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LEADERSHIP STYLE OF CHIEF NURSE EXECUTIVES IN MAGNET STATUS
HOSPITALS
by
Mary Davis
A Dissertation Presented in Partial Fulfillment
of the Requirements for the Degree
DOCTOR OF MANAGEMENT IN ORGANIZATIONAL LEADERSHIP
UNIVERSITY OF PHOENIX
JULY 2007
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3337522
3337522
2007
Copyright 2007by
Davis, Mary
All rights reserved
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ii
2007
ALL RIGHTS RESERVED
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LEADERSHIP STYLE OF CHIEF NUR SE EXECUTIVES IN MAGNET STATUS
HOSPITALS
by
ary
E
H
Davis
May
2 7
Approved:
Mentor
Committee Member
Committee Member
Dawn Iwamoto EdD
Dean School of Advanced Studies
University of Phoenix
Month Day
ye
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ABSTRACT
The purpose of this quantitative descriptive correlational study was to investigate a
correlation between leadership style and outcomes of chief nurse executives in Magnet
Status hospitals in the United States and explore if there was a dominant leadership style
being used by the chef nurse executives. The research questions guiding the study were 1.
What is the relationship between the chief nurse executives leadership style and extra
effort, 2. What is the relationship between the chief nurse executives leadership style and
effectiveness and 3. What is the relationship between the chief nurse executives
leadership style and the nurse managers level of satisfaction with the chief nurse
executives leadership?
The MLQ-5x by Avolio and Bass (2004) was used as the survey tool to collect data from
the participants. The data was analyzed using the SPSS software to perform descriptive
and correlational analysis. The leadership style explored in the study was the
transformational, transactional and laissez-faire. Overall results from the data revealed
that there was a positively statistical significance correlation between leadership style,
extra effort, effectiveness and satisfaction. The findings also revealed a dominant
leadership style being used among participating Magnet Status Hospital within the United
States. Further studies should be initiated to investigate the leadership styles of the non-
Magnet Status hospitals and determine if there is a dominant style being used by their
chief nurse executives.
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1
DEDICATION
I dedicate this dissertation in memory of my loving husband Minister Rudolph Davis,
who supported me through most of my doctoral studies and dissertation process before
suddenly slipping away home to be with the Lord. I also dedicate this dissertation to the
memory of my parents James and Captoria Hardy-Hawkins for their love and their
encouragement to strive for the best in whatever I do. To my son Rudolph Deandr, my
daughter Annie Lee and my son-in-law Steve, and my grandson Deandr Daquan, who
looks after Grandma, thank you all for your love and support and for being there for me.
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ACKNOWLEDGMENTS
I first give honor to God for my Lord and Savior Jesus Christ, who is head of my
life. I thank Him for His word and presence at all times. I thank Him for when I look
around and see no physical being, He is there, and He sends others into our life according
to our needs.
I would like to acknowledge others the Lord placed in my life: Dr. Lloyd
Williams, my mentor, and Dr. Deborah Schaff Johnson and Dr. Rhonda Waters, my
committee members. I am eternally grateful to each of my dissertation committee
members for being there, for their support, encouragement, and guidance. I would like to
also acknowledge my University of Phoenix cohort for their friendship and support,
especially my learning team members Dr. Quelanda Clark and Dr. Alice Gobeille.
To some very special caring people God placed in my life: Dr. Ted Sun, a
wonderful person and great coach, Dr. Steve Creech, a brilliant statistician with the
patience of Job and the wisdom of Solomon; Toni Williams, a very meticulous editor;
and Dr. Denise Jenkins, the best academic counsel.
I also want to thank the Magnet Status hospital participants for taking part in this
study, for without their participation the study could not have been conducted.
Finally, I thank a very special person, my pastor and bishop, Bishop Moses
Williams, Jr., a true man of God, for his constant prayers of encouragement and support,
and the Love of God, church, and family.
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TABLE OF CONTENTS
LIST OF TABLES............................................................................................................... 7
CHAPTER 1: INTRODUCTION........................................................................................8
Background of the Problem ...............................................................................................10
Statement of the Problem...................................................................................................16
Purpose of the Study.......................................................................................................... 17
Significance of the Study to the Problem ..........................................................................18
Significance of the Study to Leadership............................................................................20
Nature of the Study............................................................................................................ 22
Research Questions............................................................................................................ 26
Hypotheses......................................................................................................................... 26
Hypothesis 1 ............................................................................................................... 27
Hypothesis 2 ............................................................................................................... 27
Hypothesis 3 ............................................................................................................... 27
Theoretical Framework...................................................................................................... 27
Transformational Leadership......................................................................................30
Transactional Leadership............................................................................................32
Laissez-faire Leadership.............................................................................................33
Multifactor Leadership Questionnaire ...............................................................................34
Definition of Terms............................................................................................................34
Assumptions....................................................................................................................... 36
Scope of Study ................................................................................................................... 37
Limitations ......................................................................................................................... 38
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Delimitations...................................................................................................................... 39
Summary............................................................................................................................ 39
CHAPTER 2: REVIEW OF THE LITERATURE............................................................41
Title Searches, Articles, Research Documents, and Journals ............................................41
General Systems Theory....................................................................................................49
Models of Patient Care.......................................................................................................57
Total Patient Care Model............................................................................................58
Functional Patient Care Model...................................................................................58
Team Nursing Model..................................................................................................59
Primary Care Model ................................................................................................... 60
Patient Satisfaction............................................................................................................. 60
Employee Job Satisfaction.................................................................................................62
Nursing Shortage ............................................................................................................... 63
Leadership Styles............................................................................................................... 66
Autocratic Leadership.................................................................................................68
Laissez-Faire Leadership............................................................................................69
Participative Leadership .............................................................................................70
Transactional Leadership............................................................................................71
Transformational Leadership......................................................................................71
Overview of Magnet Status Hospitals ...............................................................................73
Conclusion ......................................................................................................................... 75
Summary............................................................................................................................ 77
CHAPTER 3: METHOD...................................................................................................78
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Research Design................................................................................................................. 80
Appropriateness of Design.................................................................................................82
Feasibility and Appropriateness.........................................................................................83
Research Questions............................................................................................................ 84
Hypotheses......................................................................................................................... 85
Hypothesis 1 ............................................................................................................... 85
Hypothesis 2 ............................................................................................................... 85
Hypothesis 3 ............................................................................................................... 85
Data Analysis ..................................................................................................................... 85
Power Analysis .................................................................................................................. 87
Population .......................................................................................................................... 88
Sampling Frame................................................................................................................. 90
Informed Consent............................................................................................................... 91
Confidentiality ................................................................................................................... 93
Geographic Location.......................................................................................................... 93
Instrumentation .................................................................................................................. 94
Data Collection .................................................................................................................. 95
Descriptive Analysis...................................................................................................96
Correlational Analysis ................................................................................................96
Validity and Reliability......................................................................................................97
Internal Validity.......................................................................................................... 98
External Validity......................................................................................................... 99
Reliability ................................................................................................................. 100
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Summary.......................................................................................................................... 101
CHAPTER 4: RESULTS.................................................................................................103
Research Design............................................................................................................... 104
Data Analysis................................................................................................................... 104
Frequency and Hypothesis Testing..................................................................................113
Correlational Analysis ..................................................................................................... 115
Findings............................................................................................................................ 116
Summary.......................................................................................................................... 127
CHAPTER 5: CONCLUSIONS AND RECOMMENDATIONS...................................129
Limitations ....................................................................................................................... 133
Implications...................................................................................................................... 134
Recommendations............................................................................................................ 135
Summary.......................................................................................................................... 136
REFERENCES ................................................................................................................ 139
APPENDIX A: Multifactor Leadership Questionnaire 5X-Short ...................................155
APPENDIX B: Informed Consent Form .........................................................................160
APPENDIX C: Demographic Data..................................................................................162
APPENDIX D: Consent to Use Multifactor Leadership Questionnaire..........................164
APPENDIX: E MLQ Scale Scores..................................................................................165
APPENDIX F: Histograms..............................................................................................186
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LIST OF TABLES
Table 1 Summary of Literature Review by Search Topic ..................................................43
Table 2Age of Participants in the Study .........................................................................105
Table 3Marital Status .....................................................................................................106
Table 4Participants Gender..........................................................................................107
Table 5Educational Level of Participants ......................................................................107
Table 6 Years Working in Present Position .....................................................................109
Table 7Nurse-to-Patient Ratio........................................................................................110
Table 8Retention Rate.....................................................................................................110
Table 9Employee Satisfaction.........................................................................................112
Table 10Extra Effort Correlations (N = 37)...................................................................114
Table 11MLQ Statistics...................................................................................................116
Table 12 Correlation Effectiveness (N = 37)...................................................................120
Table 13 Satisfaction Correlation....................................................................................123
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CHAPTER 1: INTRODUCTION
Health care organizations continue to be challenged by nursing shortages (Coile,
2001) that are the result of nurses retiring as well as a declining interest in entering the
nursing field. The current shortage exceeds 120,000 nurses in all fields, which seriously
diminishes the quality of health care in the United States (Gelinas & Loh, 2004;
Hassmiller & Cozine, 2006; Kleinman, 2004c). Health care organizations require leaders
to improve customer satisfaction for constituents (Coile). Decreases in quality care,
employee job satisfaction, and employee morale contribute to the concerns health care
leaders, including chief nurse executives, encounter in health care in the United States
(Coile; Upenieks, 2002). Research suggests many variables contribute to the challenges
and organizational resistance faced by health care leaders, including high job turnover
and escalating health care costs (Coile; Upenieks, 2002).
