Introduction
Demand for staff nurses continues to increase rapidly, with the worldwide nursing shortage now estimated to be in excess of one million (Elkholy et al., 2020). Nurses play an essential role in health institutions. However, several factors, including unfavorable working conditions, the pull of more-attractive remuneration, and poor leadership styles, are known to cause nurses to leave their jobs (Ozer et al., 2019; Zhao et al., 2021). The COVID-19 crisis has further exacerbated the existing nursing shortage because of extra workloads (Ministry of Health Jordan, 2020). The nursing shortage may encourage healthcare institutions to recruit less-experienced nurses and result in declines in productivity and performance and increases in mortality and medical errors. These problems are major concerns for nurse leaders and supervisors who work with nursing staff (Elkholy et al., 2020).
Effective leadership creates beneficial behaviors and improves job satisfaction and commitment to the organization (Othman & Khrais, 2022). Much nursing research has focused on authentic leadership because of its grounding in human values, which are the core of nursing (Alilyyani et al., 2018). "Authenticity" is an ancient concept. The Greek philosopher Socrates emphasized the importance of knowing oneself and being true to oneself (Covelli & Mason, 2017). "Authentic leadership" is a complex concept that applies authentic principles to leadership in the workplace with the belief that being true to oneself is expected to yield desirable consequences in the workplace (Avolio & Gardner, 2005). "Authentic leadership" is considered an emerging leadership style rooted in humanism (Johnson, 2019).
Intention to leave refers to an individual's desire and plan to leave their organization and, for nurses, suggests they are actively searching for a job in another health institution (Blake et al., 2013). According to Azanza et al. (2015), authentic leadership decreases the desire of staff to quit their jobs. According to Lee et al. (2019), authentic leadership impacts nurses' intention to leave, but some personal and work-related factors can mediate this effect. The authentic leader contributes to work by maximizing the suitability of the environment and available resources and by supporting the staff.
Wong and Laschinger (2013) reported a link between authentic leadership and employee outcomes such as job satisfaction and staff performance, with staff performance influenced through staff empowerment and encouragement. Furthermore, when nurses perceive their leaders as engaged authentically, openly, and honestly in decision making, they react positively to their work and report increased commitment to their job, better confidence in management, and improved performance. Previous research indicates authentic leadership effectively contributes to improving nurse performance (Labrague et al., 2021).
In Arab countries, Islam is the prevalent religion and plays a main role in creating a common Arab culture. In Arab culture, leaders are considered to be great individuals who lead their followers and attend to their needs (Khaidir & Suud, 2020). The Arabic or Islamic perspective of leadership provides a moral basis for leadership promoting performance through adherence to key principles such as justice, consultation, commitment, honesty, trust, and integrity (Gazi, 2020). Marinakou and Nikolic (2016) argued that the four dimensions of authentic leadership (i.e., self-awareness, relational transparency, internalized moral perspective, and balanced processing) of Walumbwa et al. (2008) are consistent with moral principles of leadership from Arab and Islamic perspectives. However, authentic leadership is a relatively new concept in Arab work culture, which differs substantially from this culture in the West. Nurse leaders should be aware of the role that leadership style plays in shaping staff nurse outcomes in different cultures and adapt their leadership style accordingly.
The assumptions of social exchange theory hold that positive interactions within the context of workplace dynamics are linked to positive work-related behaviors (Cropanzano & Mitchell, 2005). On the basis of this assumption, nurse leaders who employ authentic leadership in health settings may realize better nurse job performance and reduce their intention to leave.
Whereas some studies have shown that authentic leadership reduces nurses' intention to leave (Lee et al., 2019), other studies have found no significant relationship between authentic leadership dimensions and intention to leave in nurses (Ozer et al., 2019). An additional gap in the literature relates to the link between nurses' performance and, respectively, key organizational variables and nurse managers' authentic leadership, as these relationships have been little studied. In addition, although authentic leadership and its impact on employee outcomes have been studied in the literature, its association with staff performance and staff intention to leave is not well understood in the Arab cultural context. Investigating this will provide further insight into whether the benefits of authentic leadership are universal or culturally specific. The authors hope the findings of this study provide nurse managers, nurses, and researchers with recommendations to improve authentic leadership and staff performance as well as reduce intention to leave among registered nurses.
Purpose and Research Questions
This study was designed to explore demographic-based differences in nurse performance and intention to leave and to investigate the relationship between authentic leadership and, respectively, nurse performance and intention to leave. The following research questions were addressed:
1. Are there sociodemographic-based differences in nurse performance and intention to leave?
2. After controlling for sociodemographic variables, is authentic leadership related to nurse performance and/or intention to leave?
