leadership styles in nursing management

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Leadership styles in nursing management: preferred andperceived

STINA SELLGREN M S c , R N1

, GO RAN EKVALL P h D2

and GO RAN TOMSON M D , P h D3

1Deputy Nursing Director, Karolinska University Hospital, Stockholm and PhD Student, Medical ManagementCenter (MMC), Karolinska Institute, Stockholm, 2Professor Emeritus, Institution of Psychology, University ofLund, Lund, Sweden and3Professor, MMC and Division of International Health (IHCAR), Karolinska Institute,Stockholm

Introduction

Leadership style

Leadership ability is fundamental in influencing a group

to achieve the stated vision and goals (Bass 1985, Yukl

2002). During times of dramatic organizational changes

in health systems, nursing management is both a

challenging and difficult task. The style of the manager

can be important for subordinates acceptance of

change and in motivating them to achieve high quality

of care (Bass & Avolio 1985).

Leadership style in the sense of a managers way of

influencing the subordinates arose during the 1940s at

the universities of Ohio and Michigan in the USA. The

research focused the behaviour and attitudes of man-

agers and supervisors in contrast to earlier research that

mainly had been looking for inborn personality and

intellectual traits, which paved the way for leadership

positions.

Research on leadership styles is mostly based on a

theory that there are specific behaviours, which together

build leadership style dimensions (Ekvall 1992). The

Correspondence

Stina Sellgren

Department of Nursing

Karolinska University Hospital

17176 StockholmSweden

E-mail:

[email protected]

S E L L G R E N S . , E K V A L L G . & T O M S O N G . (2006) Journal of Nursing Management14, 348355

Leadership styles in nursing management: preferred and perceived

Aim The aim was to explore nursing leadership regarding what nurse managers and

subordinates see as important and to explore subordinates opinions of their nursemanagers performance in reality.

Background The managers style can be fundamental for subordinates acceptance

of change and in motivating them to achieve stated visions and goals and high

quality of care.

Methods Nurse managers (n 77) and 10 of each included nurse managers sub-

ordinates received a questionnaire to assess preferred leadership behaviour in three

dimensions: change, production and employee/relation orientations. The same

questionnaire was used to assess subordinates opinions of their managers leader-

ship behaviour.

Results There are statistically significant differences in opinions of preferred lead-

ership between managers and subordinates, especially related to production and

relation orientation. The subordinates perception of real leadership behaviour has

lower mean values than their preferred leadership behaviour in all three dimensions.

Conclusions Subordinates prefer managers with more clearly expressed leadership

behaviour than managers themselves prefer and demonstrate.

Keywords: leadership dimensions, perceived leadership behaviour, preferred leadershipbehaviour

Accepted for publication: 13 October 2005

Journal of Nursing Management, 2006, 14, 348355

348 2006 Blackwell Publishing Ltd


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individual leader has a basic general operating style,

emanating from personality, experiences and learning

of leadership (Ekvall 1992). Leadership style was des-

cribed in the early studies as consisting of two broad

and independent behaviour dimensions, the one

production-/task-oriented, the other with focus on

employees and relations. Leadership behaviour can be

learned, but some researchers believe that personalattributes such as intelligence and temperament sets

limits for the learning (Smith & Petersson 1988).

The Michigan and Ohio researchers studied leader-

ship styles in relation to outcome criteria such as pro-

ductivity, motivation and morale (Michigan, Likert

1967) and turnover (Ohio, Fleishman & Harris 1962).

The Michigan researchers identified two orientations of

supervision, production centred and employee centred,

while the Ohio researchers identified two styles which

they called, initiating structure and consideration. Both

Ohio and Michigan researchers came to the conclusion

that effective leadership is dependent on an interaction

between employee orientation (consideration) and

production orientation (initiating structure); (Fleishman

& Harris 1962, Likert 1967).

Today change is the natural state in many private

companies as well as in the public sector and leadership

is more focused on renewal and change and less on

stable efficiency (Ekvall 1992).

New leadership behaviour has developed, more

focused on change within the company. This style,

called change-oriented leadership behaviour, was not

required before the middle of the 1980s (Ekvall 1988,Ekvall & Arvonen 1991). The leadership style is seen as

a combination of the three dimensions: change, pro-

duction and employee/relations (Ekvall & Arvonen

1994, Yukl 2002). Representative behaviours for the

three leadership dimensions are:

Production (task)-oriented

Plans carefully

Gives clear instructions

Is very exact about plans being followed

Defines and explains the work requirements

Employee (relation)-oriented

Shows regards for the subordinates as individuals

Is considerate

Is just in treating subordinates

Relies on subordinates

Allows subordinates to decide

Change-oriented

Offers ideas about new ways of doing things

Pushes for growth

Initiates new projects

Gives thoughts about the future

Likes to discuss new ideas.

