contextualization and standardization of the supportive...

Original Articlehttp://mjiri.iums.ac.ir Medical Journal of the Islamic Republic of Iran (MJIRI)

Iran University of Medical Sciences

____________________________________________________________________________________________________________________1. (Corresponding author) Assistant Professor Educational Development Center (EDC), Faculty of Medicine, Tehran University of MedicalSciences, Tehran, Iran & Affiliated Assistant Professor of LIME and Clinical Education Science Departments, Karolinska Institute, [email protected]. MD, Oncologist- Associate Professor, Faculty of Medicine, Tehran University of Medical Sciences, Imam Khomeini Hospital, Tehran, [email protected]. MD, Msc Ed Director of Educational Development Center (EDC), Faculty of Medicine, Sabzevar University of Medical Sciences, Sabzevar,Iran. [email protected]. PhD in Epidemiology, Faculty of Medicine, Bojnord University, Bojnord, Iran. [email protected]. MD, PhD Candidate Deputy of Research at Qom University of Medical Sciences, Iran. [email protected]. MSc, Nursing in Critical Care Nursing and Midwifery Care Research Center, Tehran University of Medical Sciences, Tehran, [email protected]. Associate Professor Director Klinicum, Soder Hospital, Karolinska Institute, Sweden. [email protected]

Contextualization and standardization of the supportive leader-ship behavior questionnaire based on socio- cognitive theory in

Iran

Mandana Shirazi1, Amir Hosein Emami2 ,Seyed Jamal Mirmoosavi3, Seyed Moham-mad Alavinia4, Hadi Zamanian5, Faezeh Fathollahbeigi6, Italo Masiello7

Received: 10 November 2013 Accepted: 26 February 2014 Published: 8 November 2014

AbstractBackground: Effective leadership is of prime importance in any organization and it goes through changes

based on accepted health promotion and behavior change theory. Although there are many leadership styles,transformational leadership, which emphasizes supportive leadership behaviors, seems to be an appropriate stylein many settings particularly in the health care and educational sectors which are pressured by high turnover andsafety demands. Iran has been moving rapidly forward and its authorities have understood and recognized theimportance of matching leadership styles with effective and competent care for success in health care organiza-tions. This study aimed to develop the Supportive Leadership Behaviors Scale based on accepted health andeducational theories and to psychometrically test it in the Iranian context.

Methods: The instrument was based on items from established questionnaires. A pilot study validated the in-strument which was also cross-validated via re-translation. After validation, 731 participants answered the ques-tionnaire.

Results: The instrument was finalized and resulted in a 20-item questionnaire using the exploratory factoranalysis, which yielded four factors of support for development, integrity, sincerity and recognition and explain-ing the supportive leadership behaviors (all above 0.6). Mapping these four measures of leadership behaviorscan be beneficial to determine whether effective leadership could support innovation and improvements in med-ical education and health care organizations on the national level. The reliability measured as Cronbach’s alphawas 0.84.Conclusion: This new instrument yielded four factors of support for development, integrity, sincerity andrecognition and explaining the supportive leadership behaviors which are applicable in health and educationalsettings and are helpful in improving self –efficacy among health and academic staff.

Keywords: Contextualization, Socio- cognitive Theory, Standardization, Supportive Leadership Behavior Ques-tionnaire.

Cite this article as: Shirazi M, Emami A.H, Mirmoosavi S.J, Alavinia S.M, Zamanian H, Fathollahbeigi F, Masiello I. Contextualizationand standardization of the supportive leader-ship behavior questionnaire based on socio- cognitive theory in Iran. Med J Islam Repub Iran2014 (8 November). Vol. 28:125.

