1. Introduction

Since the concept of leadership appeared in the literature early in the 19^th century, the concept of leadership has been attributed to quality management, research, and education ^[1]. The main theme is about how effective leadership styles may improve quality of health care outcomes. Effective leadership comprises enabling ordinary people to produce extraordinary performance in face of challenge and change, and maintenance of constant performance and benefits ^[2]. Furthermore, leadership in healthcare organizations is considered an important element for assuring quality health care services, patient satisfaction, and financial performance ^{[3, 4]}. Cummings et al. ^[5] maintained that that leadership practices in health organizations influence work environments, productivity and organization effectiveness.

Recently, there has been growing knowledge identifying practices related to leadership and management that associate with better patient's outcome ^[6]. The increased demands on health care services required that nurses’ leaders produce high quality performance with fewer available resources ^[7]. In response to these demands, nurse leaders need to recognize the leadership styles that help them to overcome the socioeconomic constrain to provide a cost-effective quality of nursing care. This contributes to change the assumed roles of nurse leaders in global health systems ^[8]. Jooste ^[9] asserts that the role of nurse leader is no more limited to control, and rather to act as visionary person who assist, organize, and lead employees' activities. However, nurses also need to adopt an accurate perception of the leaders’ roles. The misperception may create unpleasant working environment producing low quality nursing care ^[10]. In previous studies, Manfredi ^[7] reported that nurses perceived their leaders’ duties to include challenging, inspiring, and motivating staff to higher levels of achievement, while, Hamdan-Mansour and Dawani ^[10] found that nurses perceived their leaders as dishonest, not supportive, and manipulators. Nevertheless, the literature agrees that positive leadership characteristics among nurse leaders were associated with increased patient satisfaction, high patient safety measure, reduced adverse events and complications, decrease nurses turnover, and high level of nurses' satisfaction ^{[11, 12, 13]}.

With increased patient health needs’ demands and advancement in health care delivery system, there is a need to explore more about nurses’ perception of their leaders. However, the world is witnessing shortage of nursing workforce that contributes to shortage in nurses’ leaders producing low quality nursing leadership ^[14]. The literature provided a solid understanding for the importance and need for nurse leaders. However, nurses need to define and identify the effective leadership characteristics to be able to join and practice leadership appropriately. This may include understanding the nurses’ perception of the leadership characteristics and factors associated with this perception. Particularly in Saudi Arabia, no previous study discussed leadership characteristics among the nurses. Therefore, the purpose of this study was to identify nurses’ perception of leadership styles and factors that affect nursing care in Saudi Arabia. Research questions were:

•  To identify nurses’ perception of leadership styles in health care delivery system in Saudi Arabia

•  To examine differences in nurses’ perception of leadership styles related to their sociodemographic characteristics.

2. Methods

A cross sectional descriptive -correlational design utilized to collect data from nurses’ from two large, government-owned, tertiary hospital in Riyadh, Saudi Arabia during the 3^rd quarter of 2013. Data were collected with regard to nurses’ perception of leadership characteristics.

A convenience sample of 272 registered nurses represented the sample of this study. About 400 nurses approached and 272 agreed to participate in the study with an agreement rate of 70%. Data collection took place at two regional hospitals in Riyadh, Saudi Arabia. The hospital is considered a referral, tertiary, education and multi-specialty hospital with bed strength of more than 700 beds. Inclusion criteria includes: 1) working as registered nurses, 2) has at least 6 months of experience at the current institution that will allow nurse to pass orientation program and be familiar with rule and polices at the hospitals. Exclusion criteria include nurses who have or had managerial position.

Prior to data collection, the principal investigator obtained ethical approval from ethical research committee at King Saud University and the targeted institutions. Head of units served as liaisons to approach nurses. A co-investigator was available during distributing and receiving the packages, so the nurses returned them directly to the co-investigator. Only those who express interest in participation were asked to fill out the questionnaires. The package was introduced in both Arabic (for native Arabic nurses) and English language (for non-Arabic speaking nurses).

The package had a cover letter that includes information about the purpose of the study, what is expected from them, where to return the packages, and that the study is anonymous. In addition, the package includes a cover letter that includes the contact information of the principal investigator and co-investigators for any further information and for answering the questions related to the study. The cover letter included a statement informing nurses that returning the questionnaire will be considered an approval to participate in the study. At the end of the cover letter, there was a statement included that their participation in the study is voluntarily and that their decision is of their own choice without any direct or indirect influence.

The data were collected using an in both Arabic (for native Arabic nurses) and English language (for non-Arabic speaking nurses) format of the survey. Regarding the Arabic version, and after obtaining approval from the author to use the scale, a translation and validation back- translation carried out by linguistic professionals. Pilot testing of the instrument carried out (n = 20) also to check for understanding, clarity and time required for filling the questionnaires following guidelines described by Brislin ^[15]. In addition, an author-develop profile was used to obtain demographic and personal information from nurses.