Methods
Study Design, Sample, and Settings
A comparative and correlational design and a cross-sectional survey were used in this study. A convenience sampling technique was used to recruit the study sample. The target population included all registered nurses currently working at Jordanian governmental hospitals. The accessible population included registered nurses in the medical and surgical buildings of Al-Basheer Hospital, the largest public hospital in Jordan. The surgical building in this hospital includes 22 general and specialized surgical departments, whereas the medical building consists of 14 specialized medical departments.
The inclusion criteria were as follows: (a) holding a bachelor or higher degree, (b) having at least 1 year of experience in the current workplace, (c) providing direct bedside care, and (d) working in rotating shifts. Exclusion criteria included working in an administrative position, not working at the bedside, holding a diploma degree only, and having less than 1 year of experience in the current workplace.
A rule of thumb for identifying the minimum sample size required for multiple regression analysis is to include 20 respondents for each independent variable (Memon et al., 2020). Using this rule of thumb as a guide, a minimum sample size of 80 is required for four tested predictors. A post hoc power analysis was performed to calculate the effect size from the squared multiple correlation coefficients reported in this study. We found a small-to-medium effect size for the relationship between authentic leadership and performance, f2 = 0.11, and a large effect size for the relationship between authentic leadership and intention to leave, f2 = 0.35. With regard to the required sample size for this study, using regression analysis, a power = 0.80, [alpha] = .05, with four tested predictors, and a conservative estimate of effect size (f2 = 0.11), a minimum sample of 114 participants was identified. The number of participants enrolled was 166, indicating the sample size as reasonably adequate for detecting significant relationships between the main study variables.
Measures
Sociodemographic characteristics
Participants were asked about their gender, age, marital status, educational level, public/private university status, total years of experience in nursing, total years of experience in their current hospital, hospital type, working unit, perception of their first-line managers, and self-perception as a manager.
Authentic Leadership Scale
Perception of authentic leadership was measured using the Authentic Leadership Scale (ALS; Walumbwa et al., 2008). Participants reported the frequency (0 = never to 4 = always) with which their leaders exhibited 16 leadership behaviors. Sample items included (a) "Seeks feedback to improve interactions with others" (self-awareness), (b) "Says exactly what he or she means" (relational transparency), (c) "Demonstrates beliefs that are consistent with actions" (internalized moral perspective), and (d) "Listens carefully to different points of view before coming to conclusions" (balanced processing). The range of total possible scores is from 0 to 64, with higher scores associated with greater use of authentic leadership behaviors. Internal consistency was evaluated using Cronbach's alpha, which was .96 in Ribeiro et al. (2018) and .94 in this study.
The Turnover Intention Scale
The Turnover Intention Scale was developed by Michaels and Spector (1982) to assess intention to leave among employees. The three items of this scale are scored on a 6-point Likert scale (1-6 representing strongly disagree, moderately disagree, slightly disagree, slightly agree, moderately agree, and strongly agree, respectively). Scale questions inquire as to how often the respondent thought seriously about quitting their job. The three items are averaged to yield a single, total score ranging between 3 and 18, with higher scores associated with higher intention to leave. The Cronbach's alpha score for this scale was .80 in a previous study and .90 in this study.
The six-dimension scale of nursing performance
This 52-item scale, developed by Schwirian (1978) to measure nursing performance, has been widely used in nursing literature recently because of its conceptual coherence and simplicity as well as the appropriateness of its properties for measuring nursing performance (Al-Ajarmeh et al., 2022; Ghazy et al., 2021; Vitale et al., 2022). Respondents are asked to rate the quality of their performance on a Likert scale from 1 to 4 (1 = not at all, 2 = satisfactorily, 3 = well, and 4 = very well). The scale consists of six domains: (a) quality of interpersonal relation communications, (b) quality of leadership, (c) quality of critical care, (d) quality of teaching collaboration, (e) quality of planning evaluation, and (f) quality of professional development. The total possible score ranges from 52 to 208, with higher scores indicating better job performance. The alpha coefficients range in value from a low of .84 for the leadership/employer subscale to .98 for the professional development/self-subscale (Schwirian, 1978). The Cronbach's alpha for the total scale in this study was .97.
Data Collection
Data collection commenced after obtaining institutional review board (IRB) approvals in September-October 2021. Participant recruitment was conducted in cooperation with nurse administrators, who provided the researcher with data on their nurses and announced the details of the study to their staff nurses via WhatsApp. All of the study data were collected online. A link explaining the study purpose, procedure, and implications of participation was sent to all of the participants. Screening questions were included as part of the consent process to confirm that potential participants meet the inclusion criteria. The study survey was constructed using Google Forms. The expected time for completing the survey was 20-25 minutes. Participants were allowed to ask any questions regarding the study by phone or email.
