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Nurses Perceptions of Nursing Leadership Styles in the Eastern Healthcare Cluster in Saudi Arabia

Adel Harb*, Zainab Althunian, Janette Silva, Abdulrahman Alayed, Saleh Aljarudi, Abrar Barshaid

Nursing Professional Development, Eastern Healthcare Cluster, Dammam, KSA

Abstract: The type of leadership style adopted by the manager and how it is perceived by nurses can play a critical role in influencing staff performance and healthcare outcomes. This study aims to examine nurses’ perceptions about the managers’ leadership and to determine whether the style used may play a role in determining the quality of patient care. Methodology: A cross-sectional quantitative study was conducted in Eastern Health Cluster was over a four- month period from April 5th to July 30th 2021. A purposive sampling technique was used whereby all nurses and midwives working in EHC facilities, 8,699 staff, were invited to participate in the research adopting multifactor leadership questionnaire (MLQX5) to rate leadership styles and outcomes in relation to transformational, transactional, and passive avoidant leadership styles. The questionnaire was evaluated by a panel of expert nurse leaders against construct validity then piloted to test reliability. Data were collected after ethical approval was granted from King Fahad Specialist Hospital. Results: 577 nurses provided a 3.98% margin of error at the 95% confidence level. Statistical analysis was conducted using SPSS version 23.0. Results show that nurses perceive that their managers are using transformational and transactional leadership styles more often than passive avoidant leadership style. There was a positive and highly significant correlation between leadership and outcome factors. The analysis shows a positive correlation between leadership outcome factors (effectiveness, extra effort and satisfaction) and transformational and transactional leadership styles and a negative correlation with passive avoidant leadership style. A comparison of sociodemographic characteristics within the nursing workforce found that there are no significant differences in perceived leadership styles relating to gender although mean scores show that females had a higher perception of transformational and transactional styles compared to men who had a higher perception of passive avoidant style. Recommendations and Implication for Nursing: Transformational leadership appears to be best suited for nursing as it has positive nursing outcomes There is a strong need to implement leadership education and training amongst all nurses and to continuously train and educate nurse leaders and those potential leaders under succession planning programs about leadership skills and competencies and how to promote a culture for transformational leadership. Conclusion: The transformation of the healthcare system in Saudi Arabia, and challenges that are inherent, emphasize the importance of ensuring that nurses are effective leaders if organizational needs are to be met in the future. It is therefore important to conduct further qualitative and quantitative nursing researches amongst this nurse population to provide evidence about how leadership style is perceived and how it may influence outcomes within the nursing workforce and work environment.

Keywords: nurses, perceptions, leadership styles, eastern healthcare cluster, Saudi Arabia

Received December 09, 2021; Revised January 14, 2022; Accepted January 23, 2022

Citation: Adel Harb, Zainab Althunian, Janette Silva, Abdulrahman Alayed, Saleh Aljarudi, Abrar Barshaid, Nurses Perceptions of Nursing Leadership Styles in the Eastern Healthcare Cluster in Saudi Arabia. American Journal of Nursing Research, 10 (1). 16-25. January 2022. doi:10.12691/ajnr-10-1-3

1. Introduction

Leadership is a vital function of management within any organization that helps to channel resources for improved efficiency and achieve organizational goals. However, the role of leadership in healthcare is more significant because it has been linked to patient mortality, quality of patient care and patient satisfaction, and better staff wellbeing and morale. Furthermore, nursing leadership plays a key role within the healthcare system in motivating and inspiring nurses to practice to the best of their ability and to deliver quality patient care.

The healthcare system in Saudi Arabia is rapidly evolving, as services develop to meet the 2030 vision in providing a comprehensive, effective and integrated health system. This transformation has presented many challenges within the nursing sector as responsibilities in the nursing service increase and new nursing roles are developed and adopted to meet the changing needs of healthcare.

Nurses form the backbone of the healthcare system as they account for 50% of clinicians that provide 80% of healthcare services in Saudi Arabia [1,2,3]. Although the Saudization process started in 2011 [4], there is still an ongoing shortage of nurses [5], which has led to deficiencies in the quality of care delivered. The Kingdom remains reliant on expatriate nurses and it is expected that the demand for nurses will more than double by 2030 to meet the healthcare needs of a population that is growing at a rate of 2.52% per annum [6].

