Transformational leadership in nursing service. A test of theory

A scoping review of strategies used to recruit and retain nurses in the healthcare workforce

AIMS

This article reports the results of a scoping review to identify initiatives for improving recruitment and retention of nurses in healthcare and ascertain their effectiveness.

BACKGROUND

The global shortage of nurses has results in greater competition for vacant posts and an increased need to retain existing post holders. While there are a large number of publications discussing ways to improve recruitment and retention, the effectiveness of these need to be established.

EVALUATION

Thirteen papers met the inclusion criteria. There was no literature identified focusing on recruitment and only one paper reported a formal evaluation of a retention initiative.

KEY ISSUES

Five themes summarised the initiatives for retaining nurses: leadership and support; ongoing professional development; recognition; work environment; and flexible scheduling.

CONCLUSION

While strategies have been proposed to retain nurses, there is a dearth of evidence supporting the effectiveness of these.

IMPLICATIONS FOR NURSING MANAGEMENT

Although there is a lack of evaluations of retention strategies, the review identified a number of initiatives that warrant consideration. With the launch of the National Health Service People Plan in England in 2021, which is recommending initiatives identified in this review without robust evidence, an integrated programme of research evaluating this is recommended.

The Impact of Transformational Leadership on Job Satisfaction and Organisational Commitment Among Hospital Staff: A Systematic Review

Background:

Improving quality of relationship among hospital staff and leaders is a necessity to increase levels of job satisfaction and organisational commitment. Transformational leadership style has become an ideal practical solution that can resolve these dilemmas and enhance the quality of healthcare services and patients’ safety. This study aims to examine the impact of transformational leadership on job satisfaction and organisational commitment among hospital staff.

Methods:

The research strategy for this systematic review involves four electronic databases. Empirical peer-reviewed studies that uses quantitative design and that examines the relationship among transformational leadership, job satisfaction and organisational commitment among hospital staff, are included. Studies are evaluated by using a quality assessment tool, and the data extraction table and analysis are completed on the entire included studies.

Results:

A total of 367 titles and abstracts are screened, yielding 26 studies that are included in this review. The collected variables are analysed to determine the effect of transformational leadership style on job satisfaction and organisational commitment. A total of 19 studies examining the relationship between transformational leadership and job satisfaction ( n = 15) are found to have a positive relationship, while 13 studies examining the relationship between transformational leadership and organisational commitment ( n = 11) are found to have a positive relationship.

Conclusion:

The results of the review provide evidence that transformational leadership has a great effect on hospital staff and the hospital environment. The transformational leadership style should be universally used in hospitals to increase medical staff job satisfaction and organisational commitment, which may lead to increased productivity, quality of healthcare services and patients’ safety.

'Professional-supportive' versus 'economic-operational' management: the relationship between leadership style and hospital physicians' organisational climate

BACKGROUND

Health systems across the world have implemented reforms that call for a reconsideration of the role of management in hospitals, which is increasingly seen as important for performance. These reorganisation efforts of the hospitals have challenged and supplemented traditional profession-based management with more complex systems of management inspired by the business sector. Whereas there is emerging evidence on how medical professionals in their role as leaders and managers adapt to the new institutional logics of the health care sector with increasing demands for efficiency and budgetary discipline, no previous studies have investigated whether leaders' emphasis on clinical or financial priorities is related to how hospital physicians' view their working situation. The purpose of this study was therefore to examine the relationship between leadership style and hospital physicians' organisational climate.

METHODS

We utilised data from a survey among 3000 Norwegian hospital physicians from 2016. The analysis used three additive indexes as dependent variables to reflect various aspects of the organisational climate: social climate, innovation climate and engagement at the workplace. The variables reflecting leadership style were based on an item in the survey asking the respondents to rate the leadership qualities of their proximate leaders (department chair) on 11 specific dimensions. We used factor analysis to identify two types of leadership styles: a traditional profession-based leadership style that emphasises the promotion of professional standards and quality in patient treatment, and a leadership style that reflects the emerging management philosophy with focus on economic administration and budgetary control. Controlling for demographic background, leader role, foreign medical exam and specialty, the empirical model was estimated via multivariate regression.

