Staff Nurses’ Perception toward Leadership Effectiveness and Its Relation to Innovative Work Behavior at selected hospital

Background: In recent years, innovation is considered necessary for organizations to adapt to the changing environment and increase need for effective nurse leader for enhancing leadership qualities, supportive work environment that is critical for staff nurses innovation. The study aimed to: assess staff nurses‘ perception toward leadership effectiveness and its relation to innovative work behavior. Design: A descriptive correlational design was utilized to conduct this study. Setting: the study was conducted in all ICUs at emergency hospital which is affiliated to Cairo University Hospitals. Subjects: A convenience sample of 73 staff nurses who volunteered to participate in this study was included. Tools: three tools were used for data collection as follows: (a) personal characteristics sheet (b) Leadership Effectiveness Questionnaire, (c) Innovative Work Behavior Questionnaire. Results: the study results revealed that more than half (61.6%) of staff nurses had high perception level regarding leadership effectiveness. also the highest percentage (76.7%) of them had high perception level regarding innovative work behavior. Conclusions: data of the present study concluded that there was statistically significant positive correlation between overall perception of leadership effectiveness and innovative work behavior of staff nurses. Recommendations: Raise the nursing leaders‘ awareness regarding their role in building trust relationships with their followers and in creating healthy work environment that enhance their innovations.


Introduction
Since ancient times of history, man has known that the difference between success and failure is mainly due to the effectiveness of leadership, whether in wars or in various fields of human life. Every group and organization need effective leadership, as it constitutes the vital axis that underpins various activities in both public and private organizations. (1) Leadership is one of the most crucial elements of organizational success, as it would direct all resources towards achieving the goals. The level of achieving the goals is commensurate with the level of leadership effectiveness in utilizing the staff energies by raising their motivation and revealing their latent energies to reach a high level of organizational commitment. (2) For improving quality and care integration, management and leadership of healthcare workers are essential. Leadership is the behavior of guiding and coordinating the activities of a team or group of people towards a shared goal. It is also defined as the relationship between the individual who led and those who choose to follow. (3) Leadership has also been described in terms of the power dynamic that exists between leaders and followers. According to this perspective, leaders have power and utilize it to influence others. Others see leadership as a transformational process that inspires 54 Vol. 29. No. 2 (Suppl) ,May 2023 followers to go above and beyond what is often expected of them. Finally, some academics approach leadership from the perspective of competencies. This viewpoint emphasizes the capacities (knowledge and skills) that enable effective leadership. (4) Leadership effectiveness begins with the intrinsic ability to believe in oneself. It involves a level of maturity, principle and competence that changes into the determination, direction, and clarity of vision that armored leaders with confidence needed to take the responsibility of fostering motivation, self-esteem, and teamwork. Leaders concentrate on developing a thorough awareness of the surrounding conditions. They must make sure that the surrounding conditions are suitable for carrying out the tasks and activities. (1) The effective leaders should be capable of facilitating changes that result in efficient growth and development. They believe in promoting the improvement of human resources. They adopt the perspective that the organization can effectively expand and flourish only if its human resources are treated as basic assets. (5) In order to understand the characteristics of effective leadership, it is necessary to take into consideration the intrinsic characteristics, namely physical capacity, energy level and stress tolerance. These traits enable the leaders to take control over stress and other types of difficult situations, even though they are overloaded with work tasks. Effective leaders should be aware with time management skills and provide enough time for all duties and activities; also require physical vitality and emotional