Developing and sustaining effective nurse leadership is critical if organizational goals are to be met and the quality of care maintained despite the challenging healthcare environment. However, deliberation about how leaders lead and the impact of leadership upon organizations and work effectiveness is not new. In 2004, the Institute of Medicine (US) Committee on the work environment for nurses and patient safety identified the necessity of implementing transformational leadership in nurse lead efforts to address work environmental deficiencies [7]. The American Nurses Credentialing Center endorsed this recommendation in 2017 in its revised Magnet Model by identifying transformational leadership as one of five components necessary for an organization to be recognized for nursing excellence [8].

The importance of effective leadership for organizations and employees is illustrated in the literature where its influence within the healthcare environment is apparent.

A systematic review of the literature found that nursing leadership influences staff perception and motivation to perform by fostering autonomy, building relationships, providing resources and through leadership practices that guide, mentor and coach [9]. Leadership attributes were also found to be directly related to nursing job satisfaction and intent to stay in a further systematic review conducted [10]. A study conducted in Saudi Arabia found that effective leadership was a crucial factor in generating job satisfaction and retention amongst nurses [11]. This finding takes on critical significance given the current national and anticipated global nursing staffing shortages [6,12].

When nurse leaders promote a positive environment at work, it reflects their emotional commitment in nurturing staff satisfaction and engagement. The leaders develop trust and amicable relations with their staff when they allow visibility and pay attention to their staff concerns [13,14]. Structured leadership rounds may also help to foster a personal connection by building steady relationships amongst managers and staff which can have a positive impact on the quality of care and healthcare outcomes [15].

This research is conducted on the premise that nursing leadership styles influence nurse performance. Additionally, it may provide information about leadership styles and characteristics which could be included in an ongoing succession plan program within Eastern Healthcare Cluster (EHC) facilities to transform nursing services by developing effective nurse leaders to meet vision 2030.

2. Literature Review

Effective nursing leadership is essential to the success of healthcare facilities in achieving organizational goals and ensuring the delivery of a quality healthcare service given that nurses form the largest group of healthcare providers. The type of leadership style adopted by the manager and how nurses perceive it can play a critical role in influencing staff performance and healthcare outcomes.

Leadership is defined as a process whereby an individual influences’ a group of individuals to achieve a common goal [16]. By defining leadership as a process, Northouse suggests that leadership is not a characteristic or trait that we are gifted at birth but rather something that can be developed and perfected according to the environment. The importance of the leaders’ role in guiding, directing, motivating and inspiring a group or organization towards achievement of common goals is further elaborated [17]. These competencies must therefore be developed if nursing leadership is to be effective.

2.1. Leadership Theories and Styles

Leadership theories study the qualities of leaders to identify the behaviors that can be adopted within leadership styles to improve leadership abilities in different situations. There are many leadership theories and styles described in the literature.

The Behavioral Theory proposes that an individual can learn to become a good leader and emphasizes the importance of behaviors and actions. It considers effective leadership to be the result of learned or acquired skills and is reflected in autocratic and laissez-faire leadership styles. An autocratic leadership style is exemplified when the manager retains as much power and decision-making authority as possible. The manager does not consult employees, nor are they allowed to give any input. Employees are expected to obey orders without receiving any explanations and accept punishment for mistakes. Laissez-leadership style is one in which the manager provides little or no direction and gives employees as much freedom as possible. This may be effective if employees are highly skilled, experienced and educated [18].

The Transformational Leadership Theory [19], focuses on the relationship between leaders and followers and describes the kind of leader who is inspirational and charismatic. Transformational leaders motivate staff members to work to the best of their ability to achieve organizational goals and to realize the value of what they do [20].

Transactional Theories, or exchange leadership theories revolve around the role of supervision, organization and teamwork and consider rewards and punishments as the basis for leadership actions. In Transactional leadership the leader satisfies the need of employees through recognition or rewards after reaching the agreed task objectives and goals [21,22].

