Relationship between leadership style, job satisfaction and stress among nurses

Assessment Description
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Nurses are the most important component as well as the largest workforce in the field of healthcare in Malaysia. The nurses work under the directions given by physicians but they are also trained in order to function independently in case of emergency. While the nursing profession can be interesting and rewarding, it has its own challenges which will be explored in this study.  The nursing profession provides a chance for the pursuant to enhance others’ lives at the time of need.
A hundred years ago, nursing was defined by Florence Nightingale as the function of utilizing the surrounding environment of a patient for his/her recovery. (Wilkins, 2007)(Page no. 15) Nightingale is considered as the first nurse theorist who was able to raise the standard of nursing through education. After upgrading the standard of nurses, they were now being considered as the person who is educated for the care of sick instead of a housekeeper. Nightingale believed that having a healthy, clean, well-ventilated, and quiet environment would result in early improvement of the sick patients.
Virginia Henderson (Halloran, 1996) was a modern nurse after Nightingale who defined nursing as a unique function of assisting and performing activities that contribute towards the health and recovery of patients (or their peaceful deaths). As mentioned by Henderson, a nurse is a person who does not discriminate between healthy and ill individuals. The teaching and advocacy roles of nursing mention that nurses need to properly interact with clients, no matter whether recovery is feasible or not. (Halloran, 1996)
In Malaysia, the profession of nursing in the field of health care is for the improvement and care of patients, families, and communities. The nurses at all levels are trained in respect of attaining, maintaining, and recovering optimal health and the quality of life. Nurses cannot be substituted with other health care providers. This is because the approach that is being used by the nurses are based on caring for patients, their training and scope of practice (Primary care for the 21st century, 2012) Nurses work under the supervision of physicians and thus are considered as the care providers. Depending on their level of training, they are trained in such a way that they could practice independently in certain situations without seeking the permissions of the physicians. Activities that do not require an order includes nursing diagnosis to identify the condition of the patient, wound care: cleansing, irrigating, probing, packing and dressing of wounds, collecting a blood sample, administration of oxygen or humidified air etc. (Scope of Practice for registered nurses, 2012)
It would not be wrong to say that opting for nursing as a career is interesting, rewarding and challenging (NHS, 2012). This is a profession that gives the nurses an ultimate chance of enhancing the lives of people during the times of need. Nurses are trained in order to work in every sort of health setting from accident and emergency. In other words nurses are given the best possible information to handle all the situations including the case of accidents and emergencies, working in patients’ homes with people of all ages and backgrounds.
In Malaysia, if an individual wants to opt for nursing as a profession for his career, then the required minimum qualification is diploma, which qualifies him/her to work as a nurse. Nursing is divided in different groups that includes Staff Nurse, Male nurse,  “Jururawat  Masyarakat”,  “Jururawat Desa”, Sisters  and  Matrons.
The staff nurses are trained in order to handle the various jobs that are being carried on in any ward or clinic such as medical, surgical, pediatric, orthopedic, cardio and so on. On the other hand, the nurses who work as “Jururawat Masyarakat” or “Jururawat Desa” are given training for midwifery which deals with childbirth and provides prenatal and postpartum care. They can handle the situations of the delivery of babies on their own unless and until there are circumstances that require consulting a physician. The nurses are being headed by the senior nurses, sisters and matrons (Career in Nursing, 2011).
The Journal of Nursing Management (Mahoney, 2001) states that providing care for a patient or giving assistance to others is considered as leadership. Leaders are not merely controllers but they act as visionaries who help employees to plan, lead, and control and organize their activities. (Leadership Skills for Nurses)
Nurses are the ones who provide assistance to others. Thus we could consider them as leaders. But being a leader is not an easy task. The nurses should possess powerful leadership skills, especially if they are providing care to other working nurses, doctors and other officials.
 Thus being soft and polite while working with the top management is necessary. Moreover the nurse should possess an influential nature while carrying on his/her work so that she could treat the top management officials properly.  
