Leadership style and organisational commitment among nursing staff in Saudi Arabia

Aims : To examine how nurse managers(cid:146) leadership styles, and nurses(cid:146) organisational commitment in Saudi Arabia relate. Background Effective staff and is an increasing problem in Saudi Arabia. Methods Using a survey design, the Multifactor Leadership Questionnaire and the Organisational Commitment Questionnaire were distributed to a sample of 219 nurses and nurse managers from two hospitals in Saudi Arabia. leadership for the influence of manager/staff status, nationality and hospitals, transformational leadership the strongest contributor to organisational commitment. of both transformational and transactional leadership styles, for nurse managers and nursing staff. the Full Range of Leadership model the Saudi nursing workforce to for positions as nurse managers and leaders. that transformational leaders could influence and induce positive changes in nursing. To examine, managers(cid:146) leadership style and nurses(cid:146) organisational commitment are related in Saudi Arabia.

| BACKGROUND Employment of nurses in Saudi Arabia numbers 36 per 10,000 population (Almalki, FitzGerald, & Clark, 2011), which is lower than in Bahrain (58/10,000), the USA (98/10,000) and the UK (101/10,000) (WHO, 2010). Nursing in Saudi Arabia relies greatly on expatriates from 52 countries (Suliman, 2009) The social conditions for expatriate nurses tend to be poor, and religious and cultural differences, social values and language create barriers between them and local patients (Al-Mahmoud et al., 2012;Fielden, 2012). Expatriate nurses tend to move when they have acquired enough knowledge and experience, to developed countries where they experience better working conditions (Aldossary, While, & Barriball, 2008).
Job dissatisfaction is the main driver of nursing turnover in Saudi Arabia, and effective leadership is crucial in generating job satisfaction and retention issues (Zaghloul, Al-Hussaini, & Al-Bassam, 2008). Identifying the prevailing nursing leaders' styles, and any correlation with organisational commitment and nursing retention, will help to develop our understanding of effective leadership (Eneh, Inen-Julkunen, & Kvist, 2012;Lavoie-Tremblay, Fernet, Lavigne, & Austin, 2016). There is a growing body of Saudi literature on the retention of nursing staff as measured by job satisfaction (Abualrub & Alghamdi, 2012;Al-Ahmadi, 2009), intention to leave (Zaghloul et al., 2008) and gender (Alghamdi, Topp, & AlYami, 2017). However, we know little about the impact of leadership styles on retention.

| CONCEPTUAL FRAMEWORK
The conceptual framework was the full range of leadership (FRL) model (Bass, 1985), which is a model of transformational leadership (Fischer, 2016) largely based on Burns' (1978) conceptualization. It is the most widely adopted leadership model used (Kirkbride, 2006) and a framework used to develop their knowledge and skills related to leading staff (McGuire & Kennerly, 2006). Transformational leadership includes: charisma or idealized influence; inspirational motivation; intellectual stimulation, and individualized consideration -which tend to be positively associated with 'emotional intelligence (Echevarria, Patterson, & Krouse, 2017). Idealized influence characterizes leaders who are ideal role models for followers (Bass & Riggio, 2006). The model also includes laissezfaire or no leadership which is the avoidance or absence of leadership where leaders do not actively participate in any processes of leadership: this is regarded as the least effective style (Bass & Riggio, 2006).
Effective nursing leadership has been positively linked to nurses, patients and organisation outcomes (Cummings et al., 2010;Squires, Tourangeau, Laschinger, & Doran, 2010). A recent Netherlands study (Schreuder et al., 2011), involving 699 nurses showed that effective leadership style was inversely associated with the number of days of sickness absence and short episodes of sickness absence. Therefore, training nurse leaders in effective leadership styles could decrease understaffing. The present study was designed to examine the relationship between nurse managers' leadership styles, and nurses' organisational commitment in Saudi Arabia.

| Procedure
Two hundred and sixty nurses from two medical cities in Riyadh, Saudi Arabia, were approached to complete the study.

| Participants
Based on the power analysis described below two random samples were taken from each medical city and the resulting sample is described in the Results section.

| Setting
The two biggest MOH medical cities in Riyadh were selected. The first site, one of the biggest independent medical cities in the Middle East, consists of four hospitals: a general hospital; a specialist women's hospital; a paediatric hospital, and a rehabilitation hospital. It is part of a project by the Saudi MOH that aims to decentralize public hospitals to give them more operational and financial independence to provide high quality. The medical city is governed and funded independently and the total population of nursing staff is 2,100.
The second hospital is a medical complex composed of six different hospitals (general, paediatric, dental, diabetic, rehabilitation and women's health) and is the main referral MOH facility in Riyadh region.
It receives its budget and regulations from the central MOH and the total population of nursing staff is 2,758.

