Effect of Humble Leadership on Staff Nurses’ Proactive and Innovative Work Behaviors

Background: Humble leadership has a vital role in inspiring staff nurses to achieve their goals through influencing and leading them with humility and providing atmosphere that fosters their proactive and innovative work behaviors. Aim: Study the effect of humble leadership on staff nurses’ proactive and innovative work behaviors. Subjects and Method: Research design: A descriptive correlational research design was used. Setting: The study was conducted in Intensive Care Units at Tanta University Main Hospital. All (n = 565) staff nurses working in the Intensive Care Units. Tools: Three tools were utilized for data collection, Head Nurse’s Humble Leadership Behavior Questionnaire, Proactive Work Behavior Scale, and Innovative Work Behavior Scale. Results: At Tanta University Main Hospital, the majority of staff nurses perceived that their leaders had a moderately humble overall leadership level. Also, staff nurses perceived a moderate level of overall proactive and innovative work behaviors. Conclusions: There was a statistically significant positive correlation between total staff nurses’ proactive and innovative work behavior and their humble leadership. Recommendations: Nurse managers need to develop strategies to improve their staff nurses' innovative work behavior and learn how to work proactively with problem recognition.


Introduction
Today's healthcare environment faces many challenges, such as national and international competition, individual diversity, development, innovations, management approaches and new leadership behaviors.Hence, nursing leadership plays a vital role in health care services at all levels which creates a favorable work environment that promotes staff nurses' contributions to the healthcare organizational work and strengthens their sense of responsibility and attitudes toward their work. (1,2) mongst leadership styles, humble leadership is a new concept that has gained more attention from researchers especially in the nursing field and has emerged as a significant indicator of nurses' success, and proactive work behavior. (3,4) 7) Humble leaders exhibit some characteristics, such as setting goals, communicating openly, valuing staff nurses' skills and building relationships as well as, appreciating nurses' strengths and contributions where supportiveness and guidance are key components and creating humble team members with a positive team climate and higher collaboration.Vol. 31.No. 4 (Suppl 1) ,November 2023 13) Proactive work behavior is taking the initiative to improve current conditions, challenging the status quo rather than passively adapting to present circumstances.It is self-starting, change-oriented and future-focused aiming to improve aspects of a nurse's work. (14)Proactive work behaviors allow staff nurses to feel themselves motivated thereby creating positive outcomes in health care settings as well as facilitating the innovation process through by effecting the transition of idea generation from idea implementation necessary to improve for overall work conditions in the long-term. (15)n nursing, proactive work behavior dimensions involve problem prevention, nurse's innovation, voice, and taking charge.Problem prevention is the ability to make efforts to improve work methods and try to find the root cause of things that go wrong by suggesting ideas to prevent the reoccurrence of work problems.Nurse's innovation is the ability to create and implement ideas including identifying an opportunity, searching out new techniques and implementing them.Voice is the ability to speak up about work issues to others in the workplace, even if others disagree as well as making innovative suggestions that are constructive for organization change.& 29) Humble leaders who seek suggestions and knowledge from their nurses, treat them with compassion by being polite, seeking advice, and providing a safe space for them to express their problems openly.These features may be critical requirements for nurses to demonstrate proactive work behaviors. (17)lso, humble leaders in general affect staff nurses' willingness to engage in creative endeavors by creating autonomy in work, involving them in decision-making, creating a sense of self-confidence about high performance.Moreover, those professionals consider their mistakes and failures as a tool for learning and success and encouraging free interaction with them, which allows them to be able to develop and implement new and useful ideas as well as feel comfortable enough to share their ideas freely with their supervisors and expect that their supervisors listen and respond to them constructively.Furthermore, humble leaders create a climate where their innovative efforts are supported through motivating their staff nurses to develop creative alternatives, making them receptive toward uncertainty by teaching ability, openness to feedback and allowing them to try new things based on a trial and error approach.
(18-21) Innovative work behavior is the ability to create new and valuable products, services, Vol. 31.No. 4 (Suppl 1) ,November 2023 processes, and management strategies and implement new ideas to nurses to increase job function. (22,23) Staff nurses, for innovative work behavior, can be encouraged when their leaders meet their job needs, respond to inventive goal advancement, and reward them.Additionally, they allow their nurses to manage and solve work problems, deal with all patients and use various medical equipment, which in turn leads to successful organizational growth.(24,25) Innovative work behavior dimensions involve idea generation, idea search, idea communication, involving others, implementation starting activities, overcoming obstacles, and innovation outputs.Idea generation is the nurses' ability to recognize problems and generate innovative solutions to deal with them.Its success depends on the quality of the best opportunity recognized.Idea search is the nurses' ability to search for new ideas based on searches of existing knowledge sources in their environment.Idea communication is the nurses' ability to communicate new ideas to their leaders and find ways to implement it.Involving others is nurses' ability to use external motivation to persuade their leaders that the changes are necessary and beneficial for the hospital department.Implementation starts with nurses' ability to anticipate problems and put efforts into creative ideas by preparing plans for implementation in an unstructured environment.Overcoming obstacles is the nurses' ability to achieve innovation output by adapting the idea or implementation strategies until service, or process has been enhanced.Innovation outputs are nurses' ability to develop, test, and commercialize a new service and make innovations for an aspect of their working processes.(27)(28) Significance of the study Nowadays, there is a critical need for leaders who can work cooperatively in their workplace and create a climate where innovative efforts are supported through motivating their nurses. Humble ldership behavior is a relatively new approach that is open to their nurses' suggestions, encourage open exchange of ideas and appreciate their strengths and contributions as well as providing space for them to arrange in a way to freely control their manners of work.Furthermore, humble leadership encourages their nurses to take on additional responsibilities, give space for thinking outside the box and take the initiative to improve work performance creatively, which is conducive to proactively promoting their behaviors.(29,30) Thus, this study is directed to study the effect of humble leadership on staff nurses' proactive and innovative work behaviors.