Following such a leadership style allows consistent superior performance with long term benefit to all. Moreover, there are other functions of a nurse leader which include being a role model, collaboration to provide optimum care, provision of information and support, and also be an advocate for patients and the health care organization (Dowding, 2012).
Nurse Leaders should have knowledge of management so that they could manage each and every situation. They should have knowledge of communication to communicate with their fellow workers for a successful teamwork. Knowledge of teamwork skills and also personal qualities which include competence, confidence, courage, collaboration and creativity are also required.
However, the role of leadership is different from management. It is proven by the statement mentioned in Stephen Covey’s (1989) book “The Seven Habits of Highly Effective People” (Covey, 1989) that “management is doing things  right; leadership is doing the right th. ngs (Shelton, 2000) (Page no.366). For example a manager is required to carry out specific duties and has definite responsibilities whereas nurses are skilled at coordinating the resources following rules, and meeting the goals and objectives of the organizations. The rapid and dramatic changes in health care make these skills more important than ever.
Critical thinking skills, active listening skills, and good coping skills are essential at all levels in today’s nursing workforce.
In addition, management directly relates to the task that has to be completed whereas leadership indirectly relates to how the task will be done. (Carr, 2009 ) Also a manager focuses on the structure and the systems whereas a leader focuses on the people associated with the organization. Thus Leadership and management must go hand in hand. They are not the same thing but are linked and complimentary to each other. (Jones, 2009) Furthermore, leadership is about perception, judgment, skill and philosophy whereas management is about tasks. (Frankel, 2008) Though leadership is necessary for nursing, it can be attained only if the nurses are satisfied with the job. If the nurse is not satisfied with the job, she would not be able to create a sense of leadership in her profession (Milt, 2009)
Job Satisfaction  
Job satisfaction is one such component of a nurse’s life that may have a severe impact on the productivity and the efficiency of the nurse, his/her safety, performance, and retention, quality of care and turnover, commitment to the profession and the organization. However, the level of satisfaction in the job may vary from person to person. (Zappe, 2012) For some the job satisfaction could be in terms of money whereas for some it could be the prevailing working conditions.
It would not be wrong to say that the productivity, creativity and commitment to the job of a nurse depend on the level of satisfaction that a nurse could derive from the job (AL-Hussami, 2008). The perceived leadership style of nurse leaders may give rise to positive results and will increase the level of job satisfaction among nurses. The reason could be that leadership brings privileges as well as responsibilities. If the leader adopts the right manner and approach of providing direction, implementing plans and motivating he/she would be definitely be able to enhance the productivity of the fellow nurses.
If a nurse leader does not use the appropriate style of leadership while working in the hospital, she would have to face a lot of problems with regards to dissatisfaction among the other nurses. (SPA, 2010) She may encounter a lot of disagreement in her group of nurses and will not be able to work as a team. She has to be a good communicator so that she could express herself in front of others. Lastly the stress that is faced by a dissatisfied nurse is not a good sign. The stress faced by nurses in the hospital could be because of their work pattern, the leadership style of their bosses, the behavior of the patients, etc. All these three factors are vital components in the nursing profession and one should keep all these factors in mind to increase the productivity and efficiency of the nurses.
If the nurses are dissatisfied with their job, this would lead to increased  turnover rates, declining quality in patient care, increase in stress  and can cause the nurses to leave the profession. There would also be a greater chance of mistakes to occur. Thus Job satisfaction has a vital effect in the lives of nurses.
Stress among nurses
Stress in nursing profession could be defined as the emotional and physical reaction which is a result of communication between the nurse and the work environment where the demands of the job exceed capabilities and resources. (Nitasha Sharma, 2011)
There is the existence of stress in every profession. However if we compare nursing with other professions in the health care services, then the level of stress that hovers on the mind of nurses is even greater  (Fegan, 2012)
As per the Malaysian Journal of Public Health Medicine 2011 stress is defined as a situation where people tend to focus on the negative feelings and emotions it produces. (Aljunid, 2011) The causes of stress could be internal or external forces such as behavior of patients, fulfillment of responsibilities, low salaries, over burdening, high expectations etc. It could make a nurse tensed, upset and anxious towards a harmful event that may or may not occur.
