Abstract
Background:
Staff’s level of empowerment plays a significant role in the success of hospitals as complex systems. Therefore, using effective leadership styles by head-nurses is necessary to create an ideal clinical environment to make the most from nurses’ abilities and potential capabilities.Objectives:
The current study aimed to evaluate the relationship of nurses and head-nurses’ psychological empowerment with head-nurses’ leadership style.Methods:
This correlational study was conducted on nurses and head-nurses working in Valiasr (PBUH) hospital, Birjand, Iran, recruited through the census method. All participants held bachelor’s degree with a minimum work experience of two years. The data were collected by a demographic questionnaire, the leader behavior description questionnaire and the Spreitzer psychological empowerment questionnaire. The questionnaires were given to the participants in different working shifts. Finally, thirteen head-nurses and 170 nurses completely filled their questionnaires. The SPSS software ver. 16.0 was employed to analyze data through conducting the Fisher exact, the Spearman and the Mann-Whitney U test, in addition to the independent-samples T-test, at a significance level of 0.05.Results:
All head-nurses were married and above 35 years old and 84.6% of them were female. Moreover, most of the nurses were female (75.9%) and married (82.4%) and aged 26 - 30 years. Most of head-nurses (69.2%) believed that they used the selling leadership style while most of the nurses (76.9%) noted that their head-nurses’ used the telling style. All these nurses and head-nurses had higher levels of empowerment compared with other nurses.Conclusions:
The study findings revealed that the nurses who were empowered had perceived their managers’ leadership style to be the telling style. This finding showed that managers’ leadership style was not congruent with staff’s level of empowerment, denoting managers’ poor familiarity with leadership styles. Therefore, educating managers about leadership styles seems crucial to enhance staff’s empowerment, working motivation and efficiency and promoting organizational dynamism.Keywords
1. Background
Significant increase in the number of organizations, diversity of tasks and responsibilities, and the necessity to ensure coordination between human and financial resources necessitate particular attention to the issue of management (1). One of the key components of organizational management, particularly in healthcare organizations, is the management of human resources (2) whose skills, abilities, and motivations have a significant role in achieving organizational goals (1). On the other hand, nurse managers have a critical role in retaining their staff, particularly professional care providers. Through their leadership styles and skills, nurse managers can decrease undesirable changes in their staff. Therefore, their leadership styles are of paramount importance (2).
Based on their own, their staff’s and their environmental conditions, managers adopt one of the leadership styles (3). According to Hersey and Blanchard, the leadership style of each person includes his/her behavioral pattern to affect others’ activities and is based on others’ perceptions of his/her behaviors (2). The Fiedler contingency theory to leadership states that a certain leadership style does not fit all situations; rather, each situation necessitates a certain leadership style which should be selected based on staff’s desire and capacity (4, 5). Accordingly, managers can facilitate staff’s acceptance of changes in approaches to care delivery and enhance their productivity and empowerment through adopting effective leadership styles (6). This theory suggests that managers behave based on maturity, capacities and desires of their staff (7). The concept of maturity in this theory points to the quality of staff’s motivation, competence, experiences, and interests to accept responsibilities. Based on staff’s maturity, Hersey and Blanchard proposed four leadership styles of telling, selling, participating and delegating (8). Consequently, a manager needs to adopt situation-specific leadership styles according to the immediate organizational culture and staff’s maturity (5).
Shakour et al. found that most managers who participated in their study (60%) adopted task-oriented leadership style, equated leadership with task performance, found ideality in greater productivity, and hence paid little attention to humanistic aspects of leadership and rarely used relationship-oriented style (3). Seyed Javadi et al. also reported that most hospital managers adopted the telling leadership style and paid little attention, if any, to staff’s competence, skills, motivations, and desires (9). Lajavardi and Nazari noted that managers’ ability to perceive management enhances staff’s cooperation and commitment to their organizations, improves their motivations and productivity and increases organizational profitability (10).