RESULTS

The results documented a clear relationship between leadership style and organisational climate: a 'professional-supportive' leadership style is associated with better social climate, innovation climate and engagement at the workplace, while an 'economic-operational' leadership style is associated with a poorer social climate.

CONCLUSIONS

The cross-sectional study design makes it impossible to draw inferences about direction of causality and causal pathways. However, the positive relationship between professional-supportive leadership and organisational climate is a matter, which should be seriously considered regardless of direction of causality.

Factors influencing retention among hospital nurses: systematic review

BACKGROUND

Recruitment and retention of nursing staff is the biggest workforce challenge faced by healthcare institutions. Across the UK, there are currently around 50 000 nursing vacancies, and the number of people leaving the Nursing and Midwifery Council register is increasing.

OBJECTIVE

This review comprehensively compiled an update on factors affecting retention among hospital nursing staff.

METHODS

Five online databases; EMBASE, MEDLINE, SCOPUS, CINAHL and NICE Evidence were searched for relevant primary studies published until 31 December 2018 on retention among nurses in hospitals.

RESULTS

Forty-seven studies met the inclusion criteria. Nine domains influencing staff turnover were found: nursing leadership and management, education and career advancement, organisational (work) environment, staffing levels, professional issues, support at work, personal influences, demographic influences, and financial remuneration.

CONCLUSION

Identified turnover factors are long-standing. To mitigate the impact of these factors, evaluation of current workforce strategies should be high priority.

Comparing nurse leader and manager perceptions of and strategies for nurse engagement using a positive deviance approach: A qualitative analysis

AIMS

To understand nurse leader and manager perspectives on employee engagement and their own role to foster engagement. To examine differences between managers of units with high versus low engagement.

BACKGROUND

Health systems recognize the impact of employee engagement, yet alignment of leader and frontline-manager perspectives remains unclear.

METHODS

A qualitative study at the Veteran Affairs New England Healthcare System. Leaders at five facilities (N = 13) and managers of units with high and low nurse engagement (N = 31) were interviewed.

RESULTS

Nurse leaders almost universally conceptualized staff engagement as involvement in quality improvement service, while managers defined engagement as either commitment to excellence in direct patient care or involvement in quality improvement efforts. Intra- and interprofessional attitude contagion, and organisational factors of staffing-time-workload and senior leadership support were most common to support or detract from nurse engagement. A variety of strategies were identified, including protecting nurses as people and professionals. Differences in perceived roles and constraints to engaging nurse staff exist between managers of units with high versus low engagement.

CONCLUSION

Nurse managers and leaders perceive engagement differently; strategies exist to facilitate engagement.

IMPLICATIONS FOR NURSING MANAGEMENT

Leader and manager partnerships are needed to provide clarity on and resources for engagement.

Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review

BACKGROUND

Leadership is critical in building quality work environments, implementing new models of care, and bringing health and wellbeing to a strained nursing workforce. However, the nature of leadership style, how leadership should be enacted, and its associated outcomes requires further research and understanding. We aimed to examine the relationships between various styles of leadership and outcomes for the nursing workforce and their work environments.

METHODS

The search strategy of this systematic review included 10 electronic databases. Published, quantitative studies that examined the correlations between leadership behaviours and nursing outcomes were included. Quality assessments, data extractions and analysis were completed on all included studies by independent reviewers.