Health care challenges for chief nurse executives often occur in Magnet Status
hospitals. Magnet Status hospitals are facilities that have reputations of being excellent
with low turnover rates in personnel, high job satisfaction among employees at all levels
of the organization, and leaders that work well with diverse populations (Upenieks,
2003a). The position of chief nurse executive is important to hospital organizations, as
chief nurse executives seek to lead organizations within the existing economic and
political environments to become facilities identified as excellent (Coile, 2001; Upenieks,
2002). The study assessed the possible correlation between leadership style and
leadership outcomes of chief nurse executives that achieved Magnet Status hospital
recognition. Research suggests the leadership style of the chief nurse executive influences
the culture of the organization (Gillespie & Mann, 2004). Chief nurse executives in
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health care organizations have multiple functions with limited resources and conflicting
demands for times and resources (Colvard, 2003). Additionally, chief nurse executives
are responsible for establishing performance priorities, creating work processes, and
overseeing the performance of multiple job functions (Colvard).
According to Hassmiller and Cozine (2006), hospitals have experienced shortages
of nurses in the past as well as in the present. The current nursing shortage is driven by a
decrease in the population of health care workers, a decrease in the number of individuals
entering the health care field, an aging workforce population, unsatisfying work
environments, a decrease in job satisfaction, and complex leadership styles (Hassmiller &
Cozine). It is believed that chief nurse executives implement leadership styles that
increase the overall success of quality care and have the capability to influence
employees to be more productive by recognizing the employees contribution to
organizational goals, providing a supportive work culture, and implementing a work
culture built upon teamwork and trust (Meterko, Mohr, & Young, 2004).
Changes in health care such as shifts in markets and reimbursement strategies
have caused competition among institutions. The competition has led to organizational
restructuring to increase patient satisfaction and employee satisfaction through power
sharing (Reinhardt, 2004; Taccetta-Chapnick, 1996; Trofino, 2003). Such changes
require new leaders with vision who can guide an organization through challenging times
(Reinhardt).
Health care organizations need chief nurse executives whose style of leadership
gives them the confidence to make decisions, who accept responsibility for functions
outside of their expertise, and who can rely on others to provide information and validate
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facts (Parran, 2004). As the highest level of nursing personnel within hospitals, chief
nurse executives have an obligation to ensure the effectiveness of nursing practice,
including (a) ensuring the safety of the organizations constituents with a balance
between production, efficiency, and reliability; (b) creating and sustaining a trusting
organization; (c) managing the change process; (d) involving employees in the decision-
making process and in processes pertaining to work design and work flow; and (e) using
knowledge-based management practices to establish the organization as a learning
organization (Parran).
Chapter 1 presents the specific problem and the theoretical implications of the
study, introduces previous work in the area, and outlines the design of the investigation.
Chapter 1 also outlines the research methodology chosen. The findings from the study
add to the literature and body of knowledge with some implication for leadership
practice. The focus of the study is to explore whether there is a correlation between
leadership style and leadership outcomes among chief nurse executives whose health care
facilities achieved Magnet Status hospital recognition.
Background of the Problem
Effective and efficient leadership in the field of nursing is an important factor in
the delivery of quality health care. Gelinas (2000) noted a solution to the concerns in the
nursing field is a variation of leadership styles such as transformational leadership.
Health care facilities need leaders who know how to work with diverse populations and
how to address organizational issues. Leaders, such as chief nurse executives, who
engage in positive health care practices and who demonstrate empathy for customers
could increase patient and employee satisfaction within health care organizations
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(Gelinas & Loh, 2004). This research study focuses on health care facilities that achieved
Magnet Status.
In 1982, the American Nurses Association sponsored an original hospital study
that resulted in the designation of 41 hospitals across the United States as Magnet Status
hospitals (Kramer, 1990). Magnet Status hospitals were chosen because they have been
identified by the American Nurses Credentialing Center (ANCC) as being excellent
facilities that provide quality care to patients, have a high rate of job satisfaction among
employees, and have low turnover rates in employment (Upenieks, 2003a). Turnover
rates are the percentage of employees separated from their job within 1 year of
employment. Organizations compute employee turnover rates according to the following
formula (Gillies, 1989):
___Number of terminations per year_____ x 100 = Annual turnover rateAverage number of employees for the unit
According to Gillies (1989), the annual nurse turnover rate in hospitals is 30%.
Kramer (1990) noted that when the national turnover rate of registered nurses (RNs) in
acute care hospitals was 25%, the Magnet Status hospital turnover rate ranged from 2%
to 27%, with a median turnover rate of 9%. Upenieks (2003a) identified Magnet Status
hospitals as excellent facilities and claimed the Magnet Status hospitals chief nurse
executives work well with diverse populations within and outside of their practicing
facility. According to Upenieks (2003c), the leadership styles of chief nurse executives
are of immense value in the functioning of the health care environment.