Many studies reported a significant relationship between managers’ leadership behaviors and staff’s professional empowerment (6, 11, 12). There are two approaches to empower staff with structural and psychological bases. Structural empowerment deals with modifying environmental structures by managers and facilitating staff’s access to organizational facilities. According to Spreitzer, psychological empowerment is the perception of staff regarding their working environment. Spreitzer used the psychological model of Velthouse and Thomas and determined four dimensions for psychological empowerment (13). Thereafter the results of a study conducted by Mishra added the ‘trust’ dimension to psychological empowerment dimensions. Consequently, psychological empowerment consists of five dimensions including senses of competence, self-determination, impact, meaningfulness and trust (14). The steps to the empowerment of workforce are congruent with the four leadership styles. In the telling step or style, managers dominate workforce. In this step, managers possess supreme authority and hence, make decisions. Accordingly, staff is only the follower of manager’s commands. This step helps staff develop competence. The aim of the selling step is to help staff learn that in this step managers consult with them and even accept their wrong advice to face problems. In the participating step, decisions are made through participation while in the delegating step, authorities are transferred to staff and they are authorized to make decisions (15). Given the diversity of staff’s capability and competence, managers need to change their leadership style based on the capability and competence of staff. Once staff develops abilities and desires, leadership style is shifted from close supervision to delegation. Leadership style is a determining factor in staff empowerment. The success of managers greatly depends on the flexibility of their leadership styles in different situations (16). Managers who choose their leadership styles based on the level of staff’s maturity helps to increase organizational effectiveness and staff satisfaction (17).
Laschinger et al. noted that managers’ improper performance results in failure to access empowerment structures as well as nurses’ emotional and psychological fatigue (11, 18). Thus, managers need to create a working environment in which staff can perform their tasks with a high morale and a healthy body. However, only managers who have clinical, leadership and communicative skills can create such an environment. Efficient leadership is a key component to create a supportive environment to train empowered staff. Contrary to traditional managers who weaken their staff and hence, cannot empower them, empowered managers act as guides, facilitators and mentors. They can enhance staff’s openness to changes in healthcare delivery approaches, productivity, and empowerment through adopting effective leadership styles (19).
Empowerment is of great importance in nursing education, practice and management. Previous studies reported conflicting findings regarding nurses’ level of empowerment. For instance, Zaeimipour et al., found that nurses’ empowerment score was low (20); while Faulkner and Laschinger and Laschinger et al. reported that nurses’ psychological empowerment was at moderate level (11, 21). On the other hand, Ebrahimi et al., found that the scores of all aspects of psychological empowerment, except for the effectiveness and independence dimensions, were high (22). Abili and Nastezaie noted that nurses’ empowerment mean score was 57.91, denoting a high empowerment level. In their study, the mean scores of all dimensions of empowerment, except for the trust dimension, were at an optimum level (23). Eskandari et al. also reported a mean score of 58.7 for nurses’ psychological empowerment. They found that the highest- and the lowest-scored dimensions were competence and impact, respectively (24). The findings reported by Özaralli (25) also showed a positive correlation between participatory leadership and staff’s psychological empowerment. In addition, Zaeimi et al. reported that changes in managers’ behaviors promoted nurses’ empowerment and professional practice (26).
2. Objectives
Given the importance of making the most from nurses’ abilities to promote public health and the key role of head-nurses’ managerial style in enhancing nurses’ motivation and empowerment, it was necessary to conduct a study to answer this question: “Are head-nurses’ leadership styles selected based on their staff’s level of empowerment?”; the current study aimed to evaluate the relationship of nurses and head-nurses’ psychological empowerment with head-nurses’ leadership style.
3. Methods
This correlational study was conducted on nurses and head-nurses working in Valiasr (PBUH) hospital, Birjand, Iran, recruited through the census method. All participants held bachelor’s degree with a minimum work experience of two years.
