Morrison, Ruby S. DSN, RN; Jones, LaDon PhD, RN; Fuller, Bryan MBA
Healthcare delivery systems are experiencing dramatic organizational changes. To manage the changes effectively, nursing leaders must understand the social processes that affect employees' work-related attitudes, particularly leadership style and psychological empowerment. At the unit level, nurse managers are responsible for ensuring that patient care and changes in care delivery are implemented successfully. Because current restructuring strategies represent a change from traditional delivery of care, the nurse manager's leadership style can be an important factor in influencing subordinates' acceptance of change and their productivity.1 In addition, to be effective in restructured systems, nursing staff must be empowered to make judgments about the tasks of care delivery and to delegate effectively.2 Restructuring strategies frequently include work redesign to shift more direct care delivery to unlicensed assistive personnel.3 Therefore, empowerment of unlicensed personnel is also becoming an increasingly important aspect of healthcare restructuring. Previous studies indicate that leadership style and empowerment positively affects nurses' job satisfaction levels.2,4 However, no research has examined the relations among leadership style, empowerment, and job satisfaction.
Review of Literature
Leadership is the ability to influence a group toward the achievement of its goals.5 Much importance has been placed on the leader's effectiveness. The most commonly used measure of leader effectiveness is the extent to which the leader's group or organization performs its tasks successfully or attains its goals.
Bass6 described leadership behaviors by contrasting transformational and transactional leader behavior. Transformational leadership includes four components: idealized influence, inspiration, intellectual stimulation, and individualized consideration. Idealized influence (charisma) is a process whereby the leader provides followers with a vision and a sense of mission and gains respect, trust, and confidence from followers. Inspirational leaders engage in confidence building of their subordinates, thereby influencing their ability to perform assignments and tasks successfully. Transformational leaders use inspiration to increase optimism and enthusiasm of the followers and to articulate the leader's vision. Intellectual stimulation is a process whereby the leader increases follower awareness of problems and influences followers to view problems from a new perspective. Finally, individualized consideration includes providing support, encouragement, and developmental experiences for followers.
In contrast, transactional leadership "pursues a cost-benefit, economic exchange to meet subordinates' current material and psychic needs in return for contracted services rendered by the subordinate."6(p. 14) Transactional leaders use two types of behaviors-contingent reward and management-by-exception. Contingent reward is a process in which the leader contracts with the follower by providing rewards for an agreed on effort. The leader and follower agree on what the follower needs to do to be rewarded or to avoid punishment. Followers are given a clear understanding of what is expected of them. Management-by-exception is a leadership behavior in which the leader intervenes only if standards are not met or something goes wrong. According to Hater and Bass,7 management by exception can be either active (watching and searching for deviations from rules and standards to take corrective action) or passive (intervening only if standards are not met).
Several empirical studies on transformational leadership found that transformational leadership behaviors were positively related to work team success and leadership effectiveness.8-10 Fuller et al.11 conducted a meta-analysis aggregating research using Bass's measure of charisma (idealized influence) and found charismatic leader behaviors to be significantly related to performance, leader effectiveness, and followers' satisfaction with the leader. Jones12 found that employees on patient care units with high levels of patient satisfaction described the nurse managers of the units as having significantly higher transformational leadership behaviors than did employees on units that had lower patient satisfaction.
Transformational leadership processes have been suggested to enhance followers' work-oriented values and shape the self-efficacies of followers.6 Leaders can empower their followers by providing role models that reflect the organization's value system as well as transmit the organization's vision of quality. Employee empowerment may also be influenced by the perception that the organization cares about its employees' well-being and that their work is valued. Persons who perceive that they are strongly supported by the organization are more likely to"repay" the organization by increasing their attachment to the organization and by performing duties that go beyond formal job descriptions. Therefore, individual and organizational performance is influenced by perceived "debts" incurred by the individual, as well as by motivational processes that orient the individual toward organizational values that increase individual's self-efficacy.