The Contingency Theory proposes that no one way or style of leadership may be applicable to all situations. It recognizes that there may be variables influencing any particular situation, and the leader must choose the right course of action, taking into account those variables. Researchers suggest that effective leadership is not just about the quality of the leader, it is about striking the right balance between behaviors, needs, and context [23].

Systematic reviews which examine leadership styles and outcome patterns in the nursing workforce and healthcare environment found that relational leadership styles have a more positive influence compared to leadership styles that focused solely on task completion, which were deemed insufficient to achieve optimum outcomes for the nursing workforce. The reviews concluded that transformational and relational leadership styles should be encouraged and developed in order to enhance nurse satisfaction, recruitment, retention, and healthy work environments and individual productivity within healthcare settings [10,24,25,26].

Research suggests that nurse managers in critical care areas and special care units are more likely to use transactional leadership styles compared to nurses working in general care units that used transformational leadership styles [27]. This maybe because the transactional leadership style is known to be more effective in emergency and crisis situations which occur more frequently in these departments [28]. However, it has been identified that transformational leadership styles may also be effective in critical care areas where they have been found to guarantee a higher quality of nursing care in intensive care units [29].

Nurse managers in one study were also found to use different leadership styles depending on the situation (30) which resulted in moderate levels of job satisfaction and low intention to stay. Findings from this study suggest that nurse managers need to understand their own leadership styles and constantly assess their subordinates need for a particular leadership style if they are to maximize staff satisfaction, retention and productivity.

There are several studies available in the literature that use the multifactor leadership questionnaire to rate leadership styles and outcomes in relation to transformational, transactional, and passive avoidant leadership styles [27,4,31,32]. The studies all found significant relationships between transformational leadership style and outcomes of leadership in terms of extra effort, effectiveness and satisfaction. Additionally, a positive relationship was also found in one of the studies [27] between transactional leadership style and leadership outcomes.

There are a number of other studies available in the literature which evaluate how the different leadership styles affect outcomes in the healthcare setting.

2.2. Work Environment

Transformational leadership styles were found to contribute to a positive work environment by promoting a safety climate compared to a laissez -faire leadership style which was shown to negatively contribute to unit socialization and a culture of blame when errors occurred [33].

2.3. Organizational Commitment

Some studies found that transformational and transactional leadership styles have a positive correlation with organizational commitment, although a more significant relationship was identified in relation to transformational leadership styles [34,35]. A positive correlation was also identified between transformational leadership and organizational commitment [36]. Nurses were found to be more committed to their organization when a manager displays transformational leadership characteristics which may be beneficial in increasing productivity.

2.4. Stress Reduction

Transformational and transactional leadership styles can reduce stress and intention to leave in contrast to laissez-faire leadership which was found to increase job stress and anticipated turnover [37]. Transformational leadership was also found to be beneficial in decreasing stress and burnout and improving well-being [38]. These studies suggest that transformational and transactional leadership styles may be beneficial in improving job satisfaction and the quality of nursing services.

2.5. Productivity

Transformational leadership Style was found to have a positive impact on productivity. Leaders who demonstrated transformational skills were effective in stimulating motivation and consolidating teamwork among healthcare workers compared to those who demonstrated transactional skills [39]. Leaders who demonstrated laissez-faire characteristics had a negative effect on consolidating teamwork among health workers. Transformation characteristics were also found to have a positive impact on productivity where access to empowerment structures increased work effectiveness [40].

2.6. Job Satisfaction

Research findings were mixed in relation to job satisfaction and leadership styles. One study found transformational leadership styles beneficial in improving staff satisfaction [39] compared to another study which found that it had no significant impact [36]. Further research found that both transformational and transactional leadership styles can have a positive impact on nurse job satisfaction compared to laissez- faire leadership [41]. However, conversely transactional leadership was found to have a negative impact on nurses’ job satisfaction in another study [42]. The variations in findings between these studies suggest that it is not only the leadership style which is important, the managers level of leadership competence and the relationship with subordinates may also be influential factors.

