The Perspective of Leader-Member Exchange and Its Relation with Workplace Empowerment and Organizational Citizenship Behavior among Nurses

Context: Leader-member exchange captures the impact of nurses’ perceptions of support from their supervisors’ high-quality relationships, which may promote extra-role behaviors, enabling increased job satisfaction and workplace empowerment and nurses` organizational citizenship behavior. Aim: Assess the perspective of leader-member exchange and its relation with workplace empowerment and organizational citizenship behavior among nurses. Methods: A descriptive correlational design was used to achieve the aim of the study. This study was conducted at Benha University Hospital in general medical and surgical units. A Convenient sample consisted of 190 nurses who were working in the study setting, as mentioned earlier. Three tools used to collect the data; Subordinate (LMX-MDM) survey portion, Condition of Work Effectiveness Questionnaire (CWEQ), and Organizational Citizenship Behavior Scale. Results: The findings of this study indicated that more than half of nurses (54.7%) reported that they had a high-quality relationship with their supervisors, and 71.1% of nurses had a moderate level of workplace empowerment. Also, more than half of nurses (51.1%) had a moderate level of organizational citizenship behavior. Conclusions: There was a highly statistically significant positive correlation between the total score of leader-member exchange and total workplace empowerment, total organizational citizenship behavior. Also was a highly statistically significant positive correlation between the total workplace empowerment, total organizational citizenship behavior. The study recommended that hospital management needs to focus on involving staff nurses in the political processes in an organization and keep them informed about significant changes in the organization and have a protective attitude toward it.