Aim of the study
This study aimed to study the effect of humble leadership on staff nurses' proactive and innovative work behaviors.

Research question
-What are the levels of humble leadership perceived by staff nurses?-What are the levels of staff nurses' proactive and innovative work behaviors?-What is the relation between humble leadership and staff nurses' proactive and innovative work behaviors?

Subjects and method Research Design
A descriptive-correlational research design was used.

Setting
The study was conducted in intensive care units at Tanta University Main Hospital which included Medical, Cardiac, Neuro, Tropical, Pediatric, Neonate and Chest ICUs.

Subjects
The subjects included all (565) ICU nurses who were working in the previously mentioned settings and willing to participate in the study.Tools of the study: It consisted of three tools as the following: Tool (1): Head Nurse's Humble Leadership Behavior Questionnaire This tool was adopted by researchers guided by Owens et al. (2013) (31) to assess the staff nurses' perception of humble leadership behavior.The tool included two parts: Part (1): personal characteristics including department, age, years of experience, and level of education.Part (2): humble leadership behavior questionnaire to assess the staff nurses' perception of humble leadership behavior.It is unidimensional consists of nine items; such as whether a leader is willing to learn from others.Staff nurses' responses were measured on a fivepoints-Likert-Scale that takes values between 1 (strongly disagree) and 5 (strongly agree).Levels of humble leadership are represented statistically based on the cut-off values as value high level >75%, moderate level 60% -75% and low level ˂60%.A higher score denoted that staff nurses perceived had a high level of humble leadership among their leaders.

Tool (2): Proactive Work Behavior Scale
This tool was modified by the researchers based on Parker, and Collins (2010) (32) and Kanten and Alparslan (2013) (33) to assess the level of staff nurses' proactive work behavior through thirteen items, which distributed into four subscales: problem prevention (3 items), individual innovation (3 items), voice (4 items) and taking charge (3 items).Staff nurses' responses were measured on a three-point Likert Scale ranging from (0) for very infrequent, (1) for somewhat frequently, (2) for very frequently.The respondents' total scores were classified into three levels: high level >75%, moderate level 60% -75% and low level ˂60%.A higher score denoted that staff nurses had a high level of proactive work behavior.

Tool (3): Innovative Work Behavior Scale
This scale was adapted from Mahgoub.(2019) (34) to assess the levels of staff nurses' innovative work behavior through (22) items distributed into seven subscales: idea generation (3 items), idea search (3 items), idea communication (4 items), involving others (3 items), implementation starting activities (3 items), overcoming obstacles (3 items), and innovation outputs (3 items).Staff nurses' responses were measured in five points Likert Scale that takes values between 1 (strongly disagree) and 5 (strongly agree).The respondents' total scores were classified into three levels, high level >75%, moderate level 60% -75% and low ˂60%.A higher score denoted that staff nurses had a high level of innovative work behavior.

Method: 1. Ethical considerations:
Approval from the Scientific Research Ethical Nursing Committee at Faculty of Nursing was obtained with no 298.Moreover, an official permission will be obtained from the Dean of Faculty of Nursing to Tanta University Main Hospital.The aim of the study was explained to staff nurses to gain their cooperation, verbal consent for their participation in the study were obtained with the right to withdraw, as well as informed about the confidentiality of their information.

Validity and reliability:
The questionnaire was translated into Arabic and presented to a jury of five experts in specialty to check their content validity.The content validity was 95%, 96% and 95% for tools I, II and III, respectively.Reliability of tools was tested using Cronbach Alpha Coefficient test, its value = 0.834 for humble leadership behavior scale and proactive work behavior scale and 0.816 for innovative work behavior scale.

Pilot study:
A pilot study will be carried out on 10% of staff nurses (n= 57) to test the clarity, reliability of tools, and identify problems that may be encountered during data collection and make modification.The questionnaire took 15-20 minutes for each staff nurse to fill out.