RESULTS

A total of 50,941 titles and abstracts were screened resulting in 129 included studies. Using content analysis, 121 outcomes were grouped into six categories: 1) staff satisfaction with job factors, 2) staff relationships with work, 3) staff health & wellbeing, 4) relations among staff, 5) organizational environment factors and 6) productivity & effectiveness. Our analysis illuminated patterns between relational and task focused leadership styles and their outcomes for nurses and nursing work environments. For example, 52 studies reported that relational leadership styles were associated with higher nurse job satisfaction, whereas 16 studies found that task-focused leadership styles were associated with lower nurse job satisfaction. Similar trends were found for each category of outcomes.

CONCLUSIONS

The findings of this systematic review provide strong support for the employment of relational leadership styles to promote positive nursing workforce outcomes and related organizational outcomes. Leadership focused solely on task completion is insufficient to achieve optimum outcomes for the nursing workforce. Relational leadership practices need to be encouraged and supported by individuals and organizations to enhance nursing job satisfaction, retention, work environment factors and individual productivity within healthcare settings.

Messung und Erfolgswirksamkeit transformationaler Führung

Diese empirische Studie untersucht die Beziehung zwischen transformationaler und transaktionaler Führung und deren langfristige bzw. kurzfristige Erfolgswirksamkeit. Das Führungsverhalten wird anhand des Multifactor Leadership Questionnaires (MLQ) gemessen, dessen psychometrische Qualität überprüft wird. Wir verwenden objektive Erfolgsindikatoren von Bankbetrieben, bei deren Herleitung situative Einflußfaktoren berücksichtigt werden. Wir finden Unterstützung dafür, daß die Erfolgswirksamkeit transformationaler über jene transaktionaler Führung hinausgeht. Transformationale Führung in Form eines freundlichen, individuell wertschätzenden Führungsverhaltens ist positiv mit kurzfristigem und negativ mit langfristigem Erfolg assoziiert.

Top management leadership style and quality of care in nursing homes

PURPOSE

The purpose of this study was to examine the association of Nursing Home Administrator (NHA) leadership style and Director of Nursing (DON) leadership style with quality of care.

DESIGN AND METHODS

Leaders were categorized into 4 groups: consensus managers, consultative autocrats, shareholder managers, or autocrats. This leadership style assessment came from primary data collected from approximately 4,000 NHAs and DONs that was linked to quality information (i.e., Nursing Home Compare Quality Measures and 5-Star rating scores) and nursing home information (i.e., Online Survey, Certification, And Reporting data).

RESULTS

A consensus manager leadership style has a strong association with better quality. Top managers using this style solicit and act upon input from their employees. For NHAs exhibiting this leadership style, the coefficients on 5 of the 7 quality indicators are statistically significant, and all 7 are significant when the DON exhibits this style. When the NHA and DON both have a consensus manager leadership style, 6 of the 7 quality indicator coefficients are significantly associated with better quality.

IMPLICATIONS

The findings indicate that NHA and DON leadership style is associated with quality of care. Leadership strategies are amenable to change; thus, the findings of this study may be used to develop policies for promoting more effective leadership in nursing homes.

Leadership styles of nursing home administrators and their association with staff turnover

PURPOSE

The purpose of this study was to examine the associations between nursing home administrator (NHA) leadership style and staff turnover.

DESIGN AND METHODS

We analyzed primary data from a survey of 2,900 NHAs conducted in 2005. The Online Survey Certification and Reporting database and the Area Resource File were utilized to extract organizational and local economic characteristics of the facilities. A general linear model (GLM) was used to estimate the effects of NHA leadership style, organizational characteristics, and local economic characteristics on nursing home staff turnover for registered nurses (RNs), licensed practical nurses (LPNs), and nurse's aides (NAs).

RESULTS

The complete model estimates indicate that NHAs who are consensus managers (leaders who solicit, and act upon, the most input from their staff) are associated with the lowest turnover levels, 7% for RNs, 3% for LPNs, and 44% for NAs. Shareholder managers (leaders who neither solicit input when making a decision nor provide their staffs with relevant information for making decisions on their own) are associated with the highest turnover levels, 32% for RNs, 56% for LPNs, and 168% for NAs.

