Transformational Leadership of Clinical Nutrition Managers

RESEARCH

Transformational leadership of clinical nutrition managers MARY BETH FOLTZ ARENSBERG, PhD, RD; M. ROSITA SCIIILLER, PhD, RD; VIRGINIA M. VIVIAN, PhD; WAYNE A. JOHNSON, PhD; STEVEN STRASSER, PhD

I

I

ABSTRACT Objective To identify leadership qualities of clinical nutrition managers and associate these leadership qualities with selected demographic variables (eg, traffdng/degree, length of time in management, number of people supervised, income, and participation in advanced practice activities). Design The theory of transformational leadership, that is, leadership that incorporates specific interpersonal behaviors of the leader and his or her actions within the organization, provided the framework for the study. Specific transformational leadership qualities - - leader behavior, leader personal characteristics, and the effect of the leader on organizational functioning and culture - - were measured using the Leadership Behavior Questionnaire (LBQ). The reliability and validity of the LBQ have been reported previously. Other data were obtained using two demographic surveys. Sample Demographic surveys were mailed to 1,599 members of the Clinical Nutrition Management dietetic practice group. From the 951 (59.8%) respondents, a study sample of 150 clinical nutrition managers and their subordinates was selected to receive the LBQ; 116 (77.3%) instrument sets were used for analysis. Statistical Analysis Descriptive statistics were used to analyze the demographic storeys. A specified mixed linear model repeated measures Statistical Analysis System

procedure was used to compare clinical manager and subordinate LBQ scores. Association of the selected demographic variables with leadership qualities was measiJred by %, a predictive value measure, using the BMDP 4F program. Results Clinical nutrition managers exhibited transformational leadership qualities as rated by the LBQ, rating lowest on the communication leadership score and highest on the respectful leadership score. Most of the clinical nutrition manager self LBQ scores were significantly higher than the clinical nutrition manager LBQ scores rated by subordinates. The selected demographic variables appeared to have the strongest predictive effect for the visionary culture building subscore of the LBQ. The visionary culture building subscore is a measure of how well the leader interacts with and affects the functioning of an organization. Applications/Conclusions More research is needed to define leadership in dietetics: this study can serve as a possible model. One way clinical nutrition managers may be able to enhance their leadership behaviors is to strengthen their skills in communicating their vision. Programs are needed to help clinical nutrition managers shape their organizations to foster leadership development in their subordinates. J A m Diet Assoc. 1996; 96:39-45.

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sion only. Such theories do not consider the new values of people who are no longer fulfilled solely by their work. Nor do these theories explain why some organizations are successful and have enthusiastic members whereas others do not. The answers to these questions are found, in part, in the more contemporary theory of transformational leadership (6). Transformational leadership theory is characterized by a much broader, more multidimensional approach than traditional leadership theories. In transformational leadership theory, leadership is viewed not as a single factor, but rather as resulting from several interacting factors. Leadership reflects personal characteristics of the leader, such as power and influence, and situational or organizational contexts in which the leader and followers interact, thus accounting for the leader's ability to affect the organization's functioning. In addition, this new theory incorporates specific interpersonal behaviors of the leader and his or her actions within the organization. Transformational leaders help people and organizations survive in a complex world, master change, and move ahead in the future. Such leaders also help employees gain a greater sense

strong need for leadership in dietetics exists today. Yet what do we mean by "leadership"? The traditional theories that have been used to define leadership in the past, Lsuch as trait theories (1,2), situational or environment theories (3), or the definition of unique leadership styles/ behaviors (4,5), seem to define leadership along one dimen-

M: B. Iq Arensberg is the manager of nutrition services of Ross Products Division, Abbott Laboratories, Columbus, Ohio. M. R. Schiller is the director and a professor in the Medical Dietetics Division in the School of Allied Medical Professions, K M. Vivian is a professor emeritus, and W. A. Johnson is a professor in the Department of H u m a n Nutrition and Food Management in the College of H u m a n Ecology, and S. Strasser is an associate professor of Health Services Management and Policy at The Ohio State University, Columbus. Address correspondence to: Mary Beth Foltz Arensberg, PhD, RD, Nutrition Services, Department 106717-$5, Ross Products Division, Abbott Laboratories, 625 Cleveland Ave, Columbus, OH 43215.

