Title Slide: Authentic Nurse Leadership

Name and Credentials: Marie Mulligan, PhD, RN, CNOR, NEA-BC

 Disclosure slide
Author- Marie Mulligan
Learning Objectives of This Presentation are:
• Identify three types of leadership styles
• Discuss key attributes that contribute to authentic leadership
• Explain design of research study
• Discuss conclusion of study

This presenter has no conflicts of interest to disclose.

 AUTHENTIC
NURSE LEADERSHIP
Marie Mulligan PhD, RN, CNOR,NEA-BC
Vice President and Chief Nursing Officer
Mather Hospital
Northwell Health
Port Jefferson, New York
Sigma Theta Tau International Leadership Conference
Purpose of the Study:
To develop and validate an instrument measuring
perceived Authentic Leadership among nurses that is

Grounded in a nursing theoretical framework to

support clinical practice and knowledge
development.
 Introduction:
• The healthcare environment is experiencing unprecedented
and intense reformation.

• Challenges and opportunities have never been greater within

our complex healthcare system.
(Porter-O’Grady, 2011).

• Nurse leaders must have in-depth knowledge of pertinent

issues in order to challenge and change organizational culture,
while simultaneously sustaining and supporting Human Caring.
(Turkel, 2007).
 Introduction:
• Nursing is rooted in the Science of Human Caring.

Caring is essential to the personal and professional

lives of nurses (Boykin & Schoenhofer, 2013).

Today’s nurse leaders face a myriad of challenges that

require a new type of leadership… Authentic
Leadership.
 Introduction:
Authentic Leadership ensures the balance between
healthcare business and Caring as a human need (Porter-
O’Grady, 2011).

Nurse leaders who are authentic are behaviorally altruistic,

transparent, have personal integrity; possess attributes
of caring, ethical moral values, shared and balanced
decision making, effective communication, and integral
relationships.
Background:
• National Leadership Index Survey indicates:
distrust in leadership (Gergen & Kalikow, 2009)
• Past restructuring of healthcare has negatively effected nursing
environments, which led to distrust among nurses regarding
leadership, thus leading to lack of engagement.

IOM (2004) recommends positive nursing environment.

Literature supports three types of Leadership Styles:

1. Servant.
2. Transformational.
3. Authentic.
 Servant Leadership:

• Foundational principles
are altruistic in nature.
• Focus on leaders’ self awareness.
• Responds to followers’ needs.
• Embodies practices that emphasize caring, nurturing and
enrichment of the individual lives of followers.
• Focuses on consensus of all.
• Timelines not crucial.
• Not effective for today’s healthcare environment.
• More appropriate for stable environment, in which evolutionary
development can take place.
Transformational Leadership:
• Meets internal and external demands of fast paced healthcare
environment.
• Used by ANCC to achieve excellence in healthcare services.
• Concerns regarding critical review of the model & assessment of
instruments commonly used to measure TL (MLQ, Global Inventory,
Kouzes, and Posners LPI).

• MLQ: Dichromatic interpretation of leadership

• Measures two different leadership models.
• (Transformational and Transactional).
• Contains limited amount of transformational attributes.
• Therefore, assumes that leader has transactional style.
Transformational Leadership:
• Lacks conceptual framework development and clarity.

• Controversy as to what mediates follower

psychological wellbeing.

• Charismatic Leadership (CL) often used

synonymously with component of TL.
• CL can often lead to self-serving behavior:
Lack of check and balance may result in significant
risks.
Authentic Leadership (AL)
Conceptualized Framework by Avolio & Gardner (2005)
Proposed that authentic leaders make a difference in organizations
by:
 Helping followers to find meaning at work
 Building optimism and commitment among followers
 Developing transparent relationships that build trust
 Promoting ethical climate
Developed and validated an instrument to measure leaders authentic
leadership attributes based on Authentic Leadership conceptual
framework
(Walumbwa et al. 2008)
Authentic Leadership (AL) Practice Approach
Authentic leadership based on a practice approach and/or real life events
(George,2004; Terry 1993). No instrument developed to measure either concepts.