The instrument is:

The Multifactor Leadership Questionnaire Rater Form (5x-Short) ^[16] was used to collect data regarding perception of leadership characteristics. The scale is originally developed to describe followers' perception of their supervisors' leadership. The scale is formed of 80 items with reposes ranged from 0 (not at all) to 4 (frequently, if not always). The Scale was scored by adding all factors to get a transformational, transactional, and ‘Laissez-Faire’ score for each participant. The scale has good reliability with coefficients ranged from .73 to .94 ^[16]. In this study Cronbach alpha was .78.

Potential covariates include gender, age, level of education, length of work in the nursing profession, previous working experience, and managerial levels.

The Statistical Package for Social Science (SPSS 18) software (IBM, Chicago, IL, USA) was considered as suitable software for data entry, storage and analysis. Descriptive statistical analysis such as frequency count, percentage, mean, median and standard deviation was employed to describe the research sample. The Pearson product moment correlation coefficient was used to describe the association between variables. T-test for two independent samples (or ANOVA as appropriate) was used to compare means. Statistical significance was set at p > 0.05.

3. Results

The analysis showed that 83.5% (n=227) were females; 42.3% (n=115) were at age 31-40 years, 54.1% (n=147) worked as a nurse for less than 10 years while 46.0% (n=125) worked as a nurse for more than 10 years. The nurses were assigned in various service units: 30.5% (n=83) were at medical/surgical unit, 31.6% (n=86) were at the oncology unit, 18.8% (n=51) were at critical care units and 19.1% (n=52) were on other units.

As shown in Table 1, the analysis showed that nurses’ perception of their supervisor in according to the three leadership styles was as follow: supervisors fairly used transformational leadership style (M = 2.78, SD = .78), while they have used transactional leadership style sometimes (M=2.36, SD = .63), and Laissez-Faire leadership style was used once in a while (M=1.51, SD = 1.19). Moreover, the analysis showed nurses indicates that their supervisors had fairly used all domains of transformational leadership style (M = 2.69-2.99), while domains of transactional leadership style in a variable way ranging from fairly to sometimes (M = 1.80-2.88). Supervisors had sometimes used active and passive management by exception style, while they have sometimes used contingent reward style. The results infers that nurses had a perception that their supervisors are sing transformation and transactional leader styles more often than using more laissez-faire leadership style. Nevertheless, nurses still have low scores of perception for the frequency of using theses styles are most of the mean scores of domains in the leadership styles ranging from sometimes to fairly often.

Table 1. Descriptive statistics on perceived leadership styles, factors, and outcomes (N=272)

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Regarding leadership outcomes, nurses reported that outcomes of their supervisors’ leadership styles are fair. The analysis (see Table 1) showed that nurses had fair perception in regards to extra efforts (M = 2.69, SD = .97), effectiveness (M = 2.92, SD = .91), AND satisfaction (M = 2.99, SD = .97). The results indicate that nurses had fair perception of the expected outcomes of their supervisors’ leadership styles which is consistent with their perception to their perception of their supervisors’ leadership styles.

Using Pearson correlation coefficient (r) to examine correlation between leadership styles and outcome factors, the analysis showed that there was positive and highly significant correlation between outcome factors (effectiveness, extra efforts and satisfaction) and transformational (r = .77, .74, .74; p < .001) and transactional leadership styles (.39, .42, .34; p < .001) and negative significant correlation with laissez-faire leadership style (-.25, -.13, -.29, p < .05). Notably, the correlation magnitudes between outcome factors and laissez-faire leadership style were low, while the magnitudes with transactional styles were fair compared to magnitudes of correlation with transformational styles that was high. The analysis indicate that nurses perceived that transformational leadership styles of supervisors are associated with more positive outcome, while laissez-faire leadership style were the lowest.

Regarding differences in perceived leadership styles related to sociodemographic characteristics, and using t-test for two independent sample, the analysis (see Table 2) showed that there were significant differences between male and female nurses in regards to using transactional leadership style (t = 2.74, p < .001) and laissez-faire leadership style (t = 3.35, p < .001) with male nurses mean score higher than female nurses mean score in both styles (transactional style: male = 2.60, female 2.31; laissez-faire leadership style: male = 2.04, female = 1.41). The analysis also showed that the females and males were different in passive management by exception style (t = 3.43, p < .001) domain of transactional leadership style with males mean score (2.29) higher than females nurses one (1.70). However, there were no significant differences between males and female in regards to transformational leadership and its domains and outcomes factors (p > .05).

Table 2. Differences in perceived leadership styles, factors, and outcomes according to gender

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Regarding age differences related to age, the analysis showed that the only significant difference was found in using laissez-faire leadership style (F_{272, 3} = 2.75, p = .043). Using post hoc comparison (Tukey HSD), analysis showed that nurses at age 20-30 years old had lower mean score of laissez-faire leadership style (1.26) that all other age groups. The results indicate that young nurses are more apt to use laissez-faire leadership style than older nurses.

