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LEADERSHIP STYLE OF CHIEF NURSE EXECUTIVES IN MAGNET STATUS

HOSPITALS

by

Mary Davis

A Dissertation Presented in Partial Fulfillment

of the Requirements for the Degree

DOCTOR OF MANAGEMENT IN ORGANIZATIONAL LEADERSHIP

UNIVERSITY OF PHOENIX

JULY 2007


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Copyright 2007by

Davis, Mary

All rights reserved


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2007

ALL RIGHTS RESERVED


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LEADERSHIP STYLE OF CHIEF NUR SE EXECUTIVES IN MAGNET STATUS

HOSPITALS

by

ary

E

H

Davis

May

2 7

Approved:

Mentor

Committee Member

Committee Member

Dawn Iwamoto EdD

Dean School of Advanced Studies

University of Phoenix

Month Day

ye


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ABSTRACT

The purpose of this quantitative descriptive correlational study was to investigate a

correlation between leadership style and outcomes of chief nurse executives in Magnet

Status hospitals in the United States and explore if there was a dominant leadership style

being used by the chef nurse executives. The research questions guiding the study were 1.

What is the relationship between the chief nurse executives leadership style and extra

effort, 2. What is the relationship between the chief nurse executives leadership style and

effectiveness and 3. What is the relationship between the chief nurse executives

leadership style and the nurse managers level of satisfaction with the chief nurse

executives leadership?

The MLQ-5x by Avolio and Bass (2004) was used as the survey tool to collect data from

the participants. The data was analyzed using the SPSS software to perform descriptive

and correlational analysis. The leadership style explored in the study was the

transformational, transactional and laissez-faire. Overall results from the data revealed

that there was a positively statistical significance correlation between leadership style,

extra effort, effectiveness and satisfaction. The findings also revealed a dominant

leadership style being used among participating Magnet Status Hospital within the United

States. Further studies should be initiated to investigate the leadership styles of the non-

Magnet Status hospitals and determine if there is a dominant style being used by their

chief nurse executives.


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DEDICATION

I dedicate this dissertation in memory of my loving husband Minister Rudolph Davis,

who supported me through most of my doctoral studies and dissertation process before

suddenly slipping away home to be with the Lord. I also dedicate this dissertation to the

memory of my parents James and Captoria Hardy-Hawkins for their love and their

encouragement to strive for the best in whatever I do. To my son Rudolph Deandr, my

daughter Annie Lee and my son-in-law Steve, and my grandson Deandr Daquan, who

looks after Grandma, thank you all for your love and support and for being there for me.


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ACKNOWLEDGMENTS

I first give honor to God for my Lord and Savior Jesus Christ, who is head of my

life. I thank Him for His word and presence at all times. I thank Him for when I look

around and see no physical being, He is there, and He sends others into our life according

to our needs.

I would like to acknowledge others the Lord placed in my life: Dr. Lloyd

Williams, my mentor, and Dr. Deborah Schaff Johnson and Dr. Rhonda Waters, my

committee members. I am eternally grateful to each of my dissertation committee

members for being there, for their support, encouragement, and guidance. I would like to

also acknowledge my University of Phoenix cohort for their friendship and support,

especially my learning team members Dr. Quelanda Clark and Dr. Alice Gobeille.

To some very special caring people God placed in my life: Dr. Ted Sun, a

wonderful person and great coach, Dr. Steve Creech, a brilliant statistician with the

patience of Job and the wisdom of Solomon; Toni Williams, a very meticulous editor;

and Dr. Denise Jenkins, the best academic counsel.

I also want to thank the Magnet Status hospital participants for taking part in this

study, for without their participation the study could not have been conducted.

Finally, I thank a very special person, my pastor and bishop, Bishop Moses

Williams, Jr., a true man of God, for his constant prayers of encouragement and support,

and the Love of God, church, and family.


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TABLE OF CONTENTS

LIST OF TABLES............................................................................................................... 7

CHAPTER 1: INTRODUCTION........................................................................................8

Background of the Problem ...............................................................................................10

Statement of the Problem...................................................................................................16

Purpose of the Study.......................................................................................................... 17

Significance of the Study to the Problem ..........................................................................18

Significance of the Study to Leadership............................................................................20

Nature of the Study............................................................................................................ 22

Research Questions............................................................................................................ 26

Hypotheses......................................................................................................................... 26

Hypothesis 1 ............................................................................................................... 27

Hypothesis 2 ............................................................................................................... 27

Hypothesis 3 ............................................................................................................... 27

Theoretical Framework...................................................................................................... 27

Transformational Leadership......................................................................................30

Transactional Leadership............................................................................................32

Laissez-faire Leadership.............................................................................................33

Multifactor Leadership Questionnaire ...............................................................................34

Definition of Terms............................................................................................................34

Assumptions....................................................................................................................... 36

Scope of Study ................................................................................................................... 37

Limitations ......................................................................................................................... 38


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Delimitations...................................................................................................................... 39

Summary............................................................................................................................ 39

CHAPTER 2: REVIEW OF THE LITERATURE............................................................41

Title Searches, Articles, Research Documents, and Journals ............................................41

General Systems Theory....................................................................................................49

Models of Patient Care.......................................................................................................57

Total Patient Care Model............................................................................................58

Functional Patient Care Model...................................................................................58

Team Nursing Model..................................................................................................59

Primary Care Model ................................................................................................... 60

Patient Satisfaction............................................................................................................. 60

Employee Job Satisfaction.................................................................................................62

Nursing Shortage ............................................................................................................... 63

Leadership Styles............................................................................................................... 66

Autocratic Leadership.................................................................................................68

Laissez-Faire Leadership............................................................................................69

Participative Leadership .............................................................................................70

Transactional Leadership............................................................................................71

Transformational Leadership......................................................................................71

Overview of Magnet Status Hospitals ...............................................................................73

Conclusion ......................................................................................................................... 75

Summary............................................................................................................................ 77

CHAPTER 3: METHOD...................................................................................................78


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Research Design................................................................................................................. 80

Appropriateness of Design.................................................................................................82

Feasibility and Appropriateness.........................................................................................83

Research Questions............................................................................................................ 84

Hypotheses......................................................................................................................... 85

Hypothesis 1 ............................................................................................................... 85

Hypothesis 2 ............................................................................................................... 85

Hypothesis 3 ............................................................................................................... 85

Data Analysis ..................................................................................................................... 85

Power Analysis .................................................................................................................. 87

Population .......................................................................................................................... 88

Sampling Frame................................................................................................................. 90

Informed Consent............................................................................................................... 91

Confidentiality ................................................................................................................... 93

Geographic Location.......................................................................................................... 93

Instrumentation .................................................................................................................. 94

Data Collection .................................................................................................................. 95

Descriptive Analysis...................................................................................................96

Correlational Analysis ................................................................................................96

Validity and Reliability......................................................................................................97

Internal Validity.......................................................................................................... 98

External Validity......................................................................................................... 99

Reliability ................................................................................................................. 100


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Summary.......................................................................................................................... 101

CHAPTER 4: RESULTS.................................................................................................103

Research Design............................................................................................................... 104

Data Analysis................................................................................................................... 104

Frequency and Hypothesis Testing..................................................................................113

Correlational Analysis ..................................................................................................... 115

Findings............................................................................................................................ 116

Summary.......................................................................................................................... 127

