In organisations, workplace characteristics have a significant mediating influence on employee dispositions, behaviours, and job outcomes. In clinical contexts, nurses, just like other workers, develop diverse dyadic relationships with their supervisors and peers that influence their behaviours and attitudes (Jutras & Mathieu, 2016). The quality of the nurse-supervisor relationship is particularly critical in determining individual-level variables, including job satisfaction levels, retention/turnover, organisational commitment, and wellbeing (Portoghese, Galletta, Battistelli, & Leiter, 2015). Thus, supervision practices related to intra-communication or social exchanges can predict nurse outcomes.
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An important model for examining the quality of supervisor-employee relationships is the leader-member exchange (LMX) theory. The LMX’s premise is that supervisors/leaders manage personnel differently, and therefore, staff outcomes would differ between employees (Trastek, Hamilton, & Niles, 2014). According to Xerri (2012), “the quality of the social exchanges” between supervisors and employees would determine if a superior-quality or low-quality LMX relationship is produced in the workplace (p. 119).
Hence, in clinical contexts, improving the quality of the LMX relationship through the reinforcement of positive employee behaviours and attitudes is critical in achieving higher nursing outcomes. This essay critically examines the real or potential issues associated with LMX in contemporary nursing contexts. It will involve the definition of LMX, an analysis of the aspects of research on LMX, a discussion of LMX’s relevance to nursing workplaces, and practical strategy recommendations for obtaining high-quality LMX relationships between supervisors and nurses.
Discussion of the Basis and Importance of LMX
The Basis of the LMX Theory
As aforementioned, the basis of LMX is the premise that diversity in supervisory practices produces dissimilar results for different groups of workers. The fundamental tenet of this theory is that employee outcomes differ depending on the quality of the LMX relationship. The LMX theory or the Vertical Dyad Linkage Theory is defined as the “mutual support, trust, and respect” obtained from a higher-quality supervisor-employee relationship (Farr-Wharton, Brunetto, & Shacklock, 2011, p. 3498).
It centres on the quality of the dyadic relationship between supervisors and employees. Unlike earlier leadership models that emphasised on the supervisor’s qualities, styles, and behaviours, the LMX model considers the leader-follower relationships that emerge within teams (Thomas & Lankau, 2009). It also focuses on how the quality of dyadic relationships could hinder or foster employee growth or outcomes.
The supervisor-subordinate relationship can be viewed as a continuum of social exchanges of varying quality. The two key aspects of the LMX theory are social exchange and reciprocity (Uhl-Bien & Maslyn, 2003). With regard to social exchange, research on LMX links quality dyadic relationships to improved employee trust in their supervisors, and subsequently, better citizenship behaviour (Chen, Wang, Chang, & Hu, 2008).
Therefore, citizenship behaviour, which is a performance parameter, could be achieved through strategies that promote high-quality social exchanges between the two parties. High-quality LMX relationships in most workplace contexts have been directly linked to the acquisition of positive staff attitudes, performance improvement, and organisational commitment (Han & Jekel, 2011). They are characterised by mature partnerships and trust. In contrast, low-quality relationships involve limited social exchanges that stifle the development of positive staff behaviour and attitudes.
The outcomes of the LMX exchanges have been described in the literature. In some studies, the reported outcomes of the social exchange include “mutual trust, respect, and commitment” (Han & Jekel, 2011, p. 46). In others, the key benefits of the LMX social exchanges include emotional effect, loyalty, and psychological empowerment or autonomy (Farr-Wharton et al., 2011). The dyadic relationship is characterised by continuous social exchanges between the supervisor and the employee. The LMX model defines how both the supervisor and subordinate influence these exchanges through their interactions (Pundt & Herrmann, 2015).
The social exchanges produce in-groups and out-groups in the workplace. LMX theory holds that the in-group employees are able to handle work-related challenges better than the out-group ones due to “information access, support, and involvement in decision-making” (Farr-Wharton et al., 2011, p. 3498). The affectionate treatment of the ‘in-group’ extends to promotions, incentives, and additional job assignments.