IMPLICATIONS

The findings indicate that NHA leadership style is associated with staff turnover, even when the effects of organizational and local economic conditions are held constant. Because leadership strategies are amenable to change, the findings of this study may be used to develop policies for lowering staff turnover.

Leadership behaviour of nurse managers in relation to job satisfaction and work climate

AIM

This study examines how nurse managers' leadership behaviour relates to job satisfaction and a creative work climate.

BACKGROUND

The nursing shortage is a challenge for managers all over the world. Leadership is a core element of management and it is important to elucidate leadership behaviour in order to increase knowledge about attracting and retaining talented staff.

METHOD

We studied 770 subordinates at a large university hospital. Three questionnaires for assessing perceived leadership behaviour, creative work climate and job satisfaction were used.

RESULTS

Subordinates with a manager perceived as 'super' have the highest rates on job satisfaction. The correlation between leadership and creative work climate is stronger than between leadership and job satisfaction. Between job satisfaction and work climate the correlation is strong.

CONCLUSIONS

The study shows that the relationship between a creative work climate and job satisfaction is strong. A managers' ability to lead has a major affect on work climate.

IMPLICATION FOR NURSING MANAGEMENT

Nurse managers must work on developing their leadership behaviour towards being an all-round leader that cares about people, is concerned about productivity and can handle changes. Support of ideas and initiatives are important in order to enable subordinates to perceive their work as challenging.

The impact of ED nurse manager leadership style on staff nurse turnover and patient satisfaction in academic health center hospitals

INTRODUCTION

Nurse managers with effective leadership skills are an essential component to the solution for ending the nursing shortage. Empirical studies of existing ED nurse manager leadership styles and their impact on key nurse management outcomes such as staff nurse turnover and patient satisfaction have not been performed. The specific aims of this study were to determine what types of leadership styles were used by ED nurse managers in academic health center hospitals and examine their influence on staff nurse turnover and patient satisfaction.

METHOD

ED nurse managers were asked to complete the Multifactor Leadership Questionnaire and a 10-item researcher defined nurse manager role and practice demographics survey. Completed surveys (15 managers and 30 staff nurses) representing 15 out of 98 possible U.S. academic health centers were obtained.

RESULTS

Fisher's exact test with 95% confidence intervals were used to analyze the data. The sample percentage of managers who exhibited Transformational leadership styles and demographic findings of nurse manager age, total years experience and length of time in current position matched current reports in the literature. A trend of lower staff nurse turnover with Transformational leadership style compared to non-Trasformational leadership styles was identified. However, the type of leadership style did not appear to have an effect on patient satisfaction.

DISCUSSION

The ED is an ever-changing, highly regulated, critical-care environment. Effective ED nurse manager leadership strategies are vital to maintaining the standards of professional emergency nursing practice to create an environment that can produce management outcomes of decreased staff nurse turnover, thereby enhancing staff nurse retention and potentially impacting patient satisfaction.

The Effect of Nursing Care on Overall Patient Satisfaction and Its Predictive Value on Return-to-provider Behavior

OBJECTIVES

To determine the extent of patient satisfaction with care provided at the hospital at all levels and to correlate patients' satisfaction with nursing care, in particular, with their overall satisfaction. Also, to assess the predictive value of patient satisfaction on subsequent return to the hospital.

DESIGN

A survey study of a random sample of 420 inpatients to determine the extent of their satisfaction with the overall care provided at the hospital.

SETTING

A 110-bed private hospital in Kuwait, January 1-March 31, 2004.

RESULTS

The extent of overall patient satisfaction with the quality of care provided at the hospital was found to be quite high (Excellent, 74.7%; Very good, 23.7%). Individually, nursing care received the maximum patient satisfaction ratings (Excellent, 91.9%; Very good, 3.9%). A positive correlation (r = 0.31, P = .01) was noted between patients' perception of nursing care and their overall satisfaction with the health care provided at the hospital. Significant positive correlation (r = 0.36, P = .01) was also found between overall patient satisfaction and their reported intentions of returning and recommending the hospital to others.