JOURNAL OF THE AMERICANDIETETICASSOCIATION/ 39

RESEARCH

Table 1 Leadership Behavior Questionnaire (LBQ) scales ( a d a p t e d from Sashkin [27])

Scale

Definition

Visionary leadership behavior scales Scale 1: Focused leadership Scale 2: Communication leadership Scale 3: Trust leadership Scale 4: Respectful leadership Scale 5: Risk leadership

Leader's ability to manage his or her attention and to direct the attention of others Leader's interpersonal communication skill, including the ability to convey meaning of message, and attention to and appreciation for feelings, including leader's own feelings and those of others Leader's perceived trustworthiness, willingness to take clear positions and avoid "flip-flop" shifts in position, and ability to follow through on commitment Leader's treatment of others and himself or herself in daily interactions, ability to consistently express concern for others and their feelings, and sense of how he or she fits into the organization Leader's ability to take risks that help implement parts of his or her vision and ability to design risks that others can "buy into" so others participate in making the leader's vision real

Visionary leadership characteristics scales Scale 6: Bottom-line leadership Scale 7: Empowered leadership Scale 8: Long-term leadership

Leader's sense of self-assurance and belief that he or she can personally make a difference and affect people, events, and organizational achievements Leader's need for power and influence to get things done, and use of power to empower others who can then use their power and influence to carry out elements of leader's vision Leader's ability to think clearly over relatively long time spans (at least a few years) and use of visions and specific goals as conditions to achieve long-term actions, and leader's ability to explain visions to others and understand how visions could be expanded beyond current plans

Visionary culture-building scales Scale 9: Organizational leadership Scale 1O: Cultural leadership

Leader's degree of positive impact on achievement of organizational goals and degree of helping organization adapt effectively, improve organizational functioning, and build teamwork Leader's ability to develop those values that will strengthen organizational functioning and at the same time build and support the leader's vision

of self-worth. Burns (7) described transformationalleadership as leadership that "occurs when one or more persons engage with others in such a way that leaders and followers raise one another to higher levels of motivation and morality" (p 20). Although there appears to be important commentary on the subject of leadership among health care professionals (8-19), there is little research applying leadership theory to specific health care disciplines, such as dietetics (20). To develop leaders in dietetics, it is important to discover the factors that will be critical to future practice. As explained by Parks et al (21), such questions can be answered by using research and a scholarly approach. Clinical dietetics represents the largest area of dietetics practice (22) and can serve as a model for leadership research. Clinical dietitians in management positions would logically lead their employees and, thus, are an appropriate group for initial research. In this study, transformational leadership qualities were identified for clinical nutrition managers who were members of the Clinical Nutrition Management (CNM) dietetic practice group of The American Dietetic Association (ADA). METHODS

In September 1992, a 60-item, demographic questionnaire was mailed to the US membership of the CNM dietetic practice group. The study population was defined as the 951 CNM members (59.8%) who responded to this questionnaire. A separate, nine-item demographic survey was used to help define the working relationships of the clinical nutrition managers with their subordinates. Drafts of both demographic questionnaires were reviewed by a panel of experts that included persons who had held leadership positions in CNM or who had experience in mail survey design. The Leadership Behavior Questionnaire (LBQ), developed by Sashkin and Burke (23), was used to measure transformational leadership qualities of the clinical nutrition managers. The LBQ defines the three key elements of transformational leadership - - the leader's behavior, the leader's personal characteristics, and the leader's effect on organizational function40 / JANUARY1996 VOLUME 96 NUMBER 1