CHAPTER 5: CONCLUSIONS AND RECOMMENDATIONS...................................129

Limitations ....................................................................................................................... 133

Implications...................................................................................................................... 134

Recommendations............................................................................................................ 135

Summary.......................................................................................................................... 136

REFERENCES ................................................................................................................ 139

APPENDIX A: Multifactor Leadership Questionnaire 5X-Short ...................................155

APPENDIX B: Informed Consent Form .........................................................................160

APPENDIX C: Demographic Data..................................................................................162

APPENDIX D: Consent to Use Multifactor Leadership Questionnaire..........................164

APPENDIX: E MLQ Scale Scores..................................................................................165

APPENDIX F: Histograms..............................................................................................186


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LIST OF TABLES

Table 1 Summary of Literature Review by Search Topic ..................................................43

Table 2Age of Participants in the Study .........................................................................105

Table 3Marital Status .....................................................................................................106

Table 4Participants Gender..........................................................................................107

Table 5Educational Level of Participants ......................................................................107

Table 6 Years Working in Present Position .....................................................................109

Table 7Nurse-to-Patient Ratio........................................................................................110

Table 8Retention Rate.....................................................................................................110

Table 9Employee Satisfaction.........................................................................................112

Table 10Extra Effort Correlations (N = 37)...................................................................114

Table 11MLQ Statistics...................................................................................................116

Table 12 Correlation Effectiveness (N = 37)...................................................................120

Table 13 Satisfaction Correlation....................................................................................123


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CHAPTER 1: INTRODUCTION

Health care organizations continue to be challenged by nursing shortages (Coile,

2001) that are the result of nurses retiring as well as a declining interest in entering the

nursing field. The current shortage exceeds 120,000 nurses in all fields, which seriously

diminishes the quality of health care in the United States (Gelinas & Loh, 2004;

Hassmiller & Cozine, 2006; Kleinman, 2004c). Health care organizations require leaders

to improve customer satisfaction for constituents (Coile). Decreases in quality care,

employee job satisfaction, and employee morale contribute to the concerns health care

leaders, including chief nurse executives, encounter in health care in the United States

(Coile; Upenieks, 2002). Research suggests many variables contribute to the challenges

and organizational resistance faced by health care leaders, including high job turnover

and escalating health care costs (Coile; Upenieks, 2002).

Health care challenges for chief nurse executives often occur in Magnet Status

hospitals. Magnet Status hospitals are facilities that have reputations of being excellent

with low turnover rates in personnel, high job satisfaction among employees at all levels

of the organization, and leaders that work well with diverse populations (Upenieks,

2003a). The position of chief nurse executive is important to hospital organizations, as

chief nurse executives seek to lead organizations within the existing economic and

political environments to become facilities identified as excellent (Coile, 2001; Upenieks,

2002). The study assessed the possible correlation between leadership style and

leadership outcomes of chief nurse executives that achieved Magnet Status hospital

recognition. Research suggests the leadership style of the chief nurse executive influences

the culture of the organization (Gillespie & Mann, 2004). Chief nurse executives in


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health care organizations have multiple functions with limited resources and conflicting

demands for times and resources (Colvard, 2003). Additionally, chief nurse executives

are responsible for establishing performance priorities, creating work processes, and

overseeing the performance of multiple job functions (Colvard).

According to Hassmiller and Cozine (2006), hospitals have experienced shortages

of nurses in the past as well as in the present. The current nursing shortage is driven by a

decrease in the population of health care workers, a decrease in the number of individuals

entering the health care field, an aging workforce population, unsatisfying work

environments, a decrease in job satisfaction, and complex leadership styles (Hassmiller &

Cozine). It is believed that chief nurse executives implement leadership styles that

increase the overall success of quality care and have the capability to influence

employees to be more productive by recognizing the employees contribution to

organizational goals, providing a supportive work culture, and implementing a work

culture built upon teamwork and trust (Meterko, Mohr, & Young, 2004).

Changes in health care such as shifts in markets and reimbursement strategies

have caused competition among institutions. The competition has led to organizational

restructuring to increase patient satisfaction and employee satisfaction through power

sharing (Reinhardt, 2004; Taccetta-Chapnick, 1996; Trofino, 2003). Such changes

require new leaders with vision who can guide an organization through challenging times

(Reinhardt).

Health care organizations need chief nurse executives whose style of leadership

gives them the confidence to make decisions, who accept responsibility for functions

outside of their expertise, and who can rely on others to provide information and validate


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facts (Parran, 2004). As the highest level of nursing personnel within hospitals, chief

nurse executives have an obligation to ensure the effectiveness of nursing practice,

including (a) ensuring the safety of the organizations constituents with a balance

between production, efficiency, and reliability; (b) creating and sustaining a trusting

organization; (c) managing the change process; (d) involving employees in the decision-

making process and in processes pertaining to work design and work flow; and (e) using

knowledge-based management practices to establish the organization as a learning

organization (Parran).

Chapter 1 presents the specific problem and the theoretical implications of the

study, introduces previous work in the area, and outlines the design of the investigation.

Chapter 1 also outlines the research methodology chosen. The findings from the study

add to the literature and body of knowledge with some implication for leadership

practice. The focus of the study is to explore whether there is a correlation between

leadership style and leadership outcomes among chief nurse executives whose health care

facilities achieved Magnet Status hospital recognition.

Background of the Problem

Effective and efficient leadership in the field of nursing is an important factor in

the delivery of quality health care. Gelinas (2000) noted a solution to the concerns in the

nursing field is a variation of leadership styles such as transformational leadership.

Health care facilities need leaders who know how to work with diverse populations and

how to address organizational issues. Leaders, such as chief nurse executives, who

engage in positive health care practices and who demonstrate empathy for customers

could increase patient and employee satisfaction within health care organizations


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(Gelinas & Loh, 2004). This research study focuses on health care facilities that achieved

Magnet Status.

In 1982, the American Nurses Association sponsored an original hospital study

that resulted in the designation of 41 hospitals across the United States as Magnet Status

hospitals (Kramer, 1990). Magnet Status hospitals were chosen because they have been

identified by the American Nurses Credentialing Center (ANCC) as being excellent

facilities that provide quality care to patients, have a high rate of job satisfaction among

employees, and have low turnover rates in employment (Upenieks, 2003a). Turnover

rates are the percentage of employees separated from their job within 1 year of

employment. Organizations compute employee turnover rates according to the following

formula (Gillies, 1989):

___Number of terminations per year_____ x 100 = Annual turnover rateAverage number of employees for the unit

According to Gillies (1989), the annual nurse turnover rate in hospitals is 30%.

Kramer (1990) noted that when the national turnover rate of registered nurses (RNs) in

acute care hospitals was 25%, the Magnet Status hospital turnover rate ranged from 2%

to 27%, with a median turnover rate of 9%. Upenieks (2003a) identified Magnet Status

hospitals as excellent facilities and claimed the Magnet Status hospitals chief nurse

executives work well with diverse populations within and outside of their practicing

facility. According to Upenieks (2003c), the leadership styles of chief nurse executives

are of immense value in the functioning of the health care environment.