CONCLUSIONS

Patient satisfaction surveys can be of great value to health care providers not only in recognizing and improving the quality of care, but also as predictors of return-to-provider behavior of the patients. Overall patient satisfaction is linked with quality nursing care, which, in turn, depends on the quality of leadership practiced at the institution. Transformational leadership behavior promotes nurse satisfaction, which adds to their work effectiveness and motivates them to provide quality patient care.

Transformational leadership: a cascading chain reaction

Historical influences still permeate contemporary nursing practise. These are mirrored in organizational philosophies, transactional and autocratic leadership styles and disempowered staff. Whilst there is disparity amongst the theorists' definitions of leadership, there is consensus pertaining to the attributes necessary to realize effective leadership. Transformational leadership is heralded as new criterion for nurse managers, and can be achieved through training, education and professional development in key leadership competencies. To achieve a chain reaction, charismatic transformational leaders espouse intellectual stimulation and individual consideration to empower staff and enhance patient care. Nurse managers that develop and foster transformational leadership can surmount oppressive traditions and confidently navigate a complex and rapidly changing health care environment.

Transformational and transactional leadership: a meta-analytic test of their relative validity

This study provided a comprehensive examination of the full range of transformational, transactional, and laissez-faire leadership. Results (based on 626 correlations from 87 sources) revealed an overall validity of .44 for transformational leadership, and this validity generalized over longitudinal and multisource designs. Contingent reward (.39) and laissez-faire (-.37) leadership had the next highest overall relations; management by exception (active and passive) was inconsistently related to the criteria. Surprisingly, there were several criteria for which contingent reward leadership had stronger relations than did transformational leadership. Furthermore, transformational leadership was strongly correlated with contingent reward (.80) and laissez-faire (-.65) leadership. Transformational and contingent reward leadership generally predicted criteria controlling for the other leadership dimensions, although transformational leadership failed to predict leader job performance.

Transactional Versus Transformational Style of Leadership—Employee Perception of Leadership Efficacy in Public and Private Hospitals in Kuwait

OBJECTIVES

To determine whether employees working for a transformational leader perceive their leader as more effective than do those working for a transactional leader. To assess whether employees in private hospitals are more likely to perceive their leaders as transformational than are employees in public hospitals.

DESIGN

A questionnaire study of a random sample of employees working at 4 hospitals (private and public) in Kuwait; 266 respondents included.

RESULTS

Analysis of varience and regression analysis showed that the transformational style of leadership was linked to high level of employee perception of leadership efficacy. Also, the employees in private hospitals were more likely to perceive their leaders as transformational than were employees in public hospitals.

CONCLUSIONS

Hospitals in Kuwait may benefit by recruiting leaders with a transformational style, as it is directly related to quality, employee satisfaction, increased productivity, and employee perception of leadership efficacy.

Leadership: A Key Strategy in Staff Nurse Retention

Nursing administrators are challenged to recruit and retain staff nurses in the midst of increasing job vacancies and staff nurse turnover rates averaging 21%. The prevailing issues related to staff nurse recruitment and retention in the current healthcare environment are briefly reviewed as introductory content. The article outlines the case from nursing administration literature that effective leadership styles of nurse managers and nurse administrators enhance staff nurse retention. As nurse administrators continue to struggle with staff nurse recruitment and retention, evidenced-based strategies are discussed that address leader preparation and organizational leadership structure including advanced education, leadership training, and shared leadership models.