The data were collected by a demographic questionnaire, the leader behavior description questionnaire and the Spreitzer psychological empowerment questionnaire. The questionnaires were given to the participants in different work shifts. Finally, thirteen head-nurses and 170 nurses completely filled their questionnaires. The demographic questionnaire contained items such as age, gender, marital, educational, and employment status, work experience, work place and working shift. The head-nurses determined their leadership style through completing the leader behavior description questionnaire (LBDQ). The nurses also completed the same questionnaire in order to determine their head-nurses’ leadership style. In other words, they determined the degree to which their head-nurses adopted each of the leadership styles included in the LBDQ. The LBDQ was introduced by Mitty in the ‘handbook for directors of nursing in long-term care’. It contains 40 items in the subscales as relationship-oriented behaviors (fifteen items), task-oriented behaviors (fifteen items) and controlling behaviors without exerting any effect (ten items) (27). The LBDQ items are scored on a five-point Likert scale as follows: always: 5; often: 4; occasionally: 3; seldom: 2; and never: 1. Three items are scored reversely. The four possible leadership styles are determined based on the scores of the task-oriented and relationship-oriented dimensions of the LBDQ as follows:
S1: Telling style: high task orientation (41 - 60) and low relationship orientation (0 - 44)
S2: Selling style: high task orientation (41 - 60) and high relationship orientation (45 - 60)
S3: Participating style: low task orientation (0 - 40) and high relationship orientation (45 - 60)
S4: Delegating style: low task orientation (0 - 40) and low relationship orientation (0 - 44)
The content validity of the LBDQ was assessed through the experts’ judgment method. The LBDQ was given to five faculty members experienced in research and management. Their comments on the content, face and wording of the LBDQ were used to revise it and thereby, the validity of the questionnaire was confirmed. Zaeimipour et al. (20) reported a reliability coefficient (Cronbach’s alpha) of 0.88 for the Persian version of the LBDQ.
The psychological empowerment questionnaire (PEQ) was developed by Spreitzer (13, 14). It contains fifteen items in five domains of competence, self-determination, impact, meaningfulness and trust three items in each domain. These fifteen items are scored by a five-point Likert scale from 1 to 5 (13, 14). Thus, the minimum and the maximum possible scores of the questionnaire are 15 and 75, respectively. Higher scores reflect higher empowerment. Teymournejad and Sarihi-Asfestani validated the Persian version of the PEQ and reported a Cronbach’s alpha of 0.95 for the questionnaire (28). One item from each PEQ domain is presented below as examples:
- The competence domain: ‘I am confident about my ability to do my job.’
- The self-determination domain: ‘I have significant autonomy in determining how to do my job.’
- The impact domain: ‘I have a great deal of control over what happens in my department.’
- The meaningfulness domain: ‘The work I do is meaningful to me.’
- The trust domain: ‘I’m confident that my colleagues provide me with important information.’
The SPSS ver. 16.0 was employed for data analysis. The results of the Kolmogorov-Smirnov test illustrated that the scores of all domains of the PEQ were not distributed normally while the distribution of the total PEQ score and the scores of the task-oriented and relationship-oriented dimensions of the LBDQ were normal. Consequently, the Fisher exact, the Spearman and the Mann-Whitney U tests, in addition to the independent-samples T-test, were conducted to analyze the data at a significance level of 0.05.
4. Results
In total, thirteen head-nurses and 170 nurses participated in the study whose mean age was 32.42 ± 6.89 years. Most of the head-nurses and nurses were female (84.6% and 75.9%, respectively), married (100% and 82.4%, respectively), did rotational working shift (76.9% and 86.5%, respectively), and worked six-hour working shifts (100% and 61.2%, respectively). Moreover, most of the head-nurses (69.2%) had two children while most nurses (40.6%) had no children.
The dominating leadership styles in the study setting were the telling and the selling styles. In other words, the participating and the delegating styles were not practiced by the head-nurses (Table 1). Head-nurses mean scores of the task-oriented and the relationship-oriented leadership styles were significantly higher than those of the nurses (P<0.05; Table 2).
The Frequency Distribution of Leadership Styles
| Variable | No. (%) |
|---|---|
| The frequency distribution of head-nurses’ leadership styles from their own perspectives | |
| Telling | 4 (30.8) |
| Selling | 9 (69.2) |
| The frequency distribution of head-nurses’ leadership styles from the participating nurses’ perspectives | |
| Telling | 10 (76.9) |
| Selling | 3 (23.1) |
Comparing Head-Nurses and Nurses’ Perspectives on the Dimensions of Leadership Styles
| Dimensions | No. | Mean ± SD | P Value |
|---|---|---|---|
| Relationship- oriented | 0.001 | ||
| Nurses | 170 | 36.68 ± 7.38 | |
| Head-nurses | 13 | 46.38 ± 5.67 | |
| Task-oriented | 0.001 | ||
| Nurses | 170 | 41.79 ± 9.07 | |
| Head-nurses | 13 | 55 ± 4.06 |
The Mann-Whitney U test and the independent-samples T-test showed that the mean PEQ score of nurses whose managers used the telling leadership style was significantly higher than those of the nurses who reported that their managers adopted the selling style (P < 0.05). Moreover, the mean PEQ scores of head-nurses who reported adopting the telling and the selling leadership styles were respectively 66.50 ± 6.56 and 70.87 ± 3.31 (Table 3).
