How are empowering leadership, self-efficacy and innovative behavior related to nurses' agency in distributed leadership in Denmark, Italy and Israel? 在丹麥、義大利和以色列，賦權領導力、自我效能和創新行為與護士的能動性有何關係？
Thomas Faurholt Jønsson PhD, Associate Professor ^(1){ }^{1} (D) | Esther Bahat PhD, Teaching Fellow Professor ^(2){ }^{2} | Massimiliano Barattucci PhD, Assistant Professor ^(3){ }^{3} Thomas Faurholt Jønsson 博士，副教授 ^(1){ }^{1} （D） |Esther Bahat 博士，助教教授 ^(2){ }^{2} |Massimiliano Barattucci 博士，助理教授 ^(3){ }^{3}
^(1){ }^{1} Department of Psychology and Behavioral Sciences, Aarhus School of Business and Social Science, Aarhus University, Aarhus, Denmark ^(1){ }^{1} 奧胡斯大學奧胡斯商業與社會科學學院心理學與行為科學系，丹麥奧胡斯 ^(2){ }^{2} The Israel Academic College, The University of Haifa, Israel, Haifa, Israel ^(2){ }^{2} 以色列海法大學以色列學術學院， 以色列海法， 以色列 ^(3){ }^{3} Faculty of Psychology, E-Campus University, Novedrate, Italy ^(3){ }^{3} E-Campus 大學心理學學院，義大利 Novedrate
Correspondence 通信
Thomas Faurholt Jønsson, Department of Psychology and Behavioral Sciences, Aarhus Business and Social Science School, Aarhus University, Bartholins Allé 11, DK-8000 Aarhus C, Denmark. Thomas Faurholt Jønsson，奧胡斯大學奧胡斯商業和社會科學學院心理學和行為科學系，Bartholins Allé 11， DK-8000 Aarhus C， Denmark。
This study was partially funded by the Velux Foundation. 這項研究部分由 Velux 基金會資助。
Abstract 抽象
Aim: The purpose of the study was to introduce the concept of distributed leadership to international nursing management by conducting a cross-national investigation of its relationships with empowering nursing leadership, nurses’ work self-efficacy and nurses’ innovative behaviour. 目的： 本研究的目的是通過對分散式領導與賦權護理領導、護士工作自我效能感和護士創新行為的關係進行跨國調查，將分散式領導的概念引入國際護理管理。
Background: Distributed leadership theory suggests that when more people lead processes together, innovation will be superior to solo leadership. However, we need knowledge about how nurse managers may enhance nurses’ distributed leadership agency (DLA), and whether such results are generalizable across countries. 背景：分散式領導理論表明，當更多的人一起領導流程時，創新將優於單獨領導。然而，我們需要瞭解護士管理者如何加強護士的分散式領導機構 （DLA），以及這些結果是否可以在各個國家推廣。
Method: The cross-national survey with an overall purposeful sampling method used questionnaire data from hospital nurses from Israel ( n=239n=239 ), Italy ( n=226n=226 ) and Denmark ( n=709n=709 ). We used validated scales measuring Empowering Leadership, Self-efficacy, Innovative Work Behavior and DLA. 方法：採用總體目的性抽樣方法的跨國調查使用了來自以色列 （ n=239n=239 ）、義大利 （ n=226n=226 ） 和丹麥 （ ） 的醫院護士的問卷數據 n=709n=709 。我們使用了經過驗證的量表來衡量賦能領導力、自我效能感、創新工作行為和 DLA。
Results: The results from all three countries showed that empowering leadership and work self-efficacy were positively related to DLA, which, in turn, was also related to more innovation. 結果： 所有三個國家的結果都表明，授權領導力和工作自我效能感與 DLA 呈正相關，而 DLA 反過來也與更多的創新有關。
Conclusion: The results may imply that nursing managers can increase workplace innovativeness by adopting an empowering leadership style that supports nurses’ self-efficacy and distributes leadership tasks. 結論：結果可能意味著護理管理者可以通過採用支援護士自我效能感和分配領導任務的賦權領導風格來提高工作場所的創新性。
Implications for Nursing Management: The cross-country robustness of the results may encourage further research in distributed leadership in nurse management, notably with a focus on causal mechanisms. 對護理管理的影響：結果的跨國穩健性可能會鼓勵進一步研究護士管理中的分散式領導，特別是關注因果機制。