Kramer and Schmalenberg (1998a) noted some of the reasons for the nursing

shortage in the 21st century are (a) high turnover rates among nursing personnel, (b)

constant orientation of new personnel, and (c) lack of commitment and identification with


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institutional values and goals. Other factors that contribute to the shortage of nurses are

the high percentage of inexperienced staff, the large numbers of per diem nurses and

agency personnel, and a nursing staff that does not consistently work together (Kramer &

Schmalenberg, 1998a). Many hospitals hire agency nurses and travelers who work for a

limited assignment in the facility and receive pay at rates 50% to 100% higher than the

rates of hospital-owned nurses (Coile, 2001, p. 224). Hospital-owned nurses are

employed by the hospital as full-time employees (Coile). The regular use of travelers and

agency nurses is seen as a cause of low morale and job dissatisfaction among nurses

(Kramer & Schmalenberg, 1998b). One third of nurses surveyed in Armstrong (2004)

reported dissatisfaction with their workloads and with staffing issues as the determining

factors for departure from the workforce.

The nursing shortage crisis has created a culture that promotes distrust and

negative behavior among employees who are not held accountable for their work

performance (Rantz, Zazworsky, Zerull, & Cohen, 2004). Baker, Greenberg, and

Hemingway (2006) identified different work cultures within organizations. The culture of

blame was identified as a culture in which a climate of resentment or fear persisted within

the workplace and where employees were pessimistic about their future. The culture of

ambition and the culture of success were identified as the more successful cultural

models. The nurses within the cultures of ambition and success were more satisfied with

their work and felt they could achieve their personal and professional goals (Baker et al.),

which indicates that workforce culture affects employees job satisfaction.

Organizational culture is a way of thinking, believing, and behaving that

organizational members have in common (Marquis & Huston, 2003). Organizational


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culture encompasses the background of organizational behavior and sets the tone for

employee interactions. Organizations identified as having a positive culture display a

constructive interacting culture in which members interact with others and approach tasks

in a positive way that ensures their success (Marquis & Huston). Employees perception

of the organizations culture has an impact on the shortage of nursing personnel.

Nursing shortages could lead to significant problems in the provision of quality

care to patients and to an increase in medical errors (Coile, 2001). The nursing shortage

affects the public because of increased fears concerning the impact of health care on

consumer safety within health care facilities. Coile noted, The Institute of Medicine

reports that approximately 44,000 to 98,000 people die in hospitals worldwide annually

as a result of medication errors (p. 174). In 1993, medication errors in the United States

accounted for 7,391 deaths, compared to 2,876 deaths in 1983 (Stetina, Groves, &

Pafford, 2005). The delivery of medication involves multiple interactions among different

disciplines, and errors may occur at any step in the process of medication distribution,

such as prescription, transcription by the nurse or pharmacist, dispensing, or the

administration process (Stetina et al.).

Medication errors and adverse reactions associated with medications result in

longer hospital stays, higher costs of care, patient injuries, disabilities, and death

(Contino, 2004; Stetina et al., 2005). Other countries have similar concerns in the

delivery of health care. Armstrong (2004) noted approximately 4,500 patient deaths occur

in Australia each year as a result of medication errors, and the deaths could be prevented

through patient safety measures and quality health care. Armstrong also indicated


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approximately 17,000 permanent disabilities and 18,000 deaths occur each year as a

result of being admitted to hospitals with diverse work cultures.

According to Buch and Wetzel (2001), most employees have worked in

organizations in which people do the opposite of what they say. Organizations are

identified as having two cultures, the true culture and the espoused culture. Espoused

values are audible and spoken. Espoused values include organizational goals,

philosophies, sayings, slogans, and strategies. The true culture of the organization is the

set of unstated assumptions the members share. The unstated assumptions of the true

culture have worked well enough in the past to be considered valid and to be taught to

new members as the correct way to perceive, think, and feel in interactions within the

organization (Buch & Wetzel). Leaders in the health care industry, such as chief nurse

executives, are in a position to address the disjuncture between the espoused culture and

the true culture by sharing values and by modeling adherence to the espoused cultures in

providing health care to their customers.

Chief nurse executives have a broad perspective on the health care provided

within the health care setting. Chief nurse executives work collaboratively with other

health care professionals as they examine the predictable variables that facilitate care

planning. The expertise of chief nurse executives allows for an increase in the accuracy

of care provided to patients and the quantity of service needed (Maljanian, Effken, &

Kaerhle, 2000). Chief nurse executives are also in a position to examine the patients

characteristics, such as their demographic data and socioeconomic status, and to find

means of matching the service and care to the patients characteristics (Maljanian et al.)


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in an effort to meet the needs of the patient and provide the best quality care to those

being served.

The development of quality health care involves many issues. Some of the issues

can be identified as decreasing quality outcomes due to job dissatisfaction, high turnover

rates in nursing, staffing and scheduling concerns, and nurse-to-patient ratios (Armstrong,

2004; Peltier, Schibrowsky, & Neill, 2004; Rodts, 2004). Chief nurse executives in

Magnet Status hospitals function from a leadership style that fosters practice that

promote[s] safe, more efficient and effective care while improving on and maintaining

high nurse satisfaction and job retention (Parran, 2004, p. 6). Chief nurse executives use

a scientific decision-making model that consists of the best evidence in making decisions

in the delivery of care to patients (Cliff, Harte, Kirschling, & Owens, 2004).

The role of chief nurse executives changes within the organization from

maintaining organizational values to creating and upholding organizational values

(Colvard, 2003). The leadership style of chief nurse executives is characteristic of their

intent in using scientific-based decision making in the development of policies relating to

staffing patterns and nurse-to-patient ratios. Steps used by chief nurse executives in their

scientific-based decision-making process include (a) assessing the need for change within

the practice, (b) connecting problems with interventions and outcomes, (c) incorporating

best evidence, (d) designing a change in practice, (e) implementing and evaluating the

change, and (f) integrating and maintaining the practice (Cliff et al., 2004).

Chief nurse executives do not always use benchmark information from other

institutions target budgets to find solutions to problems. Instead, chief nurse executives

look within their own organization and apply scientific decision making to gather and use


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data to measure safety, patient outcomes, and nurse satisfaction (Parran, 2004). Chief

nurse executives examine the history of their organization as they make decisions about

future organizational goals.

Statement of the Problem

Many factors contribute to a hospital achieving Magnet Status recognition. Some

research (Colvard, 2003; Marquis & Huston, 2003; Parran, 2004) suggested the

leadership style of chief nurse executives is a contributing factor in achieving Magnet

Status recognition. The aim of the study was to determine if one leadership style is

perceived to be more effective than others from the perspectives of nurse managers that

report to the chief nurse executives. Chief nurse executives face many health care

concerns such as health care expenditure, the delivery of quality care, job satisfaction of

employees, and employee turnover rates.

According to Fine (2002), total health care spending in the United States has

increased by 7.5% since the 1990s because of inadequate leadership. Langreth (2005)

purported the health care system is directly responsible for a decrease in quality care

costing an estimated $500 billion per year based on litigations surrounding medical

errors. This figure is equal to 30% of all health care costs in America. Unsafe care

practices within health care facilities, combined with inadequate leadership, have

contributed to a large number of preventable patient injuries and deaths (Gelinas & Loh,

2004). Magnet Status hospitals may have a model of interest that should be studied. For

example, leadership and job satisfaction are recognized as fundamental components

influencing the overall effectiveness of an organization (Chen, Beck, & Amos, 2005, p.