The relationship between managerial leadership behaviors and staff nurse retention

The purposes of this study were to describe perceptions of managerial leadership behaviors associated with staff nurse turnover and to compare nurse manager leadership behaviors as perceived by managers and their staff nurses. Effective leadership styles among nurse managers have been associated with staff nurse job satisfaction and retention. Although both transformational and transactional leadership styles have been described as effective, it is unclear which nurse manager leadership behaviors contribute most to staff nurse retention. This descriptive, correlational study was conducted at a 465-bed community hospital in the northeastern United States. All staff nurses and nurse managers employed in both ambulatory and acute care nursing units were invited to participate in the study. The study sample comprised 79 staff nurses and 10 nurse managers, who completed demographic forms and the 45-item Multifactor Leadership Questionnaire, which measures 12 dimensions of leadership style. Data were collected from July through September 2003. Active management by exception as perceived by staff nurses was the only managerial leadership style associated with staff nurse turnover (r = .26, p = .03). Compared with the perceptions among their staff nurses, nurse managers consistently perceived that they demonstrated a higher mean frequency of transformational leadership behaviors. The transactional leadership style of active management by exception not only appeared to be a deterrent to staff nurse retention but also reflected leadership perceptions among staff nurses who work evening and night shifts. This study also provides further evidence regarding a trend in which nurse managers and staff nurses do not concur on the frequency of transformational leadership behaviors but do demonstrate agreement on the frequency of transactional leadership behaviors.

Discourse on the transformational leader metanarrative or finding the right person for the job

Changes in healthcare today have called for leadership styles that place a heavy demand on organizations. Shifts in markets and reimbursement strategies call for new leaders with vision that can guide healthcare organizations to change. In a postmodern era, organizations see the transformational leader as a valuable asset in changing times. This article addresses the foundations of the transformational leader metanarrative and, through a postmodern discourse, deconstructs the concept. The article presents a review of postmodern thought in relation to the metanarrative of leadership and applications to nursing administration.

What Constitutes Effective Leadership?

Magnet hospitals, so named because of their ability to attract and retain nurses, have been operating for nearly 20 years. Although research on their success, particularly related to job satisfaction and retention of nurses, is available, research on magnet nurse leader effectiveness has been limited to the pivotal role the nurse leader plays in supporting a magnet culture. To enhance the research groundwork in magnet hospitals and nursing leadership, 16 nurse leaders from magnet and nonmagnet hospitals were interviewed. They were asked to identify leadership qualities they considered valuable in today's healthcare setting. The author contrasts the opinions of magnet and nonmagnet leaders relating to their leadership traits, organizational structures they discern as being supportive of professional nursing practice, and their perceptions of how a successful organization is created.

The concept of clinical leadership

This paper examines the concept of clinical leadership and finds that the concept has been used in a number of ways within the nursing literature. The paper argues that in a nursing practice setting the concept of clinical leadership is an appropriate one. In the clinical setting the nurse leader often has followers in the health care team, patients and their relatives. Thus it is argued that clinical leadership can be defined as the expert nurse who leads patients to better health care.

Nurse executive transformational leadership found in participative organizations

OBJECTIVE

The study examined a national sample of 396 randomly selected hospital nurse executives to explore transformational leadership, stage of power, and organizational climate.

BACKGROUND

Results from a few nurse executive studies have found nurse executives were transformational leaders. As executives were more transformational, they achieved better staff satisfaction and higher work group effectiveness. This study integrates Bass' transformational leadership model with Hagberg's power stage theory and Likert's organizational climate theory.

METHODS

Nurse executives (396) and staff reporting to them (1,115) rated the nurse executives' leadership style, staff extra effort, staff satisfaction, and work group effectiveness using Bass and Avolio's Multifactor Leadership Questionnaire. Executives' bosses (360) rated executive work group effectiveness. Executives completed Hagberg's Personal Power Profile and ranked their organizational climate using Likert's Profile of Organizational Characteristics.

RESULTS

Nurse executives used transformational leadership fairly often; achieved fairly satisfied staff levels; were very effective according to bosses; were most likely at stage 3 (power by achievement) or stage 4 (power by reflection); and rated their hospital as a Likert System 3 Consultative Organization. Staff satisfaction and work group effectiveness decreased as nurse executives were more transactional. Higher transformational scores tended to occur with higher educational degrees and within more participative organizations.