Distributed leadership designates when more people share leadership tasks, which is a rather new concept in nursing management. It differs from traditional leadership theory in that leadership is conceived of behaviour that is distributable among many persons, whose 分散式領導是指當更多的人分擔領導任務時，這在護理管理中是一個相當新的概念。它與傳統領導理論的不同之處在於，領導力是由許多人之間可分配的行為構成的，他們的
cooperation may ensure better management than when only one or a few lead to complex processes (Gronn, 2002). The concept of distributed leadership attracts increasing attention in the area of health care management at large because its practices promise to explain how complex health care organisations may be led and developed effectively with increased staff engagement, staff satisfaction and team 與只有一個或幾個導致複雜過程時相比，合作可以確保更好的管理（Gronn，2002 年）。分散式領導的概念在整個醫療保健管理領域引起了越來越多的關注，因為它的實踐有望解釋如何通過提高員工參與度、員工滿意度和團隊來有效地領導和發展複雜的醫療保健組織
performance (De Brún et al., 2019). While the benefits of distributed leadership for performance have been supported in a recent review (Jambo & Hongde, 2020), less is known about what may stimulate a nurse to engage with leadership activities, instead of merely focusing on executing her task. Research suggests that distributed leadership may have a potential to improve innovation in health care organisations (Chreim et al., 2010), which may be a key factor in employeedriven innovation (Jønsson et al., 2020). Such innovation processes may be of great importance in a time, in which rapid environmental changes in the economy, politics/policies, medical technology, professional knowledge and epi- and pandemics require nurses to develop innovative responses to new demands and conditions for providing sustainable health care services (McSherry & Douglas, 2011). 性能（De Brún et al.， 2019）。雖然最近的一篇評論（Jambo & Hongde，2020）支援了分散式領導對績效的好處，但對於什麼可能會激發護士參與領導活動，而不僅僅是專注於執行她的任務，人們卻知之甚少。研究表明，分散式領導可能具有改善醫療保健組織創新的潛力（Chreim et al.， 2010），這可能是員工驅動創新的關鍵因素（Jønsson et al.， 2020）。這樣的創新過程可能在一個時代非常重要，在這個時代，經濟、政治/政策、醫療技術、專業知識以及流行病和大流行病的快速環境變化要求護士針對提供可持續醫療保健服務的新需求和條件制定創新反應，提供可持續的醫療保健服務（McSherry & Douglas）。
Exploring relationships between assumed antecedents (i.e. empowering leadership and nurses’ self-efficacy) and assumed consequences (nurses’ innovative behaviour) of distributed leadership agency (DLA) can help shed light on whether it has a potential for nursing management, and what factors may likely stimulate distributed leadership among nurses. Moreover, it can be crucial to investigate whether findings regarding distributed leadership are similar in different countries, thereby elucidating the possibilities of an international generalization of findings; if the results support crosscountry generalization, the phenomenon of distributed leadership may be more relevant for international nursing management than for merely a selected group of similar countries. 探索分散式領導機構 （DLA） 的假設前因（即授權領導和護士的自我效能）與假設後果（護士的創新行為）之間的關係，可以説明闡明它是否具有護理管理的潛力，以及哪些因素可能會刺激護士之間的分散式領導。此外，調查不同國家關於分散式領導的調查結果是否相似，從而闡明對調查結果進行國際推廣的可能性可能至關重要;如果結果支持跨國推廣，那麼分散式領導現象可能與國際護理管理更相關，而不僅僅是一組選定的類似國家。
1.1 | Distributed leadership agency 1.1 |分散式領導機構