374). A specific problem is the lack of effective leadership among nursing leaders


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nationwide. At the turn of the 21st century, leaders were asked to do more with less time

and fewer resources (Marlow, 1996). A quantitative descriptive correlational research

study may identify a correlation between leadership style and leadership outcomes of

chief nurse executives in Magnet Status hospitals. The Multifactor Leadership

Questionnaire 5X (MLQ 5X; Avolio & Bass, 2004; see Appendix A) survey instrument

using a Likert-type scale was administered to a targeted sample of 180 chief nurse

executives working in Magnet Status hospitals. The chief nurse executives were asked to

invite their nurse managers to respond to the survey according to their perception of their

chief nurse executives leadership style and leadership outcomes.

Purpose of the Study

The purpose of the quantitative descriptive correlational research study was to

investigate a correlation between leadership style and leadership outcomes of chief nurse

executives in Magnet Status hospitals in the United States. The chief nurse executives

were chosen because they are at the highest level in the nursing hierarchy in health care

facilities, and nurse managers report directly to them. These chief nurse executives and

nurse managers are employed in Magnet Status hospitals, which have been identified as

being excellent, highly recommended places to work and having low nurse turnover rates

(Upenieks, 2003a). A nonprobability sample of 180 chief nurse executives in the United

States was asked to invite their nurse managers to respond to the MLQ-5X survey

(Avolio & Bass, 2004) to identify their chief nurse executive leadership styles and

leadership outcomes that may have attributed to achieving Magnet Status recognition.

The independent variable in the study was leadership style: transformational,

transactional, and laissez-faire. Leadership style is defined as the process of influencing


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others in an organizational culture (Marquis & Huston, 2003, p. 16). The dependent

variables in the study were the leadership outcomes of extra effort, effectiveness, and

satisfaction for achieving Magnet Status recognition, which includes decreased turnover

of nurses, retention rate, nurse-to-patient ratio, and employee satisfaction.

Significance of the Study to the Problem

Although prior research has examined leadership styles, job satisfaction, and

organizational culture relative to best practice organizations, little research has explored a

correlation between leadership styles and leadership outcomes of chief nurse executives

in health care organizations. Few studies have been conducted concerning the

relationships between leadership styles and employees who are satisfied with their job,

who have low turnover ratios, or whose culture encourages lifelong learning, creativity,

and compassion for others (Amendolair, 2003). The focus of the study was to establish a

correlation between leadership styles and leadership outcomes of a targeted sample of

180 chief nurse executives working in Magnet Status hospitals within the United States

by their nurse managers. The MLQ 5X survey was administered to a targeted sample of

180 chief nurse executives working in Magnet Status hospitals who invited their nurse

managers to rate them according to the nurse managers perception of their chief nurse

executives leadership styles used in their health care setting. Chief nurse executives in

Magnet Status hospitals run facilities described as excellent and have a reputation as

having high employee job satisfaction, low employee turnover, and high patient

satisfaction (Upenieks, 2003a). Kramer (1990) identified Magnet Status hospitals as

hospitals that have been particularly successful in attracting and retaining professional

nursing staff and had reputations as being good places to work (p. 35). Upenieks 2003


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studies comparing Magnet and non-Magnet hospitals (2003a, 2003b, 2003c, 2003d)

reaffirmed the advantages of Magnet Status hospitals were decreased turnover rates and

increased job satisfaction (Upenieks 2003d,p. 43). According to the Center for Nursing

Advocacy (2006),

Magnet status is an award given by the American Nurses Credentialing Center to

hospitals that satisfy a set of criteria designed to measure the strength and quality

of their nursing. A Magnet hospital is stated to be one where nursing delivers

excellent patient outcomes, where nurses have a high level of job satisfaction and

where there is a low staff nurse turnover rate and appropriate grievance

resolution. (1)

Nurse researchers studying leadership behaviors of nurse executives and nurse

managers have predominantly used the MLQ 5X because the instrument is designed to

examine leadership behavior from a transformational, transactional, and laissez-faire

perspective (Kleinman, 2004b). The MLQ 5X is also designed to allow nurses to rate the

leadership behavior of their supervisors and also for leader self-assessment. The chief

nurse executives in the research study were instructed to invite their nurse managers to

identify their chief nurse executives leader characteristics with a rating determined by

their perception (Kleinman). Chief nurse executives leadership style and leadership

outcomes are important because they can influence the development of a dominant

successful leadership style in other facilities and enhance the leaders overall

performance and employee job satisfaction.


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Significance of the Study to Leadership

The changing patterns in health care and the complexity in practice have

intensified the delivery of nursing care (Donley, 2005). Health care organizations need

visionary leaders (Armitage, Brooks, Carlen, & Schulz, 2006) who have the knowledge,

skills, and ability to affect and contribute to the organizations worth (Bridgeforth, 2005).

Armitage et al. posited, Organizations employ leaders for one purpose: to accomplish

what is required to help the company achieve its mission and strategic vision (p. 41) in

providing the best quality care at market rates.

Organizations are standing firm and supporting a weak structure with demand,

acceptance, and the awareness they lack control over the social environment, as identified

in the general system theory (Bridgeforth, 2005). Organizations seek chief nurse

executive leaders who are visionaries and who think and perform using a cognizant

process that helps other nurses expand their thoughts (Charon, 2003; Donley, 2005).

Expanding the thoughts of leaders in the 21st century demands a professional

commitment to think creatively about the practice of nursing and to have the courage to

try different things using different strategies (Donley) in their effort to increase retention

of staff, to enhance the quality of care to customers, and to provide service to customers

at an affordable rate.

According to Heller, Drenkard, Esposito-Herr, and Romano (2004), Magnet

Status hospitals are successful in recruiting and retaining nurses and have lower turnover

rates and higher job satisfaction among nurses. Upenieks (2003b) conducted follow-up

research of Magnet Status hospitals to determine if magnet status hospitals maintained

lower rates of vacancy and turnover, and higher levels of job satisfaction than non-


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magnet status hospitals (p. 9). Heller et al. surveyed 16 of the original Magnet Status

hospitals using five indicators: a.) Vacancy rate, which was calculated as the monthly

average percentage of RN positions filled, b.) RN to patient ratio, c.) turnover rate, d.)

Use of supplementary agency staff and, and e.) Number of multiple applicants per

available position (p. 9). The results of the survey revealed a nurse-to-patient ratio of 1:4

in Magnet Status hospitals compared with a 1:7 nurse-to-patient ratio in non-Magnet

Status hospitals. This statistically significant finding from Heller et al.s study supported

previous studies that found a relationship between lower rates of nursing turnover and

greater job satisfaction among nurses working in Magnet Status hospitals (Upenieks,

2003b). The results of this quantitative descriptive correlational study identify the

correlation between leadership and leadership outcomes of a targeted sample of 180 chief

nurse executives by their nurse managers employed in the 180 Magnet Status hospitals.

The results of the study help identify leadership styles and leadership outcomes that are

favored in Magnet Status hospitals.

Health care organizations need chief nurse executives whose style of leadership

gives them the confidence to make decisions, who accept responsibility for functions

outside of their expertise, and who can rely on others to provide information and validate

facts (Parran, 2004). Chief nurse executives rely on empirical evidence from management

research to understand current issues and gain insight into nursing practice as it relates to

health care and the environment in which the care is delivered. As the highest level

persons in nursing within hospitals, chief nurse executives have an obligation to ensure

the effectiveness of nursing practice, including to (a) ensure the safety of the

organizations constituents with a balance between production, efficiency, and reliability;


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(b) create and sustain a trusting organization; (c) manage the change process; (d) involve

employees in the decision-making process and in processes pertaining to work design and

work flow; and (e) use knowledge-based management practices to establish the

organization as a learning organization (Parran).