Introduction
The study of leader-member exchange (LMX) has received enormous attention in health care management discourse over the past three decades. The LMX theory is grounded on the impression that leaders (supervisors) develop an exclusive relationship with every individual member (subordinates) (Aledeinat & Alrfou, 2017;Cropanzano et al., 2017). This theory showed two types of leader-member relationships, namely the in-group relationship and out-group relationship. This relationship ranges from those usually based on employment contracts and low-quality relationships (out-group) to those characterized by mutual trust, respect, liking, and reciprocal influence, and high-quality relationship (in-group) (Breevaart et al., 2015).
The quality of the relationship between leader and follower, how they influence each other in health care organization and their interdependency, the amount of physical or mental effort, material resources, information 1 Corresponding author: Nora Ahmed Abd Allah Mohamed and, or social support exchanged between the supervisor and subordinate promote organizational success or failure depending on the quality of the affiliation. High-quality relationships may produce extra-role behaviors enhancing outcomes, whereas low-quality relationships may lead to negative associations, dysfunction, and lower organizational outcomes (Breevaart et al., 2015).
Effective (high-quality) LMX relationships are characterized by high levels of mutual support, trust, and respect. LMX theory argues that high-quality supervisorsubordinate relationships are characterized by high levels of mutual support, trust, and respect, including access to information and participation in decision-making. Such high-quality supervisor-subordinate relationships result in staff that can undertake and complete tasks quicker and solves work-related problems more efficiently and effectively than staff in low-quality relationships. Likely, staff in high-quality supervisor-subordinate relationships will have access to relevant information and resources, as well as an empowering relationship because supervisors allocate increased organizational resources (time) towards them (Inanc, 2018).
The supervisors and their organizations may benefit because staff who are enthusiastic as they demonstrate creativity and enterprise in the workplace and have increased esteem and loyalty to their supervisor and organization. High-quality supervisor-subordinate relationships are likely to encourage supervisors to delegate decision making and power to their subordinates, empowering them. In contrast, low-quality relationships result in staff that tends to have inadequate information sharing and involvement in decision making and, in turn, lower perceived workplace empowerment (Rodwell et al., 2017).
Leader-member exchange operates as a construct with multiple dimensions, including; effect, contribution, loyalty, and professional respect. These dimensions were, affect that defined as "the mutual affection members of the dyad have for each other based primarily on interpersonal attraction rather than work or professional values." Loyalty has been explained as "the extent to which both leader and member publicly support each other's actions and character." The contribution has been defined as "the perception of amount, direction, and quality of work-oriented activity each member puts forth towards the mutual goals (explicit or implicit) of the dyad." Professional respect defined as "the perception of the degree each member of the dyad built a reputation, within and, or outside the organization, of excelling at his or her line of work" (Kapil & Rastogi, 2018).
Empowerment is a framework for nurse's professional growth and development. It seems likely to provide for an umbrella concept of professional development in nursing. Empowerment has been defined as the process of thinking and behaving as if one has power in the sense of control over significant aspects of one's life and work. To feel empowered, in the context of the nurses' relationship, means to understand the purpose and contribution of their work, and to believe that they are responsible for the work they do, and to own continual development and growth, personally and professionally (Zhang et al., 2018).
Workplace empowerment is a management technique used by healthcare organizations to improve organizational effectiveness. Also, working in an empowered condition has a positive impact on nurses, which have increased feelings of self-confidence and job satisfaction, higher motivation, and low physical/mental fatigue. Working situations in structural empowerment will be more likely to have management practices that increase nurses' feelings about trust in the organization and job satisfaction (Chamberlin et al., 2018).
Four structural conditions contributed to empowerment. These are; Access to opportunity refers to the possibility for growth and movement within the organization through increasing knowledge and skills. Access to resources relates to nurses` ability to acquire the financial means, materials, time, and supplies required to do the work. Access to information refers to having the formal and informal knowledge necessary to be useful in the workplace (technical knowledge and expertise required to accomplish the job and an understanding of organizational policies and decisions).
Access to support refers to receiving feedback and guidance from subordinates, peers, and superiors (Smith, 2019).
Organizational citizenship behavior (OCB) is a particular type of work habits which defines nurses' behavior as highly favorable to the organization and freedom of choice, indirectly or explicitly recognized by the formal reward system. OCB has the characteristics of extra-role behaviors that are not included in the job description, spontaneous behavior, without specific suggestions or commands, cooperative behavior, and behavior, which are not readily visible and assessed through performance evaluation. Behavior helps employees with work when the employee is absent, and orientation helps new employees in the department where they work, the supervisor's assistant with tasks, as well as supervisors coming early or staying late. So, it can be concluded that OCB is willing to cooperate outside individuals without expecting rewards (Shahab et al., 2018).
Organizational citizenship behavior has five dimensions: Altruism, civic virtue, sportsmanship, conscientiousness, and courtesy. Altruism is voluntary, discretionary behavior that includes helping others and preventing work-related problems from occurring. Civic virtue is voluntary behavior intended for a group or an organization. Nurses who show this behavior are willingly involved in the political processes in an organization and feel that they are "a part of a larger whole" they want to be well informed about significant changes in the organization and have a protective attitude toward it and its property (Arsenich, 2018).
Sportsmanship is discretionary and prosocial behavior. Nurses who display sportsmanship maintain a positive attitude toward work regardless of the inconveniences and frustrations that might arise. They also frequently display problem-solving behaviors and can contribute to positive work environments and group cohesion. Conscientiousness is a voluntary, extra-role behavior; nurses are "going above and beyond the call of duty". They exhibit high precision, tenacity, innovation, creativity, and ideal attendance. Courtesy is discretionary-helping behavior that involves cooperation and consideration. It manifests in work-related problems that would otherwise affect other nurses also, can also reduce tensions and conflict-prone attitudes and behaviors among colleagues. Courtesy could be considering a helping behavior, altruism, peacemaking, and cheerleading (Diaz, 2019).

Significance of the study
In nursing, Leader-member exchange, high-quality work relationships, workplace empowerment, and organizational citizenship behavior are the main factors for the organization's growth and success. However, lack of leader-member exchange, trust toward nurses, and misunderstanding of the nurse empowerment may decrease nurse organizational citizenship behavior. Fostering quality supervisor-subordinate relationships will encourage nurses to perform extra-role behavior, put more effort towards work, uplift the organization's image, and produce many favorable outcomes to support the organizational goals when they have strengthened a close association and support with their organization that will promote the occurrence of OCB. So, this study will be conducted to assess the perspective of leader-member exchange and its relation with workplace empowerment and organizational citizenship behavior among nurses.

Aim of the study
The present study aimed to assess the perspective of leader-member exchange and its relation with workplace empowerment and organizational citizenship behavior among nurses.

Research questions
-What is the level of quality of the relationship between leader-member from the nurses' perspective? -What is the level of workplace empowerment from the nurses' perspective? -What is the level of organizational citizenship behavior from the nurses' perspective? -Is there a relation among leader-member exchange, workplace empowerment, and organizational citizenship behavior among nurses?