Kramer and Schmalenberg (1998a) noted some of the reasons for the nursing
shortage in the 21st century are (a) high turnover rates among nursing personnel, (b)
constant orientation of new personnel, and (c) lack of commitment and identification with
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institutional values and goals. Other factors that contribute to the shortage of nurses are
the high percentage of inexperienced staff, the large numbers of per diem nurses and
agency personnel, and a nursing staff that does not consistently work together (Kramer &
Schmalenberg, 1998a). Many hospitals hire agency nurses and travelers who work for a
limited assignment in the facility and receive pay at rates 50% to 100% higher than the
rates of hospital-owned nurses (Coile, 2001, p. 224). Hospital-owned nurses are
employed by the hospital as full-time employees (Coile). The regular use of travelers and
agency nurses is seen as a cause of low morale and job dissatisfaction among nurses
(Kramer & Schmalenberg, 1998b). One third of nurses surveyed in Armstrong (2004)
reported dissatisfaction with their workloads and with staffing issues as the determining
factors for departure from the workforce.
The nursing shortage crisis has created a culture that promotes distrust and
negative behavior among employees who are not held accountable for their work
performance (Rantz, Zazworsky, Zerull, & Cohen, 2004). Baker, Greenberg, and
Hemingway (2006) identified different work cultures within organizations. The culture of
blame was identified as a culture in which a climate of resentment or fear persisted within
the workplace and where employees were pessimistic about their future. The culture of
ambition and the culture of success were identified as the more successful cultural
models. The nurses within the cultures of ambition and success were more satisfied with
their work and felt they could achieve their personal and professional goals (Baker et al.),
which indicates that workforce culture affects employees job satisfaction.
Organizational culture is a way of thinking, believing, and behaving that
organizational members have in common (Marquis & Huston, 2003). Organizational
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culture encompasses the background of organizational behavior and sets the tone for
employee interactions. Organizations identified as having a positive culture display a
constructive interacting culture in which members interact with others and approach tasks
in a positive way that ensures their success (Marquis & Huston). Employees perception
of the organizations culture has an impact on the shortage of nursing personnel.
Nursing shortages could lead to significant problems in the provision of quality
care to patients and to an increase in medical errors (Coile, 2001). The nursing shortage
affects the public because of increased fears concerning the impact of health care on
consumer safety within health care facilities. Coile noted, The Institute of Medicine
reports that approximately 44,000 to 98,000 people die in hospitals worldwide annually
as a result of medication errors (p. 174). In 1993, medication errors in the United States
accounted for 7,391 deaths, compared to 2,876 deaths in 1983 (Stetina, Groves, &
Pafford, 2005). The delivery of medication involves multiple interactions among different
disciplines, and errors may occur at any step in the process of medication distribution,
such as prescription, transcription by the nurse or pharmacist, dispensing, or the
administration process (Stetina et al.).
Medication errors and adverse reactions associated with medications result in
longer hospital stays, higher costs of care, patient injuries, disabilities, and death
(Contino, 2004; Stetina et al., 2005). Other countries have similar concerns in the
delivery of health care. Armstrong (2004) noted approximately 4,500 patient deaths occur
in Australia each year as a result of medication errors, and the deaths could be prevented
through patient safety measures and quality health care. Armstrong also indicated
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approximately 17,000 permanent disabilities and 18,000 deaths occur each year as a
result of being admitted to hospitals with diverse work cultures.
According to Buch and Wetzel (2001), most employees have worked in
organizations in which people do the opposite of what they say. Organizations are
identified as having two cultures, the true culture and the espoused culture. Espoused
values are audible and spoken. Espoused values include organizational goals,
philosophies, sayings, slogans, and strategies. The true culture of the organization is the
set of unstated assumptions the members share. The unstated assumptions of the true
culture have worked well enough in the past to be considered valid and to be taught to
new members as the correct way to perceive, think, and feel in interactions within the
organization (Buch & Wetzel). Leaders in the health care industry, such as chief nurse
executives, are in a position to address the disjuncture between the espoused culture and
the true culture by sharing values and by modeling adherence to the espoused cultures in
providing health care to their customers.
Chief nurse executives have a broad perspective on the health care provided
within the health care setting. Chief nurse executives work collaboratively with other
health care professionals as they examine the predictable variables that facilitate care
planning. The expertise of chief nurse executives allows for an increase in the accuracy
of care provided to patients and the quantity of service needed (Maljanian, Effken, &
Kaerhle, 2000). Chief nurse executives are also in a position to examine the patients
characteristics, such as their demographic data and socioeconomic status, and to find
means of matching the service and care to the patients characteristics (Maljanian et al.)
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in an effort to meet the needs of the patient and provide the best quality care to those
being served.
The development of quality health care involves many issues. Some of the issues
can be identified as decreasing quality outcomes due to job dissatisfaction, high turnover
rates in nursing, staffing and scheduling concerns, and nurse-to-patient ratios (Armstrong,
2004; Peltier, Schibrowsky, & Neill, 2004; Rodts, 2004). Chief nurse executives in
Magnet Status hospitals function from a leadership style that fosters practice that
promote[s] safe, more efficient and effective care while improving on and maintaining
high nurse satisfaction and job retention (Parran, 2004, p. 6). Chief nurse executives use
a scientific decision-making model that consists of the best evidence in making decisions
in the delivery of care to patients (Cliff, Harte, Kirschling, & Owens, 2004).
The role of chief nurse executives changes within the organization from
maintaining organizational values to creating and upholding organizational values
(Colvard, 2003). The leadership style of chief nurse executives is characteristic of their
intent in using scientific-based decision making in the development of policies relating to
staffing patterns and nurse-to-patient ratios. Steps used by chief nurse executives in their
scientific-based decision-making process include (a) assessing the need for change within
the practice, (b) connecting problems with interventions and outcomes, (c) incorporating
best evidence, (d) designing a change in practice, (e) implementing and evaluating the
change, and (f) integrating and maintaining the practice (Cliff et al., 2004).
Chief nurse executives do not always use benchmark information from other
institutions target budgets to find solutions to problems. Instead, chief nurse executives
look within their own organization and apply scientific decision making to gather and use
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data to measure safety, patient outcomes, and nurse satisfaction (Parran, 2004). Chief
nurse executives examine the history of their organization as they make decisions about
future organizational goals.
Statement of the Problem
Many factors contribute to a hospital achieving Magnet Status recognition. Some
research (Colvard, 2003; Marquis & Huston, 2003; Parran, 2004) suggested the
leadership style of chief nurse executives is a contributing factor in achieving Magnet
Status recognition. The aim of the study was to determine if one leadership style is
perceived to be more effective than others from the perspectives of nurse managers that
report to the chief nurse executives. Chief nurse executives face many health care
concerns such as health care expenditure, the delivery of quality care, job satisfaction of
employees, and employee turnover rates.
According to Fine (2002), total health care spending in the United States has
increased by 7.5% since the 1990s because of inadequate leadership. Langreth (2005)
purported the health care system is directly responsible for a decrease in quality care
costing an estimated $500 billion per year based on litigations surrounding medical
errors. This figure is equal to 30% of all health care costs in America. Unsafe care
practices within health care facilities, combined with inadequate leadership, have
contributed to a large number of preventable patient injuries and deaths (Gelinas & Loh,
2004). Magnet Status hospitals may have a model of interest that should be studied. For
example, leadership and job satisfaction are recognized as fundamental components
influencing the overall effectiveness of an organization (Chen, Beck, & Amos, 2005, p.