2.7. Educational Implications

One study found that nurse managers mostly adopted a transactional leadership style which had a negative impact on staff nurses' levels of job satisfaction and rarely practiced transformational leadership which may have led to improved satisfaction [42]. The study concluded that this may be due to educational deficiencies by identifying the need for nurses to step out of their traditional borders and acquire new competencies. This finding was supported by another study which also identified the need for educational initiatives if nurses are to become more effective leaders [30]. The study found that a significant number of managers had not received any training in management prior to or after their appointment as nurse managers and may not have sufficient knowledge and competence to navigate between various leadership styles required for optimal outcomes. This suggests that some managers may not have the level of knowledge, skill or attitude required to be effective leaders and identifies the need to develop management and leadership competence through educational initiatives if they are to promote optimal outcomes in the healthcare environment.

A systematic review that examined factors and educational interventions influencing nursing leadership found that targeted educational interventions are an effective method of leadership development in nurses [43]. However, due to equivocal results reported in many included studies and heterogeneity of leadership measurement tools, the review was unable to conclude which specific nurse characteristics and organizational factors most effectively contribute to the development of nursing leadership. Future studies must therefore use good methodological rigor if they are to add valuable findings to the current body of evidence about how to develop effective leaders.

There is a large body of literature which identifies the importance of nursing leadership in achieving successful outcomes within the nursing workforce and work environment. Evidence suggests that different types of leadership styles can be used effectively, independently or simultaneously according to the situation, and that the healthcare context and level of competence of the nurse may influence the type of leadership style adopted and the degree of its effectiveness.

The transformation of the healthcare system in Saudi Arabia, and challenges that are inherent, emphasize the importance of ensuring that nurses are effective leaders if organizational needs are to be met in the future. It is therefore important to conduct nursing research amongst this nurse population to provide evidence about how leadership style is perceived and how it may influence outcomes within the nursing workforce and work environment.

3. Methodology

The study used a cross-sectional quantitative research design to identify leadership styles and outcome patterns in the nursing workforce and healthcare environment in order to involve more subjects.

4. Setting

The study took place in Eastern Health Cluster (EHC) which consists of 22 hospitals: 5 Specialist, 5 Health Network and 12 Rural Healthcare network and 137 Primary Health Care centers that provide primary, secondary and tertiary level care to Saudi Nationals and citizens of the Gulf States, which is situated in the Eastern province of Saudi Arabia.

5. Participants

The study was conducted over a four- month period from April 5th to July 30th 2021. A purposive sampling technique was used whereby all nurses and midwives working in EHC facilities, 8,699 staff, were invited to participate in the research. The aim of recruiting this population was to ensure that gathered data would provide insight into nurses’ perceptions of nursing leadership styles and the influence they may have on outcomes in the healthcare setting. It was hoped that 954 nurses (10.96%) would complete the survey, consistent with a 95% confidence interval and 3% margin of error, in order to ensure that the results were representative of the target sample and reduce the risk of sampling bias [44].

6. Instruments

The study used the multifactor leadership questionnaire (MLQX5) to rate leadership styles and outcomes in relation to transformational, transactional, and passive avoidant leadership styles [45]. There are several versions available, MLQX5 was utilized as it has been broadly used in many subject areas. The tool comprises of 45 items: the first 36 items measure the type of leadership style and remaining 9 items examine the effectiveness of the manager. The items are evaluated using a 5-point Likert scale. It has been found to have good psychometric properties [45,46]. Permission was received from the publisher to use the tool for the purpose of the study. A demographic questionnaire was also used to describe the characteristics of the nurses who participated in the research in relation to age, gender, years of experience and nursing role.

7. Pilot / Data Collection

The quality of the MLQX5 questionnaire was evaluated by a panel of expert nurse leaders who assessed construct validity to ensure that it met its objectives in measuring nurses’ perceptions about leadership styles and their influence on outcomes in the healthcare setting. Additionally, a pilot study was tested on ten program participants to confirm reliability through the clarity of questions and effectiveness of instructions [47]. No variables were identified which it was felt may affect the study [48]. Nonetheless, as the pilot size was small, the possibility cannot be excluded that certain problems may not have been detected.

After completion of the pilot study, Directors of Nursing in EHC facilities were informed about the research and asked to promote awareness of it by encouraging nurses to participate in the survey. The questionnaires were then distributed to each facility in the middle of June 2021 with a deadline for completion after ten days. It was accompanied by a letter explaining the purpose of the study and outlining any potential risks to subjects. Staff were requested to participate in the study on a voluntary basis with waiver of consent, as it was perceived that the research involved minimal risk.

