transformational leadership of clinical nutrition managers

RESEARCH

Transformational leadership of clinical nutrition managers MARY BETH FOLTZ ARENSBERG, PhD, RD; M. ROSITA SCIIILLER, PhD, RD; VIRGINIA M. VIVIAN, PhD; WAYNE A. JOHNSON, PhD; STEVEN STRASSER, PhD

ABSTRACT I I

Objective To identify leadership qualities of clinical nutrition managers and associate these leadership qualities with selected demographic variables (eg, traffdng/degree, length of time in management, number of people supervised, income, and participation in advanced practice activities). Design The theory of transformational leadership, that is, leadership that incorporates specific interpersonal behaviors of the leader and his or her actions within the organization, provided the framework for the study. Specific transformational leadership qualities - - leader behavior, leader personal characteristics, and the effect of the leader on organizational functioning and culture - - were measured using the Leader- ship Behavior Questionnaire (LBQ). The reliability and validity of the LBQ have been reported previously. Other data were obtained using two demographic surveys. Sample Demographic surveys were mailed to 1,599 members of the Clinical Nutrition Management dietetic practice group. From the 951 (59.8%) respondents, a study sample of 150 clinical nutrition managers and their subordinates was selected to receive the LBQ; 116 (77.3%) instrument sets were used for analysis. Statistical Analysis Descriptive statistics were used to analyze the demographic storeys. A specified mixed linear model repeated measures Statistical Analysis System

A strong need for leadership in dietetics exists today. Yet what do we mean by "leadership"? The traditional theories that have been used to define leadership in the past,

L such as trait theories (1,2), situational or environment theories (3), or the definition of unique leadership styles/ behaviors (4,5), seem to define leadership along one dimen-

M: B. Iq Arensberg is the manager of nutrition services of Ross Products Division, Abbott Laboratories, Columbus, Ohio. M. R. Schiller is the director and a professor in the Medical Dietetics Division in the School of Allied Medical Professions, K M. Vivian is a professor emeritus, and W. A. Johnson is a professor in the Department of Human Nutrition and Food Management in the College of Human Ecology, and S. Strasser is an associate professor of Health Services Management and Policy at The Ohio State University, Columbus.

Address correspondence to: Mary Beth Foltz Arensberg, PhD, RD, Nutrition Services, Department 106717-$5, Ross Products Division, Abbott Laboratories, 625 Cleveland Ave, Columbus, OH 43215.

procedure was used to compare clinical manager and subordinate LBQ scores. Association of the selected demographic variables with leadership qualities was measiJred by %, a predictive value measure, using the BMDP 4F program. Results Clinical nutrition managers exhibited transformational leadership qualities as rated by the LBQ, rating lowest on the communication leadership score and highest on the respectful leadership score. Most of the clinical nutrition manager self LBQ scores were significantly higher than the clinical nutrition manager LBQ scores rated by subordinates. The selected demographic variables appeared to have the strongest predictive effect for the visionary culture building subscore of the LBQ. The visionary culture building subscore is a measure of how well the leader interacts with and affects the functioning of an organization. Applications/Conclusions More research is needed to define leadership in dietetics: this study can serve as a possible model. One way clinical nutrition managers may be able to enhance their leadership behaviors is to strengthen their skills in communicating their vision. Programs are needed to help clinical nutrition managers shape their organizations to foster leadership development in their subordinates. J A m Diet Assoc. 1996; 96:39-45.

sion only. Such theories do not consider the new values of people who are no longer fulfilled solely by their work. Nor do these theories explain why some organizations are successful and have enthusiastic members whereas others do not. The answers to these questions are found, in part, in the more contemporary theory of transformational leadership (6).

Transformational leadership theory is characterized by a much broader, more multidimensional approach than traditional leadership theories. In transformational leadership theory, leadership is viewed not as a single factor, but rather as resulting from several interacting factors. Leadership reflects personal characteristics of the leader, such as power and influence, and situational or organizational contexts in which the leader and followers interact, thus accounting for the leader's ability to affect the organization's functioning. In addition, this new theory incorporates specific interpersonal behaviors of the leader and his or her actions within the organization.