| Measures
Two measures were used: the Arabic version of the Multifactor Leadership Questionnaire (MLQ) and the Organisational Commitment Questionnaire (OCQ; translated into Arabic). The MLQ (Bass, 1985) purports to measure the extent to which transactional and transformational leadership is present and consists of 36 items which is composed of three main dimensions: transformational leadership (this includes idealized attributes; idealized behaviours; inspirational motivation; intellectual stimulation, and individualized consideration; transactional leadership (contingent reward and management-by-exception [active], and passive/avoidant (management-by-exception [passive] and laissez-faire); the Arabic version had been reported to have acceptable reliability (Abualrub & Alghamdi, 2012) with Cronbach's alpha > .60 for all three dimensions. The OQC (Mowday, Steers, & Porter, 1979) purports to measure the degree of commitment a member of staff experiences towards the organisation as demonstrated by the employee's readiness to give back to the organisation. The OCQ, which consists of 15 items: value commitment (9 items) and commitment to stay (the remaining 6 negatively worded items), was translated into Arabic for the present study and had Cronbach's alpha of .77 and the confirmatory factor analysis is reported in Alyami (2013).

| Ana ysis
Statistical analyses were carried out using SPSS version 20.0 and included t tests, Pearson's correlation and hierarchical regression. Cases with missing data were listwise deleted. Outliers were detected using a box and whisker plot with the application of Hoaglin and Iglewicz's (1987) rules regarding the interquartile range. Only one outlier was identified by this method but a histogram plot of the data indicated that it could be included in the analysis without prejudice. The primary outcome was the correlation between leadership style and organisational commitment as measured by the MLQ and the OCQ, respectively, and according to Cohen's (1992) criteria for power analysis, at a power of .80, p < .05 and to detect a medium effect, a sample size of 85 is required.

| Ethics
Ethical approval for the study was obtained from the University of Sheffield Research Ethics Committee. Participation was voluntary and completion and return of the information sheet and questionnaires was taken as consent to participate. Anonymity was assured.

| The perception of eadership sty e
Two hundred and twenty-three nurses agreed to participate and 219 completed the questionnaire; the response rate was 84% which, according to the power analysis, was adequate. Of the participants, 55 (25%) were nurse managers and 164 (75%) were staff nurses.
Nurse managers and nursing staff concurred in their perception of different leadership behaviours: transformational leadership gained the highest mean score, followed by transactional leadership and passive-avoidant leadership respectively (Table 1).
There was a significant difference in organisational commitment scores between Saudi staff (mean = 4.53; SD = 1.33) and non-Saudi staff (mean = 5.21; SD = 0.89; t p = .01), which indicates that the level of organisational commitment was higher for non-Saudi staff (Table 3).

| Leadership sty e and organisationa commitment
The correlation between different leadership styles and organisational commitment was determined using Pearson Product-Moment correlation. Transformational leadership (TRL) and organisational commitments were positively related represented by value commitment and commitment to stay (r = .374, p < .01 and .345, p < .01, respectively). Transformational leadership subscales were positively correlated to organisational commitment. However, the

TABLE
Nurse managers' and staff nurses' perceptions of leadership styles strongest correlations were found between inspirational motivation related to value commitments (r = .387, p < .01) and between the individual consideration subscale related to commitment to stay (r = .333, p < .01) ( Table 4). Transactional leadership is more strongly related to commitment than to transformational leadership. This is particularly evident in the relationship between the contingent reward and both value commitment and commitment to stay (r = .409, p < .01 and .355, p < .01, respectively). Passive avoidant leadership (PAL) and commitment were negatively correlated (r p < and p < .01, respectively). Both management by-exception-passive and laissez-faire leadership styles were found to have negative correlations with both value commitment and commitment to stay. Although there were significant correlations between different leadership styles and organisational commitment, there were also variations between groups and cities which could confound this.
Hierarchical regression was carried out as follows (Dancey & Reidy, 2011) variables were entered in a fixed order of entry to control for the effects of covariates or to test the effects of certain predictors (Seber & Lee, 2003), this procedure was followed to investigate the effects of leadership styles on organisational commitment, controlling for medical city, manager/staff status and Saudi/non-Saudi nationality.
Controlled variables were entered first into a model predicting organisational commitment followed by three consecutive models where the variables of transformational, transactional and passive avoidance leadership styles were added respectively to each model.

