Discussion

This research was carried out to compare the perceived and preferred perceptions of nursing staff and nurse managers toward leadership styles employed by the nurse staff. In the current research, a statistically significant difference was found between managers and personnel regarding all areas of the perceived viewpoint, which is in line with the results obtained by Sellgren et al.²⁰ In contrast, Zampieron et al¹⁸ marked a significant difference only in the area of employees. The difference between the preferred perception of nursing personnel and managers demonstrated that the staff expects their managers to have a clearer leadership style, compared to what is considered suitable by managers themselves. In this regard, our findings are in congruence with the results obtained by Naseem et al.²⁵ In the above-mentioned research, the nursing personnel preferred their managers to have a more active leadership role.

According to the results of the current research, the highest score of preferred perception of nursing personnel was related to the area of employees. Results obtained by Safi et al²⁶ indicated that the more leadership styles moved toward relational-oriented and supportive leadership styles, the more the total satisfaction level of employees increased. Moreover, increased level of using relational-oriented leadership led to reduced emotional exhaustion of employees. In this regard, Akhtar Shojaei et al²³ concluded that guiding the decision making of the staff by managers about their own affairs or creating a counseling environment led to increased occupational satisfaction of the employees. In addition, the highest score of preferred viewpoint of the nurse managers was related to the area of production.

In a study by Zampieron et al,¹⁸ the main focus of preferred perception of nursing managers was in production. On the other hand, Amerioun et al²⁷ expressed the opinion of nurse managers, who believed that work of the staff must be organized by explaining the responsibilities of the personnel (when what, how,). By doing so, nurse managers pay more attention to workplace and change and less emphasize the relations between the staff. In other words, principles of work are the main determinates of goals of hospitals, and there is no desire for delegating work to employees. Differences in all three areas of preferred viewpoint of the nursing personnel and managers might be due to the fact that managers have understood the reality of nurse management and are directly involved in daily complications of leadership.

In the current research, a significant difference was observed between mean scores of perceived perception of nursing managers in terms of leadership styles and their preference in areas of change and production. Meanwhile, no significant difference was observed regarding the area of employees.

In the present study, the score of perceived viewpoint of nurse managers was lower, compared to the preferred perception, indicating that nurse managers expect hospitals to have better conditions in terms of change, task, and employees. The highest score of perceived perception of nurse managers was related to the area of employees, which might be due to higher attention to this area, compared to other aspects by managers or inadequate attention to other dimensions. The lowest score of perceived perception was related to the area of task, whereas the highest difference between perceived and preferred perception was related to the same aspect. This difference might be due to internal factors, such as professional and individual problems, that have limited their performance in reality or environmental factors related to organization or the cultural situation of organization, which prevent the implementation of actions that are regarded important by nurse managers. In this regard, our findings are in line with the results obtained by Zampieron et al.¹⁸

In management studies, evaluation of leadership styles from the perspective of managers demonstrated their attitude, whereas assessment of leadership style from the viewpoint of employees indicated the behavior of managers. It means that understanding the behavior of manager-leader by employees is important.²⁸ According to the results of the current research, mean score of preferred perception was higher, compared to mean score of perceived viewpoint of the nurse personnel toward leadership style employed by nurse managers. In addition, a significant difference was observed between perceived and preferred perceptions in all areas. The highest scores in both perceived and preferred perceptions of the nursing personnel were related to the areas of employees and change, whereas the lowest scores of the perceived and preferred viewpoints of the nursing staff were related to the area of production, which is consistent with the results obtained by Sellgren et al.²⁰ However, in the research by Zampieron et al,¹⁸ higher scores were observed in two areas of change and employees of the perceived viewpoint of nursing personnel, which is in line with our findings. Meanwhile, the scores of employees and task areas were higher in the preferred perception of the nursing personnel in the study by Zampieron et al. ¹⁸In the current research, areas of employees and change had higher scores in both preferred and perceived perceptions of the nursing personnel, demonstrating the application of transformational leadership style by managers. In some previous leadership theories, it has been mentioned that leadership based on task and relationship orientations led to more efficient performance in all situations as an effective leader.²⁰