Conversely, employees reciprocate through a display of high-level motivation, job satisfaction, wellbeing, and good citizenship (Hooper & Martin, 2008; Schriesheim, Castro, & Cogliser, 1999). Since the LMX theory is a relationship-based model, reciprocal actions determine supervisor and employee outcomes. Consequently, it is argued that positive staff outcomes translate into an empowered workforce and a high-level affective commitment by employees to the organisation (Schyns & Day, 2010). Further, affective commitment is considered to ameliorate turnover intentions and enhance employee productivity.
Besides social exchanges, another key aspect of this theory examined in the literature relates to the LMX group differentiation. Chen et al. (2008) argue that LMX differentiation occurring within the confines of a dyadic relationship determines subordinate outcomes. In this regard, in order for the employee to receive rewards or incentives from the supervisor, he or she must adjust his/her behaviour to match supervisor expectations (Chen et al., 2008). Conversely, in order for the supervisor to receive subordinate trust, respect, and support, he/she must reciprocate with affection and trust. Thus, the LMX theory is grounded in reciprocity and social exchanges between the supervisor and the individual employee.
Importance of LMX
High-quality LMX relationships are significant because they are positively correlated with improved workplace outcomes. Studies associate quality LMX to improved staff productivity, employee satisfaction, positive organisational citizenship behaviour, higher retention rates, and worker allegiance/dedication (Jutras & Mathieu, 2016; Trybou, De Pourcq, Paeshuyse, & Gemmel, 2014). Quality LMX has also been associated with reduced turnover rates due to staff involvement in decision-making and nurse-physician collaboration (Galletta, Portoghese, Battistelli, & Leiter, 2013). In contrast, lower-quality LMX relationships produce unmotivated employees, poor intra-communication, and inadequate career development opportunities (Galletta et al., 2013).
One of the most significant outcomes of LMX is the additive influences that the leader and the follower have on each other. This additive influence prompts individuals to perform beyond what is expected of them by displaying extra-role behaviour (Dulebohn, Bommer, Liden, Brouer, & Ferris, 2012). Thus, high-quality LMX can elicit positive work attitudes in employees, contributing to improved performance. Various factors contribute to successful LMX relationships. Examples include the personality and attributes of the supervisor, supervisor-subordinate similarity, and better working conditions.
Interpretation of what is known about LMX in Nursing
The LMX concept has been utilised to analyse dyadic relationships in the nursing field in light of the growing need to enhance accountability and alleviate the turnover problem. High-quality LMX is known to improve nursing outcomes and teamwork (Brunetto et al., 2013). The impact of LMX on nursing outcomes can occur at the individual level or at the unit level.
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The social exchanges seen in other organisational contexts also occur in a nursing Workgroup. The practice context is characterised by interactions and intra-communication to realise the set therapeutic goals (Skinner, Van Dijk, Elton, & Auer, 2011). Therefore, the interactive context would influence supervisor and nurse behaviour and dispositions, including the desire to leave the organisation.
Research in this area has established that the dyadic relationship between the Nurse Manager and the nurse influences job satisfaction and turnover intentions (Nunes & Gasper, 2016). A cross-sectional survey by Han and Jekel (2011) found that job satisfaction has a significant mediating influence on the relationship between LMX and turnover. This shows that high-quality LMX between Nurse Managers and nurses can lower the intention to leave an organisation because it mediates job satisfaction.
The turnover intentions are high in clinical contexts that involve heavy workloads, inflexible work schedules, greater accountability demands, and minimal autonomy (Farr-Wharton et al., 2011). This means that contextual factors of unit-level leadership affect nurse outcomes. In this view, building higher quality LMX through unit-level empowerment initiatives can enhance organisational commitment.
Laschinger, Finegan, and Wilk (2009) found that positive supervisor-nurse LMX relationship creates an empowering clinical environment that produces a dedicated nursing workforce. Further, nurse perceptions of the LMX quality have been shown to correlate with job satisfaction (Laschinger, Purdy, & Almost, 2007). The leadership role in the LMX relationship is seen as an important factor in achieving nurse job satisfaction. Laschinger et al. (2007) established that quality nurse-supervisor relationships translate into enhanced empowerment of staff nurses. Empowering social environments can lead to greater job satisfaction.