Nature of the Study

The purpose of this quantitative descriptive correlational research study was to

investigate a correlation between leadership style and leadership outcomes of chief nurse

executives in Magnet Status hospitals that impacts Magnet Status hospital recognition. A

target sample of 180 chief nurse executives from 180 Magnet Status hospitals throughout

the United States were asked to invite their nurse managers to participate in the survey

using the MLQ 5X to identify their chief nurse executives leadership style. The

Multifactor Leadership Questionnaire is a 45-item self-report questionnaire that measures

a full range of leadership behaviors through its 12 subscales (Kleinman, 2004c, p. 4).

Bass and Avolio (2000, as cited in Kleinman, 2004c) noted, The MLQ 5X has been

utilized in over 200 research studies within the past four years and has well established

reliability and validity as a leadership instrument in both industrial and service settings

(p. 4). Based on prior research (Avolio & Bass, 2004), the MLQ 5X was appropriate for

the study. The MLQ 5X was ideal because of its ability to allow chief nurse executives to

identify their leadership styles according to their responses they make on the survey. The

MLQ 5X also allows subordinates to rate their manager. Kleinman (2004b) noted, Nurse

researchers studying leadership behavior of nurse executives have predominantly used

the MLQ 5X (p. 112). According to Kleinman (2004b), a particular advantage and

feature of the MLQ 5X is that it allows chief nurse executives to rate themselves using


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the same Likert-type scale. The MLQ 5X captured the dominant leadership style of each

participant and collected quantitative data from nurse managers according to their

perception of their chief nurse executives in Magnet Status hospitals.

The quantitative descriptive correlational study based on established research

strategies investigated a correlation between leadership style and leadership outcomes of

chief nurse executives in Magnet Status hospitals. The population of Magnet Status

hospitals in 2006 consisted of approximately 180 facilities, although the numbers

fluctuated (ANCC, 2006). The study attempted to recruit the chief nurse executives in all

the Magnet Status hospitals. In a study by Kleinman (2004c), the MLQ 5X survey was

distributed to 315 staff nurses and 16 nurse managers in a 465-bed hospital. The returned

questionnaires resulted in a study sample of 79 staff nurses (25% of the staff nursing

population) and 10 nurse managers (62% of the nurse manager population).

Other research designs such as the quasi-experimental method and the qualitative

research method were considered for the study. Qualitative studies consist of a large

amount of narrative data and use in-depth interviews and direct observation of

participants, which allows for researcher bias in making assumptions based on their

beliefs and past interactions. Qualitative data are not analyzed using statistical tests for

accuracy or to examine relationships. Another qualitative design considered was the

phenomenological approach, which consists of intensive dialogue with the participants to

obtain knowledge of their lived experience (Denzin & Lincoln, 2000).

Qualitative studies allow for biases of the researcher (Denzin & Lincoln, 2000).

Researcher bias occurs when the researcher intentionally or unintentionally record

responses of the person being interviewed incorrectly. Qualitative research data are


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gathered through interviews using open-ended questions and observations of individuals

interacting in a social setting (LoBiondo-Wood & Haber, 2002). According to Salkind

(2003), researchers using the qualitative research approach interpret data according to

their perception, interaction with participants, and feelings, rather than using numbers to

quantify the data. The quantitative method of research was used in the study. The

correlational design was used to statistically quantify the magnitude of leadership style

to that of leadership outcomes. Quantitative studies analyze data quantitatively and are

more efficient than other designs that use observations or interviews.

A quantitative descriptive correlational method was selected for the study.

Quantitative research uses an inquiry approach for describing trends and explaining the

relationships among different variables using numerical data (Creswell, 2002).

Descriptive research was used to describe the characteristics of the variables being

investigated. A correlational design was used to describe a linear relationship (Salkind,

2003, p. 198). A correlational design was appropriate because in quantitative research a

correlational design can be used to describe the relationship between the study variables,

leadership style, and Magnet Status hospital leadership outcomes. In quantitative

correlational designs, participants are selected so generalizations will be made about the

population being investigated and groups should be of adequate size, such thatN 30;

larger sizes result in a decreased chance for error and an increased chance of obtaining an

accurate representation of the population (Creswell). The study examined the leadership

style of chief nurse executives employed in Magnet Status hospitals to determine the

dominant leadership style being used by chief nurse executives and their relationship to

Magnet Status hospital recognition. The styles of leadership used by chief nurse


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executives directly influence the delivery of care within health care organizations (Mass,

2005).

Felfe and Schyns (2004) found consistency in the MLQ 5X when 213 supervisors

from two public administration offices related their own leadership behavior as well as

their leaders behavior on the MLQ 5X. Felfe and Schyns assessed transformational

leadership styles using the MLQ 5X, which consists of five transformational subscales.

Several outcomes were included in the analysis, which resulted in leadership-specific

criteria. Research is uncovering important clues to tell us what type of persons become

the most effective leaders in an organization (Barling & Turner, 2005, p. 25). According

to Barling and Turner, current research supports transformational leaders as the most

effective leaders and identifies them as individuals who are more likely to have the

strongest commitment to corporate social responsibility.

One qualitative study showing support for transformational leadership consisted of

a point of view based in part, on research that asked managers to respond, in survey

form, to a number of stories that present ethical issues and apologies (Barling & Turner,

2005, p. 25). The MLQ 5X was used to ask subordinates to rate the kind of leaders their

managers were and repeatedly found those managers who showed a more evolved,

postconventional form of moral reasoning were also likely to be managers who practice

the transformational leadership style approach: The transformational leadership style

approach is the leadership style that is most valued by employees and most desired by

companies that wish to do better and to grow (Barling & Turner, p. 25). The

transformational style of leadership positively determines the success of the organization

(Barling & Turner).


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Research Questions

The focus of the study was to investigate a correlation between leadership style

and leadership outcomes of chief nurse executives that influences Magnet Status

recognition in hospitals. The following research questions were developed to guide the

study:

1. What is the relationship between the chief nurse executives leadership style

and the extra effort exerted by the nurse manager?


and the chief nurse executives effectiveness?


and the nurse managers level of satisfaction with the chief nurse executives leadership?

The MLQ was used to identify the various leadership styles used by chief nurse

executives in Magnet Status hospitals. The MLQ 5X consists of a Likert-type scale that

identifies the characteristics of each leadership style. Participants were asked to have

their nurse managers rate the frequency of leadership behaviors using a Likert-type scale

with a range of 0 (not at all) to 4 (frequently if not always) to identify their leadership

style. The MLQ was used to understand the relationship between the leadership style and

the leadership outcomes that influence Magnet Status hospital recognition.

Hypotheses

The study investigated the correlation between leadership style and leadership

outcomes of chief nurse executives that influences Magnet Status recognition in

hospitals. Three statistical hypotheses were tested. H0represents a null hypothesis and Ha


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represents an alternative hypothesis. Each hypothesis is repeated for each of the nine

leadership scores.

Hypothesis 1

H10: There is no correlation between the leadership style score and the nurse

managers extra effort score.

H1a: There is a correlation between the leadership style score and the nurse

managers extra effort score.

Hypothesis 2


managers perception of leadership effectiveness.


managers perception of leadership effectiveness.

