First-Line Nurse Managers 'Leadership Styles and Its Relation with Nurses` outcomes and Readiness to Work

: Background: Leadership style is the manner by which leaders influence the group members to achieve organizational goals. In nursing leadership, the effectiveness of first -line nurse manager is defined as a process whereby nurse manager influences a nursing staff to achieve a common goal. Each leadership style can have different outcomes in the nursing staff effectiveness, satisfaction and hence, make extra efforts (Albagawi, 2019). The outcomes of leadership styles were significantly related to nurses' work readiness indicating their positive effect on nurses' work readiness (Lau et al., 2020). The work readiness, has been defined as “The extent to which graduates are perceived to possess the attitudes and attributes that make them prepared or ready for success in the work environment” (Magagula et al., 2020) Objective: To identify the relationship between first -line nurse managers’ leadership style outcomes and nurses’ readiness to work. Settings: The study was carried out in medical, surgical inpatient care units and critical care units at Alexandria Main University hospital in Alexandria governorate. Subjects: All nursing staff (n=480) , was working during the time of data collection in the previously mentioned units. Tools: Two tools were used for data collection. Tool (I) was "The Multifactor Leadership Questionnaire" in addition, nurses' demographic data. Tool (II) was the work readiness scale (WRS) tool. Results: The findings of the present study showed that there was moderate, positive and statistically significant correlation between the overall leadership style outcomes and transformational style. There was low but positive and significant correlation between the overall leadership styles outcomes and transactional style. However, there was a negative, weak and statistically significant correlations between nurses` leadership outcomes and the laissez faire style. There was a weak, positive and significant correlation between the overall FLNM leadership styles outcomes and the work readiness. But there were weak, negative and significant correlations between the laissez-faire leadership style, and work readiness. Conclusion: there was a significant relation between the outcomes of leadership style with nurses' work readiness which indicating the positive effect of the outcomes on work readiness Recommendations: Developing the professional competencies of the first-line nurse managers’ leadership style through leadership training program and its impact on developing their planning skills, competencies and awareness; to achieve high quality of patient care.


Introduction
Nowadays, the nursing staff is the cornerstone in providing a high level for quality of patient care (Parker, 2022).This requires first -line nurse managers to have an effective leadership style, that can have a substantial impact on staff nurses' readiness to work (Younes, 2014).Leadership style is the manner by which leaders influence the group members to achieve organizational goals.In nursing leadership, the effectiveness of firstline nurse manager is defined as a process whereby nurse manager influences a nursing staff to achieve a common goal (Northouse, 2018).Avolio and Bass (2004) classified leadership styles into three types namely: transformational, transactional and laissez-faire.Transformational leadership style encourages nursing staff to view problems from new perspectives, provide support as well as encouragement, and communicate a vision.This style has five dimensions namely: idealized influence (attributes), idealized influence (behavior), inspirational motivation, intellectual stimulation and individualized consideration.
Transactional leadership style is characterized by the processes of recognition, reward or punishment, corrective actions by the leader based on how the employees perform the tasks assigned to them.This style uses the contingent rewards, management by exception (active) that refers to clarify the role and the task requirements of the followers and management by exception (passive) (Abuo Ghanema, 2014).
Laissez-faire leader is considered to be an essentially absence or an avoidance of leadership (Robert, & Vandenberghe, 2022).Therefore, the leader lacks the response to subordinate performance.This style has two forms: the reward omission and the punishment omission (Liu et al., 2022).
Each of the leadership styles can have different outcomes in the nursing staff ` effectiveness, satisfaction and do extra efforts (Asrar-ul-Haq & Kuchinke, 2016).Effectiveness is an outcome which identifies the leaders who are able to be efficient.Satisfaction also identifies leaders who are able to generate satisfaction in their followers.Leaders are nurturing, open, authentic, honest persons, and with good interpersonal and social skills (Farghaly, 2017); (Latif, et al., 2022).
Mohamed & Saleh, (2019) concluded that there were positive correlations between leadership styles and all work readiness factors with statistically significant difference.
Work readiness is the extent to which employee has the ability and willingness to accomplish a specific task.Walker, Storey, Costa and Leung (2015) divided nursing staff` work readiness into four-dimensions.These are: work competence, social intelligence, organizational acumen and personal work characteristics.
First, work competence refers to clinical skills, technical knowledge, experience, confidence, and responsibility.Second, social intelligence refers to the ability to communicate with a range of people, to work as a team, manage interpersonal conflict, and seek support (Walker et al., 2013).
Thirdly, organizational acumen refers to knowledge of hospital policies as well as procedures, maturity and professional development, (Walker & Campbell, 2013).Finally, personal work characteristics refer to traits such as personal skills, self-direction, selfknowledge, and adaptability (Walker et al., 2015).
Hersey and Blanchard (2013) mentioned that at the lower levels of readiness to work among nurses, the leader needs to provide direction but with higher levels of readiness, in which nurses become responsible for task direction.It was observed that there was lack of commitment, high rate of the absence increase of the turnover, burnout and unit cohesiveness of the nurses in the study setting, so the studying the relationship between effectiveness of first-line nurse managers' leadership style and nurses' readiness to work can assist in enhancing a positive work environment, that enhances their commitment, readiness to work reduce turnover, absence, burnout and increase unit cohesiveness.

