Staff nurse perceptions of nurse manager leadership styles and outcomes

Journal of Nursing Management, 2011, 19, 478 486 Staff nurse perceptions of nurse manager leadership styles and outcomes JESUS CASIDA PhD, RN, CCRN-CSC, APN-C 1 and JESSICA PARKER MSN, RN, ACNP-BC 2 1 Assistant Professor, Adult Health College of Nursing, Wayne State University, Detroit and 2 Acute Care Nurse Practitioner, Emergency Department, Oakwood Healthcare System, Dearborn, MI, USA Correspondence Jesus Casida 5557 Cass Avenue Cohn Building 352 Wayne State University Detroit MI 48202 USA E-mail: jcasida@wayne.edu CASIDA J. & PARKER J. (2011) Journal of Nursing Management 19, 478 486 Staff nurse perceptions of nurse manager leadership styles and outcomes Aim To explore the correlations of leadership styles of nurse managers (NMs) and outcomes. Background Little is known about the linkages among leadership styles [transformational (TFL), transactional (TRL)] of NMs and outcomes [a leaderõs extra effort (LEE), leadership satisfaction (LS) and effectiveness (LE)] using the full-range leadership theory. Methods An exploratory correlational design was employed using data from a 2007 study in which staff nurses (n = 278) from four hospitals in the Northeastern US were asked to rate the leadership styles of NMs (n = 37) and outcomes using the Multifactor Leadership Questionnaire Form 5x-Short. Data were analysed using descriptive and inferential statistical methods. Results TFL leadership has strong correlations to LEE, LS and LE, and was a predictor for leadership outcomes. Conversely, TRL leadership has week correlations to LEE, LS and LE and did not predict leadership outcomes. Conclusion NMs who frequently display TFL leadership styles will probably achieve goals in a satisfying manner, warranting further research. Implication for Nursing Management TFL leadership training should be a basic competency requirement of NMs. Placing successful and effective TFL leaders in nursing units are the professional and moral obligations of nurse executives. Keywords: acute care hospitals, leadership outcomes, leadership styles, nurse managers Accepted for publication: 18 February 2011 Introduction The health sciences literature is replete with evidence suggesting that the leadership of nurse managers (NMs) directly impacts the performance (e.g. effectiveness) of hospital nursing units. Key to superior performance and organizational effectiveness is the consistent display by NMs of transformational (TFL) leadership behaviours (Casida & Pinto-Zipp 2008). Typically, a TFL leader exhibits vision, charisma, risk taking, out-of-the box thinking and an aptitude for motivating others while acting as a role model and mentor for the follower (Northouse 2010). The TFL leadership behaviours of NMs have been linked to an increase in staff nursesõ (SNs) retention, job satisfaction and empowerment (Laschinger & Finegan 2005, Raup 2008). Moreover, studies show that NMs who frequently utilized TFL leadership had successfully shaped a nursing unit DOI: 10.1111/j.1365-2834.2011.01252.x 478 ª 2011 The Authors. Journal compilation ª 2011 Blackwell Publishing Ltd

Nurse manager leadership styles and outcomes culture that manifested trust, collaboration, confidence, autonomy, shared governance and organizational commitment (Firth-Couzens 2004, Weston 2009). Notably, autonomy is most associated with job satisfaction in the acute care setting (Zangaro & Soeken 2007). Therefore, SNs on a unit with a TFL leader are empowered to meet the mission of the hospital and make a significant impact on the Ôbottom lineõ or financial health of the organization by promoting staff satisfaction and organizational commitment and by encouraging innovative practices (Casida & Pinto-Zipp 2008, Grimm 2010). Another style of leadership behaviour is transactional (TRL) leadership, which complements and enhances the effects of TFL leadership outcomes (Bass & Riggio 2006). For example, a key element of TRL leadership, contingent reward (CR), places a greater focus on rewarding employees for their work. Strategies aligned with CR include verbal praise, financial incentives and public recognition to motivate employees (Northouse 2010). Novice NMs tend to be more comfortable using TRL leadership while expert NMs utilize TFL leadership more frequently and are more versatile with which type of leadership style to use in a given situation (Casida 2007). In spite of the numerous references about first-line nursing leadership (e.g. NMs or head nurses) in the literature, little is known about the relationships of their leadership styles (e.g. TFL and TRL) and leadership outcomes, specifically the leaderõs extra effort (LEE), leadership satisfaction (LS) and leadership effectiveness (LE), within the context of the full-range leadership theory. The full-range leadership theory (FLT) is a multidimensional theory consisting of TFL, TRL and non-transactional leadership paradigms. It depicts a continuum of leadership styles spanning from highly engaged at one-end (TFL) to highly avoidant on the other end (non-transactional). Conceptually, TFL leadership refers to the leaderõs ability to influence others towards achieving extraordinary goals by changing the followersõ beliefs, values and needs. The concept is elaborated further by the following key elements: Idealized influence: attributed (IA) is the socialized charisma of the leader, where he/she is perceived as confident, powerful, ethical and an initiator of higher standards. Idealized influence: behavioural (IB) is the charismatic manifestations of the leaderõs values, beliefs and a sense of mission aligned with organizational goals. Inspirational motivation (IM) is the ways leaders energize their followers by viewing the future with optimism, stressing ambitious goals, projecting and idealizing a realistic vision that is clearly understood by the followers. Intellectual stimulation (IS) is the leader actions that appeal to the followersõ sense of logic and analysis by challenging them to think creatively and find solution to difficult problems. Individualized consideration (IC) is the leaderõs attribute that contributes to the followersõ satisfaction by advising, supporting and attending to the individual needs essential for their professional development and self-actualization. TRL leadership refers to the exchange process based on the fulfilment of contractual obligations in which the leader typically sets objectives and monitors and controls outcomes. The key elements that further elaborate the concept are the following: Contingent reward (CR) is characterized by leaders focusing on clarifying role and task requirements and providing followers with material or psychosocial rewards contingent on the fulfilment of contractual obligations. Management-by-exception (MBE) active refers to the vigilance of the leader whose goal is to ensure that standards are met. Management-by-exception (MBE) passive refers to leaders who only intervene after mistakes or noncompliance has occurred. Non-transactional leadership (i.e. laissez-faire) is the absence of a purposeful interaction between the leader and the follower. These leaders avoid making decisions, abdicate responsibility and do not use their authority (Antonakis et al. 2003). In spite of the global utility of FLT, the present authors could find only one study in the published literature in which a research team used the theory in exploring the correlations of leadership styles and outcomes of first-line nursing unit leaders in hospitals. In a study involving 41 head nurses and 411 SNs from eight hospitals in Belgium, investigators found that the TFL leadership of head nurses was a strong predictor for LEE and LS but a weak predictor for LE (Stordeur et al. 2000). However, to date, no study of this type has been published in the United States. The objective of the present study was, therefore, to explore and describe the correlations of NMsÕ leadership styles and the outcomes conceptualized within the FLT. To meet that objective, we pursued the following specific aims: (1) describe the NMÕs TFL and/or TRL leadership and the presence of LEE, LS and LE as ª 2011 The Authors. Journal compilation ª 2011 Blackwell Publishing Ltd, Journal of Nursing Management, 19, 478 486 479

J. Casida and J. Parker perceived by SNs; (2) identify the correlations of the studied variables; and (3) determine the extent to which TFL and TRL leadership predict LEE, LS and LE variables. Methods Design and sample We employed a descriptive exploratory correlational design using data from a 2007 dissertation study that was approved by five institutional review boards (Casida 2007). The sample of the study consisted of 278 SNs and 37 NMs who consented to participate and subsequently provided usable data. In that sample, 91% of the SNs were females and 7.6% males, mean age of 40.9 (SD ± 10.2) years, and racially diverse (54% White, 30% Asian, 6% Black and 10% mixed/other). About 64% of the SNs were educated at or above baccalaureate level, with mean nursing experience and hospital employment of 14.8 (SD ± 10.3) and 7.9 (SD ± 6.8) years, respectively. Almost all (94.6%) of the NMs were females (5.4% males) with a mean age of 45.7 years, and primarily White (76%). Nearly 81% were educated at or above baccalaureate level. They had mean leadership experience and hospital employment of 9.2 (SD ± 7.2) and 12.1 (SD ± 7.4) years, respectively. This sample (n = 278 SNs) provided an effect size of 0.10, a power of 0.98 and an error probability of a = 0.05 calculated with G*power statistical program version 3.1 (Faul et al. 2009). Measures and data collection The multifactor leadership questionnaire (MLQ), which is based on the FLT, was used to measure the independent variables of TFL and TRL leadership (operationally defined above) and the dependent variables of LEE, LS and LE. The LEE refers to the NMÕs ability to influence followers in achieving their potentials above and beyond the benchmark or usual results. The LS is an outcome of the NMÕs ability to meet the