374). A specific problem is the lack of effective leadership among nursing leaders
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nationwide. At the turn of the 21st century, leaders were asked to do more with less time
and fewer resources (Marlow, 1996). A quantitative descriptive correlational research
study may identify a correlation between leadership style and leadership outcomes of
chief nurse executives in Magnet Status hospitals. The Multifactor Leadership
Questionnaire 5X (MLQ 5X; Avolio & Bass, 2004; see Appendix A) survey instrument
using a Likert-type scale was administered to a targeted sample of 180 chief nurse
executives working in Magnet Status hospitals. The chief nurse executives were asked to
invite their nurse managers to respond to the survey according to their perception of their
chief nurse executives leadership style and leadership outcomes.
Purpose of the Study
The purpose of the quantitative descriptive correlational research study was to
investigate a correlation between leadership style and leadership outcomes of chief nurse
executives in Magnet Status hospitals in the United States. The chief nurse executives
were chosen because they are at the highest level in the nursing hierarchy in health care
facilities, and nurse managers report directly to them. These chief nurse executives and
nurse managers are employed in Magnet Status hospitals, which have been identified as
being excellent, highly recommended places to work and having low nurse turnover rates
(Upenieks, 2003a). A nonprobability sample of 180 chief nurse executives in the United
States was asked to invite their nurse managers to respond to the MLQ-5X survey
(Avolio & Bass, 2004) to identify their chief nurse executive leadership styles and
leadership outcomes that may have attributed to achieving Magnet Status recognition.
The independent variable in the study was leadership style: transformational,
transactional, and laissez-faire. Leadership style is defined as the process of influencing
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others in an organizational culture (Marquis & Huston, 2003, p. 16). The dependent
variables in the study were the leadership outcomes of extra effort, effectiveness, and
satisfaction for achieving Magnet Status recognition, which includes decreased turnover
of nurses, retention rate, nurse-to-patient ratio, and employee satisfaction.
Significance of the Study to the Problem
Although prior research has examined leadership styles, job satisfaction, and
organizational culture relative to best practice organizations, little research has explored a
correlation between leadership styles and leadership outcomes of chief nurse executives
in health care organizations. Few studies have been conducted concerning the
relationships between leadership styles and employees who are satisfied with their job,
who have low turnover ratios, or whose culture encourages lifelong learning, creativity,
and compassion for others (Amendolair, 2003). The focus of the study was to establish a
correlation between leadership styles and leadership outcomes of a targeted sample of
180 chief nurse executives working in Magnet Status hospitals within the United States
by their nurse managers. The MLQ 5X survey was administered to a targeted sample of
180 chief nurse executives working in Magnet Status hospitals who invited their nurse
managers to rate them according to the nurse managers perception of their chief nurse
executives leadership styles used in their health care setting. Chief nurse executives in
Magnet Status hospitals run facilities described as excellent and have a reputation as
having high employee job satisfaction, low employee turnover, and high patient
satisfaction (Upenieks, 2003a). Kramer (1990) identified Magnet Status hospitals as
hospitals that have been particularly successful in attracting and retaining professional
nursing staff and had reputations as being good places to work (p. 35). Upenieks 2003
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studies comparing Magnet and non-Magnet hospitals (2003a, 2003b, 2003c, 2003d)
reaffirmed the advantages of Magnet Status hospitals were decreased turnover rates and
increased job satisfaction (Upenieks 2003d,p. 43). According to the Center for Nursing
Advocacy (2006),
Magnet status is an award given by the American Nurses Credentialing Center to
hospitals that satisfy a set of criteria designed to measure the strength and quality
of their nursing. A Magnet hospital is stated to be one where nursing delivers
excellent patient outcomes, where nurses have a high level of job satisfaction and
where there is a low staff nurse turnover rate and appropriate grievance
resolution. (1)
Nurse researchers studying leadership behaviors of nurse executives and nurse
managers have predominantly used the MLQ 5X because the instrument is designed to
examine leadership behavior from a transformational, transactional, and laissez-faire
perspective (Kleinman, 2004b). The MLQ 5X is also designed to allow nurses to rate the
leadership behavior of their supervisors and also for leader self-assessment. The chief
nurse executives in the research study were instructed to invite their nurse managers to
identify their chief nurse executives leader characteristics with a rating determined by
their perception (Kleinman). Chief nurse executives leadership style and leadership
outcomes are important because they can influence the development of a dominant
successful leadership style in other facilities and enhance the leaders overall
performance and employee job satisfaction.
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Significance of the Study to Leadership
The changing patterns in health care and the complexity in practice have
intensified the delivery of nursing care (Donley, 2005). Health care organizations need
visionary leaders (Armitage, Brooks, Carlen, & Schulz, 2006) who have the knowledge,
skills, and ability to affect and contribute to the organizations worth (Bridgeforth, 2005).
Armitage et al. posited, Organizations employ leaders for one purpose: to accomplish
what is required to help the company achieve its mission and strategic vision (p. 41) in
providing the best quality care at market rates.
Organizations are standing firm and supporting a weak structure with demand,
acceptance, and the awareness they lack control over the social environment, as identified
in the general system theory (Bridgeforth, 2005). Organizations seek chief nurse
executive leaders who are visionaries and who think and perform using a cognizant
process that helps other nurses expand their thoughts (Charon, 2003; Donley, 2005).
Expanding the thoughts of leaders in the 21st century demands a professional
commitment to think creatively about the practice of nursing and to have the courage to
try different things using different strategies (Donley) in their effort to increase retention
of staff, to enhance the quality of care to customers, and to provide service to customers
at an affordable rate.
According to Heller, Drenkard, Esposito-Herr, and Romano (2004), Magnet
Status hospitals are successful in recruiting and retaining nurses and have lower turnover
rates and higher job satisfaction among nurses. Upenieks (2003b) conducted follow-up
research of Magnet Status hospitals to determine if magnet status hospitals maintained
lower rates of vacancy and turnover, and higher levels of job satisfaction than non-
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magnet status hospitals (p. 9). Heller et al. surveyed 16 of the original Magnet Status
hospitals using five indicators: a.) Vacancy rate, which was calculated as the monthly
average percentage of RN positions filled, b.) RN to patient ratio, c.) turnover rate, d.)
Use of supplementary agency staff and, and e.) Number of multiple applicants per
available position (p. 9). The results of the survey revealed a nurse-to-patient ratio of 1:4
in Magnet Status hospitals compared with a 1:7 nurse-to-patient ratio in non-Magnet
Status hospitals. This statistically significant finding from Heller et al.s study supported
previous studies that found a relationship between lower rates of nursing turnover and
greater job satisfaction among nurses working in Magnet Status hospitals (Upenieks,
2003b). The results of this quantitative descriptive correlational study identify the
correlation between leadership and leadership outcomes of a targeted sample of 180 chief
nurse executives by their nurse managers employed in the 180 Magnet Status hospitals.
The results of the study help identify leadership styles and leadership outcomes that are
favored in Magnet Status hospitals.
Health care organizations need chief nurse executives whose style of leadership
gives them the confidence to make decisions, who accept responsibility for functions
outside of their expertise, and who can rely on others to provide information and validate
facts (Parran, 2004). Chief nurse executives rely on empirical evidence from management
research to understand current issues and gain insight into nursing practice as it relates to
health care and the environment in which the care is delivered. As the highest level
persons in nursing within hospitals, chief nurse executives have an obligation to ensure
the effectiveness of nursing practice, including to (a) ensure the safety of the
organizations constituents with a balance between production, efficiency, and reliability;
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(b) create and sustain a trusting organization; (c) manage the change process; (d) involve
employees in the decision-making process and in processes pertaining to work design and
work flow; and (e) use knowledge-based management practices to establish the
organization as a learning organization (Parran).