The ameliorating effect of LMX on nurse turnover is well established in the current body of nursing literature. At the unit level, the quality of the leader-nurse relationship impacts on the nurses’ work attitudes, turnover intentions, and positive behaviours like affective commitment (Portoghese et al., 2015). In contrast, at the individual level, nurse satisfaction and work-related attributes influence the desire to leave a healthcare organisation (Portoghese et al., 2015). This shows that job attributes determine a nurse’s perception of satisfying jobs. In addition, the LMX helps illuminate unit-specific factors related to the supervisor that affect the job satisfaction of the staff nurses.
In the public sector, accountability and nurse turnover are a major problem affecting healthcare quality. For this reason, the quality of LMX at the unit level is of greater significance to public sector nursing than in it is to private practices (Brunetto et al., 2012).
Quality LMX has been shown to produce an empowered and committed nursing workforce in the units of public hospitals (Brunetto et al., 2012). Increased empowerment and organisational commitment are good indicators of lower turnover rates. Empowered staff often shows greater professional autonomy – an important component of nursing practice. Supervision practices have been shown to affect perceptions of autonomy among professionals, nurses included (Farr-Wharton et al., 2011). Therefore, improving the LMX quality could help reinforce positive perceptions of professional autonomy to realise improved organisational commitment.
In nursing, just like other sectors, the practice environment influences nurse dispositions and behaviour. An analysis of the LMX and person-organisation (P-O) fit frameworks by Jutras and Mathieu (2016) found that quality LMX mediates the relationship between the person-organisation fit and nurse outcomes. The person-organisation fit is higher in engaged employees than in disengaged ones. As such, higher outcomes – satisfaction and retention – can result in LMX relationships that focus on creating P-O fit for nurses and nurse assistants (Trybou et al., 2014).
Informal supervisor-nurse relationships, also called ‘Jeitinho’ in Brazil, could help realise the desired P-O fit through the “reciprocity of resources, emotional support, workload management, and staff participation in decision-making” (Brunetto, Shacklock, Teo, Farr-Wharton, & Nelson, 2015, p. 1030). This means that quality LMX can foster knowledge transfer to support evidence-based practice. The role of LMX in quality care is related to knowledge transfer. Davies, Wong, and Laschinger (2011) found that LMX coupled with nurse empowerment fosters evidence-based practice through enhanced knowledge sharing between nurses. Thus, improved nursing and patient outcomes could be achieved through LMX and structural empowerment initiatives that promote evidence-based care.
Supervisor-nurse relationships provide a mechanism for information sharing and communication, which contribute to cohesive clinical teams (Brunetto et al., 2013). A team would comprise of staff nurses with complementary skills in a clinical context. Creating high-performance teams depends on the quality of LMX relationships and related outcomes, such as trust, knowledge sharing, and support (Hanse, Jarebrant, Ulin, & Winkel, 2015). Cultivating positive behaviours, such as information exchange or communication, collaboration, and support, is dependent on supervisor styles and attributes with servant leadership producing a high LMX impact. In nursing, the impact of LMX quality on teamwork is of particular significance due to its potential effect on patient outcomes (Hanse et al., 2015).
In particular, lapses in supervisor-nurse communication can increase the risk of sentinel events and create role ambiguity. Therefore, based on the LMX model, the quality of the supervisor-nurse relationship would affect nursing teamwork, and by extension, patient outcomes. Poor supervisor-nurse relationship would affect teamwork, enhance role ambiguity, and hinder nurses’ access to “resources, information, and support” and their involvement in decision-making (Shanock & Eisenberger, 2006, p. 693). In this case, poor teamwork experiences are likely to lead to low patient outcomes.
Exploration and Discussion of LMX Issues in Nursing Workplaces
The global nature of nursing workplaces means that they attract individuals with diverse cultural, religious, and racial/ethnic backgrounds. The staff diversity extends to educational levels, ranks, and age. Achieving a balance between the different needs and styles/skills of the diverse workforce would help avoid negative LMX issues such as generational, religious, gender, and racial stereotypes that would impede quality social exchanges. It requires leaders to develop workplace policies and practices that support diversity to avert the LMX challenges.
Since the nursing workforce is ageing, clinical environments contain a mix of the ‘millennials’ generation and baby boomers who are nearing retirement. The growing population of millennials in the workplace is bound to change workplace dynamics because of diverse values, beliefs, and preferences (Siantz, 2008). Additional generational differences related to educational level and training experiences. Stereotypes against older or younger generations could strain workplace relationships.