IntroductionThere are many leadership styles used by

effective leaders, but two of the most com-mon approaches are transactional and trans-

formational styles. These styles are seen ina wide range of domains such as politics,business, education, sport, law (1), healthsystem, nursing and police work (2). Trans-

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http://mjiri.iums.ac.ir/article-1-2523-en.html

Contextualization and standardization of the supportive leader-ship behavior…

2 MJIRI, Vol. 28.125. 8 November 2014http://mjiri.iums.ac.ir

actional leadership is identified by a senseof duty based on reward and punishment toreach goals (3). In this style, emphasis isput on the interaction between leaders andtheir subordinates, asserting a sense of self-worth in the followers. Transformationalleadership focuses on shaping change byemphasizing supportive leadership behav-ior (SLB) (4, 5) for which people feel in-spired and committed. Leaders who makeuse of SLB show concern for followers’needs, consideration and understanding,trust and respect, friendship and encour-agement, and they help followers developtheir abilities and careers. The transforma-tional leadership approach leans toward asearch of subordinates’ happiness (6).Based on the findings of some research inthe healthcare sector and nursing, it isnoteworthy to mention that transformation-al leadership styles can reduce work-lifeconflict(7), increase staff job satisfaction(7,8) and psychological wellbeing (7) andresult in effectiveness and better leadershipoutcomes (9).

There is no one “right” way to lead in away that fits all situations, but the imple-mentation of transformational leadershipand of SLB can be appropriate in many cir-cumstances. This may become apparent inthe current health care sector, which ispressured by a global shortage of healthcare workers, demanding patients and fiscalconstraints. Employees are being asked todo more than ever before: making sugges-tions for continuous improvement, handlingcomplex problems quickly, and takinggreater responsibilities on the front linewhile the resources and support are beingdecreased. Due to the standardization ofcompetences and globalization, in generalemployees do not tend to remain at thesame job for their entire working career.Employees' loyalty has therefore shifteddramatically since the 60’s and 70’s (6).Employees bring value to the customer,especially in the health care system whereeffective quality care is promised and of-fered to the patient (6).Therefore, to keep acompetent staff, which thrives and delivers

effective quality patient care, leaders ofhealth system organizations ought to makeuse of SLB (10). In one study conducted innursing homes, a large number of nursesleft their job because of insufficient com-munication skills, weak teamwork and non-supportive leadership in their workplace. Inthat study, it was revealed that the annualaverage turnover rate of the nurses was be-tween 70% and 100%. Furthermore, it wasdemonstrated that this problem reduced thequality of care (11). Therefore, it was sug-gested that a supportive work environmentbe developed to solve this dilemma (11);other researchers also found the same re-sults (8, 12).

Transformational leadership consequenc-es on health sector call for more attention,and training should be provided based onkey leadership competencies (8, 13). Due tothe significant effect of leadership on healthprofessions with the increasing complexi-ties of medical education, leadership stylesand their development have become in-creasingly important in medical education(14). Multiple studies have developed orresearched many courses, programs, curric-ula, etc., to promote leadership styles inmedical education (15-19).

The current Iranian research on leadershipstyle and its effects on subordinates revealsthat task-oriented behavior is the dominantstyle among Iranian leaders in the healthcare and educational systems (11). Thisstyle focuses on accomplishment and in-creases the rate of subordinates’ burn out(20). Research shows that in the field ofmedical education and health care, Iranianleaders should apply cooperative learningto improve critical thinking among theirstaff. Leaders should be able to encouragenew ideas to promote the organizationaloutcomes, improve learning abilities, leadchange and spur innovation among them-selves and their followers (20).

Assessing the effects of SLB on subordi-nates' satisfaction and performance hasprovided valuable data for the health careadministration in recent years, and it hashad a tremendous effect on the quality of

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M. Shirazi, et al.

3MJIRI, Vol. 28.125. 8 November 2014 http://mjiri.iums.ac.ir

health care services (21, 22). In Iran, as inmany other developing countries, employ-ees are suffering from lack of supportiveleadership (un- published data). More re-search on supportive leadership is neededto promote supportive leadership styles es-pecially in healthcare and educational or-ganizations, which need a valid and reliabletool to assess leaders' performance. Theavailable instruments in the world may notbe appropriate to assess SLB and its' corre-lation with educational theory in the Iraniancontext, and therefore developing a newinstrument in this field is a serious demand.The aim of this study was to develop a val-id tool for assessing supportive behavioramong leaders by standardizing and devel-oping the Iranian version of a SLB instru-ment for nurses through a cross-sectionaland correlation study using factor analysis.