Nature of the Study
The purpose of this quantitative descriptive correlational research study was to
investigate a correlation between leadership style and leadership outcomes of chief nurse
executives in Magnet Status hospitals that impacts Magnet Status hospital recognition. A
target sample of 180 chief nurse executives from 180 Magnet Status hospitals throughout
the United States were asked to invite their nurse managers to participate in the survey
using the MLQ 5X to identify their chief nurse executives leadership style. The
Multifactor Leadership Questionnaire is a 45-item self-report questionnaire that measures
a full range of leadership behaviors through its 12 subscales (Kleinman, 2004c, p. 4).
Bass and Avolio (2000, as cited in Kleinman, 2004c) noted, The MLQ 5X has been
utilized in over 200 research studies within the past four years and has well established
reliability and validity as a leadership instrument in both industrial and service settings
(p. 4). Based on prior research (Avolio & Bass, 2004), the MLQ 5X was appropriate for
the study. The MLQ 5X was ideal because of its ability to allow chief nurse executives to
identify their leadership styles according to their responses they make on the survey. The
MLQ 5X also allows subordinates to rate their manager. Kleinman (2004b) noted, Nurse
researchers studying leadership behavior of nurse executives have predominantly used
the MLQ 5X (p. 112). According to Kleinman (2004b), a particular advantage and
feature of the MLQ 5X is that it allows chief nurse executives to rate themselves using
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the same Likert-type scale. The MLQ 5X captured the dominant leadership style of each
participant and collected quantitative data from nurse managers according to their
perception of their chief nurse executives in Magnet Status hospitals.
The quantitative descriptive correlational study based on established research
strategies investigated a correlation between leadership style and leadership outcomes of
chief nurse executives in Magnet Status hospitals. The population of Magnet Status
hospitals in 2006 consisted of approximately 180 facilities, although the numbers
fluctuated (ANCC, 2006). The study attempted to recruit the chief nurse executives in all
the Magnet Status hospitals. In a study by Kleinman (2004c), the MLQ 5X survey was
distributed to 315 staff nurses and 16 nurse managers in a 465-bed hospital. The returned
questionnaires resulted in a study sample of 79 staff nurses (25% of the staff nursing
population) and 10 nurse managers (62% of the nurse manager population).
Other research designs such as the quasi-experimental method and the qualitative
research method were considered for the study. Qualitative studies consist of a large
amount of narrative data and use in-depth interviews and direct observation of
participants, which allows for researcher bias in making assumptions based on their
beliefs and past interactions. Qualitative data are not analyzed using statistical tests for
accuracy or to examine relationships. Another qualitative design considered was the
phenomenological approach, which consists of intensive dialogue with the participants to
obtain knowledge of their lived experience (Denzin & Lincoln, 2000).
Qualitative studies allow for biases of the researcher (Denzin & Lincoln, 2000).
Researcher bias occurs when the researcher intentionally or unintentionally record
responses of the person being interviewed incorrectly. Qualitative research data are
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gathered through interviews using open-ended questions and observations of individuals
interacting in a social setting (LoBiondo-Wood & Haber, 2002). According to Salkind
(2003), researchers using the qualitative research approach interpret data according to
their perception, interaction with participants, and feelings, rather than using numbers to
quantify the data. The quantitative method of research was used in the study. The
correlational design was used to statistically quantify the magnitude of leadership style
to that of leadership outcomes. Quantitative studies analyze data quantitatively and are
more efficient than other designs that use observations or interviews.
A quantitative descriptive correlational method was selected for the study.
Quantitative research uses an inquiry approach for describing trends and explaining the
relationships among different variables using numerical data (Creswell, 2002).
Descriptive research was used to describe the characteristics of the variables being
investigated. A correlational design was used to describe a linear relationship (Salkind,
2003, p. 198). A correlational design was appropriate because in quantitative research a
correlational design can be used to describe the relationship between the study variables,
leadership style, and Magnet Status hospital leadership outcomes. In quantitative
correlational designs, participants are selected so generalizations will be made about the
population being investigated and groups should be of adequate size, such thatN 30;
larger sizes result in a decreased chance for error and an increased chance of obtaining an
accurate representation of the population (Creswell). The study examined the leadership
style of chief nurse executives employed in Magnet Status hospitals to determine the
dominant leadership style being used by chief nurse executives and their relationship to
Magnet Status hospital recognition. The styles of leadership used by chief nurse
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executives directly influence the delivery of care within health care organizations (Mass,
2005).
Felfe and Schyns (2004) found consistency in the MLQ 5X when 213 supervisors
from two public administration offices related their own leadership behavior as well as
their leaders behavior on the MLQ 5X. Felfe and Schyns assessed transformational
leadership styles using the MLQ 5X, which consists of five transformational subscales.
Several outcomes were included in the analysis, which resulted in leadership-specific
criteria. Research is uncovering important clues to tell us what type of persons become
the most effective leaders in an organization (Barling & Turner, 2005, p. 25). According
to Barling and Turner, current research supports transformational leaders as the most
effective leaders and identifies them as individuals who are more likely to have the
strongest commitment to corporate social responsibility.
One qualitative study showing support for transformational leadership consisted of
a point of view based in part, on research that asked managers to respond, in survey
form, to a number of stories that present ethical issues and apologies (Barling & Turner,
2005, p. 25). The MLQ 5X was used to ask subordinates to rate the kind of leaders their
managers were and repeatedly found those managers who showed a more evolved,
postconventional form of moral reasoning were also likely to be managers who practice
the transformational leadership style approach: The transformational leadership style
approach is the leadership style that is most valued by employees and most desired by
companies that wish to do better and to grow (Barling & Turner, p. 25). The
transformational style of leadership positively determines the success of the organization
(Barling & Turner).
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Research Questions
The focus of the study was to investigate a correlation between leadership style
and leadership outcomes of chief nurse executives that influences Magnet Status
recognition in hospitals. The following research questions were developed to guide the
study:
1. What is the relationship between the chief nurse executives leadership style
and the extra effort exerted by the nurse manager?
2. What is the relationship between the chief nurse executives leadership style
and the chief nurse executives effectiveness?
3. What is the relationship between the chief nurse executives leadership style
and the nurse managers level of satisfaction with the chief nurse executives leadership?
The MLQ was used to identify the various leadership styles used by chief nurse
executives in Magnet Status hospitals. The MLQ 5X consists of a Likert-type scale that
identifies the characteristics of each leadership style. Participants were asked to have
their nurse managers rate the frequency of leadership behaviors using a Likert-type scale
with a range of 0 (not at all) to 4 (frequently if not always) to identify their leadership
style. The MLQ was used to understand the relationship between the leadership style and
the leadership outcomes that influence Magnet Status hospital recognition.
Hypotheses
The study investigated the correlation between leadership style and leadership
outcomes of chief nurse executives that influences Magnet Status recognition in
hospitals. Three statistical hypotheses were tested. H0represents a null hypothesis and Ha
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represents an alternative hypothesis. Each hypothesis is repeated for each of the nine
leadership scores.
Hypothesis 1
H10: There is no correlation between the leadership style score and the nurse
managers extra effort score.
H1a: There is a correlation between the leadership style score and the nurse
managers extra effort score.
Hypothesis 2
H20: There is no correlation between the leadership style score and the nurse
managers perception of leadership effectiveness.
H2a: There is a correlation between the leadership style score and the nurse
managers perception of leadership effectiveness.