8. Data Analysis / Findings

A total population sample of 8,699 nurses were invited to participate in the research; Five hundred and seventy-seven (577) nurses agreed to participate which is representative of 6.63% of the total population. Although a sample size of 954 participants would have provided a more representative sample, the sample of 577 nurses provided a 3.98% margin of error at the 95% confidence level which is acceptable. The demographic questionnaire and MLQX5 were returned completed in all categories. Statistical analysis was conducted using Statistical Product and Services Solutions (SPSS version 23.0. Demographic data analysis was performed using frequency count, percentage, mean and standard deviation to describe the research sample. Inferential statistics were analysed using the Pearson product moment correlation to describe the relationship between variables. T-test for two independent samples (or ANOVA) was used to compare means. Statistical significance was set at p ≤ 0.05 to indicate evidence against the null hypothesis. Further analysis was completed using Pearsons Coefficient Correlation to examine the relationship between leadership styles and outcome factors (+1 to -1).

Cronbach alpha scores were calculated to determine the internal reliability of the MLQX5 questionnaire. An Alpha coefficient score of 0.954 was obtained on the questionnaire. A consistency of 95% in scores indicates that the questionnaire has good scale reliability. All sub-leadership style scores were high except for Management by Exception (Active) 0.64 and Management by Exception (Passive) 0.69 which were more than average.

8.1. Sample Characteristics

The analysis showed that most of the nurse managers and staff nurses were females (92.5%) aged between 25-35 years of age (59.8%) and of Saudi nationality (73.1%). Most of the staff were educated to the level of Bachelor’s degree (48.2%) or Diploma (46.3%), compared to those with Master’s (5.4%) or PhD (0.2%). The majority of nurses had 6-10 years’ experience (34.5%) and worked in secondary level hospitals (41.2%).

Table 1. Demographic characteristics of participants

8.2. Perceived Leadership Styles, Factors and Outcomes

Table 2 shows that nurses perceived that their managers sometimes used transformational (M=2.08, SD= 0.85) and transactional leadership styles (M=2.04, SD+ 0.74) compared to passive avoidant leadership style which was used once in a while (M=1.29, SD=0.80). The data also indicates that managers sometimes used all transformational leadership style domains identified in the subscales (M=2.04-2.18), with the exception of Individual consideration which was used once in a while (M=1.96), and that they sometimes used all transactional leadership style domains identified in the subscales (M=2.00-2.07). With regard to passive avoidant leadership style, a laissez -faire approach to leadership was sometimes adopted (M=2.1) and once in a while a passive management by exception style was used (M=1.35). Although the results show that nurses perceive that their managers are using transformational and transactional leadership styles more often than passive avoidant leadership style, most of the nurses had low perception scores for the frequency of leadership styles used as most mean scores indicate that styles are only used sometimes rather than fairly often or frequently.

Table 2. Descriptive statistics to show perceived leadership styles, factors and outcomes (N=577)

The managers’ effectiveness was measured in terms of leadership outcomes. Nurses reported that their effort as a nurse increased once in a while (M=1.6, SD = .73) while the effectiveness of the manager in meeting staff and organization requirements was sometimes met (M=2.17, SD=.93). Staff satisfaction regarding the managers methods of leadership used and ways of working with staff were also sometimes met (M=2.19, SD=1.05).

Figure 1. Key of frequency interpretation

8.3. Intercorrelation between Leadership Styles and Outcome Factors

Pearson’s correlation coefficient (r) analysis was used to examine the correlation between leadership styles and outcome factors.

Figure 2. Pearson’s correlation values

There was a positive and highly significant correlation between outcome factors (effectiveness, extra effort and satisfaction) and transformational (r = 0.805, 0.857, 0.817) and transactional leadership styles (r = 0.714, 0.742, 0.712) and a negative significant correlation with passive avoidant leadership style (r = -0.197, -0.265, -0.251). This shows that nurses perceived that managers’ who displayed transformational and transactional leadership styles have a positive effect on leadership outcomes in the clinical setting and were therefore effective managers compared to managers with passive avoidant leadership styles who were perceived to have a negative effect on leadership outcomes.

