The association of leadership styles and empowerment with nurses’ organizational commitment in an acute health care setting: a cross-sectional study

Acute care environments in hospitals are in a state of continuous improvement and rapid change due to the pressures of reduced average length of hospital stays (ALOS), cost-containment, unpredictability, and uncertainty. Moreover, the shortage of nursing staff within the hospital increases the difficulty of maintaining acceptable health care standards. Also, by replacing nursing positions, such as the nurse manager, which requires strong leadership and at least minimal management experience and training, with less-qualified health care personnel has led to a devalued nursing role within organizations [1]. Nurses might perceive that managers, both with autocratic and weak leadership styles, present barriers to effective nursing practice. Overly controlling managers are likely to discourage individual initiative and creative thinking. Weak nurse managers, meanwhile, may fail to advocate for nurses’ employment rights, the respect they deserve within the health care team, to support their need for resources, and may fail to effectively negotiate and retain nursing positions. Thus, failed leadership due to the absence of qualified nurse managers results in the nursing staff becoming further disempowered, demotivated and ultimately disengaged, less satisfied and committed [2].

Nursing managers have an essential role in hospital management. This includes facilitating care, ensuring patient safety, enhancing the quality of work life of nurses, and championing change processes that serve these ends [3, 4]. This requires managers to empower their nurses to perform their obligations using best practices. It, also, requires managers to ensure the staffing nurses’ commitment by means of providing an optimal work environment whilst maintaining a high level of quality care and patient safety. Nurse empowerment is not only an essential requirement, but it also affects work performance to achieve these outcomes. In this context, Kanter (1993) states that Work Empowerment Theory is conceptually consistent with the nursing care process and can be logically extended to support nurses’ interactions with their patients, as empowered nurses will enable best care practices for their patients, hence, resulting in optimal patient care outcomes [5]. However, it has been reported that the relations between nurse managers and staffing nurses have grown more strained, leading to less opportunity for nurses to communicate their concerns about patient care and their own roles with their managers [6]. Previous studies showed nurses perceive that they are underrepresented in the organizational hierarchy [4‐6]; thus limiting their capacity to have meaningful role in decision making and influencing change to improve organizational processes that are relevant to the nurse’s role, quality of work life and patient care. Correspondingly, these conditions affect not only the staffing nurses’ emotional and physical health outcomes, but also their efficiency, productivity, performance and commitment. Failing to provide nurses with a significant voice in health care system management, eventually leads to adverse effects in the workplace environment and organizational culture and functioning, and this ultimately results in lower-quality patient care [7].

The available literature provides considerable evidence that nurses’ limited participation in clinical decision-making is ineffective and harmful to patient safety. There is evidence that nurses may also be overextending themselves to ensure the quality of care under deteriorating working conditions [5]. It has also been reported that limited participation of nurses in decision-making, affecting their jobs and work environment, entails a cost to the organization in terms of mistrust of hospital management and resentment [6]; high levels of stress, decreased morale, reduced job satisfaction and lower organizational commitment [2, 5, 6, 8, 9]. These conditions collectively would, likely, contribute to nursing burnout and nurses leaving the organization and even the profession.

Thus, as a priority, the role of the nurse manager, in continually and effectively empowering staff in the care process, is to ensure a work environment and culture that encourages and sustains quality of healthcare and patient safety. However, the relationship between leadership style and behavior and employee commitment and empowerment has not been investigated in Saudi Arabian health care context. Furthermore, the work empowerment construct itself has not been previously tested within the Saudi Arabian context. Hence, this study aims primarily to test a model that links leadership style and employee empowerment, and their impact on organizational commitment among nurses working in an acute healthcare setting in Riyadh, Saudi Arabia.

The relationship between leadership styles and staff perceptions of their empowerment is important for nursing mangers and leaders, in order to create a work environment that encourages and facilitate a high level of commitment among the nursing staff. This is particularly important, especially in the wake of the current challenges facing healthcare systems in relation to the shortages of health professionals, especially among nursing profession.