Hypothesis 3
H30: There is no correlation between the leadership style score and the nurse
managers level of satisfaction with the leadership.
H3a: There is a correlation between the leadership style score and the nurse
managers level of satisfaction with the leadership.
Theoretical Framework
The theoretical framework for the study, as it relates to chief nurse executives
leadership styles, was selected from the domain of nursing practice based on Orlandos
(1961) nursing process theory and Meades (1934) symbolic interaction theory.
Orlandos nursing process theory focuses on the interactions between individuals,
perception validation, and the use of the nursing process in the practice of producing
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positive outcome interactions (Faust, 2002). Orlando was one of the earliest authors to
use the term nursing process(Kelly & Joel, 1995). The nursing process is a systematic
method used by health care professionals to identify client or organizational health,
identify specific problems related to health, identify methods to solve health-related
problems, implement problem solving, and evaluate the outcomes (Kelly & Joel). The
study provides an overview of Orlandos nursing process theory, Meads symbolic
interaction theory, and the transactional, transformational, and laissez-faire leadership
styles.
Orlandos (1961) nursing process theory revolves around five concepts: (a) the
function of professional nursing; (b) the behaviors of patients or individuals in different
situations; (c) the response of the nurse or the individual with leadership responsibilities;
(d) the nursing process of assessing, planning, implementing, and evaluating; and (d)
improvement in interactions and practice. Orlando defined the purpose of nursing as the
ability to supply patients with the help needed and to ensure that patients needs are met
to enhance the overall well-being of the individual. Her lived experiences involved taking
into consideration the perceptions of others. Orlando considered the role of others and
envisioned circumstances from others perspectives, which enriched her perception of
those she engaged with and helped her to be creative in devising methods that would help
her to help others in their personal and professional growth. Orlandos nursing process
theory is used in diverse environments to shape the views and behaviors of others.
Orlando posited that social and environmental structuring in hospitals creates the need for
people to change and learn new behaviors in response to new goals, new situations, and
new collaborative workforces.
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Meades (1934) symbolic interaction theory augments Orlandos (1961) theory by
focusing on the aspects that give meaning to interactions and situations. Meads symbolic
interaction theory is based on three assumptions: (a) people use different symbols in their
interactions with others, (b) people respond according to their perception of the message
received from others, and (c) people in general react through cooperative behaviors,
which involves perceived responses and interpreted stimuli from others. Mead noted
people grow and change through their interactions with others, which is demonstrated in
reflected feedback of behavior. The theoretical concepts of Orlando and Mead extend
beyond hospital settings to different leadership styles of chief nurse executives and their
effects on the outcomes of organizations.
Leaders in organizations have many functions. Leaders help and encourage
followers to commit to organizational goals (Upenieks, 2003a). The transformational
leader, as a professional, has a sense of corporate social responsibility (Barling & Tucker,
2005). Transformational leaders see the big picture and engage employees and the
community in their vision (Barling & Tucker). Transformational leaders view situations
from others perspectives and inspire, motivate, and prompt others to change and move
beyond what they perceive as their limits in meeting professional and organizational
goals.
The transactional leader is focused on tasks and outcomes. The transactional
leaders actions are based on three components: (a) contingent reward, in which the
employees are rewarded for desired work performed; (b) active management by
exception, in which the leader monitors the work of the employees; and (c) passive
management by exception, in which the leader waits until problems arise. The laissez-
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faire leader sets goals for the employees and gives them an accompanying set of rules for
guidelines to guide them in the process of meeting specific objectives (Brennen, 2003).
These leadership styles are discussed in more detail in the following sections.
Transformational Leadership
The transformational leadership style, developed by Burns in 1978, describes the
leader as being a visionary who shares his or her vision with subordinates of the desired
direction of the organization. Transformational leaders instill pride within followers by
valuing them and their contributions. These leaders motivate followers to accomplish
more than the followers thought possible and demonstrate open consideration of
employees ideas (Kleinman, 2004a).
Transformational leaders, through their behaviors, transmit a sense of mission to
followers (Tickle, Brownlee, & Nailon, 2005). Transformational leaders delegate
authority to followers that enhances followers autonomy and teach and coach team
members to problem solve and use their critical thinking skills. Transformational leaders
are stimulated by their core beliefs and affect followers in a positive way that enhances
positive organizational outcomes (Tickle et al.). These positive effects, according to
Tickle et al., are well documented in the literature as improvements in subordinate job
satisfaction and increased subordinate commitment to the organization.
There are five identified characteristics of transformational leaders.
Transformational leaders have a charismatic personality, are confident in their
interactions, and respond in a way that leads subordinates to respect and admire them
(Harland, Harrison, Jones, & Palmon, 2005). The characteristic identified as idealized
influence by transformational leaders can be observed when leaders are seen as a role
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model sharing their vision with subordinates in a positive way such that it influences the
subordinates to model the same behavior(Tickle et al., 2005). Idealized influence also
involves the transmission of a sense of higher purpose by the leader that extends beyond
the goals of the individual to that of the organization (Harland et al.). The
transformational leader helps subordinates by increasing their awareness of
organizational goals and by helping the subordinates achieve goals.
Inspirational motivation is the behavior of the transformational leader that
transmits enthusiasm, optimism, and the ability to have ones vision of the future
accepted and shared among the subordinates (Harland et al., 2005). Inspirational
motivation also communicates a clear, attainable picture of the organizations future and
inspires the subordinates to try harder and develop themselves beyond the norm (Tickle
et al., 2005). Harland et al. noted inspirational motivation is the behavior that provides
meaning and challenge to the work of the subordinates.
Intellectual stimulation is used by the transformational leader to encourage
subordinates to view problem solving in different ways. The transformational leader
encourages subordinates to be creative and innovative in trying new approaches, knowing
they will not be criticized publicly (Harland et al., 2005; Tickle et al., 2005). The
transformational leader trusts and respects subordinates, which creates an environment
with some tolerance for mistakes that occur during a learning process (Tickle et al.).
Idealized consideration allows the transformational leader to develop employees
by treating them as individuals (Harland et al., 2005). The leader develops the
subordinates through mentoring, teaching, and being a facilitator, a confidante, and a
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counselor. The transformational leader also responds to the needs of the subordinate and
treats each individual as an important contributor to the workplace (Tickle et al., 2005).
According to Kleinman (2004b), there is a relationship between the effective
leadership style of the nurse executive and the job satisfaction of staff nurses. During the
1980s through the early 1990s, research demonstrated that effective leadership enhances
job satisfaction. Kleinman (2004b) assessed a body of research and found that chief nurse
executives in hospitals of excellence had characteristics of transformational leaders
embodied in their style of leadership.
Transactional Leadership
Transactional leaders are more concerned than transformational leaders with the
day-to-day operations of the organization (Kleinman, 2004c). The transactional leader
accomplishes organizational goals and motivates employees through rewards in
exchanges for their services (Kleinman, 2004c). Transactional leaders are also identified
as adapters who work toward the fulfillment of contractual obligations with their
followers (Sternberg, 2005). Transactional leaders provide contingent rewards by
specifying roles and task requirements and rewarding desired performance, or they may
monitor the meeting of standards and intervene when the standards are not met
(Sternberg).
