751742

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PSH0010.1177/2010105817751742Proceedings of Singapore HealthcareGoh et al.

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Short Communication OF SINGAPORE HEALTHCARE

Proceedings of Singapore Healthcare

Leadership style of nurse managers 2018, Vol. 27(3) 205­–210

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as perceived by registered nurses: sagepub.com/journals-permissions
DOI: 10.1177/2010105817751742
https://doi.org/10.1177/2010105817751742

A cross-sectional survey journals.sagepub.com/home/psh

Andy Ming Jin Goh1, Shin Yuh Ang1 and Phillip Roy Della2

Abstract
Given rapid changes in the health care landscape, nurse leaders need to be equipped with effective leadership skills. Those
who are aware of their styles of working and its impact on their employees could adopt a better leadership style. The study
aim was to assess the leadership styles of nurse leaders, as perceived by their employees. The secondary objectives were to
explore differences between self-ratings and others’ ratings of leadership styles, as well as correlation between perceived
leadership styles and organisational outcomes. A cross-sectional survey was conducted among registered nurses from four
inpatient wards in an acute tertiary hospital in Singapore. Respondents were asked to complete a questionnaire that consisted
of demographic questions, the Multifactor Leadership Questionnaire and the Organizational Commitment Questionnaire,
as well as a Three-index item Questionnaire, to elicit turnover intention. A total of 111 completed surveys (37% response)
were received. Overall, registered nurses reported that their nurse leaders exhibited both transformational and transactional
leadership behaviours and, to a lesser extent, laissez-faire. Of interest was the finding that nurse leaders in this study tend to
rate themselves higher than others rate them. The results implied a need to incorporate self-awareness elements in nursing
leadership development programmes.

Keywords
Nurse leader, job satisfaction, organisation commitments, staff retention, transformational leadership

Introduction
Effective leadership in health care is crucial in improving and
enhancing the effectiveness and efficiencies of health care
systems.1 Given global trends, such as ageing populations and
rapid adoption of new technologies, the way in which health
care is being delivered has changed substantially2 in the last 10
years, which in turn brings a need for new ways of leading a
health care team.
More specifically, transformational leadership, which
refers to a leader’s ability to influence others towards attain-
ing common goals,1 was reported to increase job satisfac-
tion among nursing staff.2 Similarly, relational leadership
styles that focus on creating positive relationships were
associated with higher patient satisfaction, and reductions in
patient mortality, medication errors, restraint use and hos-
pital-acquired infections.3
Although there is a proliferation of literature on leadership
styles of nurse leaders, there is a dearth of studies focused on
nurse leaders in Singapore. On the one hand, given the
influence of societal culture on leadership and employee
commitment,4 it is of interest to evaluate leadership styles
among nurse leaders in Singapore and its influence on organi-
sational outcomes. On the other hand, given leniency and
social desirability biases, self-ratings of one’s leadership may
be overinflated, which in turn could result in poorer perfor-
mance.5 Henceforth, it is important to examine the level of
self-awareness of local nurse leaders to inform the design and
implementation of leadership development programmes.
This study aimed to assess the leadership styles of nurse
leaders as perceived by employees, that is, registered nurses
under their charge. The secondary objectives were as follows.
1Division of Nursing, Singapore General Hospital, Singapore
2School of Nursing, Midwifery and Paramedicine, Curtin University,
Australia
Corresponding author:
Andy Ming Jin Goh, Division of Nursing, Singapore General Hospital,
169608, Singapore.
Email: andy.goh.m.j@sgh.com.sg

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206 Proceedings of Singapore Healthcare 27(3)