Source: Ekvall and Arvonen (1991).

Cook (2001) identified five attributes that character-

ize effective nursing leaders: highlighting, respecting,

influencing, creativity and supporting. Cook (2001) also

identified five different types of effective leaders: dis-

coverer, valuer, enabler, modifier and shaper. Cooks

(2001) research points out a component of leadership

style, creativity and two leader types, discoverer and

shaper; findings that indicate the need for the dimensionof change even in nursing leadership.

In other research, the classical leadership styles,

i.e. production-/task-oriented and employee-/relation-

oriented have been transposed into new dimensions

called transactional contra transformational leadership

styles (Burns 1978, Bass 1985).

Burns (1978) described transformational leadership as

a process that motivates subordinates by appealing to

higher ideals and moral values. The transformational

leadership style can be seen as a combination between the

employee relation-oriented and the change-oriented

leadership styles. A transformational leader can be

characterized as a gardener who shapes a developing

and growing culture through stimulating and empower-

ing the staff in creative thinking and gives freedom for

innovation and individual growth. The following four

components are highly valued in transformational lead-

ership: inspirational motivation, idealized influence,

intellectual stimulation and individualized consideration

(Bass & Avolio 1985, Ward 2002). An American study

shows that this leadership style is a little more common

among women leaders (Bass et al. 1996). A transactional

leader is more focused on structure, role expectations andpossibilities to reward the staff. A key criterion is that

every extra effort has to be rewarded, as you will not get

anything from anybody if you do not give him or her

something in exchange (Bass & Avolio 1985).

Nursing management

Nursing as a profession is people-oriented with an

emphasis of humanism and this is probably influencing

leadership in the area. The nature of health care at a

university hospital where life and death, every day

probably has its own demands within leadership com-

pared, for example, with industrial industries.

Nursing management is today seen as a profession of

its own with special training and skills. To be able to

deal with everyday management where behaviour is

adapted to the situation (situational leadership), the

manager needs to be aware of their own leadership

profile, the system and task. Managers who are able to

combine these in their leadership have the greatest

potential for success (LaMonica 1990).

Leadership styles in nursing management

2006 Blackwell Publishing Ltd, Journal of Nursing Management, 14, 348355

349


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Nurse managers tasks, as all managerial positions

independent of area, represent different competencies.

One is the managing role including competencies such

as analytical thinking, knowledge in management, work

environment analysis, business knowledge, leadership

and visioning (Wallick 2002). These competencies

relate to the production dimension. The continuous

status of change in health care places demands onnursing managers in competencies such as, social

awareness, ability to see the big picture and interper-

sonal relationship building (Wallick 2002). These last

competencies relate to the dimensions of change and

relation. Based on Basss (1985) theory, Prenkert and

Ehnfors (1997) studied whether nurse managers who

expressed both transactional and transformational

behaviour are more organizationally effective. They did

not find any evidence for this hypothesis but noticed a

higher correlation between transformational leadership

and nursing quality and a lower correlation between

transactional leadership and nursing quality.

With exception of the above studies there is a lack of

research on leadership style and preferred leadership in

nursing management providing the rationale for this

study.

The aim of this study was to explore nursing leader-

ship regarding what nurse managers and subordinates

see as important and to explore subordinates opinions

of their nurse managers performance.

Research questions

The research questions were:

What kind of leadership behaviour do managers and

subordinates prefer?

How is the managers real leadership behaviour

compared with the preferred?

Is it possible to identify different leadership profiles

(combinations of change, production and employee

orientations) in nursing management.

Method

The study was conducted at the Karolinska Hospital in

Stockholm, Sweden in November 2003.

Study population

The criteria for including the nurse manager in the study

were: responsibility for budget and human resources

and 10 subordinates or more, having been in charge at

least 6 months and not tendered resignation. It takes

time for a new manager to get to know the workplace

and to build a good relation with the subordinates. In

this study we decided that 6-months would be a rea-

sonable time for building this relationship. In Sweden,

you have to work 3 months after tendering your resig-

nation. During this time it may be difficult to be

enthusiastic for the work and to perform effectively. At

the time of the study there were 92 nurse managers atthe hospital of which 77 corresponded to the inclusion

criteria. These managers represented all kinds of units.