Ethical Considerations
Official IRB approvals were obtained from the IRB of the Faculty of Nursing of Zarqa University (Approval No. 18/2021) before data were collected. Consent to participate in the study was implied upon completion of the online survey and electronic cover letter. Participants were provided with written information via the electronic cover letter about study objectives, procedures, and the implications of participation. Participation in the study was voluntary, and no participant was forced to participate in the study against their will. A confidential link was sent to all participants. Collected data were kept in a password-locked personal computer of the researcher, and no one except the research team had access to the data. The participants were assured that all obtained information would be used for research purposes only. The participants were reminded of their right to withdraw from the study at any time without being affected in any way. In addition, the WhatsApp number of the researcher was included and made available for any participant to ask questions.
Data Analysis
Data analysis was performed using IBM SPSS, Version 26 (IBM, Inc., Armonk, NY, USA). Descriptive statistics were employed to present the sample characteristics and describe the scores of the main study variables. One-way analysis of variance and independent samples t test were conducted to examine differences in performance and intention to leave according to the participants' categorical sociodemographic characteristics. The relationships between the continuous variables were examined using the Pearson correlation coefficient. Multiple hierarchical regression analysis was performed to examine the unique relationship between authentic leadership and both intention to leave and staff performance. According to univariate analysis in this study and prior articles in the literature (Al-Ajarmeh et al., 2022; Ozer et al., 2019; Ragab et al., 2021), some sociodemographic characteristics were identified as potential confounding factors in the relationship between authentic leadership and each of nurse performance and nurse intention to leave. To control for the effects of these potential confounders, the multiple regression analysis was hierarchical and used nursing performance and intention to leave as the dependent variables, with sociodemographic characteristics entered as independent variables in Model 1 followed by authentic leadership in Model 2. The normality and linearity of the study variables were examined by visually inspecting graphs and plots and interpreting the descriptive statistics. The homogeneity of variances' assumptions was examined using Levene's test. Assumptions of multiple linear regression were also assessed (i.e., normality, independence, linearity, and no multicollinearity). A significance level of .05 (two-tailed) was chosen.
Results
Sample Characteristics
A sample of 166 registered nurses completed the study (response rate = 83%). Most were females (65.1%) and married (65.1%). The mean age was 31.3 years (SD = 5.2), ranging from 21 to 55 years. Most held a bachelor's degree in nursing (78.9%) and had graduated from a government university (66.3%). The average mean of experience was 9.3 years (SD = 5.4). Forty-one participants (24.7%) worked in medical units, 35 (21.1%) worked in surgical units, 26 (15.7%) worked in intensive care units, 18 (10.8%) worked in emergency units, and the remaining 46 (27.7%) worked in other units or wards (i.e., labor rooms, operating rooms, pediatric wards, and maternity wards). Regarding perception of their first-line manager, 71 (42.8%) perceived them as "autocratic," 81 (48.8%) perceived them as "democratic," and 14 (8.4%) perceived them as "laissez-faire" (see Table 1).
The Mean Scores for Authentic Leadership, Performance, and Intention to Leave
The overall mean score for the authentic leadership questionnaire was 2.08 (SD = 0.87). The rank order of mean scores for the authentic leadership subscales, from highest to lowest, was 2.14 (SD = 0.90) for the moral ethical domain, 2.09 (SD = 0.93) for the transparency domain, 2.06 (SD = 1.02) for the self-awareness domain, and 2.03 (SD = 1.04) for the balanced processing domain.
The overall mean score for the Turnover Intention Scale was 3.57 (SD = 1.76). For the Staff Performance Scale, the overall mean score for all items was 3.00 (SD = 0.51), whereas the mean total performance score was 156.13 (SD = 26.44). The rank order of mean scores for the performance scale subscales, from highest to lowest, was 3.22 (SD = 0.55) for the professional development subscale, 3.10 (SD = 0.59) for the critical care subscale, 3.01 (SD = 0.62) for the leadership subscale, 2.99 (SD = 0.53) for the interpersonal relations communications subscale, 2.83 (SD = 0.55) for the teaching collaboration subscale, and 2.88 (SD = 0.61) for the planning evaluation subscale.
Differences in Mean Scores for Nurses' Job Performance and Intention to Leave by Sociodemographic Characteristics
Independent t test (Table 2) revealed that married participants earned significantly higher performance mean scores (M = 3.12, SD = 0.41) than their unmarried peers (M = 2.94, SD = 0.47), t(164) = 2.56, p = .011. No statistically significant difference was found in mean scores for nursing performance based on gender (p = .190), educational level (p = .530), university of graduation (p = .429), perception of first-line manager (p = .159), or current working unit (p = .895).