Table 1.  Demographics of employees – registered nurses. always). Ratings were summed and divided by the number of
items in each sub-scale to derive average ratings.6 For this
N (%)
study, contingent reward and management by exception
Sex Male 18 (16%) (active) are labelled transactional leadership, while manage-
Female 93 (84%) ment by exception (passive) and laissez-faire management
Race Chinese 44 (40%) are labelled passive and avoidant leadership, respectively.
Malay 24 (22%) The Organizational Commitment Questionnaire con-
Indian 14 (13%) sisted of 15 items, of which six were negatively phrased, to
Other 29 (26%) elicit nurses’ level of affective commitment.10 A Likert scale
Age 20–25 12 (11%) rating was used, whereby 1 indicated ‘strongly disagree’ and 7
26–30 49 (44%) referred to ‘strongly agree’. The reliability of the tool is well
31–35 27 (24%) established, with reported values between 0.82 and 0.93.11
36–40 11 (10%)
The validity of the tool was also established, with the demon-
41–45 7 (6%)
stration of a positive association between commitment and
46 and over 5 (5%)
intention to leave an organisation.12
Highest education Diploma 37 (33%)
qualification The Three-index item Questionnaire13 sought informa-
Advanced diploma 8 (7%)
Degree 64 (58%)
tion on intention to quit by asking respondents to rate their
Other 2 (2%) level of agreement with the three items: ‘I will actively look for
Place of work Ward A (speciality) 60 (54%) a new job in the next year,’ ‘I often think about quitting,’ and ‘I
Ward B (surgical) 17 (15%) will probably look for a new job in the next year.’ Similarly, a
Ward C (surgical) 13 (12%) Likert scale rating was used, where 1 referred to ‘strongly
Ward D (medical) 21 (19%) disagree’, and 7 referred to ‘strongly agree’.
A convenient sample of nurses from four inpatient wards was
invited to participate in the study. The inclusion criteria were:
1. To explore differences between nurse leaders’ self-
rated leadership styles and their leadership styles as • Had worked under the direct supervision of the
perceived by their employees. named nurse leader for a continuous period of at least
2. To explore the correlation between perceived lead- 6 months; and
ership styles and organisational outcomes, namely job • Staff nurses, senior staff nurses and nurse clinicians.
satisfaction, organisational commitment and turnover
intention. The results of the questionnaires were analysed using
Statistical Package for the Social Sciences (SPSS) Version 23.
Correlation between leadership styles and organisational
Method and results commitment or intention to quit was analysed using
A cross-sectional survey was conducted among registered Spearman’s rho. The one-sample t test was used to compare
nurses from four inpatient wards in an acute tertiary hospital the employees’ ratings with the nurse leaders’ self-rating
in Singapore. Data collection was carried out in April and May scores.
2017. Employees were asked to complete a questionnaire A total of 111 completed questionnaires were collected
that consisted of demographic questions, the Multifactor from the employees (response rate: 37%). The majority
Leadership Questionnaire (5× short version) and the (n = 93; 84%) were female, Chinese (n = 44; 40%) and
Organizational Commitment Questionnaire, as well as a between 26 and 30 years of age (n = 49; 44%) (Table 1). Only
Three-index item Questionnaire to elicit turnover intention. three out of four nurse leaders (75%) participated in the self-
Nurse leaders from the four wards were asked to complete rating. Ward D’s nurse leader was not available during the
a demographics form as well as the Multifactor Leadership period of data collection for this study.
Questionnaire, as a self-rating.
The Multifactor Leadership Questionnaire is made up of Perceived leadership styles
five transformational (inspirational motivation, idealised influ-
ence (attributed), idealised influence (behaviour), intellectual Employees in Wards A, C and D reported that their nurse
stimulation, individualised consideration) three transactional leaders displayed more transformational leadership behav-
(contingent reward, active management by exception, passive iours than transactional, passive or avoidant behaviours
management by exception), one laissez-faire and three out- (Table 2). In Ward B, employees gave their nurse leader
come sub-scales (extra effort, the effectiveness of leader’s the highest rating (mean score, 2.59) on the contingent
behaviour, followers’ satisfaction with their respective reward.
leader).6 The reported internal consistency was above 0.70
for all scales, except for active management by exception,
which was 0.63.6 The external validity of the Multifactor
Differences between self-ratings and others’
Leadership Questionnaire has also been established in previ-
ratings
ous studies conducted in health care organisations.7–9 Each In the three wards where the nurse leaders provided self-
item is rated on a scale of 0 (not at all) to 4 (frequently, if not rating scores, the leaders tended to rate themselves higher in
 Goh et al.