The number of subordinates of the 77 nurse managers

ranged between 10 and 80 in total. Seven hundred and

seventy, 10 per nurse manager, were asked to partici-

pate in the study. If the nurse managers had 10 subor-

dinates all were asked to participate. When the staff

consisted of more than 10 subordinates every subor-

dinate on the staff list got a number and an assistant

independent from the hospital and the study, randomly

drew numbers from a box.

Included subordinates were registered nurses, assist-

ant nurses and various administrative staff. Excluded

were subordinates with time-based employment

because they mostly work nightshifts or weekends when

the manager is not in charge.

Questionnaires

A questionnaire, based on the change, production,

employee (CPE) model, was used to assess preferred

leadership behaviour. This questionnaire, developed

and validated by Ekvall and Arvonen (1991, 1994),consists of 30-items covering the three dimensions,

change/ development, production/task/structure and

employee/relations, with 10-items for each dimension.

These three fundamental dimensions can be combined

into leadership profiles.

The same questionnaire was used with instructions to

respondents to assess perceived leadership behaviour in

reality. The questionnaire is reliability tested with

Cronbachs-a with coefficients between 0.86 and 0.94

(Arvonen & Ekvall 1999) and its validity is demon-

strated in several large studies (Arvonen 2002, Ekvall

2002).

The answers are rated from 1 to 6 in a Likert scale

(from do not agree at all to agree totally).

Examples of items are:

initiate new projects (change dimension);

trusts the subordinates (employee/relation dimen-

sion);

creates order and clarity (production/task/structure

dimension).

S. Sellgren et al.

350 2006 Blackwell Publishing Ltd, Journal of Nursing Management, 14, 348355


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Bass (1995) developed a tool for measuring leader-

ship styles, multifactor leadership questionnaire

(MLQ). This tool relates to transformational and

transactional leadership style. The CPE tool was

chosen because it measures leadership from three

fundamental dimensions (Yukl 2002) that could

be combined into leadership profiles; is reliability

tested and validated in the Swedish language and hasbeen widely used both in Sweden and in other coun-

tries (Ekvall & Arvonen 1994, Arvonen & Ekvall

1999).

The questionnaires were distributed to all partici-

pants at their home addresses and one reminder was

distributed after 2 weeks to the participants who did

not answer.

Statistical analyses

Significance testing was applied with t-tests of mean

differences between perceived and preferred leadership

style and between managers and subordinates ratings

on each of the three dimensions. The analysis was

performed using S P S S .

The perceived leadership style was also analysed

(mean scores of the subordinates ratings on each of the

three dimensions) to identify specific leadership profiles.

In this part only leaders who had five or more subor-

dinates that responded to the questionnaire were

included (n 52).

The scores on each dimension of every single manager

were compared with the mean value and standarddeviation for the whole population of 52 nurse man-

agers as carried out in earlier studies with the CPE

instrument. These analyses were partly performed using

S P S S and partly manually.

Ethics

Confidentiality and anonymity was guaranteed. Parti-

cipation was voluntary and informed consent was

obtained. The anonymity and the confidentiality were

particularly important as the first author was working

at the hospital as nursing director at the time of the

study. The study was approved by the Ethical com-

mittee of the Karolinska Institute (Dnr 03-348).

Results

Respondents

The total number of respondents in the whole study was

492 of 847 (58%). Sixty-six of the 77 (86%) nurse

managers answered the questionnaire and 426 sub-

ordinates (55%) responded. The total number of non

respondents (subordinates and nurse managers) was

355. Most (217) did not give any explanation as to why

they did not respond, 138 gave some explanation such as

being on the sick leave (six), were pregnant or on

maternity leave (10), on leave for other reasons (15)

and nine had just resigned. Six gave the explanation thatthe questionnaires were just too extensive to go through.

Five of the subordinates had not answered all of the

questions and their answers could therefore not be used

in the study. Units where five or more subordinates

responded were 52. Basic facts of the respondents are

presented in Table 1.

All of the 66 responding nurse managers were nurses,

of the subordinates 268 (62.9%) were nurses/midwifes,

126 (29.5%) assistant nurses or child assistant nurses,

13 (3%) were secretaries, four (


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Preferred leadership behaviour

The comparison between managers and subordinates

ratings of preferred leadership behaviour is presented in

Table 2. The preferences of leadership behaviour dif-

fered between managers and subordinates. The subor-

dinates tended to value every dimension higher than the

managers. However, the differences in statistically sig-

nificant means are fairly modest. The most statistically

significant differences between managers and subor-

dinates (P < 0.001) are in the dimensions production

orientation and employee orientation. Whereas for the

dimension change orientation was P < 0.05.

