Abstract

Background: Servant leadership is a powerful tool for nurse leaders to empower nurses to practice well in a constantly changing environment of care. The study aimed to assess the relation between first-line managers' servant leadership behaviour and staff nurses’ empowerment at Benha University hospital, Materials and Methods: A descriptive correlational research design was utilized. The study was conducted in randomly selected units at Benha University Hospital (no=9 units). The subject of the present study consisted of two groups; first-line managers (n=30) and a convenient sample of staff nurses (n=60) at the selected study units. Two tools were utilized including; Servant leadership questionnaire and Staff nurses’ empowerment questionnaire. Results: a high percentage of first-line managers and nearly two-thirds of staff nurses reported that first-line managers were highly adopting servant leadership behaviour. However, there were statistically significant differences between first-line managers' self-report and staff nurses' reports. Nearly half of staff nurses reported a high level of empowerment, while nearly one-third of them reported a moderate level of empowerment. Conclusion and implication: There was a significant positive relation between first-line managers’ adopted servant leadership behaviour and staff nurses’ level of empowerment. Therefore, nurse managers can benefit from integrating the principles of servant leadership and be enthusiastic in focusing on servant leadership attributes when leading their followers by considering them as valuable assets to the organization and thus empower them structurally and psychologically. Recommendation: Continued training on servant leadership characteristics and values through formal workshops and feedback from staff nurses on their nurse managers’ leadership behaviours through polling should be a basic competency requirement for nurse managers.

1. Introduction

Nursing leadership should emphasize a work environment that enables nurses to be positively motivated, empowered, and led through change. For this reason, nursing leaders need to move away from traditional leadership practices and behaviours ¹. New leadership models incorporate leader behaviours that include a commitment to individuals, foster psychological bonds, attend to individual needs, and provide intellectual growth opportunities ².

Based on servant leadership dimensions, the following definitions clarified the servant leadership concept as follows: Servant leadership is a nontraditional leadership style that includes behaviours related to putting the interests and needs of others over self-interest and valuing others. Servant leadership symbolizes a set of practices that boosts the lives of individuals, promote organizational development, and ultimately creates a more just and caring work environment. Servant leadership is clarified as a caring leadership that helps to build trust because followers believe that their leader cares about their welfare resulting in psychological safety and building healthy work environments that attract and retain staff ^{3, 4, 5}.

Traditional leadership- unlike servant leadership- based mainly on exercising of power by those at the top of the pyramid while servant-leaders share power, puts the needs of others first and helps people develop and perform ⁶.

According to ⁷, there are four basic elements included in servant leadership (1) Service: Servant-leaders put service before leadership because they focus on the needs of others. (2) Collaborative Authority: Servant-leaders make the final decisions, but only after considering what others want and what is best for them. (3) Mentoring: Servant-leaders provide their followers with a wide range of experiences and training, mentor employees rather than controlling them, and allow others the authority to make decisions as soon as possible. (4) Foresight: is a characteristic that enables the servant leader to understand the lessons from the past, the realities of the present, and the likely consequences of a decision for the future.

Staff nurses could be structurally empowered based on four conditions at the workplace which identified by ⁸ including; having the opportunity for advancement activities beyond one’s job description; access to information about all facets of the organization; support for one’s job responsibilities and decision-making; and access to resources as needed by the nurses to complete their tasks.

Psychological empowerment of staff nurses has four dimensions namely: meaning, competence, self-determination, and impact. Meaning mirrors congruence between staff nurse’s beliefs, values, behaviours, and job requirements. Competence: refers to having the necessary knowledge, skills, and abilities to perform the job. Self-determination illustrates feelings of control that are exerted over one’s work and individuals’ sense of having choices of initiating and controlling regulating actions. Impact indicates a sense of being able to influence the strategic, administrative, and operating outcome of the organization. Therefore, a positive effect among nurses toward their organizations positively affects job satisfaction and performance, increases the meaning and fulfillment of work, promotes the ability to self-determination, and builds competence ^{9, 10}.

Servant leadership is perceived by ¹¹ as a model that promotes empowerment, personal growth, teamwork values, quality services, and exemplifies caring and ethical behaviour. Empowerment has been called the central element in excellent leadership, especially servant leadership.

For first-line managers as a servant-leader, empowerment is entrusting power to others, involving effective listening, making people feel significant, putting emphasis on teamwork, and valuing love and equality. Empowering is imparting meaning, attending to followers’ needs, caring for them, and expressing appreciation for servant behaviours. ¹².