ing and culture as visionary leadership behavior, visionary leadership characteristics, and visionary culture building, respectively. The LBQ is a standardized, self-administered instrument designed for use in management training and development. It comprises 50 items or questions, with five questions forming each of 10 scales. The 10 scales are then summed to form three subscores and an overall total score (Table 1). The reliability and validity of the LBQ have been reported previously (23-26). Because of the expense of the LBQ instrument and its marling, a study sample of 150 was systematically selected from the study population. First, we identified 222 clinical nutrition managers who met the following criteria: current CNM membership; current dietetic registration and/or licensure; employment as a clinical nutrition manager in a US hospital; direct supervision of astaff of three or more dietetics professionals; and consent to participate in the study and to recruit three subordinates (dietitians and/or dietetic technicians who directly report to the clinical nutrition manager) for participation. These surveys were arranged in zip code numerical order and every third survey was discarded to yield a final study sample of 150. This study sample of 150 clinical nutrition managers reeeived explanatory letters, instruction sheets, sets of LBQs (one "self" and three "others"), three copies of the subordinate demographic survey, and return envelopes. Participants were instructed to complete the self LBQ and provide the explanatory letters, subordinate demographic surveys, other LBQs, and envelopes to each of three direct-report subordinates. The subordinates were instructed to complete the instruments, using the other LBQ to rate their clinical nutrition manager, and return the subordinate demographic survey and other LBQ in sealed envelopes to their clinical nutrition managers. Clinical nutrition managers were asked to collect and mail all completed sm'vey instruments to the investigator (M.B.F.A.). Both demographic instruments and the LBQs were coded and processed at The Ohio State University Polymetrics Laboratory. We calculated statistics working with The Ohio State University Statistical Consulting Service and using Statistical

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Analysis System software (version 6.07, 1992, SAS Institute, Inc, Cary, NC) and BMDP statistical software package (1990, University of California, Berkeley, Calif). We analyzed the demographic surveys using descriptive statistics. For the LBQs, means and standard deviations were calculated for scale scores, subscores, and totals and were used to evaluate transformational leadership according to the LBQ's rating guidelines (27). The LBQ rating guidelines were based on normative data collected from 500 managers of business and community organizations (25). The few individual missing values in the LBQs were imputed with a nearestneighbor hot-deck procedure. This procedure was only used for individual missing values and not to generate entire LBQ survey scores. To compare clinical nutrition manager (self) LBQ scores and clinicalnutritionmanager subordinate (other) LB0 scores, a specified mixed linear model repeated measures Statistical Analysis Systems procedure was used; significance was computed by the approximate P test. Clinical nutrition manager (self) LBQ subseores and totals were used to associate transformational leadership qualities with these selected demographic variables: training/degree, length of time in management, number of people supervised, income, and participation in advanced practice activities (eg, management, research, and scholarly activities). Each subscore and total score was classified into three groups: the tow group comprised persons with ratings in the "very low" and "low" categories, the medium group comprised those rating "average," and the high group comprised those rating "high" and "very high," as evaluated by Sashkin's (27) rating scale. Missing values for the LBQ were again imputed with the nearestneighbor hot-deck procedure. The few missing defined study variables in the demographic surveys were equated to zero. The ability of the defined study variables to predict transformational leadership qualities was measured by calculating ~,, a predictive value measure, using the BMDP 4F program. RESULTS

Although the aim was to include 150 clinical nutrition managers in the study sample, only 121 (80.0%) survey instrument sets (including the clinical nutrition manager and subordinate LBQs and the subordinate demographic surveys) were returned. One set (1.0%) was returned late and four clinical nutrition managers (2.6%) chose not to participate and returned the survey sets uncompleted. One hundred thirteen sets (75.3%) were complete; that is, they contained the self and three other LBQs. Three sets had fewer than three other LBQs but were included in the study sample. Thus, the study sample consisted of 116 clinical nutrition managers. The clinical nutrition managers in the study sample were predominantly women (97.4%), and a majority had earned (67.2%) or had completed work toward (7.8%) a master's degree. Although respondents were employed in a variety of institutions, most worked in teaching (40.5%) or worked in community hospitals (39.7%), and most worked in hospitals with a bedsize of 250 to 499 beds (44.8%). Most respondents supervised at least some clinical nutrition staff and 91.2% had a staff of more than five full-time equivalent employees. Further demographic characteristics are summarized in Table 2. The study sample included 344 subordinate demographic surveys. The majority (88.1%) of these subordinates worked full-time. The most frequently reported titles were dietitian or nutritionist (57.1%), nutrition specialist (13.9%), dietetic technician (10.1%), or a management-level title (12.7%). In considering mean LBQ scores of clinical nutrition managers (self) and subordinates (other), clinical nutrition managers rated lowest on the communication leadership and highest