Research design
A descriptive correlational design was used to achieve the aim of the current study. Descriptive study/research is research intended to supply a picture of the current state of affairs. Correlational study/research is a research designed to determine relations among variables and predict future events from present knowledge (Walinga, 2019).

Research Setting
The study was conducted at Benha University Hospital, in general, medical and surgical units; general medical units, including (6) units and general surgical units, include (4) units.

Subjects
A convenient sample of all available nurses working at the setting mentioned above recruited for this study at the time of data collection. The sample consisted of 190 nurses who were working in the study setting, as mentioned earlier, with more than three years of experience and agreed to participate in the study.

Tools of data collection
Data for the present study were collected using the following three tools:

Subordinate (LMX-MDM) Survey Portion
It was developed by Liden and Maslyn (1998). It aimed to assess the quality of the supervisor-subordinate relationship from the nurses' perspective. It consisted of two parts. The first part included personal data about studied nurses such as unit, age, gender, educational qualification, and years of experience, and marital status. The second part included 12 statements subdivided into four main domains; affect (3 statements), loyalty (3 statements), contribution (3 statements), and professional respect (3 statements).

Scoring system
The nurses' responses were measured using a five-point Likert scale. Strongly disagree scored as 0, to strongly agree scored as 4. Scores of each domain summed up and converted into percent scores that reflect the agreement regarding the quality of their supervisor-subordinate relationships. High-quality relationships counted when the percentage ≥60% was ≥ 29 marks. Low-quality relationships <60% that equals less than 29 marks. (Brunettoa et al., 2012).

Condition of Work Effectiveness Questionnaire (CWEQ)
This questionnaire was developed by Laschinger et al. (1999) and adopted by researchers to assess workplace empowerment as perceived by nurses. It consisted of 31 statements that distributed over four main dimensions of structural empowerment; opportunity (7 statements), information (8 statements), support (9 statements), and resources (7 statements).

Scoring system
The nurses' responses were measured using a five-point Likert scale that was ranged from none scored as 0 to a lot scored as 4. The total score ranged from 0 to 124. Scores of each dimension summed up and converted into percent scores that reflect workplace empowerment as perceived by nurses. High workplace empowerment counted when the percentage ≥75% that was ≥ 93 marks. Moderate workplace empowerment ranged from 60%-<75% that equals between 75-92 marks. Low workplace empowerment ranged from < 60% that equals less than 75 marks (Soliman, 2014).

Scoring system
The nurses' responses were measured using a sevenpoint Likert scale that was ranged from 0 strongly disagree to 6 strongly agree. The total score ranged from 0 to 144. The nurse was considered had high organizational citizenship behavior with total percentage ≥ 75% that equals ≥ 108 marks, moderate level of organizational citizenship behavior with total percentage 60-<75% that equal between 87-108 marks, and low level of organizational citizenship behavior with total percentage <60% that equals < 87 marks (Kamel et al., 2019).

Procedures
The procedure was carried out on three phases; a preparation phase, pilot study, and fieldwork. The preparatory phase started from the beginning of September 2019 to the end of November 2019. It covered three months and included the following: Reviewing the national and international related literature using journals, periodicals, internet, and theoretical knowledge of the various aspects concerning the topic of the study and translating the study tools into Arabic format for better understanding and back translation to check its accuracy.
Tools' validity test was done through a panel of five experts in the field of nursing administration to test the content validity, relevance, and completeness. Cronbach's Alpha coefficient test used to test the tools' reliability. Cronbach's alphas were (r= 0.91, 0.88, and 0.92) for Subordinate (LMX-MDM) Survey Portion, Condition of Work Effectiveness Questionnaire (CWEQ), and Organizational Citizenship Behavior Scale, respectively.
A research pilot study was carried out on 10.0% of the total nurses' sample (19) during December 2019 to check the clarity, the applicability of the tool, and estimated the time needed for data collection. It ranged from 10-15 minutes for each tool, besides testing the feasibility of the study process. No modifications were made, and all nurses who participated in the research pilot study were included in the primary research sample.
Fieldwork: Data collection was carried out over two months from January 2020 to February 2020. Official approval was obtained from the Dean of the Benha Faculty of Nursing to the director of Benha University Hospital. The researchers met the head nurse of each unit to determine the appropriate time to collect the required data from the nurses and seek staff support.
After explaining the study's purpose to the studied nurses, data was collected through meeting with the nurses to explain the purpose of the study. Data were collected from nurses before and between their work shifts (morning and afternoon shifts) according to their availability through 3 days/week. The number of interviewed nurses daily was ranged from 6 to 8 nurses. The time required to fill the questionnaires sheet was from 20 to 30 minutes. The filled forms were collected in time and revised to check their completeness to avoid any missing data.
Ethical consideration: At the interview with nurses to collect data, they were informed about the purpose and benefits of the study, their participation is voluntary, and they have the right to refuse to participate in the study without giving any reason, and oral consent obtained from each nurse. Bedsides, confidentiality, and anonymity of the subjects were assured through coding of all data.