Creating an empowering work environment for staff nurses requires the nursing leadership to shift to a nontraditional leadership style that is based on sharing power sources with followers. Servant leadership may be the preferable paradigm for the health care organizations as servant leaders equip their followers with the necessary resources to make changes and impacting outcomes in the organization ¹³. Actually, from the researchers’ observation through clinical training in the study setting, first-line managers behave like a servant with their staff in different situations because of the virtue relationship that connects them. However, they didn’t realize that behavior as being servant leaders or its positive impact on their staff. Consequently, the present study was conducted to assess the relation between adopting servant leadership behaviour and the level of empowerment of nurses.

The study aimed to assess the relation between first-line managers' servant leadership behaviour and staff nurses' empowerment at Benha University Hospital.

The research questions for this study were:

Q1. To what extent do first-line managers adopt servant leadership behaviour from their perspectives?

Q2. To what extent do first-line managers adopt servant leadership behaviour from staff nurses’ perspectives?

Q3. Is there a difference between the first-line managers' self-report and staff nurses’ report regarding the adoption of servant leadership?

Q4. What is the level of staff nurses’ empowerment as reported by them?

Q5. Is there a relation between adopted servant leadership behaviour and the level of staff nurses’ empowerment?

Servant Leadership Theory by ¹⁴ provided the framework for the current study for two reasons: First: - Greenleaf introduced servant leadership on the foundation of social exchange theory by proposing that relationship exists between followers and their leader where employees search for positive benefits associated with leaders’ behaviours, and as a result, respond positively. Thus, explaining the nature of the relationship between servant leadership behaviour and nurses’ empowerment. Followers are more empowered when the behaviours of the leader are conducive to building a mutually beneficial and trusting relationship ¹⁵.

Second: In follow-up research of servant leadership theory by ¹⁶, the researchers reported on seven dimensions for servant leadership included; emotional healing, creating value for the community, helping subordinates grow, conceptual skills, putting subordinates first, behaving ethically, and empowering others.

These dimensions highlighted the broad lines of servant leadership behaviour, and adopted in the current study as the measuring tool for servant leadership characteristics.

Based on the servant leadership theory and follow up research of servant leadership, the following conceptual framework for the current study can be developed: -

2. Material and Methods

Descriptive, Correlational research design was utilized.

The study was conducted in randomly selected units of medical and surgical departments at Benha University Hospital [No =9 units].

The subjects composed of two groups, all first-line managers (n=30) as follows: (17) of them working in medical units, (13) of them working in surgical units., and a convenient sample of staff nurses in the above-mentioned study units (n=60).

Inclusion criteria for staff nurses: staff nurses included in the study have at least two years of experience, available at the time of the study, and agreed to participate after clarification of the purpose of the study.

First Tool: Servant leadership questionnaire:

The questionnaire adopted from Liden et al., (2008) ¹⁷ to measure servant leadership characteristics adopted by first-line managers. The questionnaire included seven-dimensions covering (28) items; emotional healing, creating value for the community, helping subordinates grow, conceptual skills, putting subordinates first, behaving ethically, and empowering others as follows:

Ÿ Servant-leader behaviour (Self-Report) by first-line managers

Ÿ Servant-Leader Behaviour (Nurses' Rater) by staff nurses.

Scoring system of the first tool

Three-point Likert scale (1) Disagree, (2) Neutral, (3) Agree was used to rate first-line managers’ and staff nurses’ responses. The total score ranged from 28 to 84. These scores were converted into a percent score. Scoring was calculated as follows:

Ÿ Poorly adopting behaviour representing (<33%),

Ÿ Moderately adopting behaviour ranged from (33% - < 67%), and

Ÿ Highly adopting behaviour representing (≥ 67%).

Second Tool: Staff nurses empowerment questionnaire:

Tools for measuring nurses’ empowerment included; structural empowerment settled by Laschinger et al., (2001) ¹⁸ and Psychological Empowerment Inventory (PEI), developed by (Spreitzer, 1995) ⁹. The researcher integrated two tools in one questionnaire aimed to assess to what extent staff nurses are empowered by their first-line managers in their work area.

The newly developed questionnaire composed of two parts as follows:

Part (1): Structural empowerment organized into five dimensions; access to information, access to support, access to resources, providing opportunity, and Work environment which included (32) items.