Perceived leadership behaviour compared withpreferred

The answers of the subordinates on the questionnaires

of preferred leadership behaviour were compared with

the answers of perceived leadership behaviour. The

total number of respondents that could be compared

was 420. The mean values perceived leadership of the

managers are, as rated by subordinates, far below the

level of their preferred leadership. The difference

between preferred and perceived leadership behaviour

can be found in all three dimensions and are statistically

significant (P < 0.001; Table 3).

Perceived leadership profiles

The mean values for the whole population (n 52) in

the three dimensions are presented in Table 4. In earlier

studies with the CPE instrument it had been possible to

identify 10 different leadership profiles, although five of

them were only found in between 2.3% and 7.3% of

the population (Ekvall & Arvonen 1994, Ekvall 2002).

The most common styles were, Middle of the road,

Super leader and Management by Objectives (MBO)

leader while the least common were Dominatingentrepreneur and Idea squirt (Table 5). In our study we

could identify seven of the above most common lead-

ership profiles. The Super leaders in our study were 12

(23.1%). Nine managers (17.3%) got low scores in all

three dimensions and are identified as invisible leaders.

These managers are vague in their leadership profiles.

The third most common identified profile, 26 managers

(50%), were the Middle of the road leaders with scores

inside one half standard deviation from mean values in

all three dimensions. In addition to these three common

profiles we identified five managers with other profiles

(Table 6).

Discussion

Our result with the most evident difference between

subordinates and nurse managers in preferred leader-

ship about production orientation, could indicate that

subordinates want a leader with a clearer leadership

style than the manager themselves think is accurate.

This supports the findings of Morrison et al. (1997) in

Table 2

Preferred nursing leadership beha-

viour in mean values between man-

agers and subordinatesDimension

Managers

(n 66)

Subordinates

(n 421)

Difference t -test P-valueMean SD Mean SD

Change orientation 5.07 0.437 5.14 0.512 )0.07 )1.01


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their study of nursing staff, using the MLQ scale (Bass

1995). They found that the staff preferred their leaders

to take a more active leadership role.

In this world of change it can be safe to have one

person who points out the direction and lead the way.

But it could also be an expression of lack of demands

and a desire to have more structure. There is a risk of

loose structure in an environment of constant change.

Both nurse managers and subordinates express high

preferences in the dimensions employee and change. In

a study among nursing managers of their perceptions of

the highest ranking among their responsibilities, com-

munication was shown to be the highest ranked issue

and thereafter followed in order, facilitation of goal

achievement, effective interpersonal relationships, in

fourth place came decision-making and in 10th change

agent (Purnell 1999).

The differences in all three dimensions might to some

degree arise from the fact that the managers understand

the reality of nursing management. They are facing the

difficulties and complexities of the first line leader role

daily.

The mean value of perceived leadership behaviour

was lower than the preferred in all three dimensions.

There is a lack in mean values between the leadership

behaviour that the subordinates prefer and the manag-

ers can perform. Although it seems to be possible to

reach the preferred levels as there are 12 nurse man-agers who are rated near the preferred mean values in

all three dimensions.

The two highest valued dimensions by the subordin-

ates in our study (employee and change), both in pre-

ferred and in perceived leadership, represent the basis of

transformational leadership style. In some earlier lead-

ership theories a leader that was high performing in

both task and relation orientation was supposed to be

the most effective in all kind of situations (Blake &

Mouton 1982). The advocates for transformational

leadership prefer high performance in relation and

change to garden the followers (Bass & Avolio 1985,

Prenkert & Ehnfors 1997). Boumans and Landeweerd

(1993) found that the Netherlands nurses were most

satisfied if the nurse manager had a combination of

high-social/high-instrumental (task and production)

leadership. In that research only two dimensions of

leadership were studied and the dimension change ori-

entation was not included.

It was not possible in our study to identify all of the

10 leadership profiles that have been identified in the

other studies carried out with the CPE instrument

(Ekvall & Arvonen 1994, Ekvall 2002). These studiescomprised large samples of managers from different

organizations (industry, trade, transportation, service,

care, education, media and consultancy). Both male and

female managers were included. In our study only five

managers had values that were unequal in the three

dimensions according to standard deviation for the

mean value. All the others had equal values in all three

dimensions. This could depend on the fact that the

nurse managers are mostly fostered in the nursing

profession and this pattern becomes a part of their

behaviour. Their way to promote leadership is also as a

role model, which influences others to behave in a

similar way (Eagly & Johannesen-Schmidt 2003).