Data analysis
Data entry and analysis were done using the Statistical Package for Social Sciences (SPSS version 22.0). Data were presented using: Descriptive statistics in the form of (mean, and standard deviation) for quantitative variables and (frequency and percentages) for qualitative variables. The correlation coefficient (r) was used to investigate the correlation between the study variables. For all statistical tests done, the threshold of significance was fixed at the 5% level, P-value ≤ 0.05 was significant. Table 1 illustrates that more than half of nurses (58.9%) were working at surgical departments, and 40.5% had aged 26 to less than 30 years old with a mean age of (32.7±4.2) years. The majority of them (84.2%) were females. Concerning their qualification, two-fifths of studied nurses (40.0%) had Secondary nursing school diploma. According to their years of experience, less than half of them (46.8%) had years of experience from 5 to >10 years. As far as their marital status, the majority of them (81.6%) were married. Table 2 shows that the mean of leader-member exchange was 26.91±9.01, representing 56.1% of the total score, the highest domain was, affect 66.5% followed by professional respect 56.3%, then loyalty 52.7%, finally the lowest domain was contribution 48.5%. Figure 1 displays that more than half of nurses (54.7%) reported that they had high-quality relationships with their supervisors, and 45.3% reported that they had low-quality relationships with their supervisors. Table 3 shows that the mean of total workplace empowerment was 77.25±5.98 that represents 62.3% of the total score, and the highest domain was an opportunity 65.78%, followed by information 64.75%, then support 61.11%. Finally, the lowest domain was resources at 60.42%. Figure 2 illustrates that 71.1% of nurses had a moderate level of workplace empowerment and, 5.3% of nurses had a high level of workplace empowerment, while less than onequarter of them (23.6%) had a low level of workplace empowerment. Table 4 shows that the mean of organizational citizenship behavior was 94.34±28.46 that represent 65.57% of the total score, and the highest domain was civic virtue 71.75%, followed by altruism 67.83%, then sportsmanship 66.2%, then conscientiousness 64.63%, finally the lowest domain was courtesy 58.36%. Figure 3 portrays that more than half of nurses (51.1%) had a moderate level of organizational citizenship behavior and, 15.3% of nurses had a high level of organizational citizenship behavior while one-third of them (33.6%) had a low level of organizational citizenship behavior. Table 5 shows a highly statistically significant positive correlation between total score of leader-member exchange and total workplace empowerment, total organizational citizenship behavior (at p<0.000). Also, a highly statistically significant positive correlation between the total workplace empowerment, total organizational citizenship behavior was revealed.