Comparing Head-Nurses and Nurses’ Empowerment Scores Based on Leadership Styles
| Variable | No. | Leadership Style | Mean ± SD | P Value |
|---|---|---|---|---|
| Nurses’ empowerment score based on head-nurses’ leadership styles from the perspectives of head-nurses | 4 | Telling | 61.31 ± 2.43 | 0.08 |
| 9 | Selling | 57.88 ± 3.19 | ||
| Nurses’ empowerment score based on head-nurses’ leadership styles from the perspectives of nurses | 10 | Telling | 60.23 ± 2.22 | 0.003 |
| 3 | Selling | 54.60 ± 2.65 |
5. Discussion
The current study aimed to evaluate the relationship of nurses and head-nurses’ psychological empowerment with head-nurses’ leadership style. About 69.2% of the participating head-nurses reported adopting the selling leadership style; i e, being highly relationship- and task-oriented (S2). While adopting this style, leaders explain the intended decisions to their staff. However, final decisions are made by leaders. On the other hand, 30.8% of the participating head-nurses reported using the telling leadership style which equates with high task orientation and low relationship orientation (S1). In this style, leaders educate staff about activities needed to be done to achieve the intended goals and carefully supervise staff’s obedience to their orders (8).
Respectively, 76.9% and 23.1% of the participating nurses reported that their managers used the telling and the selling leadership styles. This finding revealed that nurses’ perceptions of their managers’ leadership style were different from managers’ perceptions of their own leadership styles. It was in line with the findings reported by Zaeimi et al. (26). In other words, the participating nurses believed that task allocation and job description were not clear enough. The work experience of more than 50% of the participating nurses was over five years, denoting that they had necessary expertise (i e, knowledge and skills) to perform their tasks. Thus, managers can enhance staff’s inner motivation and job satisfaction through employing participatory leadership behaviors. Zaeimi et al. also reported a difference between managers’ attitudes towards their own leadership styles and perception of staff regarding managers’ leadership styles. They found that 79% of head-nurses who participated in their study reported adopting the selling leadership style (26). Pazargadi et al. also reported that 65.4% of head-nurses evaluated their leadership as the selling type (17).
The study findings revealed that head-nurses with the selling leadership style had higher levels of empowerment while their nurses had low levels of empowerment. Moreover, head-nurses with the telling leadership style were also highly empowered. These conflicting findings can be attributed to the fact that managers do not treat staff according to their degree of maturity. Nurses with higher levels of empowerment feel greater need to latitude, while nurses who are limited by their managers as well as nurses with lower levels of empowerment justify the telling leadership style of their managers as latitude. The results of the present study illustrated that head-nurses who considered themselves as highly empowered were unsuccessful at employing appropriate and effective strategies to create an ideal working environment.
According to the situational leadership model, managers need to change the guiding and the supporting aspects of their leadership style based on the degree of their staff’s readiness to adopt a style which is congruent with the immediate situation. Therefore, they need to constantly evaluate their staff to determine the levels of their commitment, ability and motivation to do their tasks (8). In line with the current study findings, Morrison et al. and Ozaralli also reported that highly empowered head-nurses can empower the staff (6, 25). Empowered head-nurses usually use effective leadership styles and affect their staff through creating ideal subjective and working environments. They can give their staff a feeling of empowerment and enhance their motivation. Seyed Javadi et al., also found that managers who had selected their leadership styles according to the degrees of maturity and readiness of their staff were more successful. Their study was conducted in Ardebil, Iran, and showed that 50% 0f nurses had minimum levels of maturity and 63.2% of managers had adopted the telling leadership style. Contrary to the findings of the present study, the findings reported by Seyed Javadi et al. implied that managers and head-nurses treated their staff based on their maturity level (9).
Mahmoudirad et al. noted that nurse managers can support their staff and enhance care quality, professional improvement, and the level of empowerment through leadership skills. However, their findings revealed that most nurse managers did not appropriately use these skills (19). Laschinger et al. reported that manager’s poor performance results in limited access to empowerment structures, staff’s emotional and psychological fatigue and high staff turnover and attrition (29-31). In contrast, managers’ effective leadership can improve staff’s attitude, practice, empowerment, productivity, effectiveness; hence, it can facilitate the process of achieving organizational goals (19). Holdsworth and Cartwright also quoted previous studies and concluded that empowerment decreases staff’s absences from work and increases their tendency to remain in their job (32). Apparently, nurses who perceive that they are working in an empowering working environment probably provide high-quality care which in turn provides them and their patients with greater satisfaction.
