Impact of Authentic Leadership and Areas of Work Life among Nurses on Patient Outcomes at King Khalid Majmaah Hospital, Saudi Arabia

Majmaah University
College of Applied Medical Sciences
Nursing Department
Masters of Nursing in Management & Leadership
Impact of Authentic Leadership and Areas of Work Life among Nurses on
Patient Outcomes at King Khalid Majmaah Hospital, Saudi Arabia
Principal Investigator Student:
Mohammed Saed Almudhaybiri
391104176
Supervisor:

Dr. Brian Anonat Vasquez
Table of Contents
List of Tables and Figures
Introduction
Background 1
Aims and objectives 3
Hypothesis 4
Significance of the study 4
Definition of terms 5
Literature Review and Framework 6
Methodology 18
Sample of study 18
Research Design 18
Study sample 18

Sampling Design 18
Sample size 19
Inclusion and exclusion criteria 19
Research Instruments 19
Data collection 22
Data Analysis 22
Ethical Consideration 23
Limitations of the study 23
References 24
Appendix 29
List of Tables and Figures
List of Figures:
Figure 1: How the power of authentic leadership drives organizational performance.
Figure 2: Relationship among variables: Authentic leadership, organizational culture,
and healthy work environments.
List of Tables:
Table:1 Authentic Leadership Components

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CHAPTER 1 INTRODUCTION
1.1. Background
In current healthcare industry, retention of nurses has become a priority
worldwide. It is crucial to ensure the substitution of nurses who are retiring with fresh
graduates having favorable work environment to nurture professional practice thereby
promoting job satisfaction and discouraging thoughts of leaving the profession. It has
been noticed that there is direct relation between the qualities of care a patient’s
receive with nurse’s job satisfaction. Studies in the past have shown that a good
leadership skill plays a pivotal role in shaping the professional practice to allow the
nurses to provide safe and effective patient care resulting in higher perceptions of
patient care quality and job satisfaction.
An authentic leadership has an effect not only the nursing workforce and the
profession but the healthcare delivery system and society as a whole. The key
distinction of authentic leaders is that they are anchored by their own deep sense of
self and know where they stand on important issues, values, and beliefs. In nursing
practice, a healthy work environment is fundamental in sustaining a suitable nursing
workforce; the stressful nature of the profession frequently leads to burnout,
disability, and high absenteeism and ultimately contributes to the escalating shortage
of nurses (Avolio, Wernsing & Gardner, 2018). Healthcare settings not having
supportive work environments pose a threat to the organization itself and its workers.
Areas of work life match (person-job fit) have also been related to intrapersonal
resources, such as, psychological capital (Tahhan, 2019). It is reasonable to expect
that when nurses feel that their expectations match existing conditions in the

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workplace, they will be more likely to meet job demands and therefore have increased
self-efficacy for performing their roles.
In numerous regions of the world, contemporary medical clinic care is faced
by workforce challenges, changing shopper desires and requests, financial limitations,
expanding requests for access to mind, a command to improve understanding focused
consideration, and issues worried about degrees of value and wellbeing of social
insurance (Boamah, Read, & Laschinger, 2017). Viable administration is urgent to
endeavors to expand powerful administration of care in the emergency clinic setting.
Rising up out of this mind boggling writing is the job of initiative in the clinical
setting. According to Avolio, Wernsing and Gardner (2018), the significance of viable
clinical initiative in guaranteeing a great human services framework that reliably
gives protected and productive consideration has been emphasized in the academic
writing and in different government reports.
Late requests, commissions, and reports have advanced clinician commitment
and clinical administration as basic to accomplishing and supporting upgrades to mind
quality and patient wellbeing. Right now, we talk about clinical administration in
human services, think about distributed meanings of clinical initiative, blend the
writing to portray the attributes, characteristics, or ascribes required to be a successful
clinical pioneer, consider clinical authority according to emergency clinic care, and
examine the facilitators and boundaries to compelling clinical initiative in the medical
clinic division (Avolio, Wernsing & Gardner, 2018. In spite of the across the board
acknowledgment of the significance of successful clinical authority to tolerant results,
there are some very extensive hindrances to cooperation in clinical initiative (Avolio,
Wernsing & Gardner, 2018). Future methodologies should expect to address these
boundaries in order to improve the nature of clinical authority in medical clinic care.

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Managers in formal leadership positions are influential in delivering nurses
with access to these four empowerment structures (Boamah, Laschinger, Wong &
Clarke, 2018). The most imperative quality of efficacious leader is authenticity in
nurse managers. According to authentic leadership theory, authentic leaders are
insightful and self-aware, with high ethical and moral standards; they engage in
balanced decision-making and present their genuine selves to others (Eyong &
Rathee, 2017). There are four foundational frameworks of authentic leadership:
balanced processing, relational transparency, an internalized moral perspective and
self-awareness (Avolio, Wernsing & Gardner, 2018).
Figure: 1 How the power of authentic leadership drives organizational performance.
High levels of stress are frequently noticed in step-down units due to high
patient acuity, shortage of staff, and fatigue. Research has shown that stress and high
workloads among nurses’ results in negative effect patient’s level of care and overall
satisfaction (Avolio, Wernsing & Gardner, 2018. Nursing manager’s authentic
leadership has been indicated in the past have positive influence on outcomes such as
trust in leadership, organizational behavior, leader and follower wellbeing, and
organizational commitment (Laschinger & Fida , 2015). Studies linking nursing