Transformational leaders help people and organizations survive in a complex world, master change, and move ahead in the future. Such leaders also help employees gain a greater sense

JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 39

RESEARCH

Table 1 Leadership Behavior Quest ionnaire (LBQ) scales (adapted from Sashkin [27] )

Scale Definition

Visionary leadership behavior scales Scale 1 : Focused leadership Scale 2: Communication leadership

Scale 3: Trust leadership

Scale 4: Respectful leadership

Scale 5: Risk leadership

Leader's ability to manage his or her attention and to direct the attention of others Leader's interpersonal communication skill, including the ability to convey meaning of message, and attention to and

appreciation for feelings, including leader's own feelings and those of others Leader's perceived trustworthiness, willingness to take clear positions and avoid "flip-flop" shifts in position, and ability

to follow through on commitment Leader's treatment of others and himself or herself in daily interactions, ability to consistently express concern for others

and their feelings, and sense of how he or she fits into the organization Leader's ability to take risks that help implement parts of his or her vision and ability to design risks that others can "buy

into" so others participate in making the leader's vision real

Visionary leadership characteristics scales Scale 6: Bottom-line leadership Leader's sense of self-assurance and belief that he or she can personally make a difference and affect people, events,

and organizational achievements Scale 7: Empowered leadership Leader's need for power and influence to get things done, and use of power to empower others who can then use their

power and influence to carry out elements of leader's vision Scale 8: Long-term leadership Leader's ability to think clearly over relatively long time spans (at least a few years) and use of visions and specific goals

as conditions to achieve long-term actions, and leader's ability to explain visions to others and understand how visions could be expanded beyond current plans

Visionary culture-building scales Scale 9: Organizational leadership

Scale 1 O: Cultural leadership

Leader's degree of positive impact on achievement of organizational goals and degree of helping organization adapt effectively, improve organizational functioning, and build teamwork

Leader's ability to develop those values that will strengthen organizational functioning and at the same time build and support the leader's vision

of self-worth. Burns (7) described transformationalleadership as leadership that "occurs when one or more persons engage with others in such a way that leaders and followers raise one another to higher levels of motivation and morality" (p 20).

Although there appears to be important commentary on the subject of leadership among health care professionals (8-19), there is little research applying leadership theory to specific health care disciplines, such as dietetics (20). To develop leaders in dietetics, it is important to discover the factors that will be critical to future practice. As explained by Parks et al (21), such questions can be answered by using research and a scholarly approach.

Clinical dietetics represents the largest area of dietetics practice (22) and can serve as a model for leadership research. Clinical dietitians in management positions would logically lead their employees and, thus, are an appropriate group for initial research. In this study, transformational leadership qualities were identified for clinical nutrition managers who were members of the Clinical Nutrition Management (CNM) dietetic practice group of The American Dietetic Association (ADA).

METHODS In September 1992, a 60-item, demographic questionnaire was mailed to the US membership of the CNM dietetic practice group. The study population was defined as the 951 CNM members (59.8%) who responded to this questionnaire. A separate, nine-item demographic survey was used to help define the working relationships of the clinical nutrition managers with their subordinates. Drafts of both demographic questionnaires were reviewed by a panel of experts that included persons who had held leadership positions in CNM or who had experience in mail survey design.

The Leadership Behavior Questionnaire (LBQ), developed by Sashkin and Burke (23), was used to measure transformational leadership qualities of the clinical nutrition managers. The LBQ defines the three key elements of transformational leadership - - the leader's behavior, the leader's personal characteristics, and the leader's effect on organizational function-

ing and culture as visionary leadership behavior, visionary leadership characteristics, and visionary culture building, re- spectively. The LBQ is a standardized, self-administered instrument designed for use in management training and development. It comprises 50 items or questions, with five questions forming each of 10 scales. The 10 scales are then summed to form three subscores and an overall total score (Table 1). The reliability and validity of the LBQ have been reported previously (23-26).