5.1. Conclusion
The study findings revealed that the empowered nurses had perceived their managers’ leadership style as the telling style. This finding shows the incongruence between managers’ leadership style and level of staff’s empowerment which denotes that managers were not familiar enough with leadership styles. Therefore, educating managers about leadership styles seems crucial to enhance staff’s empowerment, work motivation, efficiency and promoting organizational dynamism.
Acknowledgements
References
-
1.
Zandian F,, Riahnia N,, Keshavarz L. Determining the management style and its relation to librarians job satisfaction of Tehran Academic Libraries [ in Pesian]. J Academic Librarian Info Res. 2011;45(57):87-109.
-
2.
Ojian P, Vanaki Z, Hajizadeh E, Parandeh A, Sharifnia H. Effect of management development program based on concept mapping for head nurses on their leadership style and its' effectiveness. Quarterly J Nurs Manag. 2012;1(3):65-74.
-
3.
Shakour M, Bazrafkan L, Alizadeh M, Ghasemi M. Assessing the leadership styles and effectiveness of administrators in Isfahan University of Medical Sciences in 2009 [in Persian]. Iran J Med Edu. 2012;11(9):1255-64.
-
4.
Almasian A, Rahimikia A. Study of the relationship between the leadership style of managers and Job Burnout among the staff of Lorestan university of medical sciences in 2010 [ in Persian ]. Yafteh. 2012;14(1):69-79.
-
5.
Mosadeghrad AM. A study of Relationship between Leadership Style Managers and Hospital Efficiency in Isfahan University Hospitals [ in Persian ]. Sci Econ J Univ Isfahan. 2006;17(4):23-37.
-
6.
Morrison RS, Jones L, Fuller B. The relation between leadership style and empowerment on job satisfaction of nurses. J Nurs Adm. 1997;27(5):27-34. [PubMed ID: 9159611].
-
7.
Joyce Covin T, Kolenko TA, Sightler KW, Tudor RK. Leadership style and post‐merger satisfaction. J Manag Develop. 1997;16(1):22-33. https://doi.org/10.1108/02621719710155454.
-
8.
Azadi E. Proper leadership style for managers on the basis of Employees' maturation quantity [ in Persian]. Monthly economic, social and cultural Bank Sepah. 2013;140:49-56.
-
9.
Seyed Javadi M, Khalesi N, EbadiFard Azar F. A Study of Leadership and Organizational Maturity at Teaching Hospitals Affiliated with Ardebil University of Medical Sciences. J Health Management. 2004;7(20):95-135.
-
10.
Lajavardi SJ, Jamali Nazari A. Relationship between emotional intelligence and prefered leadership style [ in Persian]. J Public Admin Perspec. 2010;1(1):69-86.
-
11.
Laschinger HK, Wong C, McMahon L, Kaufmann C. Leader behavior impact on staff nurse empowerment, job tension, and work effectiveness. J Nurs Adm. 1999;29(5):28-39. [PubMed ID: 10333859].
-
12.
Allameh SM, Heydari M, Davoodi SMR. Studying the relationship between transformational leadership and psychological empowerment of teachers in Abade Township. Procedia - Social Behavl Sci. 2012;31:224-30. https://doi.org/10.1016/j.sbspro.2011.12.046.
-
13.
Spreitzer GM. Psychological, Empowerment in the Workplace: Dimensions, Measurement and Validation. Academy Manag J. 1995;38(5):1442-65. https://doi.org/10.2307/256865.
-
14.
Mishra A, Spreitzer GM. Survivor Responses to Downsizing: the Mitigating Effects of Trust and Empowerment. Southern California Studies Center: University of Southern California; 1997, [cited November 14]. Available from: http://www.researchgate.net/profile/Aneil_Mishra/publication/228458235Survivor_Responses_to_Downsizing_The_Mitigating_Effects_of_Trust_and_Empowerment/links/02e7e528e18cbb68ea000000.pdf/.
-
15.
Hashemi H, Puraminzad S. Challenges Facing TO Development Of Human Resources And Strategy To Overcome [ in Persian ]. Kar va Jamehe. 2011;136:5-21.
