The Correlation between First –Line Nurse Managers′ Leadership Style and Staff Nurses ΄Structural Empowerment and Work Engagement

Background: Healthcare organizations are facing many complex challenges that affect organizational success like providing best health care within affordable cost and nursing staff retention. These challenges need well prepared nurse leader who adopt an effective leadership style to manage and overcome these challenges. Leadership styles of first –line nurse managers can have a favorable impact on staff nurses′ engagement and empowerment, resulting in increased nurses’ performance. Aim: To identify the correlation between first –line nurse managers′ leadership style and staff nurses ′structural empowerment and work engagement. Settings : This study was conducted in all inpatient’s medical units (24 units) and surgical units (15 units) at Alexandria Main University Hospitals, as it is the largest hospital, contained a large number of beds and staff nurses with different qualifications. Subjects : convenience sample of 340 staff nurses with 6 months experience and more who provided direct and indirect care to patients, and who worked in the previously mentioned units and available at the time of data collection. Tools : Three tools were used in this study Namely; The Multifactor Leadership Questionnaire 5X Short Form, Conditions of Work Effectiveness Questionnaire (CWEQ Ⅱ) and Utrecht Work Engagement Scale (UWES). Results : The study showed there was significant positive high correlation between transformational leadership style and staff nurses ′structural empowerment where (r = 0.754, p = 0.000*), and significant positive moderate correlation between transformational leadership style and staff nurses ′ work engagement where (r = 0. 575, p = 0.000*). Additionally, there was insignificant low correlation between transactional leadership style and staff nurses ′structural empowerment where (r = 0.047, p = 0.384). furthermore, there was significant low correlation between transactional leadership style and staff nurses ′ work engagement where (r = 0.129, p = 0.017*). Also, there was significant negative correlation between laissez – faire leadership style and staff nurses ′structural empowerment and work engagement. Recommendations: For the nursing administrators Providing a healthy work environment that characterized with open communication through conducting a schedule for staff meeting and workshops with their managers to improve the ability of the manager to consider structural empowerment and work engagement. For the first -line nurse manager Conducting frequent meeting and open discussion with staff nurses to identify their needs and problems, discuss issues related to their clinical practice as well as facilitate their participation in decisions making regarding to their work environment and patient to improve their satisfaction & self-esteem.


INTRODUCTION
Healthcare organizations are facing many complex challenges that affect organizational success like providing best health care within affordable cost and nursing staff retention.These challenges need well prepared nurse leader who adopt an effective leadership style to manage and overcome these challenges (Coomber, Barriball, Leadership styles of first -line nurse managers can have a favorable impact on staff nurses′ engagement and empowerment, resulting in increased nurses' performance (Cowden & Cummings, 2012).
Leadership is defined as the ability to mobilize, influence and communicate the organizational mission and vision to motivate, empower and inspire others to act willingly toward achieving organizational goals (Aberese-Ako, Agyepong, & Van Dijk,2018;Perfecto. Aquino, 2015).Leadership style is defined as the behavioral pattern used to influence staff nurses ′motivation and drives performance (Gilitinane, 2013).
Leadership styles of first-line nurse managers include: transformational, transactional and laissez-faire leadership styles.Transformational leaders; work to enhance the motivation and engagement of nurses by directing behavior toward a shared vision, transactional leaders ; focus on the role of supervision, organization, and group performance, laissez-faire leadership (passive ⁄avoidant) ; is the nearest to the absence of leadership; laissez faire leader delays decisions, does not provide feedback and makes very little effort to satisfy the needs of staff nurses (Amegayibor, 2021).
Transformational leaders influence staff nurses through using five major factors namely : idealized influence attributes refers to the leaders΄ charismatic attributes, idealized influence behavior, refers to the leaders role modeling behaviors , inspirational motivation , refers to the leaders ΄visionary and inspirational behaviors , intellectual stimulation , refers to the leader's creative and innovative stimulation regarding challenges , and individualized consideration , refers to the leader's respect and recognition displayed by the leader to the staff nurses (Bayram, Dinç, 2015).Transactional leaders influence staff nurses using factors which are : contingent reward which characterized by the exchange between leaders and followers where there is an exchange for a specific reward , management by exception (active) refers to the manner by which a leader watches for mistakes and takes corrective action soon after the mistake is identified , and management by exception (passive) refers to the manner by which the leader watches for mistakes and takes corrective action in a passive manner such as during staff nurses ΄evaluation (Rowold, & Schlotz, 2009).Laissez faire leadership style (passive ⁄ avoidant) can be described as a nondirective, passive and inactive style.The leader in this style sets few rules for processing the issues in the organization and then delegates them to the subordinates.The leader needs to know very well the level of knowledge, competence and integrity of followers to be able to delegate the tasks.This style helps the follower to invest their talents and abilities to the maximum.It is more effective if used with very mature and autonomous nurses, but mostly it is not an effective or productive style (Haile, 2017).Nurse manager leadership style can potentially result in significant positive impact on organization as well as nurses work engagement, structural empowerment.Kanter & Nedd (2006) defined structural empowerment as a workplace structure that enables nurses to accomplish work in meaningful ways.For structural empowerment to take place Laschinger et al., (2003) classified structural empowerment into six dimensions which include: access to opportunity, means to the possibility for growth, movement within the organization, ability to increase knowledge and skills within the organization ; access to resources, means the ability to acquire time, materials, supplies.and financial means necessary to do work successfully ; access to information, means having the knowledge needed to be effective in work this includes an understanding of the organizational policies, expertise, and technical knowledge ; access to support, means the guidance and feedback received from the subordinates, peers, and superiors in health care organization.Formal power, which is obtained from specific job characteristics such as adaptability, flexibility, visibility, and centrality to organizational goals; informal power, which is obtained from developing communication with peers, subordinates, cross functional groups, and sponsors, social connections.Bakker (2011) defined work engagement in nursing as a positive work-related state where an employee is fully connected with their job and is characterized by vigor, dedication and absorption: vigor is defined as high level of energy and mental resilience while working, dedication is defined as being strongly involved in ones' work, absorption is characterized by being fully concentrated and happily engrossed in work.