I

Table 2 Demographic characteristics of clinical nutrition managers participating in leadership study Characteristic

Clinical nutrition managers No. %

Years in current position (n = 116) <3 3-8 >8

46 45 25

39.7 38.8 21.6

Years in management (n = 116) <3 3-8 >8

21 54 41

18.1 46.6 35.3

Years in dietetics (n = 116) <1 1-5 6-10 11-15 16-20 >20

0 6 31 35 23 21

0.0 5.2 26.7 30.2 19.8 18.1

Number of promotions in dietetics field (n = 116) 0 1 1-2 61 3-5 50 >5 4

0.9 52.6 43.1 3.4

Route to registration (n = 116) Internship Coordinated program Master's/experience Approved preprofessional practice program traineeship Other Annual salary (n = 116) <$20,000 $20,000-30,000 $30,001-40,000 $40,001-50,000 $50,001-60,000 <$60,000

60 26 18

51.7 22.4 15.5

6 6

5.2 5.2

0 3 56 47 6 4

0.0 2.6 48.3 40.5 5.2 3.4

Number of clinical dietitians supervised a (n = 115) 0.0 0 0.1-5.0 53 5.1-10.0 42 10.1-15.0 17 15.1-20.0 2 >20 0

0.0 47.0 36.5 14.8 1.7 0.0

Number of clinical technicians supervised a (n = 83) 0.0 10 0.1-5.0 58 5.1-10.0 14 10.1-15.0 1 15.1-20.0 0 >20 0

12.0 69.9 16.9 1.2 0.0 0.0

aRefers to full-time equivalent employees.

JOURNAL OF THE AMERICANDIETETICASSOCIATION/ 41

RESEARCH

Table 3 Mean ( -+ standard deviation [SD]) self scores (self) and subordinate's scores (other) for clinical nutrition m a n a g e r s on the L e a d e r s h i p Behavior Questionnaire (LBQ) and ratings according to LBQ guidelines a Scale

Clinical nutrition manager (self) LBQ score (n = 116)

LBQ guideline rating a

",--- M e a n + S D ---.',

Focused leadershipb Communication leadership b Trust leadershipb Respectful leadershipb Risk leadershipb Visionary leadership behavior subscore c

Subordinate (other) LBQ score for clinical nutrition manager (n = 344)

LBQ guideline rating a

',---- M e a n +_ S D - ~

20.0 + 2.0 18.8 ± 2.5 21.0 + 2.0** 22.0 + 2.1" 19.9 +_2.5* 101.7 ± 8,4*

Average Average High High Average High

20.1 ± 3.1 18.4_+ 3.8 20.3 ± 3.2 21.4 + 3.0 19.3 ± 3.6 99.5 _+14.2

Average Average Average High Average Average

Bottom-line leadership b Empowered leadershi pb Long-term leadership b Visionary leadership characteristics subscore a

21.4-+ 2.4** 19.8 + 2.2** 19.6 _+3.2 60.7 ± 5.9**

High Average Average High

19.9-+ 3.2 18.5 _+3.1 19.1 _+3.7 57.4 -- 8.5

Average Average Average Average

Organizational leadership b Cultural leadershipb Visionary culture-building subscore e

21.8 ± 2.1 ** 20.4 ± 2.2** 42.2 _+3.6**

High Average Average

20.6 _+3.8 19.7 _+2.8 40.3 ± 6,0

High Average Average

197.3 _+26.9

Average

Visionary leadership total score f

204.6 ± 15,6"*

High

aLBQ rating as described by Sashkin (27). bpotential scale ratings: very high (23-25), high (21-22), average (18-20), low (16-17), very low (5-15). Cpotential visionary leadership behavior subscore ratings: very high (113-125), high (102-112), average (92-101), low (75-91), very low (25-74). dpotential visionary leadership characteristics subscore ratings: very high (68-75), high (60-67), average (51-59), low (42-50), very low (15-41). epotentiat visionary culture-building subscore ratings: very high (48-50), high (43-47), average (37-42), low (29-36), very low (10-28). fPotential visionary leadership total score ratings: very high (226-250), high (201-225), average (176-200), low (146-175), very low (50-145). *Significant difference when P<.05. **Significant difference when P<.01.