Because of the expense of the LBQ instrument and its marling, a study sample of 150 was systematically selected from the study population. First, we identified 222 clinical nutrition managers who met the following criteria: current CNM membership; current dietetic registration and/or licensure; employment as a clinical nutrition manager in a US hospital; direct supervision of astaff of three or more dietetics professionals; and consent to participate in the study and to recruit three subordinates (dietitians and/or dietetic technicians who directly report to the clinical nutrition manager) for participation. These surveys were arranged in zip code numerical order and every third survey was discarded to yield a final study sample of 150.

This study sample of 150 clinical nutrition managers re- eeived explanatory letters, instruction sheets, sets of LBQs (one "self" and three "others"), three copies of the subordinate demographic survey, and return envelopes. Participants were instructed to complete the self LBQ and provide the explanatory letters, subordinate demographic surveys, other LBQs, and envelopes to each of three direct-report subordinates. The subordinates were instructed to complete the instruments, using the other LBQ to rate their clinical nutrition manager, and return the subordinate demographic survey and other LBQ in sealed envelopes to their clinical nutrition managers. Clini- cal nutrition managers were asked to collect and mail all completed sm'vey instruments to the investigator (M.B.F.A.).

Both demographic instruments and the LBQs were coded and processed at The Ohio State University Polymetrics Labo- ratory. We calculated statistics working with The Ohio State University Statistical Consulting Service and using Statistical

40 / JANUARY 1996 VOLUME 96 NUMBER 1

u 0 O m 0 0 0 O 0 I I j O O 0 0 0 I 0 0 O 0 0 0 0 0 0 0 0 0 i 0 0 0 Q 0 Q 0 0 0 0 I t I m O m 0 I I D I a 0 0 0 D 0 Q O I i 0 0 6 0 ~ 0 0 I Q 0 0 g i 0 m g a a I Q 0 Q 0 0 0 I 0 g 0 D Q I I I 6 m Q Q i Q ~ a 0 D D O 0 0 I j I 0 D 0 D I Q 0 0 0 g g I 0 O Q 0 D m O g 0 0 D 0 0 Q Q D Q Q O ~ Q 0

Analysis System software (version 6.07, 1992, SAS Institute, Inc, Cary, NC) and BMDP statistical software package (1990, University of California, Berkeley, Calif).

We analyzed the demographic surveys using descriptive statistics. For the LBQs, means and standard deviations were calculated for scale scores, subscores, and totals and were used to evaluate transformational leadership according to the LBQ's rating guidelines (27). The LBQ rating guidelines were based on normative data collected from 500 managers of business and community organizations (25). The few individual missing values in the LBQs were imputed with a nearest- neighbor hot-deck procedure. This procedure was only used for individual missing values and not to generate entire LBQ survey scores. To compare clinical nutrition manager (self) LBQ scores and clinicalnutrition manager subordinate (other) LB0 scores, a specified mixed linear model repeated measures Statistical Analysis Systems procedure was used; significance was computed by the approximate P test.

Clinical nutrition manager (self) LBQ subseores and totals were used to associate transformational leadership qualities with these selected demographic variables: training/degree, length of time in management, number of people supervised, income, and participation in advanced practice activities (eg, management, research, and scholarly activities). Each subscore and total score was classified into three groups: the tow group comprised persons with ratings in the "very low" and "low" categories, the medium group comprised those rating "average," and the high group comprised those rating "high" and "very high," as evaluated by Sashkin's (27) rating scale. Missing values for the LBQ were again imputed with the nearest- neighbor hot-deck procedure. The few missing defined study variables in the demographic surveys were equated to zero. The ability of the defined study variables to predict transformational leadership qualities was measured by calculating ~,, a predictive value measure, using the BMDP 4F program.

R E S U L T S Although the aim was to include 150 clinical nutrition managers in the study sample, only 121 (80.0%) survey instrument sets (including the clinical nutrition manager and subordinate LBQs and the subordinate demographic surveys) were returned. One set (1.0%) was returned late and four clinical nutrition managers (2.6%) chose not to participate and returned the survey sets uncompleted. One hundred thirteen sets (75.3%) were complete; that is, they contained the self and three other LBQs. Three sets had fewer than three other LBQs but were included in the study sample. Thus, the study sample consisted of 116 clinical nutrition managers.