intelligence. (6) Secondly, it requires the capability of removing any potential barriers and offering answers to various challenges. The development and promotion of communication skills is necessary for effective leadership to communicate with their subordinates, empower their team, manage, and assign tasks, listen to feedback, and have the flexibility to address problems in a workplace that is constantly changing. (7) In response to the rapid advancements and progress in technology and communications aspects over the recent decades, innovation became mandatory for organizations survival, growth, and competition especially in health care organizations. (8) Innovation is a change that results from new idea generation and adaptation. Creativity occurs with novel ideas relying on the institution management and individuals producing novel ideas. The knowledge and experience of nurses are required to create innovative solutions to solve the novel problem. (9) Nurses' innovative behavior in the work environment is seen as a crucial requirement for organizational survival. Additionally, the evolving economic environment, globalization, and rising competing demands have also increased the need of innovation and innovative behaviors. (10) Innovative work behaviors is described as an individual ‗s behavior to achieve the inception and intentional introduction of novel and valuable ideas, procedures, methods or products. (11) Furthermore, innovative work behavior is all individual behaviors that aim to generate, process, apply, or implement new ideas about how to do things, including new product concepts, techniques, processes, or work procedures, with the intention of enhancing the effectiveness and organization success. (12) It is also presented as a cognitive and motivating process that entails coming up with ideas, looking for novel ones, sharing 54 Vol. 29. No. 2 (Suppl) ,May 2023 them, initiating application activities, including others, and overcoming hurdles. (3) Innovative work behavior is not a part of nurses' main responsibilities. It is excessive responsibility that is outside the scope of nurses' job description for attempts to help in achievement of the organizational goals. (9) Idea generation, coalition building, and implementation are the three phases of innovative work behavior. In the first phase (idea generation), innovation starts with problem identification, problem definition and solution discovery for managing the problem. Solution discovery is based on a novel idea or a novel application of existing ideas. In the second phase (coalition building), the innovator searches for support for his novel ideas. As innovation involves both change and resistance to change, the innovator should form alliances to support the noel ideas and ensure their commitment for the innovation. In the third phase (idea implementation), the innovation ideas have to be transformed into practice. Persistence is required in the implementation process to control over change resistance and ensure the achievement of desired outcomes. (12) Significance The functionality of nursing staff in healthcare organizations is greatly influenced by leadership effectiveness. An incompetent leader can diminish employee morale, creativity, and lead to job dissatisfaction. (13) Zawawi et al. (2020) (14) found that one of the hindering factors that impede organizational success is ineffective leaders. So, it is necessary to assess and identify the competencies or skills required for effective nursing leaders to adequately deal with organizational challenges and to enhance staff competitiveness and performance efficiency.
In Egypt, it was noted that the current healthcare systems do not offer a supportive working condition that enhance staff nurses innovative work behaviors. Also, it was noted that studies on the relationship between leadership effectiveness and work innovative behavior in the health care sector are scarce. The current study would grasp the attention of study nurses and their organization to the importance of innovative work behaviors and stay away from routine and bureaucracy. Moreover, the healthcare organizations in Egypt are facing intense competitive market which requires a great care to create positive working environment for the advancement and utilization of beneficial and effective ideas of their staff. It is clear that innovative behavior of nursing staff is a significant need for an organization's innovation, productivity and sustainability. Therefore, the purpose of this study sought to assess staff nurses' perception toward leadership effectiveness and its relation to innovative work behavior.