Results
Table (1) shows distribution of staff nurses according to their personal data.17.7% and 14.7% of staff nurses worked in cardiac and neonate ICUs, respectively.The staff nurses' age ranged from 25 to 43 years, and the highest percent (62.6%) of them were from 30 to 40 years old with mean 35.28±4.84.As regard to years of experience 42.6% of them had less than 10 years of experience with a mean score of 10.27 ± 4.80 and range from 1-18 years and the most (64.5%) of them had a bachelor of sciences in nursing.Leaders with humble behavior can recognize their limitations and take responsibility for their mistakes, appreciate the advantages and contributions of their staff nurses, and give recognition to them.They are also teachable, which is reflected on their willingness to learn from others and accept new knowledge, which help them clarifying their career development path and strengthens their internal motivation to learn, which leads to promoting their staff nurses innovative behavior and working proactively. (7,35) e findings of this study demonstrated that the majority of staff nurses perceived that their leaders had a moderately overall  (36) and Mrayyan (2023) (37) found that nurses perceived a moderate level of humble leadership from their nurse managers.

Figure
The result of the current study illustrated that staff nurses had a moderate level of overall proactive work behavior, more than sixty of them had a moderate level in problem prevention, individual innovation, voice, and taking charge dimensions of proactive work behavior.This could be because their leaders can appreciate nurses' contributions and accept their mistakes which conveys a message to them that their leaders are open.They seek suggestions and knowledge from their nurses and providing a safe space for them to express their problems openly which in turn inspires them to work proactively.These results agree with the study conducted by El-Gazar et al.
(2022) (4) and Matsuo et al. (2021) (38) who revealed that staff nurses perceived a moderate level of proactive work behavior.Also, Ding et al. (2020) (39) indicated that humble leadership facilitates followers' learning, promotes job satisfaction, commitment, work engagement and creates an empowering climate.
The result of the present study illustrated that staff nurses had a moderate level of overall innovative work behavior also, more than sixty of them had a moderate level in idea generation, idea search, idea communication, involving others, implementation starting activities, overcoming obstacles, and innovation outputs dimensions of innovative work behavior.This could be because their leaders appreciate nurses' strengths and contributions and give them a space of freedom to generate new ideas and help them implement innovative ideas which in turn makes nurses feel more safe with risktaking and contributing creative ideas as well as perform innovative behavior, question suggestions and decisions and respond positively to them.This result agrees with Elsayed et al. (2022) (40) who found that nurses had a moderate level of innovative work behavior.Saleh et al. (2021) (41) denoted that leaders are critical in allowing and supporting the growth and nurturing of creativity as well as helping followers to discover meaning and affiliation at work.Luo et al. (2022) (42) found that humble leadership was significantly related to a series of important nurses' outcomes (e.g., task performance and creativity).Moreover, Salas-Vallina et al. and Zhong et al. (2018) (43,44) indicated that humble leadership has a direct and positive effect on nurses' innovative work behavior.Wang Liu and Zhu (2018) (45) found that humble leaders help organization to create a psychological climate of safe knowledge sharing that facilitates their subordinates to generate novel ideas and solutions.While these results disagree with Mahgoub et al. (2019) (46) indicated that staff nurses perceived a high level of innovative behavior.The findings of this study demonstrated that there was a statistically significant positive correlation between staff nurses' overall proactive and innovative work behavior and their humble leadership.This could be because humble leaders give their staff nurses the opportunities to participate in decision-making with creating sense of confidence about their performance and encouraging free interaction with nurses.As well, nurses can develop and implement new and useful ideas that provide them with a safe space to express their problems openly, which is a critical requirement to demonstrate proactive and innovative behaviors.This agrees with El-Gazar et al. (2022) (4) and Ali et al. (2020) (18) who revealed that humble leadership and proactive work behavior were significantly positively correlated.Also, Ehrenhard (2014) (47) revealed that humble leadership is beneficial for the creativity, motivation of members, facilitates an independent and engaged working of nurses.Moreover, Owens and Hekman (2016) (48) denoted that humble leaders consider mistakes and failures of their subordinates as a tool for learning and success.

Conclusion
Findings of the current study concluded that the majority of staff nurses perceived that their leaders had a moderate overall humble leadership level and a moderate level of overall proactive and innovative work behavior among staff nurses at Tanta University Main Hospital.Also, there is a significant positive correlation between staff nurses' proactive and innovative work behavior with their humble leadership.These findings need to be used by hospitals management by using the educational programs for applying strategies to promote leadership and their staff nurses' proactive and innovative work behavior which in turn improves their work performance.

Figure ( 1
Figure (1): Level of humble leadership behavior as perceived by staff nurses (n = 265) 001 * Vol. 31.No. 4 (Suppl 1) ,November 2023 humble leadership level.This could be because their leaders have accurate selfawareness and a willingness to learn from others as well as they can recognize their limitations and inadequacies and open to new ideas, knowledge and unique insights that are linked to a set of positive outcomes among nurses.These results agreed with El-Gazar et al. (2022)(4)  who revealed that staff nurses perceived that their nurse managers have moderate humility.As well as,Yang et  al. (2019)

Table ( 1): Distribution of staff nurses according to their personal data (265)
SD: Standard deviation