Leadership becomes distributed at a workplace in two ways: in a top-down fashion via delegation and in a bottom-up fashion in which employees seize leadership of an issue (Bolden, 2011). The former pertains to the phenomenon when head nurses delegate leadership tasks to subordinates, who may or may not have a formal leadership position. Many institutional ‘hybrid’ roles reflect the delegation of leadership tasks to nurses without leadership positions and with continuous clinical tasks (Fitzgerald et al., 2013); they include roles such as team leaders, clinical coordinators, development nurses, quality managers and clinical supervisors. Nurses assigned with these roles exert leadership of a particular area: for example, a development nurse keeps up with clinical evidence and innovations in medical technology and uses her updated knowledge to develop practice at a ward. Leadership can also become distributed among more persons spontaneously and in a bottom-up process by nurses, who simply take the lead of action through their own initiative. Situational factors, such as a recurring problem or suboptimal processes, may instigate nurses to initiate cooperation, making problem-solving decisions, coordinating their efforts and implementing solutions (Gronn, 2002). Since employees influence each other to achieve a common goal, by definition, such behaviour is leadership, and it is distributed because it increases the number of people involved in leading a ward unit. 領導力以兩種方式在工作場所分佈：通過授權以自上而下的方式，以及以員工抓住某個問題的領導權的自下而上的方式（Bolden，2011）。前者與護士長將領導任務委派給下屬的現象有關，這些下屬可能具有也可能沒有正式的領導職位。許多機構的「混合」角色反映了將領導任務委派給沒有領導職位和有連續臨床任務的護士（Fitzgerald 等人，2013 年）;他們包括團隊負責人、臨床協調員、開發護士、質量經理和臨床主管等角色。被分配這些角色的護士在特定領域發揮領導作用：例如，發展護士跟上臨床證據和醫療技術的創新，並利用她的最新知識來發展病房的實踐。護士也可以自發地和自下而上的過程將領導力分配給更多的人，他們只是通過自己的主動性來領導行動。情境因素，例如反覆出現的問題或不理想的流程，可能會促使護士開始合作，做出解決問題的決定，協調他們的工作並實施解決方案（Gronn，2002 年）。由於員工為了實現一個共同的目標而相互影響，因此根據定義，這種行為就是領導力，它是分散式的，因為它增加了參與領導病房單位的人數。
While distributed leadership is inherently a collective concept, DLA focuses on individuals’ degree of active goal-oriented engagement, 雖然分散式領導本質上是一個集體概念，但 DLA 關注個人積極目標導向的參與程度，
that is ‘agency’ in leadership tasks (Jønsson et al., 2016). Jønsson et al., (2016) departed from Yukl et al., (2002), three meta-categories of leadership, and measured DLA as the intensity of active engagement in leading tasks and work processes, sustaining and developing human capital, and influencing towards organisational change. From a managerial perspective, the mean level of DLA indicates the intensity of distributed leadership in a given unit. By implication, a well-led unit would depend on a great deal of nurses contributing to leading the many activities necessary for a successful ward unit, including more innovative behaviour. To the individual nurse, DLA may also be important, as findings show employees with higher degrees of DLA to be more autonomous, satisfied with their jobs and committed to their organisations, than employees with less DLA (Barattucci et al., 2020; Jønsson et al., 2016; Unterrainer et al., 2017). 這就是領導任務中的“能動性”（Jønsson et al.， 2016）。Jønsson 等人（2016 年）離開了 Yukl 等人（2002 年）的三個領導力元類別，並將 DLA 測量為積极參與領導任務和工作流程、維持和發展人力資本以及影響組織變革的強度。從管理的角度來看，DLA 的平均水準表示給定單位中分散式領導的強度。這意味著，一個領導良好的單位將取決於大量的護士為領導一個成功的病房單位所需的許多活動做出貢獻，包括更具創新性的行為。對於護士個體來說，DLA 可能也很重要，因為研究結果表明，與 DLA 程度較低的員工相比，DLA 程度較高的員工更自主、對工作感到滿意並致力於自己的組織（Barattucci 等人，2020 年;Jønsson 等人，2016 年;Unterrainer 等人，2017 年）。