With regard to intention to leave, the results revealed that unmarried nurses earned a significantly higher mean score for intention to leave (M = 3.95, SD = 1.65) than their married peers (M = 3.36, SD = 1.80), t(164) = 2.08, p = .039. In addition, a statistically significant mean difference was found in intention to leave based on perception of their first-line manager, F(2, 163) = 11.24, p < .001. Nurses who described their first-line managers as autocratic reported higher intention to leave than those who described their first-line managers as following democratic or laissez-faire leadership styles. However, no statistically significant difference was found in the mean score for intention to leave based on gender (p = .194), educational level (p = .449), university of graduation (p = .195), or current working unit (p = .299).
Pearson correlation analysis showed nursing performance to be significantly and positively correlated with age (r = .21, p = .006), whereas intention to leave was significantly and inversely correlated with experience (r = -.17, p = .029; see Table 3).
Relationship Between Authentic Leadership and Both Job Performance and Intention to Leave
Pearson correlation analysis showed job performance to be significantly and positively correlated with transparency, self-awareness, and overall ALS score (p < .05). The results also showed nurses' intention to leave to be significantly and negatively correlated with the overall ALS score (r = -.45, p < .01) and all ALS subscales (transparency [r = -.44, p < .01], moral/ethics [r = -.34, p < .01], balance processing [r = -.37, p < .01], and self-awareness [r = -.43, p < .01]; see Table 3).
Hierarchical multiple regression analysis was also performed to examine the unique relationship between authentic leadership and performance. Age and marital status were entered into the first model of the regression analysis, whereas authentic leadership was entered into the second model. Overall, the two regression models were significant, F(2, 163) = 5.54, p = .005, and F(3, 162) = 5.95, p = .001, respectively. For the final model, R2 = .099 and adjusted R2 = .083. Age and marital status accounted for 5% of the variance in participant performance, whereas authentic leadership score accounted for 3% more variance above and beyond the 5% accounted for by the first model. In the second model (Table 4), both age (B = 0.17, p = .033) and overall authentic leadership score (B = 0.19, p = .012) were identified as significant predictors of staff performance (see Table 4).
Hierarchical multiple regression analysis was performed to examine the unique relationship between authentic leadership and intention to leave. Experience, marital status, and perceiving the first-line manager as autocratic were entered into the first model of the regression analysis, whereas authentic leadership was entered into the second model. Overall, the two regression models were significant, F(3, 162) = 8.91, p < .01, and F(4, 161) = 13.00, p < .001, respectively. For the final model, R2 = .260 and adjusted R2 = .242. The first model accounted for 14% of the variance in intention to leave, whereas the authentic leadership score accounted for 10% additional variance above and beyond the 14% accounted for by the first model. In the second model (Table 4), only the overall authentic leadership score (B = -0.39, p < .05) was found to significantly predict intention to leave.
Discussion
This study was designed to investigate the correlation among authentic leadership, performance, and intention to leave in registered nurses. Overall, the participants reported their first-line leaders "sometimes" practiced authentic leadership behaviors. The overall mean score for ALS in this study was average, which is consistent with a previous study conducted in Canada (Laschinger & Fida, 2014). However, these scores may be enhanced by nurse leaders who integrate core human values such as trust, transparency, morals, and empowerment into their staff leadership style. Improving authentic leadership behaviors is required to maximize staff empowerment, inspire work engagement, provide safe and effective nursing practices, and improve staff creativity (Laschinger & Fida, 2014; Malik et al., 2016).
The moral-ethical domain of authentic leadership earned the highest mean score of all of the subscales, whereas the self-awareness domain earned the lowest mean subscale score. These results are consistent with a study of ICU nurses in Ontario, Canada (Wong & Laschinger, 2013).
Participants in this study reported a high intention to leave, which is similar to studies conducted in Jordan, China, and Turkey that found relatively high intention to leave among registered nurses (Al-Hamdan et al., 2020; Ozer et al., 2019; Zhao et al., 2021). The high mean score for intention to leave may be attributed to working conditions, leadership, workload, working environment, and job dissatisfaction, which may encourage staff to explore better opportunities elsewhere. Thus, staff intention to leave their jobs may be addressed through effective leadership and improved working conditions.