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leadership styles with patient outcomes are limited particularly in Kingdom of Saudi
Arabia suggesting the need for additional research to investigate the mechanisms by
which leadership may influence patient outcomes. Also, there is a lack of research
that compares newly promoted nurse managers who didn’t receive formal leadership
development and the consequence on organizational or clinical outcomes.
The findings of this study is believed to add to the mounting evidence in support
of authentic leadership theory and improve the understanding of how leaders can
positively inspire the new graduate nurses towards health promotion and their
retention outcomes by creating favorable environment. By the means of this study we
would like to address the gap between effective nursing managers and its role on job
performance and satisfaction of staff nurses.
1.2. Aim and objectives
Based on theory and research in the literature we hypothesize that experienced
nurses perceiving higher levels of authentic leadership and sustainable areas of work
life may have positive outcomes on their outcome in quality of patient’s care.
This study is aimed to examine the effects of nursing manager’s authentic leadership
and areas of work life on quality of patient’s care at King Khaled Hospital, Majmaah.
The objectives of the present study will include the following
1. To explore the role of authentic leadership and areas of work life amongst
nursing manager at King Khalid Hospital, Majmaah, KSA
2. To investigate the effect of nursing manager’s authentic leadership and
areas of work life on quality of patient’s care at King Khalid Hospital,
Majmaah, KSA

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1.3. Hypothesis
1. Authentic leadership and areas of work life amongst nursing manager will
have positive influence
2. Authentic leadership and areas of work life will be positively correlated
with quality of care provided to the patients and outcome.
1.4. Significance of the Study
This study will have practical implications for nurse managers and organization. It
is believed that Managers, who stress on transparency, balanced processing, self-
awareness and high ethical standards in their interactions with nurses may play a part
to safer work environments for patients and nurses. Managers exhibiting a sense of
genuine caring concerning their staff in understanding their requirements in terms of
ethical and moral standards in their working relationships promote empowering
workplace environment (Laschinger & Fida, 2015). Also, the nurses feel motivated
when they have more input to how their work is to be done and when they have prior
information and resources need to perform their role. This will further result in
assuming greater responsibility when they see their manager is trustworthy, ethical,
balanced, and fair decision-making.
This study is aimed to address the research gap identified by various researchers.
Authentic leadership has significant relationship with certain types of employee
satisfaction but not with dimensions of satisfaction and that future studies should
study the intervening mechanism (Kim and Han, 2019). This study will also help to
know how the authentic leaders inculcate the organization citizenship behavior among
employee through greater employee empowerment. Thus, the study not only aids to
the existing body of research on authentic leadership and employee work performance

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but also explore it in the current setting (King Khalid Hospital, Majmaah, KSA)
which will further expand the validity of authentic leadership theory.
1.5. Definition of terms
What is Authentic Leadership?
George explains an authentic leader as an individual in a position of
responsibility who is genuine, trustworthy, reliable, and believable. Avolio and his
colleagues offered a conceptual definition of authentic leadership as part of the
beginning development of a theoretical framework to guide future research (Avolio,
Wernsing & Gardner, 2018). Authentic leaders are the individuals who are deeply
aware of how they think and behave and are perceived by others as being aware of
their own and others’ values/ moral perspective, knowledge, and strengths, aware of
the context in which they operate, and who are confident, hopeful, optimistic,
resilient, and high on moral character.”

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CHAPTER 2 LITERATURE REVIEW AND FRAMEWORK
New graduate nurses are particularly vulnerable to negative workplace
behavior that negatively impacts their job and career satisfaction and their mental and
physical health. Issues related to work life which put in jeopardy the retention rate of
fresh graduates are a matter of concern for nurse administrators given reports of
turnover rates as high as 60% in the first year of employment (Laschinger & Fida,
2015). Researchers have expressed concern that many new graduates may actually
leave the profession altogether as a result of stressful working conditions. As a large
cohort of the nursing workforce approaches retirement, a cadre of new nurses who
find their work fulfilling is essential for sustaining the nursing workforce and for
ensuring that nursing resources are available to provide high quality patient care in the
future. Thus, every effort must be made to create working conditions that are
welcoming to newcomers and support the positive transition from the student to
graduate role. (Laschinger & Fida, 2015).
Past investigations have demonstrated that the activity fulfillment of nursing
staff is identified with their assessment of the nature of care gave in their clinic unit.
Occupation fulfillment can be characterized as the degree to which workers like their
employments. It is an enthusiastic express that is upgraded by accomplishing wanted
outcomes at work and the sentiment of having a place with a productively working
work network (Yun & Kang, 2018). Employment fulfillment is reliant on a few
components, including the patient-to-staff proportion, nature of the workplace,
attendants' expert self-rule, regard for medical caretakers, connections between staff
individuals and pioneers, duty to the association and the measure of pressure
experienced(Giles, Parker, Mitchell & Conway, 2017). One of the hugest components