1.2 | Empowering leadership 1.2 |賦予領導力權力
Several authors have proposed how leaders may stimulate and support employees’ agency in distributed leadership, including involving and supporting interested and talented employees in leadership activities (Huggins et al., 2017). Little research exists about leadership styles and distributed leadership. A notable exception is GünzelJensen et al., (2016), who found that empowering leadership was more strongly associated with DLA than transformational leadership. Empowering Leadership intends to increase employee experiences of meaning, competence, self-determination and impact on the organisation (Ahearne et al., 2005); empowerment has proven to be important for nurses, as it has been associated with a higher job satisfaction (Cicolini et al., 2014), organisational commitment and fewer intentions to quit the job (Spence Laschinger et al., 2009). Empowering leadership may stimulate a DLA in at least two ways. First, empowering leaders may delegate leadership tasks more, and second, the experiences of an empowering leader may support an empowering climate, in which employees take the lead and solve problems autonomously. 幾位作者提出了領導者如何在分散式領導中激發和支持員工的能動性，包括讓感興趣和有才華的員工參與領導活動並提供支援（Huggins et al.， 2017）。關於領導風格和分散式領導的研究很少。一個值得注意的例外是 GünzelJensen 等人（2016 年），他們發現授權領導與 DLA 的相關性比變革型領導更強。授權領導力旨在增加員工對意義、能力、自決和對組織的影響的體驗（Ahearne et al.， 2005）;事實證明，賦權對護士很重要，因為它與更高的工作滿意度（Cicolini 等人，2014 年）、組織承諾和更少的辭職意圖有關（Spence Laschinger 等人，2009 年）。授權領導可能至少以兩種方式刺激 DLA。首先，授權領導者可能會更多地委派領導任務，其次，授權領導者的經驗可能會支援一種授權氛圍，在這種氛圍中，員工帶頭並自主解決問題。
Hypothesis 1 The more empowering leadership a nurse experiences, the more DLA he/she displays. 假設 1 護士經歷的賦權領導越多，他/她表現出的 DLA 就越多。
1.3 | Work self-efficacy 1.3 |工作自我效能感
Not every person desires to be involved in leadership activities, but may prefer to focus on executing their normal tasks. Some may perceive it uncomfortable to expand one’s role to include leadership tasks, for example if they do not feel competent enough. In other words, a willingness to engage in leadership tasks may depend on work self-efficacy, that is a belief in one’s capacity to master the tasks at work. Theoretically, self-efficacy is a motivating force that facilitates a higher goal-setting and effort to reach goals (Bandura, 2006). A person who feels confident about her professional skills and abilities may be more inclined to accept and proactively reach out for 並非每個人都希望參與領導活動，但可能更願意專注於執行他們的正常任務。有些人可能會覺得將自己的角色擴大到包括領導任務是不舒服的，例如，如果他們覺得自己不夠稱職。換句話說，參與領導任務的意願可能取決於工作自我效能感，即相信自己有能力掌握工作任務。從理論上講，自我效能感是一種推動力，有助於設定更高的目標並努力實現目標（Bandura，2006）。對自己的專業技能和能力有信心的人可能更傾向於接受並主動伸出援手
participation in leadership activities. Jønsson et al., (2016) confirmed the positive relationship between self-efficacy and DLA among hospital employees with various occupational backgrounds. We hypothesize that the same relationship can be found when focusing specifically on nurses. 參與領導活動。Jønsson 等人（2016 年）證實了具有不同職業背景的醫院員工的自我效能與 DLA 之間的正相關關係。我們假設，當專門關注護士時，可以找到相同的關係。
Hypothesis 2 The more work self-efficacy a nurse experiences, the more distributed leadership he/she displays. 假設 2 護士經歷的工作自我效能感越多，他/她表現出的分散式領導能力就越強。