Several studies have related transformational leadership to a number of important attitudes, behaviors, and performance measures. Empowerment is perhaps the most widely discussed influence transformational leaders have on followers.6,13,14 Thomas and Velthouse13 indicated that transformational leadership should influence the competence, meaningfulness, and impact dimensions of empowerment. By articulating a meaningful organizational mission or vision, a transformational leader provides the most critical type of information required for empowerment.15
Empowerment in the workplace has been studied from several perspectives. According to Arad,16 the practice of empowering employees is often a principal component of management and organizational effectiveness; organizational productivity increases when power and control are shared with subordinates, and empowerment plays a crucial role in group development and maintenance. Empowerment refers to either psychological empowerment focusing largely on the individual's self-efficacy, or organizational empowerment, focusing on shared power in the organizational structure and decision-making processes.17 Because psychological empowerment is essential for organizational empowerment to be effective, this study focuses on psychological empowerment.
Conger and Kanungo18 define empowerment as a motivational process whereby employee's self-efficacy is increased, enabling him or her to complete work more effectively. Thomas and Velthouse13 offer a broader conceptualization of empowerment, describing it as not only self-efficacy (competence) but also as task meaning, self-determination, and impact. Based on the work of Thomas and Velthouse, Spreitzer defined empowerment as "increased intrinsic task motivation manifested in a set of four cognitions (meaning, competence, self-determination, and impact) reflecting an individual's orientation to his or her work role."19(p. 1443)
Empowering nurses can increase job satisfaction and improve patient care.20 Recently, the interest in empowerment of nurses has increased greatly. Evidence of this interest includes many journal articles devoted to nursing empowerment and a new journal devoted exclusively to nursing empowerment, Revolution: A Journal of Nursing Empowerment. Douglas2 found that empowerment was positively correlated with outcomes of performance, customer satisfaction, organizational commitment, satisfaction with supervisors, and satisfaction with work. Spreitzer19 found that empowerment was significantly correlated with innovative behavior and managerial effectiveness, both of which are necessary for an organization to succeed in times of dramatic changes.
Research suggests that empowerment may be influenced by several factors. There is some evidence that empowerment varies by employment status.21 In a healthcare context, licensed personnel should be perceived as having a different status than nursing assistants or secretaries and clerks. Therefore, it seems logical that empowerment for licensed and unlicensed personnel may differ with regard to its influence on job satisfaction.
Job satisfaction is a multivariate human attitude that has been defined as"an affective response of the workers to his job ... consequence of the worker's experience on the job in relation to his own values, that is, what he wants or expects from it."22(p. 272) Warr et al.23 define job satisfaction as "the degree to which a person reports satisfaction with intrinsic and extrinsic features of the job. Total job satisfaction is the sum of all separate items, and overall job satisfaction is reported satisfaction with the job as a whole" (p. 133). Basic components of total job satisfaction were determined to be extrinsic and intrinsic job satisfaction.
This study examined the relations among leadership style, empowerment, and job satisfaction for the nursing staff of a regional medical center. Based on the previous literature review, it seems logical to expect that leadership style should influence aspects of job satisfaction not accounted for by empowerment. This study sought to determine if transformational leadership influences job satisfaction beyond what is accounted for by empowerment. In addition, this study investigates the relative influences of transformational leadership and empowerment on job satisfaction by nursing staff group (i.e., licensed versus unlicensed personnel).
A regional medical center was selected as the site for the study because of its convenient location and the administration's expressed commitment to quality improvement. Permission to conduct the study was obtained from the institutional review board and the medical center's research committees, unions, and administration. All 442 nursing department staff were invited to participate. Included in the nursing staff are executives, nurse managers, licensed practical nurses, registered nurses, nursing assistants, and various administrative staff. The response rate was 64%, with 275 useable questionnaires returned.