The clinical nutrition managers in the study sample were predominantly women (97.4%), and a majority had earned (67.2%) or had completed work toward (7.8%) a master's degree. Although respondents were employed in a variety of institutions, most worked in teaching (40.5%) or worked in community hospitals (39.7%), and most worked in hospitals with a bedsize of 250 to 499 beds (44.8%). Most respondents supervised at least some clinical nutrition staff and 91.2% had a staff of more than five full-time equivalent employees. Fur- ther demographic characteristics are summarized in Table 2.

The study sample included 344 subordinate demographic surveys. The majority (88.1%) of these subordinates worked full-time. The most frequently reported titles were dietitian or nutritionist (57.1%), nutrition specialist (13.9%), dietetic tech- nician (10.1%), or a management-level title (12.7%).

In considering mean LBQ scores of clinical nutrition managers (self) and subordinates (other), clinical nutrition managers rated lowest on the communication leadership and highest

I

Tab le 2 Demographic characterist ics of clinical nutrition managers participat- ing in leadership study

Characteristic Clinical nutrition managers No. %

Years in current position (n = 116) <3 46 39.7 3-8 45 38.8 >8 25 21.6

Years in management (n = 116) <3 21 18.1 3-8 54 46.6 >8 41 35.3

Years in dietetics (n = 116) <1 0 0.0 1-5 6 5.2 6-10 31 26.7 11-15 35 30.2 16-20 23 19.8 >20 21 18.1

Number of promotions in dietetics field (n = 116) 0 1 0.9 1-2 61 52.6 3-5 50 43.1 >5 4 3.4

Route to registration (n = 116) Internship 60 51.7 Coordinated program 26 22.4 Master's/experience 18 15.5 Approved preprofessional

practice program traineeship 6 5.2

Other 6 5.2

Annual salary (n = 116) <$20,000 0 0.0 $20,000-30,000 3 2.6 $30,001-40,000 56 48.3 $40,001-50,000 47 40.5 $50,001-60,000 6 5.2 <$60,000 4 3.4

Number of clinical dietitians supervised a (n = 115) 0.0 0 0.0 0.1-5.0 53 47.0 5.1-10.0 42 36.5 10.1-15.0 17 14.8 15.1-20.0 2 1.7 >20 0 0.0

Number of clinical technicians supervised a (n = 83) 0.0 10 12.0 0.1-5.0 58 69.9 5.1-10.0 14 16.9 10.1-15.0 1 1.2 15.1-20.0 0 0.0 >20 0 0.0

aRefers to full-time equivalent employees.


RESEARCH

Table 3 Mean ( -+ s tandard deviat ion [SD]) self scores (self) and subordinate 's scores (other) for clinical nutrition Quest ionnaire (LBQ) and ratings accord ing to LBQ guidel ines a

Scale Clinical nutrition LBQ manager (self) LBQ guideline score (n = 116) rating a

managers on the Leadersh ip Behavior

Subordinate (other) LBQ LBQ score for guideline clinical nutrition rating a manager (n = 344)

",--- Mean + SD ---.', ',---- Mean +_ SD - ~ Focused leadership b 20.0 + 2.0 Average 20.1 ± 3.1 Average Communication leadership b 18.8 ± 2.5 Average 18.4_+ 3.8 Average Trust leadership b 21.0 + 2.0** High 20.3 ± 3.2 Average Respectful leadership b 22.0 + 2.1" High 21.4 + 3.0 High Risk leadership b 19.9 +_ 2.5* Average 19.3 ± 3.6 Average Visionary leadership behavior subscore c 101.7 ± 8,4* High 99.5 _+ 14.2 Average

Bottom-line leadership b 21.4-+ 2.4** High 19.9-+ 3.2 Average Empowered leadershi pb 19.8 + 2.2** Average 18.5 _+ 3.1 Average Long-term leadership b 19.6 _+ 3.2 Average 19.1 _+ 3.7 Average Visionary leadership characteristics subscore a 60.7 ± 5.9** High 57.4 -- 8.5 Average