In our study, nurses perceive themselves to have moderate levels of overall psychological empowerment, high levels of meaning, moderate levels of confidence and autonomy, and low impact on their working environment. These results are consistent with findings from other previous studies in acute care settings [2, 4, 6, 13]. These findings suggest nurses may feel less motivated when they perceive that their work has no significant value to the organization, and important aspects of their job, work environment, and patient care. This may be experienced as burnout or apathy and the nurses’ sense that they are exerting too much effort with too little reward or return.

The psychological empowerment subscale, autonomy, was the only statistically significant predictor of commitment, suggesting that nurse managers have and authentic commitment to full engagement of the nurses in appropriate decision-making about patient care processes, patient safety and their working environment. This finding is inconsistent with literature showing that increased participation empowerment facilitates greater commitment. In this context, Clifford (1992) noted that if management does not allow for staff participation in decision-making, the effort to empower frustrates employees, resulting in an increased dependence on authoritarian structures. The findings further show that AC has the lowest mean score, where nurses who did not feel a sense of belonging or attachment to their organization are less likely to stay with their organization to find more desirable jobs than nurses with high AC. This result is inconsistent with existing literature [12, 14‐16]. Thus, the development of AC is influenced by the degree to which an organization shows that it values and supports its employees. In contrast, NC has the highest mean score, suggesting that some nurses are staying with the organization because of a sense of obligation and moral responsibility not because they “want to” based on other factors, for example, the perception that their work is appreciated. This particular result is consistent with literature showing that feeling of obligation to stay with an organization probably results from internalization of normative pressure exerted on an individual before entry into the organization (i.e. cultural socialization, or familial) or following entry (i.e. organization socialization) [17].

Contrary to expectation that TFL promotes employees’ capacities and capability, the results of the study further reveal that nursing managers in acute care units do not motivate and encourage their nurses to envision attractive future states as indicated by IM mean score of 2.65 (SD = 0.86). These findings is inconsistent with studies showing that employees who have high level of capabilities feel a greater sense of control and are more likely to try learning more to become even more capable (Avolio & Bass, 1995). The nurses in our study rated Individualized Consideration (IC) with a lower score implying that nurse managers often do not display IC leadership behaviors in interaction with their staffing nurses. According to our conceptual model, these managers should pay more attention to the nurses’ self-efficacy and their organizational performance. Taking the initiative to interact with their employees and responding appropriately to personal concerns and needs expressed by their staff should help them to be more effective and trusted managers [18]. Accordingly, the leadership training for nursing managers should emphasize supportive and responsive leadership to support nurses and encourage their autonomy and empower them to take on more accountability in line with their growing expertise and engagement [19].

Moreover, the nursing managers are advised to demonstrate behaviors that will encourage the development of mutual trust, respect, and competence, which will increase the credibility and authority of the nurse manager and provide inspirational and normative behavior. Although not all nurse managers can be expected to possess charismatic personalities, the dimensions of transformational leadership discussed should encourage followers to respect and admire their leaders as role models and valued advocates. Thus, health care organizations should recruit and promote nurse managers who possess these transformational qualities, who are likely to be more effective in instilling shared mission, vision, and values as guidelines for achieving organizational goals. Nurse Managers should promote their organization by demonstrating transformational leadership traits as models for the nursing staff. Furthermore, policy makers, health care educators, and executives should insure that nursing education and supervisory training includes the development of transformational leadership qualities among the nurse managers.

The second leadership style (TAL) contains the leadership components of Contingent Rewards, and Management-by-Exception both Active and Passive forms. According to Bass et al. (2003) [20], the TAL style is an essential precondition for TFL as it helps to ground the relationship between the follower and the leader. Among the three components of TAL, the contingent reward CR subscale had the highest mean score among the nurses surveyed which is consistent with the findings from other studies [21]. Consequently, this result indicates that nurse managers often structure and clarify the task requirements and roles for their followers. They discuss performance expectations and outcomes with nurses; explain how these results are achieved, and the rewards they should expect for their performance and satisfactory effort. In general, these nurse managers provided tangible and intangible resources and support to followers in exchange for the nurses’ efforts and contributions. In this context, Bass and Avolio (2003) stated that the ideal CR rating must be greater than the benchmark rating of 2. In our study, the mean score of the nurses’ responses to CR was 2.50, which satisfies this criterion. On the other hand, Bass and Avolio (2003) indicate that the mean score of MBEP should be less than 1 score and the rate of MBEA subscale should be less than 1.5 for effective managers. In our study findings, the mean score for MBEA was 2.47, which is outside the desired range indicating that nurse managers actively keep track of all mistakes, concentrate on enforcing standards, and directly monitor staff behavior and performance [22, 23].