on the respectful leadership scales (Table 3). All of the mean self LBQ scores were higher than the mean other LB0 scores, with the exception of the focused leadership score; a number of those differences were statistically significant (Table 3). The selected demographic variables appeared to have the strongest predictive effect (ie, ;%values were highest) for the visionary culture-building subscore (Table 4). This subscore measures the leader's ability to create policies and programs that have a positive effect on how an organization functions and the leader's ability to support the values of the organization. Two demographic variables, appointment/election to local/regional offices and implementing techniques to enhance staff retention, also appeared to have predictive effect because ;%values for these variables were greater than 0.10 for several of the subscores and for the total (Table 4). DISCUSSION

In this descriptive study, clinical nutrition managers exhibited transformational leadership qualities as rated by the LBQ. Although there has been very limited research on transformational leadership in dietetics, this finding was not unexpected. First, transformational leadership is more likely to be found during crisis conditions rather than static or stable conditions (28). In other words, the impetus of change could promote the development of transformational leadership. Although the stability of individual institutions where clinical nutrition managers worked was not measured in tiffs study, in general, health care institutions are in a state of flux because of the impact of cost containment, managed care, and other challenges. Second, the study sample had several demographic characteristics that have been shown to be related to transformational leadership. The study sample was predominantly female. Some investigators have argued that gender does not affect transformational leadership (29,30), but others have 42/JANUARY 1996 VOLUME96 NUMBER 1

found that women are more transformational in their leadership than men (31). Having an advanced degree has also been shown to be related to transformational leadership (81,32), and the majority of the clinical nutrition managers in this sample either had master's degrees or had completed some work toward those degrees. Situational variables may have contributed to the transformational leadership exhibited by the clinical nutrition managers in this sample. The majority of clinical nutrition managers were from institutions with greater than 250 beds. Young (22) found that, as a group, nurse leaders with high transformational leadership scores worked in larger hospitals, on large[" nursing units, and supervised more employees. On the other hand, Dunham and Klafehn (21) found no significant relationship between transformational leadership and hospital size. Finally, personality factors might have affected the disposition of clinical nutrition managers for transformational leadership. Although this investigation did not evaluate specific personality factors, some, such as power, were indirectly measured by the LBQ. On the LBQ, the empowered leadership scale was a measure of the use of power to influence others. Few investiga!;ions have considered the power exhibited by dietitians. In our study, clinical nutrition manager (self) LBQ scores and subordinate's (other) LBQ scores for clinical nutrition managers were rated as average on empowered leadership. In contrast, Schiller et al (20) reported that the mean score for power in the clinical dietitians they studied was low compared with all other measured behavioral styles of clinical dietitians and compared with the normative data for their studyinstrument. Because their data were collected from 1986 to 1989, it could be that in the current health care environment clinicaI dietitians have developed a greater appreciation of and use for power. Another and more important consideration is the definition of power on the scale used by Schiller et al

Table4 Association of selected d e m o g r a p h i c variables with clinical nutrition manager (self) Leadership BehaviorQuestionnaire (LBQ) subscores and totals

Selected demographic variable

Visionary leadership behavior subscore

Years in management Route to registration Highest degree Annual salary Number of clinical dietitians supervised Number of clinical technicians supervised