needs of the followers through positive communication, interaction and other strategies such as an Ôopen-doorÕ policy and increased visibility, thus keeping his/her SNs happy and satisfied with their work. Finally, the LE is a consequence of the NMÕs ability to satisfy SNs, as evidenced in creating and maintaining a positive work environment and successfully meeting organizational needs and outcomes (Bass & Avolio 2004). For the present study, 41 items (out of 45) in the MLQ Form 5x-short (rater form) were included in the analysis, which consisted of five leadership scales (TFL, TRL, LEE, LS and LE) and eight subscales [key elements of TFL (n = 5) and TRL (n = 3) described previously]. The MLQ uses a five-point (0 4) response Likert scale, with 0 indicating a complete absence of leadership and 4 indicating that a particular leadership style is Ôfrequently, if not alwaysõ utilized by the NM. Several studies (including the present) utilizing the MLQ Form 5x-short showed consistent, strong reliability coefficients (a > 0.90) and robust validity with a confirmatory factor index of 0.91 and goodness of fit of 0.92 (Antonakis et al. 2003). This version of the MLQ is the most common instrument used in nursing leadership research, and has shown stable validity results in different leadership roles, organizations, gender and cultures worldwide (Bass & Avolio 2004, Casida 2007). In the dissertation study, SNs and NMs were asked by the researcher to complete demographic questionnaires. The SNs then completed the MLQ to evaluate the leadership styles and outcomes of their NMs. To minimize threats of internal validity, SNs were instructed to complete the questionnaire in the staff lounge with the door locked, and a drop box was provided for return of completed MLQ and demographic questionnaires. The researcher retrieved the questionnaires and collected demographic data from individual NMs. Then, the data were entered into a Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, USA) spreadsheet. Data analysis We calculated the means and standard deviations of all scales, subscales and items showing a normal distribution of data. Next, we identified the relationships among the leadership variables using PearsonÕs moment correlational analyses. Finally, multiple linear regression analyses were employed to determine which leadership style of NMs predicts a specific leadership outcome. We used SPSS version 18.0 software for data analyses. Results Descriptive statistics for the SNsÕ perceptions of their NMsÕ leadership styles and the leadership outcomes are presented in Table 1. In the present study, we found that NMs fairly often displayed leadership styles that were consistent with TFL and contingent-reward (CR) leadership, as shown by MLQ mean scores of >2.6 (out of 4.0). In addition, SNs perceived their NMs/leadersÕ extra effort favourably (mean = 2.65) and indicated 480 ª 2011 The Authors. Journal compilation ª 2011 Blackwell Publishing Ltd, Journal of Nursing Management, 19, 478 486

Nurse manager leadership styles and outcomes Table 1 Descriptive statistics for the staff nurse perceptions of nurse manager leadership styles and outcomes Leadership styles and outcomes Means Standard deviations Transformational leadership 2.78 0.84 Idealized influence (attributed) 2.85 0.97 Idealized influence (behaviour) 2.71 0.88 Inspirational motivation 3.00 0.86 Intellectual stimulation 2.66 0.93 Individual consideration 2.65 1.04 Transactional leadership 2.10 0.48 Contingent reward 2.86 0.94 Management-by-exception (active) 2.40 0.95 Management-by-exception (passive) 1.06 0.91 LeaderÕs extra effort 2.65 1.10 Leadership satisfaction 2.94 1.01 Leadership effectiveness 2.91 0.97 that they were satisfied with their NMsÕ leadership effectiveness (means = 2.94 and 2.91, respectively). Table 2 illustrates the correlations between the NMsÕ leadership styles and outcomes. TFL leadership demonstrates positive, strong and significant correlations with LEE, LS and LE. Conversely, the strength of positive and significant correlations between TRL leadership, LEE, LS and LE was weak. However, it is worth knowing that CR leadership was positively and significantly correlated with LEE, LS and LE. Finally, we found that negative correlations among managementby-exception (MBE) passive (a TRL trait) and LEE, LS and LE were also strong. Table 2 Correlations among nurse manager leadership styles and outcomes Leadership styles and key elements Leadership outcomes Extra effort Satisfaction Effectiveness PearsonÕs r Transformational leadership 0.83* 0.82* 0.89* Idealized influence 0.80* 0.80* 0.86* (attributed) Idealized influence 0.66* 0.73* 0.77* (behaviour) Inspirational motivation 0.70* 0.71* 0.79* Intellectual stimulation 0.77* 0.73* 0.79* Individual consideration 0.82* 0.76* 0.84* Transactional leadership 0.29* 0.27* 0.28* Contingent reward 0.74* 0.76* 0.82* Management-by-exception 0.23* 0.19* 0.19 (active) Management-by-exception (passive) )0.54* )0.55* )0.62* All correlation is significant at the 0.01 