Results
Article number 3 page 5 of 10

Discussion
Organizational effectiveness requires coordination between leaders and subordinates. In order to affect coordination, leaders exhibit behaviors that, in turn, elicit actions and conduct from subordinates that go beyond organizational norms. The collective effort was established in organizations through the social exchange and power between leaders and followers. Empowered leadership provides the catalyst to promote collective effort through leadership behaviors such as leading by example, coaching, participating in decisions, showing concern, and providing direction (Henkel, 2017).
High-quality relationships were developed with staff members that are productive and motivate staff to extend their efforts beyond rational expectations. Productive highquality relationships demonstrate loyalty and consideration and affect the organization, and its leaders often referred to as organizational citizenship behavior (OCB) (Boockoff, 2016). The present study aimed to assess the perspective of leader-member exchange and its relation with workplace empowerment and organizational citizenship behavior among nurses.
The findings of the current study reveal that more than half of the studied nurses reported that they had a highquality relationship with their supervisors. From researchers' point of view this may be due to nursing supervisors oversee and encourage the active work participation of nurses that create a positive work environment for the generation of constructive attitudes towards work which enhance their willingness to make an effort on behalf of the organization; the degree of congruence of personal goals and organizational values; and the desire to remain a member of the organization.
This study finding was in the same line with Meiners and Boster (2012), who stated that high-quality LMX relationships were reported among study subjects. They also found that supervisors and subordinates had high levels of affect, loyalty, and professional respect related to higherquality relationships. Hassan et al. (2013), in their study, indicated that LMX mediates the positive relationship between the subordinates and the supervisors. On the other hand, this finding disagreed with Greguras and Ford (2006), who had found that subordinates viewed their relationship quality with supervisors, had lower levels.
The findings of the current study reveal that more than two-thirds of studied nurses reported moderate workplace empowerment. From the researchers' point of view, this may be due to nurses may not feel empowered enough and had lacked support from their leaders that needed to involve them in decision-making and to enhance their job performance, which is part of their empowerment.
This study finding was in the same line with Ahmed et al. (2015), who conducted a study about the "effect of working condition and fatigue on performance of staff nurses at Mansoura University Hospital." They stated that nearly two-thirds of studied staff nurses showed a moderate level of working conditions (structure empowerment). Also, Davies et al. (2011), who conducted a study about "nurses' participation in personal knowledge transfer: The role of leader-member exchange (LMX) and structural empowerment" and Garcia-Sierra, and Fernandez-Castro, (2018), who conducted a study about "relationships between leadership, structural empowerment, and engagement in nurses." They concluded that nurses had moderately structurally empowered. Furthermore, Eskandari et al., (2017), who conducted a study about "investigation of the relationship between structural empowerment and organizational commitment of nurses in Zanjan hospitals," the study found that hospital-working nurses' perceived the "structural empowerment" as moderate.
While disagreed with Ali et al. (2018), who conducted a study about "the effect of head nurses` empowerment educational program on staff nurses' burnout" and found that nurses had a low level of structure empowerment preprogram phase. Also, Çavuş and Demir, (2010), conducted a study entitled "the impacts of structural and psychological empowerment on burn out" and demonstrated that nurses had a low level of structural empowerment.
The findings of the current study reveal that the highest domain of workplace empowerment was an opportunity. From the researchers' point of view, this may be due to empowerment is possible when nurses have a feeling of challenge, and the chance to learn and grow, discover, and develop in their workplace.
This finding was paralleled with Barden et al. (2011), who conducted a study about "shared governance and empowerment in registered nurses working in a hospital setting" and found that nurses rated opportunities as the highest subscale of empowerment. Also, Eskandari et al. (2017), stated that the nurses knew "opportunity" as the most crucial element in the structural empowerment . Smith, (2019), also conducted a study regarding "perception of structural empowerment and job satisfaction for front-line nurse leaders: A descriptive phenomenological study." The study reported that opportunities increase foundational considerations for empowerment access and the measures to maximize nursing personnel effectiveness.
About staff nurses' perception of organizational citizenship behavior (OCB), the current study findings reveal that more than half of staff nurses had a moderate level of organizational citizenship behavior, and one-third of them had a low level of organizational citizenship behavior. This result may be due to OCB being an essential factor contributing to the organization's survival and success. At the same time, it is a voluntary behavior, not a predetermined duty, and not a part of the official duties of the nurses. It is a behavior that is not rewarded directly or through the formal organizational structure and is not appreciated. Nurses may lose the incentive to behave with citizenship behavior.
The findings of the current study were supported by Abd El-Helium (2018), who conducted a study about "relationship between staff nurses' job autonomy and organizational citizenship at Benha University Hospital," the study found that the majority of staff nurses had a moderate organizational citizenship behavior. Moreover, Abed and Elewa (2016) conducted a study about "the relationship between organizational support, work engagement and organizational citizenship behavior as perceived by staff nurses at different hospitals," they found that staff nurses had a moderate level of organizational citizenship behavior. The finding of the current study is inconsistent with Kamel et al. (2019), who conduct a study about "quality of work-life and organizational justice: Its relation to citizenship behavior among staff nurses." The study revealed that more than half of the staff nurses had a high level of organizational citizenship behaviors.