Organizational leadership b 21.8 ± 2.1 ** High 20.6 _+ 3.8 High Cultural leadership b 20.4 ± 2.2** Average 19.7 _+ 2.8 Average Visionary culture-building subscore e 42.2 _+ 3.6** Average 40.3 ± 6,0 Average

Visionary leadership total score f 204.6 ± 15,6"* High 197.3 _+ 26.9 Average

aLBQ rating as described by Sashkin (27). bpotential scale ratings: very high (23-25), high (21-22), average (18-20), low (16-17), very low (5-15). Cpotential visionary leadership behavior subscore ratings: very high (113-125), high (102-112), average (92-101), low (75-91), very low (25-74). dpotential visionary leadership characteristics subscore ratings: very high (68-75), high (60-67), average (51-59), low (42-50), very low (15-41). epotentiat visionary culture-building subscore ratings: very high (48-50), high (43-47), average (37-42), low (29-36), very low (10-28). fPotential visionary leadership total score ratings: very high (226-250), high (201-225), average (176-200), low (146-175), very low (50-145). *Significant difference when P<.05. **Significant difference when P<.01.

on the respectful leadership scales (Table 3). All of the mean self LBQ scores were higher than the mean other LB0 scores, with the exception of the focused leadership score; a number of those differences were statistically significant (Table 3).

The selected demographic variables appeared to have the strongest predictive effect (ie, ;% values were highest) for the visionary culture-building subscore (Table 4). This subscore measures the leader's ability to create policies and programs that have a positive effect on how an organization functions and the leader's ability to support the values of the organization. Two demographic variables, appointment/election to local/regional offices and implementing techniques to enhance staff retention, also appeared to have predictive effect because ;% values for these variables were greater than 0.10 for several of the subscores and for the total (Table 4).

D I S C U S S I O N In this descriptive study, clinical nutrition managers exhibited transformational leadership qualities as rated by the LBQ. Although there has been very limited research on transformational leadership in dietetics, this finding was not unexpected. First, transformational leadership is more likely to be found during crisis conditions rather than static or stable conditions (28). In other words, the impetus of change could promote the development of transformational leadership. Although the stability of individual institutions where clinical nutrition managers worked was not measured in tiffs study, in general, health care institutions are in a state of flux because of the impact of cost containment, managed care, and other challenges.

Second, the study sample had several demographic characteristics that have been shown to be related to transformational leadership. The study sample was predominantly fe- male. Some investigators have argued that gender does not affect transformational leadership (29,30), but others have

found that women are more transformational in their leadership than men (31). Having an advanced degree has also been shown to be related to transformational leadership (81,32), and the majority of the clinical nutrition managers in this sample either had master's degrees or had completed some work toward those degrees.

Situational variables may have contributed to the transformational leadership exhibited by the clinical nutrition managers in this sample. The majority of clinical nutrition managers were from institutions with greater than 250 beds. Young (22) found that, as a group, nurse leaders with high transformational leadership scores worked in larger hospitals, on large[" nursing units, and supervised more employees. On the other hand, Dunham and Klafehn (21) found no significant relationship between transformational leadership and hospital size.

Finally, personality factors might have affected the disposi- tion of clinical nutrition managers for transformational leadership. Although this investigation did not evaluate specific personality factors, some, such as power, were indirectly measured by the LBQ. On the LBQ, the empowered leadership scale was a measure of the use of power to influence others. Few investiga!;ions have considered the power exhibited by dietitians. In our study, clinical nutrition manager (self) LBQ scores and subordinate's (other) LBQ scores for clinical nutrition managers were rated as average on empowered leadership. In contrast, Schiller et al (20) reported that the mean score for power in the clinical dietitians they studied was low compared with all other measured behavioral styles of clinical dietitians and compared with the normative data for their studyinstrument. Because their data were collected from 1986 to 1989, it could be that in the current health care environment clinicaI dietitians have developed a greater appreciation of and use for power. Another and more important consideration is the definition of power on the scale used by Schiller et al

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Table4 Association of selected demographic variables with clinical nutrition manager (self) Leadership BehaviorQuest ionnaire (LBQ) subscores and totals