0.000 0.059 0.020 0.020 0.000 0,000

0.000 0.000 0.089 0.067 0.000 0.000

O.148 0.097 0,081 0.129 O,148 0,210

0.000 0.000 0,023 0.023 0.000 0.000

116 116 116 116 115 83

0.020 0.000 0.098 0,118 0.020 0.039 0.039

0.000 0.000 0.000 0.111 0.067 0.133 0.067

0,113 0.145 0.226 0.194 0.081 0,323 0.177

0.023 0.000 0.047 0.163 0.047 0,093 0.047

115 116 116 116 116 116 116

0.000 0.020

0.000 0.000

0.113 0.161

0.000 0.000

116 116

Professional presentations local/regional Professional presentations state/national Public presentations--local/regional Public presentations--state/national Public p r e s e n t a t i o n s - r a d i o ~ t e l e v i s i o n

0.039 0.000 0.039 0.000 0.020

0.000 0.000 0.000 0.000 0.000

0.129 0.113 0.145 0.081 0.226

0.000 0.000 0.047 0.000 0.000

115 103 116 96 101

Publication of professional articles Publication of professional abstracts Publication of professional book chapters Publication of professional books Publication of consumer articles Publication of consumer brochures/monographs Publication of consumer book chapters Publication of consumer books

0.020 0.000 0.000 0.000 0.000 0.000 0,000 0.020

0.022 0.000 0.000 0.000 0.000 0.044 0.000 0.022

0.145 0.081 0.081 0.081 0,065 0.097 0.048 0.065

0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.023

116 107 102 104 114 110 97 98

Have/had professional mentor Serve/served as professional mentor Appointed/elected to local/regional office Appointed/elected to state/national office Attendance at workshops Involvement in leadership activities

0.039 0.000 0.118 0.000 0.039 0.000

0.000 0.022 0.067 0.000 0,022 0.000

0.146 0.113 0.242 0.161 0.113 0.129

0.000 0.000 0,070 0.000 0.000 0.000

116 115 115 101 114 116

Visionary leadership characteristics subscore

Visionary culture-building subscore

Visionary leadership total score

k value b

<

na

>

Management Developed performance objectives Developed CQI° program Implemented CQI programs Implemented staff retention programs Implemented staff development programs Implemented management programs Implemented marketing programs

Research Authored research proposals Managed research studies

Scholarly activities

aMissing values were equated to zero for this analysis. % is a predictive value measure and in this analysis measured the ability of the defined study variables to predict the LBQ subscores and total, X can have a minimum value of 0.000 and a maximum value of 1.000. Defined study variables with a X value >0.100 were interpreted as indicating a possible ability to predict LBQ subscores and total. cCQI = continuous quality improvement.

JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 43

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RESEARCH

(20) - - p o w e r was described as a negative trait and power managers were described as dogmatic, abrupt, hostile, and had little regard for others' feelings. This negative definition of power is somewhat similar to words dietitians themselves have used to describe power (33). In contrast, on the LBQ, empowered leadership was described positively. The clinical nutrition managers in our study may have found this new definition of power more acceptable than previous definitions. The evidence of strong transformational leaders in clinical nutrition management as documented in the present research is more definitive than the previous study of Schiller et al (20). In the study by Schiller et al (20) researchers documented that many clinical dietitians had a nigh self-actualization score, which the researchers believed indicated transformational leadership. However, the researchers also reported that a number of dietitians had high scores for dependency and severM other "negative" traits, which they concluded did not reflect transformational leadership. Several reasons may account for the difference in strengths of transformational leadership documented in the two studies. First, the study sample of Schiller et al (20) comprised clinical dietitians who, in general, represented smaller hospitals. Smaller hospital size itself could have been a factor limiting transformational leadership as previously found by Young (32). Also, it is possible that even though the sample of Schiller et al included clinical dietitians with supervisory responsibility, there could have been a smaller number of clinical dietitians who were in true management and leadership positions. These positions could have represented low-level managers who, as McDaniel and Wolf (34) documented, may have weaker transformational leadership skills. Another consideration is that the data presented by Schiller et al (20) were collected over a 4-year period, during which time the health care field was not faced with the severe pressures seen today. Also, the instrument used by those researchers, the Life Styles Inventory (LSI), was not developed to examine transformational leadership. Finally, their data were based exclusively on self-reports. It is not known if our data from subordinates would have provided similar or conflicting results to those Schiller et al (20) reported. We anticipated that the self and other LBQ scores for clinical nutrition managers would differ, but the finding that the self LB0 scores were consistently higher was unexpected. Some researchers (35,36) have documented that with their respective transformational leadership instruments, self-ratings are typically higher than ratings of the same leaders by subordinates and others. Yet the opposite has been reported by the LBQ developed by Sashkin and Burke (23). However, in the most recent normative data of Sashkin et al (37) this does not always appear to be true. In the field of dietetics, researchers investigating areas related to leadership, such as the image of the dietitian, reported that dietitians rated themselves lower than their peers rated them in the area of image (38-40). Perhaps in our study, the low score on the communication leadership scale indicates that dietitians did not clearly communicate their mission, vision, and values and, thus, were not perceived as being as high in transformational leadership qualities as they believed themselves to be. We anticipated that there would be some association between the defined selected demographic variables and the LBQ subscores and the LBQ total score because reports by other researchers (20,31,32) had indicated an association. However, the finding that the selected demographic study variables appeared to have a closer association with one par44 / JANUARY1996 VOLUME 96 NUMBER 1