Regarding differences related to nurses’ educational level and length of work in nursing, the analysis showed that there were no significant differences between nurses’ perceptions of leadership styles, factors, and outcomes.

Table 3. Differences in perceived leadership styles, factors, and outcomes according to Assigned Unit (N = 272)

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Regarding differences related to nurses’ assigned unit, the analysis (see Table 3) showed that there were significant differences in transformation leadership style (F_{272, 3} = 2.70, p = .047), transactional leadership style (F_{272, 3} = 6.66, p < .001), laissez-faire leadership style (F_{272, 3} = 8.29, p < .001), and perception of effectiveness (F_{272, 3} = 3.50, p = .016). post hoc comparison (using Tukey HSD), analysis showed that nurses working in medical-surgical units have almost lower perception of all leadership styles and outcome factors than nurses working in oncology, critical care, and other units at the hospitals.

4. Discussion

Leadership is an important component that assures organizational quality health care services, patient satisfaction, and financial performance ^[17]. Moreover, nurses’ perception of their supervisors’ leadership styles may influence nurses’ quality of care and their ability to manage patients’ health needs appropriately ^[10]. Therefore, this study is the first to address this issue and explore outcome factors among nurse working in Saudi health care services. The results suggest that leadership styles, behaviors, and outcomes described by full range leadership theory ^[18] were demonstrated by the nurse supervisors in the targeted institutions. However, nurses had fair level of perception that their supervisors are able to use transformation leadership style and transactional leadership style, and almost low perception in using laissez-faire leadership style. The results demonstrate that staff nurses perceive that transformational leadership and its factors are utilized more often than transactional and laissez-faire leadership styles. Furthermore, analysis showed that there was positive correlation between outcome factors (effectiveness, extra efforts and satisfaction) and transformational and transactional leadership styles and negative correlation with laissez-faire leadership style. Although cause and effect was not measured, a combination of transformational leadership styles and behaviors/factors contributed to an increase in extra effort, satisfaction, and perceived leader effectiveness among nurses. The results support previous studies ^{[5, 19, 20]} that transformational leadership styles enhanced satisfaction, effectiveness, and improved extra effort from staff. However, Cummings et al. ^[5] reported that transactional leader behaviors resulted in reduced satisfaction and effectiveness and productivity among nurses that counteract the results in this study. Although this study found significant association between nurses’ satisfaction and effectiveness and transactional leadership style, the magnitudes of correlation were low indicating poor association. The results are not causative and non-indicative which might explain the inconsistency with previous international reports. Moreover, Cummings et al. ^[5] had also report that laissez-faire leadership was associated with lower levels of nurse job satisfaction and effectiveness which corresponds with reports in this study.

Regarding sociodemographic characteristics of nurses and leadership styles, this study found that there were differences related to gender and that male nurses had higher mean score than females in all leadership styles. Male nurses perceived their supervisors to focus on the fulfillment of contractual obligations that include setting objectives, monitoring, and controlling outcomes (TSL) more than female nurses. Males were also more likely than females to report that their supervisors intervene only after noncompliance or mistakes occur (MBEP) and avoid making decisions, abdicate responsibility, and do not use their authority (LFL). These differences support earlier studies ^{[21, 22]} that there are gender differences in perception of leadership behaviors, and that leadership behaviors were mixed based on gender ^[23]. One possible explanation for gender differences in leadership perception in this study is related to leadership behaviors in the institutions. Leader seems to empower nurses and support them to make their own decisions which may positively affected their nurse perception of leadership.

One significant finding in this study is differences in nurses’ perception related to their working area. Staff nurses in the medical/surgical unit had higher perception that their supervisors are using transaction and transformational leadership style more than nurses in oncology and critical care units. The results support previous findings that leadership styles may depend on nature of working setting of nurses ^{[23, 24]}. The results infer that nurse supervisors practice leadership in a various forms depending on the type and requirement of nursing care provided at the unit. In this study, nurse supervisors in critical care units and special care units (e.g., oncology) were more apt to use transactional leadership style, while general care units (e.g., medical surgical unit) are more likely using transformation leadership style.

One limitation of this study is that this study used s structured format of data while using triangulated data collection might allow better understanding.

5. Conclusion

The findings in this study contribute to the body of knowledge on leadership. The similarities and differences in the findings of the current study support earlier research suggesting there is no most effective leadership style. The study supports the notion that leadership styles can be combined to produce extra effort from followers as well as leadership effectiveness and satisfaction. Effective and balanced use of various leadership styles and behaviors require knowledge, skills, and commitment from both supervisors and nurses. A collaborative approach is needed to employ the most effective leadership styles in a situation to achieve the desired outcome. Further studies are recommended to determine best matches of leadership styles and behaviors between leaders and followers.

Acknowledgments

The authors extend their appreciation to the College of Nursing Research Center and the Deanship of Scientific Research at King Saud University for funding this research.

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