Hypothesis 3


managers level of satisfaction with the leadership.


managers level of satisfaction with the leadership.

Theoretical Framework

The theoretical framework for the study, as it relates to chief nurse executives

leadership styles, was selected from the domain of nursing practice based on Orlandos

(1961) nursing process theory and Meades (1934) symbolic interaction theory.

Orlandos nursing process theory focuses on the interactions between individuals,

perception validation, and the use of the nursing process in the practice of producing


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positive outcome interactions (Faust, 2002). Orlando was one of the earliest authors to

use the term nursing process(Kelly & Joel, 1995). The nursing process is a systematic

method used by health care professionals to identify client or organizational health,

identify specific problems related to health, identify methods to solve health-related

problems, implement problem solving, and evaluate the outcomes (Kelly & Joel). The

study provides an overview of Orlandos nursing process theory, Meads symbolic

interaction theory, and the transactional, transformational, and laissez-faire leadership

styles.

Orlandos (1961) nursing process theory revolves around five concepts: (a) the

function of professional nursing; (b) the behaviors of patients or individuals in different

situations; (c) the response of the nurse or the individual with leadership responsibilities;

(d) the nursing process of assessing, planning, implementing, and evaluating; and (d)

improvement in interactions and practice. Orlando defined the purpose of nursing as the

ability to supply patients with the help needed and to ensure that patients needs are met

to enhance the overall well-being of the individual. Her lived experiences involved taking

into consideration the perceptions of others. Orlando considered the role of others and

envisioned circumstances from others perspectives, which enriched her perception of

those she engaged with and helped her to be creative in devising methods that would help

her to help others in their personal and professional growth. Orlandos nursing process

theory is used in diverse environments to shape the views and behaviors of others.

Orlando posited that social and environmental structuring in hospitals creates the need for

people to change and learn new behaviors in response to new goals, new situations, and

new collaborative workforces.


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Meades (1934) symbolic interaction theory augments Orlandos (1961) theory by

focusing on the aspects that give meaning to interactions and situations. Meads symbolic

interaction theory is based on three assumptions: (a) people use different symbols in their

interactions with others, (b) people respond according to their perception of the message

received from others, and (c) people in general react through cooperative behaviors,

which involves perceived responses and interpreted stimuli from others. Mead noted

people grow and change through their interactions with others, which is demonstrated in

reflected feedback of behavior. The theoretical concepts of Orlando and Mead extend

beyond hospital settings to different leadership styles of chief nurse executives and their

effects on the outcomes of organizations.

Leaders in organizations have many functions. Leaders help and encourage

followers to commit to organizational goals (Upenieks, 2003a). The transformational

leader, as a professional, has a sense of corporate social responsibility (Barling & Tucker,

2005). Transformational leaders see the big picture and engage employees and the

community in their vision (Barling & Tucker). Transformational leaders view situations

from others perspectives and inspire, motivate, and prompt others to change and move

beyond what they perceive as their limits in meeting professional and organizational

goals.

The transactional leader is focused on tasks and outcomes. The transactional

leaders actions are based on three components: (a) contingent reward, in which the

employees are rewarded for desired work performed; (b) active management by

exception, in which the leader monitors the work of the employees; and (c) passive

management by exception, in which the leader waits until problems arise. The laissez-


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faire leader sets goals for the employees and gives them an accompanying set of rules for

guidelines to guide them in the process of meeting specific objectives (Brennen, 2003).

These leadership styles are discussed in more detail in the following sections.

Transformational Leadership

The transformational leadership style, developed by Burns in 1978, describes the

leader as being a visionary who shares his or her vision with subordinates of the desired

direction of the organization. Transformational leaders instill pride within followers by

valuing them and their contributions. These leaders motivate followers to accomplish

more than the followers thought possible and demonstrate open consideration of

employees ideas (Kleinman, 2004a).

Transformational leaders, through their behaviors, transmit a sense of mission to

followers (Tickle, Brownlee, & Nailon, 2005). Transformational leaders delegate

authority to followers that enhances followers autonomy and teach and coach team

members to problem solve and use their critical thinking skills. Transformational leaders

are stimulated by their core beliefs and affect followers in a positive way that enhances

positive organizational outcomes (Tickle et al.). These positive effects, according to

Tickle et al., are well documented in the literature as improvements in subordinate job

satisfaction and increased subordinate commitment to the organization.

There are five identified characteristics of transformational leaders.

Transformational leaders have a charismatic personality, are confident in their

interactions, and respond in a way that leads subordinates to respect and admire them

(Harland, Harrison, Jones, & Palmon, 2005). The characteristic identified as idealized

influence by transformational leaders can be observed when leaders are seen as a role


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model sharing their vision with subordinates in a positive way such that it influences the

subordinates to model the same behavior(Tickle et al., 2005). Idealized influence also

involves the transmission of a sense of higher purpose by the leader that extends beyond

the goals of the individual to that of the organization (Harland et al.). The

transformational leader helps subordinates by increasing their awareness of

organizational goals and by helping the subordinates achieve goals.

Inspirational motivation is the behavior of the transformational leader that

transmits enthusiasm, optimism, and the ability to have ones vision of the future

accepted and shared among the subordinates (Harland et al., 2005). Inspirational

motivation also communicates a clear, attainable picture of the organizations future and

inspires the subordinates to try harder and develop themselves beyond the norm (Tickle

et al., 2005). Harland et al. noted inspirational motivation is the behavior that provides

meaning and challenge to the work of the subordinates.

Intellectual stimulation is used by the transformational leader to encourage

subordinates to view problem solving in different ways. The transformational leader

encourages subordinates to be creative and innovative in trying new approaches, knowing

they will not be criticized publicly (Harland et al., 2005; Tickle et al., 2005). The

transformational leader trusts and respects subordinates, which creates an environment

with some tolerance for mistakes that occur during a learning process (Tickle et al.).

Idealized consideration allows the transformational leader to develop employees

by treating them as individuals (Harland et al., 2005). The leader develops the

subordinates through mentoring, teaching, and being a facilitator, a confidante, and a


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counselor. The transformational leader also responds to the needs of the subordinate and

treats each individual as an important contributor to the workplace (Tickle et al., 2005).

According to Kleinman (2004b), there is a relationship between the effective

leadership style of the nurse executive and the job satisfaction of staff nurses. During the

1980s through the early 1990s, research demonstrated that effective leadership enhances

job satisfaction. Kleinman (2004b) assessed a body of research and found that chief nurse

executives in hospitals of excellence had characteristics of transformational leaders

embodied in their style of leadership.

Transactional Leadership

Transactional leaders are more concerned than transformational leaders with the

day-to-day operations of the organization (Kleinman, 2004c). The transactional leader

accomplishes organizational goals and motivates employees through rewards in

exchanges for their services (Kleinman, 2004c). Transactional leaders are also identified

as adapters who work toward the fulfillment of contractual obligations with their

followers (Sternberg, 2005). Transactional leaders provide contingent rewards by

specifying roles and task requirements and rewarding desired performance, or they may

monitor the meeting of standards and intervene when the standards are not met

(Sternberg).

Transactional leaders engage subordinates in contingent reward. In contingent

reward, the leader outlines the specific tasks to be conducted by the subordinates, along

with expected outcomes and the benefits that will result from achieving the outcomes

(Tickle et al., 2005). If the subordinates fail to achieve the goals as outlined, no reward

will be given; it is of significant importance that the subordinates understand what the


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goals are and the process for achieving positive outcomes (Harland et al., 2005). The

transactional leader also uses active and passive management by exception. Active

management by exception focuses on a subordinates mistakes, failures, and complaints.