Results obtained by Boumams and Landeweerd²⁹ demonstrated that managers who used a combination of relational- and task-oriented leadership styles had more satisfied nursing personnel. Another issue expressed in the current research was higher mean scores of perceived viewpoint of nursing staff, compared to the mean scores of perceived perception of the nurse managers. In addition, the nursing personnel had a more positive attitude toward leadership styles employed by their nurse managers. This difference might be due to lack of confidence of nurse managers in their performance, who consider their behaviors to be inappropriate as a manager due to possible problems and cultural conditions of an organization. In this regard, Scott-Cawiezell et al³⁰ suggested that strategies be used by nurse managers to improve their perception of management problems, especially organizational limitations that prevent applying some of the leadership behaviors.

Results obtained by Zahrani et al²⁸ demonstrated that 67.7% and 61% of the managers regarded proper leadership style to be counseling and benevolent-autocratic, respectively, which is inconsistent with our findings. In a research by Javadi et al,³¹ leadership style of the majority of managers was commanding from the perception of employees in training hospitals affiliated to Ardabil University of Medical Sciences, which is not in congruence with our findings. On the other hand, results obtained by Safi et al²⁶ indicated that most of the managers used the relational-oriented leadership style (85.9%) and then applied the task-oriented leadership style (11.5%), and the rest applied the interstitial method, which is consistent with our findings. This variation in use of leadership styles might be due to various reasons, such as the thinking and ability of managers, nature and type of organizational activity, and tasks of managers. In the nursing profession, the main emphasis is on timely implementation of tasks according to the standards of this field due to the nature of cares and vital nature of the activities. Therefore, the nurse managers have always moved toward more task-oriented methods. However, studies have shown that this type of leadership leads to the neglecting of human aspects in the long-term, causing absence, non-commitment movement, reduced team cohesion and turnover of nurses, which can decrease the total efficiency of an organization and create new problems for units.³²

As expressed by Asamani et al,³³ an influential manager has no need for creating balance between management performance according to task and relational-oriented methods. Even when there are better reasons for emphasizing on tasks, managers still need to pay attention to employees in the daily management of the organization. According to the results of the above-mentioned studies, it seems that different organizations have various leadership styles. Without a doubt, experience, knowledge, values and background of managers, properties of employees and favorable factors (eg, styles or methods that are approved or preferred by organizations, specific groups working in organizations, nature of tasks performed by groups, and organizational pressure or limitations) and even environmental factors (all of which can affect the attitude of employees toward the authority and power of the manager), affect the proper leadership style that must be applied by managers One of the major drawbacks of the research was performing the study only on nurse managers and nursing personnel of teaching hospitals of Yasuj, which limited the generalizability of the final results. Therefore, it is recommended that this type of research be performed in other hospitals. Another factor that might have affected the results is the mental and emotional states of evaluated individuals during the process.

Conclusion

According to the results of the current research, a significant difference was observed between the perceived perception of nursing personnel toward leadership styles of nurse managers and the ideal features of leadership styles they have in mind in all areas. Moreover, a statistical difference was found between perceived and preferred viewpoints of nurse managers toward change and task. Meanwhile, the difference was not significant in the area of employees and the expectations of the nurse managers about leadership styles were different to that of the nursing personnel, which emphasized the importance of comparison and evaluation of perceived and preferred leadership styles of managers and personnel. Therefore, it is recommended that the results of the current study be used by planners and managers to establish curriculums at various educational levels of nurse managers and continuous professional development plans for these individuals. In addition, this information can be applied to develop the potential of a new profession with equal conditions for both nursing personnel and managers.

Furthermore, it is suggested that nurses be trained to be effective by having logical requests and providing insight into the efficient and inefficient performance of leaders. It should also be noted that there is a need for interaction between nurse managers of hospitals and hospital management. Nurse Managers of hospitals must evaluate the leadership styles of nurse managers and provide them with feedback. Moreover, a support team must exist to achieve organizational goals and help managers eliminate the barriers to employing the preferred leadership styles. It is also recommended that managers be trained to apply a global evaluation approach based on client satisfaction and confirmation of their peers.