Robert Terry utilized a formula to leadership (1993):

 Focused on actions of: leader, leadership team or organization.
 Leaders should strive to do right thing, knowing and acting on true self.
Bill George (2003):
 Lead from core values
 Identified 5 basic characteristics
1. Understand purpose
2. Have strong values about right thing to do
3. Establish trusting relationships
4. Demonstrate self-discipline and act on values
5. Passionate about their mission
Authentic Leadership (AL) in Nursing
Numerous studies in disciplines other than nursing (education,
business, psychology, correctional facilities, etc.) utilize the AL
model and theory.
Based on previous empirical studies in AL, several nursing
studies utilized and analyzed AL.
 Focused on positive role modeling, honesty, integrity, and high ethical
standards in leader-follower relationship (Wong et al. 2010)
 Described effects of preceptors’ AL on new grads’ work engagement and
job satisfaction (Gillonardo et at., 2010)
 Identified the relationship of AL and New grad and bullying (Laschinger et
al.,2012)
 AL and staff nurse structural empowerment (Wong & Laschinger,2013)
 Conducted a Qualitative Study on Nurse Exec AL (Murphy, 2012).
Authentic Leadership:
Authentic nurse leader attributes:
Personal Integrity:
• Characterized by sound ethical/moral courage and
self-awareness.

• Can lead to positive outcomes, such as: trust,

engagement, commitment, job satisfaction, and
overall positive workplace wellbeing (Avolio et.al.,
2004: Gardner et. al., 2005).
Transparency:
• Behavioral manifestation of authentic leadership.
(Van Iddekinge, ., 2005).

• Encompasses relational integrality and shared decision

making which can lead to positive follower outcomes.

• Open and honest and have innate ability to connect with

others through sharing their own experiences or stories.

• Genuine desire to serve others and support shared

decision making.
Altruism:
• “Unselfish interest in the welfare of others.”
(Webster, 2015)

• Self-transcending values and higher levels of

compassion (care) and altruistic attributes,
which prepares authentic leaders to engage in
positive modeling (George, 2003; Gardner, 2005).
 Authentic Nurse Leadership
• Conceptual Framework:

Personal Altruism
Transparency
Integrity
Moral Shared
Self Relational
Ethical Decision Caring
Awareness Integrality
Courage Making

Work Life/Engagement

Developed based on critical review of literature:

● Authentic Leadership Theory (George, 2003; Avolio, etal., 2004)
● Concept of Caring (Ray, etal., 2002; Watson, 2006; Boykin&
Schoenhofer, 2013).
 Self
Moral Ethical Courage
Awareness

• Intrinsically motivated

• Personal insight
• Self regulating from belief system.
• Have a vision
• Listens to inner compass even
when under pressure.
• Passionate
• Know what the right thing is to do.
• Resilience

• Confidence
 Relational Integrality Shared Decision Making

• Innate ability to connect with others.

• Open communications.
• Open to ideas of others.
• Share experiences acknowledge
weaknesses and strengths. • Makes informed decisions based on
input from others and with an ethical
• Honest consideration for self and others.

• Trustworthy

• Respectful
 Caring

• Compassionate

• Empathetic

• Aware of own needs and needs of others.

• Cares for self and others without self-gains or self-interest.

Methodology:
• Cross-over design (pilot and full scale testing).
• Participants randomly assigned to receive the Authentic Nurse Leadership Questionnaire (ANLQ) and the
Authentic Leadership Questionnaire (ALQ) either Week 1 or Week 2.

• Participant sample:
Expert Panel included19 Masters/Doctoral RNs with nurse executive experience.
Pilot (n=20).
Full Scale testing (n=309) included RNs providing ≥ 50% patient care.

Setting: Acute care hospital(s).