ticular subscore, the visionary culture-building subscore, was unexpected. We did not find an association of this type in the literature. Dunham and Klafehn (31) and Young (32) considered various demographic variables and the relationship of those variables to transformational leadership, but used total measures of transformational leadership and did not consider subscores. Schiller et al (20) did consider subscores and the relation of the subscores to the characteristics of dietitians. However, the instrument used by these researchers to measure leadership, LSI, did not have scales that were well-correlated with those of the LBQ. We did not expect the finding that only two study variables, appointment/election to local/regional offices and implementing techniques to enhance staff retention, seemed to be more predictive of transformational leadership than were other defined variables. Schiller et al (20) found an association between holding local and regional offices and the scores of dietitians on the LSI instrument used to measure leadership in their study. Yet they also found an association between a number of other characteristics and the LSI scores of dietitians. Again, it may be that those differences were indicative of the differences in the instruments used for the two studies.

Transformational leaders help people and organizations survive in a complex world, master change, and move ahead in the future

As one of the first studies to explore transformational leadership in dietetics, the current investigation extends the work of Schiller et al ( 2 0 ) ' ~ several ways: an instrument was used that evaluated transformational leadership specifically; a defined area of dietetics practice, clinical nutrition management, was investigated; and the ratings of subordinates were considered. However, several limitations should be considered in data interpretation. First, the sample chosen for this research might not have been representative of clinical nutrition managers as a whole. We did not survey clinical nutrition managers who were not members of the CNM dietetic practice group. In addition, those selected for inclusion in the research were from larger hospitals and had supervisory responsibilities. Second, both clinical nutrition managers and subordinates might have responded t o t h e LBQ as they believed they should have and might not have answered truthfully. Also, some clinical nutrition managers could have selected those subordinates who would rate them the most positively. Third, there was the limitation of nonresponse, which frequently occurs in mailed surveys. In this study, nonresponse occurred at two levels - when the initial demographic smazey was mailed and when the LBQ was mailed. A fourth limitation was related to the selection of the LB0 and demographic instruments. The LB0 has been validated by previous research (23,25). However, it is still possible that the LBQ did not accurately evaluate all elements of transformational leadership. Finally, the demographic sur-

B~000QO0Q00000Dgg0Q0IiQtQ0Qo0000g0Q0t0a00Q0Q0I000Q000Q0gQoOQQI0t0O0000OQQ00oi0gI0I0IOQoQ00DIB00000O00O00QI00OQ000Dg00Oii0Q0I0tI0DQ0Q00QQ0IQOIiDQ0D0

veys d e v e l o p e d for this s t u d y w e r e r e v i e w e d by c o n t e n t exp e r t s b u t w e r e n o t validated.