8.4. Differences in Perceived Leadership Styles Related to Sociodemographic Characteristics

A t-test analysis for two independent samples was conducted to analyze perceived differences between leadership styles related to sociodemographic characteristics. Table 3 shows that there were no significant differences between male and female nurses in regards to using transformational leadership (p ≤ 0.28), transactional leadership (p ≤ 0.44) or passive avoidant leadership style (p ≤ 0.17). However, female nurses mean score was higher in transformational (female = 2.10, male = 1.83) and transactional leadership (female = 2.05, male = 1.05) compared to male nurses whose mean score was higher in passive avoidant leadership style (female = 1.29, male = 1.36). The analysis found a significant difference between females and males in intellectual simulation, domain of transformational leadership (female t = -1.55, male t = -1.79, p ≤ 0.04) with females mean score (2.06) higher than males mean score (1.81). A difference was also found between females and males in the laissez faire subscale of passive avoidant leadership (female t = .11, male t = .12, p ≤ 0.02) with males mean score (1.25) higher than females mean score (1.23). With regards to perceived outcomes of leadership styles, there was a significant difference between females and males regarding the effectiveness of the manager (female t = -1.23 male t = -1.44, p ≤ 0.05) with female nurses mean score (2.20) higher than the males mean score (1.98).

Table 3. Differences in perceived leadership styles, factors and outcomes according to gender

Data analysis relating to age differences found only a significant difference in using laissez faire leadership style (F= 2.764, P= .041). Post hoc comparison using a Tukey test showed that nurses aged 46-55 years had a lower mean score of laissez faire leadership style (M=1.03) than other age groups. This indicates that older nurses are more likely to perceive that their managers use a laissez- faire leadership style compared to younger nurses. A difference was also found relating to effectiveness of leadership styles (F= 2.64, P= .049). Post hoc comparison using a Tukey test showed that nurses aged more than 55 years had a lower mean score (M=1.5) indicating that they perceived their manager to be effective compared to other age groups.

There were no differences found in the nurses’ perception of leadership styles, factors and outcomes relating to level of education, years of work experience or health care sector.

9. Discussion

Effective nursing leadership is an essential factor in assuring the delivery of quality health care services [1]. The nurses’ perception of the managers’ leadership style may influence the ability to deliver care and the quality of patient care outcomes. The findings of this study aim to provide insight into the perception of leadership styles, factors and outcomes in EHC and provide information to further develop nurse leaders to meet the 2030 vision to deliver excellence in health care.

The current study of 577 nurses aimed at identifying perceptions of leadership styles, factors and outcomes shows that nurses perceive that transformational, transactional and passive-avoidant leadership styles are demonstrated by nurse managers working in EHC facilities. However, nurses perceive that manager’s only use transformational and transactional leadership styles occasionally, rather than often, and use passive avoidant leadership styles even less frequently. The fairly low level of perception amongst nurses regarding the frequency of leadership styles used may be due to several factors. As suggested previously [16], leadership ability must be developed and nurtured. The complex nature of EHC where different levels of care are provided in a variety of health care settings may mean that nurses have limited opportunities to develop leadership skills in the clinical setting. Additionally, many nurses working in EHC are educated to diploma level and may not have previously received any education or training to develop leadership competence despite adopting leadership roles due to staffing shortages. The need for educational initiatives to develop leadership competence is emphasised in the literature [30,42]. The importance and role of nursing education in developing leadership competence within EHC facilities has already been acknowledged where succession plan programs to develop nurse leaders at different levels have recently been implemented and as such their effectiveness is yet to be seen.