Instruments:
• Demographic Form.
• Authentic Nurse Leadership Questionnaire (ANLQ)
• Area Work-life Scale (AWS)
• Authentic Leadership Questionnaire (ALQ)
• Utrecht Work Engagement Scale (UWES)

Data Analysis: Descriptive, inferential, exploratory factor analysis and structural equation modeling.
Sample Demographics:
• Mean age = 47.4 (2.6 years younger than ANA survey and slightly
older than HRSA analysis of Nursing workforce).
• Female gender = 95.4% Male gender = 4.6% males
(9% lower that RN population according to ANA)
• 31.4% worked in Magnet®-designated hospital.
• 6% board certified.
• (No significant findings regarding demographics, other than board
certification in surgery and pediatrics was identified.)
Educational Degrees

12%
22% Assoc.
BSN
MSN
57%
Methodology:
• Process used in Instrument Development:
• Polit & Beck’s Steps of Developing Multi-Item Scale.
• COSMIN Study Taxonomy of Measurement Properties
for Evaluating Health Instruments (Mokkink, et al., 2010)
Steps:
Conceptualizing the construct.
Developing item pool.
Deciding scaling/scoring methods.
Evaluating wording features, readability.
Expert review of content validity.
Pilot Testing
Full Scale testing
Test-retest reliability week 3 after baseline data completion
Study Aim One:
• Examine content validity through panel of experts.

• Content validity questionnaire calculated content validity

score by each item.

• 6 questions dropped.
• Final questionnaire had 29 items.
Study Aim Two:
• Evaluate internal consistency and test-retest.
• Reliability of the developed questionnaire measuring perceived
authentic leadership in staff nurses.
• Full Study:
• Positive correlation between the initial ANLQ and
• re-test ANLQ (r =.888, p < .001)
• Significant positive relationship between all subscales
• (all p < .05)
• Cronbach's alpha coefficients were .984 for the 29-item scale
(n=185) and ICC for test-retest reliability is .937 (n=129) Power = .99
• Cronbach’s alpha coefficient ranged from .87 to .99 for all
subscales, and ICCs for test-retest reliability ranged from .874 to
.926, power > .88
Study Aim Three:
• Evaluate construct validity through exploratory factor
analysis and confirmatory factor analysis and hypothesis
testing.
• Exploratory Factor Analysis (EFA):
• Analysis of 29 item ANLQ.
• 185 completed questionnaires (no missing data identified).
• Principle Axis Factoring with Promax rotation used to analyze the
first order structure of 3 factor and 5 factor solution.
(The rotated factor loading matrix supported the theoretical item pf
questionnaire.)
● Looked at percentage of variance explained by each model.
● Examined how well EFA matched conceptual framework.
● Looked at overlap (decide whether to keep or move).
Confirmatory Factor Analysis (CFA):
• Model comparison determined that the first order 3 factor and
first order 5 factor model were not the best fit.
• The second order structure model was the best of the
three models.
• Examined different type of model fit, indices include: absolute,
relative and parsimony fit. The values met indicated good
model fit.
• Examined relationship among subscales and entire scale.
(Research Questions # 2-3)
• Results show co-variance among subscales and three domains
indicate they are complex and not independent.
• Looked at weight and co-efficient and the contribution of each subscale.
Subscale of self-awareness is a little lower than .9 in comparison to
all other subscales. Future studies needed to explore if consistent.
CFA: Estimated Model for Second Order
Structure
Findings:
• Significant relationship between perceived authentic
leadership and nurse engagement, as measured by UWES.
• In particular, the moral-ethical courage subscale.
• ANLQ was significant predictor of nurse engagement as
measured by the UWES (12.5% variance).

• Significant relationship between perceived authentic

leadership and nurse work-life, as measured by AWS.
• Multiple linear regressions indicated moral-Ethical Courage
and Shared Decision Making subscales are significant
predictors for Nurse Work-Life (47% variance).
Hypothesis 1-4 Construct Testing:
• ANLQ demonstrated better nursing values than ALQ, as
indicated by a stronger relationships with Nursing Work
Life.
• Correlation coefficients between subscales of the AWS and
ANLQ ranged from .289 to .678 (n =182).