MethodsDesignThis cross-sectional, correlational study

consisted of a pilot study followed by thefirst phase of a randomized control trial(RCT) to develop and validate a question-naire, which on a national level determineswhether effective supportive leadershipcould maintain innovation and improve-ments in medical education institutions andhealth care organizations. The study wasconducted between June 2009 and Novem-ber 2010. The pilot study was conducted inJune 2009 while the data for the first phaseof the study were collected in September2009 after the pilot study. Both phases ofthe study had been approved by The EthicalCommittee of Tehran University of Medi-cal Sciences, Tehran, Iran. All participantswere informed about the study and its aims,and they participated in the project volun-tarily.

Development of the QuestionnaireThe first step in the development of the

questionnaire items was reviewing the re-lated literature on the concept of SLB. Tothe best of our knowledge, no similar ques-tionnaire had been developed in Iran.

Therefore, from the field of behavioralleadership, relevant SLB questions wereextracted from the three different question-naires of Developmental Leadership (DL),Hersey and Blanchard's Situational theory(HBS) and Ohio State (OSQ) (23-25); andthen they were translated to Persian. Agroup of experts, consisting of two medicaleducation specialists (MS, SJM), one man-agement specialist in education (AE), oneepidemiologist (SMA), and one researcherin the field of medical education (SJMM)assessed the first draft of the translatedquestionnaires. Questions were extractedfrom three original questionnaires (DL),(HBS) and (OSQ), which were not directlyrelevant to the supportive leadership behav-ior, but they had some questions pertain-ing to supportive leadership. The expertpanel developed and added some new SLBrelated questions to make the questionnairemore complete and comprehensible. Final-ly, the first draft of the Iranian question-naire consisting of a 50-item Likert-scalequestionnaire was developed. The face andcontent validity of the instrument was en-sured through the two rounds Delphi meth-ods, and finally the results of Delphi wasdiscussed in the expert panel and was ap-proved by the consensus of the panel. Theexpert panel consisted of ten faculty mem-bers of TUMS from different fields (medi-cal education, management, epidemiologyand psychology), who were selected basedon their specialty and availability. The re-sponses were based on a five-point scale:“completely agree”, “agree”, “Do notknow“, “disagree” and “completely disa-gree”. Scoring of each item was betweenone for “completely agree “to 5 for “com-pletely disagree”. The instrument couldyield an overall ranging from 40 to 200.

Pilot StudyThe number of the participants in the pilot

study was 20 nurses with different qualifi-cations, who were excluded from the mainsample population.

The reliability of the questionnaire was

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assessed via a test-retest approach. Thequestionnaire was answered twice by theparticipants of the pilot study and in a 10-day interval. We used Kappa as a measureof agreement between the two measure-ments. All the items with Kappa less than0.7 were excluded because the agreementwas low in those cases. The results of theassessment were discussed within the groupof experts, and the required modificationswere made accordingly. The remainednumber of the items in the questionnairewas 40, and the mean Kappa for all ques-tions was 0.86.

To ensure external validity, the question-naire was cross-validated by retranslating itto English and sending it to an authority inthe field, Gerry Larsson, to seek his advice.The content validity of the questionnairewas assessed through the experts’ consen-sus. Finally, 40 items were determined. Theinstrument could yield an overall scoreranging from 40 to 200.

The First Phase of the StudyThe first phase of the study was conduct-

ed at all 16 hospitals of Tehran Universityof Medical Sciences (TUMS, the largestUniversity located in the capital of Iran,Tehran) to determine the validity and relia-bility of the developed questionnaire. Weassessed the leadership performance of 110head nurses, including 6 subordinates foreach head nurse, making a total of 660 sub-ordinate nurses with different levels of

nursing education such as registered nursesand nurse aids (N = 621); some of the nurs-es (N = 39), however, did not agree to par-ticipate in the study (Fig. 1). The totalnumber of the participants was 731 and inorder to increase the response rate, the re-searchers visited the participants and talkedwith them about the project, and this result-ed in a response rate of 94%. We also pro-vided credit points toward ContinuingNursing Education (CNE) to all those whoanswered the questionnaire.