This style of leadership supports avoidance coping, because feedback from the leader is

primarily negative and does not foster positive relationships. Transactional leaders use

passive management by exception when they do not intervene in identified problems the

subordinate is encountering (Harland et al). A transactional leader intervenes in a

subordinates interactions when the leader observes a particular situation has gone

seriously wrong and the subordinate is unable to respond appropriately in the given

situation before the leader takes any action (Harland et al.).

Laissez-faire Leadership

Laissez-faire leaders relinquish full control to group members and offer support

and guidance as needed (Barbuto, 2005). The laissez-faire leader works best with

subordinates who are highly skilled and need little direction, which allows the leader to

maintain good relationships with the subordinates (C. L. Cooper, Makin, & Cox, 1993).

Laissez-faire leaders are highly innovative and have a high level of technical competence

that steers their interest toward technical matters instead of managing the department.

Laissez-faire leaders are energetic, enthusiastic, and creative, and their interpersonal

skills are good, which allows them to maintain a good relationship with their

subordinates. Due to laissez-faire leaders lack of interest in managing their department,

the department is often run by itself, with problems arising concerning who is responsible

for what task and some jobs left incomplete (C. L. Cooper et al.).


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Multifactor Leadership Questionnaire

According to Kleinman (2004b), the MLQ 5X developed by Bass and Avolio

(1995) has been used predominantly in studies to measure leadership styles. In addition,

nurses studying leadership behavior of nurse executives and managers have

predominantly used the MLQ 5X. The use of the MLQ 5X in nursing research explains

the rationale for the historical trend of examining leadership behavior from a

transformational, transactional, and laissez-faire perspective using a 45-item Likert-type

survey (Kleinman, 2004b). The scales of the MLQ 5X survey help identify leadership

styles based on responses that identify characteristics such as idealized influence,

behavior, motivation, intellectual stimulation, consideration, and contingent reward.

Definition of Terms

The operational definitions are consistent with the theoretical framework and

research focus of the study. The following are definitions of key terms:

Autocratic leadershipstyle:Exploitative autocratic leaders lead by dictate and the

style is characterized by total leader domination (McConnell, 2003). Benevolent

autocratic leaders are kind, insist upon having their way, and are characterized by nearly

total domination but include consideration of the followers in the form of what the leader

has decided is good for them (McConnell, p. 363).

Chief nurse executive:The person in the highest level of the hierarchy in nursing

in hospital organizations (Grant, 1993).

General systems theory(GST): A function of the management system used to

connect or process energy, information or material into a product or outcome for use


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within the system or outside the system into the environment or both (Begley, 1999, p.

1).

Laissez-faire style of leadership: A loose style in which the leader coordinates and

placates employees for immediate relief of sensitive situations (Christman, 1996). Gillies

(1989) defined the laissez-faire leader as a person that surrenders leadership

responsibility, leaving workers without directions, supervision or coordination, and

allows the followers autonomy to plan, execute, and evaluate the work in the way they

see fit (p. 374).

Leadership styles: The process of influencing others in an organizational culture

(Marquis & Huston, 2003, p. 16) and the distinctive or characteristic manner in which

one performs (Gillies, 1989, p. 374).

Magnet Status hospitals: Designated facilities that have been certified by the

American Credentialing Center for their excellence in nursing practice (Upenieks,

2003d, p. 43).

Nurse manager: The clinical leader of the nurses working on a given unit (Gillies,

1989).

Nursing shortage: The number of nursing vacancies within the health care

organization (Coile, 2001).

Organizational culture: The total of an organizations values, language, history,

formal and informal communications, networks, rituals and sacred cows those few

things present in an institution that are never to be discussed or changed (Marquis &

Huston, 2003, p. 166).


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Participative leaders: Leaders who are key members in a team and provide

advice, information, resources, and assistance in any way possible (McConnell, 2003).

Transactional leaders: Leaders who base their transactions on an exchange of

rewards and benefits to employees for the completion of transactions and goals being met

(Upenieks, 2003c).

Transformational leaders: Leaders who practice a type of leadership that involves

individual consideration, intellectual stimulation, and willingness to embrace change

(Upenieks, 2003a). Transformational leaders are also identified as change agents who

have the ability to transform the attitudes, behaviors, and values of others by displaying

favorable, influential, and supportive interactions that bring about organizational change

(Upenieks, 2003a).

Assumptions

The first assumption within the study was that chief nurse executives in Magnet

Status hospitals would be voluntary participants in the study and invite their nurse

managers to respond to the survey questionnaire. It was assumed the chief nurse

executives would be willing to participate because of the studys potential significance to

add to the body of nursing knowledge. Using research to determine the correlation

between leadership style and leadership outcomes may enhance chief nurse executives

workforce performance in the provision of quality care by satisfied employees. It was

also assumed the participants would allot time to complete the survey in one setting

without interruptions and the generalizability of the study would be under the

researchers control. Another assumption was that the participants would be honest in

completing the MLQ 5X questionnaire according to their lived experiences and the


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perception of their chief nurse executive and that the nurse managers will return the

questionnaire in a timely manner. It was also assumed the participants would respond

honestly due to a high degree of professional integrity among health care workers. By

answering honestly, the information gained rendered true value in hypothesis testing to

determine the correlation between leadership style and leadership outcomes of chief

nurse executives.

Another assumption was that chief nurse executives in Magnet Status hospitals

have a positive correlation between leadership styles and leadership outcomes. A positive

relationship between leadership styles and leadership outcomes in Magnet Status

hospitals is due to the hospitals satisfaction scores of patients and employees, a low

turnover rate of staff, and an increased quality of care provided. The last assumption was

that, due to the chief nurse executives busy schedule, an incentive to participate would

enhance the return survey success. Five Visa gift cards in the amount of $50 each were

offered as prizes to be drawn among the participants who return completed, usable

surveys within the specified time frame. The offer was made to encourage the

participants who are interested to respond carefully while answering the surveys and

return them in the time specified.

Scope of Study

The scope of the study was an examination of the relationship between leadership

styles and leadership outcomes of chief nurse executives working in Magnet Status

hospitals in the United States. According to Lash and Munroe (2005), the Magnet

Recognition Program for hospitals was developed in the 1980s by the ANCC to

recognize health care organizations that provided the best health care(Cimiotti, Quinlan,


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Larson, Pastor, Lin & Stone, 2005). The objective of the Magnet Recognition Program

was to recognize excellence in nursing service, to recognize an environment that

promotes and sustains professional nursing practice, and to recognize an organizational

system that supports the professional development of nursing personnel (Lash &

Munroe, p. 326). Health care organizations that receive Magnet Status recognition

identify themselves as being the best in class organization (Curran, 2006, p. 5). Magnet

Status hospitals create environments that attract and keep talented employees (Curran).

Chief nurse executives are in positions that determine the type of care being delivered to

patients. The influence of chief nurse executives in Magnet Status hospitals goes beyond

patient outcomes, nurse outcomes, and market share to defining best practices through a

quantifiable impact on patient care (Smith, 2005). The study investigated the leadership

styles of the chief nurse executives in the targeted sample of 180 Magnet Status hospitals

to determine if a relationship exists between the leadership style and leadership outcomes

for Magnet Status recognition.