Selected demographic variable Visionary Visionary Visionary Visionary leadership leadership culture-building leadership total behavior characteristics subscore score subscore subscore

n a

< k va lue b >

Years in management 0.000 0.000 O. 148 0.000 116 Route to registration 0.059 0.000 0.097 0.000 116 Highest degree 0.020 0.089 0,081 0,023 116 Annual salary 0.020 0.067 0.129 0.023 116 Number of clinical dietitians supervised 0.000 0.000 O, 148 0.000 115 Number of clinical technicians supervised 0,000 0.000 0,210 0.000 83

Management Developed performance objectives Developed CQI ° program Implemented CQI programs Implemented staff retention programs Implemented staff development programs Implemented management programs Implemented marketing programs

0.020 0.000 0,113 0.023 115 0.000 0.000 0.145 0.000 116 0.098 0.000 0.226 0.047 116 0,118 0.111 0.194 0.163 116 0.020 0.067 0.081 0.047 116 0.039 0.133 0,323 0,093 116 0.039 0.067 0.177 0.047 116

Research Authored research proposals 0.000 0.000 0.113 0.000 116 Managed research studies 0.020 0.000 0.161 0.000 116

Scholarly activities Professional presentations local/regional Professional presentations state/national Public presentations--local/regional Public presentations--state/national Public p r e s e n t a t i o n s - r a d i o ~ t e l e v i s i o n

0.039 0.000 0.129 0.000 115 0.000 0.000 0.113 0.000 103 0.039 0.000 0.145 0.047 116 0.000 0.000 0.081 0.000 96 0.020 0.000 0.226 0.000 101

Publication of professional articles Publication of professional abstracts Publication of professional book chapters Publication of professional books Publication of consumer articles Publication of consumer brochures/monographs Publication of consumer book chapters Publication of consumer books

0.020 0.022 0.145 0.000 116 0.000 0.000 0.081 0.000 107 0.000 0.000 0.081 0.000 102 0.000 0.000 0.081 0.000 104 0.000 0.000 0,065 0.000 114 0.000 0.044 0.097 0.000 110 0,000 0.000 0.048 0.000 97 0.020 0.022 0.065 0.023 98

Have/had professional mentor Serve/served as professional mentor Appointed/elected to local/regional office Appointed/elected to state/national office Attendance at workshops Involvement in leadership activities

0.039 0.000 0.146 0.000 116 0.000 0.022 0.113 0.000 115 0.118 0.067 0.242 0,070 115 0.000 0.000 0.161 0.000 101 0.039 0,022 0.113 0.000 114 0.000 0.000 0.129 0.000 116

aMissing values were equated to zero for this analysis. % is a predictive value measure and in this analysis measured the ability of the defined study variables to predict the LBQ subscores and total, X can have a minimum value of 0.000 and a maximum value of 1.000. Defined study variables with a X value >0.100 were interpreted as indicating a possible ability to predict LBQ subscores and total. cCQI = continuous quality improvement.


• • e • • t t o e • • • - e Q o • • • • o e e e • • • • o o ° • • • • o o e o o e o o o ° Q ~ • • • • • c o . s e e • e • • • e o ~ • o H • • ° l e • • • • ~ a a t ~ • • • • • t o o • • • • • e • • • • • • • • • • • • • . . • • • e e e • • • • • t o • • • • • • • • • • • •

RESEARCH

(20) - - p o w e r was described as a negative trait and power managers were described as dogmatic, abrupt, hostile, and had little regard for others' feelings.

This negative definition of power is somewhat similar to words dietitians themselves have used to describe power (33). In contrast, on the LBQ, empowered leadership was described positively. The clinical nutrition managers in our study may have found this new definition of power more acceptable than previous definitions.

The evidence of strong transformational leaders in clinical nutrition management as documented in the present research is more definitive than the previous study of Schiller et al (20). In the study by Schiller et al (20) researchers documented that many clinical dietitians had a nigh self-actualization score, which the researchers believed indicated transformational leadership. However, the researchers also reported that a number of dietitians had high scores for dependency and severM other "negative" traits, which they concluded did not reflect transformational leadership.