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that impacts work fulfillment and medical attendants' assessments of the nature of
care gave at the unit level is the training condition and the accessibility of sufficient
assets. On the off chance that medical caretakers can't do nursing mediations to a
suitable standard, they won't be happy with their employments. This recommends the
nature of care can be improved by altering factors that influence work fulfillment.
While a few late examinations have depicted the connection between medical
caretakers' activity fulfillment and their view of the training condition and nature of
care, it would be fascinating and valuable to analyze the connection between
attendants' assessments of their activity fulfillment comparable to patients' impression
of the nature of their consideration (Laschinger & Fida, 2015). Patients' impression of
nature of care have been seen as fundamentally unique in various emergency clinics
and more established patients believe nature of care to be higher than do more
youthful patients(Laschinger & Fida, 2015). It is essential to contemplate patients'
impression of nature of care since they can assist with improving quality, which will
in general be higher in efficient medical clinics with a low patient-to-nurture
proportion.

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Figure 1. Relationship among variables: Authentic leadership, organizational culture,
and healthy work environments.

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Table: 1 Authentic Leadership Components based on Panczyk and colleagues
Authentic Leadership
According to Eyong and Rathee (Eyong & Rathee, 2017), AL is a positive
relational leadership style whereby leaders behave in an authentic manner with their
followers and focus on furthering their development. Authentic leaders time and again
make use of four key performances in the work setting: relational transparency
(presenting themselves as they truly are), balanced processing (considering differing
points of view before making decisions), moral/ethical behavior (acting in accordance
with internal moral and ethical values), and self-awareness (having insight about self

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and influence on others); (Eyong & Rathee, 2017; Panczyk, Jaworski, Iwanow &
Gotilib, 2018). Empirical support for this model has been shown in both general
management settings and in nursing. According to Irshad, Ahmad and Rashid (2019),
AL positively influenced nurses’ performance through structural empowerment in
their workplace. More recently, Davidson and his collegues (Davidson, Mitchell, et
al., 2018) found that AL played a protective role against early career burnout of
nurses. These findings highlight the importance of AL in creating healthy, effective
nursing work environments.
Six areas of work life model
Kim and Han (2019) theorized that there are six areas of work life in which a
person-job match can enhance employee engagement at work. Workload refers the
amount of time and resources available to an employee to satisfy job demands.
Control relates to professional autonomy and is the extent to which employees are
able to make important decisions about their work. Rewards involve the financial,
social and/or internal recognition for employee work contributions. Community
involves the quality of working relationships with others in the organization including
managers, colleagues and subordinates. Fairness is the extent to which decision-
making processes are open and respectful. Finally, value congruence represents the
match between the organization’s priorities and values and those of the employee
(Kim & Han, 2019). In an examination of data from several databases (n = 6815) the
results showed that the six areas of work life were all significantly related to burnout.
Areas of work life match (person-job fit) have also been related to
intrapersonal resources, such as, psychological capital (Giordano-mulligan & Eckardt,
2019). It is reasonable to expect that when nurses feel that their expectations match

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existing conditions in the workplace, they will be more likely to meet job demands
and therefore have increased self-efficacy for performing their role.
Nurse-Assessed Patient Care Quality
High-quality patient care (HQPC) is the ultimate goal of any healthcare
delivery system and is arguably the essence of nursing. Often, HQPC is defined as
care that results in optimal patient functioning. Nurses, given their 24/7 contact with
patients, play an integrative role in the patient care process and are well qualified to
provide accurate assessments of the quality of patient care in their units. In fact,
Lamiani, Dordoni and Argentero found that nurse-assessed quality of patient care was
significantly associated with objective hospital quality indicators, such as patient
satisfaction, failure to rescue, and mortality odds (Lamiani, Dordoni& Argentero,
2016). They suggest that it is therefore important to consider nurses’ reports of patient
care quality in addition to objective measures when monitoring patient care quality in
hospitals.
Adequate staffing is important for accomplishing satisfactory patient care
(Boamah, & Laschinger, 2016; Wagner, Rieger, 2019). Inadequate nurse staffing
levels interfere with nurses’ ability to appropriately manage patient care needs and are
a source of nurse frustration, heavier workload, and job dissatisfaction (Boamah, &
Laschinger, 2016; Mortier, Vleric & Clays, 2016). Laschinger found that structural
empowerment and staffing adequacy were significant predictors of nurse-assessed
quality of care (Giordano-mulligan & Eckardt, 2019), and Buruck and colleagues
(Buruck et al., 2019) linked poor staffing levels to patient mortality. Poor nurse
staffing levels have also been associated with increased risk of in-hospital
complications, patient mortality, and patient morbidity (Macphee, Dahinten & Have,
2017; Lishchinsky & Benoliel, 2018).