-
16.
Nassar ME, Abdou HA, Mohmoud NA. Relationship between management styles and nurses’ retention at private hospitals. Alexandria J Med. 2011;47(3):243-9. https://doi.org/10.1016/j.ajme.2011.06.003.
-
17.
Pazargadi M, Sefidpoush P, Khazaei N, Alavi Majed H. Study of association between management styles of head nurses with nurses' empowerment in medical and surgical wards in hospitals of Nezaja health and medical services in Tehran 1388 [ in Persian]. Faculty of Nurs Midwif Quarter. 2011;21(74):21-8.
-
18.
Almost J, Laschinger HK. Workplace empowerment, collaborative work relationships, and job strain in nurse practitioners. J Am Acad Nurse Pract. 2002;14(9):408-20. [PubMed ID: 12375360].
-
19.
Mahmoudirad G, Ahmadi F, Vanaki Z, Hajizadeh E. The effect of "Expectation based managerial competency acquisition in nursing model" on nursing staff empowerment and efficacy of leadership style. J Birjand Univ Med Sci. 2010;17(2):127-35.
-
20.
Zaeimipour Kermanshahi M, Vanaki Z, Hajizadeh E. Learning Groups in Training Programs for Nurse Managers: A Method to Enhance Nursing and Leadership Capabilities [ in Persian ]. Iran J Med Edu. 2007;7(1):69-77.
-
21.
Faulkner J, Laschinger H. The effects of structural and psychological empowerment on perceived respect in acute care nurses. J Nurs Manag. 2008;16(2):214-21. [PubMed ID: 18269553]. https://doi.org/10.1111/j.1365-2834.2007.00781.x.
-
22.
Ebrahimi H, Hosseinzadeh R, Zaghari Tefreshi M, Hosseinzadeh S, Asghari Jafarabadi M. Clinical competency and psychological empowerment of nurses and their correlation with demographic characteristics [ in Persian]. J Health Promotion Manag. 2013;2(4):30-8.
-
23.
Abili K, Nastezaie N. Surveying the Relationship between Psychological Empowerment and Organizational Commitment in Nursing Staff [ in Persian]. Toloo-e-Behdasht. 2009;8(1 - 2):26-38.
-
24.
Eskandari F, Pazargadi M, Zagheri Tafreshi M, Rabie Siahkali S, Shoghli A. Relationship between Psychological Empowerment with Affective Commitment among Nurses in Zanjan, 2010 [ in Persian]. Preventive Care Nurs Midwif J. 2014;3(2):47-60.
-
25.
Özaralli N. Effects of transformational leadership on empowerment and team effectiveness. Leadership Organ Develop J. 2003;24(6):335-44. https://doi.org/10.1108/01437730310494301.
-
26.
Zaeimi M, Vanaki Z, Hajizadeh A. The Relationship between Nurse managers leadership styles and stuff nurses empowerment [ in Persian]. Teb va Tazkiyeh. 2005;13(4):34-46.
-
27.
Mitty EL. Handbook for director of nursing in long term cares. 1 ed. New York: Delmar Cengage Learning; 1998.
-
28.
Teymournejad K, Sarihi Asfestani R. Effects of Organizational Learning on Psychological Empowerment, in the Ministry of Economic Affairs and Finance [in Persian]. J ManagStud Develop Eval. 2010;20(62):37-59.
-
29.
Laschinger HKS, Shamian J, Thomson D. Impact of magnet hospital characteristics on nurses' perceptions of trust, burnout, quality of care, and work satisfaction. Nursing economics. 2001;19(5):209.
-
30.
Laschinger HK, Finegan J, Shamian J, Wilk P. Impact of structural and psychological empowerment on job strain in nursing work settings: expanding Kanter's model. J Nurs Adm. 2001;31(5):260-72. [PubMed ID: 11388162].
-
31.
Spence Laschinger HK, Havens DS. The Effect of Workplace Empowerment on Staff Nurses' Occupational Mental Health and Work Effectiveness. J Nursing Admin. 1997;27(6):42-50. https://doi.org/10.1097/00005110-199706000-00012.
-
32.
Holdsworth L, Cartwright S. Empowerment, stress and satisfaction: an exploratory study of a call centre. Leadership Organ Develop J. 2003;24(3):131-40. https://doi.org/10.1108/01437730310469552.