Statistical AnalysisTo better understand the dimensions un-

derlying the questionnaire, an exploratoryfactor analysis was conducted based onprinciple axis factoring and varimax rota-tion. This analysis was used for data reduc-tion to identify a small number of factorsthat could explain most of the variance ob-served in a much larger number of manifestvariables. The Kaiser-Meyer-Olkin (KMO)measure of sampling adequacy in factoranalysis was used. Cronbach’s Alphas werecalculated to evaluate the internal reliabilityand item homogeneity of the scales. SPSSversion 16 was used to analyze the data.

Nominating the FactorsThe expert panel, consisting of one psy-

chologist, two nursing management spe-cialists, and two medical educationalistsnominated the factors based on the contentof the questions in each domain.

Fig.1. Hierarchy of nursing samples in the study

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ResultsKMO showed that 95% of the variance

was caused by 5 underlying factors with anEigen value larger than one: 15.31, 3.99,2.69, 1.48, 1.38, respectively (Tables 1 and2). Thus, in the first step of the study, weselected a five-factor solution for furtheranalysis from the scale which consisted of40 mixed items of positive and negativeoriented leadership behaviors. Gradually,the questionnaire was streamlined and re-

tested for validity. We decided to removeitems with loading of less than 0.6 (1, 2, 3,4, 5, 10, 11, 12, 13, 1518, 19, 24, 25, 26,27, 28, 29, 33, 35.), and this resulted in theremoval of one factor and a final version of20-item questionnaire with a four- factorssolution. Considering the varimax rotationanalysis, factor 1 accounted for 20.07 % ofthe explained variance and was related tosupport for development; factor 2 explained11.84% of the variance regarding integrity;

Table1. Load of each item in the four factors (loading below 0.6 are not presented in the table). Variance, eigen values, andCronbach’s alphas are also shown

Questions Factors1

(20.07% oftotal variance)

2(11.84% of total

variance)3

(11.77% of totalvariance)

4(6.35% of total

variance)

1. He "needles" foremen under him forgreater effort.

0.79

2. He backs up the members in theiractions.

0.65

3. He is friendly and approachable. 0.654. He makes group members feel at

ease when talking with them.0.90

5. He tries to keep the foremen underhim in good standing with those inhigher authority

0.75

6. Expresses values that have an hu-manistic basis.

0.85

7. Accepts responsibility for the opera-tions–even in hard times.

0.68

8. Encourages to develop my abilities .649. Inspiration to think creativity 0.6110. Inspires me to try new working

methods0.74

11. Looks for the mistakes. 0.9212. He encourages his junior officials

immediately after they have accom-plished their tasks successfully.

0.66

13. He encourages his junior officialsregularly after they have accom-plished their tasks successfully.

0.70

14. He formally encourages his juniorofficials in group meetings becauseof their proper performance

0.60

15. Creates enthusiasm for a task.16. He emphasizes high morale among

his underhand authorities.17. He gives appropriate feedback to

subordinate regarding their individ-ual and group performance

0.720.60

0.67

18. Creates chummy, flexible and dy-namic environment

19. Mentioned his ideas and strategiesfor his followers

20. He makes possibility for growingup and learning new skill amongsubordinates for achieving the or-ganizational goals

0.60

0.68

0.66

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factor 3 represented 11.77% of the ex-plained variance and was related to sinceri-ty; and finally, factor 4 accounted for6.35% of the explained variance and wasrelated to recognition. Table 1 demonstratesthe load of each item on the four factors.

The reliability estimate measured asCronbach’s alpha of the20-item question-naire was 0.84. The Cronbach’s alpha forall factors were all above 0.6 except forFactor 3 which was 0.37.

DiscussionSLB style was in line with the fundamen-

tal socio- cognitive theory in learning; forinstance, Bandura emphasized context, in-

dividual and personal behavior as the threeimportant elements of this theory. The SLB is based on two out of the three issues ofBandura theory (individual and personalbehavior). The psychometric findings ofthe instrument endorsed the usefulness ofthe scale.