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Nurse Job Satisfaction and Perceptions of Patient Care Quality
Job satisfaction has been shown to be a key retention factor among nurses.
Nurses’ autonomy to provide patient care in line with their knowledge and experience
has been consistently found to be a strong predictor of nurses’ job satisfaction,
(Ibrahim, Abdullah & Kaliappen, 2016) and job satisfaction has been consistently
associated with nurse turnover intentions (Roche, Duffield, Homer, Buchan &
Dimitrelis, 2015). Numerous studies have demonstrated strong relationships between
supportive professional practice environments and nurse job satisfaction and
perceived quality of care (Giles, Parker, Mitchell & Conway, 2017). Research has
also shown that nurses’ job satisfaction is related to the quality of care on their units
(Fallatah & Laschinger, 2016).
More recently, Cho and colleagues found that process factors, such as
inadequate staffing and nurses’ reports of missed care, were significant predictors of
job dissatisfaction (Cho, Chin, Kim & Hong, 2016). Although these studies
demonstrate the importance of nurses’ perceptions of patient care quality for their job
satisfaction, they do not provide a more nuanced description of how various work
environment factors interact to influence nurses’ satisfaction. We draw from theory
and research to propose a theoretical model linking AL to supportive practice
environments and, subsequently, to NAPCQ and job satisfaction (Frasier, 2019).
According to Laschinger hypothesized model AL will lead to greater structural
empowerment which in turn, will lead to a more supportive practice environment and
more adequate staffing. When adequate staffing and a supportive practice
environment are in place, nurses will perceive greater quality of patient care, which
will lead to greater job satisfaction (Laschinger & Fida , 2015).

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Literature Framework
In his study, Huan‐Fang and his colleagues explored the mediating effects of
work environment and burnout on the relationship between authentic leadership and
the intention of nurses to leave their job (Lee, Chiang & Kuo, 2019). This was a
cross‐sectional study based on self-reported questionnaire of 946 nurses from three
different levels of hospital (medical center, regional, and district). The result of this
study revealed that the nurses considered their head nurses to be frequently applying
authentic leadership. Authentic leadership had a positive direct effect on work
environment, which in turn had a direct negative effect on emotional exhaustion
component of burnout. Authentic leadership also influenced intent to leave indirectly
through work environment and emotional exhaustion. Leaders with authentic attitudes
create positive work environments that decrease burnout and intent to leave (Lee,
Chiang & Kuo, 2019). Cross-section study design and sample selection bias from the
same hospital was the main limitation to this study. The findings of this study
indicated the need for implementation of strategies to create a positive work
environment and strengthen individual coping skills. Moreover, the administrators
should adopt authentic leadership practices and make efforts to improve the work
environment and decrease burnout in order to decrease nurses’ intent to leave.
A Korean study by Kim and Han explored the effects of head nurses' authentic
leadership and empowerment on job satisfaction, and nursing performance of nurses
and identified the mediating effect of empowerment in the relationships of head
nurses' authentic leadership, with nurses' job satisfaction, and nursing performance
(Kim & Han, 2019). This study was self-administered questionnaires involving 149
nurses from 2 general hospitals. The results showed that Head nurses' authentic
leadership had positive correlations with empowerment, job satisfaction, and nursing

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performance. Empowerment showed partial mediating effects in the relationship
between head nurses' authentic leadership and nurse’s job satisfaction, and a perfect
mediating effect in the relationship between head nurses' authentic leadership and the
performance of nursing (Kim & Han, 2019). The main limitations of this study were
self-reported biasness to questions. The results indicated the need to develop
strategies and applications to enhance nurses' empowerment for improved job
satisfaction and nursing performance.
A cross-sectional study from Nora Frasier (2019) examined the impact of a
pilot leadership development program on nurse managers' (NMs') (n = 16) use of
authentic leadership behaviors (Frasier, 2019). The ALQ Self version 1.0 and ALQ
Rater version 1.0 were used to assess participants' self-perceived and direct report
RN-perceived use of authentic leadership behaviors. The results reported measurable
increases in authentic leadership behaviors in both the self-assessments and RN direct
report assessments, with statistical significance achieved in 1 self-awareness behavior.
The study had few limitations. First limitation of this study was small sample size
cohort at a single hospital. In addition, the cross-sectional design limits conclusions
regarding the sustainability of the behavior changes, and the short interval for post
program data collection may not have allowed time to detect behavior changes that
will continue to develop over time. Further the cohort was a convenience sample of
NMs, which may not be representative of the larger nurse leader population. This
study opened the scope for further research with larger cohorts. The prevalence of
authentic nursing leadership in Magnet versus non-Magnet hospitals should also be
explored.
A study conducted in Pakistan by Poonam Irshad and group aimed to
investigate the effect of authentic leadership on work outcomes with mediating role of

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empowerment (Irshad , 2019). The population of this study consists of employees in
healthcare sector of Peshawar. A sample of 211 medical professionals was selected by
purposive sampling technique. The results of the study revealed that authentic
leadership has positive and significant effect on work outcomes such as organizational
citizenship behavior, employee performance and job satisfaction. Mediation results
show that Empowerment partially mediates the relationship of authentic leadership
with organizational citizenship behavior and job satisfaction while full mediation
support was found with employee performance. This study considered the effect of
authentic leadership on three different employee performance outcomes. It is also
possible that other follower’s outcomes such as employees’ withdrawal behaviors
(e.g., turnover, tardiness and absenteeism) should be further explored to check the
significance of authentic leadership on follower’s attitude and behavior. This research
study is limited in scope to various private and public hospitals of Peshawar KPK
(Irshad, 2019).
A study conducted on Canadian newly graduated nurses was published by
Laschinger HKS and his group (Spence, Laschinger, Wong, Read, Cummings, Leiter,
Macphee& Grinspun, 2019). This was a time-lagged mail survey done at two time
points involving new graduate nurses (n=406). This study is considered to be the first
to demonstrate that positive work environment factors are associated with better
health outcomes for new graduate nurses. Results add to growing evidence that
development of new graduate nurses’ intrapersonal resources contributes to their
health and well‐being during their stressful transition to practice. Findings linking
incivility to new graduate nurses’ post‐traumatic stress disorder risk add to past
research by demonstrating that incivility, while thought to be less severe than
bullying, is also psychologically harmful to new graduate nurses. Moreover, this study