Several reasons may account for the difference in strengths of transformational leadership documented in the two studies. First, the study sample of Schiller et al (20) comprised clinical dietitians who, in general, represented smaller hospitals. Smaller hospital size itself could have been a factor limiting transformational leadership as previously found by Young (32). Also, it is possible that even though the sample of Schiller et al included clinical dietitians with supervisory responsibility, there could have been a smaller number of clinical dietitians who were in true management and leadership positions. These positions could have represented low-level managers who, as McDaniel and Wolf (34) documented, may have weaker transformational leadership skills.

Another consideration is that the data presented by Schiller et al (20) were collected over a 4-year period, during which time the health care field was not faced with the severe pressures seen today. Also, the instrument used by those researchers, the Life Styles Inventory (LSI), was not developed to examine transformational leadership. Finally, their data were based exclusively on self-reports. It is not known if our data from subordinates would have provided similar or conflicting results to those Schiller et al (20) reported.

We anticipated that the self and other LBQ scores for clinical nutrition managers would differ, but the finding that the self LB0 scores were consistently higher was unexpected. Some researchers (35,36) have documented that with their respec- tive transformational leadership instruments, self-ratings are typically higher than ratings of the same leaders by subordinates and others. Yet the opposite has been reported by the LBQ developed by Sashkin and Burke (23). However, in the most recent normative data of Sashkin et al (37) this does not always appear to be true.

In the field of dietetics, researchers investigating areas related to leadership, such as the image of the dietitian, reported that dietitians rated themselves lower than their peers rated them in the area of image (38-40). Perhaps in our study, the low score on the communication leadership scale indicates that dietitians did not clearly communicate their mission, vision, and values and, thus, were not perceived as being as high in transformational leadership qualities as they believed themselves to be.

We anticipated that there would be some association between the defined selected demographic variables and the LBQ subscores and the LBQ total score because reports by other researchers (20,31,32) had indicated an association. However, the finding that the selected demographic study variables appeared to have a closer association with one par-

ticular subscore, the visionary culture-building subscore, was unexpected. We did not find an association of this type in the literature.

Dunham and Klafehn (31) and Young (32) considered vari- ous demographic variables and the relationship of those variables to transformational leadership, but used total measures of transformational leadership and did not consider subscores. Schiller et al (20) did consider subscores and the relation of the subscores to the characteristics of dietitians. However, the instrument used by these researchers to measure leadership, LSI, did not have scales that were well-correlated with those of the LBQ.

We did not expect the finding that only two study variables, appointment/election to local/regional offices and implementing techniques to enhance staff retention, seemed to be more predictive of transformational leadership than were other defined variables. Schiller et al (20) found an association between holding local and regional offices and the scores of dietitians on the LSI instrument used to measure leadership in their study. Yet they also found an association between a number of other characteristics and the LSI scores of dietitians. Again, it may be that those differences were indicative of the differences in the instruments used for the two studies.

Transformational leaders help people and organizations

survive in a complex world, master change, and move

ahead in the future

As one of the first studies to explore transformational leadership in dietetics, the current investigation extends the work of Schiller et al (20) '~ several ways: an instrument was used that evaluated transformational leadership specifically; a defined area of dietetics practice, clinical nutrition management, was investigated; and the ratings of subordinates were considered. However, several limitations should be considered in data interpretation. First, the sample chosen for this research might not have been representative of clinical nutrition managers as a whole. We did not survey clinical nutrition managers who were not members of the CNM dietetic practice group. In addition, those selected for inclusion in the research were from larger hospitals and had supervisory responsibilities. Second, both clinical nutrition managers and subordinates might have responded t o t h e LBQ as they believed they should have and might not have answered truthfully. Also, some clinical nutrition managers could have selected those subordinates who would rate them the most positively. Third, there was the limitation of nonresponse, which frequently occurs in mailed surveys. In this study, nonresponse occurred at two levels - - when the initial demographic smazey was mailed and when the LBQ was mailed. A fourth limitation was related to the selec- tion of the LB0 and demographic instruments. The LB0 has been validated by previous research (23,25). However, it is still possible that the LBQ did not accurately evaluate all elements of transformational leadership. Finally, the demographic sur-

44 / JANUARY 1996 VOLUME 96 NUMBER 1

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veys deve loped for this s t udy were r ev iewed by c o n t e n t exper t s bu t were n o t val idated.