Aim of the study:
The aim of the study is to identify the relationship between first -line nurse managers' leadership style outcomes and nurses' readiness to work.

Research Questions:
1-What is the level of each type of leadership style?2-What is the type of correlation between firstline nurse managers' leadership style and nurses' outcomes?3-What is the type of correlation between firstline nurse managers' leadership style outcomes and nurses' readiness to work?

Materials and Method
Materials: Research design: Descriptive correlational design was used to conduct this study.

Settings:
This study was conducted in medical, surgical inpatient care units and critical care units at Alexandria Main University hospital in Alexandria governorate; as it is the largest educational hospital: it contains 1619 beds and also had variety of different categories of nursing personnel and wide range of specialties and services.The study setting included all the following units: medical care units and their specialties (n= 24), Surgical care units and their specialties (n=17) and intensive care units (n=14).

Subjects:
The study included all nursing staff (n= 480) who were available at the time of data collection in the previously mentioned units with 6 months experience and more, who provided direct and indirect patient care.They were classified as follows: medical care units (n=145) nurses, surgical care units (n=195) nurses and intensive care units (n =140) nurses.
Tools: two tools were used in this study.Tool (I):"The Multifactor Leadership Questionnaire (MLQ 360-degree feedback).This tool was adapted by the researcher from an original framework that was developed by Avolio and Bass (2004); (Antonakis, Avolio & Sivasubramaniam, (2003).It was used to assess levels of leadership styles and leadership outcomes as perceived by the study subjects.It comprised of (53 items) divided into four parts namely: transformational leadership style included (20 items), transactional leadership style which included (12 items), laissez-faire (12 items) and outcomes, which included (9 items).Nurses' responses were measured on a 5-point likert rating scale ranging from (5) strongly agree to (1) strongly disagree.The scoring system was as follows:-1) The scoring system of transformational leadership style (TFLS).The overall score ranged from 20 to 100: the range from 20 -59 described as low level of (TFLS).The range from 60 -79 described as moderate level of (TFLS).The range from 80 -100 described as high level of (TFLS).
2) The scoring system of transactional leadership style (TALS).The overall score ranged from 12 to 60: the range from 12-35 described as low level of (TALS).The range from 36-47 described as moderate level of (TALS).The range from 48-60 described as high level of (TALS).
3) The scoring system of laissez-faire leadership style (LFLS).The overall score ranged from 12 to 60: the range from 12-35 described as low level of (LFLS).The range from 36-47 described as moderate level of (LFLS).The range from 48-60 described as high level of (LFLS).
4) The scoring system of the outcomes of leadership style (OCLS) ranged from 9 to 45: the range from 9 -26 described as low level of (OCLS).The range from 27-35 described as moderate level of (OCLS).
The range from 36-45 described as high level of (OCLS).This tool was tested for validity and reliability by Abuo Ghanema, (2014).It was reliable with the mean value (r=0.939).Tool (II): " The Work Readiness Scale (WRS): ", This tool was developed by ( Caballero, Walker & Fuller-Tyszkiewicz, 2011) and adapted by Walker et al. (2015) to assess the degree of nurses` readiness to work.Walker et al. (2015) adapted the WRS from (64-items) to (46-items).It was divided into four dimensions namely: work competence (WC) (14 items), social intelligence (SI) (8 items), organizational acumen (OA) (16 items) and personal work characteristics (PWC) (8 items).The original tool was developed 10-point likert rating scale and it was adapted to 4-point likert rating scale to ease the responses (Hayter, 2017).
Nurses responses were measured on a 4-point likert rating scale ranging from (4) strongly agree to (1) strongly disagree.The The scoring system of work readiness ranged from 46 to 184.The range from 46-114 described as low level of work readiness, the range from 115 -149 described as moderate level of work readiness and the range from 150-184 described as high level of work readiness.
This tool was tested for validity and reliability by Hayter, K. ( 2017), it was reliable with value.92.Good internal consistency was indicated with Cronbach alpha values of.88 for WC, .87 for SI, .85 for OA, and .84 for PWC.
In addition, nurses' demographic data sheet was developed by the researcher to collect data for nursing staff such as: age, sex, marital status, unit name, educational qualification and years of experiences in unit.