level (two-tailed). *P < 0.0001; P = 0.003. Results of multiple linear regression analyses are summarized in Table 3. More than 67% of the effects on leadership outcomes (LEE, LS and LE) can be explained by TFL and TRL variables; however, the best predictor for these outcome variables was TFL leadership. Further, another set of regression analyses was done to identify the extent to which any the five TFL leadership subscales [idealized influence: attributed (IA), idealized influence: behaviour (IB), inspirational motivation (IM), intellectual stimulation (IS) and individual consideration (IC)] presented in Table 2 predict a specific leadership outcome. We found that 71.2% of the effects on the LEE can be explained by the combination of IA, IS and IC, but the best predictor for LEE was IC (b = 0.4, P<0.0001). Moreover, 68.6% of the effects on the LS variable can be explained by the combination of IA, IB and IC, but the best predictor for the LS variable was IA (b = 0.4, P < 0.001). Although 80.2% of the effects on the LE can be explained by IA, IM and IC, we found that IA (b = 0.4, P < 0.0001) was the best predictor for the LE variable (Table 4). Discussion The present study explicated the positive relationships among TFL leadership augmented by CR and the outcomes of LEE, LS and LE within the context of first-line nursing leadership in acute care hospitals in the Northeastern United States. TFL leadership was found as a strong predictor for all leadership outcome variables. Interestingly, two out of the five TFL leadership subscales, IC and IA, were the strong contributors for TFL leadership as predictors for LEE, LS and LE (Table 4). In spite of the strong correlations between CR (a TRL trait) and LEE, LS and LE, TRL leadership variables were not a predictor for any of the three leadership outcomes. As expected, the weak and negative strong correlations among MBE passive and MBE active, LEE, LS and LE suggest that these TRL leadership behaviours utilized by the NMs participating in the 2007 study (Casida) were unfavourable to SNs. Nonetheless, these findings were inconsistent with the results reported by the Belgian research team (Stordeur et al. 2000) in three major areas. One, they found strong, positive correlations among TFL leadership, LEE and LS, but correlations between TFL leadership and LE were weak. Two, positive but weak correlations among CR, MBE active, LEE, LS and LE were found. Three, they also found weak, negative correlations among MBE passive, LEE, LS and LE. Several aspects that might have contributed to the contrasting results between the two studies include but ª 2011 The Authors. Journal compilation ª 2011 Blackwell Publishing Ltd, Journal of Nursing Management, 19, 478 486 481

J. Casida and J. Parker Table 3 Transformational leadership as strong predictor of nurse manager leadership outcomes Leadership outcomes Extra effort Satisfaction Effectiveness Leadership styles R 2 b P R 2 b P R 2 b P Transformational leadership 0.678 0.827 <0.0001 0.673 0.833 <0.0001 0.786 0.904 <0.0001 Transactional leadership )0.006 )0.031 )0.047 All R 2 are adjusted values; b, standardized coefficients. Table 4 Key elements of transformational leadership predicting nurse manager leadership outcomes Leadership outcomes Extra effort Satisfaction Effectiveness Elements of transformational leadership styles b P b P b P Idealized influence: attributed (IA) 0.33 <0.0001 0.39 <0.001 0.40 <0.0001 Idealized influence: behaviour (IB) )0.09 NS 0.20 0.004 0.04 NS Inspirational motivation (IM) 0.10 NS 0.05 NS 0.16 0.005 Intellectual stimulation (IS) 0.18 0.021 0.01 NS )0.01 NS Individual consideration (IC) 0.38 <0.0001 0.20 0.010 0.28 <0.0001 b, standardized beta coefficient; NS, not significant (P > 0.05). are not limited to: (1) instrumentation, (2) organizational context, (3) national culture and (4) sample. First, Stordeur et al. (2000) had employed the older version of the MLQ and a different measurement tool for LE, which may not have had psychometric property equal to the current MLQ Form short-5x. Second, in the present study the NMsÕ roles took place in a potentially influential context; 82% were employed in two magnet hospitals and in one hospital about to receive its magnet status. Nursing leadership in magnet hospitals has long been recognized as exemplary consistent with TFL leadership styles, vs. leadership from those employed by non-magnet hospitals (Kramer et al. 2010). Results of a meta-analysis revealed that the TFL leadership of NMs in magnet hospitals is an essential structural and organizational processes component paramount for creating healthy work environments (Kramer et al. 2010). Some features of healthy work environments, aside from quality leadership at all levels, included an integrated structure for SNsÕ professional development, autonomous and collaborative practice, sufficient staffing, and reward and recognition practices that are consistently implemented. Notably, evidence suggesting that healthy work environments mediate positive patient care