Table 2.  Comparison between ratings by registered nurses and self-ratings by nurse leaders.

Leadership styles Ward A (n = 60) Ward B (n = 17) Ward C (n = 13) Ward D

(n = 21)

Self- Rating by RN One-sample P Self- Rating by RN One-sample P Self- Rating by RN One-sample P Rating by RN
rating (mean) t test rating (mean) t test rating (mean) t test (mean)
Idealised influence behaviours 3.00 2.65 −4.094 <0.0001 2.75 2.19 −3.196 0.006 3.00 2.81 −1.0 0.337 2.38
Idealised influence attributes 3.25 2.75 −5.753 <0.0001 3.5 2.35 −6.486 <0.0001 3.75 2.96 −5.704 <0.0001 2.54
Inspirational motivation 3.00 2.76 −2.508 0.015 3.25 2.37 −4.987 <0.0001 3.25 2.92 −1.889 0.083 2.48
Intellectual stimulation 3.50 2.35 −12.896 <0.0001 3.5 2.22 −10.570 <0.0001 3.25 2.69 −3.928 0.002 2.27
Individual consideration 2.75 2.37 −3.728 <0.0001 4.00 2.10 −11.515 <0.0001 3.75 2.52 −8.297 <0.0001 2.18
Contingent reward 3.25 2.62 −7.329 <0.0001 3.50 2.59 −8.046 <0.0001 3.00 2.77 −1.477 0.165 2.45
Management by exception 2.50 2.60 1.006 0.319 3.00 2.24 −4.478 <0.0001 2.00 2.92 6.743 <0.0001 2.18
(active)
Management by exception 1.00 1.06 0.550 0.584 0.25 1.16 4.192 0.001 1.00 1.10 0.750 0.468 0.95
(passive)
Laissez-faire 0.50 0.61 1.103 0.274 1.00 1.04 0.215 0.832 2.00 0.60 −10.012 <0.0001 0.56
Leadership styles Self- Rating by RN One-sample P Self- Rating by RN One-sample P Self- Rating by RN One-sample P Rating by RN
rating (mean) t test rating (mean) t test rating (mean) t test (mean)
Extra effort 2.67 2.48 −1.815 0.075 3.33 2.33 −5.657 <0.0001 3.33 2.41 −4.765 <0.0001 2.02
Effectiveness 3.00 2.76 −2.475 0.0016 3.25 2.41 −5.374 <0.0001 3.25 2.71 −3.895 0.002 2.33
Satisfaction 3.00 2.69 −2.899 0.005 2.50 2.38 −0.621 0.543 3.50 2.81 −4.185 0.001 2.45

RN: registered nurse.

207
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Table 3.  Correlation between perceived leadership styles and organisational outcomes.

Leadership style Ward A (n = 60) Ward B (n = 17) Ward C (n = 13) Ward D (n = 21)

Rating by registered nurse (mean) Rating by registered nurse (mean) Rating by registered nurse (mean) Rating by registered nurse (mean)
Transformational 12.88 11.24 13.90 11.85
Transactional 5.21 4.82 5.69 4.63
Passive or avoidant 1.67 2.21 1.69 1.52
OCQ 4.88 4.55 5.13 4.59
TIQ 3.97 3.80 2.77 4.08
  Correlation Correlation Correlation Correlation Correlation Correlation Correlation Correlation Correlation Correlation Correlation Correlation
with EE with EFF with SAT with EE with EFF with SAT with EE with EFF with SAT with EE with EFF with SAT
Transformational 0.735** 0.704** 0.755** 0.382 0.644** 0.693** 0.810** 0.770** 0.393 0.895** 0.941** 0.882**
Transactional 0.570** 0.475** 0.472** 0.393 0.511* 0.618** 0.715** 0.875** 0.550 0.532* 0.622** 0.555**
Passive or avoidant 0.091 −0.197 −0.325* −0.321 −0.608** −0.536* 0.247 −0.114 −0.220 −0.286 −0.392 −0.208
  Correlation with OCQ Correlation Correlation with OCQ Correlation Correlation with OCQ Correlation Correlation with OCQ Correlation
with TIQ with TIQ with TIQ with TIQ
Transformational 0.204 −0.368** 0.207 0.057 0.594* −0.443 0.393 −0.61**
Transactional 0.211 −0.272* 0.134 0.016 0.674* −0.427 0.576** −0.53*
Passive or avoidant −0.131 0.081 −0.570* 0.079 −0.236 −0.188 −0.375 0.289