PROBLEM STATEMENT                                                                          
The nursing profession comprises the largest part of the workforce in Malaysia. In 2011, 60000 of the total workforce or approximately 2.25 nurses per 1,000 populations were in the nursing profession (Vincent, 2011).
It is the moral as well as the ethical duty of a nurse to treat patients competently in a caring and professional way. The code of conduct for nursing care is framed by the Nursing Board of Malaysia and the first edition of the code was published in April 1988. This Nursing Board of Malaysia keeps a check on all the registered nurses and is responsible for the standard of nursing. The values, responsibilities, and duties to which nurses are expected to adhere in the course of making sound ethical decision and providing high quality nursing care is mentioned in the code of conduct for nurses.
There are always certain situations in the nursing career where nurses are often challenged with clinical situations that give rise to ethical conflicts (Ethical Situations and Dilemmas in Clinical Practice, 2005). In such circumstances, the role of nursing is bound by litigation related to negligence, informed consent and confidentiality. The case of Dr. KS Sivananthan v's The Government of Malaysian & Anor (LEE, 2012)  on medical negligence for delaying in giving the proper treatment to the patient has affected the role of nurses. Basically, the delay was caused by the failure of the nurse in recording adequate and timely observations in the patient's chart. However, nurses in Malaysia are not sued but if a nurse is found guilty of her action, a disciplinary action against the nurse under Act 1950 (Act 14) can be taken by the Nursing Board of Malaysia. The board could either suspend or remove the registered nurse from the Register or suspend the registered nurse as they deem fit for a period not exceeding 2 years. Thus it is necessary for the nurses to have a good understanding of their role.
It was studied that the job satisfaction involves the adaption of workers to the organization and the way in which the organization adapts to the employees need. (Zappe, 2012)
As per a global interview (Kingma, Nurses on the Move: A Global Overview, 2007) it was stated that (Kingma, Nurses on the Move: A Global Overview, 2007)if a nurse experiences dissatisfaction in job and expressed herself in a negative way, then it can affect the quality of care, sense of being and reduce the reputation, productivity and efficiency of a health care organization.
There are also some more factors that could be the reasons for job dissatisfaction among the nurses. For instance, if there is a shortage of nurses in the nursing workforce, then it could lead to work overload for a nurse, burnout and dissatisfaction of nurses (Jennings., 2008) . Thus it is necessary to make possible efforts to provide satisfaction for the nursing workforce.
Nurses act as visionaries who help employees such as other nurses, ward boys etc. to plan, lead, and control, and organize their activities. Thus the sense of leadership in nurses may have an influential effect over others and may also affect their job satisfaction (Saver, 2006). If the relations of a nurse with the leader are not satisfactory, then there are chances that the nurse may not be happy working in that environment.
These stressful situations or environments may also negatively affect the performance of the nurses in one way or another. As discussed above, a leader in nursing is a one who provides care to patients and assists them with their health care.  When nurses are stressed, or when they do not get along with their leaders/managers, they don’t behave properly with the fellow people such as the patients, wards, etc. Moreover the performance of the nurses may deteriorate resulting in high turnover rates for the hospital. In short, it is would be necessary to have a mutually beneficial relationship between nurses and management that favors increased efficiency, productivity and job satisfaction.
Research questions
  • Is there a relationship between leadership style and stress among nurses?
  • Is there a relationship between job satisfaction and stress among nurses?
Research Objective
The objectives of this research are:
  • To determine whether leadership style is related to stress among nurses.
  • To identify the correlation between job satisfaction and stress among nurses.
Significance of study
This research, which explores  the leadership style,  job satisfaction and stress  among nurses at the Sultanah Bahiyah Hospital in Alor Setar.. This has several implications on management practice and administrators’ roles at the hospital under study. The results of the study can be utilized by the administrators to educate sisters and matrons on effective leadership styles. This will pave the way for administrators to determine all the possible reasons for job dissatisfaction and stress levels among nurses that are prevailing at the Sultanah Bahiyah Hospital in Alor Setar Kedah and how leadership styles affect job satisfaction and contribute stress.