The present study findings show that the highest mean for organizational citizenship behavior was civic virtue followed by altruism, then sportsmanship then consciousness; finally, the lowest domain was courtesy. This finding may be due to constructive participation in the organization's political process, such as making suggestions for improvement in meetings. Also, nurses who feel "a part of a larger whole" want to be well informed about significant organizational changes. Accordingly, nurses perform better and exert a high level of effort when they perceive that they are supported by organizations that care about their wellbeing and value their contributions, which encourages them to engage in organizational citizenship behavior.
The result of the current study disagrees with Mahmoud and Ibrahim (2016), who conducted a study about "factors in nurses' organizational citizenship behavior" and observed that the nurses behave with the same mean percentages related to organizational citizenship behavior dimensions with a similar overall mean. Also, this result of the current study is inconsistent with Kamel et al. 's (2019) study who reported that the highest mean percentage of staff nurses' perception of organizational citizenship behaviors was related to courtesy, while the lowest mean percentage of staff nurses' perception related to the civic virtue. The previous findings were in disagreement with Abd El-Helium (2018) study. The study reported that the highest mean percentage of staff nurses' perception toward organizational citizenship behaviors were related to courtesy, while the lowest mean percentage of staff nurses` perception related to the sportsmanship.
The findings of the current study reveal a highly statistically significant positive correlation between the total score of leader-member exchange and total organizational citizenship behavior. This finding may be referred to as the importance of leader-member exchange that helps nurses enhance their citizenship behaviors and positively shape the organization's future.
This result was in the same line as Ibrahim et al. (2017). Their study showed that a "high-quality" exchange relationship (LMX) results in enhanced organizational citizenship behavior. Also, Kapil and Rastogi (2018) stated that the overall basis of LMX and OCB is correlated significantly. They also stated that organizations could proactively enhance OCB through the high quality of LMX. Estiri et al. (2018) concluded that positive social exchanges enable high-quality LMX relationships to produce extra-role behaviors such as commitment and OCB for the organization to succeed. Kim et al. (2010) stated that increasing the quality of LMX leads to increasing OCB. Ibrahim and Salleh (2014) found that prompting employees' willingness to exhibit OCB and foster a quality supervisor-subordinate relationship (LMX) are among the essential ingredients in heightening the level of subordinates' satisfaction. On the other hand, Soldner and Crimando, (2010) stated that the relationship between perception of the quality of the leader-member relationship (LMX) and their willingness to engage in organizational citizenship behavior was not significant.
The findings of the current study reveal a highly statistically significant positive correlation between the total score of leader-member exchange and total workplace empowerment. This finding may be due to the role of the supervisor in hospitals is to oversee and encourage the active work participation of nurses that lead to the creation of a positive environment for the generation of high-quality supervisor-nurse relationships that affect nurses` perceptions of empowerment. This result was in the same line with Laschinger et al. (2014), who stated that developing highquality relationships with staff helps to empower work environments.
The present study findings show a highly statistically significant positive correlation between total workplace empowerment and total organizational citizenship behavior. These findings may be due to the organizational citizenship behavior empowered work climate that motivates the staff to work harder and be involved with their work and become highly committed and feel highly satisfied with the organization. This finding agrees with Abd El-Alim and Elsayed (2017), who reported a statistically significant correlation between organizational citizenship behavior and empowerment practices.

Conclusion
Based on the results of the present study, it can be concluded that: More than half of nurses reported that they had a high-quality relationship with their supervisors, and more than two-thirds had a moderate level of workplace empowerment, also, more than half of them had a moderate level of organizational citizenship behavior. Moreover, there was a highly statistically significant positive correlation between the total score of leader-member exchange and total workplace empowerment, total organizational citizenship behavior. Also was a highly statistically significant positive correlation between the total workplace empowerment, total organizational citizenship behavior.

Recommendations
Based on the study findings, the following recommended: Nursing practice -Staff development programs should be a prerequisite to prepare nurse managers and expose them to the updates on the quality of workplace relationships. -Nurse supervisors have to pay attention to conduct periodical meetings with their staff and encourage them to express their feelings, interests, voice their opinion, and view about jobs to improve supervisor and nurses' relationships. -Nursing supervisors need to encourage nurses to exercise leadership roles in their careers. -The nursing leader should create empowering work environments that enable nurses to provide excellent quality patient care and achieve organizational outcomes. -Hospital management is recommended to enhance staff feelings of accountabilities and citizenship by allocating incentive tasks and decision-making accountabilities to enhance staff citizenship behavior. Further research -Develop and test strategies to enhance organizational citizenship behavior among nurses.