CONCLUSIONS

Transformational qualities can be enhanced by further education, by achieving higher power stages, and by being within more participative organizations.

Leadership styles across hierarchical levels in nursing departments

BACKGROUND

Some researchers have reported on the cascading effect of transformational leadership across hierarchical levels. One study examined this effect in nursing, but it was limited to a single hospital.

OBJECTIVES

To examine the cascading effect of leadership styles across hierarchical levels in a sample of nursing departments and to investigate the effect of hierarchical level on the relationships between leadership styles and various work outcomes.

METHODS

Based on a sample of eight hospitals, the cascading effect was tested using correlation analysis. The main sources of variation among leadership scores were determined with analyses of variance (ANOVA), and the interaction effect of hierarchical level and leadership styles on criterion variables was tested with moderated regression analysis.

RESULTS

No support was found for a cascading effect of leadership across hierarchical levels. Rather, the variation of leadership scores was explained primarily by the organizational context. Transformational leadership had a stronger impact on criterion variables than transactional leadership. Interaction effects between leadership styles and hierarchical level were observed only for perceived unit effectiveness.

CONCLUSIONS

The hospital's structure and culture are major determinants of leadership styles.

A logit analysis of the likelihood of leaving rural settings for registered nurses

This study examined the net effects of individual and community factors on the likelihood of registered nurses leaving current jobs using a logit analysis. Based on data from a survey of 2,509 rural nurses, four separate models were estimated and compared: one for nurses in rural settings as a whole and the other three for nurses in hospitals, skilled nursing facilities, and community/public health agencies. Results of the general model indicated that nurses' marital status, age, position, income, job satisfaction, and satisfaction with the community were significant determinants of the likelihood of leaving current jobs. Job satisfaction was the most significant factor, followed by satisfaction with the community. Findings from the models for three different employment settings were similar to those of the general model. However, the significance of factors and their strength of effect on nurses' decisions to leave or stay in their current jobs differed across the three types of facilities. Based on these findings rural nursing administrators and policy-makers should give priority to retention strategies that focus on improving the job environment. The development of different strategies for different groups of nurses (i.e., by age or marital status) and different types of facilities should increase the benefit/cost ratio. In addition, programs that involve rural health care agencies in community and economic development should be further explored as an avenue to increased nurse retention in rural areas.

Transforming curriculum for a nursing leadership course: a collaborative approach

The purpose of this project was to strengthen the transformational leadership competence of students by incorporating perceptions of all course participants in the curriculum of a nursing leadership course. Students and faculty collectively assessed each other's ability to communicate, associate, sanction, delegate, initiate, and achieve external legitimacy by completing a Leadership Performance Competence Profile. Profile results guided the teaching strategies and activities used during the course. At the beginning of the course the sanction competence was perceived as a mutual weakness; at the end of the course perceptions of all six leadership competencies were stronger. End-of-course student satisfaction was also examined. This project suggests collaborative teaching strategies can enhance perceptions of competence and satisfaction of course participants.

Transformational leadership of clinical nutrition managers

OBJECTIVE

To identify leadership qualities of clinical nutrition managers and associate these leadership qualities with selected demographic variables (eg, training/degree, length of time in management, number of people supervised, income, and participation in advanced practice activities).

DESIGN

The theory of transformational leadership, that is, leadership that incorporates specific interpersonal behaviors of the leader and his or her actions within the organization, provided the framework for the study. Specific transformational leadership qualities--leader behavior, leader personal characteristics, and the effect of the leader on organizational functioning and culture--were measured using the Leadership Behavior Questionnaire (LBQ). The reliability and validity of the LBQ have been reported previously. Other data were obtained using two demographic surveys.