• ANLQ demonstrated better nursing values than ALQ, as

indicated by a stronger relationships with Engagement.
• Correlation coefficients between subscales of the UWES and
the coefficients between subscales of the UWES and the ANLQ
ranged between .192 to .328 (n =182).
Research Question # 1:
What characteristics do the staff nurses associate with
perceived authentic leadership and its subscales?

• Three of the AWS (fairness, reward and value) were significant

predictors of all 5 scales of ANLQ.

• Nurses with board certification in Surgical Nursing perceived

their leader lower in ethical moral courage.

• Nurses with Pediatric board certification perceived less shared

decision making than non-certified nurses.
Research Question # 2:
• What are the weights and contributions of each
subscale to the entire perceive Authentic Leadership
Questionnaire (ANLQ)?

• CFA was conducted and co-variances among subscales

were all positively significant.
• T test for correlation relationships for both the 3 factor
structure and the 5 factor structure demonstrated co-
efficients among three domains ranging from .92 to .98
Research Question # 3:
• What are the relationships (co-variances among subscales
of the perceived Authentic leadership Questionnaire
(ANLQ)?

• All subscales were significantly positive.

• The assumption was tested in the CFA for both 3 factor and 5
factor structure.
• Correlation coefficients among domains were greater than .96
• High correlations among domains and subscales indicates that
there are conceptual overlaps among subscales.
 Research Question # 4:
What is the relationship of authentic leadership as
measured by the Authentic Nurse Leadership Questionnaire
(ANLQ), and the Authentic Leadership Questionnaire
(ALQ)?
ALQ was missing domain Altruism with subscale of Caring.
However, correlation
testing for criterion
validity determined a
stronger relationship
between ANLQ and
ALQ because Pearson
correlation coefficients
were > .66
Conclusions:
• 1. ANLQ is a reliable and valid instrument to measure perceived Authentic
Nursing Leadership.

• 2. ANLQ questionnaire developed based on the Authentic Nurse Leadership

Framework was statistically supported by both exploratory and confirmatory factor
analysis.

• 3. Bivariate correlation analyses showed significant and positive relationships of

perceived Authentic Leadership with Nursing areas of Work-Life and Nurse
Engagement.

• 4. Findings supported that the ANLQ demonstrated better Nursing Values, as

indicated by stronger relationship with Nursing areas of Work Life and Nurse
Engagement.
• (Continuation and pursuit of further multiple samples and testing is necessary for
the continued validation of instruments to measure Authentic Nurse Leadership).
Limitations:
• May include demographic influence, survey design, survey
response and sample size.
• Majority of subjects were female (96.3%).
• Difficulty in recruitment due to lack of email contact information and a time lag in
participants receiving the survey link.
• 60.2% response rate from peri-operative nurses.
(May be a limitation to the generalization of study findings)
• Study cross-over design:
• May have impacted sample size (participants required to answer multiple
surveys at three different times over the course of three weeks.)
• May have caused a carry-over effect resulting from two similar surveys given
at two different times during the survey. (May have affected the participants’
responses).
• Demographic survey design regarding collecting administrative delayed
responsibilities.
Recommendations:
• Caring was a significant finding in this study, identified as
embodied in the discipline of Nursing and what nurses
seek in their nurse leaders.

• Nurse leaders must…

• Demonstrate personal integrity ability to clearly articulate and define goals with
self awareness and moral ethical courage modeling attributes in concordance
with confidence and deeply held values under pressure.

• Communicate with transparency and embrace shared decision making to open

ideas that enhance relationships and quality outcomes.

• Engage in authentic presence and listen carefully to foster follower trust, which
leads to engagement.
Recommendations:
• Include Authentic Leadership in Nursing Education at all
levels of Nursing curriculum and demonstrate in daily
Nursing Practice from bedside to boardroom.

• Conduct further Nursing Research with another samples

in various clinical settings to refine conceptual framework
and instrument. Also, conduct qualitative study from staff
nurse perspective identifying nurse leader attributes.
References:
• Available upon request.

• Contact Information:
• [email protected]