Part (2): Psychological Empowerment Inventory incorporated four dimensions; self-determination, meaning, competence, and impact, which included (9) items.

Scoring system of tool 2:

Three-point Likert Scale; (1) Disagree, (2) Neutral, (3) Agree was used to rate staff nurses’ responses. The total score ranged from (41to 123). These scores were converted into a percent score. Scoring was calculated as follows:

Ÿ Low empowered representing (<33%),

Ÿ Moderately empowered ranged from (33% - <67%), and

Ÿ High empowered ranged from (≥ 67%).

Tools validity:

The data collection tools were translated into Arabic to fit the study subjects and tested for its content validity by a jury of 3 psychiatric nursing experts and 3 nursing administrative experts to check the relevance, completeness, coverage of the content, and clarity of the items.

Pilot study

Before actual data collection, a pilot study was conducted by the researcher via distributing questionnaire sheets on 10% of study subjects from different units to ascertain clarity and applicability of the study’s tools, as well as define obstacles that may be encountered during data collection.

Tools reliability:

Servant leadership and Empowerment questionnaires’ reliability was evaluated through test-retest reliability to be (α = 0.89) and (α = 0.79) receptively.

Ÿ Actual data collection was conducted from 17^th of November 2018 until the 28^th of February 2019.

Ÿ Servant leadership questionnaire was distributed among first-line managers in the morning shift to determine their leadership behaviours with followers (self-report). The time required to fill the sheets was extended from 10 to 15 minutes.

Ÿ The servant leadership questionnaire was rephrased and translated into Arabic, then distributed among staff nurses to determine the leadership behaviours from their perspectives (staff rating).

Ÿ The empowerment questionnaire was also translated into Arabic then distributed among nurses. The collection of data from staff nurses was carried out in morning and afternoon shifts but was more suitable in the afternoon shifts when the workload became less.

A letter of approval was obtained from the director of Benha university hospital where the study was conducted. The participants were asked for approval for their participation. The researchers explained to the participants that their willingness to participate in this study is optional and they can withdraw from the study at any time. In addition, it was explained to the research subjects that anonymity and confidentiality would be guaranteed, so the questionnaire sheets were coded.

The data was refined by the researcher for any continual or lost responses, then coded, analyzed, and tabulated. The researcher utilized Statistical Packages for the Social Sciences (SPSS), Version 20.0 for Windows, and Microsoft Excel Spreadsheet Package (Office 2010) for result analysis of the study. Data were expressed as number and percentage (No. & %), mean and standard deviation and analyzed by applying the chi-square test. Tests of significance at P<0.05 and Pearson correlation was employed in the current study.

3. Results

Table 1 shows the personal data of studied staff nurses, it was clear from the table that the highest percent (63.3%) of the nurses were the age group 31-40 years old with Mean ±SD (30.7±3.40), (63.4%) of them had technical nursing institute qualification and (76.7%) of them had 5-10 years of experience.

Table 2 displays the personal data of studied first-line managers, as indicated from the table, the highest percent (63.3%) of the subjects were the age group 41-60 years old with Mean ±SD (30.7±3.40) , (46.7%) had bachelor nursing degree qualification, (43.3%) had 5-10 years of experience with Mean ±SD (10.03±3.57), and the highest percentage (73.3%) did not attend previous workshops about leadership.

Table 3 presents the degree of the adoption of the servant leadership behaviour as reported by first-line managers and staff nurses. As indicated in the table, first-line managers and staff nurses had high mean and standard deviation scores (77.7±5.23) and (71.1±13.04) receptively regarding the adoption of servant leadership behaviour, However, there was a statistically significant difference (p= 0.001) between first-line managers' self-report and staff nurses' report.

Figure 1 illustrates the level of adoption of the servant leadership behaviour as reported by first-line managers and staff nurses. As presented in the figure, a high percentage of first-line managers (93.3%) and nearly two-thirds of staff nurses (65.0%) reported that first-line managers were highly adopting servant leadership behaviour.

Figure 2 shows total levels of empowerment among studied staff nurses. As indicated in the figure, nearly half of staff nurses (45.0%) reported a high level of empowerment, while nearly one-third (35.0%) of them reported a moderate level of empowerment.