The analysis shows a positive correlation between leadership outcome factors (effectiveness, extra effort and satisfaction) and transformational and transactional leadership styles and a negative correlation with passive avoidant leadership style. The results support previous studies which also found that transformational leadership styles improved effectiveness, extra effort and satisfaction [27,4,31,32]. One study [4] also found a significant correlation between transactional leadership style and leadership outcome factors but the results identified a weaker correlation compared to those from this study. Conversely, other studies emphasise the importance of transformational leadership styles compared to transactional leadership, as they have a more positive influence on leadership outcome factors. Transactional leadership styles which focus on task completion have resulted in reduced nurse satisfaction and productivity within healthcare settings [10,24,25,26]. Nonetheless, there is a positive correlation between transformational and transactional leadership styles and leadership outcome factors in this study. However, they are not used often enough and must be used more frequently if they to have a positive impact on outcome patterns in the nursing workforce and healthcare environment.

A comparison of sociodemographic characteristics within the nursing workforce found that there are no significant differences in perceived leadership styles relating to gender although mean scores show that females had a higher perception of transformational and transactional styles compared to men who had a higher perception of passive avoidant style. There was a significant difference in the perception of some factors within the leadership domains which is reflected by the higher mean scores. Female nurses perceive that their managers examine and question nursing practice to find new ways of doing things (IS) compared to male nurses who perceive that their managers avoid getting involved and making decisions when important or urgent issues arise (LF). The difference in perceptions of leadership styles between female and male nurses may be due to the manager applying different styles of management according to the nurses’ gender in a male centred society.

10. Recommendations & Implications for Nursing

There is a strong need to implement leadership education and training amongst all nurses. Almost half of the nurses in EHC have a Diploma qualification but their curricula contain no Nursing Management courses. Nursing management and leadership styles and skills need to be part of their continuous education, in-service and Continuous Professional Development. This will allow them to better understand their managers’ leadership skills and provide them with an accurate perception of the leadership styles employed. Furthermore, there is a need to develop Diploma nurses and upgrade their qualifications to enhance their knowledge and skills through Bridging Programs to BSN in order to invest in them as future Nurse Leaders.

Transformational leadership appears to be best suited for nursing as it has positive nursing outcomes (reflected in care effectiveness, extra efforts and satisfaction) that will ultimately and expectedly lead to positive patient outcome. It is recommended to continuously train and educate nurse leaders and those potential leaders in succession planning programs regarding leadership skills and competencies A culture for transformational leadership should be promoted by creating a warm, safe healthy empowering and supportive work climate. The main plan is to transform nursing services by developing effective nurse leaders to meet KSA vision 2030.

The transformation of the healthcare system in Saudi Arabia, and challenges that are inherent, emphasize the importance of ensuring that nurses are effective leaders if organizational needs are to be met in the future. It is therefore important to conduct further qualitative and quantitative nursing research amongst larger nurse populations to provide evidence on how leadership styles are perceived and how they may influence outcomes within the nursing workforce and work environment

11. Limitations

Despite the encouraging results, the study has some limitations. The possibility of sampling bias cannot be excluded although steps were taken to reduce the possibility by inviting all eligible nurses working in EHC facilities to participate in the study. It was hoped that 954 nurses (10.96%) would complete the survey, consistent with a 95% confidence interval and 3% margin of error, in order to ensure that the results were representative of the target sample and reduce the risk of sampling bias

The instrument used in the study consists of 45 questions. It is a lengthy tool that nurses may not have time to respond to and therefore they not complete the questionnaire accurately.

The generalization of the study is also a limitation. Results are limited to EHC staff nurses. It is recommended to replicate the study and conduct it as a multi cluster study on national level using qualitative and quantitative mixed designs methodology

12. Conclusion

The importance of leadership in nursing cannot be understated. Nursing Leadership skills and styles need to be effectively taught and integrated into nursing as they have a positive impact on practice. The effectiveness of ongoing leadership training within the context of CPD needs to be continued. Such developments should promote better practice as well as enhance the organizational culture. It is recommended that EHC continue to develop and support leadership training, while also seeking ways of maintaining and promoting leadership development in practice. Furthermore, there is a need to conduct qualitative and quantitative nursing research within larger nurse populations to provide evidence how leadership styles are perceived and how they may influence outcomes within the nursing workforce and work environment

Acknowledgements

The authors would like to thank Nursing Administrative services in all EHC facilities for their support and encouragement with this study. The IRB at King Fahad Specialist Hospital is also appreciated for their approval of this study.

Conflict of Interest Disclosure

There are no conflicts of interest.

References

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