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presented that burnout is positively related to increased risk of post‐traumatic stress
disorder in this population.
Psychological capital and occupational coping self‐efficacy were significantly
related to all three health outcomes, highlighting the important role that new graduate
nurses’ intrapersonal resources play in protecting their health, thought to be related to
their ability to handle work‐related stressors. Lighting the important role that new
graduate nurses’ intrapersonal resources play in protecting their health, thought to be
related to their ability to handle work‐related stressors. Limitations to this study
include the low survey response and the use of self‐report questionnaires (Spence,
Laschinger, Wong, Read, Cummings, Leiter, Macphee& Grinspun, 2019).Authentic
leadership and structural empowerment have proven to lower initial career burnout
among nurses.
New graduate nurses consistently report high levels of stress and difficulty
finding work-life balance due to heavy workloads, which are often exasperated by
short-staffing. Boamah and his group performed a study to better understand how
work environment and personal factors influence burnout development, and
ultimately, nurse and patient outcomes (Boamah, Read, & Laschinger, 2017). This
was accomplished by testing a hypothesized model investigating the effect of
authentic leadership and structural empowerment on staffing adequacy and work-life
interference, and subsequently, burnout, job satisfaction and patient care quality one
year later. Random samples of approximately 400 Registered Nurses were selected
from the nursing registry database of each of the 10 Canadian provinces.
The results reported that new graduate nurses’ perceptions of authentic
leadership were positively linked to structurally empowering working conditions,

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which in turn, negatively influenced short-staffing and work-life interference. Also,
the study reported that short-staffing and work-life interference predicted burnout
development one year later, with short -staffing increasing burnout both directly and
indirectly, through its effect on work-life interference. Burnout amongst new graduate
nurses negatively affects job satisfaction and patient care quality, while job
satisfaction positively influences patient care quality (Boamah, Read, & Laschinger,
2017). Finally, Short-staffing and work-life interference were significant mediators of
the relationship between authentic leadership, structural empowerment and new
graduate nurse burnout. The main limitations of this study are the use of self-report
questionnaires, low response rates and common method bias.
A study by Kretzschmer et al tested predictors of nursing empowerment and
job satisfaction in nurses (Kretzschmer, Walker, Myers, Vogt, Massouda, Gottbrath &
Logsdon, 2017). This study tried to answer two questions, first is higher levels of
nursing empowerment predicted by characteristics of the workplace environment and
organizational support and second is higher levels of job satisfaction predicted by
nursing empowerment, characteristics of the workplace environment. The results of
this study reported that the nurses are having moderate access to information and
average access to resources. Further higher levels of workplace empowerment were
positively correlated with perceptions of autonomy control over practice environment,
collaboration with physicians within the work setting, and organizational
support/trust. Similarly, higher levels of empowerment were positively related to
nurses’ job satisfaction (Kretzschmer, Walker, Myers, Vogt, Massouda, Gottbrath &
Logsdon, 2017). The strongest significant predictors of empowerment were the
physician-nurse relationship, autonomy, and organizational support/trust and the
strongest significant predictors of job satisfaction were empowerment, the physician-

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nurse relationship, and organizational support/trust. A limitation to this study is that
the survey was assigned through the organization’s learning management system.
This methodology could possibly have skewed the perception of anonymity.
Another study published by Emily Read & Heather Laschinger examined the
effects of authentic leadership, structural empowerment and relational social capital
on the mental health and job satisfaction of new graduate nurses over the first year of
practice (Laschinger & Fida, 2015). A longitudinal survey design was used to test the
hypothesized model. The study demonstrated that the effect of authentic leadership on
new graduate nurses’ perceptions of relational social capital on their work unit was
fully mediated through structural empowerment, highlighting the important role that
nurse managers play in shaping the context of the workplace. In addition to this new
graduate nurses’ perception of positive workplace relationships (relational social
capital) were related to fewer mental health symptoms and greater feelings of job
satisfaction over the first year of practice(Laschinger & Fida, 2015). The results of
this study supported a model suggesting that authentic leaders create structurally
empowering work environments which in turn positively influences new graduate
nurses’ relational social capital in the workplace.
New graduate nurses experiencing a strong sense of community, an important
type of relational social capital, were also found to experience fewer mental health
symptoms and higher job satisfaction 1 year later. The main limitation of this study is
attrition from Time 1 (n = 342)–Time 2 (n = 191) which may have introduced non-
response bias that influenced our findings (Laschinger & Fida, 2015). Retention of
nurses to ensure high-quality patient care (HQPC) is a worldwide priority in current
healthcare settings.