outcomes is emerging (Kramer et al. 2010). The third aspect contributing to the differences in the findings is national culture. Although the link between national culture and individual leadership styles has not been clearly examined in nursing, it is worth mentioning that the strong correlations among TFL, CR leadership, LEE, LS and LE in the present study can be attributed to the American culture. In business, Americans are viewed as competitive, goal and results oriented; a typical feature found in Anglo societies. On the contrary, in Latin European (e.g., Belgium) societies, people tend to place highest value on their individual autonomy rather than the competitive group values (Northouse 2010). Based on this distinction, some TFL leadership styles such as supporting, advising, mentoring, satisfying and concerns on meeting the needs of the SNs may not have been frequently displayed by the head nurses who participated in the Belgian study. Finally, a disproportion in the gender composition of the sample between the two studies is another factor that explains the contrasting results. The proportion of female participants in the present study was higher than the Belgian study, 93% and 88%, respectively. Several meta-analytic studies synthesized by Marshall (2011) and Northouse (2010) showed slight differences in leadership styles and outcomes between males and females, which maybe context-dependent (e.g. roles and settings). For example, in the military services, males tend to excel more than females, while in healthcare and education services the opposite appears. Interestingly, 482 ª 2011 The Authors. Journal compilation ª 2011 Blackwell Publishing Ltd, Journal of Nursing Management, 19, 478 486

Nurse manager leadership styles and outcomes females have higher propensity in utilizing TFL and CR leadership styles than males; a finding supported by the present study. In spite of the contrasting results, the present study findings are consistent with empirical evidence that effective nursing unit leaders utilize TFL behaviors more frequently than TRL leadership in studies involving managers from different types and levels of organizations, including nursing units of acute care hospitals (Bass & Avolio 2004, Casida & Pinto-Zipp 2008). Likewise, the correlations between CR and leadership outcomes validated the theoretical assumption that CR may augment the effects of TFL leadership, which has been linked with effective performance of nursing units. These included high patient satisfaction ratings, low SN turnover and decreased infection rate and hospitalization days (Casida & Pinto-Zipp 2008). In view of the high correlations between CR and leadership outcome variables, however, CR was not found as an independent predictor for LEE, LS and LE. This finding is linked with the evidence that CR leadership behaviour is resource dependent, which worked best in business settings where tangible rewards (e.g. financial incentives) is a common practice for recognizing an employeeõs efforts or performance (Judge & Piccolo 2004). NMs should leverage the CR concept through constant praising of SN excellent performance, flexibility with work schedules to accommodate staff personal and professional needs (e.g. continuing education), giving time off in exchange for doing work outside direct patient care (e.g. data collection, committees and publications) and similar rewards. However, research is still needed to: (i) examine the nature and type of CR practices among NMs in magnet and non-magnet hospitals in the US and across the globe, and (ii) determine the extent to which these practices predict and explain the impact of CR on NMsÕ leadership outcomes. The SNsÕ perceptions of the frequent display of their NMsÕ TFL leadership styles can also be explained by the demographic data. In the present study, NMs were primarily comprised of experienced and highly educated (80% had baccalaureate or masterõs degrees) leaders who regularly attended (84%) continuing leadership trainings. According to Ohman (2000), years of experience and educational levels beyond baccalaureate degrees are antecedent variables that can positively influence NMs to be TFL leaders. Another aspect that elucidated the frequency of TFL leadership behaviours by the NMs was that they were purposely selected in the dissertation research that tested the implicit theoretical understanding that leadership influences organizational culture and vice versa (Casida 2007). One of the eligibility criteria to partake in the earlier research was that the NMs were leaders of Ôhigh performingõ nursing units that consistently met or exceeded the healthcare systemõs benchmark for quality and cost-effective patient care driven by nursing interventions. In that research, Casida (2007) found that TFL leadership was strongly and positively correlated with organizational culture traits and a strong predictor for a specific organizational culture aligned with the strategic plan of the hospital and organizational effectiveness. Thus, the