The overall mean score for the Six-Dimension Scale of Nursing Performance in this study was around 3, which is similar to nurses' performance scores reported in previous studies (Fujino et al., 2014; Ta'an et al., 2020). The high mean score for the professional development domain in this study indicates that the participants regularly pursue opportunities to empower themselves by engaging in career development activities. The low mean score for the teaching and collaboration domain in this study indicates that, because of workload and long working hours, the participants may focus on performing their tasks rather than explaining them. Busy working conditions may also negatively impact on the ability of staff to communicate effectively with patients.
Nursing performance was found to significantly and positively correlate with age, which is similar to Ragab et al. (2021), who revealed a statistically significant, positive correlation between nurses' age and performance. Older nurses may acquire more skills that enable them to perform better over time. In addition, older nurses typically have more interactions with their colleagues, patients, and managers and are better aware of their feelings, strengths, and weakness, which can help them improve their performance. Married participants in this study earned higher performance scores than unmarried participants. This may be attributed to married nurses having a sense of commitment and financial obligations that make them more willing to perform their work well to maintain their jobs.
In this study, after controlling for sociodemographic variables, an independent relationship was found between authentic leadership and both staff performance and intention to leave. This indicates that, regardless of sociodemographic attributes, authentic leadership is associated with better job performance and lower intention to leave.
In this study, authentic leadership scores were found to account for 3% of the total variance in performance. Thus, increased perception of nurse managers as authentic by staff nurses may foster better performance. Ozer et al. (2019) used a multiple regression model to investigate the relationship between authentic leadership and nurse performance, finding that authentic leadership explained 6.8% of the total variance in performance. This may be attributed to nurses being inspired by transparency from their managers, which may subsequently be reflected in their practice (Al-Ajarmeh et al., 2022). Furthermore, nurses may emulate the trustworthiness of their managers, which may help them foster and maintain trusting relationships with their patients. The authentic nurse manager may offer a role model for subordinates, fostering a healthy work environment that maximizes trust, support, transparency, and performance.
In this study, authentic leadership was associated with reduced intention to leave. A study conducted by Azanza et al. (2015) similarly found authentic leadership to correlate negatively with intention to leave. The role of authentic leadership in reducing intention to leave in nurses has important implications, as the shortage of nurses is a major problem currently facing healthcare. Intent to leave increases the cost and quality of care and reduces patient safety (Spence Laschinger & Fida, 2015). Intention to leave may be effectively reduced by nurse managers adopting authentic leadership attributes to create healthy working conditions, encourage work transparency, and promote fairness in the workplace. These results are consistent with Lee et al. (2019), who found a statistically significant, negative correlation between authentic leadership and intention to leave. However, Ozer et al. (2019) did not find a significant relationship between these two factors, possibly because many other factors (e.g., occupational stress) also influence intention to leave (Mosadeghrad, 2013).
Limitations
The convenience sampling technique used in this study may reduce the generalizability of the findings. In addition, the study was limited to one governmental hospital only. Thus, the results may not be applicable to private hospitals, charities, and other healthcare organizations.
Implications and Recommendations
This study may provide a foundation for future research into authentic leadership and staff outcomes. One potentially fruitful direction for this research may be examining interventions aimed at reducing staff turnover intention and maximizing staff retention. In addition, more variables affecting staff performance, for example, occupational stressors, emotional intelligence, and staff satisfaction, should be investigated in future research. Furthermore, authentic leadership and authenticity in Jordan deserve further investigation. Nevertheless, the promising findings on authentic leadership, to date, encourage the development of a related framework to integrate authenticity and authentic leadership in Jordan's healthcare system.
The authors hope that this study and its findings will help nurse managers to be more-authentic role models and encourage them to learn the core values of authenticity and teach these to their staff. In nursing education, a current emphasis is on merging the concepts of authentic leadership and modern ways of management within nursing student curricula to prepare them as future nurses ready to lead and be trustworthy. Having nursing students learn the true meaning of authenticity will help them survive their first years of work after graduation by minimizing their intention to leave, enforcing related values such as transparency and trust, appreciating their limitations, and improving their self-esteem.
Conclusions
Nurses who perceive their first-line managers as authentic exhibit better performance and lower intention to leave. Authentic leaders are perceived by their followers as sincere, real, and honest, which affects their performance positively and encourages them to provide quality and effective care. Adopting fair and ethical treatment and listening to all employees may be effective ways to increase staff retention. Particularly in light of the existing nursing shortages and high turnover rates in developing countries like Jordan, it is important to utilize leadership styles that effectively reduce intention to leave among nurses. The findings of this study contribute to helping health organizations better address important human resources issues.
Author Contributions
Study conception and design: AHR
Data collection: SAA
Data analysis and interpretation: Both authors
Drafting of the article: SAA
Critical revision of the article: AHR
References