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With many nurses approaching retirement, every effort must be made to
ensure that nurses’ work environments foster optimal professional practice, thereby
promoting job satisfaction and discouraging thoughts of leaving the profession.
Laschinger & Fida in their study proposed a theoretical model linking authentic
leadership to supportive practice environments and, subsequently, to nurse-assessed
patient care quality (NAPCQ) and job satisfaction (Laschinger & Fida, 2015). This
cross-sectional study was carried on 723 Canadian nurses and tested the hypothesis
using structural equation modeling. The results supported the hypothesized model
linking authentic leadership to nurses’ perceived structure empowerment and support
for professional practice and their subsequent ratings of patient care quality and job
satisfaction. This study imparted empirical support for a more widespread explanation
of how leaders may motivate nurses’ perceptions of patient care quality and,
ultimately, satisfaction with their jobs by creating empowering professional practice
environments.
The primary limitation of this study was cross-sectional study design which
precludes strong statements of causality. Common method variance was also one of
the limitations where the data were collected using self-report measures from the
same individuals at the same time (Laschinger & Fida, 2015).A cross-sectional
national survey of Canadian new graduate nurses conducted by Laschinger HKS et al
tested a model linking authentic leadership, areas of work life, occupational coping
self-efficacy, burnout, and mental health among new graduate nurses (Laschinger &
Fida, 2015). This study was intended to see the effect of authentic leadership, person-
job fit within areas of work life, and occupational coping self-efficacy on new nurses’
burnout and emotional wellbeing. A total of 1009 of 3743 surveyed new graduate
nurses were included in the final sample (useable response rate 27%).

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The findings of this study reported that authentic leaders play an important
role in creating working conditions that optimize the match between new graduate
nurses’ expectations and the reality of the work environment (AWL match) and
strengthen new nurses’ confidence in their ability to cope with the demands of their
jobs, thereby protecting them from burnout development and poor mental health.
Also, the study suggested an expanded model of burnout recently proposed by
Laschinger and colleagues (2015) incorporating interpersonal strain at work in
addition to emotional exhaustion and cynicism provides a more comprehensive
description of new graduate burnout. The primary limitation of this study was cross-
sectional nature of the study design, common method variance, lower response rates
which limited the generalizability to some extent.

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CHAPTER 3 METHODOLOGY
2.1. Sample of the Study:
2.1.1. Research Design:
Cross-sectional study design which is a type of observational study will be used in the
present study. This research tool is used to acquire outcome and exposure of subject
established on data collected for a specific point in time. Inclusion and exclusion
criteria are used in order chose the subject in this type of study design prior to which
the subjects will be informed of the purpose and goals of the study (Yun & Kang,
2018). They will be informed about the time that will be required to fill the
questionnaire and also the voluntary nature of the study where the participants
enrolled in the study can withdraw them out of the study at any time, they feel they
are not comfortable. The importance of consent to participate in the study in
conformity with an ethics and preservation of confidentiality of data will also be
explained to them.
2.1.2. Sample of Study:
This study will be conducted in King Khaled Hospital, Majmaah with a total bed
capacity of 225 beds. The number of nursing staff working in this hospital is around
234 including 1 nursing director, 1 deputy nursing director, 12 nursing supervisors,
and 14 head nurses. Nursing managers including the directors, supervisors and head
nurses will be recruited to participate in the present study.
2.1.3. Sampling Design:
In the present study, a non-probability type of sampling technique, that is
Convenience sampling will be used. The reason being its easy access to participants.

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Informed consent will be obtained from the staff nursing for participating in the
present study.

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2.1.4. Sample Size
Following sample size formula is used in the present study
Sample size ¿ Z1−∝/22 p (1-p)
d2
Here Z1−∝/ 2 is standard normal variate (at 5% type I error (p<0.05) it is 1.96 and at 1%
type I error (P<0.01) it is 2.58. As in majority of studies P values are considered
significant below 0.05 hence 1.96 is used in formula.
P is expected proportion in population based on previous studies or pilot studies.
D is absolute error or precision – has to be decided by researcher.
The estimated target population size in King Khaled Hospital, Majmaah is 234, with
5% margin of error and 0.01 Alpha level (t-value 2.58), in our study, therefore the
sample size will consist of 146 nurses.
2.1.5. Inclusion and exclusion criteria
The inclusion criteria for the nurses in this study will be that they should have worked
more than three months at their current hospital; exclusion criteria will be to eliminate
those who had not passed the probation period even after 3 months.
The inclusion criteria for the nursing manager will be to include those having
experience of 3 years in managing nursing administration. Exclusion criteria of
nursing manager will be to exclude those having experience of less than 3 years and
those with physical disability and psychological ailments
2.1.6. Research Instruments:
Standardized self-reported questionnaires with acceptable reliability (Cronbach’s
alpha) will be used to measure each of the main study variables.