Aim of the Study
This study aimed to assess staff nurses' perception toward leadership effectiveness and its relation to innovative work behavior at selected hospital.

Research Questions
To fulfill the aim of the study, the following research questions were formulated: 1-What is the staff nurses' perception toward leadership effectiveness? 2-What is the staff nurses' level of innovative work behaviour? 3-Is there a relationship between staff nurses' perception of leadership effectiveness and their level of innovative work behaviour? 54 Vol. 29. No. 2 (Suppl) ,May 2023

Research Design
A descriptive correlational research design was utilized to achieve the aim of the present study.

Setting
This study was conducted in all intensive care units (surgical, neurology, medical, chest and cardiac unit) at New Emergency and Burn Hospital (185) which is affiliated to Cairo University Hospital, in Egypt which provide free services. It has 7 floors and the total bed capacity is120.

Study Sample
A convenience sample of 73 staff nurses who are working in the previously mentioned study settings and available during the time of data collection was constituted the study sample. All staff nurses should have at least one year's experience, working full-time and providing direct nursing care activities for the patients.

Tools of Data Collection:
For the purpose of the current study, three tools were used for data collection: 1st tool: personal characteristics data Sheet It was developed by the researchers to assess the personal characteristics of the study subjects such as age, educational qualification, unit, and years of experience. 2 nd tool: leadership effectiveness questionnaire It is self-administered; structured questionnaire was developed by the researcher through review of recent related literature. (15,16) It was used to assess the staff nurses' perception toward head nurses' leadership effectiveness. The questionnaire consisted of 33 items categorized under ten main dimensions namely: Effective communication (5 items), team building (3 items), Change management (5 items), Conflict management (2 items), Negotiation (2 items), Management of organisational climate and culture (2 items), Inspiration (3 items), trust and credibility (3 items), Professionalism (6 items) and Commitment to customers (2 items). Scoring System: the staff nurses' responses were checked against three-point Likert scale ranging from; (1) disagree, (2) average and (3) agree. According to the total scores of nurses' responses, the head nurses' leadership effectiveness was classified as follow: -High effectiveness: ≥ 75% -Moderate effectiveness: 60-<75%. -Low effectiveness: <60% (16) 3 rd tool: innovative work behavior questionnaire It is self-administered; structured questionnaire was developed by De Jong, (2007) (17) and modified by the researchers. It was used to assess the staff nurses' perception toward their innovative work behaviors. It consisted of (11) items categorized under four dimensions, namely: Idea exploration (4 questions), Idea generation (2 questions), Idea championing (2 questions) and Idea implementation (3 questions). Scoring system: the staff nurses' responses were checked against three-point Likert scale ranging from; (1) never, (2) sometimes and (3) always. According to the total scores of staff nurses' responses, the level of innovative work behaviours was classified as follow: -High level of innovative work behaviours: ≥ 75%. -Moderate level of innovative work behaviours: 65 -< 75%. -Low level of innovative work behaviours: < 65% (17) 54 Vol. 29. No. 2 (Suppl) ,May 2023

Validity of the study tools
The study tools were submitted to a panel of five experts in the field of nursing administration. They asked to judge the content`s coverage, clarity, wording, length, format, and overall appearance of the study tools. The two tools were translated into Arabic to match staff nurses' level of education. Double English -Arabic-English translation was done. Based on experts` comments and recommendations, necessary modifications were done as correcting some grammatical errors and rephrasing of some sentences.

Reliability of the study tools
Internal consistency reliability of the study tools was determined by using Cronbach's alpha coefficient for independent variable. Internal consistency using Cronbach's alpha was 0.97 for leadership effectiveness questionnaire and was 0.95 for innovative work behavior questionnaire. Procedure Upon receiving the agreement of both medical and nursing directors of study hospital, the researchers proceeded with the data collection. Researchers met the staff nurses during two shifts (morning and afternoon) in their units to explain the purpose of the study and invited them to voluntary participate and gain their acceptance by formal written consent. The study questionnaires were distributed individually by the researchers to staff nurses with giving them instructions about how they will be filled, the time required to fill the questionnaires was from 15 to 25 minutes. The filled questionnaires were collected at the same time and revised to check their completeness to avoid any missing data. The data were collected over 2 months, from May to June2022.

Ethical Consideration
Before conducting the study, the preliminary approval was received from the Faculty of Nursing, Cairo University's scientific research ethics committee. Also, an official agreement was obtained from the medical and nursing directors of the study hospital to conduct the study. Participation in this study was completely voluntary; each participant had the option to accept or decline participation in the study. Informed consent was obtained from the study`s nurses. Every participant had the choice to withdraw from the study at any time, and subjects were informed that their data would not be utilized in another study without their consent. Anonymity and confidentiality were ensured through the coding of the data. The ethical issues considerations include explaining the purpose and nature of the study, participation was protected from any risk. Collected data were used for the purpose for the research.

Statistical Design
After the data collection was finished, the -statistical package for the social science‖ (SPSS), version 21 was used to score, tabulate, and analyze the data. Descriptive statistics such as frequency mean, and standard deviation was utilized in analyzing data pretended in this study. Relative statistical tests of significance, such as (independent ttest, correlation coefficient) were used to identify the relations among the study variables. The p value is the degree of significance, and the significance level of all statistical analysis was at ≤0. 05 (P-value) while, the p value > 0.05 indicates nonsignificant result.  Figure (1): shows that more than half (61.6%) of staff nurses had high perception level regarding leadership effectiveness. Table (3) It is obvious from the above table that staff nurses had high level of innovative work behavior: (85.2%). Moreover, the highest mean percentage scores (87.5% & 86.0%) of staff nurses' perception toward the innovative work behaviors dimensions was related to idea generation and idea implementation dimensions. While the lowest mean percentage score (83.9%) was related to idea exploration dimension. Figure (2): Illustrates that the highest percentage (76.7%) of staff nurses had high level regarding their innovative work behaviors. Table (4): shows that there were highly significant positive correlations (r=.55*, p .0001) between staff nurses' total perception toward leadership effectiveness and total perception of their innovative work behaviors.

