Assessing the Effectiveness of Leadership Styles among Nurses in Tertiary Hospitals of Peshawar

Background: The healthcare sector increasingly recognizes the importance of leadership styles in shaping the work environment, employee satisfaction, and patient care outcomes. Leadership within nursing teams, particularly in tertiary hospitals, plays a crucial role in addressing the challenges of healthcare delivery and staff retention. The diversity in leadership styles—authoritarian, democratic, and laissez-faire—offers various approaches to managing nursing teams and influencing healthcare outcomes. Objective: This study aimed to assess the prevalence of different leadership styles among nurses working in tertiary hospitals in Peshawar and to explore their impact on nursing practice and healthcare delivery. Methods: A cross-sectional study design was employed, involving 240 nurses from Khyber Teaching Hospital and Lady Reading Hospital in Peshawar. Participants were selected using a convenience sampling technique. A structured questionnaire, comprising socio-demographic items and leadership style assessments, was utilized for data collection. Statistical analysis was conducted using SPSS version 25, focusing on frequencies, percentages, means, and standard deviations to evaluate the distribution of leadership styles. Results: The majority of participants reported a high range of authoritarian (44.2%), democratic (44.2%), and laissez-faire (46.3%) leadership styles. The prevalence of very high range was significant for authoritarian (43.3%) and democratic (40%) styles, indicating a strong inclination towards these leadership approaches among nursing staff. The study also highlighted a positive association between democratic leadership styles and job satisfaction among nurses.


INTRODUCTION
The significance of leadership within the nursing domain, particularly in tertiary hospitals, cannot be overstated, given its crucial role in shaping healthcare outcomes and the professional development of nursing staff.The landscape of healthcare is fraught with challenges that necessitate effective leadership to navigate.This is particularly true in the context of Peshawar, where nursing professionals are at the forefront of delivering healthcare services.The ability of nursing leaders to influence decision-making processes, prioritize healthcare interventions, and allocate resources efficiently is essential for achieving health objectives and addressing the myriad of challenges facing the healthcare system (1).The prevailing shortage of nursing staff, exacerbated by a lack of leadership and administrative skills, poses a significant barrier to enhancing the quality of care, expanding healthcare services, and achieving global health targets, including the Millennium Development Goals (2).Addressing these challenges is imperative for advancing towards the 2030 Sustainable Development Goals.It necessitates a concerted effort from national nursing leaders worldwide to devise strategies for sustainable development.Such strategies should focus on advancing nursing science, developing nursing education, promoting industrial nursing, and improving public health outcomes.This collective effort is crucial for mitigating the global nursing staff shortage and enhancing healthcare delivery (3).The role of nursing leaders extends beyond clinical care to encompass operational excellence across various healthcare settings.Their leadership is instrumental in creating conducive work environments that foster teamwork and effective communication among healthcare staff (4).The advancement of the nursing profession, therefore, hinges on leadership that is participative, positive, and capable of influencing nursing staff towards achieving organizational goals and delivering quality patient care (6).Effective communication between leaders and their subordinates is pivotal for clarifying tasks, reducing ambiguities, and providing emotional and professional support.Such communication fosters a supportive work environment, conducive to professional development and high-quality patient care (7).Leadership qualities in nursing not only enhance staff performance but also contribute to the psychological well-being of the nursing team, thereby reducing turnover rates (8).Despite these benefits, nursing leaders often face challenges in conflict resolution and leadership execution, with a tendency to focus on task completion over delegation and subordinate relationship-building.This issue is compounded by high workloads, which further strain leadersubordinate relationships (9)(10)(11)(12).The rationale for this study lies in the critical need to assess the effectiveness of leadership styles among nurses in tertiary hospitals in Peshawar.Understanding these leadership styles is vital for multiple stakeholders, including healthcare organizations, patients, and the nursing community at large.Insights from this study could inform policy development aimed at enhancing leadership competencies among nurses, thus improving healthcare outcomes and staff retention.The primary objective of this research is to evaluate the effectiveness of leadership styles among nurses in a tertiary hospital setting in Peshawar.This involves exploring how these leadership styles impact nursing practice, patient care, and the overall healthcare delivery system.In pursuit of this aim, a comprehensive literature review was conducted using narrative review methodology to critically appraise existing research on nursing leadership.This review utilized major databases such as Google Scholar, PubMed, and CINAHAL, focusing on studies published within the last five years.The literature search employed keywords related to leadership styles and nursing, ensuring a focused and relevant collection of studies for analysis.The critical review of the literature reveals a diverse array of leadership styles employed by nursing leaders, with a significant emphasis on leader-member exchange and its impact on employee engagement and performance.High-quality leader-member interactions were associated with better performance outcomes and reduced intentions to leave, underscoring the importance of leadership in fostering workplace engagement and organizational culture (14,15).Moreover, the literature highlights the role of social exchange in encouraging proactive behavior among staff, with leadership styles significantly predicting creativity, voice, and innovative behavior (16).Key elements of effective leadership include interpersonal support, a sense of achievement, and the provision of resources and flexibility, all of which contribute to a positive and productive work environment (17).In summary, the literature underscores the complexity of leadership in nursing, with varying styles contributing differently to healthcare outcomes.This study aims to build on this foundation by examining the effectiveness of these leadership styles in the specific context of tertiary hospitals in Peshawar, providing valuable insights for policy formulation and leadership development in nursing.