Besides that, by carefully employing the findings of this study, the hospital can attain its vision to deliver the highest quality patient care, positive clinical outcomes and has the highest level of patient in the nursing unit, and family satisfaction with the organization. It is also possible that with a more effective leadership style, the administrators in the Nursing unit will be able to effectively encourage nurses to achieve a high level of professional growth, excellence in practice and service to the organization. Moreover, the administrators may be able to raise the standard of job satisfaction among the nurses and reduce their stress levels as well. Thus this will result in higher productivity, efficiency and retention of nurses at the Sultanah Bahiyah Hospital. This will further result in an overall decrease in the cost of hiring and induction of new employees. Finally, this study will be have implication for the training of nursing leaders like sisters,i matrons and also nurses enhance their  productivity and efficiency.
Definition of the Key Terms
Job satisfaction
Job satisfaction represents the level of feeling that an individual gets about his or her job and what he or she feels about his or her own job. (Alam, 2009). Colquitt, Lepine & Wesson (2009) add a positive dimension to this definition where they claim that job satisfaction is a pleasurable emotional state resulting from the appraisal of one’s job or job experience
 On the other hand, Bhuian & Mengue (2002), include in their job satisfaction definition, the attitude that is possessed by an individual with regards to   his or her job. They further explain that it is the limit to which an individual feels positive or negative about the intrinsic and extrinsic aspects of his or her job (Shooshtarian, 2013).
So, in this study the definition of job satisfaction will include variables such as positive feelings about one’s job and one’s attitude towards their job which includes their job environment (stress factors and leadership style of their nurse leaders).
Stress is defined as either physical or mental strain that is caused because of an inability to adjust in the environmental factors that result in physiological tension or pressure. (MAKIE, 2006). Stress not only affects the health of nurses but also their abilities to cope with job demands (Mojoyinola, 2008) This will result in the impairment of the provisions of the quality care and efficacy of the health service delivery.
The International Journal of Nursing practice (Lee, 2003) evidently states that stress not only affects the health of nurses but also their abilities to cope with job demands. This will result in the impairment of the provisions of the quality care and the health service delivery efficacy.
The leadership style “is about listening to people, supporting and encouraging them and involving them in the decision-making and problem-solving processes. It is about building teams and developing their ability to make skillful decisions” (Clarkson, 2009) (Rowe, 2007).
There are several types of leadership styles. The ones that are evident at the SB Hospital setting are transformational leader and a Transactional Leader
Transformational Leader
Transformational nursing leaders in the clinical settings intellectually stimulate other people by acting as an effective communicator, possessing inspirational traits, having a trustworthy character and promoting teamwork (Trofino, Transformational leadership in Health Care).
Effective Healthcare Leadership (Jasper, 2008) states that transformational leaders analyze all the barriers and identify all conflicts when they arise and work to achieve all the aims with team collaboration to resolve all the conflicts, and remain a part of them sharing in the work and being able to understand the employees’ perspective. (Trofino, Transformational Leadership in Health Care, 1995)
Transactional Leader
A transactional leader works in the direction of providing day to day care and is most concerned with managing predictability and order. This type of leaders possesses the skills required in effective day to day running of a team. (Trofino, Transformational Leadership in Health Care, 1995) (Team, 2006)
The leader tries to achieve his/her personal needs without any consideration of the needs of the followers. The leader gets his/her work done and achieves the required objectives. Moreover, the followers get promotion, money or other adjoining benefits (Muenjohn, 2005).
The quality of the services provided by the Sultanah Bahiyah Hospital nurses may be influenced  by three factors that revolve around  leadership styles, job satisfaction and  stress  that is faced by nurses. This problem will  be investigated using quantitative data collection technique such as a  questionnaire, and this will be explained in the next chapter. These factors may have a bearing on nurses’ performance, and the quality of patient care. 

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