Method:
-Permission from Research Ethics Committee was obtained.
-Permission to collect the necessary data for the study was obtained from the Faculty of Nursing, Alexandria University directed to the administrative authorities at Main University Hospital.
-Content validity of the questionnaire was done by seven juries of experts from the Faculty of Nursing, in the field of the study. - The reliability coefficient was measured for the study tools by Cronbach's Alpha.It was r=0.934 for the Multifactor Leadership Questionnaire and r= 0.920 for the Work Readiness Scale (WRS).
-A pilot study was carried out on a sample of (10%) from participants (n=48) to check and ensure the clarity and applicability of the tools.Based on the findings corrections were done.
Data collection for this study was conducted by the researcher through self-administered questionnaires that was hand delivered to the study subjects after meeting with the nurses in each unit for about 10 minutes.Data collected in a period of 7 weeks from 9-10-2021 to 30-11-2021.

Ethical Considerations:
• Informed consent was obtained from all participants of the study after explanation of the study purpose and confidentiality of data was ensured.

•
The study subjects' right to withdraw at any time from the study was assured.

Results: Table (I)
shows that nearly one-third (33.8%) of studied subjects were in age group range from 30 to less than 40 years old with a mean age of (36.60 ± 9.449), while the lowest percentage (8.5%)were in the age group range more than or equal 50 years old.Regarding gender, the same table shows that the majority of the study subjects (89.6%) were females.Also, it can be noted that approximately two-thirds (62.7%) of the studied nurses held Diploma of Secondary Nursing School, while, the low percentages (5.6%) held Bachelor degree in Nursing Science.Concerning their years of experience, the highest percentage (27.9%) of the studied nurses had 5 to less than 10 years of experience with a mean score of (11.30 ± 7.187), while, the lowest percentage (11.9%) of them had 15 to less than 20 years of experience.
As for the type of unit, 40.6% of the studied nurses were working in the surgical units, while, the lowest percentage (29.2%) of the nurses were working in the intensive care units.Moreover, it can be noted that most of the studied nurses (81.0%) were married and only (1.0%) of them were divorced.

Table (II)
illustrates that more than half (56.0%) of the first line nurse managers (FLNM) have moderate level of transactional leadership style, whereas slightly more than half (54.2 %) of FLNM have low level of the laissez faire leadership style as perceived by the studied nurses.
Regarding the transformational leadership style, more than one third (40.8%) of study nurses perceived the FLNM adopted it at high level and only 19.8% of them chose low adoption.Regarding the highest mean percentage of the dimensions of leadership styles outcomes, they were assigned to the high level of extra effort (49.0%), effectiveness (50.45%) and satisfaction (57.7%).
Table (III) shows that 55.4% of the studied nurses showed moderate levels of overall work readiness, compared to 7.5% mean percentage for the low level of overall work readiness.To clarify, nearly one half (49.6%, 49.8%) of them showed moderate level of work readiness in terms of work competence and social intelligence.In addition, 52.3% of them showed high level of organizational acumen.However, more than one half (31.7%) of them showed low level of personal work characteristics.
Table (IV) illustrates that there was statistically significant difference & high positive correlation between overall leadership style outcomes and transformational style (r=0.703,p=0.000).Also, there was statistically significant difference & low positive significant correlation between overall leadership styles outcomes and transactional style (r=-0.229p=0.000).Whereas, a statistically significant difference weak negative correlations between nurses` leadership outcomes and laissez faire style (r=-.319p=0.000).

Table (V)
shows that there was statistical significant & weak positive correlation between the overall nurses' multifactor leadership style outcomes with work readiness a (P=0.001,r=0.523).

Table (VI)
shows that there was a statistical significant & weak positive correlation between the overall nurses' multifactor leadership style outcomes with work readiness (P=0.001,r=0.523).