SAMPLE

Demographic surveys were mailed to 1,599 members of the Clinical Nutrition Management dietetic practice group. From the 951 (59.8%) respondents, a study sample of 150 clinical nutrition managers and their subordinates was selected to receive the LBQ; 116 (77.3%) instrument sets were used for analysis.

STATISTICAL ANALYSIS

Descriptive statistics were used to analyze the demographic surveys. A specified mixed linear model repeated measures Statistical Analysis System procedure was used to compare the clinical manager and subordinate LBQ scores. Association of the selected demographic variables with leadership qualities was measured by lambda, a predictive value measure, using the BMDP 4F program.

RESULTS

Clinical nutrition managers exhibited transformational leadership qualities as rated by the LBQ, rating lowest on the communication leadership score and highest on the respectful leadership score. Most of the clinical nutrition manager self LBQ scores were significantly higher than the clinical nutrition manager LBQ scores rated by subordinates. The selected demographic variables appeared to have the strongest predictive effect for the visionary culture building subscore of the LBQ. The visionary culture building subscore is a measure of how well the leader interacts with and affects the functioning of an organization.

APPLICATIONS/CONCLUSIONS

More research is needed to define leadership in dietetics: this study can serve as a possible model. One way clinical nutrition managers may be able to enhance their leadership behaviors is to strengthen their skills in communicating their vision. Programs are needed to help clinical nutrition managers shape their organizations to foster leadership development in their subordinates.

Development and validation of scales to measure organisational features of acute hospital wards

In order to make comparisons between wards and explain variations in outcomes of nursing care, there is a growing need in nursing research for reliable and valid measures of the organisational features of acute hospital wards. This research developed The Ward Organisational Features Scales (WOFS); each set of six scales comprising 14 subscales which measure discrete dimensions of acute hospital wards. A study of a nationally representative sample of 825 nurses working in 119 acute wards in 17 hospitals, drawn from seven Regional Health Authorities in England provides evidence for the structure, reliability and validity of this comprehensive set of measures related to: the physical environment of the ward, professional nursing practice, ward leadership, professional working relationships, nurses' influence and job satisfaction. Implications for further research are discussed.

Reflection on clinical leadership behaviours

This paper uses leadership theory and personal observations to reflect on leadership behaviours observed during a third year clinical placement on an Oncology Unit. It examines the consequences of the different leadership styles of two registered nurses, firstly a clinical nurse consultant (CNC) and secondly a level one registered nurse, who acted as the author's preceptor. Conclusions are drawn about the value of preceptoring baccalaureate undergraduates.

Dietitians' self-perceptions: implications for leadership

This article reports usual modes of thinking and behavior as measured by the Life Styles Inventory--Level 1, Self-Description (LSI--Level 1), which was completed by 893 dietitians who attended at least one invitational leadership seminar during 1986 through 1989. The LSI--Level 1 measures 12 lifestyles, both positive and negative, and there is a score for each style. On a scale of 1 to 40, mean scores of the study sample were highest for Affiliative (32.0), Humanistic-Helpful (31.6), Achievement (31.1), and Self Actualize (28.8) styles. These are positive styles that characterize creative thinkers who have been described as good leaders: confident and energetic with balanced concern for both tasks and people. When mean scores of the study sample were plotted on a scaled circumplex to give a visual profile of the scores, the Dependent and Self Actualize styles were dominant; the study sample means were above the 75th percentile of the general population sample. Dependency is described as a self-defeating style characterized by insecurity, indecision, meekness, and acquiescence. chi 2 Analysis showed that study respondents who had high scores in positive styles were significantly more likely to hold graduate degrees, publish articles, conduct research, hold offices, initiate projects, and serve as mentors. High scores in self-defeating styles were associated with the bachelor's degree level and less involvement in research and continuing education programs. These results indicate that many dietitians possess attributes associated with strong leadership skills; nevertheless, a substantial number reported self-defeating, dependent behaviors.(ABSTRACT TRUNCATED AT 250 WORDS)