Leadership, Followership, and the Context: An Integrative Examination of Nursing Leadership in Uganda

Problem: Studies examining the transformational leadership practices of healthcare providers in sub-Saharan Africa are limited. In particular, there is a substantial lack of studies examining the level of leadership ability of nurses in leadership and factors associated with leadership. As a basic step to fully engage nurses in leadership in sub-Saharan Africa, their level of leadership preparedness needs to be established. In addition, factors that may constrain or enable leadership need to be understood. Purpose: The purpose of this descriptive cross sectional study was to: (a) Assess the level of self-reported leadership practices undertaken by nurses in leadership roles in hospitals in Uganda, using Kouzes and Posner's Leadership Practice Inventory (LPI-Self); (b) Examine the perceptions of the nurse leadership ability by staff using the LPI-Observer; and, (c) Identify factors associated with self-reported leadership practices including: Demographics, Organizational Culture, and Organizational Structure. Internal consistency reliability of the LPI was also established. Methods: Surveys were collected from nurses in leadership (response rate 57%, n=120) and staff (response rate 60%, n=360) from three hospital types: private-for-profit (PFP), private-not-for-profit (PNFP), and public hospitals in Kampala, Uganda. Data collection measures included four questionnaires. (a) A demographic questionnaire with six key areas: age, gender, level of education , tenure, rank, and hospital type; (b) The LPI (Self and Observer) to measure five leadership practices of highly successful leaders: Model the way, Inspire a shared vision, Challenge the process, Enable others to act, and Encourage the heart; (c) Denison's Organizational Culture Survey to measure organizational culture with four constructs: Involvement, Consistency, Adaptability, and Mission; and, (d) The Organizational Structure Survey to measure Centralization. The Statistical Package for Social Sciences (SPSS version 22 IBM) was used for data analyses. Results: Aim 1: Self-reported leadership scores from lowest (M=7.6, SD=1.66) to highest (M=8.27, SD=1.30) were above average on the LPI. The most common self-reported leadership practices were Model the way, Challenge the process, and Encourage the heart; while the least were for Enable others to act and Inspire a shared vision respectively. Self-reported leadership scores were comparable to existing studies with one exception: Enable others to act was consistently the least common for this sample even in comparison to existing studies. Aim 2: By rank order, the five leadership practices from most frequently (1) to least the frequently used (5), were similar between head and staff nurses. Despite this similarity, staff nurses perceived the head nurse' leadership scores in general to be significantly less than what was self-reported. Aim 3: Both hospital type and Organizational Culture/Structure were significantly associated with self-reported leadership practices. In particular, specific cultures such as Involvement (of head nurses in decisions and day-to-day tasks), and Mission (a sense of direction and clear performance expectations) contribute to greater frequency of use of self-reported leadership practices. The LPI meets the psychometric standards of internal consistency reliability in this sample. Conclusions: Findings from this study indicate that self-reported leadership ability of nurses in leadership in Uganda is above average on the LPI. Leadership scores were generally consistent with other studies describing the leadership practices of nurses in leadership in both high and low-income countries. However, nurses in leadership in Uganda scored much lower on leadership practices Challenge the process and Enable others to act which suggests that targeted training to increase these leadership skills might prove useful. In addition, the perception of nurses in leadership as competent leaders ensures an inspired team and determines the legitimacy and continued success of the leader. Nurses in leadership in this context, need to develop strategies that increase their ability to inspire confidence, articulate a shared vision, and increase shared participation through enabling others to achieve goals. Further, leaders and organizations need to be acutely aware of their own environment and how it influences the ability of nurses in leadership to lead effectively. A leadership environment that enables the nurse leaders' involvement in day-to-day decisions, and a sense of direction and clear performance expectations, is also likely to enable leaders in inspiring others, leading change initiatives, fostering collaboration, and strengthening others. The more often nurses in leadership engage in leadership practices, the better chance they have of being effective leaders. If policy makers know what leadership practices and factors to look for when developing and appointing leaders, they can make a major contribution to enhancing leadership capacity as well as creating a leadership-enabling culture that supports leadership. Finally, reliability of the LPI in Uganda has potential to facilitate future leadership research and advance knowledge development in the study and practice of successful leadership. Key Words: Leadership, Nurses in Leadership, Leadership Practices Inventory, Followership, Integrated Model of Leadership, Organizational Culture, Organizational Structure, Context and Leadership, sub-Saharan Africa