desirable leadership behaviours for NMs to frequently utilize is TFL leadership, given that high-performing nursing units can significantly contribute to the hospitalõs bottom line or cost effectiveness (Casida & Pinto-Zipp 2008). In the present study, two key leadership elements were found as strong contributors for TFL leadership predicting LEE, LS and LE variables. The subscale IC was a predictor for LEE, whereas IA was a predictor for LS and LE. These results have been described in research involving first-line, middle and senior managers in private and public organizations (Lowe et al. 1996, Judge & Piccolo 2004), but have not been explored by nurse-scientists and other health science investigators. In the nursing context, NMsÕ behaviours that typify IC include mentoring, advising, coaching, supporting and other actions that facilitate self-actualization of SNs, which translated to the followersõ perceptions of their leaderõs Ômaking an extra effortõ. Collectively, these behaviours can mobilize or persuade SNs to achieve more and strive towards excellence, a foundational concept of TFL leadership that should be leveraged by NMs. Therefore, NMs must be guided by the evidence showing that TFL leadership is most likely to drive SNs to effectively contribute to the organization (Leach 2005). NMs who frequently utilize IA, a specific behaviour exemplifying the charisma, confidence and ethical and moral attributes of a leader, can achieve both LE and LS. The charismatic capacity IA involves the ability to interact with others while displaying confidence and accessibility, a key attribute of an effective leader (Kirk 2009). NMs can capitalize on this leadership style to identify the individual needs of SNs, build trust and confidence and engage the group in activities that promote fulfillment, thereby satisfactorily meeting SNsÕ needs and the needs of the nursing unit. Thus, NMs who demonstrate integrity and charisma are more likely to influence SNsÕ job satisfaction, organizational commitment and retention, all of which has a significant impact on patient outcomes and viability of the hospital ª 2011 The Authors. Journal compilation ª 2011 Blackwell Publishing Ltd, Journal of Nursing Management, 19, 478 486 483

J. Casida and J. Parker (Failla & Stichler 2008, Wong & Cummings 2009, Weberg 2010). Limitations and implications The findings illustrated in the present study should be interpreted cautiously. The methods we employed, particularly the non-probability sampling and use of secondary data, limit the validity and generalizability of results. In view of these limitations, implications related to the education, practice and research on first-line nursing unit leaders can be drawn from the study findings. Leadership can, and should, be taught. TFL leadership concepts should be included in curricular content and emphasized in the educational preparations, continuing education programmes and leadership trainings designed for NMs within or outside academic settings. The successes of NMsÕ role effectiveness have been linked to higher educational levels, organizational support and the mentorship available to them (Marshall 2011). Therefore employers, particularly hospital administrators and/or senior nurse executives, have the moral and professional obligation to assist first-line nursing leaders in acquiring and demonstrating the best or evidenced-based leadership practices, such as TFL leadership, in a contemporary healthcare system. Given the predictive power of the two key elements on NMsÕ perceived LEE, LS and LE, nurse executives should place an emphasis on using IC and IA as a guiding framework for assisting novice NMsÕ in demonstrating TFL leadership competencies. Shaping NMs who espouse and practice TFL leadership styles requires extra effort and time, as well as perseverance from nurse executives who assume the obligations as mentors and direct report for the NMs. Investing and committing to producing prepared, capable and effective leaders in the nursing units are paramount to contributing to the mission and bottom line of a hospital. At the patient care unit level, NMsÕ leadership is crucial in influencing staffõs understanding and commitment with the mission of the healthcare organization, through educating, coaching or advising, supporting and developing staff to self-actualize (Hader 2006); a leadership style that typifies the IC and IA elements of TFL. Aligning the nursing unitõs staff values with the mission of a hospital will result in a positive environment and organizational effectiveness (Hader 2006, Casida & Pinto-Zipp 2008). A resultant effect of frequent utilizations of TFL behaviours among NMs has been linked to a positive or healthy work environment. Consequently, an increase in job satisfaction, nurse retention, empowerment and professional commitment are manifested by SNs (Espinoza et al. 2009, Kramer et al. 2010). These leadership behaviours significantly and positively impact nursing unit performance and the hospitalõs overall organizational