Limitations

Limitations consisted of a possible loss of participants and a small sample size. A

loss of participants resulted from chief nurse executives retiring from their position and

new chief nurse executives entering their new role. Another limitation was that some

chief nurse executives no longer held the position in the hospital at the time the research

was conducted. The study would be impacted if only those nurse managers who had

established a good rapport with the chief nurse executive were asked to participate. The

personality and ethnicity of the nurse managers also impacted the responses. Another

limitation was the number of unusable surveys returned by the nurse managers. Thirty


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eight of the surveys were returned with completed useable data. The research provided

information on the correlation between leadership styles and leadership outcomes of

Magnet Status hospital chief nurse executives, but the research did not indicate whether

the leadership style is different from leadership styles and leadership outcomes of non-

Magnet Status chief nurse executives. An additional limitation was chief nurse executives

who were no longer be employed in a specific facility when the surveys were e-mailed or

who chose not to participate. The size of the sample would have been affected if some

Magnet Status hospitals lost their designation. Those facilities contacted had maintained

their Magnet Status recognition and were able to participate in the study. There was also

a possibility of being unable to reach the chief nurse executives due to their busy

schedules.

Delimitations

Delimitations are used to narrow the scope of the study or to list what is not

included or intended in the study (Creswell, 2002; Leedy & Ormrod, 2001). One

delimitation was the study included only health care professionals in leadership positions

as chief nurse executives and nurse managers working in Magnet Status hospitals from

April 2006 through April 2007. A second delimitation was the focus on the leadership

styles and leadership outcomes of the isolated group of chief nurse executives. A third

delimitation pertained to the variables under investigation. The study limited the styles of

leadership under examination to transformational, transactional, and laissez-faire.

Summary

The study describes health care issues pertaining to a decline in quality outcomes

as they relate to the correlation between leadership style and leadership outcomes being


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used by chief nurse executives in Magnet Status hospitals. The study also identified

different leadership styles in use among persons in leadership positions. The study invited

nurse managers to respond to the MLQ 5X survey and to share their perception of their

nurse executives and the study also determined if a correlation exists between leadership

style and leadership outcomes of chief nurse executives in Magnet Status hospitals.

The purpose of the quantitative descriptive correlational research study was to

investigate whether there is a correlation between the leadership style and leadership

outcomes used by chief nurse executives in Magnet Status hospitals and to determine if a

relationship exists between the leadership style and the leadership outcomes that impact

Magnet Status hospital recognition. A purposive sample of 180 targeted chief nurse

executives from different states within the United States was asked to invite their nurse

managers to participate in the survey to obtain information that would help identify the

relationship. The research study used the MLQ 5X to survey a targeted sample of 180

chief nurse executives in 180 Magnet Status hospitals in the United States having an

undefined bed capacity to invite their nurse managers to respond to the survey. The

leadership styles of the chief nurse executive influence the delivery of care within the

health care organization, which further determines the overall satisfaction of an

organizations employees and patients.

Chapter 2 presents an overview of the literature. The chapter begins by providing

the literature search process and proceeds with a discussion of general systems theory

(GST), which integrates systems thinking in organizations (Wang, 2004). Chapter 2

identifies and describes the different models of patient care used in hospital settings and

the leadership styles used by those in leadership positions.


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CHAPTER 2: REVIEW OF THE LITERATURE

The purpose of the quantitative, descriptive research study was to investigate the

relationship between the leadership style and leadership outcomes of chief nurse

executives that impact Magnet Status hospital recognition. Prior research on Magnet

Status hospitals showed these facilities draw and retain nurses through professional

practice models that incorporate staff autonomy and shared responsibility through their

input in decision making (Khazaal, 2003; Kleinman, 2004a). Leaders in Magnet Status

hospitals incorporate staff involvement in generating alternatives in decision making,

health career planning, and evaluating the results of care provided to its constituents, as

care relates to overall satisfaction (Khazaal). Kleinman (2004b) identified some

characteristics of the leadership style used by chief nurse executives that have a

significant impact on employee job satisfaction and retention. The characteristics include

providing an atmosphere that promotes and encourages open discussion, considering the

ideas of others, being available, maintaining high performance standards, and initiating

positive interaction between employer and employees. Effective leadership skills used by

chief nurse executives enhance employees job satisfaction (Kleinman, 2004b). Effective

leadership is also identified as a key factor in staff nurse retention (Kleinman, 2004a).

The following section presents information obtained from research articles, research

documents, and journals.

Title Searches, Articles, Research Documents, and Journals

A detailed literature review was conducted using the concepts of GST, models of

patient care, patient satisfaction, employee job satisfaction, nursing shortages, leadership

styles, and an overview of Magnet Status hospitals. Table 1 presents the sources


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reviewed, categorized by the theories and search topics that support the study. Table 1

does not show when these works were published for any of the topics. A search for

available research literature on the topic of chief nurse executives and Magnet Status

hospitals generated no results. The following section will discuss the nursing shortage.

The nursing shortage is a cyclical problem that became a national crisis at the

beginning of the 21st century, with a total number of job vacancies in the range of

158,000, including 120,000 vacancies for RNs within the hospital setting (Coile, 2001;

Upenieks, 2003c). Coile identified the chronic labor shortage as the force driving up

wage costs from 5% to 8% annually in hospitals and other health care facilities and as the

explanation for the sharp rise in health care expenditures by 5.6% in 1999 and 8.3% in

2000.

Kramer and Schmalenberg (1998a) established that some of the reasons for the

nursing shortage in the 1990s and 2000s are (a) the high turnover rate among nursing

personnel, (b) the constant orientation of new personnel, (c) the lack of commitment and

identification with institutional values and goals, (d) the high percentage of inexperienced

staff, (e) the large number of per diem nurses, (f) the frequent use of agency personnel,

and (g) a nursing staff that does not consistently work together. Because of the nursing

shortage, a large number of hospitals and health care facilities have been recruiting

Filipino and Indonesian nurses to fill job openings (Kramer & Schmalenberg, 1998a).

Many hospitals hire agency nurses and travelers who work for a limited assignment in the

facility and receive pay at rates 50% to 100% higher than the rates of hospital-owned

nurses (Coile, 2001). The regular use of travelers and agency nurses is seen as a cause of

low morale and job dissatisfaction among nurses (Kramer & Schmalenberg, 1998b).


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Table 1

Summary of Literature Review by Search Topic

Theoretical

concepts and

search topics

Journal

articles

and

periodicals

Books,

magazines,

Internet, and

reports Total

Resources

before

2001

Resources

in past 5

years

%

since

2001

General systems

theory

4 7 11 4 7 63%

Models of patient

care delivery

10 16 26 8 18 69%

Patient

satisfaction

8 4 12 0 12 100%

Employee job

satisfaction

11 9 20 1 19 95%

Nursing shortage 8 7 15 2 13 87%

Leadership styles 32 12 44 9 35 80%

Overview of

Magnet Status

facilities

8 2 10 2 8 82%

Total literature

reviewed

82 57 139 26 113 81%


49/217

44

Experts in health care have found that the nursing shortage in the 2000s is an

imbalance between supply and demand and is serious and widespread throughout the

United States (Upenieks, 2003b). On the supply side, there are concerns about the

population of aging nurses who will soon be retiring (Upenieks, 2003b). The nursing

shortage crisis has created a culture that promotes distrust and negative behavior among

employees wh