Discussion
Effective leadership is frequently viewed as a crucial component and aspect of management that affects the level of employee commitment within the organization and has the potential to increase organizational effectiveness, creative work behaviors, job satisfaction among staff nurses and a sense of confidence about problemsolving in order to achieve organizational goals. (18) Therefore, the aim of this study was to assess staff nurses' perception toward leadership effectiveness and its relation to innovative work behavior. As regards staff nurses' perception toward leadership effectiveness, the findings of the present study indicated that more than half of staff nurses had high perception level regarding leadership effectiveness dimensions with the highest mean percentage for both commitment to patients, trust and credibility. While the lowest mean percentage was related to the change management. These findings could be due to that nursing leaders' credibility and honesty are as necessary as food and water for staff nurses as it considered as a binding promise between any leader and their followers. Overall, it emerges as the single most important attribute in the leader constituent relationship. First and foremost, the presence of effective nursing leader and even all the health care team is intended to serve the patient and provide the highest possible quality of care, so the nursing leader commitment to patient is inevitable issue for the leadership effectiveness that should be accomplished. These findings were in harmony with Mostafa & EL-Sayed, (2021) (19) who reported that the highest nurses' perception level of leadership effectiveness dimensions was related to trust and healthier work environments which allow good relation with others. As well as Abd El Muksoud et al, (2022) (20) who investigated leadership behaviors and innovative work behaviors among nurses at ministry of health in Egypt; the study revealed that staff nurses had a positive perception of the transformational leadership behaviors. Regarding to staff nurses' perception toward innovative work behavior, the findings of the present study revealed that the highest percentage of staff nurses had high perception level regarding innovative work behavior dimensions with the highest mean percentage for both idea generation and idea implementation. While the lowest mean percentage was related to idea exploration. From the researchers' point of view, the potential explanation for these findings may be attributed to the fact that the innovation behavior and Innovation climate nowadays are receiving great attention and support from the hospital leaders and managers to enhance these behaviors in their organizations.
Additionally, the nursing leaders in the study hospital may give the chance for their staff to freely communicate with them regarding work-related problems and share other techniques to solve these problems via generation, contribution, and implementation of innovative ideas. The current study findings go in the same line with that of a study conducted by Mahgoub, Shazly, & Elsayed, (2019) (21) who found that the highest percentage of staff nurses had high perception level regarding innovative work behaviors with the highest mean percentage for idea championing and idea implementation. As well as, this result is supported by Shama & Ahmad, (2021) (22) who conducted a study to investigate the relationship between nurse's innovative work behavior and their job satisfaction, found that the highest percentage of the studied participants' had positive innovative behavior with the highest agreement upon the dimensions of nurses' support for innovation, nurses' vision, monitoring and work communication respectively. Moreover, Kamel& Aref (2017) (9) , pointed out that about half of staff nurses had a highly perception level toward innovative work behaviors; the results showed that about half of studied nurses always generate original solutions to solve problems and about two thirds of them always systematically introduce innovative ideas into work practices. On the contrary, the previous findings were incongruent with the results of a study done by Ahmed, Ata & Abd Elhamid, (2019) (23) who revealed that about half of the nurses have a high perception level of innovative work behaviors. Furthermore, the previous findings were inconsistent with Abd El-Fattah, (2017) (24) who conducted a study about innovation behaviors levels and its relation with TIGER-based nursing informatics competencies among critical care nurses; that pointed out that more than half of participants had a moderate level of innovative work behaviors. Additionally these findings were incongruent with Jung &Yoon, (2018) (25) who revealed that participants showed a moderate perception level of innovative behavior. Concerning the relationship between the leadership effectiveness dimensions and work innovative behaviors dimensions, the present study showed highly statistically significant positive correlations of staff nurses' perception toward leadership effectiveness and innovative work behaviors. This finding highlighted the significance of effective leadership and its crucial role in fueling the employees' innovative behaviors. As effective leaders focus on creating suitable social and working environment to achieve the organizational