Based on the aforementioned, we suggest that the combination of a highly empowering leader and a high self-efficacy will interact and boost DLA more than the two factors do separately. In other words, when an empowering leader invites a nurse to engage in leadership activities, self-efficacy may play an important role in her degree of engagement. 基於上述情況，我們認為，與這兩個因素單獨相比，高度賦權的領導者和高自我效能感的結合將更能相互作用和促進 DLA。換句話說，當賦權領導者邀請護士參與領導活動時，自我效能感可能在她的參與度中發揮重要作用。
Hypothesis 3 Empowering leadership will be more strongly related to distributed leadership agency for nurses with a higher self-efficacy than for nurses with a lower self-efficacy. 假設 3 與自我效能感較低的護士相比，授權領導與自我效能感較高的護士的分散式領導代理的關係更緊密。
1.4 | Innovative behaviour 1.4 |創新行為
Several researchers put nurses’ innovative behaviours at the centre of health care improvement in a broad range of areas spanning from research, clinical practices and technology to education (Åmo, 2006; Weng et al., 2015). Innovative behaviour can be understood as generating, getting support for and implementing creative ideas that improve outcomes, actions, products and processes (Janssen, 2000; Weng et al., 2015). The literature’s indications suggest distributed leadership to be an important factor in innovation (Chreim et al., 2010; Jønsson et al., 2016), with the main idea being that leading work processes will be a resource for nurses to think differently, get new ideas, promote those ideas and engage in the implementation of innovations. 一些研究人員將護士的創新行為置於醫療保健改進的中心，涉及從研究、臨床實踐和技術到教育的廣泛領域（Åmo，2006 年;Weng et al.， 2015）。創新行為可以理解為產生、獲得支援和實施改善結果、行動、產品和流程的創造性想法（Janssen，2000 年;Weng et al.， 2015）。文獻的跡象表明，分散式領導是創新的一個重要因素（Chreim et al.， 2010;Jønsson 等人，2016 年），主要思想是領導工作流程將成為護士以不同的方式思考、獲得新想法、推廣這些想法並參與創新實施的資源。
Hypothesis 4 Distributed leadership agency will be positively related to innovative behaviour. 假設 4 分散式領導能動性將與創新行為呈正相關。
Several variables have been identified as promoters of innovative behaviour, ranging from nurses’ psychological capital and job control (Yan et al., 2020) to nurse leadership (Weng et al., 2015). Since leadership and self-efficacy (Hammond et al., 2011) have been identified as potential factors in innovation, we suggest that DLA may be an intermediate variable between innovation and empowering leadership, as well as self-efficacy. Once again, the main idea is that self-efficacy and empowering leadership stimulate an active engagement in leading, which in turn stimulates nurses’ innovative cognition and behaviour. 幾個變數已被確定為創新行為的推動者，從護士的心理資本和工作控制（Yan et al.， 2020）到護士領導（Weng et al.， 2015）。由於領導力和自我效能感 （Hammond et al.， 2011） 已被確定為創新的潛在因素，我們認為 DLA 可能是創新與賦權領導力以及自我效能感之間的中間變數。再一次，主要思想是自我效能感和授權領導會激發護士積极參與領導，這反過來又會激發護士的創新認知和行為。
Hypothesis 5 Distributed leadership agency will mediate in relationships between self-efficacy and empowering leadership on the one hand, and innovative behaviour on the other. 假設 5 分散式領導能動性將一方面調解自我效能感和授權領導與創新行為之間的關係。
1.5 | Cross-national comparison 1.5 |跨國比較