APPLICATIONS With t h e p a u c i t y of r e p o r t e d r e s e a r c h on l e a d e r s h i p in clinical dietetics, this s t u d y p r o v i d e s i m p o r t a n t i m p l i c a t i o n s for t h e profession. First, this s t u d y c a n s e r v e as a m o d e l for m o r e r e s e a r c h to f u r t h e r define t r a n s f o r m a t i o n a l l e a d e r s h i p in dietetics a n d clinical n u t r i t i o n m a n a g e m e n t . To date, m o s t res e a r c h e r s in d i e t e t i c s h a v e n o t clearly d i s t i n g u i s h e d l e a d e r s h i p as different f r o m m a n a g e m e n t . N e w s t u d i e s are n e e d e d in which t h e d i s t i n c t i o n is specifically m a d e . A d d i t i o n a l r e s e a r c h should also b e f o c u s e d on d e l i n e a t i n g factors t h a t h e l p c o n t r i b ute to t h e d e v e l o p m e n t of t r a n s f o r m a t i o n a l l e a d e r s h i p skills in clinical n u t r i t i o n m a n a g e r s a n d o t h e r dietitians. B e y o n d b a s i c r e s e a r c h , t h e r e is a n e e d to e x a m i n e t h e o u t c o m e s of t r a n s f o r m a t i o n a l l e a d e r s h i p in t h e profession, i n c l u d i n g b o t h q u a n t i t a tive a n d qualitative outcontes. A s e c o n d r e c o m m e n d a t i o n is to i n c r e a s e c o m m u n i c a t i o n skills of clinical n u t r i t i o n m a n a g e r s . It s e e m e d t h a t o u r s t u d y group of m a n a g e r s p o s s e s s e d t h e c h a r a c t e r i s t i c s of t r a n s f o r m a t i o n a l l e a d e r s ( s u c h as s t r o n g b o t t o m - l i n e a n d l o n g - t e r m l e a d e r s h i p ) a n d visionary c u l t u r e - b u i l d i n g skills of organizational a n d c u l t u r a l l e a d e r s h i p , b u t w e r e n o t as s t r o n g in visionary l e a d e r s h i p b e h a v i o r s , p a r t i c u l a r l y c o m m u n i c a t i o n skills. Visionary l e a d e r s h i p b e h a v i o r s are i m p o r t a n t b e c a u s e t h e y inspire followers to b e c o m e e x c i t e d a b o u t t h e l e a d e r ' s goals and u n d e r s t a n d h o w as foliowers t h e y c a n build t h e s u c c e s s of the organization. This s t u d y i n d i c a t e s t h a t clinical n u t r i t i o n m a n a g e r s a l r e a d y r e c o g n i z e t h e i m p o r t a n c e of t h o s e b e h a v iors, yet m a n y lack t h e skill a n d t r a i n i n g to i m p l e m e n t s u c h behaviors effectively. Ways to e n h a n c e t h e i r i m p l e m e n t a t i o n of l e a d e r s h i p b e h a v i o r s could b e to s t r e n g t h e n t h e role of c o m m u n i c a t i o n in m a n a g e m e n t p r a c t i c e a n d to d e v e l o p u n d e r graduate and continuing education programs that provide training in c o m m u n i c a t i o n skills. F u r t h e r m o r e , t r a i n i n g prograras in t r a n s f o r m a t i o n a l l e a d e r s h i p for dietetics p r o f e s s i o n als n e e d to b e d e v e l o p e d to m o d e l b e h a v i o r s a n d e m p h a s i z e h a n d s - o n l e a d e r s h i p e x p e r i e n c e s a n d critiques of p e r f o r m a n c e s . The final r e c o m m e n d a t i o n is to develop p r o g r a m s a n d app r o a c h e s t h a t will help clinical n u t r i t i o n m a n a g e r s s h a p e t h e i r organizational e n v i r o n m e n t s to f o s t e r t h e d e v e l o p m e n t of t r a n s f o r m a t i o n a l l e a d e r s h i p in t h e i r s u b o r d i n a t e s . A s t r o n g n e e d urill c o n t i n u e to exist for t r a n s f o r m a t i o n a l l e a d e r s h i p in the profession. Clinical n u t r i t i o n m a n a g e r s a n d o t h e r d i e t e t i c s professionals m u s t l e a r n to p r e p a r e t h e way for t h e p r o f e s s i o n ' s t r a n s f o r m a t i o n a l l e a d e r s w h o will follow in t h e i r footsteps.

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