This study used a descriptive design with a self-report survey instrument. The survey questionnaire included minimal demographic information to group the data for analysis by type of position held, including nursing assistant, licensed practical nurse, registered nurse, nurse manager or supervisor, and clerk/secretary/administrative officer. Participants were grouped into licensed and unlicensed staff for data analysis. Statements to measure the variables leadership style, empowerment, and job satisfaction comprised the questionnaire, with Likert-type responses including 1) not at all, 2) once in a while, 3) sometimes, 4) fairly often, and 5) frequently, if not always. The statements were obtained from previously developed instruments.
Leadership style was determined from items for the subscales of transformational leadership (idealized influence, inspiration, intellectual stimulation, individualized consideration) and transactional leadership(management-by-exception and contingent reward) from Bass's Multifactor Leadership Questionnaire (MLQ-5X).24 In a study of nursing staff, Jones12 found the MLQ to have high reliability, with Cronbach alpha scores ranging from 0.67 to 0.93 on the subscales of the instrument. Four items from Spreitzer's19 instrument were used to measure empowerment related to meaning, competence, self-determination, and impact. Spreitzer had reported a reliability of 0.72 for the Psychological Empowerment instrument. Job satisfaction was measured by a questionnaire developed by Warr et al.23 In recent research using this scale, Kelloway and Barling25 reported reliability coefficients of 0.90 for intrinsic job satisfaction and 0.78 for extrinsic job satisfaction.
Data were collected by graduate students and volunteers employed at the medical center. Data collectors were oriented to the study and given instructions on administering the questionnaire to provide consistency. Data collectors were assigned to specific shifts and schedules to provide opportunities for all nursing staff to be invited to participate in the study. Data were collected during a 2-week period. The data collectors provided each staff member with a cover letter explaining the study and a questionnaire with return envelope.
Anonymity was assured by including no identifying information on the questionnaires or envelopes. Return of the questionnaire verified consent to participate. Participation was strictly voluntary. The only incentives to participate were the opportunity to complete the questionnaires on duty time and light refreshments.
Both transformational and transactional leadership are positively related to job satisfaction, with correlations of 0.64 and 0.35, respectively. The higher positive correlation for transformational leadership supports the augmentation concept forwarded by Bass.6 Interestingly, only transformational leadership is positively related to empowerment, with a correlation of 0.26. Empowerment is positively related to job satisfaction, with a correlation coefficient of 0.41. Table 1 shows the correlation matrix relating leadership style, empowerment, and job satisfaction.
Table 2 shows the correlations and scale reliabilities for the subscales of the study variables. All the transformational leadership subscales are strongly related to both intrinsic and extrinsic job satisfaction. However, of the transactional leadership subscales, only contingent reward is positively related to both satisfaction measures. Active management by exception is positively related to extrinsic satisfaction but is unrelated to intrinsic satisfaction. Passive management by exception is negatively related to both measures of job satisfaction.
As expected, all of the transformational leadership variables are positively related to empowerment. Of the transactional leadership variables, only contingent reward is positively related to empowerment. The management-by-exception variables have different relations with empowerment. Active management by exception is unrelated to empowerment, whereas passive management is negatively related to empowerment. Similar to the results shown in Table 1, empowerment is positively related to both intrinsic and extrinsic job satisfaction.
The results of the analysis of variance procedure indicated that there was a statistically significant difference in empowerment among the different job classifications (F4,267 = 4.31, P < 0.05). Therefore, we conducted hierarchical regression analyses to assess the different contributions of empowerment and leadership style in predicting job satisfaction for licensed and unlicensed personnel.Table 3 shows the results of the incremental partitioning of variance procedures for licensed staff, unlicensed staff, and the entire staff. For all three groups, the results show that leadership accounts for a significant amount of the variance in job satisfaction beyond variance accounted for by empowerment. Results for the total sample show that transactional leadership accounts for a much smaller amount of variance in overall job satisfaction (10%) than does transformational leadership (30%). As could be expected, empowerment accounts for less variance in extrinsic satisfaction than in intrinsic satisfaction. This noticeable difference is apparent across all three sample groups.