Table 4 illustrates correlation between total empowerment and adopted leadership behaviours as reported by staff nurses and first-line managers. As shown in the table, there was a non-significant positive correlation between adopted servant leadership behaviour as reported by staff nurses and their level of empowerment (R=0.149). However, there was a significant positive correlation between adopted servant leadership behaviour as reported by first-line managers and the level of empowerment of staff nurses (R=0.462*).

Table 5 displays the relation between adopted servant leadership behaviours of first-line managers and total empowerment of staff nurses. As shown in the table, there was a significant positive correlation (R= 0.52) between adopted servant leadership behaviour by first-line managers and the level of empowerment of staff nurses.

4. Discussion

Nurse leaders adopt servant leadership behaviour as a powerful tool to empower nurses to practice well and at the best in a constantly changing environment of care, success in a growing nursing shortage, and go well through the Magnet journey ¹⁹.

With regard to the first and second study questions, the results of the current study revealed that a high percentage of first-line managers and nearly two-thirds of staff nurses reported that first-line managers were highly adopting servant leadership behaviour. This result was in agreement with the results by ²⁰ who indicated that supervisor behaviour ranged between sometimes behaving as a servant leader role to behaving this way often. Additionally, results from a descriptive study by ²¹ revealed that nurse leaders were perceived by direct reports as displaying significant characteristics of servant leadership. Moreover, the results by ²² revealed that staff nurses perceived the servant leadership of their first-line managers at a high level.

These findings might be accounted for, those first-line managers who had been reported as adopting high servant leadership behaviour either by themselves or by their staff nurses, were well known to their staff nurses and had good relationships with them as they focus on-staff nurses and encourage their development with moral characteristics. They had good management skills including fair distribution of nurses according to unit needs, always helping subordinates to go through difficulties such as patient management and individual matters properly managing arising conflicts and handling situations. Lastly, those first-line managers were able to delegate responsibilities and assure the availability of necessary supplies and equipment.

In contrast to the current findings, the study conducted by ²³ concluded that staff nurses believed that their superiors utilizing a transformational leadership style which is ranked as the first leadership style and followed by transactional leadership.

By referring to the third study question concerning the difference between the first-line managers' self-report and staff nurses’ report regarding the adoption of servant leadership, the current study revealed that there were statistically significant differences between first-line managers' self-report and staff nurses' reports. Although there was a significant difference, first-line managers in the current study, based upon scoring interpretation, were perceived as servant-leaders.

The current result was in the same line with ²⁴ who revealed that self-ratings of personal leadership behaviours differ from the staff’s assessment of leadership behaviours, seventy-three percent of leaders who self-rated their leadership behaviours as high experienced an elevated discrepancy between their self-ratings and staff ratings, suggesting that supervisors overestimated themselves. That result might be explained by a lack of self-awareness elements in nursing leadership in which nurse leaders might not be able to rank their behaviours accordingly or even wanted to rate themselves as idealized leaders however that match their actual behaviour or not.

In addition to, the study by ²⁵ on nursing management leadership styles, who observed that subordinates disagreed almost totally with their managers’ opinion about their managerial leadership style and the study by ²⁶ who reported that the leaders tended to rate themselves higher in the domain of transformational leadership, while registered nurses gave their nurse leaders significantly lower scores.

On the contrary to the previous result, the findings by ²³ revealed that there were similar perceptions of the leadership styles of nurse managers between first-line manager respondents and staff nurse respondents. Therefore, there were no significant differences between nurse managers’ perceptions themselves and the perception of the nurses on the nurse managers’ leadership styles. Additionally, the results by ²⁷ indicated no significant differences between nurse leaders’ self-evaluation and their staff evaluations regarding servant leadership behaviours.

With reference to the fourth study question, the results of the current study revealed that nearly half of staff nurses reported high levels of empowerment, while nearly one-third of them reported moderate levels of empowerment. This result is in an agreement with the study conducted by ²⁸ where staff nurses reported experiencing structural empowerment and they were willing to be involved in decision-making processes primarily about patient care within the context of their practice unit; it could be due to a higher authority delegated to nurses. Additionally, the results by ²⁹ reported that the nurses were more empowered and committed to their organization. Moreover, the study by ³⁰ indicated that nurses experienced high psychological empowerment.

The current study, staff nurses reported that they were highly empowered might be the outcome of being responsive to leaders who delegate authority, ask for input, promote the flexibility of decision-making, enable nurses to produce fresh ideas and think of innovative ways of doing things to support others in the field of work.

