The Relationship Between Engagement and Charge Nurse Manager Leadership, the Leadership Relationship, Practice Environment and Patient Outcomes
Aim. To explore the effects of leadership style, unit level supervisor/subordinate relationships, and perceived organisational support on engagement and unit level patient outcomes. Background. Senior managers are under pressure to pursue high-quality, patient-focused care and seek opportunities to intervene and improve care delivery. As nursing’s contribution to quality gains international importance, a body of research that focuses on the relationship between staff engagement and patient outcomes is emerging. Schaufeli et al.’s (2004) definition of work engagement provides a frame for investigation in that it provides a “positive, fulfilling, work-related state of mind that is characterised by vigour, dedication, and absorption” (p. 295). Much of the literature investigating the drivers and impacts of engagement has focused on the impact on staff. There is a gap in the research that investigates the relationship between engagement and resonant leadership, the quality of leader-member relationships, perceived organisational support and patient outcomes. The research takes an objective epistemological position by hypothesising that leadership style, quality of relationships, and perception of support impact both nurse engagement and patient outcomes. Exploration of the relationships among the constructs is consistent with Social Exchange Theory, where interactions lead to obligations, which are interdependent and contingent on one another. A post-positivist perspective, in this context, reflects the objective existence of meaningful reality and that outcomes of research are not certain or totally objective. Method. The research involved a cross sectional survey at an urban District Health Board among a population of 956 nursing and clerical staff contributing to unit level quality outcomes on 20 medical/surgical inpatient wards, and unit level institutional nurse-sensitive outcome data. Exploratory and confirmatory analysis was undertaken prior to assessing the measurement model for goodness-of-fit and discriminant and convergent validity. Tests for common-method bias were undertaken, and the data were tested using structural equation modeling. Path and mediation analyses were undertaken. Results. The primary hypothesis that engagement mediates the positive relationship between resonant leadership, exchange relationships, organisational support, and perceptions of unit care quality, and the negative relationships with patient outcomes (falls) and patient experience (Friends and Family Test) was supported. Three further mediated paths were identified which bypassed engagement. Nine direct path hypotheses were also supported. Discussion. Five key findings were identified: (i) the primary hypothesis was supported, (ii) resonant leadership is confirmed as the starting point for improving patient outcomes and patient satisfaction, (iii) all indirect paths were mediated by perceptions of unit care quality and falls rates, (iv) social exchanges are evident as perceptions of unit care quality is a core element of all indirect paths, and (v) both perceived organisation support and leader-member exchange are confirmed as antecedents of engagement when investigating institutionally collected ‘falls’ and ‘friends and family test’ nurse-sensitive indicators. The exploratory nature of the research using available institutional nurse-sensitive indicator data for pressure injuries, complaints, and fundamentals of care resulted in hypotheses related to these three indicators not being supported. Conclusion. The research demonstrated that resonant leadership is a relational leadership style, which is positively associated with staff and patient experience, and patient outcomes. A real world problem for nurse leaders was investigated, that is, to identify modifiable factors to improve quality outcomes. As a result, the findings have significance for being able to improve how people feel about the experience of their care, as well as the ability to improve the safety of care.