Aim of the study:
To identify the correlation between first -line nurse managers′ leadership style and staff nurses ′structural empowerment and work engagement.

Research question:
What is the correlation between first -line nurse managers′ leadership style and staff nurses ΄structural empowerment, work engagement and intent to stay?

Research Design
A descriptive correlational design was used to conduct this study.

Setting
This study was conducted in all inpatient's medical units (24 units) and surgical units (15 units) at Alexandria Main University Hospitals, as it is the largest hospital, contained a large number of beds and staff nurses with different qualifications.It provides different services &specialties.It treats & receives large number of patients from different countries &governorates.

Subjects
convenience sample of 340 staff nurses with 6 months experience and more who provided direct and indirect care to patients, and who worked in the previously mentioned units and available at the time of data collection.

Tools:
Three tools were used in this study as follows: Tool (1): The Multifactor Leadership Questionnaire 5X Short Form: This tool was developed by Avolio &Bass (2004).It was adopted to measure three major leadership styles as perceived by staff nurses ;transformational, transactional and laissez -faire leadership styles of the first line nurse managers.The instrument contained (45) items with 4 scales, (3 leadership styles) and (one outcomes of leadership styles).The first scale included: Transformational leadership style with (5subscales) consists of: Idealized influence attributes (4 items) ; idealized influence behavior (4 items) ; inspirational motivation (4 items) ; intellectual stimulation (4 items), and individual consideration (4 items).The second scale including: Transactional leadership style consists of (3 sub-scales), namely contingent reward (4 items) ; management by exception (active, 4 items), and management by exception (passive, 4 items).
The third scale included: Laissez-faire leadership style consists of (4 items) and finally leadership outcomes which comprised from (3sub-scales) namely extra effort (3 items) ; effectiveness (4 items), and satisfaction (2 items).The responses were measured on 5 points -Likert scale ranging from (1) strongly disagree to (5) strongly agree.The overall score ranging from (45-225), low scoring ranging from (45-139), moderate scoring ranging from (140-184), and high scoring ranging from .Cronbach′s alpha Coefficient for internal consistency reliability of the tool was (0.95).

Tool (2): Conditions of Work Effectiveness Questionnaire (CWEQ Ⅱ):
This tool was developed by (Laschinger et al., 2001), it was adopted to measure nurses 'perception of structural empowerment in work place.It consists of (21 items) & six dimensions namely: access to opportunity (3 items) ; support (3 items) ; information (3 items) ; resources (3 items) ; formal power (3 items) ; informal power (4 items), and (2 items) to measure global empowerment.Responses to all items were measured on a 5-point Likert scale ranging from (1) none to 5 (a lot).The overall score ranging from (21-105), low scoring of empowerment ranging from (21-45), moderate scoring of empowerment ranging from (46-76), and high scoring of empowerment ranging from (77-105).Cronbach′s alpha Coefficient for internal consistency reliability of the tool was (0.74).

Tool (3): Utrecht Work Engagement Scale (UWES):
This tool was developed by Schaufeli and Bakker (2002) and then updated by them in (2006).
It was adopted to measure work engagement of participating nurses; it consists of 9 items classified into three dimensions namely: vigor, dedication, and absorption.Each dimension was composed of three items.For purpose of ease response, the scale was adapted from seven-point Likert scale to 5-point Likert scale ranging from (0) never to (4) always.The overall score level ranging from (0 to 36).Low scoring of work engagement ranging from (0 -11), moderate scoring of work engagement ranging from (12-23), and high scoring of work engagement ranging from (24 -36).Cronbach′s alpha Coefficient for internal consistency reliability of the tool was (0.90).