In our study, the mean MBEP rating of 1.36 exceeds the benchmarks set by Bass and Avolio (2003) as ideal for a leader; this result suggests that these nurses perceive their nurse managers as not effective in taking corrective action or resolving problems. This implies that the acute care nurse managers tend to wait for problems and mistakes to occur before taking any proactive action [20], and interfere only when the minimum standards have not been met [24].

The Management-by-Exception style, Active and Passive forms, emphasizes the controlling aspects of management, where leaders intervene only when things go wrong (Bass et al., 2003). Criticism, correction, negative contingent reinforcement, and negative feedback are examples of interventions that nurse managers rely on in managing-by-exception. Both active and passive forms of the Management-by-Exception style use more negative than positive reinforcement, a pattern associated with low satisfaction with leaders by their followers [25]. Subsequently, it is clear that appropriate supervisory training and reinforcement must be provided for nurse managers to learn and sustain more effective leadership skills.

In summary, the findings of our study indicate that the TFL style has moderate positive association with organizational commitment (OC) and were found to have relationship with both Continuance and Normative forms of commitments. This suggests that TFL leadership style affects how employees feel about their relationships with their managers and their desire and obligation to maintain their employment in the organization. Furthermore, the TAL style was found to have a strong positive relationship with perceived empowerment. These results suggest that managers accorded high TAL scores are those who have achieved high level of trust among their employees, and who in turn delegate maximum authority and responsibility to their followers. As a result, of such leadership, nurses feel they are empowered and are more committed to organizational outcomes. Our findings suggest that a TFL style can achieve a high level of employee commitment through empowerment strategies and meaningful participation in decision-making. The high TFL manager focuses on empowering their employees by delegating power to them and involving them in decision making which in turn leads to a higher level of commitment. This becomes a virtuous circle in terms of the retention of high performing and empowered nurses and successful nurse managers.

The main objective of this study was to test a conceptual framework, relating leadership styles of managers to nurses’ perception of empowerment and their level of commitment. The results of this study show that the nurses surveyed report a lower level of AC relative to NC and CC, suggesting that these nurses do not feel a strong sense of belonging or attachment to their organization. Leadership styles and psychological empowerment significantly affect commitment levels. Other factors being equal, the Transformational, Transactional and Laissez-faire styles positively affect commitment levels, with the Transformational style having a marginal effect. Similarly, the results reveal that autonomy is the only component of the psychological empowerment construct that significantly affects commitment levels. Finally, the results reveal that Arab national and North American nurses report lower commitment levels in relation to nurses of other nationalities.

Overall the findings suggest that nursing leaders in hospital acute settings can enhance the nursing work environment by practicing appropriate leadership styles and empowering strategies, including greater participation of nursing staff in the decision making process. Ultimately, more effective nursing management should result in improved nursing staff retention, job satisfaction, and work commitment.

AC, Affective Commitment; ALOS, Average Length of Hospital Stays; CC, Continuance Commitment; CR, Contingent Reward; IAII, Idealized Influence Attributed; IBII, Idealized Influence Behavior; IC, Individualized Consideration; IM, Inspirational Motivation; IS, Intellectual Stimulations; LFL, Laissez-Faire Leadership; MBEA, Management-By-Exception-Active; MBEP, Management-By-Exception-Passive; MLQ, Multifactor Leadership Questionnaire; NC, Normative Commitment; NGAH, National Guard Health Affairs; OC, Organizational Commitment; TAL, Transactional Leadership; TFL, Transformational Leadership