Supervisors must balance between the competing generational values to avoid stereotypes and turnover of the cohorts. Siantz (2008) examines the behaviour differences between baby boomer and generation X nurses. They found that the quality of LMX influenced perceptions of wellbeing and organisational commitment, which differed by 17.9% between the two groups (Siantz, 2008). Therefore, high-quality supervisor-nurse relationships enhance the wellbeing and affective commitment of nurses of all ages. In contrast, low-quality LMX affects intergenerational trust and respect and increases turnover/early retirement intentions.
Gender similarity or dissimilarity in the workplaces may affect LMX relationships because of its impact on information sharing. According to Jones (2009), gender differences between dyad members are associated with communication apprehension that leads to low-quality LMX. This often arises when the gender of the leader/supervisor differs from that of the subordinate staff member.
The impact of gender dissimilarity on LMX relationships is more significant in professions that are traditionally a preserve of one gender (Jones, 2009). For example, women have traditionally dominated the nursing field. Communication apprehension is high when there is gender dissimilarity between the dyadic members (Jones, 2009). Thus, male nurses may experience communication apprehension when interacting with female supervisors or vice versa. Dyadic members are likely to interact more when they are of the same gender. As a result, in gender dissimilar dyads, the reciprocity process will be hampered, affecting the development of high-quality LMX relationships. Furthermore, stereotypes related to the belief that nursing is a female profession may affect quality social exchanges between male and female nurses.
Level of Education
Besides age and sex, the dyadic level of education is a critical demographic factor in the development of LMX relationships. The level of education of the supervisor and subordinate influences the interactional patterns and intra-communication, which play a role in LMX formation (Duffy & Ferrier, 2003). A similarity in educational attainment between the leader and subordinate fosters compatibility in views, trustful relationships, and high-quality interactions (Duffy & Ferrier, 2003).
This rationale for this is that dyadic members with similar demographics have identical values/interests, which means that they can engage in meaningful social exchanges. Therefore, ineffective communication with the supervisor due to rank or a variation in educational levels is likely to make the subordinate withdrawn, increasing his or her desire to leave the organisation.
Further, research indicates that supervisors award higher performance ratings to in-group members because of frequent interactions and communication (Farr-Wharton et al., 2011). Further, the similarity in academic attainment between the supervisor and the nurse is likely to reduce role ambiguity, resulting in better patient outcomes. Therefore, staff training – formal courses and informal learning – could help address the variance in educational level in a dyadic relationship to achieve a high-quality LMX.
Another negative issue related to LMX is the religious affiliation of the dyadic members. Religion influences the LMX elements of loyalty, servant leadership/humility, and affective commitment (Hanse et al., 2015). This means that specific aspects of religion, including humility, collectivism, and stewardship, determine the quality of the exchanges between the leader and his/her follower. In a diverse nursing environment, positive aspects of religion, such as stewardship and humility, could help build quality relationships with the subordinates.
On the other hand, religious stereotypes or criticisms of one’s spiritual beliefs or manner of dress would strain the LMX relationship between the nurse manager and the staff nurse. Therefore, the leader should discourage religious stereotypes through diversity policies and decisions that do not infringe on the rights of minorities and servant leadership. Furthermore, creating an atmosphere of religious tolerance is likely to help foster a high-quality exchange relationship between the supervisor and the nurses.
In workplace environments, racial or ethnic stereotypes develop out of salient demographic attributes ascribed to individuals or groups. Looking at group members in stereotypical terms increases the likelihood of intra-group polarisation (Chrobot-Mason, 2004). Therefore, racial/ethnic stereotypes often lead to subgroup favouritism that tends to cause negative group processes and increases the likelihood of conflicts (Chrobot-Mason, 2004). As a result, the intra-group cohesion and interaction, which are necessary for stronger LMX relationships, will not develop.
Further, stereotypes at the societal level, such as the association of race/ethnicity to clinical competencies, could happen at the group level. When such stereotypical beliefs occur within groups, they result in skewed treatment of a nurse based on race and not clinical competencies (Chrobot-Mason, 2004). The negative group processes and biased interactions between the supervisor and staff nurse due to racial/ethnic differences would result in low quality of LMX relationships.