*Correlation significant at 0.05 level.

**Correlation is significant at 0.01 level.
EE: extra effort; EFF: effectiveness: OCQ: Organizational Commitment Questionnaire; SAT: satisfaction; TIQ: Three-index item Questionnaire.
Proceedings of Singapore Healthcare 27(3)
Goh et al. 209
the domain of transformational leadership (Table 2). The dif-
ferences were statistically significant (P < 0.05) across all sub-
scales in Wards A and B. In Ward C, the differences were
statistically significant for the sub-scales of idealised influence-
attributed, intellectual stimulation and individualised
consideration.
In the domain of transactional leadership, registered
nurses from all three wards reported lower ratings in contin-
gent rewards, as compared with the leaders’ self-rated scores,
with the difference being significantly different in Wards A
and B. Registered nurses from Ward B reported statistically
significant lower ratings (mean, 2.59) for management by
exception (active) as compared with their nurse leader (self-
rated score, 3.5); while registered nurses from Ward C gave
higher ratings (Table 2).
Differences in ratings for laissez-faire leadership styles
were not significant in Wards A and B. However, in Ward C;
registered nurses gave their nurse leaders significantly lower
scores (mean, 0.60 versus a self-rated score of 2.00) in the
laissez-faire domain.
With regards to leadership outcomes, nurse leaders con-
sistently rated themselves higher than registered nurses. The
differences were statistically significant (P > 0.05), except for
the sub-scale of extra effort in Ward A and the sub-scale of
satisfaction in Ward B (Table 2).
Correlation between perceived leadership
styles and organisational outcomes of job
satisfaction, organisational commitment and
turnover intention
As illustrated in Table 3, transformational leadership demon-
strated positive, significant and strong correlations with extra
effort (r = 0.704–0.895), effectiveness (r = 0.644–0.941) and
satisfaction (r = 0.693–0.882). Conversely, the strength of
positive correlations between transactional leadership and
outcomes was weaker.
Transformational leadership was significantly positively
correlated with organisational commitment in Ward C but
not in other wards. On the contrary, transformational leader-
ship was significantly negatively correlated with turnover
intention in Wards A, C and D.
Transactional leadership correlated positively with organi-
sational commitment in Wards C and D; and correlated nega-
tively with turnover intention in Wards A, C and D.
Passive or avoidant leadership correlated negatively with
organisational commitment in Ward B; otherwise, its relation-
ship with commitment and turnover intention was not
significant.
Conclusions
Overall, registered nurses reported that their nurse leaders
exhibited both transformational and transactional leadership
behaviours and, to a lesser extent, laissez-faire. This is in con-
gruence with that reported in a previous study conducted
among nurses,14 whereby nurse leaders put greater emphasis
on higher motivation development, and promoted followers’
motivation and positive emotions by providing an inspiring
vision of the future (transformational leadership).6 Nurse
leaders in this study also displayed contingent-reward behav-
iours, whereby they focused on clearly defined tasks and pro-
vided followers with rewards when such tasks were achieved.6
Of interest is the finding that nurse leaders in this study
tend to rate themselves higher than others rate them.
Previous studies have reported that over-estimators (i.e. lead-
ers who rated themselves higher than others perceived
them) tended not to be as effective as in-agreement and
under-estimators.15 The results implied a need to incorporate
self-awareness elements in nursing leadership development
programmes. Self-awareness is crucial to good leadership and
enables leaders to choose roles where they will succeed, as