The first factor analysis of the 40 SLBitems was carried out and streamlined to a20-item questionnaire. The items explainedthe leadership behaviors in four correlatedfactors as below:

1) Support for development2) Integrity3) Sincerity4) Recognition

Table 2. Factor Matrix for all questions of SLB questionnaireFactor

1 2 3 4 5SO1.1* ** -.476 .310 -.417 -.073 -.178

SO1.2 -.012 .514 -0.95 --.019 -.329SO1.3 -.573 -.298 .302 .039 -.025SO1.4 .249 -.147 .539 .095 -.044SO1.5 .106 .320 .370 .195 -.043SO1.6 .206 .789 .207 .157 .013SO1.7 .650 .265 .181 .196 .144SO1.8 .380 .295 .648 .126 .219SO1.9 .148 .889 -.032 .009 .008

SO1.10 .667 .223 .511 .017 .021SO1.11 -.223 -.117 .299 .184 .253SO1.12 .586 -.319 .320 .028 .052SO1.13 -.379 -.538 .185 .184 .290SO1.14 .260 .752 -.189 .145 .165SO1.15 .510 -.143 .028 -.123 .049SO1.16 .100 .849 -.062 .006 .086SO1.17 .677 -.281 -.143 -.085 .099SO1.18 .535 .009 .142 -.151 .076SO1.19 .395 .280 .066 -.013 .031SO1.20 .637 -.152 .023 -.020 .058SO1.21 .791 -.223 .177 -.074 .103SO1.22 .249 .740 .189 .132 .131SO1.23 .267 -.162 .919 -.004 -.067SO1.24 .140 .280 .455 -.114 -.441SO1.25 .187 -.044 -.455 -.114 .441SO1.26 .474 .177 -.238 .104 -.053SO1.27 .382 -.257 .488 -.325 -.160SO1.28 .310 .111 .224 .159 -.042SO1.29 .526 .013 .206 .286 -.143SO1.30 .478 -.009 -.226 .658 -.233SO1.31 .369 -.266 -.131 .685 -.098SO1.32 .528 -.415 -.156 .559 -.162SO1.33 .526 -.374 -.145 .542 -.154SO1.34 .723 -.232 -.324 .004 .100SO1.35 -.312 .103 .189 .288 -.531SO1.36 .599 -.183 -.299 -.002 -.060SO1.37 .663 -.205 -.331 -.053 .113SO1.38 .595 -.137 -.030 -.128 -.029SO1.39 .677 -.107 -.269 -.133 .151SO1.40 .662 -.211 -.082 -.055 .103

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High-quality leadership relies on attitudi-nal qualities of a leader (22). Examples ofhighly significant leadership qualities areintegrity, honesty, humility, courage, com-mitment, sincerity, passion, confidence,positivity, wisdom, determination, compas-sion and sensitivity which are in line withandrological learning theories in the socio-cognitive domain. Bandura (26) empha-sized the importance of context (interper-sonal and culture), behavior (developmen-tal behavior) and individual (sincerity) ef-fects on the learning process which is welladapted to the supportive leadership behav-ior model (27). Leaders with these types ofbehavioral qualities tend to attract follow-ers (28). The four factors of SLB in ourstudy could be considered in academicleadership as well as healthcare system.Moreover, the results of the application ofthis model could improve the performanceof the followers and increase their loyaltyto the system.

One of the strengths of this study was itsappropriate theoretical frame work, select-ed based on social cognitive and ecologicaltheories, which could be applied in manag-ing health care organizations as well as ed-ucational institutions. Secondly, the largesample size in this study provided the nec-essary element for the standardization ofthe instrument. Moreover, the advancedconstruct validity of the instrument was un-derpinned by exploratory factor analysis.

Support for DevelopmentThe first factor solution is related to the

notion of support for staff development bysupervisors. Those qualities which contrib-uted to the support of development in thefollowers' behavior are included staffchanging, adapting and moving forward.The essential issues embedded in the fac-tors of emotion, intrinsic elements ofteamwork development, mutual support,innovative thinking and responsibility arein line with cognitive capability items (27).