MATERIAL AND METHODS
This study employed a cross-sectional design to assess the effectiveness of leadership styles among nurses at Khyber Teaching Hospital and Lady Reading Hospital in Peshawar.Conducted over a two-month period following institutional approval, the research aimed to provide a comprehensive understanding of leadership dynamics within these healthcare settings.The sample size was meticulously calculated using an online calculator, based on a confidence interval of 95% and a margin of error of 5%.This calculation suggested a target sample of 240 participants, informed by previous research findings in the field (6).A convenience sampling technique was employed to select participants, focusing on nurses actively working in the specified hospitals who expressed willingness to participate.Exclusion criteria were clearly defined to omit student nurses and those on leave from the study, ensuring a focus on currently practicing nursing professionals.Data collection was facilitated through a structured questionnaire divided into two sections.The first section gathered sociodemographic information from the respondents, while the second section comprised eighteen questions dedicated to leadership self-assessment.This methodological approach was chosen to capture a broad spectrum of leadership attributes and behaviors among the nursing staff.Prior to data collection, necessary approvals were secured from both the academic institution and the hospitals' administration.Ethical considerations were paramount throughout the research process.Approval from the ethical review board was obtained, underscoring adherence to ethical standards in research.Moreover, the study conformed to the Helsinki Declaration guidelines, ensuring the protection of participants' rights and well-being.Participants were informed about the study's objectives, and consent was obtained before the commencement of data collection.Confidentiality was assured to all participants, with a guarantee that data would only be accessible to the research supervisor.Data were collected directly from the nurses through the distribution of questionnaires in various units of the hospitals.This process was conducted with utmost respect for the participants' time and professional commitments.The collected data were then analyzed using SPSS version 25, allowing for a detailed examination of frequencies, percentages, means, and standard deviations of the variables of interest.This statistical analysis provided a robust framework for understanding the leadership styles prevalent among nurses in the study setting and their implications for nursing practice and healthcare delivery.

DISCUSSION
In the conducted study, a significant proportion of participants demonstrated a preference for high to very high ranges across authoritarian, democratic, and laissez-faire leadership styles, with 44.2% reporting high authoritarian, 44.2% high democratic, and 46.3% high laissez-faire leadership styles.These findings suggest a diverse array of leadership dynamics among nurses in tertiary hospitals in Peshawar, echoing the complexity and adaptability required in nursing leadership roles.Previous studies have underscored the importance of a leader's style in shaping communication and interactions with subordinates, indicating that no singular leadership style is universally effective across all contexts (20,21).This aligns with the notion that nurse managers often adopt multiple leadership philosophies, tailoring their approach to fit the unique needs of their employees, situational demands, and organizational objectives (22,23).The significance of effective leadership in nursing cannot be overstated, particularly in terms of its impact on employee satisfaction.The current study's findings resonate with existing research indicating that leadership style significantly influences job satisfaction among nurses.Specifically, studies have shown that leadership styles more aligned with the preferences and needs of the nursing staff lead to higher levels of job satisfaction (24,25).This is further supported by evidence suggesting that the leadership style of nurse managers, rather than socio-demographic factors, predominantly contributes to nurses' job satisfaction levels (26,27).Moreover, democratic leadership styles, characterized by participative decision-making, delegation of authority, and open feedback channels, have been identified as particularly effective within the nursing domain.This approach not only facilitates a collaborative work environment but also fosters professional development among nursing staff by leveraging leadership skills to encourage shared responsibilities in patient care (28,29).Such findings are corroborated by research from Putri et al., which highlighted the significant impact of autocratic, democratic, and laissez-faire leadership styles on employee job satisfaction, with democratic leadership exerting the most profound influence (30).Similarly, Maryanto et al. found a positive correlation between democratic leadership styles and job satisfaction among nurses in a private hospital setting, further emphasizing the preference for democratic leadership in nursing practice (31).Despite these insights, the study faced several limitations, including time constraints that affected the breadth of data collection and the participation rate of nurses, potentially influencing the comprehensiveness of the findings.Additionally, the focus on tertiary hospitals in Peshawar limited the generalizability of the results, suggesting a need for broader research across multiple healthcare settings to fully understand the impact of leadership styles on nursing practice and outcomes.Given these considerations, the study underscores the nuanced relationship between leadership styles and nursing practice, highlighting the critical role of leadership in enhancing administrative efficiency and employee satisfaction.It recommends that healthcare departments prioritize leadership development among nurses to bolster their capabilities and adaptability in various healthcare contexts.Furthermore, nurses themselves should be encouraged to reflect on and enhance their leadership qualities to better meet the demands of their roles.Future research should aim to include a more extensive sample size and a wider array of healthcare settings to provide a more comprehensive understanding of leadership dynamics in nursing.

CONCLUSION
The study elucidates the diverse leadership styles-authoritarian, democratic, and laissez-faire-prevalent among nurses in tertiary hospitals in Peshawar, revealing a significant inclination towards high to very high ranges in these styles.This diversity underscores the complexity of nursing leadership and its pivotal role in shaping healthcare delivery and staff satisfaction.The findings suggest that embracing a flexible leadership approach, tailored to the situational and organizational context, can enhance job satisfaction and operational efficiency in healthcare settings.Consequently, the development and encouragement of adaptive leadership skills among nurses are imperative for improving healthcare outcomes, suggesting a critical area for policy development and educational focus within healthcare institutions.

Table 1 :
Socio-Demographic Profile of Participants