In contrast, the results of ³¹ who reported that nurses participated in the study were moderately empowered and that their access to opportunity, support, resources, and information was low. Furthermore, the findings in that study revealed that the levels of the four dimensions of psychological empowerment (meaning, competence, self-determination, and impact) were low and nurses perceived their work environment as not empowering. Additionally, ³² who showed that the nurses had a below moderate score in their perception of job empowerment.

Lastly, on the fifth study question about the relation between adopted servant leadership behaviour and the level of staff nurses’ empowerment, as indicated from the current study, there was non-significant a positive correlation between adopted servant leadership behaviour as reported by staff nurses and their level of empowerment. However, there was a significant positive correlation between adopted servant leadership behaviour as reported by first-line managers and the level of empowerment of staff nurses which was parallel to the results by ³³ who reported that employees are more likely to see the organization as one that embraces servant leadership when they perceive that their supervisors are committed to service, empowerment, and a shared vision.

Moreover, the results of the current study revealed that there was a significant positive relationship between adopted servant leadership behaviour by first-line managers and the level of empowerment of staff nurses. That agreed with the results from ²⁷ that indicated that there was a relationship between the nurse leaders that exhibit servant leadership behaviour and followers’ feelings of empowerment.

Additionally, in supporting the previous findings, the implication of the study by ³⁴ indicated that there was a strong association between overall empowerment in organizations with the servant leader behaviours displayed by their immediate supervisors, particularly in the areas of access to information, support, resources, and formal power. Thus, perceptions of empowerment may be promoted by encouraging servant leadership behaviours through coaching, training, and learning activities on these behaviours.

In the same context, ³⁵ found nurse managers who demonstrate servant leadership behaviours help followers achieve their potential by increasing individual self-confidence, creating an environment of trust, communicating necessary information, providing constructive feedback, and allocating crucial resources.

¹⁹ revealed positive linkages between servant leadership and workplace attitudes which influence intent to stay (i.e., job satisfaction and empowerment). Additionally, ³⁶ conducted a study on servant leadership, organizational trust, and empowerment in Iranian public organizations and revealed a strong relationship between servant leadership, organizational trust, and empowerment.

Accordingly, ¹⁹ found that servant leadership inspired followers to become more committed, develop trusting relationships, embrace learning, and seek work fulfillment. Moreover, ³⁷ concluded that servant leadership extends the potential for people to learn, grow, and share in power by promoting the realization of the internal and external environments.

On the contrary to the current findings, the study by ³⁸ reported that nurses who perceived their nurse managers as demonstrating transformational leadership behaviours experienced higher structural empowerment.

5. Conclusion and Implications

In the conclusion of the current study, first-line managers were adopting servant leadership behaviour as reported by them and their staff nurses, However, there were statistically significant differences between first-line managers' self-report and staff nurses' report. Nearly half of staff nurses reported high levels of empowerment, while nearly one-third of them reported moderate levels of empowerment. Additionally, there was a significant positive relation between adopted servant leadership behaviour and staff nurses’ level of empowerment. Lastly, the findings of the current study shed the light that servant leadership is followers-centered with leaders who uphold a high level of empowerment. Therefore, nurse managers can benefit from integrating the principles of servant leadership and be enthusiastic in focusing on servant leadership attributes when leading their followers by considering them as valuable assets to the organization thus empower them structurally and psychologically. When staff nurses are empowered, they can realize their self-worth, believe in their skills, show confidence, and impact their work outcomes effectively.

6. Recommendations

The current study findings recommended that:

Ÿ Incorporation of servant leadership style in undergraduate nursing administration curriculum as a means to increase awareness of nursing students to such a nontraditional leadership style and its favorable outcomes and prepare them as future leaders.

Ÿ Continued training on servant leadership characteristics and values through formal workshops and feedback from staff nurses on their nurse managers’ leadership behaviours through polling should be a basic competency requirement for nurse managers.

Ÿ Further research is required to investigate the relationship between the impact of servant leadership and stakeholders they serve or patients.

Ÿ Development of a Self-Other assessment tool that each of the rating sources (self and others) provided separately to produce accurate assessment especially in studies that require rating certain behavior or characteristics.

Conflict of interest

The author declared there was no conflict of interest

Acknowledgments

The authors’ thanks are submitted first and foremost to ALLAH who gave the strength and the ability to complete this work. The authors would like to thank the study subjects for their willingness to participate in the study.

References