In the research field of employee involvement, some research indicates that the presence and dynamics of involving employees are confined to some types of countries and cultures (Ahmad & Oranye, 2010), not least the Scandinavian countries (Gregory, 2003). However, others suggest that employee involvement has comparable mechanisms across countries (Ellefsen & Hamilton, 2000). Scandinavian health care workers’ degree of engagement in distributed leadership has been positively related to empowering leadership (Günzel-Jensen et al., 2016), work self-efficacy and innovation (Jønsson et al., 2016). Therefore, in addition to the Scandinavian sample of nurses, it seems essential to compare data from different countries and regions, such as the Middle East or the southern European nations. 在員工參與的研究領域，一些研究表明，員工參與的存在和動態僅限於某些類型的國家和文化（Ahmad & Oranye，2010），尤其是斯堪的納維亞國家（Gregory，2003）。然而，其他人認為，員工參與在不同國家之間具有可比的機制（Ellefsen & Hamilton，2000）。斯堪的納維亞醫護人員對分散式領導的參與程度與賦權領導力（Günzel-Jensen et al.， 2016）、工作自我效能和創新（Jønsson et al.， 2016）呈正相關。因此，除了斯堪的納維亞護士樣本外，比較來自不同國家和地區的資料似乎也很重要，例如中東或南歐國家。
Hypothesis 6 There will be no differences in the results between Israeli, Italian and Danish nurses. 假設 6 以色列、義大利和丹麥護士之間的結果不會有差異。
2 | METHODS 2 |方法
2.1 | Samples and settings 2.1 |樣本和設置
The overall sampling method was purposeful in that it aims at diversity in wards, thereby nurse specializations and managerial contexts. The purpose was to enhance generalizability across such contextual settings within the national samples. The crossnational sampling strategy was to extend the Danish sample from 2012 with the Israeli and Italian samples from 2019. Moreover, submethodologies to achieve diversity was snowballing (also to short cut managerial biases) (Israel), purposeful sampling different ward types (Italy) and purposefully sampling all wards in a hospital (Denmark). 總體抽樣方法是有目的的，因為它旨在實現病房的多樣性，從而瞭解護士專業和管理環境。目的是提高國家樣本中此類上下文設置的泛化性。跨國抽樣策略是將 2012 年的丹麥樣本擴展到 2019 年的以色列和義大利樣本。此外，實現多樣性的子方法是滾雪球式的（也是捷徑管理偏差）（以色列），有目的地對不同的病房類型進行抽樣（義大利）和有目的地對醫院的所有病房進行抽樣（丹麥）。
Sample sizes were calculated as the total number of valid returned questionnaires. Cases without any data in the scales at use in the present study were considered invalid. 樣本量計算為有效返回的問卷總數。本研究中使用的量表中沒有任何數據的病例被認為是無效的。
The Israeli sample consisted of 239 nurses from three public hospitals in Israel and different departments. The nurses were recruited by e-mail or in-person via a snowball strategy, in which one nurse led to another nurse, during 2019, from March to June. Addressing the nurses directly rather than through the organisations’ managers enabled respondents to feel free to answer honestly regarding their manager and organisational involvement. 以色列樣本包括來自以色列三家公立醫院和不同部門的 239 名護士。這些護士是通過電子郵件或通過滾雪球策略親自招募的，在 2019 年 3 月至 6 月期間，一名護士帶領另一名護士。直接與護士交談，而不是通過組織的經理，使受訪者能夠自由地誠實地回答他們的經理和組織的參與情況。
The final Italian sample consisted of 226 permanent nurses from three wards (surgery, general medicine and cardiology) of a public hospital in Italy (response rate on the total sample of nurses in the three wards =82.8%=82.8 \% ), who filled out the questionnaire between March and May 2019. The subsample was extracted from a larger sample of health care workers ( N=492N=492 ), which has been used for validation of the Italian DLA scale (Barattucci et al., 2020). 最終的義大利樣本包括來自義大利一家公立醫院三個病房（外科、全科醫學和心臟病學）的 226 名常設護士（三個病房護士總樣本的回復率 =82.8%=82.8 \% ），他們在 2019 年 3 月至 5 月期間填寫了問卷。子樣本是從較大的醫護人員樣本中提取的 （ N=492N=492 ），該樣本已用於驗證義大利 DLA 量表 （Barattucci 等人，2020 年）。
The Danish subsample of 709 nurses was taken from a larger sample of hospital workers of all professions, which has previously been 丹麥的 709 名護士子樣本取自所有職業的醫院工作人員的較大樣本，該樣本以前是