well as recognise how to build teams that complement their
strengths.16
Like the study by Casida and Parker,14 we found strong
significant correlations between transformational leadership
and outcomes regarding extra effort, effectiveness and sat-
isfaction. Except for the sub-scale of effectiveness in one
ward, we found weaker correlations between transactional
leadership and extra effort, effectiveness and satisfaction.
Conversely, in our study, leadership traits did not correlate
strongly with organisational commitment and turnover
intention.17 This could be because of the relatively small
samples sizes of Wards B and C. As this was a cross-
sectional survey, we also could not determine the actual
turnover rate. Nonetheless, this study provided an insight
into the leadership styles of local nurse leaders and their
self-awareness. Future studies should adopt a longitudinal
design to elicit the influence of leadership styles and behav-
iours on actual organisational outcomes.
Acknowledgements
We thank the nurses who have given their time to participate in this
study from the four study wards.
Declaration of conflicting interests
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency in
the public, commercial or not-for-profit sectors.
References
1. Vesterinen S, Suhonen M, Isola A, et al. Nurse managers’ lead-
ership styles in Finland. Nurs Res Pract 2012; 2012: 605379.
2. Choi SL, Goh CF, Adam MB, et al. Transformational leader-
ship, empowerment, and job satisfaction: the mediating role of
employee empowerment. Hum Resour Health 2016; 14: 73.
3. Wong CA, Cummings GG and Ducharme L. The relationship
between nursing leadership and patient outcomes: a systematic
review update. J Nurs Manag 2013; 21: 709–724.
4. Jackson TA, Meyer JP and Wang XH. Leadership, commitment
and culture. J Leadersh Organ Stud 2013; 20: 84–106.
5. Atwater LE and Yammarino FJ. Does self-other agreement
on leadership perceptions moderate the validity of leader-
ship and performance predictions? Pers Psychol 1992; 45:
141–164.
6. Avolio BJ, Bass BM, Walumbwa FO, et al. Multifactor leadership
questionnaire: manual and sampler set. 3rd ed. Redwood City:
Mind Garden, 2004, p. 110.
210 Proceedings of Singapore Healthcare 27(3)
7. Asiri SA, Rohrer WW, Al-Surimi K, et al. The association of
leadership styles and empowerment with nurses’ organiza-
tional commitment in an acute health care setting: a cross-sec-
tional study. BMC Nurs 2016; 15: 38.
8. Abualrub RF and Alghamdi MG. The impact of leadership
styles on nurses’ satisfaction and intention to stay among Saudi
nurses. J Nurs Manag 2012; 20: 668–678.
9. Kanste O, Miettunen J and Kyngas H. Psychometric properties
of the Multifactor Leadership Questionnaire among nurses. J
Adv Nurs 2007; 57: 201–212.
10. Mowday RT, Steers RM and Porter LW. The measure
of organizational commitment. J Vocat Behav 1979; 14:
224–247.
11. Mowday RT, Steers RM and Porter LW. Employee–organization
linkages: the psychology of commitment, absenteeism and turno-
ver. New York: Academic Press, 1982, p. 253.
12. Cooke DK. Discriminant validity of the organizational commit-
ment questionnaire. Psychol Rep 1997; 80: 431–441.
13. Mobley WH, Horner SO and Hollingsworth AT. An evalua-
tion of precursors of hospital employee turnover. J Appl Psychol
1978; 63(4): 408–414.
14. Casida J and Parker J. Staff nurse perceptions of nurse man-
ager leadership styles and outcomes. J Nurs Manag 2011; 19:
478–486.
15. Fleenor JW, McCauley CD and Brutus S. Self-other rating agree-
ment and leader effectiveness. Leadersh Q 1996; 7: 487–506.
16. Martin ES. How self-awareness helps a physician become a
leader. Clin Dermatol 2012; 30: 248–250.
17. Green AE, Miller EA and Aarons GA. Transformational leader-
ship moderates the relationship between emotional exhaus-
tion and turnover intention among community mental health
providers. Community Mental Health J 2013; 49: 373–379.