TABLE
The organisational commitment questionnaire subscales by nationality same pattern in terms of the transactional leadership style. Passiveavoidant leadership showed a significant decline in mean scores over age (the younger the age, the higher score and vice versa).
There was no significant difference between educational level and leadership styles (p > .05). Participants with less experience (fewer than 7 years) and participants with longer experience (more than 18 years) scored higher in perceiving passive-avoidant leadership style compared with participants whose experience fell between 7 and 18 years, revealing significant differences in means between experience groups (p = .04 and .01, respectively) ( Table 6).

| CONCLUSIONS
The results of this study must be viewed with the limitation that there may be an inevitable and unaccountable self-selection bias in the data; nevertheless, the composition of the participants reflects the population from which they were drawn. Moreover, the appropriateness of the measures used in the present study in Saudi Arabia may be questioned. Nurse managers perceived themselves as transformational leaders and transactional leaders simultaneously. This is congruent with Bass & Bass (2008) who said that leaders can simultaneously display transformational and transactional characteristics. However, in our study the transformational leadership styles were more evident than transactional leadership, which has also been noted in previous studies (Abualrub & Alghamdi, 2012;Al-Hussami, 2008).
A transformational leadership style can be important in effecting staff retention; a recent study found that nursing leaders demonstrating transformational leadership behaviours increased staff retention (Casida & Parker, 2011). In the current study, the most frequently displayed transformational subscale behaviour was intellectual stimulation, while the lowest average scores were for idealized influence.
The ability of nurse managers to fully implement a transformational leadership style can be affected by factors such as the culture of the working environment. In most Saudi health organisations, for example, the male physicians usually lead the medical team and do not always respect the boundaries between medical and nursing areas of responsibility in nursing procedures. The results from the MLQ mirrored the results for nurse managers in that they showed that nursing staff viewed their managers' leadership style to be both transformational and transactional. The issue of commitment to the employing organisation is relevant to the Saudi Arabia health care system that is dependent on non-Saudis whose long-term commitment may lie elsewhere. Participants in the sample had high levels of organisational commitment, relative to a study conducted in Saudi Arabia concluding that nursing staff in Saudi hospitals were not loyal and leave if they found alternative opportunities (Al-Aameri, 2000). However, the results reported here should be interpreted with caution as the Arabic version of OCQ was newly translated for this study and had not been previously validated.  (Casida & Parker, 2011).
Transformational leaders in the study who displayed inspirational motivation were more likely to lead committed nurses: the results showed that the most significant correlation was between the  (Cowden, Cummings, & Profetto-Mcgrath, 2011), and transformational leadership style has been documented as the most commonly reported style among nurses' leaders in the Magnet Recognition Program ® (Clavelle, Drenkard, Tullai-McGuinness, & Fitzpatrick, 2012).

| IMPLICATIONS FOR NURSING MANAGEMENT
This study contributes to the work on leadership and organisational commitment in non-Western health care. Nursing leadership can control or influence many of the variables that are associated with staff retention, and nurse leaders can play a key role in transforming the nursing workforce by improving satisfaction and commitment and promoting a healthy work environment. Nursing leaders in SA should work together to improve the image of nursing to increase the numbers of women in the nursing profession. Recent work (Alotaibi, Paliadelis, & Valenzuela, 2016) from Saudi Arabia indicates the aspects of staff development that nursing managers could facilitate and these include some resource intensive aspects such as educational opportunities and workload reduction but also cultural aspects -which should be amenable good leadership -such as perceived favouritism and the supportive role of religion in Saudi culture. In addition, the SA Ministry of Health hospitals could refer to those few hospitals in the Kingdom which have Magnet ® hospital status where nurse job satisfaction is reported as being high and nurse turnover rates are low (Alghamdi & Urden, 2016).
Beyond Saudi Arabia the study has implications for management of nursing across the Middle East (Aboshaiqah, 2016) where several of the oil-rich Arabic speaking countries have large expatriate nursing workforces with high turnover. These countries: e.g. Bahrain, Qatar and Kuwait are undergoing processes to increase the numbers of their own nationals working as nurses. Likewise, the study informs similar work in Jordan -where more females need to be attracted to and retained in the nursing workforce -investigating nurse manager leadership styles (Abdelhafiz, Alloubani & Almatari, 2016) where the need to increase transformational leadership styles has been identified.
In terms of a contribution to the general literature on nursing management, this study provides further support to the notion that leadership styles influence job satisfaction and, thereby, reduce turnover. While there are inconsistencies in reporting the costs of nurse workforce turnover (Li & Jones, 2013) there is no dispute that turnover is expensive. Measures to reduce it, in addition to providing a more committed workforce providing better patient care (Collini, Guidroz, & Perez, 2015), will conserve resources which can be more appropriately allocated.