Discussion
The nurse mangers can implement different leadership styles in nursing which allow nurses to be motivated to work on their own, decision making, problem solving.And provide the necessary guidance and support in order for nurses to achieve continuity in development and commitment.
Regarding distribution of the level of FLNM leadership style (By domains), as perceived by the studied nurses it revealed that FLNM had a high level of the transformational leadership style, moderate level of the transactional leadership style and low level of the laissez faire leadership style.Because of most of the nurses mentioned that the FLNM makes them participate in decision-making and some nurses said that they constantly follow their mistakes and do not solving simple problems until they become catastrophic.But some of nurses believe that they do not receive any response from their manager, whether positive or negative.
The current study result contradicts with Kise Hjertstrøm, et al., (2018) who found that more than three quarters of FLNM were following the transactional style while only minority of them were following the laissez faire style.This current study goes with Bush, et al., (2021)  The present study revealed that the study nurses had low level of overall work readiness.Because of the nurses stated that there is a lack of trust and mutual respect from colleagues and managers.In addition, the nurses said that the existence of a conflict between technical and professional nurses that may influence negatively work readiness and interpersonal problems of nurses negatively affected the quality of work.
The result of Hayter, (2017) agreed with this result of current study which clarified that majority of participants, had a moderate level of work readiness.This study finding is on contradictory with Walker, & Campbell, (2013) who found that minority of studied sample with high level of organizational acumen.But, more than three quarters of them showed low level of personal work characteristics.

Concerning
relationship between leadership styles outcomes and leadership style, the current study revealed that there was statistically significant difference and high positive correlation between overall leadership styles outcomes and transformational style and low positive significant correlation with transactional style and weak negative correlations with laissez faire style.
In the context of nurses' point of view FLNM allocates time for staff nurses, solves problems for them, treats them with respect and mutual trust, shares their opinions, this leads to promote high quality care and enhance the nurse's accomplishment, skills, staff satisfaction and decrease nurses' burnout.
This current study result supported with Berber et al., (2019).Who found that there is highly significant positive correlation between total leadership outcomes in terms of extra effort, effectiveness and satisfaction and transformational leadership style.Also agreed with Keisu et al., (2018) Regarding the significant relation between the outcomes of leadership style with nurses' work readiness indicating the positive effect of these outcomes on work readiness.This might be due to leaders are active listener to their employees and solves their problems, so nurses increase job satisfaction, oriented with the policy and have readiness to work.
This result agreed with Lorber et al., (2016), who stated that the outcomes of leadership style significantly related to nurses' work readiness indicating the positive effect of these outcomes on nurses' work and behavior.
Regarding the relationship between FLNM leadership styles and nurses' readiness to work.It revealed that there was a significant relation between the leadership styles with nurses' work readiness which indicating the positive effect of the leadership styles on work readiness.This might be due to nurse mangers can promote nurses` motivation, trust in decision making, problem solving and provide the necessary guidance and support which lead to more nurses` organizational commitment, lower nurses` turnover, absenteeism which lead to more nurses` work readiness.
The finding was supported by Rodic and Marc (2021) who indicated that there was a statistically significant correlation between, leadership style and employee readiness.And Alghazo, & Al-Anazi, (2016) found that there is a strong relationship between leadership style and employee motivation to work where the correlation was positive with transformational style and negative with transactional style.

Conclusion:
There was significant & high positive correlation between overall leadership style outcomes and transformational style (r=0.703,p=0.000).Also, there was a low positive significant correlation between overall leadership styles outcomes and transactional style (r=-0.229p=0.000).Whereas, a significant weak negative correlation between nurses` leadership outcomes and laissez faire style.There was a significantly positive correlation between the outcomes of leadership style with nurses' work readiness.

Recommendations:
Recommendations were given based on the results of the present study to enhance nurses' readiness to work through open communications, meetings and attending regular workshops with nurses to discuss their work problems and solve them.It was also recommended to conduct leadership training program for the FLNM, and to enhance nurses' work readiness through providing support, building mutual trust among nurses, listening to their problems and solve them, providing flexible schedule, providing clear communication and frequent feedback, allowing fair distribution of work load to all nurses in the units, and providing satisfying salaries.

Further studies should be conducted about:
• Developing a strategy to improve FLNM leadership styles outcomes, and nurses' work readiness.

References:
• Abuo Ghanema, I. ( 2014 who found that more than three quarters of first-line nurse manager had used transformational style and only minority of them high adoption to the same style.Casida & Parker, (2011) explicated the positive relationships among transformational leadership and the outcomes of leadership extra effort, leadership satisfaction and leadership effectiveness within the context of first-line nursing leadership in acute care hospitals in the Northeastern United States.

Table ( II): Distribution of the studied nurses according to the level of FLNM leadership (By domains) Leadership style & Outcomes Levels of Multifactor Leadership
▪ Single ▪ Married ▪ Widowed ▪ Divorced