25
Authentic leadership Questionnaire (ALQ).
The Authentic Leadership Questionnaire (ALQ) will be used to measure nurses’
perceptions of managers’ authentic leadership (Avolio, Wernsing & Gardner, 2018).
The ALQ (Regan S, 2016) consist of 16 items scale categorized into four dimensions
that reflects the components of authentic leadership: Self-awareness (e.g. my leader
seeks feedback to improve interactions with others) (four items), moral/ethical
conduct (e.g. my leader demonstrates beliefs that are consistent with actions) (four
items), balanced processing (e.g. My leader solicits views that challenge their deeply
held positions) (three items), and relational transparency (e.g.my leader says exactly
what they mean (five items). These 16 items are further assessed on 5-point Likert
scale varying from 0 (not at all) to 4 (frequently, if not always). Total AL score will
be finally calculated by taking an average of this scale. Previous studies have reported
the Acceptable internal consistency as evidenced Cronbach’s α-coefficient ranging
from 0.70 to 0.90. Confirmatory factor analysis has supported the four dimensions of
the ALQ (Regan S, 2016).
Areas of work life
The Areas of Work life Scale (AWS) consist of 29 items that measures person–job
match or congruence in six areas of work life: workload (e.g. do not have time to do
the work that must be done; six items), control (e.g. I have control over how I do my
work; three items), rewards (e.g. My work is appreciated; four items), community
(e.g. I am a member of a supportive work group; five items), fairness (e.g.
Management treats all employees fairly; six items) and values (e.g. My values and the
organization’s values are alike; five items) (Brom SS, 2015). Each item is further

26
measured on a 5-point Likert scale with ratings from 1 (strongly disagree) to 5
(strongly agree). A person–job match is evaluated by a score >3.0 (Brom SS, 2016).
A total AWS score will be created to represent the overall degree of person–job match
in the six areas of work life by taking an average of the six subscale means of the
AWS (possible score range of 6–30). Acceptable Cronbach alpha values have been
reported for the AWS ranging from 0.70 to 0.82 (Brom SS, 2016).
Measures of Nurse-Assessed Patient Care Quality
Nurse-assessed patient care quality will be measured using a single item “How would
you describe the quality of nursing care delivered to patients in your unit?” rated on a
4-point Likert scale ranging from excellent, good, fair, or poor. This measure has
good predictive validity and corresponds well with hospital quality indicators such as
mortality, failure to rescue, and patient satisfaction (Gasparino, Ferreira, de Carvalho,
Rodrigues, Tondo & da Silva, 2019). To create a positive measure of patient care
quality, the item will be reverse scored. As an additional measure of NAPCQ, nurses
responded to the question “In the last month, how often has short-staffing affected
your ability to meet your patient/clients’ needs? The item is rated on a 5-point scale,
ranging from 1 = never, 2 = monthly, 3 = weekly, 4 = several times a week, and 5 =
daily.
Nurse-assessed adverse patient outcomes
Nurses’ views regarding adverse patient outcomes will be measured using an
instrument developed by Sochalski (2001) and derived from the American Nurses
Association (ANA) Nursing Quality Indicators (American Nurses Association (ANA)
2000). This scale comprises four items that assess nurses’ perceptions of the incidence
of common adverse patient outcomes over the past year. Nurses rates the frequency of

27
occurrence of medication errors, nosocomial infections, complaints from the patient
and/or family as well as patient’s fall with injuries on a scale from 1 (never) to 4
(frequently). An overall score will be computed by averaging all four items. This
scale has been used extensively in large national studies of nurses (Schweitzer,
Martini, Wood, Mayer, Straka, Bonnano & Christy, 2017).
2.1.7. Data collection
A self-administered mode of obtaining data will be used in the study which ensures
the privacy of responses given by participants. Data collection will be done after
receiving approval to conduct the study from the research/ethical committee and the
administration of King Khaled Hospital, Majmaah and also after the participants is
fully satisfied of their role in participating in such kind of study. They will also give
their written consent to participate in this study.
Data Analysis:
Data will be entered in excel which shall be further transported to Statistical Package
for the Social Science (SPSS) version 24 for statistical analysis. Data will be checked
for aberrant values and missing values. Normality of data will be checked for all the
variables of interests. Frequencies, percentage, means, and standard deviations will be
used to describe the descriptive characteristics of demographic variables. So as to
explore any significant changes in the responses of nurses grounded on their
demographic profiles, ANOVA and t-tests will be used.
Qualitative data will be tested for any possible association through Chi-squared test.
Inferential analysis will be done for multiple choice questions in the questionnaire and
Likert scale. Finally, the correlation between the variables will be done using

28
Pearson’s correlation coefficient (r). A p-value of p<0.05 will considered as level of
significance.
Ethical Consideration
The study will be conducted only after taking Ethical Approval from Ministry of
Health Institutional Ethical Committee. Further, permission will be taken from
Ministry of Health, KSA and explaining them their contribution in achieving the aims
of the present study.
Participant enrolled in the study will be made aware of the fact that all the data that
they fill in the questionnaire will be highly confidentiality and will not be used other
than this study. A numerical code will be assigned to each of the nursing staff enrolled
in the study to ensure the anonymity of their participation.
2.1.8. Limitations of the Study
First limitation to this study shall be its nature being cross-sectional. This type of
study cannot be used to investigate behavior over a period to time and does not help to
determine cause and effect. Second inherent limitation of this type of self-reported
questionnaire is common method variance.
Common method biases create a conflicting explanation for the correlation examined
between the measures. Further concern to this study is regarding generalizability of
the findings which totally depends upon response rate and if it is inadequate, we
won’t be able to generalize of results. Finally, small sample size cohort could also be
a limitation for generalizing the results.