Transactional leaders engage subordinates in contingent reward. In contingent
reward, the leader outlines the specific tasks to be conducted by the subordinates, along
with expected outcomes and the benefits that will result from achieving the outcomes
(Tickle et al., 2005). If the subordinates fail to achieve the goals as outlined, no reward
will be given; it is of significant importance that the subordinates understand what the
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goals are and the process for achieving positive outcomes (Harland et al., 2005). The
transactional leader also uses active and passive management by exception. Active
management by exception focuses on a subordinates mistakes, failures, and complaints.
This style of leadership supports avoidance coping, because feedback from the leader is
primarily negative and does not foster positive relationships. Transactional leaders use
passive management by exception when they do not intervene in identified problems the
subordinate is encountering (Harland et al). A transactional leader intervenes in a
subordinates interactions when the leader observes a particular situation has gone
seriously wrong and the subordinate is unable to respond appropriately in the given
situation before the leader takes any action (Harland et al.).
Laissez-faire Leadership
Laissez-faire leaders relinquish full control to group members and offer support
and guidance as needed (Barbuto, 2005). The laissez-faire leader works best with
subordinates who are highly skilled and need little direction, which allows the leader to
maintain good relationships with the subordinates (C. L. Cooper, Makin, & Cox, 1993).
Laissez-faire leaders are highly innovative and have a high level of technical competence
that steers their interest toward technical matters instead of managing the department.
Laissez-faire leaders are energetic, enthusiastic, and creative, and their interpersonal
skills are good, which allows them to maintain a good relationship with their
subordinates. Due to laissez-faire leaders lack of interest in managing their department,
the department is often run by itself, with problems arising concerning who is responsible
for what task and some jobs left incomplete (C. L. Cooper et al.).
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Multifactor Leadership Questionnaire
According to Kleinman (2004b), the MLQ 5X developed by Bass and Avolio
(1995) has been used predominantly in studies to measure leadership styles. In addition,
nurses studying leadership behavior of nurse executives and managers have
predominantly used the MLQ 5X. The use of the MLQ 5X in nursing research explains
the rationale for the historical trend of examining leadership behavior from a
transformational, transactional, and laissez-faire perspective using a 45-item Likert-type
survey (Kleinman, 2004b). The scales of the MLQ 5X survey help identify leadership
styles based on responses that identify characteristics such as idealized influence,
behavior, motivation, intellectual stimulation, consideration, and contingent reward.
Definition of Terms
The operational definitions are consistent with the theoretical framework and
research focus of the study. The following are definitions of key terms:
Autocratic leadershipstyle:Exploitative autocratic leaders lead by dictate and the
style is characterized by total leader domination (McConnell, 2003). Benevolent
autocratic leaders are kind, insist upon having their way, and are characterized by nearly
total domination but include consideration of the followers in the form of what the leader
has decided is good for them (McConnell, p. 363).
Chief nurse executive:The person in the highest level of the hierarchy in nursing
in hospital organizations (Grant, 1993).
General systems theory(GST): A function of the management system used to
connect or process energy, information or material into a product or outcome for use
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within the system or outside the system into the environment or both (Begley, 1999, p.
1).
Laissez-faire style of leadership: A loose style in which the leader coordinates and
placates employees for immediate relief of sensitive situations (Christman, 1996). Gillies
(1989) defined the laissez-faire leader as a person that surrenders leadership
responsibility, leaving workers without directions, supervision or coordination, and
allows the followers autonomy to plan, execute, and evaluate the work in the way they
see fit (p. 374).
Leadership styles: The process of influencing others in an organizational culture
(Marquis & Huston, 2003, p. 16) and the distinctive or characteristic manner in which
one performs (Gillies, 1989, p. 374).
Magnet Status hospitals: Designated facilities that have been certified by the
American Credentialing Center for their excellence in nursing practice (Upenieks,
2003d, p. 43).
Nurse manager: The clinical leader of the nurses working on a given unit (Gillies,
1989).
Nursing shortage: The number of nursing vacancies within the health care
organization (Coile, 2001).
Organizational culture: The total of an organizations values, language, history,
formal and informal communications, networks, rituals and sacred cows those few
things present in an institution that are never to be discussed or changed (Marquis &
Huston, 2003, p. 166).
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Participative leaders: Leaders who are key members in a team and provide
advice, information, resources, and assistance in any way possible (McConnell, 2003).
Transactional leaders: Leaders who base their transactions on an exchange of
rewards and benefits to employees for the completion of transactions and goals being met
(Upenieks, 2003c).
Transformational leaders: Leaders who practice a type of leadership that involves
individual consideration, intellectual stimulation, and willingness to embrace change
(Upenieks, 2003a). Transformational leaders are also identified as change agents who
have the ability to transform the attitudes, behaviors, and values of others by displaying
favorable, influential, and supportive interactions that bring about organizational change
(Upenieks, 2003a).
Assumptions
The first assumption within the study was that chief nurse executives in Magnet
Status hospitals would be voluntary participants in the study and invite their nurse
managers to respond to the survey questionnaire. It was assumed the chief nurse
executives would be willing to participate because of the studys potential significance to
add to the body of nursing knowledge. Using research to determine the correlation
between leadership style and leadership outcomes may enhance chief nurse executives
workforce performance in the provision of quality care by satisfied employees. It was
also assumed the participants would allot time to complete the survey in one setting
without interruptions and the generalizability of the study would be under the
researchers control. Another assumption was that the participants would be honest in
completing the MLQ 5X questionnaire according to their lived experiences and the
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perception of their chief nurse executive and that the nurse managers will return the
questionnaire in a timely manner. It was also assumed the participants would respond
honestly due to a high degree of professional integrity among health care workers. By
answering honestly, the information gained rendered true value in hypothesis testing to
determine the correlation between leadership style and leadership outcomes of chief
nurse executives.
Another assumption was that chief nurse executives in Magnet Status hospitals
have a positive correlation between leadership styles and leadership outcomes. A positive
relationship between leadership styles and leadership outcomes in Magnet Status
hospitals is due to the hospitals satisfaction scores of patients and employees, a low
turnover rate of staff, and an increased quality of care provided. The last assumption was
that, due to the chief nurse executives busy schedule, an incentive to participate would
enhance the return survey success. Five Visa gift cards in the amount of $50 each were
offered as prizes to be drawn among the participants who return completed, usable
surveys within the specified time frame. The offer was made to encourage the
participants who are interested to respond carefully while answering the surveys and
return them in the time specified.
Scope of Study
The scope of the study was an examination of the relationship between leadership
styles and leadership outcomes of chief nurse executives working in Magnet Status
hospitals in the United States. According to Lash and Munroe (2005), the Magnet
Recognition Program for hospitals was developed in the 1980s by the ANCC to
recognize health care organizations that provided the best health care(Cimiotti, Quinlan,
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Larson, Pastor, Lin & Stone, 2005). The objective of the Magnet Recognition Program
was to recognize excellence in nursing service, to recognize an environment that
promotes and sustains professional nursing practice, and to recognize an organizational
system that supports the professional development of nursing personnel (Lash &
Munroe, p. 326). Health care organizations that receive Magnet Status recognition
identify themselves as being the best in class organization (Curran, 2006, p. 5). Magnet
Status hospitals create environments that attract and keep talented employees (Curran).
Chief nurse executives are in positions that determine the type of care being delivered to
patients. The influence of chief nurse executives in Magnet Status hospitals goes beyond
patient outcomes, nurse outcomes, and market share to defining best practices through a
quantifiable impact on patient care (Smith, 2005). The study investigated the leadership
styles of the chief nurse executives in the targeted sample of 180 Magnet Status hospitals
to determine if a relationship exists between the leadership style and leadership outcomes
for Magnet Status recognition.