Bass and colleagues emphasized the char-acteristics of rational leaders who want todevelop subordinates’ capability to develop

creativity and innovation (4, 5). Macgiltonbelieves that supportive supervisors listento their staff carefully in order to under-stand their views; they also seek the ex-pressed needs of the staff and try to findtheir capabilities, and help them developindividual and social values (29). However,researchers argue that nursing supervisorsdo not believe in supportive leadership be-cause of the rigidity defined by the profes-sional status and the intrinsic differencesamong them and their followers (2, 30).Nursing leadership styles ought to be con-sidered by health care organizations whenestablishing a positive organizational cul-ture. Since their effect on subordinate per-sonal development is still a subject of dis-cussion, close attention to contextual fac-tors is also a necessity for a successful staffdevelopment and self- efficacy.

IntegrityThe second factor, integrity, supports in-

terpersonal context, and it develops fromtrustworthiness, encouragement and goodinterpersonal communication skills, whichcould help the followers to achieve theirgoals and be more committed. Our findingsare compatible with those reported in aqualitative study assessing the impact ofsupportive leadership in an Australian po-lice work environment (2). SLB demon-strates the usefulness of integrity as a firststep towards a climate change-process in anorganization. These behaviors can increaseconsciousness and strengthen managementpractices based on the identification of in-dividual and workplace issues. Involvingsubordinates in decision making, arrangingcounseling meetings, open-door policy andproviding feedback are important work-place strategies that are emphasized in SLBpractices. In other studies, integrity alsounderpins a "build up the good communica-tion skill with staff" where supervisors playa role of coaching and mentoring. In a me-ta-analysis, the role of supervisors wasstudied with respect to organizationalcommitment and burnout (5, 31). There-fore, when intending to improve the quality

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of a healthcare or educational organization,it seems crucial to consider the integritybehaviors within a coaching role that a su-pervisor can play in decreasing burnoutamong staff (32).

SincerityThe third factor is related to sincerity.

Items in this factor show high loadings ondemonstrating friendly and approachablebehavior. In this case, supervisors do notactively look for followers’ mistakes butcollaborate with them on a more personallevel, fixing positive behavior which canlead to organizational change. Consistent toour findings, a qualitative study confirmsour findings in which a supervisor stated:“You earn the person’s respect by givingthem respect, and that goes a long way,”and “It doesn’t take any more time to treatstaff with respect (33) if you want toachieve greater goals”. A friendly and sin-cere relationship between a leader and asubordinate is an important issue forachieving success in health care and aca-demic organizations (34).

RecognitionThe last factor which had the lowest vari-

ance was the supervisors’ recognition of thesubordinates’ performance. In a study byHorn (35) on development of leadership,culture was considered to be an importantfactor. Culture provides a supportive envi-ronment in which everyone is recognizedand appreciated. The leader may even playthe role of “a parent” in the organizationand try to meet the demands of the mem-bers and this leads to the feeling of comfortand security in the members. However, it isdebatable whether or not this approach isbeneficial for the development of organiza-tions. On the other hand, in agreement withthe concept of this factor “contingent re-ward”, a behavior emphasized by Boss andAtonakis, illustrates the transformationalpower which is achievable when the super-visors recognize and praise the followers’good work (5,32).

This is also in agreement with cultural

and contextual issues which directly affectthe followers’ performance; and in an aca-demic leadership, it will affect the learners’situation and improve their self-efficacyand will also help them to promote theircapability (31, 36).

ConclusionThe use of supportive leadership behav-

iors grows in importance when successfulimprovement of health organizations andacademic leadership is desired. Mappingthe SLB can prove beneficial for sustain-ment when organizational changes are ini-tiated. The significant factors of supportiveleadership behavior are support for follow-ers’ development, integrity, sincerity andrecognition. SLB builds up a dynamic sup-portive model, consisting of “integrity" and"recognition" which affect contextual level,"sincerity" which works on the personallevel and "support for development" whichaffects behavior. Our results seem promis-ing with respect to the development of aninstrument as a valid and reliable measureof SLB capacity based on socio- cognitivetheories and with respect to its applicationin the Iranian context and perhaps othercontexts.

AcknowledgementsThe authors wish to thank Christer

Sandhal for his help in designing the study.

Conflict of interestNo conflict of interest has been declared

by the authors.

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contextualization and standardization of the supportive...

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