METHOD
An approval for conducting the study was obtained from the Research Ethics Committee of the Faculty of Nursing, Alexandria University.A Permission for conducting the study was obtained from the Vice-Dean Faculty of Nursing, University of Alexandria directed to the administrative authorities of the Main University Hospital after explanation of the aim of the study.
All the study tools were translated into Arabic language, a back-to-back translated (Arabic to English) was done.The study tools were tested for their content validity by ( 5) experts in the field of the study and some statements are reworded.A pilot study was carried out on 5% (n= 17) of the study sample in order to test the clarity and applicability of the research tools, all modifications were done.The study tools were tested for their reliability.using Cronbach's Alpha test.The reliability coefficient was .959for tool one and .741for tool two, .905for tool three.
Data collection for this study was conducted through self-administered questionnaire.It was hand delivered to the study subjects in the work settings and the needed instructions were given before the distribution of the questionnaire, for completion of the questionnaire each study subjects consumed approximately (15-20 minutes).the data collected in a period of 2 months from 28 September 2021 to 25Novamber 2021.The confidentiality of the data and the anonymity of the study subjects were assured.

Statistical analysis:
Suitable statistical analysis tests were used to determine the correlation between first -line nurse manager′ leadership style and staff nurses ′ structural empowerment and work engagement.
After collecting data, the data were revised, coded and fed to the computer using SPSS (Statistical Package for Social Science) program for statistical analysis version 20.The following statistical analysis measures were used: -Descriptive statistical measures, included the mean with standard deviation and percentage and frequencies to describe the scale and categorical data and description of the study subjects' characteristics, respectively.-Statistical analysis tests, which included: Chi square, T test and One way ANOVA (F-ratio test).

Table (1):
shows that: nurse's age enrolled in current study more than half of them (54.4%) were in the age group of 30-40 years old, In relation to nurse's gender revealed that; the majority were females (87.6%), also more than half of them (58.8%) had secondary technical nursing school diploma.In addition, more than half of nurses (57.4%) working in medical units, furthermore, the majority of nurses (40%) had 15 to 20 years of experience.Additionally, the majority of nurses (41.2%) had 15 to 20 years of experience.Moreover, more than half of nurses (89.1%) working more than or equal to 36 hours.

Table (2):
shows that; the majority of nurses (72.4%) perceived that; first line nurse managers had high level of transformational leadership style.However, it can be seen that, (92.1%) perceived that first linenurse manager had moderate level of transactional leadership style.while lowest percentage (80.3%) of nurses perceived that; laissez faire leadership style had a low level.
Table )3): shows that; there was a statistically significant difference between level of transformational leadership style of first linenurse manager and nurses′ demographic characteristics in the term of nurses′ age, working unit, years of experience since graduation, years of experience in the working hospital, years of experience in the working unit where p = (0.001*, 0.006*, 0.000*, 0.000*, 0.019*) respectively.shows that; there was statistically significant difference between nurse's demographic characteristics and level of laissezfaire style of first -line nurse manager in term of years of experience since graduation, years of experience in the working hospital, years of experience in the working unit where p= (0.000*,0.000*,0.019*)respectively.

Table (6):
Shows that; there was statistically significant difference between nurse's demographic characteristics and level of structural empowerment in term of age, gender, working unit, years of experience since graduation, years of experience in the working hospital and years of experience in the working unit where p = (0.000*,0.001*, 0.038*, 0.000*, 0.000*, 0.000*) respectively.

Table (7):
shows that; there was a statistically significant difference between nurses' demographic characteristics and levels of work engagement in term of nurses' age, gender, working unit, years of experience since graduation, years of experience in the working hospital and years of experience in the working unit where p = (0.000*, 0.001*,0.001*,0.000*0.000*,0.000*) respectively.

Table (8):
demonstrates that; there was significant positive high correlation between transformational leadership style and staff nurses ′structural empowerment and its overall dimensions where (r = 0.754, p = 0.000*), and significant positive moderate correlation between transformational leadership style and staff nurses ′ work engagement and its overall dimensions where (r = 0. 575, p = 0.000*).Additionally, there was insignificant low correlation between transactional leadership style and staff nurses ′structural empowerment and its overall dimensions where (r = 0.047, p = 0.384).Also, there was significant low correlation between transactional leadership style and staff nurses ′ work engagement where (r = 0.129, p = 0.017*) respectively.furthermore, there was significant negative Correlation between laissezfaire leadership style and staff nurses ′structural empowerment and work engagement.According to leadership style outcomes, there was significant positive high correlation between total outcomes and staff nurses ′structural empowerment where (r = 0.704, p = 0.000*) whereas, there was significant positive low correlation between total outcomes and staff nurses′ work engagement where (r = 0.478, p = 0.000*).