outcomes such as high patient satisfaction ratings, costeffective quality care and decreased cost as a result of lower staff turnover (Larrabee et al. 2003, McCutcheon et al. 2009). Indisputably, NMs are key stakeholders, and perhaps have the most difficult job in acute care hospitals today. Their role and leadership contributions, particularly in the US, will be challenged as the healthcare delivery system and nursing profession is in the midst of transformation. Recently, The Institute of Medicine (IOM 2010) released a report in which nurses are charged (and expected) to lead the transformation, not reform, of the system where healthcare is delivered. In the acute care setting, NMs will play a crucial role in implementing the majority of the recommendations in the IOM report outlined in Table 5. Utilizations of TFL leadership by NMs are strategic actions to successfully achieve a positive implementation outcome. With the growing evidence of the correlations of NMsÕ TFL leadership and higher educational level beyond baccalaureate degrees, administrators must reflect on their hiring practices. For example, basing candidatesõ clinical experience alone, without due considerations on the educational level, should be abandoned as clinical Table 5 The 2010 Institute of Medicine Report: the future of nursing: leading change, advancing health Key messages Nurses should practice to the fullest extent of their education and training Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression Nurses should be full partners, with physicians and other healthcare professionals, in redesigning health care in the United States Effective workforce planning and policy making require better data collection and an improved information infrastructure Specific recommendations Remove scope-of-practice barriers Expand the opportunities to lead and diffuse collaborative improvement efforts Implement nurse residency programmes Increase proportion of nurses with baccalaureate degree to 80% by 2020 Double the number of nurses with a doctorate degree by 2020 Ensure that nurses engage in lifelong learning Prepare and enable nurse lead change to advance health Build an infrastructure for the collection and analysis of inter-professional health care workforce data 484 ª 2011 The Authors. 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Nurse manager leadership styles and outcomes excellence does not necessarily equate to attributes of effective leadership (Espinoza et al. 2009). More research is needed to validate the findings limited to the setting in which the present study was conducted. To enhance validity and generalizability of the findings, future research should employ randomized sampling procedure and include low and high performing nursing units to discriminate effective vs. ineffective leadership outcomes from different types of hospitals (e.g. for profit and not-for-profit, community, tertiary, academic and military) in the US and beyond. Further examination and understanding of the assumed variations in leadership practices, organizational contexts, national culture and demographic variables within and between countries is worth investigating to establish a robust explanatory base of the NMsÕ leadership and outcomes. Conclusion The present study supports and expands the knowledge of the frequent utilization of TFL over TRL behaviours by NMs in acute care hospitals in the US and beyond. Specific leadersõ behaviours that aligned with IC and IA (two key elements of TFL leadership) such as charisma, integrity, supportive style, mentorship, the aptitude to encourage excellence, the ability to identify needs of staff and other positive behaviours are paramount in achieving leadership effectiveness and satisfaction. Thus, the NM who displays TFL style frequently will likely achieve his/her leadership goal effectively in a satisfying way. The notion that TFL leadership behaviours are solely for nurse executives is unequivocally refuted by the growing body of evidence that the TFL leadership of NMs has a significant influence in achieving a hospitalõs strategic goals. Therefore, demonstration of TFL leadership behaviours must be a basic competency requirement for NMs. Key to the viability of the hospital is the positive patient care outcomes through SNsÕ autonomy, retention and satisfaction, emanating from the grassroots of patient care the nursing units. This upward organizational influence can be achieved by NMs who espouse and practice TFL leadership. References Antonakis J., Avolio B.J. & Sivasubramaniam N. (2003) Context and leadership: an examination of the nine-factor full-range leadership theory using the Multi-factor Leadership Questionnaire. The Leadership Quarterly 14, 261 295. Bass B.M. & Avolio B.J. (2004) Multi-factor Leadership Questionnaire Manual and Sampler Set, 3rd edn. Mind Garden, Redwood City, CA. Bass B.M. & Riggio R.E. (2006) Transformational Leadership, 2nd edn. Lawrence Earlbaum, Mahwah, NJ. Casida J. 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