29

30
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APPENDICES
Appendix I: Characteristics of the Nurses

35
Age
Gender Male Female
Marital status
Married Divorced
Unmarried Widowed
Highest Degree
Diploma
BSN
MSN
Nonnursing master's degree
Years in Nursing 1-5 Years More than 5 years
Years at Current
Organization
1-5 Years More than 5 years
Years at Current Unit 1-5 Years More than 5 years
Years reporting to current
Manager
1-5 Years More than 5 years
Job Rank
General Nurse Nursing Director
Nursing Clinical
Coordinator
Nursing Manager
Certification in Nursing
Leadership
Yes No
Current Employment status
Full Time
Part Time
Casual
Employment Type
Permanent
Contractual
Specialty area Medical–surgical Maternal–child

36
Emergency
Ambulatory care OR/PACU
Critical care Mental health
Hours Worked (week)
<20 hours
20-39 hours
Over 39 hours

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Appendix II: Authentic Leadership Self-Assessment Questionnaire
Created by Walumbwa and associates
1 2 3 4 5
Self-Awareness
1
I can list my three greatest
weaknesses.
2 I can list my three greatest strengths
3
I seek feedback as a way of
understanding who I really am as a
person
4
I accept the feelings I have about
myself
Internalized moral perspective
5 My actions reflect my core values
6
I do not allow group pressure to
control me
7
Other people know where I stand on
controversial issues.
8
My morals guide what I do as a
leader.
Balance Processing
9
I seek others' opinions before
making up my own mind
10
I listen closely to the ideas of those
who disagree with me.

38
11
I do not emphasize my own point of
view at the expense of others.
12
I listen very carefully to the ideas of
others before making decisions.
Relational Transparency
13
I openly share my feelings with
others
14
I let others know who I truly am as a
person
15
I rarely present a "false" front to
others
16 I admit my mistakes to others.
Key: 1 = Strongly disagree 2= Disagree 3= Neutral 4=Agree 5=Strongly agree
Summation of 1-16 = Authentic
Leadership Score
Authentic Leadership very high if 64-80
Authentic Leadership high if 48-64
Authentic Leadership low if 32-48
Authentic Leadership very low if 16-32

39
Appendix III. Areas of Work life scale Questionnaire
1 2 3 4 5
Workload
1
I do not have time to do the work that
must be done.
2
I work intensely for prolonged periods
of time.
3
I have so much work to do on the job
that it takes me away from my personal
interests.
4
I have enough time to do what’s
important in my job.
Control
5 I have control over how I do my work.
6
I can influence management to obtain
the equipment and space I need for my
work.
7
I have professional
autonomy/independence in my work.
8
I have influence in the decisions
affecting my work.
9
I have input into policies and
procedures in my work unit.
10
I have control over how my work is
evaluated.

40
Rewards
11
I receive recognition from others for
my work.
12 My work is appreciated.
13 My efforts usually go unnoticed.
14
I do not get recognized for all the
things I contribute.
Community
15
People trust one another to fulfill their
roles.
16
I am a member of a supportive work
group.
17
Members of my work group cooperate
with one another
18
Members of my work group
communicate openly.
19
I don’t feel close to my colleagues.
Fairness
20 Resources are allocated fairly here.

41
21
Opportunities are decided solely on
merit.
22
There are effective appeal procedures
available when I question the fairness
of a decision.
23
Management treats all employees
fairly.
24
Favoritism determines how decisions
are made at work.
25
It’s not what you know but who you
know that determines a career here.
Values
26
My values and the organization’s
values are alike.
27
The organization’s goals influence my
day to day work activities.
28
My personal career goals are consistent
with the organization’s stated goals.
29
This organization is committed to
quality.
30
Working here forces me to compromise
my values.
Key: 1 = Strongly disagree 2= Disagree 3= Neutral 4=Agree 5=Strongly agree

42

43
Appendix IV. Measures of nurse assessed patient care quality and its outcome
Measures of Nurse-Assessed Patient Care Quality
How would you describe
the quality of nursing
care delivered to patients
in your unit?
Excellent Good Fair Poor
In the last month, how
often has short-staffing
affected your ability to
meet your patient/clients’
needs?
Never Monthly Weekly
Several
times a
week
Daily
Measures of Nurse reported patient outcomes
Medication errors
Sometimes
Often
Observed
Others
Patient falls
Sometimes
Often
Observed
Others
Nosocomial infections
Sometimes
Often
Observed
Others
Hospital acquired
Critical incidents
Sometimes
Often
Observed
Others
Pressure ulcers
Sometimes
Often
Observed
Others

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Research timeline (Gantt chart)
Research Activity Nov-2019 Dec-2019 Jan-2020 Feb-2020 Mar-2020 Apr-
Develop Research
Proposal
&discussion with
supervisor
Literature review
conducting the
survey
Data presentation
Analyzing data
Writing conclusions
Finishing first draft
Addressing
feedback of
supervisor

45
Completing study 16
4
202