Discussion:
In any health care organization, the nursing staff plays a crucial role for organizational achievement and success.Therefore, it is very important for the nurse managers to recognize nurses' work and provide them with opportunities to grow and to look after their comfort (Alam & Mohammad, 2010).Structural empowerment is a vital organizational strategy that contributes to a healthy, productive, and innovative nursing environment which increases job satisfaction and nurses' engagement.
The finding of the present study revealed that majority of nurses perceived higher level of transformational leadership of their leaders.this could be related to the transformational leader has a vision of the future, pursues change, develops the potential of every collaborator and accepts challenges and also, their decisions guided by internal moral and values without external effect from their peers, organization, or society.This study was consistent with Al-Yami et al. (2018) who reported similar findings.Also, the finding of the present study revealed that transformational leadership style of first-line nurse managers had significant positive high correlation on staff nurses' structural empowerment and play a significant role in increasing nurses′ work engagement (Asif et al., 2019).This study is study is consistent with the result of Laschinger et al. (2014) in relation to transformational leadership style of first-line nurse managers which revealed that supportive and empowering leadership styles as transformational and transactional leadership styles play significant role in increasing staff nurses ′structural empowerment.
On the other hand, the findings of the present study were inconsistent to some extent with Phillips et al. ( 2018) as only congruent with transformational leadership style had positive impact on staff nurse's structural empowerment, his study revealed that transformational leader and transactional leader had positive impact on staff nurses ′structural empowerment and the result of laissez faire leader with poor management skills had negative impact.Transactional leadership style and staff nurses ′ work engagement.Also, there was statistically significant negative low correlation between laissez -faire leadership style and staff nurses ′ work engagement The result of the study is inconsistent with result of Khan, etal (2018) which revealed that the transformational leadership behaviors of nurse managers were moderately correlated to staff nurses' structural empowerment.transactional leadership behaviors were linked with staff nurses' structural empowerment to a lesser degree.
The current study result revealed that there was a significant positive high correlation between transformational style and total outcomes and there was a significant positive low correlation between transactional style and total outcomes.Also, there was a significant moderate negative correlation between laissez faire style and total outcomes.This study was supported by Avolio and Yammarino (2013) which indicated that transformational leader has positive impact on staff nurses′ outcomes.Transformational leaders encourage staff nurses to become more committed to their tasks, leading to higher levels of organizational commitment (Chai et al., 2017).
The demographic characteristics play significant role on staff nurses' perception of transformational leadership style and also, its related dimension as the study indicates that there was statistically significant relation between nurses′ demographic characteristics as age, working unit, years of experience.The result was supported by study of Suratno ( 2018) who clarified that perception of transformational leadership style depends on the nurses′ age, gender, and years of experiences.Also, some demographic characteristics play as a factor in nurses' perception to the level of transactional leadership style of first -line nurse manager. in the form of working unit, years of experiences and working hours.This was supported by Bajaj et al. (2018), andWang et al. (2016) studies which revealed that increase autonomous personal characteristics and increasing individual feeling of success, was the cause for increasing in their motivation at work.Furthermore, some demographic characteristics does n′ t play a factor in nurses ′perception of laissezfaire leadership style except years of experience.This was supported by Breevaart and Zacher (2019), & Duwayri (2019) who stated that demographic characteristics don't have effect on nurses' perception of laissezfaire, due to lack of support, trust in their leader feedback and evaluation of staff performance.
Additionally, some demographic characteristics play as a factor in perceiving structural empowerment in term of age, gender, working unit, years of experience.This was supported by, Spence Laschinger et al. ( 2012) which revealed that supportive work environments and demographic characteristics and effective leadership style promote structural empowerment in staff nurses.Also, there was statistically significant relation between work engagement and nurses′ demographic characteristics in term of age, gender, working unit, years of experiences.
This was supported by (Bakker & Schaufeli, 2008) revealed that employees who are engaged with their work tend to have more positive emotions and think about their work more positively.

Conclusion
Transformational leadership style of first-line nurse managers has positive impact on staff nurses' structural empowerment and work engagement.

RECOMMENDATIONS
Based on the findings of the study, the following recommendations are suggested and directed to the different levels of hospital management ; nursing administrators, first -line nurse managers.
For the nursing administrators, providing a healthy work environment that characterized with open communication through conducting a schedule for staff meeting and workshops with their managers to improve the ability of the manager to consider structural empowerment and work engagement.For the first -line nurse manager, conducting frequent meeting and open discussion with staff nurses to identify their needs and problems, discuss issues related to their clinical practice as well as facilitate their participation in decisions making regarding to their work environment and patient to improve their satisfaction, self-esteem & intent to stay. .