Practical Strategies to Improve the Quality of LMX
Studies indicate that supervisor-nurse relationships influence feelings of empowerment and satisfaction, especially in public hospitals (Brunetto et al., 2012). Given the strong link between empowered staff and job satisfaction, strategies that improve empowerment and shared decision-making will improve the quality of LMX. The specific strategies identified in the literature are described below.
Supervisors could improve the quality of LMX relationships with their subordinates by implicitly displaying positive or exemplary behaviour to the staff nurses. Examples of such behaviours include positive nurse-patient interactions (comforting) and effective supervisor-nurse communication, teamwork, and mutual respect (Skinner et al., 2011). The nurse manager’s role-modelling behaviour is associated with improved teamwork in clinical settings. Schyns and Day (2010) argue that subordinates are likely to imitate positive supervisor behaviours like sharing of knowledge and resources and providing peer support. Therefore, nurse supervisor role-modelling behaviour is likely to have a positive impact on LMX relationships.
The role of cultivating and refining the behaviour of information/resource sharing at the unit level falls squarely on the supervisor. In nursing, the relationship between quality supervision and teamwork is of utmost significance because of its impact on patient outcomes (Davies et al., 2011). Therefore, supervisor support and teamwork are important role-modelling behaviours for better nursing communication to minimise the risk of adverse events.
Improved Nurse Autonomy
The quality of LMX is dependent on how the supervisory power is used by nurse managers. In the public sector, the growing demand for accountability to achieve organisational goals at minimal budgets has affected the supervisor-nurse power balance and nurse autonomy (Davies et al., 2011). The responsibility of achieving the set organisational goals is often left to the unit supervisors, resulting in higher supervisory power, but lower nurse autonomy. The result of this situation is heavy workloads, inflexible schedules, and high accountability requirements that strain the supervisor-nurse relationship, leading to decreased job satisfaction and higher turnover intentions (Davies et al., 2011).
A practical solution to this problem is nurse empowerment through delegation or new assignments. As stated, ‘in-group’ experiences constitute a key antecedent of high-quality LMX relationships (Choy, McComarck, & Djurkovic, 2016). Empowered nurses will have adequate power to make sound clinical decisions and implement evidence-based quality interventions. Low remuneration and poor working conditions make nurses feel disempowered. In this regard, adequate remuneration, training/development opportunities, better workplace conditions, and resource/support provision would help create an empowered nursing workforce.
Based on the LMX framework, high-quality relationships are likely to arise when nurses are empowered and exercise autonomy in their professional role. Brunetto et al. (2015) suggest that nurse empowerment can be realised by ensuring that unit managers have the necessary KSAs to convert HR policies into empowerment initiatives. In addition, the decentralisation of the decision-making role to individual units will also contribute to the empowerment
Training and Development Opportunities
On-the-job training of nurses could allow them to learn important skills and competencies required in practice. Nurses, like other professionals, are required to improve their skills throughout their career. As such, providing opportunities for nurses to learn and apply new skills in their role is an important supervisory role. Based on the tenets of the LMX theory, training/development opportunities will positively impact on the quality of supervisor-nurse relationship because training empowers employees and increases organisational commitment and job satisfaction (Choy et al., 2016).
Besides the formal training, informal learning opportunities can also improve the quality of LMX relationships. Informal learning is likely to arise when nurses interact in interdependent teams. Further, the likelihood of a transfer of knowledge occurring is higher in high-quality supervisor-nurse relationships or networks than in low-quality ones (Choy et al., 2016). Therefore, providing opportunities for informal learning can impact positively on the quality of LMX relationships at the unit level.
The LMX theory gives an important framework for analysing supervisor-subordinate relationships. Its core tenets are social exchanges and reciprocity. Based on the analysis of scholarly research, the importance of LMX in practice relates to improved job satisfaction, organisational commitment, retention, and teamwork. In nursing practice, the most significant LMX issues include teamwork, nursing autonomy and wellbeing, and role ambiguity. These issues could be ameliorated through supervisor role-modelling behaviour, improved nurse autonomy and empowerment, and training and development.
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