goals and caring for the needs of employees which positively affects organizational reputation. (26) Thus, employees may experience higher work performance and positive affect when they strongly identify with their effective leaders and moral organizations, which improves the likelihood that they will engage in creative activities. (27) The previous result supported with a study done by Kul& Sonmez, (2021) (7) who demonstrated that, there was highly statistically positive correlation between leadership behaviors and nurses' innovative behaviors and job performance. Also, this finding was congruent with Dong & Zhong, (2021) (28) who reported that there was positive correlation between the responsible leadership and fostering the innovative behavior of employees through enhancing employees' self-esteem and subsequently motivate them to be more willing to exert creative endeavors. In addition, this finding goes in the same line with Islam, Furuoka & Idris, (2020) (29) who revealed that there was a significant correlation between transformational leadership and the employee's readiness for change and creativity. Also, this finding was congruent with Wang, Shen, Chen & Carmeli, (2021) (30) who reported that environmentally responsible leaders drive environmental innovation by developing a sense of collective environmental identification, which facilitates employees' engagement in the organizational innovation behavior. Regarding to relation between staff nurses' Age, Experiences and educational level with both study variables, the current study indicated that there was significant statistical relation between staff nurses' age and experiences and total perception of innovative work behaviors. These results could be explained by familiarity and knowledge of expert and old nurses with work environment norms, rules, policies and procedures that qualify them to create innovative solutions and generating new ideas for solving the new problems. This finding was consistent with Mahgoub, Shazly, & El-sayed, (2019) (21) who clarified the presence of statistically significant relations between staff nurses' innovative behavior and their age and experience. Also the previous finding was in agreement with Bunpin, Chapman, Blegen,& Spetz, (2016) (31) who found that there was statistically significant difference between the nurses innovative behavior and their personal characteristics. On the other hand, the previous finding was incongruent with Shama & Ahmad, (2021) (22) who revealed that there were no statistically significant differences between nurses' age, gender, and years of experience and their total innovative behavior respectively. Although the same study was in agreement with the current study finding that showed insignificant relation between the nurses educational level and their innovative behavior. Moreover, the present study showed that there was no significant relation between staff nurses' educational level and innovative work behavior. This finding was incongruent with Mostafa & EL-Sayed, (2021) (19) who demonstrated that there was a statistically significant relationship between nurses' level of innovative work behaviors and their educational level. Also Bunpin, Chapman, Blegen, & Spetz, (2016) (31) who explored the connection between innovative work behaviors, work satisfaction, work engagement and burnout in Greece, and they revealed a significant relationship between nurses' levels of creative work behaviors and their educational backgrounds. As regards to relationship between leadership effectiveness dimensions and personal characteristics of staff nurses, the study results demonstrated absence of statistically significant relation between staff nurses' perceptions of leadership effectiveness and their personal characteristics. This result was consistent with the result of Boerrigter, (2015) (32) who indicated that there is no direct relationship between leaders' age and leader effectiveness. Also, this finding was in the same line with Mohanty, Ara Begum, & Kar, (2016) (33) who found that age and work experience were negatively related to the leadership effectiveness. While this finding was incongruent with Ahmed, Ata& Abd Elhamid, (2019) (23) who revealed a statistically significant correlation between nurses' perception of leadership behavior and their education and years of experience.

Conclusion
The present study concluded that nurses highly perceived leadership effectiveness and innovative work behaviors. There was statistically significant correlation between the total perception of staff nurses toward leadership effectiveness and their total perception of innovative work behaviors. Recommendations: -Raise the nursing leaders' awareness regarding the importance of building trust relationship with their followers. -Nurse leaders must realize their crucial role in creating healthy work environment that allow nurses to think more creatively and generate new ideas -Hospital administrators should support the nurse leaders and empower them and ensure the availability of needed resources to enhance their effectiveness.
-The nurse leaders should provide feedback and appreciate the nurses innovative efforts.
-Further research studies are recommended to detect the possible moderating factors that enhance the nurses innovative work behavior.

Financial support and sponsorship
Nil.