APPLICATIONS With t he pauc i ty of r e p o r t e d r e s e a r c h on l eade r sh ip in clinical dietet ics , th is s t u d y provides i m p o r t a n t impl ica t ions for t h e profession. Firs t , th is s tudy can serve as a mode l for m o r e r e sea rch to f u r t h e r def ine t r an s f o r m a t i ona l l eade r sh ip in di- e tet ics and clinical nu t r i t ion m a n a g e m e n t . To date , mos t re- sea rche r s in d ie te t ics have not clearly d i s t ingu i shed l eade r sh ip as d i f ferent f rom m a n a g e m e n t . New s tud ies are n e e d e d in which t he d i s t inc t ion is specifically made. Addi t iona l r e s e a r c h should also be focused on de l inea t ing fac tors t h a t he lp cont r ib - ute to t he d e v e l o p m e n t of t r ans fo rma t iona l l eade r sh ip skills in clinical nu t r i t i on m a n a g e r s and o t h e r diet i t ians . B e y o n d bas ic research , t h e r e is a n e e d to examine the o u t c o m e s of t r ans for - mat ional l e ade r sh ip in the profess ion, inc luding b o t h quan t i t a - tive and qual i ta t ive outcontes .

A second r e c o m m e n d a t i o n is to i nc rease c o m m u n i c a t i o n skills of clinical nu t r i t i on managers . It s e e m e d t h a t our s t u d y group of m a n a g e r s pos se s sed t he cha rac te r i s t i c s of t r ans for - mat ional l eaders ( such as s t rong bo t tom- l ine and l o n g - t e r m leadersh ip) a n d vis ionary cu l tu re -bu i ld ing skills of organiza- t ional and cu l tura l l eadersh ip , bu t were no t as s t rong in visionary l eade r sh ip behaviors , par t icu la r ly c o m m u n i c a t i o n skills. Visionary l eade r sh ip behaviors are i m p o r t a n t b e c a u s e t h e y inspire fol lowers to b e c o m e exc i ted abou t t he l eader ' s goals and u n d e r s t a n d h o w as foliowers t hey can bui ld t he succes s of the organizat ion. This s tudy ind ica tes t h a t clinical n u t r i t i o n managers a l ready recognize t he i m p o r t a n c e of t hose behaviors, yet m a n y lack the skill and t ra in ing to i m p l e m e n t such behaviors effectively. Ways to e n h a n c e t h e i r i m p l e m e n t a t i o n of l eadersh ip behav io r s could be to s t r e n g t h e n t he role of communica t ion in m a n a g e m e n t p rac t i ce and to deve lop u n d e r - g radua te and con t inu ing educa t i on p rog rams t h a t p rov ide t raining in c o m m u n i c a t i o n skills. F u r t h e r m o r e , t r a in ing pro- graras in t r an s fo rma t i ona l l eadersh ip for d ie te t ics p rofess ion- als n e e d to be deve loped to mode l behav io r s and emphas i ze hands-on leadersh ip exper iences and cri t iques of pe r formances .

The final r e c o m m e n d a t i o n is to develop p rog rams and ap- proaches t h a t will he lp clinical nu t r i t i on m a n a g e r s shape t h e i r organizat ional e n v i r o n m e n t s to fos te r t he d e v e l o p m e n t of t r ans fo rmat iona l l eade r sh ip in t he i r subord ina tes . A s t rong need urill con t i nue to exis t for t r ans fo rma t iona l l eade r sh ip in the profession. Clinical nu t r i t i on m a n a g e r s and o the r d ie te t ics professionals m u s t l ea rn to p r e p a r e t he way for the p rofess ion ' s t r ans fo rmat iona l l eaders who will follow in t he i r foots teps .

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