Results of the hierarchical regression analysis also show a marked difference in the amounts of variance accounted for by empowerment and leadership style variables when licensed personnel are compared with unlicensed personnel (Table 4). Empowerment accounts for more variance in job satisfaction for licensed personnel than for unlicensed personnel. The amount of variance empowerment accounts for in job satisfaction also differs by type of satisfaction. Results also show that the amount of variance accounted for by leadership is much greater for the unlicensed sample than for the licensed sample. Therefore, the results reveal that the relative contribution of empowerment and leadership varies by type of personnel.
This study examined two particularly important factors that influence the job satisfaction of healthcare personnel. Transformational leadership appears to have a powerful influence on job satisfaction both directly and indirectly through its influence on a person's intrinsic task motivation (empowerment). Transactional leadership, on the other hand, has no effect on empowerment, although it does have a direct effect on job satisfaction (seeTable 1). The results also support Bass's6 suggestion that transformational leadership augments the effects of transactional leadership. The results of this study differ from recent research by Medley and LaRochelle4 suggesting that transactional leadership style for leaders in a healthcare context does not positively influence subordinate job satisfaction. Their conclusion was based research that included contingent reward as a transformational leadership factor rather than a transactional leadership factor. Because Bass conceptualized the difference between transformational and transactional leadership as largely based on the difference between social and economic exchange, it is inappropriate to group contingent reward behavior (economic related) with the socially defined transformational factors.
The present study also provides a more concise examination of how transactional leadership relates to job satisfaction. The results of this study suggest that although contingent reward behaviors are positively related to job satisfaction, management-by-exception relates to job satisfaction differently according to whether it is active or passive. Although active management by exception is either not related to satisfaction(intrinsic) or positively related to extrinsic satisfaction, passive management by exception is negatively related to job satisfaction and empowerment. Therefore, regardless of the type of leadership style of the manager, the nursing staff in this sample preferred that their leaders take a more active leadership role.
Consistent with the idea that transformational leadership behaviors can influence job satisfaction in ways that empowerment does not, the results of this study help clarify the relative importance of leadership and empowerment in determining how nursing staff feel about their jobs. This is an important finding, because leadership has not been included in most recent studies of empowerment. Therefore, although empowerment has a significant influence on the satisfaction of nursing staff, the impact of transformational leaders can be significantly greater in scope.
Perhaps the most interesting finding of the present study was that the relative influence of leadership and empowerment on individual job satisfaction varied greatly by personnel group. Transformational leadership accounted for four times as much variance in job satisfaction as empowerment in unlicensed nursing staff, compared with a relatively equal amount of variance between leadership style and empowerment in the licensed nursing staff. This suggests that, with respect to job satisfaction, the two groups may differ in how much influence may be exerted on them by their immediate leaders. There are at least two explanations for this occurrence. The differing nature of the tasks for licensed and unlicensed personnel may affect the importance of being empowered. Chandler26 found in interviews with staff nurses that nurses experienced the most empowerment (53%) through interaction with patients and families. In contrast, being complimented and recognized by the head nurse only accounted for 7% of what the staff nurses described as being empowered. The second reason may be due to the nature of the work itself. Because of their largely professional status, licensed nursing staff are more likely to perceive their jobs as having greater meaning, as well as being more deterministic and having a greater effect on their work environment compared with the unlicensed nursing staff.
As healthcare organizations continue to undergo internal structural changes, it is important that executives not use one narrowly focused intervention program. The importance given to empowerment recently as a panacea for improving quality of work life may be unwarranted. Designing interventions that allow for the relative influence of leadership as well as empowerment on varying classifications of nursing personnel may be a more effective strategy and have a greater effect on staff attitudes and behaviors.
The authors thank Donna Bridger, RN, MSN, and Valerie Brown, RN, CS, MSN, of the Tuscaloosa Veterans' Affairs Medical Center for help in planning and conducting this research.
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