Limitations
Limitations consisted of a possible loss of participants and a small sample size. A
loss of participants resulted from chief nurse executives retiring from their position and
new chief nurse executives entering their new role. Another limitation was that some
chief nurse executives no longer held the position in the hospital at the time the research
was conducted. The study would be impacted if only those nurse managers who had
established a good rapport with the chief nurse executive were asked to participate. The
personality and ethnicity of the nurse managers also impacted the responses. Another
limitation was the number of unusable surveys returned by the nurse managers. Thirty
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eight of the surveys were returned with completed useable data. The research provided
information on the correlation between leadership styles and leadership outcomes of
Magnet Status hospital chief nurse executives, but the research did not indicate whether
the leadership style is different from leadership styles and leadership outcomes of non-
Magnet Status chief nurse executives. An additional limitation was chief nurse executives
who were no longer be employed in a specific facility when the surveys were e-mailed or
who chose not to participate. The size of the sample would have been affected if some
Magnet Status hospitals lost their designation. Those facilities contacted had maintained
their Magnet Status recognition and were able to participate in the study. There was also
a possibility of being unable to reach the chief nurse executives due to their busy
schedules.
Delimitations
Delimitations are used to narrow the scope of the study or to list what is not
included or intended in the study (Creswell, 2002; Leedy & Ormrod, 2001). One
delimitation was the study included only health care professionals in leadership positions
as chief nurse executives and nurse managers working in Magnet Status hospitals from
April 2006 through April 2007. A second delimitation was the focus on the leadership
styles and leadership outcomes of the isolated group of chief nurse executives. A third
delimitation pertained to the variables under investigation. The study limited the styles of
leadership under examination to transformational, transactional, and laissez-faire.
Summary
The study describes health care issues pertaining to a decline in quality outcomes
as they relate to the correlation between leadership style and leadership outcomes being
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used by chief nurse executives in Magnet Status hospitals. The study also identified
different leadership styles in use among persons in leadership positions. The study invited
nurse managers to respond to the MLQ 5X survey and to share their perception of their
nurse executives and the study also determined if a correlation exists between leadership
style and leadership outcomes of chief nurse executives in Magnet Status hospitals.
The purpose of the quantitative descriptive correlational research study was to
investigate whether there is a correlation between the leadership style and leadership
outcomes used by chief nurse executives in Magnet Status hospitals and to determine if a
relationship exists between the leadership style and the leadership outcomes that impact
Magnet Status hospital recognition. A purposive sample of 180 targeted chief nurse
executives from different states within the United States was asked to invite their nurse
managers to participate in the survey to obtain information that would help identify the
relationship. The research study used the MLQ 5X to survey a targeted sample of 180
chief nurse executives in 180 Magnet Status hospitals in the United States having an
undefined bed capacity to invite their nurse managers to respond to the survey. The
leadership styles of the chief nurse executive influence the delivery of care within the
health care organization, which further determines the overall satisfaction of an
organizations employees and patients.
Chapter 2 presents an overview of the literature. The chapter begins by providing
the literature search process and proceeds with a discussion of general systems theory
(GST), which integrates systems thinking in organizations (Wang, 2004). Chapter 2
identifies and describes the different models of patient care used in hospital settings and
the leadership styles used by those in leadership positions.
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CHAPTER 2: REVIEW OF THE LITERATURE
The purpose of the quantitative, descriptive research study was to investigate the
relationship between the leadership style and leadership outcomes of chief nurse
executives that impact Magnet Status hospital recognition. Prior research on Magnet
Status hospitals showed these facilities draw and retain nurses through professional
practice models that incorporate staff autonomy and shared responsibility through their
input in decision making (Khazaal, 2003; Kleinman, 2004a). Leaders in Magnet Status
hospitals incorporate staff involvement in generating alternatives in decision making,
health career planning, and evaluating the results of care provided to its constituents, as
care relates to overall satisfaction (Khazaal). Kleinman (2004b) identified some
characteristics of the leadership style used by chief nurse executives that have a
significant impact on employee job satisfaction and retention. The characteristics include
providing an atmosphere that promotes and encourages open discussion, considering the
ideas of others, being available, maintaining high performance standards, and initiating
positive interaction between employer and employees. Effective leadership skills used by
chief nurse executives enhance employees job satisfaction (Kleinman, 2004b). Effective
leadership is also identified as a key factor in staff nurse retention (Kleinman, 2004a).
The following section presents information obtained from research articles, research
documents, and journals.
Title Searches, Articles, Research Documents, and Journals
A detailed literature review was conducted using the concepts of GST, models of
patient care, patient satisfaction, employee job satisfaction, nursing shortages, leadership
styles, and an overview of Magnet Status hospitals. Table 1 presents the sources
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reviewed, categorized by the theories and search topics that support the study. Table 1
does not show when these works were published for any of the topics. A search for
available research literature on the topic of chief nurse executives and Magnet Status
hospitals generated no results. The following section will discuss the nursing shortage.
The nursing shortage is a cyclical problem that became a national crisis at the
beginning of the 21st century, with a total number of job vacancies in the range of
158,000, including 120,000 vacancies for RNs within the hospital setting (Coile, 2001;
Upenieks, 2003c). Coile identified the chronic labor shortage as the force driving up
wage costs from 5% to 8% annually in hospitals and other health care facilities and as the
explanation for the sharp rise in health care expenditures by 5.6% in 1999 and 8.3% in
2000.
Kramer and Schmalenberg (1998a) established that some of the reasons for the
nursing shortage in the 1990s and 2000s are (a) the high turnover rate among nursing
personnel, (b) the constant orientation of new personnel, (c) the lack of commitment and
identification with institutional values and goals, (d) the high percentage of inexperienced
staff, (e) the large number of per diem nurses, (f) the frequent use of agency personnel,
and (g) a nursing staff that does not consistently work together. Because of the nursing
shortage, a large number of hospitals and health care facilities have been recruiting
Filipino and Indonesian nurses to fill job openings (Kramer & Schmalenberg, 1998a).
Many hospitals hire agency nurses and travelers who work for a limited assignment in the
facility and receive pay at rates 50% to 100% higher than the rates of hospital-owned
nurses (Coile, 2001). The regular use of travelers and agency nurses is seen as a cause of
low morale and job dissatisfaction among nurses (Kramer & Schmalenberg, 1998b).
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Table 1
Summary of Literature Review by Search Topic
Theoretical
concepts and
search topics
Journal
articles
and
periodicals
Books,
magazines,
Internet, and
reports Total
Resources
before
2001
Resources
in past 5
years
%
since
2001
General systems
theory
4 7 11 4 7 63%
Models of patient
care delivery
10 16 26 8 18 69%
Patient
satisfaction
8 4 12 0 12 100%
Employee job
satisfaction
11 9 20 1 19 95%
Nursing shortage 8 7 15 2 13 87%
Leadership styles 32 12 44 9 35 80%
Overview of
Magnet Status
facilities
8 2 10 2 8 82%
Total literature
reviewed
82 57 139 26 113 81%
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Experts in health care have found that the nursing shortage in the 2000s is an
imbalance between supply and demand and is serious and widespread throughout the
United States (Upenieks, 2003b). On the supply side, there are concerns about the
population of aging nurses who will soon be retiring (Upenieks, 2003b). The nursing
shortage crisis has created a culture that promotes distrust and negative behavior among
employees wh
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