Fanslow (1984) described that leadership style was

related to a personal value system that has been for-

mulated by culture, society and life experience. Cook

(2001) identified five different types of effective nursing

leaders. In our study we have not investigated how

effective the different identified styles are.

Nursing is also a woman-dominated profession and it

is therefore natural that nurse managers are mostly

Table 5

Leadership profiles identified with the change, production, employee

(CPE) instrument in earlier studies (Ekvall & Arvonen 1994)

Change Production Employee Percentage

Transactional )) + +) 6.5

Idea squirt + )) )) 3.7

Invisible leader )) )) )) 12.7

Domineering

entrepreneur

++ ++ )) 2.3

Middle of the

road leader

+) +) +) 21.9

MBO leader +) + + 14.3

Super leader ++ ++ + 15.8

Gardener ++ ) ++ 7.3

Autocrat )) + )) 4.2

Nice guy ) )) + 11.3

++, more than one SD above mean; +, more than one half SD above

mean; +), inside one half SD from mean; ), more than one half SD

below mean; )), more than one SD below mean (Ekvall & Arvonen

1994).

Table 6Identified leadership profiles among the 52 nurse managers (n 52)

n Percentage

Transactional 0 0

Idea squirt 0 0

Invisible leader 9 17.3

Domineering entrepreneur 2 3.8

Middle of the road leader 26 50

MBO leader 1 1.9

Super leader 12 23.1

Gardener 0 0

Autocrat 1 1.9

Nice guy 1 1.9



353


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women because they are recruited from the profession.

In our study there were only three men among the

respondent nurse managers. In earlier research it is

shown that leadership style could be a gender issue

and that women are more inclined to use the transfor-

mational leadership style (Bass et al. 1996, Eagly &

Johannesen-Schmidt 2003). On the contrary, in this

research none of the managers in our study were iden-tified as a transformational leader.

In our study there were nine managers that expressed

a more vague leadership style.

Hersey and Blanchard (1982) postulated that as the

level of maturity among followers increased, leadership

required less task orientation and less socio-emotional

support (Goldenberg 1990). That is, the more experi-

enced and motivated, the more independent the subor-

dinates will be of leaders direction and support. Bass

(1985) calls this style laissez-faire and states that such

leadership style is not adequate in any situation.

In a recently published study, nursing managers

were asked what competencies they thought where

needed for nursing management in 2020 (Scoble &

Russel 2003). The key competence was identified as

leadership behaviour and specific items in the analysis

were transformational leadership, visioning and perse-

verance.

The educational training in nursing leadership is

about 5 weeks in Swedish nursing programmes

(Sverigesriksdag 1993). This 5-week education includes

leadership theories, laws and other regulations, quality

work, supervision, economy and organization (Sverigesriksdag 1993).

At several universities there are health management

courses up to 60 weeks in duration. In these courses the

student learns about the political and organizational

system, about economics, quality improvement and

scientific methodology. Leadership behaviours suitable

for health care organization are poorly explored during

education and our study shows that there is a potential

for improvement.

Methodological considerations

Questionnaires have limitations (Ekvall 1992, Arvonen

2002). An advantage of the one used in the present

study is that both construct and predictive validity of

the instrument are demonstrated (Arvonen 2002).

Behaviour description questionnaires devised to study

leadership have been questioned by several researchers

since this tradition began. The main claim has been

that they measure the attitudes of subordinates

towards the leader and not real behaviour. The re-

search group at Ohio met the critique by presenting

studies which showed significant correlations between

subordinates who described the same leader (Ekvall

1992). The CPE questionnaire has been tested in

relation to influence of attitude. The change and pro-

duction dimension showed no correlations with atti-

tude. The employee dimension had a medium size

(0.40) coefficient, which is logical, because beingaccepted and liked is a psychological drive in relation-

oriented behaviour (Ekvall & Arvonen 1994). The

dropout rate was normal for this type of study and the

dropout analysis showed no selection bias.

Conclusions

The results of this study show that subordinates wish

nurse managers to be more distinct about demands in

relation to work. It also shows that there are managers

with a vague leadership profile. These characteristics of

leadership behaviour should be considered in the selec-

tion process of nurse managers as well as in the

continually professional development programme.

Forthcoming work studies the role of leadership in rela-

tion to working climate, staff satisfaction and turn over.

Acknowledgements

The authors thank all the nurse managers and nursing staffthat have participated in this study. Also thank Ola Anders-son, statistician at Stockholm University for all his support.

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